Common Paediatric and Adolescent Knee Problems
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Presentation given by Dr Lyall Asberg to the Orthopaedic Manipulative Physiotherapy Group of South Africa.
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Common Paediatric and Adolescent Knee Problems
- 1. Common Paediatric & Adolescent Knee Problems Dr. Lyall J. Ashberg, MD Specialising in Paediatric and Adolescent Orthopaedics Offices at Netcare Blaauwberg & Sea Point Medical Centre Cape Town, South Africa Ph: 021 554 2055 Fax: 021 554 2065 Email: Ashbergortho@gmail.com
- 2. Growth and Development †Why do young children who fall so frequently not get injured more often? †Young tissues are more pliable and energy absorbing †Stage of growth and development is essential when evaluating paediatric knee problems †Physis (growth plate) is weakest part of child skeleton †Most of growth of lower limb occurs at knee (2/3)
- 3. General Principles †Kids are not little adults †Adolescent knee problems are similar to adults unless they are still growing- Preadolescent †There is a spectrum of pathology significantly dependent on stage of development †One needs to distinguish what is physiologic vs pathologic †Males and females have different biomechanics which leads to different injury profiles (ACL epidemic in females) †Preseason training/Strength and conditioning programmes are safe and effective in preventing injuries and improving performance in kids
- 4. Selenius Chart 16 month old 3 year old
- 5. Epidemiology †M>F †Adolescent females are approaching males †In the US, there has been a 4 fold increase in female ACL (1:8) injuries †Q angle, ligament laxity, genu valgum, ext tib torsion, fem Anteversion , inter condylar notch shape, ACL size, biomechanics, hormonal influences. †Highest incidence in adolescence 2 to sport
- 6. Injury Categories †Acute Trauma vs Overuse syndrome †Areas of injury †Muscle †Extrarticular Ligaments/Tendon: MCL/LCL-PLC/Extensor mechanism †Apophysis †Physis †Intrarticular structures †ACL, PCL, Meniscus, Chondral injury
- 7. Overuse Problems: Apophsitis †Apophysis: specialized growth centre/cartilage attached to a tendon or muscle †Much weaker than attached tendon. †Thus the terms tendinitis often doesn't apply †Examples: tibial tuberosity, olecranon apophysis, Calcaneal apophysis
- 8. Overuse Problems: Apophsitis Traction apophysitis is very common around the knee Osgood Schlatter's: tibial tuberosity Sindig-Larsen-Johannsen: Inferior pole patella Occurs around age 10-15, earlier in girls †Often very active in sports ††More common in boys +/- growth spurt †Relative extensor mechanism inflexibility †Associated with jumping squatting, cutting sports â€
- 9. Osgood-Schlatter's SLJ
- 10. Overuse Problems: Apophsitis †Usually self-limiting †Resolves after skeletal maturity †Improved with Extensor Mechanism stretches/physio †Modification of activities †Anti-inflammatories †Rarely surgery is necessary to remove ossicles after skeletal maturity †Pain with kneeling
- 11. Quad & IT band stretches
- 12. Patellofemoral Pain †Multiple aetiologies †Often seen in girls †No antecedent trauma or inciting event †Pain at rest and with activity
- 13. Patellofemoral Pain †Lateral patellar overload †Chondromalacia patella †Extensor mechanism inflexibility †Patellar maltracking/instability †Congenital plica
- 14. Lateral patellar overload Patella lift off test
- 15. Congenital Plica †Synovial remnant †Can cause snapping and pain †Often diagnosis of exclusion
- 16. Sddddd Knee hyperextension "Squinting patellas" Miserable malalignment syndrome
- 17. Acute Patella Instability/Dislocation Often results from direct blow or valgus load †Results from disruption of MPFL ††Primary stabilizer of the patella †Most often avulses off femur â€In otherwise normal knee, frequently associated with chondral injury
- 18. Acute Patella Instability/Dislocation †Pt usually describes hearing or feeling a "pop" †Immediate, large haemarthrosis †Knee collapsing and unable to bear weight †Tender over course of MPFL & LFC †Often have "Apprehension" with lateral glide test
- 20. Patella Dislocation-Treatment †First Time Dislocator †Acute Care †+/- evacuate haematoma for comfort †Knee immobilizer †Xrays/MRI looking for intrarticular loose body †Family given option of non-operative tx †Up to 30% fail conservative tx.
