Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103120

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Review article

Treatment of knee sprains in children

Elie Choufani a,b,∗

, Sébastien Pesenti a,b , Franck Launay a,b , Jean-Luc Jouve a,b

a
AP–HM, Service d’orthopédie pédiatrique, hôpital Timone-Enfants, 264, rue St-Pierre, 13005 Marseille, France
b
Aix-Marseille université, faculté de médecine, 27, boulevard Jean-Moulin, 13005 Marseille, France

a r t i c l e i n f o a b s t r a c t

Article history: The incidence of knee sprains in children is steadily increasing. Skeletal immaturity and anatomical fea-
Received 30 October 2020 tures of the child’s ligamentous structures explain the frequency of bone avulsions in young children.
Accepted 14 January 2021 Peripheral ligament injuries are the most common and often benign. Nevertheless, associated injuries
of the cruciate or patellofemoral ligament(s) are not rare and must not be missed. Age is a determining
Keywords: factor in diagnostic guidance. Anterior intercondylar tibial eminence fractures, otherwise known as tibial
Peripheral sprains spine fractures (TSF), usually occur in young children. Ligamentous distension at the time of the acci-
TSF
dent would explain the residual laxity that can affect the prognosis of these fractures. The treatment of
ACL repair
ACL reconstruction
interstitial ruptures of the ACL follows recommendations that are becoming clearer through multicen-
Return to sport tric studies. Reparation techniques, historically rejected as ineffective, have again become topical under
specific conditions with the aim of preserving the native ACL and its proprioceptive receptors, which
are essential in children. ACL reconstruction techniques have made progress in children, especially with
techniques adapted from adults. Preservation of growth plates remains pertinent, especially at the femur
to avoid growth disorders, thus highlighting the important role paediatric orthopaedic surgeons have in
the management of these knee sprains.
© 2021 Elsevier Masson SAS. All rights reserved.

1. Introduction has also contributed to this increase by accurately and rapidly

detecting meniscal, ligamentous and osteochondral injuries.
Knee sprains in children have increased in recent years, thus Five questions arise and we will try to answer them in this paper:
prompting paediatric orthopaedic surgical societies to develop pre-
ventive measures to reduce these injuries and the psychosocial
consequences they have on the child and his/her family, educa-
tional and sporting environment [1]. The early participation of
• What are the anatomical features of ligamentous knee structures
children in high-risk sports partially explains this increase because
in children?;
of the large number of sports-study high schools and training cen-
• Are peripheral knee sprains in children always benign?;
tres for minors. The ease of using an MRI and its radiological safety
• What are the factors that influence the occurrence of an anterior
ligament sprain rather than a tibial spine fracture (TSF) and how
to deal with possible laxity after TSF?;
• When should you consider repairing a cruciate ligament sprain
∗ Corresponding author at: AP–HM, Service d’orthopédie pédiatrique, hôpital
in children?;
• What are the “up to date” features of reconstruction techniques
Timone-Enfants, 264, rue St-Pierre, 13005 Marseille, France.
E-mail address: elie.choufani@ap-hm.fr (E. Choufani). for ACL/PCL injuries in children?

