Infection
Pain
Alignment
Soft tissue Injuries
This on-demand teaching session is a deep dive into the diagnosis and management of pediatric knee pain. The session starts by discussing growing pains, a common form of bilateral nocturnal knee pain in children, and how this or associated symptoms could potentially indicate more serious conditions like osteosarcoma or Ewing's sarcoma. The seminar then broadens to cover associated hip pathology, fractures, soft tissue injuries, infections, juvenile chronic arthritis, and concludes with the rare but important topic of knee cancer. The speaker further elucidates commonly presented hip pathologies that manifest as knee pain such as Perthes or SUFI and necessitates an X-ray examination. The contenders responsible for fractures around the knee area are also explained in depth, including distal femoral fractures, proximal tibial fractures, tibial spine avulsions or cubicle fractures. Emphasis is placed on vigilant monitoring to prevent growth disturbances following treatments, particularly with distal femoral fractures. The session will provide medical professionals with a holistic understanding of pediatric knee pain and equip them with the necessary knowledge for effective diagnosis and management.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
Growing pains, growing pains, diagnosis of exclusion. You've got to think about everything else first, but actually bilateral nocturnal knee pain, particularly if Children volunteer that when I get out of bed and I go downstairs to tell mummy and daddy my knees hurt, the pain goes away. Um, which is a very, very common phenomenon does represent somehow the fact that actually weight bearing and moving the knees somehow, um, takes away the otherwise very focused stretching of the periosteum, which we believe is the cause of growing pain. Um If, if the pain goes away quickly on massage or walking, that's reassuring. Um, swelling pain in other joints, mechanical symptoms, those are more the sorts of things that you look for in adults. And don't forget that the knee is the site of predilection of tumors. And you must also at the back of your mind have the idea that this could be an osteosarcoma or Ewing's sarcoma, um, examine the whole child, not just the knee. Um And critically importantly, ok, knee pain originates in the hip until proven otherwise. So, um when we're thinking about hip, so when we're thinking about knee pain, always think first, Perthes or SUFI or one of those other things which we will not cover today, but which, you know, all too well are frequent presentations. Um, of, of hip, the f frequent hip pathologies which actually commonly present as thigh or knee pain. Um, we'll be thinking about fractures. We'll be thinking about soft tissue injuries. We're not talking here about the anterior knee pain, which appears, has already covered. We will think about infection, not talking about growing pains, which appears has already covered. We will talk about um juvenile chronic arthritis. The commonest presentation indeed of oligoarticular juvenile chronic arthritis is an acute mono arthritis of the knee. And we will briefly not because it's common, but because it's important to talk about cancer. Um hip pathology. I said it before Perthes and SUFI got to think Perthes and Sufi and if in doubt, take an X ray and don't be put off by um by radiographers telling you that um you've made a mistake and the pain is actually in the knee because um in fact, actually they should just as they're asked. Um and every now and again, you will, um you will pick up something which otherwise would have gone undiagnosed um fractures that occur around the knee. The four commonest sites of um of fractures around the knee are distal femoral fractures, affecting the fiss tibial spine fractures, which of course, um the tibial spine or the tibial eminence um is the site is near the site of insertion of the anterior cruciate ligament. It's not actually the insertion of the anterior cruciate cruciate ligament, but the footprint, the tibial plateau footprint of the ACL is very nearby. So if you see a spine avulsion, that's almost always in association with an ACL injury, tibial cubicle fracture. So that's that um there's actually think os good Schlatter disease sits on a sort of continuum all the way through from, you know, a very benign intermittent um pain on as, as it said, particularly things where you, where the, where the the knee is um extend against um uh resistance, kicking a football, that sort of thing all the way through to actually where you tear the, the tibial tube called right off and then proximal tibial fractures which which may be physeal or metaphyseal um fractures of the distal femur are notably troublesome. So if you have uh and this, they almost always have this Salter Harris type two configuration, um may look like salter Harris one, but there will always be a little chunk of metastasis somewhere. Um The problem with these fractures is that they have an ex, those that are significantly displaced, have an exceptionally high 50% risk of growth disturbance. And therefore, they have to be followed very closely. And a 50% growth disturbance rate when they often do happen in younger Children is something to really be very