Arch Orthop Trauma Surg (2012) 132:773–779
DOI 10.1007/s00402-012-1480-0
ORTHOPAEDIC SURGERY
The epidemiology of knee injuries in children and adolescents
T. Kraus · M. Kvehlík · G. Singer ·
J. Schalamon · E. Zwick · W. Linhart
Received: 15 February 2011 / Published online: 23 February 2012
© Springer-Verlag 2012
Abstract
Background Injuries in childhood and adolescence are
frequent and the knee is one of the most common sites of
injuries. This study aimed to analyze the epidemiology,
gender distribution, age, and circumstances of knee injuries
in childhood at a Level I Trauma Center in Austria.
Methods All pediatric and adolescent trauma patients
who presented in a 2-year period were recorded. Children
managed with knee injuries were selected prospectively.
Patients were divided into Wve age groups: infants (younger
than 1 year); pre-school aged children (1–6 years); pre-
pubertal school-aged children (7–10 years); early adoles-
cent patients (11–14 years); and late adolescent patients
(15–18 years). Five diagnosis-related groups were formed:
extraarticular soft tissue injuries, intraarticular soft tissue
injuries, patella disorders, fractures, and overload injuries.
Results The study included 23,832 patients up to the age
of 18 years, who presented with 1,199 knee injuries. There
was a male predominance (m:f = 58,6%:41.4%). Boys had
a lower mean age at presentation (11.9 years) as girls
(12.3 years). The most common accident sites were out-
doors (34.8%) and sports facilities (32.8%). Leading injury
mechanisms were falls on level surfaces (58.1%) and traYc
accidents (13.4%). The number of knee injuries and its
T. Kraus (&) · M. Kvehlík · E. Zwick · W. Linhart
Department of Pediatric Orthopedics, Medical University of Graz,
Auenbruggerplatz 34, 8036 Graz, Austria
e-mail: tanja.kraus@medunigraz.at
G. Singer · J. Schalamon
Department of Paediatric and Adolescent Surgery,
Medical University of Graz, Auenbruggerplatz 34,
8036 Graz, Austria
severity increased with age. Knee injuries did not occur in
infants. In general, extraarticular soft-tissue injuries were
most common and fractures were rare.
Conclusion Knee injuries in children and adolescents are
rare and extraarticular soft-tissue injury is the most frequent
type of knee trauma. The number of knee injuries and its
severity increases with age with a male predominance.
Sports facilities and traYc injuries are important scenes of
knee trauma. Mechanisms and patterns evaluated in this
study can serve as the basis for knee-injury prevention
eVorts in children and adolescents and may be used for nec-
essary precautions.
Level of evidence: IV
Keywords Knee · Injury · Epidemiology · Child ·
Adolescent · Trauma
Introduction
Injuries are very common in childhood. In the US trauma
was identiWed to be the most frequent cause of mortality in
children up to the 17 years of age [1]. Approximately, 25%
of children are injured each year [2, 3]. Injuries account for
15% of medical costs in children and adolescents [4].
The knee joint represents one of the most common sites
of injuries [5, 6]. Pain is the leading symptom of knee inju-
ries and may result from minor injuries such as strains or
distortions or from major injuries like fractures, meniscal
tears, or torn ACL.
Knee injuries may hasten the onset of early arthritis in
young patients with poor long-term eVects [7, 8]. There-
fore, injuries to the knee joint in children and adolescents
should not be underestimated [9, 10]. While there are sev-
eral studies on the epidemiology of knee injuries in sports
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774 Arch Orthop Trauma Surg (2012) 132:773–779

Table 1 DeWned categories and their included diagnoses

Category of injury Diagnoses

Extra-articular soft-tissue injuries Strains, sprains, contusions, lacerations

Patella-disorders Anterior knee pain due to patella malalignment, subluxation of the patella, patella dislocation with or
without Xake fracture
Soft tissue intraarticular injuries Meniscal tears, collateral ligament ruptures, torn ACL
Overload injuries Embraces non-speciWc as well as known speciWc overload injuries (jumpers knee, Osgood–Schlatter
disease, Sinding–Larson disease, Morbus Menelaus Batton)
Fractures Patella, epiphysiolysis, tibial tuberosity, tibial spine fractures

