Plica Redundant fold in synovial lining of the knee Redundant
fold in synovial lining of the knee Palpable over medial or lateral
retinaculum Palpable over medial or lateral retinaculum Gradual
onset of pain increased with sitting or prolonged knee flexion and
aggravated by arising Gradual onset of pain increased with sitting
or prolonged knee flexion and aggravated by arising Can cause
snapping and can be entrapped in the patellofemoral joint Can cause
snapping and can be entrapped in the patellofemoral joint
Slide 2
Plica Treatment Cortisone injection may help Cortisone
injection may help Surgery may be required for excision of the
thickened band of tissue Surgery may be required for excision of
the thickened band of tissue
Anterior Cruciate Ligament Injuries Incidence is 0.3-0.38 per
1000 per year and increasing Incidence is 0.3-0.38 per 1000 per
year and increasing Usually sports related (football, soccer,
skiing) Usually sports related (football, soccer, skiing) Estimated
3 in 100,000 have tibial spine avulsions Estimated 3 in 100,000
have tibial spine avulsions Skeletally immature patients account
for 3-4% of all ACL injuries Skeletally immature patients account
for 3-4% of all ACL injuries
Slide 5
Anterior Cruciate Ligament Injuries Bony avulsion of tibial
spine insertion occurs more commonly found in preadolescent
children Bony avulsion of tibial spine insertion occurs more
commonly found in preadolescent children Intrasubstance tears are
more commonly seen in adolescents Intrasubstance tears are more
commonly seen in adolescents MOI is usually hyperextension, sudden
deceleration, or a valgus rotational force with a stationary foot
MOI is usually hyperextension, sudden deceleration, or a valgus
rotational force with a stationary foot
Slide 6
Isolated ACL Tears Preadolescent children best treated with
activity modification and observation Preadolescent children best
treated with activity modification and observation Repair of
ligament has high failure rate Repair of ligament has high failure
rate Recommendation for children with > 1year left of growth
remaining not to have bone tunnels for reconstruction (some
controversy) Recommendation for children with > 1year left of
growth remaining not to have bone tunnels for reconstruction (some
controversy) Adolescents are treated as adults Adolescents are
treated as adults
Slide 7
Anterior Cruciate Ligament Injuries Natural History
Preadolescent not well known due to low #s Preadolescent not well
known due to low #s Adolescents- similar to young adults
Adolescents- similar to young adults 33-86% reports episodes of
giving way when treated nonoperatively 33-86% reports episodes of
giving way when treated nonoperatively
Slide 8
Anterior Cruciate Ligament Injuries Natural History Activity,
not age is primary factor Activity, not age is primary factor
Adolescents are usually very active and they will have a higher
rate of failure with conservative treatment Adolescents are usually
very active and they will have a higher rate of failure with
conservative treatment Increase risk of meniscal damage if treated
conservatively Increase risk of meniscal damage if treated
conservatively
Slide 9
Tibial Spine Avulsion Fractures Type I-minimally displaced Type
I-minimally displaced Type II-posterior hinge but still attached to
the tibial epiphysis Type II-posterior hinge but still attached to
the tibial epiphysis Type III- fx is displaced Type III- fx is
displaced Type I Type II Type III
Slide 10
Tibial Spine Avulsion Fractures Treatment Treatment Type I
usually casting Type I usually casting Type II closed
reduction/cast Type II closed reduction/cast Type III ORIF with
screw/wire/sutures Type III ORIF with screw/wire/sutures
Meniscal Injuries Outcomes Complete meniscectomies results are
very poor Complete meniscectomies results are very poor 60%
unsatisfactory at 7 years 60% unsatisfactory at 7 years
Preservation is critical Preservation is critical 80-90% have
favorable outcomes with repair 80-90% have favorable outcomes with
repair
Slide 13