https://doi.org/10.1016/j.otsr.2021.103120
1877-0568/© 2021 Elsevier Masson SAS. All rights reserved.
E. Choufani, S. Pesenti, F. Launay et al.
Fig. 1. ACL and lateral capsule bone avulsions (author’s collection).
2. What are the anatomical features of ligamentous knee
structures in children?
The characteristics of the ligamentous structures of the child’s
knee depend on the age and their anatomical situation.
The younger the child, the more elastic the ligament. Since the
resistance of the growth plate-metaphyseal bone interface is lower
than that of the ligament, in young children, physeal fractures
and/or apophyseal injuries are more frequent. The closer the child
comes to adolescence, the greater the loss of ligament elasticity. At
the same time, resistance of the interface between the growth plate
and metaphysis increases. Traumatic forces then quickly lead to
greater ligament plastic lesions (definitive stretching lesions) and
indeed ligament breaking in place of physeal fractures (i.e. Young’s
modulus).
Anatomically, the ligaments of the child’s knee are inserted on
the epiphyses except for the tibial insertion of the medial collateral
ligament (MCL), which is metaphyseal. These anatomical relation-
ships between growth plates and ligament insertions may explain
the relative frequency of epiphyseal avulsion fractures.
Structurally, the collagen fibres of the child’s ligaments are in
continuity with the perichondrium of the epiphyseal cartilage. This
explains the frequency of bone avulsions at ligament insertion sites
(Fig. 1).
2.1. Mechanism of injury
In pivoting sports, the knee is often flexed. Two situations can
arise [2]:
• the pivot/flexion is associated with external rotation
(pivot/flexion/ER): the cruciate ligaments relax and the col-
lateral ligaments tighten. The stability of the knee depends on
the collateral ligaments. The risk of damage to the collateral
ligaments is highest, especially to the MCL. The risk of patellar
dislocation is also significant.
2
Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103120
Fig. 2. Grade 1 right knee MCL sprain (author’s collection).
• the pivot/flexion is associated with an internal rotation
(pivot/flexion/IR): the cruciate ligaments twist and the collateral
ligaments relax. The stability of the knee then only holds to the
cruciate ligaments. The risk of ACL injury is maximal.
3. Are peripheral knee sprains in children always benign?
According to Chotel [3], knee ligaments are affected in such a
proportion that: 7/10 MCL, 2/10 LCL (lateral collateral ligament),
1/10 cruciate ligaments.
Collateral ligament knee injuries are the most common cause
of knee ligament sprains. They are not usually associated with
hemarthrosis unless accompanied by ACL/PCL involvement [4]. The
classification into 3 grades is of prognostic and therapeutic interest:
• Grade 1: elongation (no laxity at 20◦ flexion);
• Grade 2: partial rupture (joint space widening with a clear stop
when testing laxity);
• Grade 3: complete rupture (joint space widening without a well-
defined stop when testing laxity).
MRI remains the baseline for these peripheral sprains:
• in a grade 1 sprain of the MCL, the deep fibres are broken with rup-
ture of the medial meniscofemoral ligament while the superficial
fibres remain intact (Fig. 2);
• in a grade 2 sprain, the deep and superficial fibres are injured but
remain attached proximally and distally;
• in a grade 3 sprain, complete rupture of the MCL at the level of
the joint or at its tibial insertion.
E. Choufani, S. Pesenti, F. Launay et al.
Fig. 3. LCL proximal avulsion (author’s collection).
Collateral ligament injuries exist as well as cruciate ligament
injuries and are increasingly seen with competitive sports that chil-
dren now do at a young age. The reported risk factors are rotational
abnormalities of the lower limbs and hyperlaxity.
Almost all the studies reporting collateral ligaments injuries are
associated with cruciate ligaments injuries but only a few studies
focus on isolated lesions. Among them, Kramer [5] studied 51 knees
under the age of 17 who had an isolated injury of the collateral
ligaments confirmed by MRI. Ten percent of these were bone avul-
sions (Fig. 3). According to the authors, high-grade injuries occur
with football while low-grade injuries occur with skiing. A history
of knee sprains is a risk factor in low-grade sprains. Conservative
treatment (immobilization for one to three weeks and physiother-
apy) is indicated. Return to sport occurs, on average, after two
months.
Of the 51 knees studied, 40 had MCL injuries (78%) and 11 had
LCL injuries (22%). The results previously reported at the 2006 SOF-
COT symposium were similar.
Moreover, it was found that 25% of isolated injuries of the MCL