vigilant to um if you're getting significant um angular deformity, you're actually better to fuse the PS or to think about whether or not you can rescue the piss sooner rather than later. The likely reason for the um high incidence of growth disturbance is because of the highly um complex three dimensional shape of the distal femoral crisis. Um If I may use the uh like um vulgar analogy, it's, it's, it has a shape similar to buttocks or similar to um if you like a sort of the, the pair of buttocks sitting in a, in a soft chair which has, has sort of moved, taken on the shape of the buttocks. It's, there's, there's two concavities with a ridge in between and um two you know, tessellating um convexity with a, with a trough in between and, and when you, if you open these up, um then you often see that big chunks of the fiss have actually been knocked off um at the time of the injury. Um the best you can do is get the best reduction you can, but then keep a close eye on them. Um Tibial spine avulsions. Well, we've said commonly um uh represent an ACL injury. Um and um indeed also equally commonly, 40% are not as commonly, nearly as commonly are associated with other knee injuries. So, if you do see a tibial avulsion fracture, which you can often see on plain film x rays, of course, often together with a lipohemarthrosis on a horizontal beam X ray. Um Then in fact, you ought to be getting an MRI irrespective to look for evidence of meniscal collateral um or osteochondral injuries. Um And that usually the articular surface is not involved, but sometimes they do propagate into the plateau and that requires um reduction and fixation as well. Um They classified according to me and Kiva. Um And this is the classification here where one is essentially an undisplaced fracture and these actually often the overlying cartilage is actually intact. You see, you see you see a a fracture through the bony components of the, of the tibial spine, but the overlying cartilage is intact. Twos are where there's just hinging on the posterior um cartilage and uh the, the but, but the, the, the, the um fragment is although it's raised anteriorly, it's not significantly displaced. Um The threes are significantly displaced. Um and the fours are significantly displaced with comminution as well. Um And almost always you will get a lipohemarthrosis. Um So you will be able to see fat and um blood in the joints on the horizontal being lateral, um must get an MRI because of the association with other soft tissue injuries. Um The ones and the twos, you can treat conservatively in a plaster and extension. Um the threes and the fours. Well, here this shows a screw which incidentally is also crossing the fires. So that's something which is going to need to come out at some stage. I think Professor mcdonnell is on the is in the audience. Professor mcdonald, I think usually does these with retrograde firewire sutures taken out through the front of the tibia. I actually most commonly do these with retrograde K wires which so you use the ACL um tibial tunnel target um to put a, put a wire up through the um the footprint to the ACL, you then use an instrument under arthroscopic um direct vision, twist the tip of it over and then pull it back down again and either wrap it around the screw or even just um uh bend it to lock it in the anterior tibia. Those I tend to take out as well. We've put in a case report in BMJ if you want to see a picture of that. Um the um but the point is to restore the articular surface if the articular surface is um involved, but much more importantly to restore, restore tension um in the uh the, the ACL. Um so uh cubicle fractures much more common in boys than in girls generally occur during sport. Um And you will, you will find that exactly the same people who get oso schlatter's disease also get tibial tuberosity, avulsions and that there is some degree of association people who get really bad at Oskar Schlatters then suddenly will occasionally um present actually with, with a on chronic presentation where everything is much more painful. Um And indeed in that situation, those I would definitely put a, put a screw screw across to, to stabilize. Um They classified according to Ogden. Um And the classification is here. Um If anybody in the audience was with me, I think it was about this. It was October 2022. So about 18 months ago, we actually had an three B variant where the plateau fragment and the tuberosity fragment not only had broken clean off the front of the tibia, but actually had then split into two as well. So took a little bit of um of, of, of, of putting back together before stabilizing it. But, but these, these generally can be reduced and stabilized fairly easily. And my technique would generally be for the, where it's just the t curiosity involved to put percutaneous screws across um the um the complication and Mr Mitchell vaguely alluded to this before it is very important. Um to be aware that if you, that the, the proximal tibial phus has this inverted L shape. Um And that if you tether the tuberosity, you are also almost inevitably tethering the anterior PHS and that leads to a risk of um of reek of art. So you get continued growth at the back of the um the, the, the plateau pis tethering at the front of the