Orthopaedic Knowledge Online: Orthopaedic Review http://www.aaos.

org/oko Author: Ryan Dopirak, MD Editors: John Sarwark, MD and James L. Bond, MD

October 2004 Section 4

Chapter 41: KNEE AND LEG: PEDIATRIC ASPECTS

1. Provide a classification for congenital dislocation of the knee (congenital hyperextension deformity of the knee) Type I: Type II: Type III: Hyperextended knee, which can typically be flexed to 90o or more Hyperextended knee, tibia is subluxed anteriorly, but reducible with knee flexion Hyperextended knee, tibia is dislocated anteriorly and irreducible with severe quadriceps contracture

2. Congenital dislocation of the knee may occur in conjunction with which other disorders? Hip dysplasia Congenital foot disorders (TEV or CVT) 45% concomitant occurrence 31% concomitant occurrence

3. What is the treatment of congenital dislocation of the knee?
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Treatment begins with manipulative stretching and serial casting Open reduction with quadricepsplasty may be required for more severe deformities at a later age If ipsilateral hip dysplasia is present, it is best treated after correction of the knee deformity

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4. What is the natural history of congenital dislocation of the patella?
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Progressive deformity that eventually becomes fixed, with an associated knee flexion deformity Symptoms of patellar pain and quadriceps weakness progressively worsen, as do functional limitations caused by the deformity 1

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©1995-2004 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and conditions, you should not access or use the website.

Orthopaedic Knowledge Online: Orthopaedic Review http://www. . and NSAIDs. MD and James L. What is the surgical treatment of congenital dislocation of the patella? Lateral release along with proximal and distal patellar realignment The distal realignment entails tuberosity osteotomy only after skeletal maturity 6. and includes activity modification. Discuss treatment for discoid menisci. you should not access or use the website. !" !" !" Surgical treatment is reserved for the rare symptomatic knees Treatment of types 1 and 2 includes partial menisectomy with meniscal contouring Treatment of type 3 discoid meniscus includes repairing the meniscus to its normal capsular attachment with partial menisectomy. MD Editors: John Sarwark." This publication and its contents may not be reproduced in whole or in part without written permission.aaos. " All Rights Reserved. Provide a classification for discoid menisci Type 1: Type 2: Type 3: Complete discoid meniscus Incomplete discoid meniscus Wrisberg type (abnormal posterior capsular attachment) 7. MD October 2004 Section 4 5.org/oko Author: Ryan Dopirak. Bond. What is Osgood-Schlatter disease and how is it treated? !" It is an osteochondrosis of the proximal tibial apophysis associated with the rapid growth of adolescence and overuse Pain and swelling is secondary to repeated tensile forces in the susceptible knee Nonsurgical management is the mainstay of treatment. casting and steroids are not recommended In 95% of patients. If you do not wish to be bound by these terms and conditions. Please read the Disclaimer agreement carefully before using the Orthopaedic Review website. an ossicle persists beyond skeletal maturity and may warrant excision if nonresponsive to conservative measures 2 !" !" !" !" ©1995-2004 by the American Academy of Orthopaedic Surgeons. you agree that you are competent and of age to enter into this Agreement and to be bound by the terms and conditions listed therein. symptoms resolve upon reaching skeletal maturity In 32% of patients. ice. By accessing or using the website. stretching. when indicated 8.

the diagnosis is likely physiologic bowing If the MDA is more than 16 degrees. no effusion. How is the metaphyseal-diaphyseal angle (MDA) useful in differentiating physiologic bowing from infantile Blount’s disease? If the MDA is less than 10 degrees. MD October 2004 Section 4 9. What is the most likely metabolic bone disease seen as a bowed leg deformity in the toddler? Rickets (all types) 13. Bond. If you do not wish to be bound by these terms and conditions.aaos. open physes 11." This publication and its contents may not be reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the Orthopaedic Review website.Orthopaedic Knowledge Online: Orthopaedic Review http://www. What is the normal alignment of the knee during normal growth and development? 10 degrees to 15 degrees of varus at birth Neutral femorotibial alignment by age 18 to 24 months Progression to femorotibial valgus which is maximal at 3 to 5 years Physiologic femorotibial valgus remodels by age 7 12. What are favorable factors for healing of OCD lesions treated nonoperatively? Lesions with a diameter smaller than 20 mm. By accessing or using the website. you agree that you are competent and of age to enter into this Agreement and to be bound by the terms and conditions listed therein. " All Rights Reserved. the diagnosis is likely Blount’s disease 3 ©1995-2004 by the American Academy of Orthopaedic Surgeons. intact articular cartilage. you should not access or use the website. MD Editors: John Sarwark. . MD and James L.org/oko Author: Ryan Dopirak. What is Sinding-Larsen-Johansson disease and how is it treated? !" !" An overuse traction phenomenon at the inferior pole of the patella Treatment is similar to that for Osgood-Schlatter disease 10.