- 21. Patella Dislocation-Treatment †Conservative Treatment †Immobilization until quad inhibition resolves (2-4 wks) †Physio for Quad (?VMO) strengthening/proprioception †Return to sports no sooner than 3 months or until they have protective quad/hamstring strength.
- 23. Operative Treatment †Very complex decision making †Need to consider †Limb alignment and rotation †Valgus limbs/Excessive femoral anteversion †Q angle †Trochlear depth †Ligamentous integrity †Both generally and MPFL
- 24. Patellar maltracking Q angle †Multiple determinants Ligament laxity Patella glide Limb alignment Valgus knee Rotational Variation Trochlear morphology/shape
- 25. Operative Treatment †Mainstay is MPFL repair or reconstruction †Many different techniques †Roux-Goldwaith procedure in skeletally immature or medialization of tibial tubercle in skeletally mature †Insall proximal realignment †Trochlear deepening procedure †Femoral/Tibial derotation
- 27. Meniscus Problems †Other than articular cartilage, the meniscus is probably the most important structure in the knee †C-Shaped, biconcave wedge shaped structures made of fibrocartilage in lateral and medial joint compartments †Functions: †Load sharing and shock absorption †Protects articular cartilage †Complete meniscectomy results in up to 350% increase in contact pressures! †Secondary Stabiliser †Proprioception †Synergistic role in joint lubrication
- 28. Meniscus Problems †Vascularity and Healing †In the neonate, meniscus is extensively vascularised †Persists until age 2 at which point begins to recede †Only 10-30% of meniscus has blood supply †Red-red †Red-white †White-white
- 29. Epidemiology †Traumatic injuries in children younger than 10 are rare †Congenital malformations (Discoid Meniscus) may predispose to injury †As children approach adolescence, potential for injury increases †Increase in organised sports has increased the number of serious intrarticular knee injuries
- 30. Meniscus Problems †History †Often sustain either twisting injury or varus/valgus load on fixed limb †+/- "pop" †Swelling/effusion (51%) †Chronic tears may present with intermittent, activity related swelling †Clicking/Popping/locking (bucket handle tear) †Stiffness and pain
- 31. Meniscus Problems †Physical †Effusion †Decreased ROM †JOINT LINE TENDERNESS †VALGUS/VARUS ROTATION and STRESS TEST †SQUAT TEST †McMurray's/Apley's: only around 58% reliable
- 32. McMurray's Apley's Rotation-Compression test
- 33. Meniscus Problems †Treatment †Indicated in acute tears and chronic tears with mechanical symptoms †In child or adolescent, make every effort to retain child's own parts †Partial excision †(Total Excision) †In ACL deficient/unstable knee, MUST address ACL at same time or repair will fail
- 35. Meniscus Problems Rehab Post Menisectomy ††WBAT †ROM †Quad-Hamstring rehab Post Repair ††Non-weightbearing at least 6 weeks †ROM †Quad-Hamstring rehab †No competitive sports at least 3-6 months
- 36. Discoid Meniscus †Congenital variant present at birth †Three types †Most often assymtomatic †In the young child may present as dramatic snapping, either audible or palpable †May result in abnormal biomechanics of knee
- 37. Discoid Meniscus †Treatment †Assymptomatic children do not require treatment †Will occasionally tear in older child or adolescent †Symptoms of swelling and lateral joint line pain †Saucerization of meniscus and repair/stabilisation †Occasionally associated with OCD of LFC †Addressed as per OCDs
- 38. Discoid Meniscus
- 39. Osteochondritis Dissecans †"Bone-cartilage separation/dissection" †Occurs in Juvenile (5-15) and adult forms (16-50) †More common in males †After skeletal maturity prognosis is much worse †Most often affects lateral aspect of medial femoral condyle †Felt to result from repetitive microtrauma although other factors probably contribute †Separation of osteochondral fragment highly likely to result in DJD