plateau pis and therefore a reek of art deformity. Um And this is a lovely guy um who live and I um both or actually um discuss various treatment option with um where in fact, he did have tethering of the anterior ph um following a tibial tuberosity injury, um which led to this progressive re of art. Um and I take you through some of the options for this because it was quite interesting, we went through the literature to think what was best for him. Um And all of the acute um options have um are a compromise of one kind or another. If you just do an opening wedge osteotomy above the patellar tendon, you get patella Baha. If you do um if you do it at the level of the patellar tendon, then you also have to um you have to take the curiosity off and then put it back on again, which means that if you are still growing, then inevitably you will get a um a further um anterior FC arrest and um sort of secondary of art, if you do a closing wedge lower on down, then you shift the tibia. Um it translates the um the, the tibia posteriorly. Um And so, in fact, what we did in the end, in fact, Liz did not, we did what Liz did in the end um was to put on a li frame um and to do a, do a um a a frame um solution and he did brilliantly couldn't have been pleased to um proximal tibial fractures, nowhere near such a high risk of, of fascial arrest, um often significantly displaced, should be reduced and fixed. Um usually with something which initially crosses the fiss and then you remove either, usually wise but sometimes a plate, um proximal metaphyseal fractures, which do also occur particularly in younger Children in the 3 to 6 year age group. Um have this very odd phenomenon where you often after the fractures healed. So this is not a, this is not a sort of fracture malalignment issue, but they, they, they're prone to this concept of Cousins phenomenon where um you get a progressive vuls um tibia vulgar, which then actually um gets better. It's, it's at its worst 18 months post fracture and then it's often completely resolved by three years and that, that it's not fully understood, but it is likely that you actually get um tibial overgrowth, um which is to a greater degree than the overgrowth, which also happens in the, in the, in the fibula and therefore the fibula on the lateral side of the tibia. Um if you like um becomes a bow string to the bow of the um tibia if that makes sense. So, because the tibia has grown longer and the fibula hasn't, um you get this vulg malalignment um which then resolves um soft tissue injuries around the knee. Um soft tissue injuries around the knee are not as common as in adults. Um And that partly represents the fact that the immature skeleton um is weaker than its soft tissue components so often where you would expect to see an ACL injury in an adult. You see a tibial eminence avulsion in a child where you would expect to see, you know, the collateral ligament injuries, you would, you would actually again see avulsion fractures. Um But we do see meniscal injuries, we also see chondral injuries, which has mentioned, but I'm going to mention again because I rather like doing osteochondral reconstructions. I think they're very satisfying to um to actually take a knee which is potentially really at high risk of um of, of young adult osteoarthritis and actually restoring it to normality. That's, that's a satisfying thing to do um in Children. Um Of course, if you find a meniscal injury in Children and if you operated on it in a timely manner, and we have a much lower threshold to try and repair these um in Children than we do in adults. They have a better chance of a successful repair. And the implications of meniscectomy in Children is, is um is again the prospect of potentially young adult arthritis when you lose the shock absorbing and um stabilizing properties of the meniscus. Um Popliteal cysts are incredibly common. Um They should virtually never be treated except in the circumstance where they represent um meniscal cysts um from a meniscal um meniscal injury. So it's not unreasonable to get um an MRI scan in Children. Um If you do have a big copper um cyst, but you're not looking to um primarily treat the cyst but to look for an underlying cause, um, this is a meniscal um repair. Um, and, you know, it's a very, it's a peripheral, um, uh tear which has, which has been, which has been neatly repaired with multiple, um, uh sutures. Um The only time when we would, um, when we would not at least attempt to repair is in the context of a disc meniscus where you've got excessive meniscal tissue and there it is legitimate to sorcerer to, to, to take the as it were extra strong mint of the discoid meniscus and turn it back into a polo. Take, take, take the, turn it back into a horseshoe um ligament injuries. Well, um they do occur um even though the bni avulsion injuries are more common and in my institution, these largely go to my expert colleague, Mr Professor Professor mcdonnell, who I think is in the audience, I could see his name on the list earlier. Um uh It's a big mcdonald's. Oh, I beg your pardon. Well, perhaps prote Professor mcdonald. Um but anyway, so, so, so Steven Steven and I suspect now also arm um do ACL repairs and have a low threshold to repair um ACL injuries, ACL ruptures