are associated with patellofemoral instabilities and 25% of isolated
injuries of the LCL are associated with posterolateral corner (PLC)
injuries; lateral collateral ligament, popliteus tendon.
Injuries associated with collateral ligament injuries (excluding
the ACL and PCL) are often surgically treated; medial patellofemoral
ligament (MPFL) and PLC. Von Heideken [6] in a series of 6 PLC
injuries among which 5 were treated surgically.
The majority of isolated collateral ligament injuries are treated
conservatively with immobilization and rehabilitation. Even in
grade 3 injuries, there is no benefit of surgical treatment over
conservative treatment [7]. Surgery is only needed for chronic
collateral laxity and when injuries involve collateral and cruciate
ligaments. Sankar [8] showed good results in the management of a
paediatric series of ACL/MCL lesions by conservatively treating the
MCL while ACL surgery was delayed.
In conclusion, collateral ligament injuries are common amongst
ligament injuries of the knee. They are considered benign because
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Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103120
they often do not require surgical treatment. If weight bearing
is painful, an X-ray is necessary to eliminate a physeal injury or
an osteochondral tear. MRI should be reserved for high-energy
injuries, with hemarthrosis, to eliminate an injury of the PLC, or
meniscal, chondral and cruciate ligaments injuries, which make
the treatment of these collateral ligament injuries surgical, in these
specific cases.
4. What are the factors that influence the occurrence of an
anterior cruciate ligament sprain rather than a tibial spine
fracture (TSF) and how to manage possible laxity after TSF?
Age plays an important role in the injury mechanism: in children
under 12 years of age, a bone avulsion or tibial spine fracture (TSF)
represent 80% of cases involving cruciate ligaments. In children
under 8 years of age, in case of hemarthrosis with a normal X-ray, a
pure cartilaginous tear must be questioned [9]. Conversely, in chil-
dren over 12 years of age, intra-ligament rupture is more common
and found in up to 90% of damage to the cruciate ligaments.
4.1. TSF
The overall annual incidence is 3 per 100,000 children [10] and
concerned 2 to 5% of knee hemarthroses in children. The usual age is
between 8 and 14 years. The mechanism consists of a frontal direct
impact on a flexed knee. The ligament is more resistant (elastic and
plastic) than its bone insertion, which leads to tearing, but this does
not prevent ligament distension before tearing, a concept described
by Noyes in 1974. The association with meniscal tears (29–40%),
meniscal entrapment (29–35%) and ligament injuries outside the
ACL (32%) [11] demonstrates the value of MRI before management,
even in orthopaedic treatment. The diagnosis remains radiological
(lateral view) and the most used classification, of therapeutic inter-
est, is that of Meyers and McKeever [12] (Fig. 4) which suggest 4
types:
• Type 1: non-displaced (20%);
• Type 2: displaced anterior margin, hinged posterior cortex (50%);
• Type 3: completely displaced (30%);
• Type 4: comminuted (< 5%).
4.1.1. Treatment
• Type 1: treatment is orthopaedic by immobilization using a long
leg cast for a duration of 4 to 6 weeks in slight flexion of 10◦ to
20◦ ;
• Type 2, 3 and 4: treatment is surgical arthroscopy or arthrotomy
to restore joint congruence and stable attachment of the torn
fragment;
• Peculiarity of type 2: treatment leans towards surgical treat-
ment but can be orthopaedic (6 weeks in a long leg cast) if the
hyper-extension manoeuvre leads to anatomical reduction with-
out secondary displacement in the first degrees of knee flexion.
Surgical treatment is indicated when an anatomical and sta-
ble reduction is impossible. Then, association with entrapment
of the anterior horn of the medial or lateral meniscus or the
inter-meniscal ligament must be suspected. The treatment of
entrapment can be either the retraction or even the resection
of the entrapped part [13]. Arthroscopic suture in TSF type 2 [14]
showed better results (IKDC and Lyshlom scores) compared to
orthopaedic treatment, especially with a significant difference in
the improvement of residual laxity.
4.1.2. Fixation method
The goal of the treatment is to restore the joint congruence and
make a stable osteosynthesis. This is achieved through suturing,
E. Choufani, S. Pesenti, F. Launay et al.
Fig. 4. Meyers and McKeever classification of TSF (photo by author).
lacing, screwing or “endobutton”. Hunter et al. comparing arthro-
scopic suturing and screwing noted no difference between the two
techniques [13]. In a meta-analysis of 26 articles, Gans [15] found