- 40. OCD †Presentation †Depends on lesion stability †Stable lesions †Aching activity related pain †No effusion †Point tenderness over lesion †Unstable Lesions †More likely to have mechanical symptoms †Effusion †More painful
- 41. OCD †Treatment †Depends on age of patient and lesion characteristics †Nonoperative †Usually involves initial period of immobilisation †Rehab †Gradual return to sports under close observation †Repeat MRI
- 42. OCD †Factors associated with failure of non-op treatment †Larger sized lesion †Greater Skeletal maturity †High signal behind lesion on MRI
- 43. OCD †Treatment †Operative †Anterograde or retrograde drilling †Lesion Stabilisation †Microfracture †Cartilage "replacement" †OATS/Mosaicplasty/Autologous chondrocyte transplantation
- 45. ACL Injuries †Embryologic development is intimately related to that of menisci †Congenital absence can occur but usually associated with other lower limb anomalies †It is an intrarticular-extrasynovial structure †This has implications for healing †The relationships of its insertion site on the femur and tibia remain constant throughout growth †Origin on the femur is all epiphyseal and very close to the distal femoral growth plate
- 46. ACL Injuries †Biomechanics †Primary restraint to anterior translation of the tibia and femur †Primary stabiliser during jump, cut and twist sports †Comprised of anteromedial and posterolateral bundles †In the growing knee it is the âmiddle componentâ of a complex viscoelastic chain
- 48. ACL Injuries †Biomechanics †Failure mode depends on a myriad of loading and host characteristics †Age of the child †Sex †Hormonal influences †Structural factors
- 49. ACL Injuries †Epidemiology and Risk factors †Increasing frequency secondary to participation in organised sports †Major risk factors include †High knee-demand sports †Female gender †Immature neuromuscular development †Concurrent meniscal injury is common †ACL injury is a common cause of haemarthrosis
- 50. ACL Injuries †Injury Patterns †Midsubstance tears more common after age 12 †Bony avulsion most common at tibial spine and in kids <12 †Partial tears are more common in pre-adolescent †Partial tears which are associated with instability are âfunctionally completeâ and should be addressed as such
- 51. ACL Injuries †Natural History †Developmental and behavioral issues may predispose children with ACL-deficient knee to become ânon-copersâ †Non operative treatment is associated with †Recurrent instability †Cumulative meniscal and cartilage damage †Sports related disability
- 52. ACL Injury †History usually reveals a non-contact, rapid deceleration mechanism often with a valgus load and rotation of the tibia on femur †Often feel a âpopâ and rapid knee swelling and pain †Childrenâs symptoms tend to resolve quickly and often return to activities †Need to distinguish between patellofemoral and ACL type instability †Lachman maneuver is easiest and most sensitive exam †Routine xrays for bony avulsions †MRI to document concurrent injuries to menisci and cartilage
- 53. QuickTimeâą and a decompressor are needed to see this picture. ACL rupture in female basketball player
- 54. Lachman Anterior Drawer QuickTimeâą and a decompressor are needed to see this picture. Pivot Shift Test
- 55. ACL Injury †Treatment Considerations †Distal femoral and proximal tibial growth plates are responsible for majority of lower extremity growth †Although rare, angular deformities have been described following reconstruction †Mostly secondary to inappropriately placed fixation or bone placed across the physis †Is is better to cause a growth disturbance or allow for arthritis?
- 56. ACL Injury †Treatment Considerations †When approaching treatment in a child I consider †Tanner stage/sexual maturity †Bone age †Activity level and type of sport †Symptomatology during ADLs †Family desires
- 57. ACL Injury †Treatment Considerations †Nonoperative: †Decrease pain and swelling †Regain quad function and normal gait †Comprehensive lower extremity strengthening and proprioception †Knee brace †Avoidance of cutting sports †Recurrent instability is not an option!
