Pediatric Orthopedic Sports Knee Injuries JOHN F. LOVEJOY III, M.D. NAILAH COLEMAN, M.D CHILDREN S NATIONAL MEDICAL CENTER DIVISION OF ORTHOPAEDICS

Transcription

1 Pediatric Orthopedic Sports Knee Injuries JOHN F. LOVEJOY III, M.D. NAILAH COLEMAN, M.D CHILDREN S NATIONAL MEDICAL CENTER DIVISION OF ORTHOPAEDICS

2 Overview Case Presentations Discussion Review of Topic Discussion PLEASE ASK LOTS OF QUESTIONS!

3 Case 1 Chief Complaint 11-year-old male soccer player Collides with another player and twists his knee. Immediate knee swelling and pain. Requires assistance to ambulate off the field.

4 Case 1 Presentation to Pediatrician Presentation 2 days from injury Reports inability to walk without assistance Knee gives out when walking on stairs History No medical problems No previous surgery Physical Exam Large effusion Global tenderness about knee Difficult to exam knee stability but appears to have increased anterior translation Neurovascularly intact

5 CASE 1 Radiographs

6 CASE 1 MRI

7 ACL Incidence 1 in 3,000 in general population per year 64,000 to 100,000 ACL reconstructions per year 47% preadolescents with a traumatic knee effusion 65% adolescents with a traumatic knee effusion Up to 60% of pediatric ACL injuries are partial tears

8 ACL Presentation Audible pop Pain Effusion (Hemarthrosis) Knee Instability Physical Exam Effusion Tenderness Anterior/Posterior Drawer Tests Lachman Test Pivot Shift Test Assess maturity Tanner Stage Girls- menarche?

9 ACL- Imaging Plain Films Fracture? Bone Age? Ultrasound MRI Tibial Spine Fracture Empty Notch

10 ACL- Treatment Prepubescent, low demand, and no concurrent intraarticular injury Brace Activity modification No pivoting or jumping No team sports Use ACL brace Participate in PT Monitor for instability Stable partial tear (Negative Pivot Shift) and no concurrent intra-articular injury Brace Activity Modifications Stable partial tear with concurrent intra-articular injury, unstable partial tear or complete tear Reconstruction

11 ACL Reconstruction Skeletal immature (Girls <12, Boys <14) Physeal sparing reconstruction Skeletally mature Standard restruction Post-op Return to regular ADLs by 3 months Return to contact sports by 6 months

12 9-year-old presents with right, stabbing, patellar knee pain of one year's duration after falling on her knee and twisting in a gymnastics competition. Case 2 Chief Complaint

13 Case 2 History and Physical Exam History Constant Worse with weight-bearing and with bending and sitting Pain affects sleeping. No sensation changes. Locking that resolves with stretching. Physical Exam Limping gait and difficulty with heel and toe walking. FROM of her left knee, ankles, and hips and a degree flexion contracture in the right knee. A clunk and pain with passive left knee flexion and extension. Strength, sensation, and neurovascular status were intact. Positive McMurray test of the right knee.

14 Case 2 Radiographs

15 CASE 2 MRI

16 Meniscal Injury Incidence in children with acute traumatic hemarthrosis Discoid meniscus 7% Non-discoid meniscal tears 47% preadolescent 45% adolescent

17 Meniscal Injury Presentation Joint line pain 63% giving way sensation 33% Mild swelling 40-45% Clicking or locking 40% spontaneous presentation Physical Exam Tenderness on palpation Mild effusion Positive McMurray s Test

18 Meniscal Injury- Imaging Plain Films Fracture? Ultrasound MRI Discoid Meniscus? Decreased sensitivity and specificity in children <12

19 Meniscal Injury Treatment Discoid meniscus Saucerization (remove abnormal tissue) Repair vs resection of torn tissue Meniscal tear >10mm Goal = prevention of tear progression and increased healing Options = Repair vs resection Loss of >1/3 meniscus = increased risk of degenerative arthritis

20 CASE 3 Chief Complaint 15 yo female field hockey player 4 weeks of left knee pain Mild knee swelling No specific trauma Symptoms most severe after sports Occasional clicking and catching in knee

21 CASE 3 Presentation to Pediatrician History Asthma No hospitalizations No previous surgery Physical Exam Left knee trace effusion No sign of traumatic injury Negative Lachman test Negative anterior and posterior drawer tests Negative McMurray s test Click with full flexion followed by extension

22 CASE 3 Radiographs

23 CASE 3 MRI

24 OsteochondritisDissecans Definition- a disorder of subchondral bone which can lead to cartilage collapse and fragmentation Etiology- Microtrauma Ischemia Genetic Endocrine Presentation Antalgic gait Non-specific knee pain Pain exacerbated by physical activity Clicking, popping, or locking of knee Exam Mild to moderate effusion Mild joint line tenderness Pain with range of motion Mild effusion Crepitance Catching or locking

25 OsteochondritisDissecans- Imaging Plain Films Fracture? Define lesion CT Defines bone not good for cartilage MRI Defines bone and cartilage Osteochondral Fracture

26 OsteochondritisDissecans Treatment Small lesions Symptomatic treatment NSAID Activity Modifications Immobilization Large lesions Stable NSAID Activity Modifications Immobilization Unstable Arthroscopic evaluation Repair Chondroplasty Microfracture Drilling

27 Outcomes OsteochondritisDissecans Up to 34% of untreated patients with juvenile OCD lesions have moderate to severe osteoarthritis in the 4 th decade of life 75%-98% healing rate of repaired meniscal tears Higher healing rates in repairs done with concurrent ACL reconstruction

28 Red Flags for Consideration of Referrel Concerning H&P points Night pain Persistent antalgic gait Large or persistent or recurrent knee swelling Clicking, clunking, or locking Initial Treatment Knee immobilizer Activity modification Toe touch weight bearing Crutches Refer to Orthopaedics Concerning exam findings Decreased ROM Inability to bear weight Large effusion Positive Lachman Test Positive McMurray Test

29 THANK YOU