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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