Kevin E. Klingele

Little league elbow: valgus overload injury in the paediatric athlete.

AbstractThis article describes a variety of elbow injuries often seen in young, throwing athletes. Understandings of normal skeletal development, as well as the biomechanics of throwing, provide a basis on which to evaluate, diagnose and manage ’little league elbow’. With emphasis on an anatomically-based differential diagnosis, the pathologic forces placed upon the young thrower’s elbow, and the subsequent injury patterns, are reviewed.Medial side injuries are the most common and relate to chronic forces of valgus overload produced during the early and late cocking phases of throwing. The majority of this force is placed on the medial epicondyle and produces age dependent injury patterns, such as apophysitis in childhood and epicondylar avulsion fractures in the more mature athlete. With repetitive valgus overload, lateral side injuries such as Panner’s disease and osteochondritis dissecans of the capitellum and radial head become more apparent. These injuries relate to the compressive forces produced by the late cocking and early acceleration phases of throwing. Finally, posterior injury patterns consisitent with olecranon apophysitis and posteromedial impingement, as well as flexion and capsular contracture, can be seen.The key in the treatment of ’little league elbow‘ is prevention and this responsibility lies not only with the evaluating or team physician, but also with the coach, trainer, parents and officials. Proper throwing mechanics must be emphasised at an early age, and the determinants of elbow injury among young pitchers better understood. Early recognition and proper treatment of such injuries will then prevent later sequelae or functional disability.

Discoid lateral meniscus: prevalence of peripheral rim instability.

The purpose of this study was to determine the prevalence of peripheral rim instability in discoid lateral meniscus. A consecutive series of 112 patients (128 knees) (mean age 10.0 years [range 1 month to 22 years]) who underwent arthroscopic evaluation and treatment of a discoid lateral meniscus between 1993 and 2001 was reviewed. Of those discoid menisci classified intraoperatively (n = 87), 62.1% (n = 54) were complete discoid lateral menisci and 37.9% (n = 33) were incomplete discoid lateral menisci. An associated meniscal tear was present in 69.5% (n = 89) of all knees studied. Overall, 28.1% (n = 36) of discoid lateral menisci had peripheral rim instability: 47.2% (n = 17) were unstable at the anterior-third peripheral attachment, 11.1% (n = 4) at the middle-third peripheral attachment, and 38.9% (n = 14) at the posterior-third peripheral attachment. Thirty-one of the 36 unstable discoid menisci underwent repair of the peripheral meniscal rim attachment. One patient underwent a complete, open meniscectomy. Peripheral rim instability was significantly more common in complete discoid lateral menisci (38.9% vs. 18.2%; P = 0.043) and in younger patients (8.2 vs. 10.7 years; P = 0.002). The frequency of peripheral instability mandates a thorough assessment of meniscal stability at all peripheral attachments during the arthroscopic evaluation and treatment of discoid lateral meniscus, particularly in complete variants and in younger children.

Anterior Cruciate Ligament Injury Versus Tibial Spine Fracture in the Skeletally Immature Knee: A Comparison of Skeletal Maturation and Notch Width Index

Both midsubstance anterior cruciate ligament (ACL) injury and tibial spine avulsion fracture occur in the skeletally immature knee. The purpose of this study was to determine whether there are differences in skeletal maturation or notch parameters between these two groups. A retrospective case-control study of 25 skeletally immature patients with tibial spine fractures compared with 25 age- and sex-matched skeletally immature patients with midsubstance ACL injuries was performed. Bone age and notch width index were determined from preoperative radiographs. There were no significant differences between the tibial spine fracture group and the ACL injury group with respect to skeletal maturation, comparing bone age to chronological age (−0.5 vs. –0.3 years; P = 0.617). The ACL injury group had narrower notch indices than the tibial spine fracture group (0.230 vs. 0.253; P = 0.020). Thus, in a comparison of age- and sex-matched skeletally immature patients, those with midsubstance ACL injuries had a significantly narrower notch index than those with tibial spine fractures. This association may account for some of the variation in injury patterns in the skeletally immature knee.

Preoperative Magnetic Resonance Imaging Cross-Sectional Area for the Measurement of Hamstring Autograft Diameter for Reconstruction of the Adolescent Anterior Cruciate Ligament

PURPOSE We conducted this study to determine if preoperative magnetic resonance imaging (MRI) cross-sectional area measurements would correlate with intraoperative graft size in hamstring anterior cruciate ligament (ACL) reconstructions. METHODS We retrospectively reviewed ACL reconstructions performed by a single surgeon using a quadruple-looped hamstring allograft. Preoperative MRI axial images were used to determine the combined cross-sectional area of the semitendinosis and gracilis tendons. These cross-sectional areas were correlated to the intraoperative graft size. RESULTS We found a strong correlation between the MRI cross-sectional areas and graft size. If the combined cross-sectional areas were >or=18 mm(2), there was an 88% probability of obtaining a graft of sufficient size at the time of surgery. CONCLUSIONS We conclude that our technique is a reliable option to assist the surgeon with preoperative determination of graft size. This is valuable to the orthopaedist to more accurately discuss graft options with the patient and improve preoperative preparation with respect to graft choice. LEVEL OF EVIDENCE Level II, development of diagnostic criteria on the basis of consecutive patients with universally applied gold standard.

Meniscal disorders Normal, discoid, and cysts

Meniscal injuries in children and adolescents are being seen with increased frequency. Meniscal tears are typically traumatic injuries in adolescents. Because of increased healing potential and the younger age of these patients, attempts at meniscal preservation should be emphasized for outer and middle third tears. Discoid meniscus typically presents as a snapping knee in younger children or as a meniscal tear in older children. Again, meniscal preservation by saucerization is emphasized. Careful attention should be given to the need for additional meniscal repair. Popliteal cysts typically present as a painless mass. Because they are usually not associated with an internal pathology and often resolve spontaneously, the preferred treatment is observation.