- 58. ACL Injury †Treatment Options †Direct Repair †Not typically an option as this has a very high failure rate †Extrarticular procedures †Avoids physis †Fixation is outside the knee
- 60. ACL Injury †Physeal Sparing procedures †Fixation either in epiphysis or across one physis †Transphyseal all soft tissue with extraphyseal fixation †Adult type reconstruction †Bone-patella tendon-Bone †Hamstrings †Allograft †Quad Tendon
- 62. Other Ligaments †âChildren are not small adultsâ †Again, in pre-adolescent child need to consider the growth plate as the âweakest linkâ †Ligaments are more likely to fail at lower rate of load †Physis fails at higher rate of load †Beware the PCL/PLC injury in ACL deficient knee †Posterolateral rotatory instability †Childrenâs knees in these injuries tend to be more âforgiving and usually amenable to non-operative management
- 63. Fractures †Becoming more common and more severe in children †Greater level of sports participation †High energy sports †motorized sports †High level contact sports †MVAs and unbuckled children in SA!!
- 64. Fractures †Fracture related growth problems are seen most frequently after injuries about the knee †Can have life and limb threatening consequences †Need to have a high index of suspicion in growing child †Not a sprain/strain unless proven otherwise †Should almost always get at least an xray in knee injured child †Have a low threshold for advanced imaging †Donât normally recommend âstress viewsâ
- 66. Fractures †Distal Femoral and Proximal Tibial Physeal fractures †Most common fractures mistaken for ligament injury †Need a high index of suspicion †Treat as such until proven otherwise †Can be most devastating to growth and life/limb †Non-displaced fractures can usually be treated in a cast †Displaced or intrarticular fractures frequently require surgery
- 69. Fractures Tibial Eminence fractures †ACL equivalent in pre-adolescent child †Most common in children 8-14 years old †3 types-Meyers and Mckeever †Type I-II usually amenable to cast immobilisation †Type III always operative †Not uncommon to have residual, post fixation laxity on objective testing †Indicates ACL âstretchâ †Usually not clinically significant
- 71. Fractures †Tibial Tubercle and Patella Sleeve Fractures †Mostly sports related †Typically occur between 12-17 y/o †Usually secondary to violent contraction of quad †eg. Landing a jump †At tubercle, fracture occurs at junction of ossified and cartilage growth plate †Sleeve fractures occur because of cartilagenous attachment at inferior pole of the patella †Difficult to diagnose, but can result in complete disruption of extensor mechanism.
- 73. Infections †Relatively common in younger children †Can occur from direct injury, haematogenous spread or concurrent osteomyelitis †Growth plates are intrarticular †Distinguished from †Toxic Synovitis - self limiting †Septic Prepatellar Bursitis - Extrarticular infection †JIA
- 74. Infection †Septic Arthritis †Often ill looking child †Will not bear weight †Definitely wonât let you move their knee †+ Effusion †Warm and sometimes red †Intrarticular bacterial infection is a surgical emergency!
- 75. Take Home Points †Children are not little adults †Need to consider the growth plate and childâs stage of development †âThe weakest linkâ †Effusions tend to mean unhappiness is brewing †Beware the occult fracture †Donât forget about the hip and referred pain
- 76. Thank you!
- 77. References 1. Micheli, Lyle J. and Kocher, M S: The pediatric and Adolescent Knee. Saunders Elsevier, 2006. 2. Davids JR: Pediatric knee: cliinical assessment and common disorders. Pediatric Clinics North Am 43: 1067-1090, 1996. 3. Arnoczky SP, Warren RF: Microvasculature of the human meniscus. Am J Sports Med 10:90-95,1982. 4. DeLee JC: Ligamentous injury of the knee. In: Drez D (ed): Pediatric and Adolescent Sports Medicine. Philadelphia: WB Saunders Company, 1994, pp 406-407. 5. American Academy of Pediatrics: Strength and Resistance training by children and adolescents. Pediatrics 107:1470-1472, 2001. 6. Guy J, Micheli L: Strength training for Children and Adolescents. J Am Acad of Orthopaedic Surgery 9:29-35,2001. 7. Barber-Westin SD, Noyes FR, Andrews M: A rigorous comparison between the sexes or results and complications after anterior cruciate ligament reconstruction. Am J Sport Med 25: 514-526, 1997. 8. Dimeglio A: Growth in pediatric orthopedics. J Pediatr Orthop 21 (4): 549-555, 2001.