the pediatric knee and ankle: orthopaedic · pdf filethe pediatric knee and ankle:...

Page 0

xxx00.#####.ppt 9/22/2012 11:53:00 AM

The Pediatric Knee and Ankle: Orthopaedic Perspectives

Scott B Rosenfeld, MD Division of Pediatric Orthopaedics

Texas Children’s Hospital

Page 1

xxx00.#####.ppt 9/22/2012 11:53:02 AM

Disclosures •I have no disclosures

Page 2

xxx00.#####.ppt 9/22/2012 11:53:03 AM

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

Page 3

xxx00.#####.ppt 9/22/2012 11:53:04 AM

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

Page 4

xxx00.#####.ppt 9/22/2012 11:53:05 AM

Page 5

xxx00.#####.ppt 9/22/2012 11:53:05 AM

Besides Sports •Location of common congenital and developmental problems

-Discoid Meniscus

-OCD

•Location of foreign bodies

•Common site of infection

Page 6

xxx00.#####.ppt 9/22/2012 11:53:06 AM

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

Page 7

xxx00.#####.ppt 9/22/2012 11:53:07 AM

Common Knee and Ankle Problems •Osteochondritis Dessicans of the knee

•Discoid Meniscus

•Osteochondral fracture of the talus

•Ankle infections

Page 8

xxx00.#####.ppt 9/22/2012 11:53:08 AM

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

Page 9

xxx00.#####.ppt 9/22/2012 11:53:09 AM

Osteochondritis Dessicans - Knee •Clinical Presentation

-+/- history of injury

-Knee pain

-Swelling/Effusion

-Tenderness over condyle

-Catching, locking

-Loss of terminal extension or flexion

Page 10

xxx00.#####.ppt 9/22/2012 11:53:09 AM

Osteochondritis Dessicans - knee •Goals of imaging

-Location

-Size

-Stability

•Modalities -Radiographs

-MRI

Page 11

xxx00.#####.ppt 9/22/2012 11:53:11 AM

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

Page 12

xxx00.#####.ppt 9/22/2012 11:53:12 AM

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

Page 13

xxx00.#####.ppt 9/22/2012 11:53:14 AM

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

Page 14

xxx00.#####.ppt 9/22/2012 11:53:15 AM

Page 15

xxx00.#####.ppt 9/22/2012 11:53:17 AM

Page 16

xxx00.#####.ppt 9/22/2012 11:53:18 AM

•Treatment decision making - Open physis

- Cartilage intact = stable

- No locking

- Full ROM

•Non-operative - Activity modification

- Knee immobilization

- PT for ROM

Page 17

xxx00.#####.ppt 9/22/2012 11:53:19 AM

4 months later…

Page 18

xxx00.#####.ppt 9/22/2012 11:53:21 AM

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

Page 19

xxx00.#####.ppt 9/22/2012 11:53:22 AM

Page 20

xxx00.#####.ppt 9/22/2012 11:53:24 AM

Page 21

xxx00.#####.ppt 9/22/2012 11:53:25 AM

•Treatment decision making

-Closed physes

-Displaced OCD fragment

-Block to full extension

•Surgical treatment -Reduction and fixation

-Removal and microfracture

Page 22

xxx00.#####.ppt 9/22/2012 11:53:26 AM

Page 23

xxx00.#####.ppt 9/22/2012 11:53:28 AM

Page 24

xxx00.#####.ppt 9/22/2012 11:53:29 AM

One year later….

Page 25

xxx00.#####.ppt 9/22/2012 11:53:30 AM

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

Page 26

xxx00.#####.ppt 9/22/2012 11:53:31 AM

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

Page 27

xxx00.#####.ppt 9/22/2012 11:53:32 AM

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

Page 28

xxx00.#####.ppt 9/22/2012 11:53:33 AM

Discoid Meniscus •Case 3

•7 y.o. female with painful snapping right knee

•Occasional swelling

•Block to terminal extension

•Visible snapping in lateral compartment

Page 29

xxx00.#####.ppt 9/22/2012 11:53:34 AM

Discoid Meniscus

Page 30

xxx00.#####.ppt 9/22/2012 11:53:35 AM

Discoid Meniscus •Treatment Plan

-Arthroscopy

-Partial meniscectomy (saucerization)

-Probable meniscal repair

Page 31

xxx00.#####.ppt 9/22/2012 11:53:35 AM

Page 32

xxx00.#####.ppt 9/22/2012 11:53:36 AM

Page 33

xxx00.#####.ppt 9/22/2012 11:53:37 AM

Page 34

xxx00.#####.ppt 9/22/2012 11:53:38 AM

Page 35

xxx00.#####.ppt 9/22/2012 11:53:39 AM

Page 36

xxx00.#####.ppt 9/22/2012 11:53:39 AM

Ankle •Injuries

-Sprains

-Fractures

-OCD lesions

•Infections -Septic arthritis

-Osteomyelitis

Page 37

xxx00.#####.ppt 9/22/2012 11:53:40 AM

Talus Osteochondral Lesion •Case 4

•12 year old s/p MVC

•Right ankle pain and swelling

•Diffusely TTP

Page 38

xxx00.#####.ppt 9/22/2012 11:53:41 AM

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?

Page 39

xxx00.#####.ppt 9/22/2012 11:53:43 AM

Page 40

xxx00.#####.ppt 9/22/2012 11:53:44 AM

Treatment Decision •Displaced anterior-lateral osteochondral fragment

-Cartilage disrupted

-Bone attached

•Open reduction and internal fixation

Page 41

xxx00.#####.ppt 9/22/2012 11:53:44 AM

Page 42

xxx00.#####.ppt 9/22/2012 11:53:45 AM

Page 43

xxx00.#####.ppt 9/22/2012 11:53:46 AM

3 months later…

Page 44

xxx00.#####.ppt 9/22/2012 11:53:47 AM

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

Page 45

xxx00.#####.ppt 9/22/2012 11:53:48 AM

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

Page 46

xxx00.#####.ppt 9/22/2012 11:53:49 AM

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

Page 47

xxx00.#####.ppt 9/22/2012 11:53:50 AM

Infections •Septic ankle

-Aspiration in ED showed pus

•Pre-op MRI -Adjacent osteomyelitis and distal tibia subperiosteal abcess

Page 48

xxx00.#####.ppt 9/22/2012 11:53:50 AM

Infections •Case 5

•2 y.o. boy with 2 day history of

-fever, refusal to bear weight, swollen lower leg and ankle

•Xrays negative

Page 49

xxx00.#####.ppt 9/22/2012 11:53:51 AM

Infections •MRI with contrast

•What I want to see -Where is the infection?

•Osteomyelitis?

• Intramuscular abcess?

•Subperiosteal abscess?

•Ankle joint effusion?

-Localizer mode

*

*

Page 50

xxx00.#####.ppt 9/22/2012 11:53:53 AM

Page 51

xxx00.#####.ppt 9/22/2012 11:53:54 AM

Thank you