Knee

• Return To Main Menu

The Young Knee and Types Of Knee Injuries

There are many childrens knee problems which typically are self-limiting with the usual result being that of a full recovery for most of our Raleigh, Cary, Chapel Hill, Garner and other Triangle patients. In some instances more serious conditions may occur. It is very important that these childrens knee problems or injuries be properly diagnosed. If these conditions are missed (especially if during the rapid growth phase) the consequences can be significant. With the proper exam and taking a step by step approach, mis-diagnosing these childrens knee problems is much less likely.

Getting A Proper History of Childrens Knee Problems,
Types Of Knee Injuries And Performing A Thorough Examination

Examination of a child may start at the moment he or she arrives in the office. With a very young child, getting a detailed history from the parents with a focus on the family history and review of developmental milestones is a high priority. In an acute, traumatic injury, documenting the exact mechanism of the injury greatly assists the physician in determining the probable type and extent of injury. It is best if the older child is accompanied by a parent who may assist the child in describing the injury and his/her short term reaction to the injury (swelling, pain and disability levels, etc).

Comprehensive Evaluation to Include Special Considerations
of Childrens Knee Problems

Is it childrens knee problems or possibly other types of knee injuries?

Pain in the knee that originates and refers from the hip
Especially in the young patient, the hip joint should always be examined first before assessing related childrens knee problems. Referred hip pain is usually noticed at the medial joint line of the knee. There is also a possibility for the patient to have isolated conditions that exist at both the hip and knee.

Loss of the ability to abduct (move the leg out to the side) with the hip in flexion indicates a high probability of hip involvement until ruled out.

Common conditions involving the hip in young patients include Perthes Disease (age 6-10) and Slipped Capital Femoral Epiphysis (age 10-14).

Other Types Of Knee Injuries

Knee Region Infection as Part of Overall Childrens Knee Problems
In the event of infection, the patient will present with pain, warmth and tenderness at the affected site and a reluctance to move the nearby joint. The most common organisms responsible for osteomyelitis, or bone infection, are Staphylococcus aureus, Streptococci, E Coli, Proteus and Pseudomonas. Often times no primary infection site is identified. All patients with an infection should be checked for diabetic condition or compromised immune function.

Tumor
Tumors and related types of knee injuries around the knee are not uncommon and can present with pain, swelling or a fracture. This pathology should be considered if signs and symptoms do not present as classic knee pain. Trauma in the area often focuses diagnostic attention on an area at which time the tumor is diagnosed.

Growth Plate Fractures
Types of knee injuries of such a nature that results in ligament injuries in adults can result in bone or growth plate fractures in children. The diagnoses of isolated knee ligament injury in children are rare if they are younger than 14 years since the ligaments are stronger than the growth plates.

Limping or inability to weight bear should increase suspicion of a fracture even in the event the initial X ray proves normal.

Juvenile Rheumatoid (Inflammatory) Arthritis and Osteoarthritis Of The Knee — osteoarthritis of the knee  and juvenile rheumatoid arthritis as diagnosed by the orthopaedist usually in concert with the rheumatologist.

Kneecap (Patellofemoral) Conditions
The most common condition at the knee experienced by children involves the kneecap. Girls experience a higher incidence of kneecap problems than boys and is especially common in girls with lower leg alignment issues such as “flat footedness”, tibial rotation and underdeveloped thigh muscles.

The causes and treatment of these problems remains highly debated and a more detailed description as well as a simplified treatment approach is presented below.

Developmental Patellar Dislocation
This condition is congenital in nature and is usually seen in the infant or toddler. The patella dislocates laterally every time the knee is flexed. The common cause is a shortened quadricep (extensor mechanism) and the treatment is a lengthening soft tissue procedure called a Z plasty which results in a lengthening of the rectus femoris musculature.

Acute Patellar Dislocation
An acutely dislocated patella usually results from a mechanism of sudden stress on the slightly bent knee while participating in sports. Reported pain is often difficult to localized. The patella dislocates or moves out of joint laterally(outwardly) and the knee remains in a flexed position.

To relocate the kneecap one would apply medial pressure to the kneecap and gently straighten the knee. If the kneecap relocates to its proper position it is necessary to determine if this injury involves a ligament rupture or a possible fracture. X-rays (including a “skyline patella view”) is important to determine if there is an associated bony/cartilage lining “osteochondral” fracture. Arthroscopy may be needed to remove any loose cartilage stemming from the injury. Standard protocol for treatment of this injury involves splinting or bracing the knee for a few weeks to allow the tissues to heal. Physical therapy follows to regain quadricep strength and mobility. As biomechanically indicated, foot orthotics or patella taping can be useful.