in Children usually um offering five seal um sparing um repair in younger Children. Um This is um an osteochondral injury. Um I've got some, these are some that I actually did myself. So this is an MRI scan showing the classic double um injury of a lateral um a lateral femoral condyle osteochondral injury together with a um patella um osteochondral injury following a high energy patella dislocation. Um and you can see um I hope the the defect here. Oops, sorry, you can see the defect here and the defect here. So we took that child's theater, sorry and actually found um fragments of cartilage which um ii or if the, if the, I think Pierce said this too, if the fragments free floating II make no attempt to do these arthroscopically, the Americans describe doing it arthroscopically, I don't I open them up, I tidy up the um the fragment until it fits neatly into um the, the um the the the the site of injury. Um and then I hold them with these. Exactly what again said these, these polygalactia smart nails from um lied. Um when I first arrived in urg, um we were using deu um arthro darts um which were a complete waste of time. If anybody uses those, then they could show me how to use them and make them effective. They all seem to just pull out. This is a, this is a much, much more effective um stabilization um modality, certainly in my hands. Um this is, this is sort of somewhere in between what pier was saying it is a flap and you might think that um actually that would be fairly easily amenable to um to an arthroscopic approach. But actually, if, if you look, if you try and push it down with your scope, that this is the flap, of course, on the back of the patella. If you try and push that flap down and it's not neatly, um fitting back into the, the, the site from where it was torn away, then actually, you're much better off opening it up, scraping it out. Um And again, putting in some, some smart nails to stabilize it. Um, and these are, these are ones that we've done in an reasonably recently, um, bone and joint infection. Ok. So acute monoarthritis in a child is bone and joint infection until proven. Otherwise, I told you that it is also the commonest presentation of, um, of a monoarthritis of the knee is the commonest present presentation of oligoarticular juvenile chronic arthritis. But actually, you got to think infection first. Um, and, um, you need to, you need to get inflammatory markers. Um, you need to then get an MRI scan. The MRI scan often will actually make the diagnosis if you've got, um, sinusitis and loculated fusion. Um, but it also gives you an idea of whether or not you've got, um, juxta articular osteomyelitis and that changes how long the course of antibiotics will need to be in order to gain an effective cure for the child. Um, we used to think that staph aureus was the commonest cause of both Osteomyelitis and septic arthritis in Children. Um But since the advent of BCR preli chain reaction um analysis to look for um bacterial DNA in the joint, we've actually discovered that probably kingella kingii is, is the most common organism. It, it's a fastidious organism. It's difficult to culture and probably it's abs or the, the, the, the um high um instance of culture negative um aspirates from Children in the past represented just an inability to culture an organism, which was there. Because if you, if you, as I say, if you do, if you send 16 S PCR off to Great Ormond Street, they pretty frequently tell you that there was, there was bacterial DNA usually from kingella in the joint. So um septic arthritis, I don't need to tell you is a surgical emergency because organisms rapidly digest cartilage and destroy damage or destroy the joint, particularly staph ais. But actually many other organisms secrete these exotoxins, like proteinases and peptidases and lipases and highly oras put every think of every type of tissue in your body and put a on the end of it. And there will be a gram positive organism um that, that has an enzyme to digest you and every bit of you. And that's, and that's why it needs, we need, it needs washing out, um why it needs any joint in the body, needs washing out quickly. If you really suspect infection, you also get a secondary effect of microvascular um uh infarction. Um and, and, and cartilage death, so, so adequately. Um, and then, um, give antibiotics and think about osteomyelitis and all the other associations in, in younger Children. Um You must get um, uh long term intravenous access because you're going to give intravenous antibiotics for at least three weeks. And actually, if there's osteomyelitis six weeks and then you must follow these people up for a reasonable length of time to ensure that there isn't a sort of a post infectious arthritis, articular injury. But also in the case of juxta, I seal osteomyelitis that there isn't a growth arrest. Um Pierce and I were both sat on the committee of, of the children's orthopedic surgery, bone and joint infection group. Pierce, of course, was the boss and I only he very junior secret assistant. But, and he's published that the, the guidelines recently um inflammatory joint disease, well, inflammation, inflammatory can be monoarthritis but it usually isn't. Um And in Children usually actually, um there are um there are