Pediatric Knee Injuries

Name: Pediatric Knee Injuries
Uploaded: 2017-07-14T10:11:34+00:00
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Description: Pediatric Knee Injuries

Pediatric Knee Injuries
Greg M. Osgood, MD Revised 2011 Additional images courtesy of Paul Sponseller, MD and Arabella Leet, MD First edition by Steven Frick, MD

Tibia tubercle growth arrest can lead to recurvatum
Significance LE growth: Distal femur: 10mm / yr Proximal tibia: 6mm / yr Tibia tubercle growth arrest can lead to recurvatum Fractures of the distal femoral and proximal tibial physis account for 2.2% of physeal fractures BUT they account for 51% of partial growth plate arrest Peterson HA, et al. JPO 1994;14(4):423.

Extra-articular injuries Intra-articular injuries
Overview Extra-articular injuries Intra-articular injuries

Overview Extra-articular Knee Injuries Distal Femoral Epiphysis
Proximal Tibia Epiphysis Tibia Tubercle Patella

Overview Intra-articular Knee Injuries Tibial Eminence Fractures
Osteochondral Fractures Patella Dislocation Menicus Injuries Ligament Injuries

Distal Femoral Epiphyseal Fractures

Extra-articular Knee Injuries Distal Femoral Epiphysis
Anatomy Distal femoral physis contributes 70% of femoral growth and 37% of lower extremity length Popliteal artery and geniculates lie posterior to metaphysis and capsule

Fracture Epidemiology Rare injury (<1% of pediatric fractures) Mechanism: Often the result of high energy trauma in <11 y.o. (pedestrian struck or fall from a height) Sports injuries in teens (2/3 of distal femoral fractures) varus/valgus force hyperextension of the knee Associated Injuries Do not miss VASCULAR INJURY or TIBIAL/PERONEAL NERVE INJURY Do not miss COMPARTMENT SYNDROME Riseborough EJ, et al. JBJS(A) 1983;65:885.

Physical Examination Pain Inability to bear weight Obvious deformity Swelling and ecchymosis Anterior displacement may be associated with vascular injury

Associated Injuries Knee ligament injury (8-43% incidence) Requires close follow-up of knee stability as fracture heals Repair at time of other intra-articular repair Vascular Injury May be associated with anterior fracture displacement Remember pulseless limb may regain normal pulses after fracture reduction and splinting Revascularization should be coordinated with vascular surgery team if necessary Nerve Injury Peroneal injury rare Observation at least 3 months is indicated, followed by EMG if symptoms persist

Radiographs AP & LAT xrays Valgus or Varus Deformity Common Rarely Anterior Displacement Oblique views may be necessary Comparison contralateral xrays (expecially in infants – consider USG) Consider stress xrays CT may help evaluate fracture complexity MRI Classification Salter-Harris (I and II most common) Displacement (anterior, posterior, valgus/varus)

Interventions Closed reduction and immobilization Closed reduction and internal fixation ORIF

Closed Reduction and Casting Used only in truly nondisplaced and stable fractures Anatomical reduction is more important close to age of skeletal maturity Remodeling potential is greatest in plane of knee motion (flexion/extension) Discuss potential for growth disturbance or malalignment with family when treatment is initiated Frequent follow-up is required to prevent malunion

Closed Reduction and Casting Closed reduction usually successful within 10 days Well molded splint in slight knee flexion Periosteum is often intact on compression side of fracture – compression side of fracture should be put under tension in splint/cast Partial WB started at 2-3 weeks Splint/cast removal between 4-8 weeks 43-70% displace without internal fixation Thomson J. JPO 1995;15:474. Graham JM. CORR 1990;255:51.

