PEDIATRIC KNEE

INJURIES
Big Sky Sports Medicine Conference 2013
Kerry Hale Ford, MD

Financial Disclosures
Legal consulting for Stryker

Pediatric Knee Injuries

Overuse injuries
OCDs and osteochondral
fractures
Meniscus tears
Anterior cruciate ligament
injuries
Patellar Instability
Fractures about the knee

Anatomy
Growth plate
Varying

degrees of openness

Assess growth potential remaining for that child

Length and angular deformity
Reconstruction

What damage are you going to do?

ACL reconstruction in a 10 yo compared to a 16yo
Tibial tubercle osteotomy vs soft-tissue recon for patellar
instability

Anatomy
Apophysis
Tensile forces from
musculotendinous
junction
Apophysitis rather than
tendonitis

Severs disease

Articular Cartilage

More susceptible to
shear stress
OCD, chondral fractures

Anatomy
Tendon and ligament
insertion
Insert into fibrous and
fibrocartilaginous periosteal and
perichrondrial regions of the
metaphysis
Progressive rather than abrupt
gradations of moduli of elasticity
Ligaments and tendons are stronger
than these attachments
ACL avulsions
Tibial tubercle avulsions
ligament instability maybe a
growth plate injury
Sharpeys fibers develop with
skeletal maturation

Anatomy
Mismatches between bone and soft tissue
growth
Longitudinal bone growth more rapid than soft tissue
growth
Increase in muscle-tendon unit tightness and a loss of
flexibility

APOPHYSEAL INJURIES

Apophyseal Conditions
Osgood-Schlatter , Sinding-Larsen-Johannson
10 15 years of age

Incidence
15% boys, 10% girls
Kujala et al Am J Sports Med 1985

Treatment
Rule out other causes
Reassurance, rest ( activity modification), stretching, antiinflammatory
No steroid injections. No surgery

Apophyseal injuries

Osgood schlatters

SindingLarsenJohannson

Tendinosis
Tenosynovitis more
common
Achilles
Patella
Popliteus

OSTEOCHONDRITIS DISSECANS

Osteochondritis Dissecans

Osteochondritis Dissecans
Major etiology is
likely repetitive
microtrauma
Necrosis of
subchondral bone
healed by creeping
substitution
Fracture of overlying
cartilage can expose
bone to synovial fluid

Osteochondritis Dissecans
Physical Findings
Vague pain with activity
Effusion
Unstable lesions will have mechanical
symptoms
Point tenderness over lesion area

Osteochondritis Dissecans - Diagnosis

Xray AP, lateral, PA
flexion, and sunrise
views (contralateral
views?)
MRI gold standard

Osteochondritis Dissecans - Treatment

4 groups: skeletally immature vs skeletally
mature, stable versus unstable lesions
Nonsurgical:

cast, brace, restrict activity

Period of rest prior to other treatments
When/who to treat???
AAOS guidelines consensus statements for groups
including the skeletally immature and mature with
symptomatic unstable or displaced lesions

May 2011, Vol 19, No 5

Osteochondritis Dissecans - Treatment

Skeletally Immature Patients
Asymptomatic

Observe, educate parents

Symptomatic period of rest, discuss surgery

Skeletally Mature Patients

Asymptomatic

role for drilling?

Symptomatic - surgery

Osteochondritis Dissecans - Treatment

Options include microfracture,
antegrade/retrograde drilling for stable lesions,
ORIF +/- bone grafting for unstable lesions

Osteochondritis Dessicans: AAOS

Practice Guidelines

Osteochondral Fractures
Fractures occur
through the zone of
provisional
calcification
Nutcracker
injuries,
patellar
dislocations

Chondral Lesion - Treatment

Fix them suture, bioabsorbable versus stainless Herbert screws

OAT, ACI for the sports guys

Osteochondral Lesions - Treatment

Trend toward stainless screw fixation
Take screw out at second procedure
Brace, NWB for 4-6 weeks, early ROM, CPM

MENISCUS TEARS

Meniscus Tears
Becoming increasingly common as
pediatric population participates in
athletics at earlier ages

Anatomy
Meniscus

Vascular
Clark C JBJS Am 1983
Kaplan E JBJS Am 1957

Discoid

Meniscus Tears Work-Up

Twisting injury
Medial meniscus more common than lateral
Pain, effusion, mechanical symptoms
Joint line tenderness
McMurrays, Apleys, duck walk
Xrays, MRI