systemic symptoms which accompany the onset of the um the the, the arthritis. So classically, um fever, fatigue, um rash, enlarged lymph nodes in AMBR. We're very fortunate now to have three and we will shortly possibly have four consultant, pediatric rheumatologists. Um not, not every hospital in the region I know has easy access to pediatric rheumatology. Um But pediatric rheumatology um team are excellent but taking on these patients very quickly and getting them on, on the appropriate um biological biological um, disease, modifying drugs that's necessary. I realize my time is shortly to expire. I won't dwell on inflammatory joint disease. I'm going to mention briefly osteochondromas, commonest site to get osteochondromas in the body is um is around the distal femoral phthisis. And that is probably because it's the fastest growing pisis in the body at nine millimeters a year. And you see it seems more frequent that you get these little bits of physeal tissue um breaking off and being carried away by the advancing tide of the bone around the, the um the knee um excise. When symp, you can also get um angular disturbance, um a coronal plane disturbance with um osteochondromas, particularly in the context of um di la or hereditary multiple exostosis syndrome, which is an autosomal dominant condition um causing multiple exostoses. Um Osteoid osteomas do also go around the knee causing pain and should be treated with radio frequency ablation always at some stage if you've got pain and it's not settling if you've got pain, which seems to have um to be sort of insidious and onset and, and getting worse. And particularly if you've got um swelling around the knee, particularly distal femur, you've got to think about malignant bone tumors and this is the classical. So a speculation of the commonest um uh tumor, primary bone tumor, which does affect Children, which is the um is the osteosarcoma. The second commonest would be chondrosarcoma. Um And there, I will pause. Um Mr Liu, if I may, except to say that neither this is talk nor business talk mentioned eight plates. So I'm going to give two minutes of bonus extra material if I may have. We got time to do that. Um, so, ok, um, bow legs and knock knees are physiological in Children. Um, all Children start in, um, uh, various and by the age of three or four, they're in vuls and then they stabilize out with an adult. Mean, same as you'd set on your, on your uh uh femoral um jig for a knee replacement of between five and seven degrees. Um People diverge off this curve which is the Soane curve, salus curve. Um uh if the for various reasons, um of which the commonest would be rickets. Um And you diverge in the direction um of the, the, the, the as it were the, the, the, the um the, the, the, the um, the C plane um abnormality at the time when the bone becomes soft because of rickets. So Children, um babies born with congenital rickets, for instance, hyperphosphatemic rickets um will get progressive genu varum. Whereas um older Children will get um, Children over four or five will get progressive genu gen. So, Rickets, Maple's bow legs or not knees, there are many other reasons for bow legs or not knees. Here's a little list, but the way we treat bow legs and not knees is that if you actually identify while the child is still growing. They come in for a simple day case surgery. You simply ba little tether, little eight plate, eight figure of eight shaped plate across the fiss with a screw above and a screw below that reduces, um, uh, growth on the side where the plate has been applied, allowing growth to continue on the other side. And these little pictures demonstrate that I hope you can see them clearly um, until that you correct Cial plain alignment. Um And there's one other thing which neither PS nor me have mentioned so far. And that is that, um, that the commonest cause of the injuries in young people in this country is actually football and FIFA paid some millions of pounds to put together a warm up program which then has been, has been subject to, to multiple studies and meta analysis and is demonstrated to reduce the incidence of all football associated injuries by 30%. So if you are, if you're talking to Children who get um, recurrent knee injuries in the context of football, ask them whether their clubs are actually, um using the evidence based um FIFA 11 plus injury prevention program for warm ups. And on that note, um I will end. Uh, so I'll do stop sharing. Thank you. There. We are. How did you and I neither of us mention eight plates aren't eight plates just the most satisfying thing in pediatric knee surgery. They are. But and if I'm just allowed to talk about anterior knee pain, the only time they kind of fit in is with valgus knees. So that's, that's the easiest cure for anterior knee pain is eight. Yes. Well, I did mention that if you've got a valgus knee, you need to straighten it out. But as you could spot, I had quite a lot of different diseases to cover. So I didn't want to go into too much depth on. So that's, that's Stephen mcdonald who's on my screen now. That's not the professor mcdonald who I saw at the field this morning. Is that right? A different Stephen mcdonald? Well done. When you, when you go for consultant interviews, you can, you can.