Juvenile osteochondritis dissecans of the knee: predictors of lesion stability.

Background: Recent data suggest magnetic resonance imaging (MRI) is the best method to analyze the status of the cartilage and subchondral bone in patients with juvenile osteochondritis dissecans (JOCD). Methods: MRI analysis of 122 knees and 132 JOCD lesions in 109 patients who underwent arthroscopic treatment for osteochondritis dissecans lesions of the knee between March 2003 and January 2011. Results: Agreement between MRI and arthroscopic grading was 62.1%. MRI sensitivity was 92% and specificity was 55%. Positive predictive value of MRI was 33% and negative predictive value of MRI was 97%. In a multivariable logistic regression model, the odds of a unstable lesion on the lateral femoral condyle nonweight-bearing location were 15.7 times greater than the odds of an unstable lesion on the medial femoral condyle weight-bearing area (95% confidence interval: 2.6-95.7, P=0.003.) The odds of the lateral femoral condyle weight-bearing lesion having an unstable grade were also greater than for a medial femoral condyle weight-bearing lesion, but the results were not statistically significant (odds ratio, 1.70, P=0.349). Conclusions: A high T2 signal retrograde to the lesion may commonly appear with an early, stable arthroscopic grade lesion. MRI continues to be reliably sensitive to JOCD lesions and a good predictor of low-grade, stable lesions. However, MRI predictability of high-grade, unstable JOCD lesions is less reliable. Lesions in atypical locations, such as the nonweight-bearing surface of the lateral femoral condyle, more commonly present as higher, arthroscopic grade lesions. Level of Evidence: Level IV, retrospective case series.

Meniscus tears in children.

Increased athletic participation by the skeletally immature athlete and a heightened suspicion by physicians have contributed to an increase in the incidence of meniscal injuries in children and adolescents. In young patient, meniscal injury could have long-term consequences, so an understanding of recognition and treatment is essential. We review the anatomy and development of the menisci, review classification and diagnosis of meniscal tears, discuss management options and outcomes of treatment, and focus on discoid lateral meniscus and meniscal cysts.

Valgus slipped capital femoral epiphysis: prevalence, presentation, and treatment options.

Background Valgus slipped capital femoral epiphysis (SCFE), defined as posterolateral slippage of the proximal femoral epiphysis on the metaphysis, is an uncommon occurrence. The purpose of this study was to review our institutions experience with valgus SCFE to better describe its prevalence, clinical presentation, and treatment. Methods Radiographs of patients undergoing treatment of SCFE between 1996 and 2008 were reviewed. Valgus SCFE was identified by increased prominence of the lateral femoral epiphysis relative to the lateral femoral neck and an increased anteroposterior physis shaft angle. We identified 12 patients (16 hips) with valgus SCFE and compared them with 123 cases identified as classic posteromedial SCFE. Results The prevalence of valgus SCFE at our institution was 4.7% (12 of 258 patients). Significant differences between patients with valgus SCFE and those with classic SCFE were found for age at presentation (mean 1.1 y younger, P=0.033), sex (58% female vs. 28% male, P=0.044), and classification as atypical SCFE (42% vs. 3%, P<0.001), respectively. Four patients in the valgus group had pituitary and growth hormone dysfunction, and 1 was diagnosed with Stickler syndrome. Hips of valgus patients had a significantly higher mean femoral neck shaft angle (154.3 degrees) as compared with classic SCFE patients (140.5 degrees) (P<0.001). Difficulty placing hardware for in situ fixation was noted in 5 of 11 valgus cases, with 1 case complicated by articular surface penetration and chondrolysis. Conclusions Valgus displacement often presents with a relatively normal appearance on anteroposterior radiographs. Valgus SCFE may be associated with obesity, coxa valga, hypopituitarism, and Stickler syndrome. Posterolateral displacement of the femoral epiphysis makes in situ fixation of valgus SCFE more difficult, due to the necessity of a more medial starting point. Level of Evidence Case series, Level IV.

Discoid Meniscus: Diagnosis and Management

Discoid lateral meniscus is a common abnormal meniscal variant in children. Detailed history and physical examination combined with an MRI of the knee predictably diagnose a discoid meniscus. The clinical presentation varies from being asymptomatic to snapping, locking, and causing severe pain and swelling of the knee. Because of the pathologic anatomy and instability, discoid menisci are more prone to tearing. Treatment options for symptomatic patients vary based on the type of anomaly, the age of the patient, stability, and the presence or absence of a tear. Improvements in arthroscopic equipment and technique have resulted in good to excellent short-term outcomes for saucerization and repair.

Septic Arthritis of the Neonatal Hip: Acute Management and Late Reconstruction

Abstract Septic arthritis of the hip in neonates is rare but can have devastating consequences. Presenting signs and symptoms may differ from those encountered in older children, which may result in diagnostic challenge or delay. Many risk factors predispose neonates to septic arthritis, including the presence of transphyseal vessels and invasive procedures. Bacterial infection of the joint occurs via hematogenous invasion, extension from an adjacent site, or direct inoculation. A strong correlation exists between younger age at presentation and severity of residual hip deformity. Diagnosis is based on clinical examination, laboratory markers, and ultrasound evaluation. Early management includes parenteral antibiotics and surgical drainage. Late‐stage management options include femoral and pelvic osteotomies, trochanteric arthroplasty, arthrodesis, pelvic support procedures, and nonsurgical measures. Early diagnosis and management continues to be the most important prognostic factor for a favorable outcome in the neonate with septic arthritis.