Closed Reduction and Internal Fixation Reduction performed with TRACTION and angular correction Fixation should not cross physis if possible Screws may be placed parallel to physis at the metaphysis (Salter II & IV) or epiphysis (Salter III & IV) Use smooth pins to cross physis if necessary

Open Reduction and Internal Fixation INDICATIONS Fractures that cannot be satisfactorily reduced closed Salter III and IV fractures Open fractures Floating knee

Open Reduction and Internal Fixation Preoperative CT may help plan fixation strategy Reduction facilitated by removal of interposed muscle and periosteum Fixation parallel to physis Cross physis with smooth wire fixation only if necessary to obtain stability Support fixation with postop splint or cast Repair associated collateral ligament injuries at time of fixation if possible Remove pins at 3-6 weeks Remove splint at 6-8 weeks

Salter IV Distal Femur Fracture

Open Reduction and Internal Fixation Plates spanning across growth plate should be avoided unless patient is at skeletal maturity Skeletal maturity is often difficult to assess and is easily overestimated

Complications of Injury Ligamentous laxity Knee stiffness Compartment syndrome Malalignment Shortening Loss of reduction

SH II Fx

6 mo postop

SH IV FX with distal metaphyseal femur fx

Outcomes Risk of damage to growth plate and growth disturbance Assess leg length, alignment and gait at 6 months Follow patients months Growth disturbance caused by direct trauma or lack of anatomical reduction Transphyseal bridging may be demonstrated on MRI

Distal Femur Physeal Bar

Valgus deformity, short limb following distal femur SII fx with growth arrest, failed bar excision

Severe growth plate injury 9 years after SH II distal femoral physeal injury in 4 y.o. girl

Proximal Tibial Epiphyseal Fractures

Extra-articular Knee Injuries Proximal Tibial Epiphysis
Fracture Epidemiology Rare injury (<1% of pediatric fractures) Mechanism: Often the result of high energy trauma (MVC or fall from a height) varus/valgus force hyperextension of the knee

Physical Examination Pain Knee effusion/hemarthrosis Tenderness at physis Limb deformity Document pulse and neurological examination before and after reduction Associated Injuries Do not miss VASCULAR INJURY or TIBIAL/PERONEAL NERVE INJURY Do not miss COMPARTMENT SYNDROME

Associated Injuries Knee ligament injury Requires close follow-up of knee stability as fracture heals Vascular Injury May be associated with posterior displacement of metaphysis Remember pulseless limb may regain normal pulses after fracture reduction and splinting Revascularization should be coordinated with vascular surgery team if necessary Compartment Syndrome Tethering of popliteal artery, posterior tibial artery, and anterior tibial artery place limb at compartment syndrome risk

Radiographs AP & LAT xrays Frequently minimally displaced & easily overlooked Stress xrays may help CT may help assess possible Salter III or IV MRI

Intervention Closed reduction and immobilization Closed reduction and internal fixation ORIF

Closed Reduction and Casting Indicated in non-displaced fractures Possible if stable anatomical reduction achieved with Salter I and II fractures TRACTION is key to reduction Monitor for iatrogenic peroneal injury after reduction Splint/cast (bivalved) reduction in slight knee flexion Cast may be removed 6 weeks after injury once radiographic evidence of healing

Closed Reduction and Internal Fixation Indicated if UNSTABLE reduction is achieved in Salter I and II fractures Percutaneous fixation parallel to physis Crossed pins that traverse the physis may be used if stable extra-physeal fixation is not possible Splint reduction in slight knee flexion

Open Reduction and Internal Fixation Indications: Non-anatomical closed reduction Displaced Salter III & IV fractures Open reduction to remove soft tissue interposition Internal fixation with screws parallel to physis or crossed K-wires traversing the physis Protect fixation with splint in slight knee flexion

SH IV Proximal Tibia Fx

Complications Loss of reduction Compartment syndrome Growth disturbance Ligamentous instability

Growth disturbance Incidence is limited by anatomical reduction May be corrected with resection of bony bridge or osteotomy depending on patient age

Tibial Tubercle Avulsion

Extra-articular Knee Injuries Tibial Tubercle Avulsion
Anatomy Tibia tubercle physeal development Cartilaginous stage: through 9-10 y.o. Apophyseal stage: ossification center appears 8-14 y.o. Epiphyseal stage: ossification centers of tubercle and epiphysis merge y.o. Bony stage: physis is closed btw tuberosity and metaphysis