[11, 12], information about epidemiologic data on knee
injuries in a general pediatric population is scarce.
The aim of this prospective study was to analyze the
incidence, demographics, and background of knee injuries
in children and adolescents based on a survey of accidents
performed over a period of 2 years. The results of this study
might help to identify the key risk factors of knee injuries in
the general pediatric population in order to develop more
eVective preventive strategies leading to a decreased inci-
dence of knee injuries in children and adolescents.
Patients and methods
The Department of Pediatric and Adolescent Surgery, Med-
ical University of Graz, Austria, is the only Level 1 Pediat-
ric Trauma Center within a catchment area covering the
entire State of Styria taking care of children and adoles-
cents up to the age of 18 years. It is part of a pediatric cen-
ter with all subspecialities. The patient data administration
is performed using a computerized documentation system
called MEDOCS, based on a SAP healthcare solution (Sys-
tem Applications and Products in Data Processing, Wall-
dorf, Germany). In 2004, a pediatric injury data entry form
was integrated to the hospital information system to collect
details on causes, location, and circumstances of all treated
accidents.
All injured children referred to the Pediatric Trauma
Center between January 2008 and December 2009 were
prospectively evaluated. Patients with knee-related injuries
up to the age of 18 years were selected for analysis. The
doctor taking care of a child at the time of the emergency
referral completed the pediatric injury data entry form.
Missing data on accident circumstances were completed
using the medical trauma reports. Statistical software pack-
age SPSS 16.0 for Mac (SPSS Inc., Chicago, IL, USA) was
used to perform the descriptive statistical analysis. In order
to facilitate the statistical analysis, accidents were described
according to several main factors: age, diagnosis, site, and
mechanism of accident. For each of these factors several
speciWc categories were deWned to allow a precise descrip-
tion of the accident.
Age categories were divided as follows: infants (younger
than 1 year); pre-school aged children (1–6 years); pre-
pubertal school-aged children (7–10 years); early adoles-
cent patients (11–14 years); and late adolescent patients
(15–18 years). In order to allow an easier analysis of the
diVerent diagnoses, Wve distinct categories were deWned as
shown in Table 1.
Clinical examination and conventional plain radiographs
were used for diagnosis. In all cases X-rays were re-evalu-
ated by a pediatric radiologist to exclude the possibility of
misinterpretation.
The sites of accident were categorized into home, school
or kindergarten, outdoors (including backyard and the play-
ground), sport facilities, traYc, and others. Similarly, the
mechanisms of accidents were categorized into falls on
level surfaces, falls from heights of less than 3 m, falls from
heights of more than 3 m, traYc accidents (including acci-
dents as pedestrian, car passenger, bicycle/motorcycle-acci-
dent), and others (e.g. involuntary lacerations caused by
contact with a person/object).
Results
During the 24-month study period a total number of 23,842
accidents were documented. Knee-related injuries were
identiWed in 1,199 patients (0.5% of all trauma cases).
There was a male predominance of overall knee-related
injuries with 703 males (58.6%) compared with 496
females (41.4%).
Age
There were no knee-related injuries in the infants group.
However, commencing from the age of 2 there was an
increase of the incidence of knee injuries until the adult-
hood with a small peak at 6 and a remarkable one at
13 years of age. Boys had a lower mean age (11.9 years) at
the time of presentation compared with girls (12.3 years).
Figure 1 shows that the number of knee injuries increased
with increasing age of the patients. Adolescents represented
the largest knee injury group with 36.3% (n = 435) in the

