The Pediatric Knee and Ankle: Orthopaedic · PDF fileThe Pediatric Knee and Ankle:...
Transcript of The Pediatric Knee and Ankle: Orthopaedic · PDF fileThe Pediatric Knee and Ankle:...
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The Pediatric Knee and Ankle: Orthopaedic Perspectives
Scott B Rosenfeld, MD Division of Pediatric Orthopaedics
Texas Children’s Hospital
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Disclosures •I have no disclosures
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Talk Outline
•Most common knee and ankle problems treated surgically by a pediatric orthopaedic surgeon
•What imaging modalities we use in the work up
•What the problem looks like on the inside compared to pre-operative images
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Why are the knee and ankle important?
•Most commonly injured joints in sports activity
•30 million children participate in organized sports in the U.S.
•3 million sports injuries/year in U.S. - 70% from youth sports – Pediatrics 2001
• Injuries: >10 million pediatric PCP office visits/year (1 in 10)
- Sports injuries ~ ¼ of all pediatric injuries
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Besides Sports •Location of common congenital and developmental problems
-Discoid Meniscus
-OCD
•Location of foreign bodies
•Common site of infection
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Children are not small adults! •Different problems/injuries with different treatments
•Anatomy is different - Joint hyper-mobility
- Apophyses
- Physis
•Weaker than ligaments
•Growth allows for remodeling
•May heal without surgical intervention
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Common Knee and Ankle Problems •Osteochondritis Dessicans of the knee
•Discoid Meniscus
•Osteochondral fracture of the talus
•Ankle infections
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Osteochondritis Dessicans - Knee •Acquired lesion of subchondral bone
•Proposed etiologies - Epiphyseal ossification abnormality (like Perthes)
- Traumatic
- Vascular
•25% bilateral
•70% located at lateral border of medial femoral condyle
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Osteochondritis Dessicans - Knee •Clinical Presentation
-+/- history of injury
-Knee pain
-Swelling/Effusion
-Tenderness over condyle
-Catching, locking
-Loss of terminal extension or flexion
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Osteochondritis Dessicans - knee •Goals of imaging
-Location
-Size
-Stability
•Modalities -Radiographs
-MRI
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Osteochondritis Dessicans - knee •Prediction of stability
- Based on MRI appearance
- Classifications made for adults
- Don’t translate well to kids
•Specificity of only 11% and 15% (DeSmitt, Haywood)
- No high level evidence in juvenile OCD
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Osteochondritis Dessicans - knee •Treatment
- Skeletal maturity
• Open or closed physis
- Perceived stability
•Activity Modification - Decreased weightbearing
- Immobilization
- Range of motion
•Surgery - Arthroscopic vs open
- Drilling
- Reduction and fixation
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Osteochondritis Dessicans - knee •Case 1
•10 year old female cheerleader
•2 week history of left knee pain, swelling, popping
•Full knee ROM, mild effusion
•TTP medial joint line
•AP, lateral, notch view, sunrise view knee
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•Treatment decision making - Open physis
- Cartilage intact = stable
- No locking
- Full ROM
•Non-operative - Activity modification
- Knee immobilization
- PT for ROM
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4 months later…
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Osteochondritis Dessicans - knee • Case 2
• 15 year old female with right knee pain for 6 months
- Swelling, catching, locking
• Basketball player - No injury
• Knee effusion
• Block to terminal extension
• Ordered AP and lateral knee radiographs
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•Treatment decision making
-Closed physes
-Displaced OCD fragment
-Block to full extension
•Surgical treatment -Reduction and fixation
-Removal and microfracture
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One year later….
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Discoid Meniscus •Common congenital anomaly
- Discoid shape not a stage in development
• Incidence 0.4%-17% - Only the symptomatic ones
•99% lateral meniscus
•20% bilateral
•Most are asymptomatic
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Discoid Meniscus •Classifications
-Watanabe •1. Complete discoid
•2. Incomplete discoid
•3. Incomplete discoid no posterior attachment
-Jordan, et al •Stable vs Unstable
•Shape
•Symptomology
�Direct treatment plan
*Andrish JT
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Discoid Meniscus •Presentation
- Type 1 and 2 – horizontal and radial tears
•Knee pain and swelling
- Type 3 – snapping knee syndrome
•Block to full extension
•What I order - AP, lateral radiographs
- MRI
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Discoid Meniscus •Case 3
•7 y.o. female with painful snapping right knee
•Occasional swelling
•Block to terminal extension
•Visible snapping in lateral compartment
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Discoid Meniscus
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Discoid Meniscus •Treatment Plan
-Arthroscopy
-Partial meniscectomy (saucerization)
-Probable meniscal repair
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Ankle •Injuries
-Sprains
-Fractures
-OCD lesions
•Infections -Septic arthritis
-Osteomyelitis
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Talus Osteochondral Lesion •Case 4
•12 year old s/p MVC
•Right ankle pain and swelling
•Diffusely TTP
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Talus Osteochonral Lesion •Looks like a lateral osteochondral lesion
•Ordered MRI
•What I want to know -Where is it?
-Is there bone attached?
-Is the cartilage intact?
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Treatment Decision •Displaced anterior-lateral osteochondral fragment
-Cartilage disrupted
-Bone attached
•Open reduction and internal fixation
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3 months later…
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Infections •Acute hematogenous osteomyelitis
-Affects 1 in 5000 children < 13 y.o.
-More resistant and virulent bacterial strains make course and treatment more complicated
•Septic arthritis
•Subperiosteal abscess
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Infections • Imaging
- Radiographs
•No changes in first week of infection
- Bone scan
•Help localize focus
•May be cold
•Doesn’t distinguish specific location of infection
- MRI
•Very sensitive
•Detects edema early
•Pinpoints abscess/osteo
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Infections •Septic arthritis
-MRI helps better understand the infectious disease
-Are there adjacent infections that need to be treated simultaneously?
Joint Adjacent infections
Knee 47%
Hip 63%
Shoulder 100%
Ankle 80%
Elbow 63%
Wrist 0
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Infections •Septic ankle
-Aspiration in ED showed pus
•Pre-op MRI -Adjacent osteomyelitis and distal tibia subperiosteal abcess
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Infections •Case 5
•2 y.o. boy with 2 day history of
-fever, refusal to bear weight, swollen lower leg and ankle
•Xrays negative
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Infections •MRI with contrast
•What I want to see -Where is the infection?
•Osteomyelitis?
• Intramuscular abcess?
•Subperiosteal abscess?
•Ankle joint effusion?
-Localizer mode
*
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Thank you