Fracture Epidemiology Mechanism Jumping sports – eccentric contraction of extensor mechanism during landing 98% males

Physical Examination Anterior proximal tibia swelling and tenderness Joint effusion/hemarthrosis Palpable bony fragment Tented skin Patella alta may be present

Associated Injuries Knee ligament injury Meniscal injury Extensor mechanism disruption Tibia plateau fracture

Radiographs AP and LAT xrays Slightly internally rotated lateral view may aid visualization of tibial tubercle due to anatomical location lateral to tibial midline Fracture is differentiated from Osgood-Schlatter by acute fracture line through physis (Osgood-Schlatter does not involve the physis)

Classification (Watson-Jones, with modifications of Ogden, Ryu, and Inoue) Type I: Fracture through the tubercle apophysis Type II: Fracture through the apophysis that extends between ossification centers of apophysis and epiphysis Type III: Fracture through apophysis extends across epiphysis Type IV: Fracture through apophysis extends posteriorly at level of tibial phsysis Type V: Avulsion of patellar tendon off tubercle physis (sleeve fracture)

Type III Avulsion Fx

Intervention Closed reduction and casting ORIF

Closed treatment and casting Indications: minimally displaced fractures after closed reduction Reduction with knee in extension Cast molding above patella is important to maintain reduction Maintain in cast for 6 weeks

Open Reduction and Internal Fixation Midline incision Periosteum is debrided from fracture line Reduction by knee extension Screw or pin fixation should be supported by soft tissue repair Protect repair with cylinder cast for 6 weeks

Type II Avulsion Fx

Type III Avulsion Fx

Complications Growth disturbance Compartment syndrome Symptomatic hardware (approx. 50%) Stiffness (loss of flexion)

Patella Fracture

Extra-articular Knee Injuries Patella Fracture
Mechanism: Avulsion fractures of patella more likely in children than adults Eccentric contraction Direct blow (comminuted fracture)

Physical Examination Painful swollen knee Inability to extend knee Inability to bear weight High riding patella Apprehension test may be positive if patient has avulsion fracture secondary to patellar dislocation

Radiographs AP & LAT knee xrays Sagittal plane fractures may be best seen with sunrise view Sleeve fracture – small fleck of bone in extensor mechanism may be only sign of disruption Comparison views of normal knee may be required

Classification Primary osseous fractures Avulsion fractures Avulsion of pole of patella without significant avulsion of cartilage Sleeve fractures Avulsion of pole of patella WITH a large portion of articular cartilage (cartilage, retinaculum, and periosteum may be involved)

Intervention Closed treatment with casting Open reduction and internal fixation

Closed treatment Extensor mechanism is intact No significant displacement (<2-3mm at articular surface)

Open reduction and internal fixation Midline incision ORIF with tension band wire, cerclage wire, nonabsorbable suture, screws Sutures alone sufficient for patella sleeve fractures Repair of retinaculum is recommended Splint for 4-6 weeks recommended

Extra-articular Knee Injuries Summary
ANATOMICAL REDUCTION Key to preventing physeal arrest, malalignment, and LLD PREVENT LOSS OF REDUCTION Loss of reduction is common if not treated with stable reduction and fixation TEMPORARY PROTECTION OF FIXATION Postop splint/cast important in treatment

Intra-articular Knee Injuries Overview
Tibial Eminence Fractures Osteochondral Fractures Patella Dislocation Menicus Injuries Ligament Injuries

Acute Hemarthrosis in Children-without Obvious Fracture
Anterior Cruciate Tear Meniscal tear Patellar dislocation +/- osteochondral fracture

Knee Injuries Acute Hemarthrosis
ACL 50% Meniscal tear 40% Fracture 10%

Intra-articular Knee Injuries Tibial Eminence Fractures
Epidemiology Usually 8-14 year old children Mechanism: Hypertension or direct blow to flexed knee Frequently mechanism is fall from bicycle