that arthroscopic techniques were comparable to open techniques
whatever the method used (screws vs. suture-lacing).
4.1.3. Outcome
An anatomical reduction does not guarantee the absence of
residual laxity. This is related to the plastic elongation of the lig-
ament at the time of stretching. However, several studies show an
excellent functional result (an absence of instability) despite the
presence of residual laxity [16].
4.1.4. Complications
4.1.4.1. Stiffness. There are several risk factors:
• prolonged immobilization. According to Patel [17], a duration
of more than 4 weeks increases the risk of stiffness and delays
the return to sport especially in adolescents. Conversely, a stable
osteosynthesis is recommended for early mobilization (Fig. 5);
• delayed surgery (≥ 7 days) or prolonged surgery (≥ 120 minutes)
[18] are risk factors for postoperative stiffness. The authors go
so far as to recommend open treatment (ORIF) when no trained
surgeon is available for arthroscopic treatment (ARIF). They rec-
ommend that the mastered technique should be chosen in every
case;
• the child’s age: the older the child, the greater the risk of a high
level of postoperative stiffness;
• a high-energy accident is an additional risk factor related to the
association with other collateral ligament injuries.
4.1.4.2. Residual laxity. ACL laxity is a common complication,
which is often seen after both conservative and surgical treatment.
It is related to interstitial damage (elongation) of the ACL at the time
of the accident. Residual laxity was found in 22% of patients treated
with conservative orthopaedic treatment versus 10% of patients
treated surgically. Patients treated with conservative orthopaedic
treatment are more likely to require a subsequent ACL reconstruc-
tion (10% vs. 1% p = 0.036) [19].
Age is a risk factor for ACL reconstruction. Mitchell [20] found
that 19% of patients under 18 years of age with TSF underwent
ACL reconstruction and that the risk increases with age by a fac-
tor of 1.3 for each year. Hence the importance of bringing this
4
Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103120
complication to the attention of parents. Mitchell did not find a
relationship between the type of TSF and undertaking ACL recon-
struction. Whereas Gans [15] found more laxity on Lachman testing
and the anterior drawer test as well as a rotational hop test in types
3 and 4 than in types 1 and 2.
However, residual laxity is not systematically expressed by clin-
ical instability. Then, the use of ACL reconstruction must not be
systematic. Countersinking of the hole of the tibial footprint is a
way to reduce laxity related to the elongation of the ACL.
4.1.4.3. Pseudarthrosis. Pseudarthrosis is a rare complication of
TSF. Gans [15] found a rate of 1.7% (10 out of 580). The majority
were Type 3 TSF, treated conservatively. It is responsible for pain,
laxity and limited range of motion of the knee. It is due to imperfect
reduction, defective fixation or orthopaedic treatment. The treat-
ment consists of a revision of the fixation or even reconstruction
of the ACL in the event of laxity. In the case of incomplete range
of motion, inter-condylar notch reshaping and debridement of the
anterior part of the ACL are required.
It is important to note that there are limitations to the TSF
studies; they are mostly retrospective, on small series, with a
heterogeneity of surgical techniques. Even if former studies have
shown good results with ARIF and ORIF techniques, the objective
advantages and disadvantages of each technique cannot be clearly
identified due to the low level of evidence in the literature. This is
also true for fixations: screws (rigidity) versus lacing (biomechan-
ical superiority).
5. When should acute repair of a cruciate ligament sprain
be considered in children?
Historically, repair of interstitial ACL injuries resulted in unac-
ceptable failure rates. The analysis of these failures led Taylor and
DiFelice, in a literature review [21] to identify a group of patients
who, unlike the others, had good repair results. These patients had
proximal ruptures of the ACL with good ligament quality. They
performed preclinical studies which concluded that:
• stabilization of the knee with a direct suture of ACL improves
healing and biomechanical properties of the ligament;
• there is an improvement in repair with local application of
platelet-rich plasma (PRP);
• histological and biomechanical results in children are improved;
E. Choufani, S. Pesenti, F. Launay et al.
Fig. 5. TSF stage 3 fixed by screwing (author’s collection).
• frequency of subsequent osteoarthritis is decreased;
• the repaired native ACL has better biomechanical performance
