Transcript Plica
Plica
Redundant fold in synovial lining of the
knee
Palpable over medial or lateral
retinaculum
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
Plica
Treatment
Cortisone injection may help
Surgery may be required for excision of
the thickened band of tissue
Plica
Synovial
plica
Patella
Plica
Trochlea
groove
Anterior Cruciate Ligament
Injuries
Incidence is 0.3-0.38 per 1000 per year
and increasing
Usually sports related (football, soccer,
skiing)
Estimated 3 in 100,000 have tibial spine
avulsions
Skeletally immature patients account for
3-4% of all ACL injuries
Anterior Cruciate Ligament
Injuries
Bony avulsion of tibial spine insertion
occurs more commonly found in
preadolescent children
Intrasubstance tears are more commonly
seen in adolescents
MOI is usually hyperextension, sudden
deceleration, or a valgus rotational force
with a stationary foot
Isolated ACL Tears
Preadolescent children best treated with
activity modification and observation
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)
Adolescents are treated as adults
Anterior Cruciate Ligament
Injuries
Natural History
Preadolescent –not well known due to low #’s
Adolescents- similar to young adults
33-86% reports episodes of “giving way”
when treated nonoperatively
Anterior Cruciate Ligament
Injuries
Natural History
Activity, not age is primary factor
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
Tibial Spine Avulsion
Fractures
Type I-minimally displaced
Type II-posterior hinge but still attached
to the tibial epiphysis
Type III- fx is displaced
Type I
Type II
Type III
Tibial Spine Avulsion
Fractures
Treatment
Type I – usually casting
Type II – closed reduction/cast
Type III – ORIF with
screw/wire/sutures
Mensical Injuries
Symptoms
Pain
Effusion
Snapping
Giving way
Intermittent locking
Locked knee
Meniscal Injuries
Outcomes
Complete meniscectomies results are
very poor
60% unsatisfactory at 7 years
Preservation is critical
80-90% have favorable outcomes with
repair
Meniscal Injuries
Blood
supply to
meniscus
Repairable zone
Meniscal
tear
Patellar Dislocation
Patellar Dislocation
Twisting injury
Collision
May not know patella dislocated
Immediate swelling
Can’t play
Patellar Dislocation
Patellar Dislocation
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
Patellar Dislocation
Predisposing
factors to recurrenceligamentous laxity, increased genu
valgum, torsional malalignment
Consider surgical treatment for
recurrent dislocation/subluxation if fail
extensive rehabilitation/exercises
Other LE Injuries
Bone Bruise
Shin Splints
Stress Fractures
Nerve Entrapements
Severe’s Disease
Subungual Hematoma’s
Bone bruise
Collision
Fall
Non-contact twist
Xrays usually normal
dx by mri
Tx rest,nwb time
Shin Splints
Exercise induced pain along
the anteriomedial tibia
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
Shin Pain
Differential Diagnosis
Shin Splints
Chronic Exertional
Compartment Syndrome
Nerve Entrapment Syndromes
Stress Fractures
Shin Splints
Treatment
Ice massage
NSAID’s
Decrease running and jumping
Correct training errors
Strengthening
Continue with cardio/vascular training
Stress Fractures
Most commonly results from training
errors (change in surfaces or shoes)
Need high index of suspicion
Difficult clinically to distinguish from
overuse type syndromes
May be seen on plain X-rays but Tc-99m
bone scan may be needed
MRI
Stress Fractures
Increasingly more frequent in
recreational and competitive
athletes
About 10% of sport injuries
Common with preexisting
conditions with decreased bone
mass, bone mineralization
[nutritional disorders (rickets),
systemic disorders (DM, RA)]
Stress Fractures
Stress Fractures
Treatment
Activity modification [you need to keep
these athletes in shape (swim, bike,
weight train, etc.)]
Rest- (it takes time)
Immobilization rarely needed
Nerve Entrapment
Syndromes
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 Entrapment
Syndromes
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 1st web
Sural n.-numbness at lateral heel
and foot
Posterior tibial n.-tarsal tunnel
symptoms
Sever’s Disease
Self limiting apohysitis of the os calcis at
the insertion site of the Achilles tendon
Pain over post. os calcis
Aggravated by activity
Recent growth spurt
Sever’s Disease
Increased density
and partial
fragmentation of
the calcaneal
apophysis
Sever’s Disease
Most commonly seen in 6 to 10 year old
males
Treatment is symptomatic
– Mild restriction of activities
– Ice
– Heel lifts
– Achilles stretches
– Arch supports
Subungual Hematoma
Think open fracture
Injuries About The Shoulder
Little
Leaguer’s Shoulder
Shoulder instability
Recurrent dislocations
Clavicle fractures
A-C separations
Little Leaguer’s
Shoulder
Pain due to a stress fracture
of the humeral physis
Overuse injury
Rest usually takes care
of the problem
Little Leaguer’s
Shoulder
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)
Little Leaguer’s
Shoulder
May help to limit the amount of pitching
in the game but doesn’t control practice
or at home
Shoulder Instability
Commonly seen in young swimmers and
throwing athletes (also volleyball &
tennis)
Overuse syndrome
Pain is exacerbated by repetitive
overhead activities that cause a stretching
of the anterior capsule and musculature
of the shoulder
Shoulder Instability
Commonly “loose jointed”
Multiple-joint laxity – check the knees,
elbows, MCP joints, thumb to flexor
surface of forearm
Check skin hyperelasticity (Marfan’s?)
Usually atraumatic instability
Voluntary instability can be associated
with psychologic instability
Shoulder Instability
Shoulder Instability
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
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)
Surgical - capsular shrinking has promise
for failures at therapy , capsular plication
Recurrent Dislocations
Initial traumatic dislocation
Can lead to long term disability
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 labrumligament complex)
Recurrent Dislocations
Treatment
Surgical
– Open
– Arthroscopically- higher
failure rate for athletes
under 20-years of age?