AAOS Comprehensive Orthopaedic Review

Section 3 - Pediatrics

Chapter 29. Musculoskeletal Conditions and Injuries in the Young Athlete

I. Overview

A. Child versus adult athlete


1. A child athlete is not a small adult.


2. Children have open physes growing at variable rates, making them prone to injury.


3. Children are less coordinated, with poorer mechanics, when compared with adult athletes.


4. Children have less efficient thermoregulatory mechanisms than adults, which is manifested as a poorer ability to acclimatize rapidly because of a less efficient sweating response.


B. Participation levels/preparticipation examination


1. Almost 4 million males and 3 million females participated in high school level sports in 2005-2006, compared with approximately 3.6 million males and 300,000 females participating in the early 1970s, according to the National Federation of State High School Associations.


2. Preparticipation physical examinations provide a good screening tool to identify most risk factors for injury as well as an opportunity to develop strategies and recommendations for preventing as well as treating them.


C. Sex-specific considerations


1. The "female athlete triad" of amenorrhea, disordered eating, and osteoporosis places the female athlete at higher risk of insufficiency or stress fractures, overuse injuries, and recurrent injuries.


2. Knee injuries


a. The female knee is also at increased risk of injury from the start of puberty on.


b. Differences in anatomy, sex hormone levels, neuromuscular control, and overall strength and coordination have been implicated in the higher incidence of knee injuries in females compared with males in the same sport.

II. Little Leaguer Shoulder

A. Overview/epidemiology


1. Little Leaguer shoulder is an epiphysiolysis, or fracture through the proximal humeral epiphysis, caused by repetitive microtrauma.


2. This injury occurs most commonly in skeletally immature overhead athletes such as pitchers and tennis players.


3. The injury is a result of repeated high loads of torque in a rapidly growing child athlete.


B. Presentation/evaluation


1. Patients present with generalized shoulder pain that is typically at its worst during the late cocking or deceleration phases, pain with resisted elevation of the shoulder and with extremes of motion in any direction, and point tenderness over the physis of the proximal humerus, which is hard to discern from subdeltoid bursal pain.


2. Radiographs show a widened proximal humeral physis compared with the opposite side (

Figure 1).


C. Treatment


1. Treatment is the same as for a fracture, with no throwing for a minimum of 2 to 3 months.


2. When painless full range of motion is obtained, physical therapy for rotator cuff strengthening is initiated.


3. After 2 to 3 months of no throwing, a progressive throwing program is started.


a. The athlete begins with short tosses at low velocity and gradually progresses to longer tosses; eventually the longer tosses are made with increasing velocity.


b. After long tosses at higher velocities have been achieved, the patient can start full playing.


[Figure 1. AP radiographs of the shoulders of a 12-year-old pitcher with right shoulder pain in the deceleration phase of throwing. Compare the physeal widening of the right shoulder (A) with the normal left shoulder (B).]


Table 1. Pitching Recommendations for the Young Baseball Player]

D. Complications


1. A low incidence of premature growth arrest with or without angular deformity is seen.


2. Subsequent Salter-Harris fractures can also occur.


E. Prevention—The key to prevention of this injury is avoiding overuse by adherence to guidelines set forth by multiple entities, including the American Academy of Orthopaedic Surgeons, USA Baseball, and the American Orthopaedic Society for Sports Medicine (Table 1).

III. Little Leaguer Elbow

A. Overview


1. Little Leaguer elbow is a generic term covering any injury to the elbow in a child that is accompanied by pain along the medial aspect of the proximal forearm or elbow. The term derives from the fact that these injuries are commonly related to the excessive stresses experienced by the immature skeleton during pitching.


2. The forces are similar to those that occur in the adult elbow; ie, valgus-hyperextension overloading of the elbow during throwing.


3. The syndrome is often associated with a habit of throwing curveballs and other "junk" pitches, or when an infielder-type bent-elbow throw that involves a whipping mechanism to gain adequate speed is used. The mechanism of all injuries in this category is similar to those seen with adult injuries, but the symptoms of each different injury in a child can be much more varied. Children often experience pain on the compressed radial side of the joint as well as the distracted ulnar side.