than the reconstructed ACL.
For these reasons, the acute repair of an ACL rupture has become
topical again, nevertheless subjected to two conditions [22]:
• proximal rupture (type 1), MRI classification: Type 1 (distal frag-
ment length > 90%), Type 2 (75%–90%), Type 3 (25–75%)
• good tendon quality (Good), MRI Classification:
Good/Average/Poor
This repair must be done within three months after the rupture
under arthroscopy by lacing-anchoring ± internal reinforcement.
Recent studies in skeletally immature children show good
results when the above indications are respected (proximal type
1 rupture and good ligament quality), however these studies were
small series and sometimes reported the use of a synthetic rein-
forcement:
• Smith et al. [23] reported 3 patients with internal reinforcement
(removed at 3 months), with 2 years of follow-up;
• Bigoni et al. [24] reported 5 patients without internal reinforce-
ment, with 4 years of follow-up.
Other techniques are becoming topical again with the aim of
preserving the native ACL. They are more interesting in children
because of the potential for biological regeneration in children.
In 2006, Steadman introduced a principle he named the heal-
ing response [25]. This was based on the stimulation of the bone
marrow by micro-fractures in the femoral footprint of the ACL asso-
ciated with intra-ligamentous injection of PRP. Between 1992 and
1998, the authors reviewed 13 children with partial ruptures of the
ACL who benefited from this technique. The re-rupture rate was
23% (3/13). Ten of the patients could return to sport and did not
need further surgeries after 69 months of follow-up.
In 2018, Koch [26] reused this technique for the treatment of
proximal partial ACL ruptures by associating micro-perforation
of the femoral footprint with the intra-ligamentous injection of
autologous conditioned plasma. The authors found a statistically
significant improvement in objective and subjective scores with a
residual laxity rate of 9.5% and a return to sport after 4.8 months.
ACL repair techniques are an interesting alternative. The indica-
tions are mainly fresh proximal ruptures with good tendon quality.
Preliminary results are encouraging with a more rapid return to
5
Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103120
sport than with reconstructive ACL techniques (role of the preserva-
tion of proprioceptive receptors in the native ACL?). The follow-up
of international cohorts will give us, in the coming years, a clear
idea of the longevity of these techniques, knowing that the use of
reconstruction remains a possibility in the event of failure.
6. What are the “up to date” features of reconstruction
techniques for cruciate ligament injuries in children?
Faced with a confirmed ACL rupture in a growing child, two
treatment options are available: conservative treatment and sur-
gical treatment.
Conservative treatment does not mean therapeutic abstention.
A rigorous rehabilitation program is necessary, accompanied by
close medical follow-up, thus allowing the child to resume their
pivoting sport. Proponents of conservative treatment rely on the
growth potential of the child’s knee, which is at risk of being harmed
by adult ACL reconstruction techniques.
Surgical treatment on the other hand, is indicated when the
stability of the knee is not ensured by conservative treatment (fail-
ure of conservative treatment with episodes of clinical instability
and meniscal injuries testifying to this instability). Proponents of
surgical treatment rely on surgical techniques specific to children
(“extraphyseal”, “transphyseal”, “epiphyseal” or mixed).
Several studies in the 1990s have shown that the conservative
treatment of an ACL rupture in children with open growth plates
approximates the natural history of this rupture with the following
consequences (Table 1):
• instability: with more than 90% after two years of follow-up;
• secondary (internal) meniscal injuries: 50% with meniscal
injuries at one year of follow-up;
• cartilaginous injuries (early osteoarthritis): 50% with abnormal
X-rays at 5£years of follow-up.
In a recent study by the French Arthroscopic Society (SFA) in
2017 [27], conservative treatment was evaluated in a cohort of 53
patients with a follow-up of 31.5 months including good rehabilita-
tion program observance (OSLO Protocol). Using precise inclusion
criteria as well as the exclusion of children with major clinical insta-
bility (more than two episodes of instability) and children with an
initial meniscal injury, the success rate of this conservative treat-
ment was 81% when 17% had meniscal injuries, 36% instability and
E. Choufani, S. Pesenti, F. Launay et al. Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103120