Meniscal Injuries Meniscal tear Repairable zone Blood supply to
meniscus
Slide 14
Patellar Dislocation
Slide 15
Twisting injury Collision May not know patella dislocated
Immediate swelling Cant play
Slide 16
Patellar Dislocation
Slide 17
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
Slide 18
Patellar Dislocation Predisposing factors to recurrence-
ligamentous laxity, increased genu valgum, torsional malalignment
Consider surgical treatment for recurrent dislocation/subluxation
if fail extensive rehabilitation/exercises
Slide 19
Other LE Injuries Bone Bruise Shin Splints Stress Fractures
Nerve Entrapements Severes Disease Subungual Hematomas
Slide 20
Bone bruise Collision Fall Non-contact twist Xrays usually
normal dx by mri Tx rest,nwb time
Slide 21
Shin Splints Exercise induced pain along the anteriomedial
tibia Exercise induced pain along the anteriomedial tibia
Encompasses a spectrum of disorders- posterior tibial tendonitis,
periostitis, and can lead to a stress fracture Encompasses a
spectrum of disorders- posterior tibial tendonitis, periostitis,
and can lead to a stress fracture Usually a result of training
errors or change in quality and quantity of running Usually a
result of training errors or change in quality and quantity of
running
Shin Splints Treatment Ice massage Ice massage NSAIDs NSAIDs
Decrease running and jumping Decrease running and jumping Correct
training errors Correct training errors Strengthening Strengthening
Continue with cardio/vascular training Continue with
cardio/vascular training
Slide 24
Stress Fractures Most commonly results from training errors
(change in surfaces or shoes) Most commonly results from training
errors (change in surfaces or shoes) Need high index of suspicion
Need high index of suspicion Difficult clinically to distinguish
from overuse type syndromes Difficult clinically to distinguish
from overuse type syndromes May be seen on plain X-rays but Tc-99m
bone scan may be needed May be seen on plain X-rays but Tc-99m bone
scan may be needed MRI MRI
Slide 25
Stress Fractures Increasingly more frequent in recreational and
competitive athletes Increasingly more frequent in recreational and
competitive athletes About 10% of sport injuries About 10% of sport
injuries Common with preexisting conditions with decreased bone
mass, bone mineralization [nutritional disorders (rickets),
systemic disorders (DM, RA)] Common with preexisting conditions
with decreased bone mass, bone mineralization [nutritional
disorders (rickets), systemic disorders (DM, RA)]
Slide 26
Stress Fractures
Slide 27
Treatment Activity modification [you need to keep these
athletes in shape (swim, bike, weight train, etc.)] Activity
modification [you need to keep these athletes in shape (swim, bike,
weight train, etc.)] Rest- (it takes time) Rest- (it takes time)
Immobilization rarely needed Immobilization rarely needed
Slide 28
Nerve Entrapment Syndromes Occur secondarily to problems such
as lower extremity edema, compression syndrome, bone impingement
and joint instability Occur secondarily to problems such as lower
extremity edema, compression syndrome, bone impingement and joint
instability Nerve problems are mostly functional: that is the nerve
is entrapped only during athletic activity Nerve problems are
mostly functional: that is the nerve is entrapped only during
athletic activity
Slide 29
Nerve Entrapment Syndromes Superficial peroneal n.-pain and
numbness over distal calf & dorsum of foot & ankle
Superficial peroneal n.-pain and numbness over distal calf &
dorsum of foot & ankle Deep peroneal n.- pain at dorsum of foot
with pain and numbness at 1 st web Deep peroneal n.- pain at dorsum
of foot with pain and numbness at 1 st web Sural n.-numbness at
lateral heel and foot Sural n.-numbness at lateral heel and foot
Posterior tibial n.-tarsal tunnel symptoms Posterior tibial
n.-tarsal tunnel symptoms
Slide 30
Severs Disease Self limiting apohysitis of the os calcis at the
insertion site of the Achilles tendon Self limiting apohysitis of