B. Pathoanatomy


1. Little Leaguer elbow is a progressive problem resulting from repetitive microtrauma. Therefore, most of the early symptoms are assumed to be a result of soft-tissue strains and sprains.


2. By the time the symptoms are severe enough to require referral to an orthopaedic surgeon, more serious ligament, cartilage, physis, and bone pathology should be assumed to be present until proven otherwise.


C. Presentation/evaluation


1. Patients experience pain after, and eventually during, a game. The pain may be mild at first but eventually inhibits throwing entirely.


2. Patients typically lose the ability to achieve throwing distance and accuracy early on, followed by a loss of velocity. Eventually, most note persistent pain at rest.



Figure 2. Medial UCL reconstruction techniques. A, Tendon graft passed through bone tunnels. B, Docking technique. C, Anatomic interference technique.]

3. The differential diagnosis includes medial epicondylar apophysitis, posterior stress impingement, osteochondritis dissecans (OCD)/Panner disease, and instability and valgus extension overload.


4. Physical examination


a. Examination is best done with the patient seated. Observe the arm for deformity. Chronic conditions may produce an increased carrying angle or a flexion contracture.


b. Look for sites of maximum point tenderness. Point tenderness over the medial epicondyle and/or flexor mass could be due to muscle strain, ulnar collateral ligament (UCL) sprain, or medial epicondylitis.


c. Apply valgus stress with the arm in varying degrees of flexion and extension.


i. As with a UCL injury where the ligament is avulsed at its origin on the apophysis of the medial epicondyle, instability may be present.


ii. Evaluate UCL instability with the valgus stress test, the milking maneuver, valgus stress radiographs, MRI, and/or MR arthrography.


iii. The younger the patient, the more likely the diagnosis is to be an apophysitis or an avulsion injury rather than a UCL sprain.


5. Radiographic evaluation


a. Compare with the normal side to determine whether an irregular appearance of the physis exists. This may also be helpful for determining degree of displacement. A radiograph of just the involved extremity is sufficient to determine whether the apophysis has closed, however.


b. Look for fragmentation of the medial epicondyle, trochlea, olecranon, or capitellum.


c. Medial epicondyle hypertrophy or radial head hypertrophy may be present as well.


D. Treatment


1. Nonsurgical treatment


a. The best treatment is prevention through education of coaches, parents, and athletes.


b. Alteration in form/motion, playing habits, and adherence to recommended pitch/inning counts should be used first for all elbow overuse injuries.


c. Medial epicondylitis is treated with 4 to 6 weeks of no stress on the physis.


d. Treatment of OCD/Panner is discussed in section V, below.


e. Valgus extension overload and posterior stress syndromes typically can be treated with activity and throwing modifications.


f. Intra-articular steroids may be used to control inflammation.


2. Surgical treatment


a. Indications


i. Failure of response to nonsurgical treatment


ii. Instability of elbow with avulsion fracture or fragmentation of medial epicondyle


b. Contraindications—Uncertain diagnosis with ulnar nerve symptoms.


c. Procedures


i. UCL reconstruction of choice when indicated for UCL insufficiency (Figure 2)


ii. Open reduction and internal fixation is recommended by most surgeons for medial epicondyle avulsion fractures in serious, competitive throwers, although definitive research is lacking.



Figure 3. AP (A) and lateral (B) radiographs of the wrist of a 13-year-old girl who was an elite-level female gymnast and who presented with persistent pain and progressive deformity of the left wrist.]

iii. Arthroscopic debridement of posterolateral synovium and olecranon osteophytes for recalcitrant posterior symptoms, and arthroscopic decompression of valgus-extension overload with failed prolonged nonsurgical treatment.