MD and James L. MD October 2004 Section 4 14. . an isolated osteotomy is often insufficient and additional procedures are required. By accessing or using the website. with osteotomy being the mainstay of treatment 17. you should not access or use the website. What is the treatment of infantile tibia vara (Blount’s disease)? Bracing with a knee-ankle-foot orthosis (KAFO) is effective for patients younger than 3 years of age with unilateral deformity and mild disease (Langenskold III or below). proximal tibia. What is the treatment of pathologic genu valgum? In the skeletally immature patient with sufficient growth remaining. Bond. or both In the skeletally mature patient. Please read the Disclaimer agreement carefully before using the Orthopaedic Review website. If you do not wish to be bound by these terms and conditions. including medial physeal bar resection with proximal lateral tibial hemiepiphyseal stapling 16. treatment is temporary staple hemiepiphysiodesis of the distal femur." This publication and its contents may not be reproduced in whole or in part without written permission. treatment typically consists of distal femoral osteotomy 4 ©1995-2004 by the American Academy of Orthopaedic Surgeons. MD Editors: John Sarwark.org/oko Author: Ryan Dopirak.aaos. surgery is usually recommended in older children with more severe disease An isolated proximal tibial osteotomy may be successful if performed prior to age 4 in patients with less than stage IV disease In stage IV and above. " All Rights Reserved.Orthopaedic Knowledge Online: Orthopaedic Review http://www. you agree that you are competent and of age to enter into this Agreement and to be bound by the terms and conditions listed therein. Are there any known risk factors for infantile tibia vara (Blount’s disease)? The genu varum deformity in this disorder is an osteochondrosis of the proximal medial tibial metaphysis Early walking and childhood obesity contribute to excessive compressive forces across the medial proximal tibial physis that prevent normal medial physeal growth 15. How is adolescent tibia vara different from infantile tibia vara (Blount’s disease)? Patients are typically obese Treatment is surgical.

you should not access or use the website. What is the most common type of congenital pseudoarthrosis of the tibia? !" !" Anterolateral bowing Neurofibromatosis occurs in approximately 50% of patients with anterolateral bowing with or without pseudoarthrosis of the tibia 19.Orthopaedic Knowledge Online: Orthopaedic Review http://www. . MD Editors: John Sarwark. What is the most common limb deficiency syndrome? !" !" Fibular hemimelia Surgical correction is typically required.aaos. but their success is variable 20. Bond. you agree that you are competent and of age to enter into this Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and conditions. What is the etiology and natural history of posteromedial bowing? !" !" !" This is a congenital anomaly associated with calcaneovalgus foot deformity The angulatory deformity predictably remodels and pseudoarthrosis does not occur A mild to moderate limb length inequality typically results 21. this condition is typically progressive Many surgical options exist." This publication and its contents may not be reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the Orthopaedic Review website. MD and James L. surgical approach is dependent on the severity of the deformity 22. Provide a treatment algorithm for limb length inequality 0 to 2 cm 2 to 6 cm 4 to 8 cm 8 to 15 cm more than 15 to 20 cm No treatment or shoe lift Shortening (epiphysiodesis or osteotomy) Lengthening Combination shortening and lengthening Amputation or van Ness rotationplasty 5 ©1995-2004 by the American Academy of Orthopaedic Surgeons. What is the treatment of anterolateral bowing? !" !" !" Orthotic treatment is initially indicated for deformity without fracture However.org/oko Author: Ryan Dopirak. " All Rights Reserved. MD October 2004 Section 4 18. By accessing or using the website.