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Arch Orthop Trauma Surg (2012) 132:773–779
Fig. 1 Percentage of knee injuries in relation to total injuries in pedi-
atric and adolescent patients separated by age
early and 35.9% (n = 430) in the late adolescence. In the
school-aged pre-puberty group we found 19.8% of injuries
(n = 237), whereas there were 8.1% (n = 97) of knee-
injured patients assigned to the pre-school age group.
Accident site
Two-thirds of the accidents happened outdoors (34.8%) or
at sport facilities (32.8%). TraYc accidents (13.8%) and
knee injuries at home (11.5%) were half as frequent. Only
4.3% of knee injuries were caused by accidents at school or
kindergarten. In 2.8% the exact accident site was not
known. The accident sites of the diVerent age groups are
shown in Fig. 2.
Fig. 2 Distribution of accident sites according to age groups without
infants
775
Fig. 3 Distribution of injury mechanisms according to age groups
without infants
Mechanisms of injury
The most common mechanism of injury was a fall on level
surfaces (58.1%). TraYc injuries were found in 13.4% of
the cases followed by falls from heights of less than 3 m
(9.7%). These three mechanisms accounted for the vast
majority of all knee injuries (81.2%).
The remaining 18.8% of the accidents were distributed
between crush injuries (7.3%), falls from heights of more
than 3 m (3.4%) and other types of injury mechanisms such
as involuntary contact with persons or objects (5.3%). In
2.8% of the cases the exact mechanism of injury was
unknown. The mechanisms of injuries of the diVerent
against age are presented in Fig. 3.
Diagnosis
Extraarticular soft tissue injuries were the most common
injuries of the knee joint accounting for 82.7% of all inju-
ries. Patella disorders represented the second most common
diagnoses with 8.8%. Intraarticular soft tissue injuries were
found in 4.3% followed by overload injuries with 3.2%.
Fractures were rarely diagnosed and accounted for 1.1% of
the cases. Gender distribution is shown in Table 2.
Pre school age group
Knee injuries in the pre-school aged group were rare (8.1%).
The leading injury mechanism in this age group was fall on
level surface (59.8%), e.g. while playing in the yard, fol-
lowed by traYc accidents (14.4%) and falls from height of
less then 3 m (13.4%). The most frequent accident sites were
outdoors (46.4%) and home (26.8%). In this age group
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776 Arch Orthop Trauma Surg (2012) 132:773–779

Table 2 Gender distribution of the diVerent diagnosis groups in relation to the age groups
Age groups Sex Diagnosis

Extraarticular Overload Fractures (%) Intraarticular Patella Total of Percent of

soft tissue injuries (%) soft tissue disorders (%) diagnosis (%) total injuries
injuries (%) injuries (%)

Pre-school age M 64.9 64.9 5.3

F 35.1 35.1 2.8
School-aged pre puberty M 55.9 33.3 50 20.0 53.2 9.3
F 44.1 66.7 50 80.0 100.0 46.8 10.5
Early adolescence M 62.4 63.2 50 64.3 37.5 60.5 14.4
F 37.6 36.8 50 35.7 62.5 39.5 21.9
Late adolescence M 57.5 56.2 75.0 68.8 55.7 58.4 14.9
F 42.5 43.8 25.0 31.2 44.3 41.6 20.9

exclusively extraarticular soft tissue injuries were diagnosed caused by high-speed trauma during sports (skiing). Frac-
(100%). Boys were twice as often aVected as girls. tures were rare (0.7%) and more frequent in boys.

School-aged pre-puberty group Late adolescent group

In this age group the most frequent injury mechanisms were
falls on level surfaces (57.8%; mainly related to leisure
time activities) and traYc accidents (10.5%). Falls from
heights of less than 3 m were found in 8.4% while crush
injuries accounted for 7.6%. Most injuries occurred out-
doors (43.5%) and at sports facilities (27%).
In the vast majority extraarticular soft tissue injuries
were diagnosed (93.7%). Patella disorders and intraarticu-
lar soft-tissue injuries were rare (2.1% each). Intraarticular
soft-tissue injuries in this age group occurred more often in
girls than in boys (4:1). Overload injuries were diagnosed
in 5.9% and almost in all cases related to soccer, with a
male predominance. Fractures were found in 2.9% and
were more frequent in girls.
Early adolescence group
The leading injury mechanism was fall on level surfaces
(57.2%) followed by traYc accidents (14.2%) and falls
from height of less than 3 m (7.7%). The main accident
sites in this age group were sport facilities (33.7%), traYc
(26.7%), and outdoors (25.6%).
In contrast to the younger age groups the number of
extraarticular soft tissue injuries decreased (72.8%) but was
still the most common diagnosis. However, patella disor-
ders were most common in this subgroup (14.2%) with an
equal distribution between boys and girls. The percentage
of soft tissue intraarticular injuries was 7.4% with a boy to
girl ratio of 2:1. In addition the majority of fractures were
identiWed in this age group (61.5% of all fractures) with
boys being aVected three times more often compared with
girls. Approximately one-third of fractures were caused by
traYc injuries.