E. Complications


1. Ulnar nerve neuropathy


2. Loss of motion


3. Infection


4. Continued pain


5. Inability to return to play at same level


6. Aggressive debridement of the olecranon or osteophytes may lead to instability.


F. Rehabilitation


1. Rehabilitation should be tailored according to whether ligament injury is involved.


2. For injuries not involving ligaments, minimal immobilization with early range of motion, strengthening, and pain modalities is indicated.


3. For ligament reconstructions, the recommended treatment is a brief period of immobilization and then protected range of motion.

IV. Distal Radius Epiphysiolysis/Epiphysitis

A. Overview/pathoanatomy


1. Injury to the distal radial epiphysis most commonly occurs in adolescent athletes in sports that require weight bearing on the upper extremities, such as gymnastics or cheerleading.


2. Children of an average age of 10 to 14 years at higher skill levels spend more time in more intensive training, making these injuries more likely to occur in this age group.


3. The mechanism involves overloading of the distal radial epiphysis, causing inflammation and/or fracture of the epiphysis.


B. Evaluation


1. Diagnosis is made by history of painful wrist with weight-bearing activities and physical examination consistent with pain and swelling at the joint with or without deformity of the wrist.


2. Radiographs may show widened physis, blurred growth plate, metaphyseal changes, and fragmentation of radial and volar aspects of the plate (Figure 3).


C. Treatment


1. Allow the patient to participate in treatment choices.


2. Relative rest is indicated in mild to moderate cases, complete rest in severe cases. In-season athletes and less severe cases may be managed with relative rest in a splint and physical therapy.


3. Immobilization is indicated in all cases, from a splint in mild to moderate cases, to casting in more severe cases. Do not be afraid to be aggressive in immobilization.


4. In severe cases, bone stimulation can be used.


5. Surgical intervention is typically indicated only for the correction of complications.


D. Complications


1. This injury may recur even with casting for 6 to 8 weeks, particularly if the athlete goes back to full activities immediately.


2. Positive ulnar variance is a common eventual outcome with untreated athletes and may result in triangular fibrocartilage complex pathology or ulnar abutment.


E. Rehabilitation—Physical therapy is useful for regaining motion after casting and also helps to control the athlete's return to activity.

V. Osteochondritis Dissecans

A. General


1. Osteochondritis dissecans (OCD) is so named because of the tendency for the untreated lesion to



Figure 4. AP (A) and lateral (B) radiographs showing capitellar OCD in a 14-year-old gymnast.]

   wind up as a loose body, "dissected" free of its original location.


2. OCD is found in the elbow, knee, and ankle in asymptomatic skeletally immature individuals, but it may not be detected until early adulthood.


3. No one etiologic theory is uniformly accepted, with the origin of OCD variously thought to be traumatic (macro or micro), vascular, or hereditary/constitutional.


B. Elbow OCD


1. Overview


a. Osteonecrosis of the capitellum, which is called Panner disease and has a relatively benign course, typically occurs in the first decade of life.


b. Capitellar OCD typically occurs after the age of 10 years. It is a frequent cause of permanent disability, ranging from inability to participate in sports at the same level to long-term arthritic changes.


2. Pathoanatomy


a. Both Panner disease and capitellar OCD are considered to be the result of overuse/overload compression-type repetitive injuries, leading to insult of the blood supply of the vulnerable immature capitellum.


b. Ossification of the capitellum usually is complete by the age of 10 years, which accounts for the distinction between Panner disease and OCD.


3. Evaluation


a. Typical presentation is an insidious onset of activity-related pain with or without stiffness in the dominant arm of an overhead throwing athlete or athlete in a sport that involves weight bearing on the upper extremity.


b. History of locking or catching may be present.


c. Physical examination typically reveals a flexion contracture, point tenderness, and possibly crepitus.


d. Staging and classification of OCD is based on both radiographic studies and arthroscopy (Figure 4).


i. Type I lesions—Intact cartilage with or without bony stability underneath.


ii. Type II lesions—Cartilage fracture with bony collapse or displacement.


iii. Type III lesions—Loose pieces in the joint.