Table 1
Results of conservative treatment through literature (inspired by Madelaine et al.) [27].

Authors Year Cohort size Age (years) Follow-up (years) Meniscal injuries ACL reconstruction

Graaf et al. 1992 12 14.5 2 58% 0%

Mizuta et al. 1995 18 12.8 4.3 33% 33%
Madelaine et al. 2017 53 11.7 3.2 15% 40%

Fig. 6. ACL reconstruction techniques in children (photo by author).

a 40% rate of ACL reconstruction surgery. The predictors of surgery Table 2

Relative risk of occurrence of femoral physeal bone-bridges (inspired by Gicquel
were clinical instability and meniscal injuries.
et al.) [28].

6.1. ACL reconstruction techniques Parameters Relative risk

ST6 2.1
Several techniques have described ACL reconstruction in chil- ST4 0.5
Quadriceps tendon 0.8
dren (Fig. 6). These techniques differ by the type of graft used
Fascia lata 1.3
(hamstrings [ST6, ST4], patellar tendon, tensor fascia lata, soft Tunnel > 9 mm 1.7
patellar tendon) and the location of the tunnels (epiphyseal, extra- Epiphyseal tunnel 1.6
physeal, transphyseal or mixed). Transphyseal tunnel 1.2
The main point is to avoid iatrogenic damage to the growth Over the top 0

(i.e. epiphysiodesis) of the knee given that the femoral and tib-
ial tunnels. These described in adults, pass through growth plates
responsible for 70% and 55%, respectively, of the growth in chil- Table 3
dren’s around knees (1.2 cm/year for the femur and 0.8 cm/year for Relative risk of occurrence of tibial physeal bone-bridges (inspired by Gicquel et al.)
the tibia). [28].

This leads us to respect a few safety rules that remain relevant: Parameters Relative risk

ST6 1.4
• bone harvesting from the anterior tibial tuberosity (i.e. Kenneth- ST4 0.3
Jones’ technique) should be avoided due to the risk of damaging Quadriceps tendon 3.6
the anterior tibial tuberosity growth plate resulting in a hyper- Fascia lata 0
Epiphyseal tunnel 0
extension deformity;
Interference screw 3.7
• the transphyseal tunnel must not exceed 9 mm in diameter;
• the rotation of the drill should be slow especially when going
through the growth plate;
• the perichondral vascularization should be respected;
• the tibial tunnel should be more vertical than in the adult tech- found 20% of physeal bridge-type abnormalities. The risk factors for
nique; these abnormalities were:
• interference screws should not be let through the growth plate.

A recent study conducted by the SFA in 2017 [28] of 71 patients • at the femoral level (Table 2): the type of graft (DIDT) and the
operated on with ligamentoplasty when open physes found no diameter of the tunnel (≥ 9 mm) and its location (epiphyseal);
clinical or radiological growth abnormalities (such as unequal • at the tibial level (Table 3): the type of graft (patellar tendon) and
length > 10 mm or an axis disorder > 5◦ ). Nevertheless, MRI analysis type of fixation (interference screw).