The most frequent accident mechanisms in the early adoles-

cence group were falls on level surface (56.3%), traYc
(13.3%), and falls from heights of less than 3 m (11.5%).
Crushes were responsible for 8.5% of injured patients in
this age group. Accidents occurring outdoors (36.6%) and
at sports facilities (37.9%) were responsible for about two-
thirds of the accidents.
Again, the main diagnosis was extraarticular soft tissue
injury (82.5%). In the early adolescence age group we were
able to demonstrate the highest number of overload injuries
(4.4%) with a clear male preponderance (2:1). Patella disor-
ders were found in 9.2% with girls being twice as often
aVected than boys. The number of intraarticular soft-tissue
injuries was 3.2% with a boy to girl ratio of 2:1 and mainly
Discussion
Knee injuries are the most common cause of permanent dis-
ability [13]. Especially the high proportion of knee injuries
requiring surgical intervention among young sport partici-
pants is alarming [14]. The epidemiology of sports-related
knee injuries is well described in the literature [15, 16].
However, there is a lack of knowledge concerning the epi-
demiology of knee injuries in a general pediatric popula-
tion. The aim of this study was to describe demographics,
circumstances, and types of knee injuries in a cohort of
1,199 pediatric patients treated with knee-related injuries
over a period of 24 months. Data derived from this analysis