4. Nonsurgical treatment


a. Panner disease and type I OCD lesions are best treated nonsurgically, which has a success rate >90%.


b. Treatment consists of rest with or without immobilization for 3 to 6 weeks, longer for OCD than Panner.


c. The patient then is allowed to slowly progress back to activities over the next 6 to 12 weeks.


5. Surgical treatment


a. Indications


i. Failure of nonsurgical management


ii. Persistent pain


iii. Symptomatic loose bodies


iv. Displacement of OCD lesions


b. Contraindications—Patients younger than 10 years without loose bodies, chondral fractures, or displacement of the OCD have Panner disease.


c. Procedures


i. Extra-articular or transarticular drilling of type I lesions without bony stability or type II lesions that are not unstable arthroscopically has good clinical success.


ii. Fixation of OCD lesions of the capitellum has variable success at best and should be reserved for large lesions with primary intact fragments that sit well or are not completely displaced.


iii. Debridement of the base of the lesion with or without drilling of the subchondral bone and loose-body excision is frequently required in unstable type II lesions and type III lesions.


iv. Cartilage restoration may be necessary if symptoms continue or lesion is large. Start with a high anteromedial portal.


d. Pearls


i. Use the posterior portals and anconeus portal for most work, as nearly all of the capitellum can be visualized through this approach.


ii. Avoid excessive cartilage debridement; only flaps or loose cartilage should be debrided.


iii. Avoid cartilage damage when possible by drilling extra-articularly.


iv. Large lesions may need cartilage restoration initially or if symptoms do not abate after debridement.


6. Complications include elbow stiffness, infection, progression of arthritis, continued pain, and inability to return to sport.


7. Rehabilitation


a. The rehabilitation protocol depends on the particular procedure.


i. Debridements/loose-body excisions call for early range of motion with or without an elbow brace. Progression to strengthening can be initiated when painless range of motion is achieved, with avoidance of valgus positions, throwing, and weight bearing for 3 to 4 months.


ii. Elbows that undergo fixation or drilling procedures need more prolonged protection, with protected early range of motion followed by strengthening at approximately 2 months, then slow return to valgus positions. Throwing and then weight bearing is begun at 4 to 6 months.


b. Overhead or weight-bearing athletes may not return to same level of play.


c. Changes in mechanics/position/sport may be necessary.


C. Knee OCD


1. Overview/epidemiology


a. The knee is the most common site of osteochondrosis in growing children, which is seen in an estimated 0.002% to 0.003% of knee radiographs.


b. The actual incidence may actually be far greater because no studies exist for a general population of asymptomatic children.


c. Often confused with irregularities of epiphyseal ossification, this entity (despite earlier beliefs) does not always get better with benign neglect.


d. Age and level of skeletal maturation at onset are considered prognostic. It is generally thought that children with closed or nearly closed growth plates at the time of onset have a worse prognosis.


2. Evaluation


a. Patients present with generalized, often anterior, knee pain and variable swelling with or without temporally related trauma.


b. Onset may also be associated with a period of relative increase of activity or change in activities.


c. Care should be taken to assess whether the symptoms include only pain or actual mechanical popping and locking. This distinction can be helpful in determining appropriate treatment.


d. In thin patients, it is not unusual for deep pressure over the medial parapatellar area to produce pain with the knee flexed but no pain when it is extended.


e. Application of varus stress throughout a similar range of motion may produce similar reports of pain and popping if the fragment is sufficiently loose.


f. A thorough provocative and ligamentous examination is necessary to identify the possibility of comorbid conditions such as meniscal tears, loose bodies, or instability.


g. Standard weight-bearing AP, lateral, tunnel, and Merchant radiographic views should be obtained.


i. An OCD lesion in the classic position on the lateral aspect of the medial femoral condyle



Figure 5. Tunnel views of the knee demonstrating the classic location of an OCD lesion, on the lateral aspect of the medial femoral condyle, before (A) and after (B) displacement.]

   may be overlooked on the AP view in extension because of overriding bone.


ii. Classic lesions are best visualized on the tunnel view (Figure 5).


h. MRI and bone scans are adjunctive studies that help stage the lesions and potentially help predict prognosis.