Myers- McKeever Classification Type I- nondisplaced Type II- hinged with posterior attachment Type III- complete, displaced

Intervention Attempt reduction with hypertension Above knee cast immobilization Operative treatment for block to extension, displacement, entrapped meniscus Arthroscopic-assisted versus open arthrotomy Consider more aggressive treatment in patients 12 and older

8 to 14 yo often bicycle accident Myer-McKeever classification

Tibial Spine Fracture Treatment
Reduction in extension Immobilize in extension or slight knee flexion Operative treatment for failed reduction or extension block

Tibial Spine Closed Reduction
Follow closely – get full extension

Tibial Spine Malunion- Loss of Extension
Injury Film – no reduction 2 years post-injury- lacks extension

Tibial Spine Fx- Arthroscopic OR,Suture Fixation

Outcomes Generally good if full knee extension regained Most have residual objective ACL laxity regardless of treatment technique Most do not have symptomatic instability and can return to sport

Intra-articular Knee Injuries Osteochondral Fractures
Usually secondary to patellar dislocation Off medial patella or lateral femoral condyle Size often under appreciated on plain films Arthroscopic excision vs. open repair if large

Intra-articular Knee Injuries Patellar Dislocation
Almost always lateral Younger age at initial dislocation, increased risk of recurrent dislocation Often reduce spontaneously with knee extension and present with hemarthrosis Immobilize in extension for 4 weeks

Patellar Dislocation Note Medial Avulsion off Patella and Laxity in Medial Retinaculum

Predisposing factors to recurrence- ligamentous laxity, increased genu valgum, torsional malalignment Consider surgical treatment for recurrent dislocation/subluxation if fail extensive rehabilitation/exercises

Lateral Patellar Dislocation

Intra-articular Knee Injuries Meniscal Injuries
Epidemiology Increasing incidence Longitudinal and bucket handle tears common Often associated with ACL tear

Mechanism Almost exclusively sporting injuries Twisting motion that occurs as knee is extending

Physical Examination Inaccurate for diagnosis of meniscal tear Acute swelling and hemarthrosis Joint line tenderness Motion at joint line with varus/valgus stress

Radiographs Conventional xrays do not visualize May be associated with discoid meniscus on MRI

Intervention Nonoperative – nondisplaced, small, outer 1/3 Partial meniscectomy - complex tears with degenerative changes Meniscal repair – simple tears in inner and middle 1/3 tears

Outcomes Poor results with sub-total meniscectomy Repair is successful in most patients < 30y.o.

Complications Hemorrhage Persistent effusion Infection Stiffness Neuropathy

Intra-articular Knee Injuries Ligament Injuries
Epidemiology Increasing incidence ACL tear occurs in 10-65% of pediatric hemarthrosis Boys y.o. in organized sports Girls y.o. in unorganized sports Stanitski CL. JPO 1993;13:506.

Mechanism Cutting maneuvers while running Lateral blow to the knee in abduction, flexion, and internal rotation while competing in sports

Intervention Nonoperative Frequently successful in isolated collateral ligament tears May be attempted for incomplete ACL and PCL tears Operative Advocated for complete ACL tears to prevent sequelae of cartilage damage and meniscal injury Advocated for displaced complete PCL injury with bony avulsion (attempted nonop treatment is encouraged for pure ligamentous injury)

Knee Dislocation Unusual in children More common in older teenagers Indicator of severe trauma Evaluate for possible vascular injury Usually require operative treatment – capsular repair, ligamentous reconstruction

Intra-articular Knee Injuries Overview
Tibial Eminence Fractures Osteochondral Fractures Patella Dislocation Menicus Injuries Ligament Injuries

Pediatric Knee Injuries
Extra-articular injuries Distal Femoral Epiphysis Proximal Tibia Epiphysis Tibia Tubercle Patella Intra-articular injuries Tibial Eminence Fractures Osteochondral Fractures Patella Dislocation Menicus Injuries Ligament Injuries

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Pediatric Knee Injuries

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