123
Arch Orthop Trauma Surg (2012) 132:773–779
may help to prevent knee injuries and thereby reduce the
costs of medical care.
Our data show that knee injuries among young patients
are relatively rare: only 0.5% of 23,842 accidents in chil-
dren and adolescents were related to the knee. These num-
bers diVer when compared with an adult population. In
47,850 adult patients, Nielsen and Yde [17] reported acute
knee injuries in 6% of the patients. While there is clear
female gender predominance in the adult population [18],
our data reveal higher injury rates in boys. This Wnding is
consistent with earlier studies [19, 20].
To omit the gender-related source of bias in our study
the gender distribution in our catchment area was assessed.
We found a nearly equal distribution of sexes (51% male;
n = 914,367 and 49% female; n = 869,900) for children and
adolescents aged 0–18 years http://www.statistik.at. The
higher number in injured boys and the lower mean age at
the time of presentation might be related to their more
aggressive behavior and higher activity level [21, 22].
There were no knee injuries in the infants group. This
may be related to the fact that infants are mainly exposed to
falls from heights resulting in trauma to diVerent body
regions such as the head [23] or upper extremities.
In pre-school aged children (aged <6 years) exclusively
extraarticular soft tissue injuries were found. Moreover, the
group of extraarticular soft tissue injuries accounted for
more than 80% of all knee injuries in our study. This rate is
much higher compared with Wndings of other studies; how-
ever, these studies focused on sports-related injuries while
our study was focused on a general pediatric population
[24].
In the school-aged prepuberty group 80% of the intraar-
ticular soft tissue injuries occurred in girls. Neuromuscular
[25] patterns in males and females diverge substantially
during maturation. Males demonstrate increases in power,
strength, and coordination with age that correlate with their
maturational stage [26, 27], whereas, on the average, girls
do not appear to make a similar neuromuscular adaptation
[28, 29]. This potentially leads to decreased dynamic knee
stability and more severe knee injuries—a well-described
phenomenon in female athletes [29]. Neuromuscular adap-
tation and coordination may lose pace with skeletal growth
at the time age of 12 [30, 31]. Despite these Wndings, our
data showed an earlier age which might be explained by an
earlier onset of puberty nowadays [32].
Falling on level surface mainly resulted in extraarticular
soft-tissue damage and severe injuries were rare. Younger
children have relatively limber joints [33]. This may protect
against severe intraarticular injuries because structures can
act in a more Xexible way against forces occurring during
traumata.
In our collective a Wrst peak of knee injuries was noted
around the age of 6 in both genders, a time that correlates
777
with start of the compulsory education in our country. A
second peak of incidence occured during the early adoles-
cence, a time that correlates with the pubertal growth
spurt—a mentally and also bodily susceptible time during
growth [34].
Most of the knee injuries in early age groups happened
at sports centers or outdoors (Fig. 2), while the numbers of
accidents at home were low. There is an ongoing trend
towards organized sports activities starting at school age in
the recent years. Sports can increase strength, endurance,
and Xexibility while improving weight management and
self esteem [35, 36]. Unfortunately, these beneWts are coun-
terbalanced by the risk of sports-related injuries [19, 37].
High rates of sports-related injuries have a signiWcant
impact on the individual, parents, and the health care sys-
tem [25]. Sports injury in children and adolescents may
also potentially aVect their involvement in future physical
activities [38]. Therefore, the prevention of sport injuries
should be an important issue not only for sports profession-
als but also for the general population. Knee injury prevention
programs do already exist (http://www.childrensmemorial.
org/depts/sportsmedicine/program.aspx) [39, 40–43]. Adapted
particularly for female athletes who are prone to knee inju-
ries due to their anatomic and hormonal diVerences [41], many
of these programs show a clear beneWt for the participants
[42, 44].
Injury prevention eVorts such as functional training to
improve muscle reaction time and proprioception or muscle
strengthening therefore should be implemented into daily
training routine to mitigate the rate and severity of knee
injuries. Physical examination (medical screenings) may
lead to the diagnosis of muscular dysbalances or functional
restrictions. Moreover, medical coverage during sports
events should be taken for granted. Further possible ways
to decrease the rate of sports-related injuries include the
proper use of protective equipment [45], adequate Weld/sur-
face playing conditions, and the changes of rules in sports.
The increased incidence of knee injuries in males cannot
be fully explained by their higher participation rate in sport
activities. During puberty several bodily and psychosocial
changes occur [46]. The behavioral changes in boys
prepares them to adopt a somewhat more aggressive and
risk-taking attitude. This risk-taking is part of normal ado-
lescence with a certain amount of “eustress” as necessary to
build self-conWdence, enhance competence and provides
reinforcement for taking initiatives [47]. Risk-taking
behaviors are the most serious threats to adolescent health
and well-being [48].
On the other hand, combination of peer pressure and
puberty can provide enough motivation for the teen to
adopt healthier lifestyle habits and therefore take part in
sports activities more frequently. With the beginning of
puberty leisure time-activities get more gender-speciWc
123
778
with remarkable diVerences between boys and girls. Boys
often get hurt in competitive sports like football [22]
while—on the contrary—girls injure their knees more often
during non-competitive sports. Gender disparities might be
also caused by diVerences in size, speed, and strength of
athletes or intensity of play [49]. Furthermore, there is the
factor of underdeveloped coordination and immature reX-
exes during growth and pubertal development. All of these
factors might lead to increased rates of knee injuries in
sports during puberty [50]. However, the gender-related
diVerences of the incidence of knee injuries might disap-
pear in the future as girls are participating more often in
activities with increased physical risks [22].
We were able to show that traYc-related knee injuries
are infrequent during childhood. However, a rapid increase
of these injuries was observed in late adolescence corre-
sponding well with the age of obtaining a motorcycle-driv-
ing license in our country. As teenagers are unexperienced
drivers, motorcycle accidents are frequent and can lead to
severe injuries with the knee being an exposed body part.
Additionally, there is a lack of awareness and inability to
recognize and evaluate risks in puberty [50, 48] combined
with overestimation of own capabilities that may contribute
to the increased prevalence of traYc injuries. Prevention
should focus on education of teenagers in traYc rules as
well as training of practical driving skills. The adolescents
should be encouraged to routinely wear protective gear and
regularly practiced safety trainings may also reduce the
number of traYc accidents.
Several limitations to this study can be noted. First of all,
not every patient had an X-ray of his knee. Therefore, we
cannot rule out that a bony injury has been missed. How-
ever, as radiation exposure is potentially harmful, the
implementation of a radiograph—especially in the imma-
ture skeleton—should be weighted carefully [51]. Most
fractures lead to characteristic clinical Wndings (e.g. pain,
swelling, limping). In case of such symptoms the attending
physician would have included an X-ray. Therefore, the
number of missed fractures in this study is probably negli-
gible.
Another limitation might be the missed cases, which
were not referred to our hospital and treated by general
practitioners, pediatricians, and orthopedic specialists.
Nevertheless, most children with acute knee injuries
within the catchment area are immediately referred to our
hospital emergency department. Furthermore, severe
intraarticular injuries may be overlooked at Wrst presenta-
tion and the Wnal diagnosis may be found during follow-
up investigations [52]. In the present study, the initial
diagnosis set up by a pediatric orthopedic surgeon was
used for evaluation.
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Arch Orthop Trauma Surg (2012) 132:773–779
Conclusion
Knee injuries are rare in pediatric and adolescent patients
while their severity increases with age. The majority of
injuries are mild, extraarticular soft tissue injuries are the
most frequent types of knee trauma, and sports injuries are
frequent. Boys are aVected most commonly except in the
occurence of patella disorders. Knee trauma related to
traYc injuries mainly occurs in older children. The results
of this study may facilitate development of future preven-
tive programs to decrease the rate and severity of the knee
injuries.
Acknowledgments The authors would like to acknowledge the
Austrian Committee for Injury Prevention in Childhood, Safe Kids
Austria (Grosse Schuetzen Kleine) for its valuable support.
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