3. Classification


a. Lesions are classified both by evaluation of radiographs and MRI and by arthroscopic evaluation, with multiple classifications in the literature.


b. Guhl MRI classification is shown in

Figure 6.


4. Nonsurgical treatment


a. Patients with stable lesions at any age are treated with rest, activity restriction, anti-inflammatory medication, and pain modalities as needed.


b. A period of 6 weeks of protected weight bearing or immobilization may be employed as necessitated if symptoms persist.


5. Surgical treatment


a. Indications


i. Unstable lesions with or without loose bodies


ii. Older children with persistent pain despite a sufficient nonsurgical treatment period


[Figure 6. Guhl classification of OCD. A, Type I: Signal change around the lesion without bright signal. B, Type II: Bright signal surrounding bone portion of lesion without signs of cartilage breach. C, Type III: Bright signal around whole lesion including cartilage (unstable lesion). D, Type IV: Empty bed of the lesion with loose body.]

iii. Younger patients with continued pain and swelling with or without loss of motion in whom 3 to 6 months of nonsurgical treatment has failed


b. Contraindications—Very young patients with inconsistent pain who have not failed a long course of nonsurgical treatment.


c. Procedures


i. Stable lesions are typically amenable to arthroscopic drilling of the lesion either extra-articularly or transarticularly. When drilling a stable OCD arthroscopically, pay attention to avoid slipping across the cartilage or producing excessive heat that creates cartilage damage when transarticularly perforating a lesion. Use fluoroscopy or an anterior cruciate ligament (ACL) type of drill guide when extra-articular drilling is to be performed.


ii. Unstable lesions are managed with either arthroscopic or open debridement with fixation. In young adolescents, fixation of unstable lesions should be attempted if at all possible; later procedures may be necessary, however. Bioabsorbable pins/screws work well; however, make sure appropriate length is chosen and cut flush so that no excess protrudes from the cartilage surface.


iii. A loose body that does not fit or is severely damaged should be treated with removal plus arthroplasty or a cartilage restoration procedure; however, every attempt should first be made to save the piece by trimming it and securing it with pins, screws, etc.


6. Complications include stiffness, infection, failure of fixation, continued pain, and arthrofibrosis.


7. Rehabilitation


a. Crutches and touch-down weight bearing is prescribed for 6 weeks.


b. Immediate active-assisted and passive motion is started, along with quadriceps activation and strengthening.


c. Progression of weight bearing is allowed from 6 to 12 weeks with or without radiographic evidence of healing, as long as no pain or swelling is clinically present.

VI. Knee Ligament Injuries

A. Overview/pathoanatomy


1. Posterior cruciate ligament (PCL) and lateral collateral ligament tears are relatively rare. Medial collateral ligament tears are the most common, but ACL tears in adolescents appear to be increasing in frequency.


2. Ligaments fail when loaded at speeds and forces that lead to elongation in excess of 10% of the original length of the ligament.


3. The speed at which the load is applied determines whether the ligament fails or the bone/physis fails.


B. Evaluation/classification


1. History can be traumatic, such as a motor vehicle accident or sports-related (contact or noncontact) injury, or atraumatic. Patients present with pain and swelling acutely, with or without instability. Loss of motion is frequent as well.


2. Physical examination in the acute setting may be difficult; however, instability and point tenderness in this initial setting can be diagnostic. Repeat examination in a few days or a week may aid in the diagnosis in lieu of an MRI.


3. Radiographs taken during the initial examination can rule out physeal or other fractures about the knee. Occasionally they will demonstrate abnormalities of alignment, such as an anteriorly translated tibia seen on a lateral view, that make it possible to diagnose a ligament injury.