Meniscus Tears
Natural History
80 -90% symptomatic
in 5-8 years
Manzione M Am J Sports
Med 1983
Medlar R Am J Sports
Med 1980

Repair
80 -90% success
Cassidy R Am J Sports
Med 1981
Scott G JBJS Am 1986

Meniscal Tears - Treatment

Aggressively treat red-red, red-white zone tears
All-inside vs inside-out vs outside-in
Nice videos on Vumedi
Post-op: WBAT, limit flexion in brace

ANTERIOR CRUCIATE LIGAMENT INJURIES

ACL injuries

ACL injuries

8 yo

14 yo

ACL injuries
Dramatic rise in incidence
Female soccer players, football players (both about
14/100,000)
Shift towards operative management earlier than
historically

ACL injuries Work-Up

Twisting injury, funny fall
Hemarthrosis over 50% of time, laxity with
Lachmans and anterior drawer testing
Xrays, MRI

ACL injuries

PATELLAR INSTABILITY

Patellar Instability
2-3% of acute knee
injuries in kids
Females, sports,
personal or family
history of instability

Patellar Instability - Treatment

First-time dislocators 62%

success with non-op mgmt
Immature with

trochlear dysplasia
only a 31% success rate

Patellar Instability
1 crossing sign
2 - supratrochlear
spur
3 double contour

Patella Instability
Patellofemoral disorders 10% of all sports injuries
DeHaven K Am J Sports Med 1986

Acute Patellar Dislocation

Look for osteochondral injury (Starship series)
Nat. History: Redislocation
11-14 yo 60%
19-28 yo 30%
Cash J Am J Sports Med 1988

Identify high risk patients

De Jour Sign

Patellar Instability Nonop treatment

Good PT; cast vs
brace; closed-chain
exercises, VMO
focused; gluteal
strengthening

Patellar Instability Operative Treatment

MPFL recon now gold
standard of surgical treatment
MPFL provides at least 50% of

medial restraint of lateral translation

Many, many described methods of
reconstruction; Single bundle
gracilis, patellar and femoral tunnels,
tension in 60 degrees of flexion; Bob
Burk Vumedi video

FRACTURES ABOUT THE KNEE

Fractures about the Knee

Two groups:
Physeal

concern for
growth arrest and NV
complications
Distal femur, proximal
tibia, tibial
tubercle/tuberosity

Extra-physeal

concern for joint

stiffness and function
Patellar sleeve, tibial
eminence fractures

Fractures about the Knee

Distal femur/Proximal Tibia analogous to knee
dislocation in adults (NV compromise possible)
Higher-energy injuries (trampoline, MVC) in
pre-adolescents
Typically anteriorly displaced in the femur
Typically posteriorly displaced in the tibia
Lower-energy injuries in adolescents (football,
basketball)

Fractures about the Knee

Treatment for physeal
fractures:
non-displaced
immobilization
Displaced anatomic
ORIF for intra-articular
SH III/IV; varus/valgus
realignment for extraarticular fractures
Undulating physes at
high risk for injury,
need vigilant follow-up
until skeletal maturity

Fractures about the Knee

Tibial tubercle avulsion fractures
Similar

to juvenile Tillaux regarding differential

closure of the physis
Remember fracture can propagate through the
physis into the joint
Displaced fractures need ORIF to avoid extensor lag
Beware of compartment syndrome

Tibial Tubercle Avulsion Fractures

Fractures about the Knee

Tibial spine fractures classic story is fall from a
bike ages 8-14
Present with hemarthrosis, pain, knee flexed,
inability to bear weight
Meyers/McKeever classification I-IV
Type

I LLC
Type II aspirate joint, reduce and LLC
Type III/IV ORIF (take your pick of techniques)
Avoid transphyseal fixation except in kids near skeletal
maturity

Fractures about the Knee

Patellar sleeve fractures
Hemarthrosis, difficult

active knee extension

Xrays show a small fleck of
bone usually off inferior
pole of patella
MRI is helpful
Non-displaced LLC
Displaced ORIF (tension
band)

 haleford@gmail.com
406-439-0715 (mobile) Texting is best
406-447-5903 (office good luck); ask for Jody Inbody

or Lena Phelps
Missoula outreach 406-327-4279
Billings Clinic outreach 406-238-5254; ask for Becky,
Jen, or Alli