6
E. Choufani, S. Pesenti, F. Launay et al.
6.2. Return to sport and re-rupture
In another multicentric study (2017), the SFA [29] evaluated sur-
gical treatment results on the return to sport and the re-rupture
rate. In the “open physis” group, the percentage of bad results (re-
rupture or an IKDC score of C or D) was 20% with a re-rupture rate
of 9% against 2.8% in the “closed physis” group.
The tibial tunnel was transphyseal in 95% of cases and the
femoral tunnel was transphyseal in 60% of cases (clear trend
toward transphyseal techniques). This rate was independent of
the technique used (technique with epiphyseal, transphyseal, ext-
raphyseal or mixed tunnels) or of the choice of transplant (ST6,
semi-tendinous ST4, patellar tendon or fascia lata). The return
to sport was slower than in adults (13 months for training and
14 months for competitions) with a return to competitive sports
rate of 63.5% in the group “open physis” against 55% in the group
“closed physis”.
In conclusion, current trends in the treatment of intraligamen-
tous ACL ruptures in children can be summarized as follows:
• there is a renewed interest in arthroscopic ACL repair techniques
in acute injuries. After having been neglected for a long time,
these techniques have again become topical if the correct con-
ditions of a proximal rupture with a good quality ligament arise.
While the results in adult populations are encouraging, very small
paediatric series are emerging. A longer follow-up and larger
cohorts are needed to validate this therapeutic option;
• well-conducted conservative treatment always has its indica-
tions when there are no clinical instability and an absence of
initial or secondary meniscal injuries. Establishing regular follow-
up with an annual MRI is mandatory to detect meniscal injuries,
which are sometimes asymptomatic;
• the different techniques used in paediatrics are comparable to
adult techniques and confirm the fact that these are definitive
reconstruction techniques and not techniques which delay fur-
ther surgery in adulthood. Analysis of recent literature (French
multicentric studies) showed a trend preferring transphyseal
techniques (95% in tibia and 60% in femur) with the absence of
axis disorders and unequal lengths. However, MRI shows the for-
mation of physeal bone-bridges to the femur and tibia in an equal
and asymptomatic way, which confirms that these techniques
should be performed by experienced paediatric surgeons who
can prevent or monitor these possible growth abnormalities;
• the re-rupture rate is higher in the paediatric population, which
encourages delaying the resumption of sport, initially planned in
adults at 6 months postoperatively to around 13 to 14 months in
children, especially since the phenomenon of ligamentization of
the transplant is known to be much slower in children [30]. An
old concept; the use of lateral plasty to control rotational laxity
by the ALL (anterolateral ligament) aiming to make the recon-
struction much more solid and become topical again with an
assessment underway. The notion of re-rupture and return to the
previous competitive sporting level (50) is important to discuss
with parents and children during the preoperative consultation to
ensure that the peri-operative rehabilitation program integrates
the length of preparation time and the length of the rehabilita-
tion period, as well as the possibility of reconsidering the career
of the high-performance child-athlete.
7. Conclusion
Knee sprains in children are a common cause of consultation and
involve several medical and surgical specialties. It requires knowl-
edge of the anatomical peculiarities of ligaments and of the growth
plate in children.
7
Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103120
Age determinism plays a key role in etiological diagnosis. Tib-
ial spine fractures (TSF) usually occur in young children. Ligament
distension at the time of the accident explains the residual lax-
ity. Apart from grade 1, the treatment is surgical (arthroscopic or
open) with the purpose of restoring an anatomical reduction (and
promoting countersinking) using osteosynthesis (screwing or lac-
ing) allowing early mobilization especially in adolescents exposed
to postoperative stiffness.
Peripheral ligament injuries (MCL and LCL) are the most
common and often benign, rarely requiring surgical treatment.
However, a surgical procedure may become necessary when these
lesions are associated with cruciate ligaments or femoro- patellar
joint injuries.
The treatment of interstitial ruptures of the anterior cruciate
ligament in children follows recommendations that are becoming
increasingly clear through multicentric studies. Repair techniques,
historically rejected as ineffective, are now considered in fresh,
proximal ruptures with good tendinous quality. The aim is to pre-
serve the native ACL and its proprioceptive receptors, which are
even more indispensable in children.
ACL reconstruction techniques have progressed with adults’
techniques. Although the current trend is towards transphyseal
techniques, respect for growth plates remains current especially
at the femur to avoid growth disorders. This gives the paediatric
orthopaedist an important role in the management of these knee
sprains.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
None.
Contribution
Each author contributed to the study.
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