Bond. you should not access or use the website. By accessing or using the website. What is the incidence of ACL tear in the child or adolescent with a knee effusion? 53% 25.Orthopaedic Knowledge Online: Orthopaedic Review http://www.org/oko Author: Ryan Dopirak. nonsurgical management is preferred In patients with substantial growth remaining. . " All Rights Reserved. you agree that you are competent and of age to enter into this Agreement and to be bound by the terms and conditions listed therein.aaos. reconstruction with quadrupled hamstring grafts through anatomic bony tunnels can be performed If more than 2 cm of growth is remaining. totally displaced 6 ©1995-2004 by the American Academy of Orthopaedic Surgeons. If you do not wish to be bound by these terms and conditions. What is important to know about magnetic resonance imaging (MRI) in the diagnosis of meniscal tears in children and adolescents? It may have a high false-positive rate in this population 24. displaced Not hinged. What is the preferred management of ACL tears in the pediatric patient? If less than 2 cm of growth is remaining. MD Editors: John Sarwark. MD and James L. Classify tibial eminence fractures in children Type 1: Type 2: Type 3: Nondisplaced Hinged posteriorly. MD October 2004 Section 4 23." This publication and its contents may not be reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the Orthopaedic Review website. extra-articular reconstructions have been associated with rates of recurrent instability of 50% to 100% 26.

What is the treatment of displaced distal femoral physeal fractures? Salter-Harris Types I and II: Closed reduction with percutaneous fixation Salter-Harris Types III and IV: Open reduction and internal fixation Limb length discrepancy may occur in 32% and angular deformity in 24% of patients despite appropriate treatment 30. What is the treatment of tibial tuberosity fractures? Type I: Types II and III: Long leg cast in extension for 6 weeks Open reduction and internal fixation 7 ©1995-2004 by the American Academy of Orthopaedic Surgeons.aaos. By accessing or using the website.org/oko Author: Ryan Dopirak.Orthopaedic Knowledge Online: Orthopaedic Review http://www. MD October 2004 Section 4 27." This publication and its contents may not be reproduced in whole or in part without written permission. with type 3 fractures having the greatest degree of instability (interstitial tearing of the ACL is thought to occur prior to avulsion of the tibial eminence) 28. MD Editors: John Sarwark. regardless of treatment technique. you agree that you are competent and of age to enter into this Agreement and to be bound by the terms and conditions listed therein. if irreducible Open reduction and internal fixation Type 3: Residual objective instability of the ACL is seen in most patients. you should not access or use the website. What are the indications for nonsurgical treatment of patella fractures and patellar sleeve fractures in children? Less than 2 mm of displacement and an intact extensor mechanism 29. Please read the Disclaimer agreement carefully before using the Orthopaedic Review website. followed by long leg casting. MD and James L. " All Rights Reserved. Bond. . If you do not wish to be bound by these terms and conditions. What is the treatment of tibial eminence fractures? Type 1: Type 2: Long long leg cast in 10 to 15 degrees of knee flexion Closed reduction via hyperextension. Open reduction and internal fixation.

you agree that you are competent and of age to enter into this Agreement and to be bound by the terms and conditions listed therein. What is the potential long-term complication associated with proximal tibial metaphyseal fractures? Tibial overgrowth and progressive valgus deformity (post-traumatic tibia valga) 33. If you do not wish to be bound by these terms and conditions.org/oko Author: Ryan Dopirak. MD and James L. . MD October 2004 Section 4 31. Bond. What is the treatment of proximal tibial physeal fractures? Salter-Harris Types I and II: Salter-Harris Types III and IV: Closed reduction and long leg casting Open reduction and internal fixation 32. Please read the Disclaimer agreement carefully before using the Orthopaedic Review website. By accessing or using the website. " All Rights Reserved. MD Editors: John Sarwark." This publication and its contents may not be reproduced in whole or in part without written permission. you should not access or use the website.Orthopaedic Knowledge Online: Orthopaedic Review http://www. What are the potential long-term complications associated with distal tibial physeal fractures? Rotational deformity (typically results from failure to recognize initially and reduce) Growth arrest or angular deformity (occurs in up to 50% of significantly displaced fractures) 8 ©1995-2004 by the American Academy of Orthopaedic Surgeons. What are the criteria for closed management of tibial shaft fractures in children? Less than 10 degrees of angulation Less than 1 cm of shortening More than 50% opposition 34.aaos.