Failure to seek treatment results in subsequent chronic dislocations

Recurrent Patellar Dislocation/Subluxing Patella

Potentially fifty percent of all acute patellar dislocations recur. The condition is often demonstrated in both knees and can affect girls in a ratio of 2:1. There is often a family history of this problem. Usually there is a mechanical/anatomical cause for this condition that can be identified by the orthopaedic surgeon. Surgery may be indicated to treat chondral lesions, remove loose bodies or tighten soft tissue structures.

Anterior (Frontal) Knee Pain
Growth rates are often a factor in the prevalence of knee complaints in adolescents. Muscle tendon complexes must adjust and lengthen to accommodate the rapid growth of the long bones. Tightness may result in increase tension of these musculo-tendinous units. This condition may be identified by many names including Patello-femoral compression syndrome, Chondromalacia patellae, and excess lateral patellar tracking or compression syndrome.

Anterior knee pain presents as pain during or after exercise and is often increased with ascending and descending stairs. Sitting in a bent knee position may create the pain. The examination is usually normal but symptoms such as an swelling or tenderness of the patellar/retropatellar surface. Nearly all patients will demonstrate poor hamstring flexibility.

Conservative treatment involves quadricep/VMO retraining, patellar bracing or taping, stretching tight lateral structures and hamstrings while incorporating activity modification of those specific reproduceable aggravating circumstances. Surgery is rarely indicated.

Sinding-Larson Johansson Disease
The patellar tendon is partially avulsed or pulled away from the lower pole of the patella. This condition is similar to Osgood Schlatters disease (which will be discussed in the following paragraph) but affects the lower patellar insertion site of the tendon. Localized tenderness occurs in this area. X ray may demonstrate soft tissue calcification or a stress fracture of the inferior pole of the patella. The patient usually recovers with rest, stretching, appropriate rehabilitation but the condition by cause chronic intermittent problems with continued impact sports.

Osgood-Schlatter’s Disease
O-S Disease is an overuse syndrome typically affecting 10 – 14 years old. This is caused by by a high level of physical activity before skeletal maturity is reached. This condition is commonly exacerbated during “growth spurts”.

The history and examination are classical. The young patient will present with complaints of pain, tenderness and swelling and prominence just below the knee at the tibial tubercle. The onset is gradual. The pain is enhanced by impact activities such as distance running and jumping. Squatting, stair climbing and stretching the quadriceps are also painful.

The Quadriceps and hamstrings are typically always tight and there may be additionally patellofemoral malalignment and anterior knee pain.

X-rays usually show enlargement of the tibial tuberosity with or without fragmentation.

It is usually not necessary to stop sport. Treatment which includes activity modification to manage the condition is usually always recommended. If the condition worsens, a prolonged period of rest may be needed.

Additional recommended management includes ice, calf and hamstring stretching.

Returning to activities my necessitate a “Go as able” mentality with the reassurance that the symptoms will eventually cease. In severe cases, long leg splinting is used and surgery is rarely necessary unless X rays show an avulsed fragment of bone that remains extremely painful in skeletally mature adults. Excision of the fragment often gives a very good result.

Other injury categories:
There are other diagnoses that are commonly managed in the young, developing knee and are listed but only briefly described below. In the event one of these conditions is diagnosed it can more deeply be described by your orthopaedic surgeon along with X-ray or MRI findings simultaneously.
• Meniscal Tear (tear of the shock absorber within the knee joint)
• OCD (Osteochondritis Dissecans) – Loose bodies
• Stress Fractures
• Ligament Injuries
• Angular Deformities

Conclusion

The most beneficial treatment approach to a young symptomatic knee problem involves a thorough and systematic approach to the initial examination.
Appropriate investigations will enable accurate diagnosis of the patient’s condition to be made. This allows early intervention and treatment and reduces the likelihood of chronic knee disability.

For more information on how the childrens knee problems specialists at Cary Orthopaedics can help you, contact us today at 919-467-4992 for an appointment!

Cary Orthopaedics serves patients from Raleigh, Garner, Cary, Apex, Holly Springs, Fuquay-Varina, Clayton, Chapel Hill, and Pittsboro, NC.