4. MRI is a useful tool for confirming a suspected diagnosis or when an adequate physical examination is not possible.


5. Classification—Ligament injuries are graded according to severity of injury of each ligament individually.


C. Treatment


1. General principles of ACL treatment in particular


a. When deciding treatment, the patient needs to be considered as a whole. This includes age, growth remaining, ligament injured, severity of injury, and level of planned activity.


b. When a patient is not within 2 years of skeletal maturity, choose treatment carefully and weigh all factors. When in doubt, repair other pathology and rehabilitate, with or without bracing.


c. Although not common, physeal injury or arrest can occur in the hands of even the most experienced surgeon, no matter what procedure is used.


d. Use all tools necessary to determine skeletal age when considering ligament reconstruction (growth charts, bone age, Tanner staging, etc).


e. Partial tears of the ACL, PCL, or medial/lateral collateral ligaments without other intraarticular pathology are amenable to nonsurgical treatment.


i. Bracing provides initial stabilization as well as support for return to sport.


ii. Physical therapy, including strength and gait training and pain modalities, is useful to obtain full range of motion.


iii. Anti-inflammatory medications may be used initially, but there is some question about their effect on the soft-tissue healing process.


iv. Return to sport may be allowed when full motion, strength, and stability have returned with or without a brace.


f. Complete tears


i. Complete PCL injuries seem to cause fewer feelings of instability than ACL tears but probably have the same potential for long-term arthritis, although surgical intervention is more easily avoided until skeletal maturity.


ii. Posterolateral corner injuries rarely occur by themselves, and when they are combined with PCL injuries, a more difficult circumstance is created.


g. The obvious concern in treatment of any ligament injury is balancing the risk of iatrogenic physeal injury from surgical reconstruction or long-term disability and/or arthritis with attempts at nonsurgical treatments. The younger the patient, the greater the risk of deformity if a growth arrest ensues after a reconstructive procedure. Such cases of iatrogenic injury have been reported.


2. Nonsurgical treatment


a. Initial treatment for all ligament tears should be nonsurgical, unless the tear is associated with meniscal damage, loose bodies, or other immediate urgent surgical indications.


b. Activity modification, brief immobilization, physical therapy, and pain modalities are all indicated initially.


c. Obtaining full motion and relative stability with bracing and muscle control may obviate the need for surgical intervention in a select group of individuals (copers) even when skeletally mature.


3. Surgical treatment


a. Indications


i. Failure to maintain stability despite physical therapy and bracing, and unwillingness to modify activities


ii. Need to assess other pathology, such as meniscal pathology


b. Procedures


i. Ligament repair—Ligament reconstruction has not been shown to prevent long-term disability or arthritis in skeletally immature or mature patients.


ii. Physeal sparing—Either all epiphyseal or extra-articular reconstructions (

Figure 7).


iii. Transtibial over the top of femur


iv. Transphyseal


v. Combination procedures


c. Surgical pearls


i. Avoid spanning the physis with bone or metal.


ii. Keep transphyseal tunnels to a minimum size in a central location.


iii. Avoid dissection or damage to the perichondral ring (ie, do not dissect subperiosteally) when going around the over-the-top position on the femur.


D. Complications include physeal arrest, either partial or complete; arthrofibrosis; infection; short/long-term ligament failure; arthritis; and atrophy.


E. Rehabilitation


1. Immediate motion, quadriceps activation, swelling and pain control


2. Prolonged physical therapy


[Figure 7. Extraphyseal ACL reconstruction.]

a. Slow, steady progress back to straightforward running at around 6 months


b. No start-stop or cutting for 8 to 12 months


c. Return to sports in 1 year with or without a brace

VII. Meniscal Injuries and Discoid Meniscus

A. Pathoanatomy


1. Injuries to the meniscus occur as a result of twisting events during loading of the knee on either a normal or discoid meniscus.


2. Common meniscal tears include horizontal, vertical, bucket-handle, parrot beak, radial, or combinations thereof (

Figure 8).


3. Meniscal injuries occur in both the vascular and avascular zones.


4. The location and pattern of the tear have significant implications for the success of repair attempts; eg, tears occurring close to the vascular zone have higher rates of success, and parrot beak and radial tears have lower rates of success.