the os calcis at the insertion site of the Achilles tendon Pain
over post. os calcis Pain over post. os calcis Aggravated by
activity Aggravated by activity Recent growth spurt Recent growth
spurt
Slide 31
Severs Disease Increased density and partial fragmentation of
the calcaneal apophysis Increased density and partial fragmentation
of the calcaneal apophysis
Slide 32
Severs Disease Most commonly seen in 6 to 10 year old males
Most commonly seen in 6 to 10 year old males Treatment is
symptomatic Treatment is symptomatic Mild restriction of activities
Ice Heel lifts Achilles stretches Arch supports
Slide 33
Subungual Hematoma Think open fracture
Slide 34
Injuries About The Shoulder Little Leaguers Shoulder Little
Leaguers Shoulder Shoulder instability Shoulder instability
Recurrent dislocations Recurrent dislocations Clavicle fractures
Clavicle fractures A-C separations A-C separations
Slide 35
Little Leaguers Shoulder Pain due to a stress fracture Pain due
to a stress fracture of the humeral physis of the humeral physis
Overuse injury Overuse injury Rest usually takes care Rest usually
takes care of the problem of the problem
Slide 36
Little Leaguers Shoulder Treatment is PREVENTION Treatment is
PREVENTION Restrict # of pitches and innings pitched Mandatory days
of rest Show proper technique ( no side arm) and do not attempt
techniques beyond the current skeletal maturity (curve balls)
Slide 37
Little Leaguers Shoulder May help to limit the amount of
pitching in the game but doesnt control practice or at home May
help to limit the amount of pitching in the game but doesnt control
practice or at home
Slide 38
Shoulder Instability Commonly seen in young swimmers and
throwing athletes (also volleyball & tennis) Commonly seen in
young swimmers and throwing athletes (also volleyball & tennis)
Overuse syndrome Overuse syndrome Pain is exacerbated by repetitive
overhead activities that cause a stretching of the anterior capsule
and musculature of the shoulder Pain is exacerbated by repetitive
overhead activities that cause a stretching of the anterior capsule
and musculature of the shoulder
Slide 39
Shoulder Instability Commonly loose jointed Commonly loose
jointed Multiple-joint laxity check the knees, elbows, MCP joints,
thumb to flexor surface of forearm Multiple-joint laxity check the
knees, elbows, MCP joints, thumb to flexor surface of forearm Check
skin hyperelasticity (Marfans?) Check skin hyperelasticity
(Marfans?) Usually atraumatic instability Usually atraumatic
instability Voluntary instability can be associated with
psychologic instability Voluntary instability can be associated
with psychologic instability
Slide 40
Shoulder Instability
Slide 41
Physical exam may also show rotator cuff and scapular weakness
and apprehension Multifactorial causes Motor imbalance Scapular
weakness Capsular laxity RARELY IS THIS ROTATOR CUFF DISEASE RARELY
IS THIS ROTATOR CUFF DISEASE
Slide 42
Shoulder Instability Treatment Physical therapy- includes
stretching posterior capsule and strengthening anterior
musculature, rotator cuff, and the muscles of the scapula ( usually
up to 6 months) Physical therapy- includes stretching posterior
capsule and strengthening anterior musculature, rotator cuff, and
the muscles of the scapula ( usually up to 6 months) Surgical -
capsular shrinking has promise for failures at therapy, capsular
plication Surgical - capsular shrinking has promise for failures at
therapy, capsular plication
Slide 43
Recurrent Dislocations Initial traumatic dislocation Initial
traumatic dislocation Can lead to long term disability Can lead to
long term disability Age is important fact for recurrent
dislocations Age is important fact for recurrent dislocations Over
50 years of age very few Children and adolescents- 25-50% 90% of
young athletes have associated Bankart lesions (avulsion of labrum-
ligament complex)
Slide 44
Recurrent Dislocations Treatment Surgical Surgical Open
Arthroscopically- higher failure rate for athletes failure rate for
athletes under 20-years of age? under 20-years of age?