5. Removing any part of the meniscus significantly decreases the effectiveness/function of the meniscus.


[Figure 8. Illustrations of common meniscal tear morphology.]

B. Evaluation


1. History


a. Like ligament tears, meniscal tears either may be associated with traumatic events or may follow a nontraumatic event such as twisting, turning, or even kneeling.


b. Young children often cannot recall when the pain began and may present with insidious onset.


2. Physical examination


a. Point tenderness at the joint line anterior and posterior to the collateral ligament on that side is typical.


b. Pain with deep knee flexion, loss of motion, and a positive provocative test may also be present.


3. Radiographs may indicate suspicion of discoid lateral meniscus with widened lateral joint line with or without lateral femoral condyle changes.


4. MRI should be used as a confirmatory test for discoid meniscus, tears of the meniscus, and evaluation of other confounding diagnoses. MRI has a high false-positive rate in children under 10 years of age because the vascularity can be misinterpreted.


C. Classification


1. Meniscal tears are classified descriptively.


a. Location of tear—Red (vascular) zone, red-white, white (avascular) zone (outer third, middle third, inner third)


b. Size


c. Pattern—Horizontal, vertical, radial, bucket-handle, parrot beak, complex, or combination (Figure 8)


2. Discoid menisci are classified by shape and stability as complete, incomplete, and Wrisberg (

Figure 9).


D. Nonsurgical treatment


1. The treatment of asymptomatic discoid menisci is observation.


2. Small or peripheral tears may heal with nonsurgical care, which may include activity modification, physical therapy, anti-inflammatory medication, and pain modalities.


3. Bracing may help diminish effusion but will not prevent incarceration of the tear.


E. Surgical treatment


1. Indications


a. True mechanical symptoms, presence of a loose body, and associated ligament tears


b. Failure of nonsurgical treatment


2. Contraindications


a. Peripheral tears in the red-red vascular zone where the meniscus is more likely to heal without intervention, unless the patient still has pain after a prolonged period of activity modification


b. Equivocal MRI without locking symptoms


3. Procedures


a. Fixation methods


i. Inside-out is the gold standard.


ii. All-inside has gained popularity as a method of fixation of torn or unstable menisci because of its relative speed of use and because it does not require an extra incision. Meniscal healing with all-inside devices is less reliable than the inside-out technique, however, particularly in the lateral meniscus. The new


[Figure 9. Classification system for lateral discoid menisci: A, type I (complete), B, type II (incomplete), and C, type III (Wrisberg ligament). Type III discoid menisci have no posterior attachment to the tibia. The only posterior attachment is through the ligament of Wrisberg toward the medial femoral condyle.]

   lower profile devices are less likely to damage articular cartilage.


iii. Outside-in is used less frequently than the others but may be useful for anterior horn repair.


b. Partial meniscectomy


4. Surgical pearls


a. It is best to leave only sutures or devices with a closely matched modulus of elasticity in the joint on the surface of the meniscus.


b. When repairing a large tear, remember to stabilize both the superior and inferior surfaces.


c. Vertical divergent suture pattern is the strongest.


d. Reserve partial meniscectomy for those tears that are irreparable only—fix first, remove second.


F. Complications


1. Arthrofibrosis


2. Infection


3. Short- or long-term repair failure


4. New tears


5. Arthritis


6. Atrophy


G. Rehabilitation


1. Immediate motion, quadriceps activation, swelling and pain control


2. For repaired meniscus, 4 to 6 weeks of touch-down weight bearing depending on size and side of tear


3. Reserve longer periods of restricted weight bearing for larger and/or lateral tears.


4. Consider 3 to 4 weeks of restricted range of motion (0° to 90°).


5. When repair is not possible, weight bearing is allowed as tolerated and as return of quadriceps strength dictates.

VIII. Plica Syndrome

A. Epidemiology


1. Painful plica is a diagnosis of exclusion and its true incidence is difficult to discern.


2. Reportedly, these are medially based parapatellar bands in approximately 90% of symptomatic patients.


B. Pathoanatomy


1. A plica is a remnant of embryologic development; it consists of normal synovial tissue that causes mechanically based synovitis from repetitive motion.


2. On occasion, plicas can even cause arthroscopically visible evidence of chondromalacia of the edge of the femoral condyle.


C. Evaluation


1. Plica syndrome is a diagnosis of exclusion of other pathologies.


2. Patients report activity-related anteromedial to medial knee pain, sometimes with catching or partial giving way.


3. Physical examination reveals a painful, palpable band of tissue along the medial parapatellar area.


a. Feel the knee while the patient performs active motion. If patellar compression is nonpainful in 45° of knee flexion but around the patellar soft tissue is painful, then plica may be present.


b. It is often also valuable to attempt to look for an accompanying and very sensitive lateral suprapatellar soft-tissue mass that lies under the vastus lateralis.


c. The parapatellar bands can also be occasionally palpated lateral and even inferior to the patella.


d. MRI may miss a plica; although it is easier to see when there is a knee effusion, it is usually difficult to visualize, so a high index of suspicion is warranted.


D. Treatment


1. Nonsurgical treatment


a. Anti-inflammatory medications, ice, activity modification, immobilization


b. Physical therapy modalities such as ultrasound and iontophoresis of cortisone solution


c. Cortisone injections


2. Surgical treatment


a. Indications


i. When the patient has pain not resolved by nonsurgical methods


ii. When the problem is discovered at the time of surgery for another diagnosis that is found to be erroneous with only an irritated plica for a plausible explanation


b. Contraindications—Reflex sympathetic dystrophy or chronic regional pain syndrome, as well as saphenous neuritis, should all be ruled out before surgical intervention.


c. Procedure


i. Arthroscopic resection of the plica is performed in a standard two- or three-portal approach.


ii. The inferomedial parapatellar portal or the medial/lateral suprapatellar portals are typically sufficient for excision with shaver/biter/heat probe of choice.


d. Surgical pearls


i. The most worrisome pitfall is a too-aggressive resection of the plica that includes the retinaculum and not just the abnormal band of synovium.


ii. Look for denuding/irritation/deformation of the medial condylar articular surface under the contact area of the plica; if found, this is an indication that it should be resected.


iii. Use an arthroscopic punch or heat device to create a working resection edge in the thickened yet smooth plicas that a shaver has a difficult time getting started on.


E. Complications—The standard complications that can occur after routine arthroscopy also can occur after arthroscopy for plica syndrome: arthrofibrosis, infection, nerve/vessel injury, patellar instability, unresolved pain.


F. Rehabilitation


1. Immediate motion and quadriceps activation, with quick return to weight bearing as tolerated


2. At 3 to 4 weeks the patient may be ready to return to full participation, depending on other pathology present at the time of surgery.

Top Testing Facts

1. Little Leaguer shoulder is an epiphysiolysis, or a fracture through the proximal humeral physis, that causes pain during the late cocking or deceleration phases of pitching.


2. Little Leaguer elbow occurs secondary to valgus-hyperextension overloading at the elbow during pitching. Initial treatment of apophysitis is activity modification.


3. The radiographic diagnosis of a capitellar lesion in a child younger than 10 years is Panner disease; in a child older than 10 years, it is OCD.


4. OCD of the knee classically involves the lateral aspect of the medial femoral condyle and is best visualized on a tunnel view. The stability of the lesion influences the prognosis.


5. Initial treatment of OCD in the knee is with activity modification/rest with or without immobilization, unless locking symptoms or a loose body is present.


6. A feared complication of ACL reconstruction is partial or complete physeal arrest in the skeletally immature.


7. Tears of the meniscus in the outer, vascular zone should be operated on only if locking symptoms exist or if there is no improvement after prolonged nonsurgical treatment.


8. The treatment of asymptomatic discoid menisci is observation.


9. Partial ACL tears can be treated nonsurgically, with physical therapy with or without bracing.


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