AAP Boot Camp KNEE AND ANKLE EXAM

AAP Boot Camp KNEE AND ANKLE EXAM

Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and or providers of commercial services discussed in this CME activity. I do not intend to discuss unapproved/investigative use of a commercial product/device in my presentation.

Case 1 13 y.o. female with no history of right knee pain collides with an opponent during a soccer match. She is struck on the lateral part of her knee and her knee buckles as she goes down to the ground. She cannot rise to her feet and is helped off the field. By the end of the game there is mild swelling but no effusion in the knee and the pain is slightly improved but she requires crutches to leave the field. The next morning, the pain in the knee is much more significant but the swelling is about the same. She presents to your office for evaluation and treatment

Physical Exam Inspection Mild effusion. No obvious ecchymosis. Child wincing with any attempt at active and passive motion. Knee ROM - is very limited. She prefers having the knee flexed slightly Palpation - Tender diffusely but exquisitely tender over medial femoral condyle. Manipulation Doesn t permit more than 30 degrees of motion. Knee stable to varus and valgus stress but very painful with valgus stress at the same point at which she is tender. Lachman test a little difficult to interpret because of guarding but feels intact

Imaging of Knee AP and lateral radiographs of right knee

Any additional history? Exam? Differential diagnosis? Likely Diagnosis?

Medial Collateral Ligament Sprain Treatment How do you counsel patient and what is expected course?

Teaching Points Knee injuries can be diagnosed with a good history and physical examination Knee injuries usually hurt where the problem is. Elicitible symptoms usually very helpful in ascertaining diagnosis. Bruising and swelling are common causes of delayed worsening of pain. Treatment of most knee injuries involves immobilization, ice, and time. MRI often not necessary

Same patient different story 13 yo female soccer player with no history of knee problems collides with another player while she pivots to dribble the ball away, her knee buckles and gives out from under her. Her knee is locked and exquisitely painful as the trainers come out to examine her. She describes a big pop to the trainers. Her knee looks deformed As she is helped off the field, she feels another pop The deformity resolves and she feels a little more comfortable The next morning, the knee is massively swollen, she cannot bend or straighten it She comes to your office for evaluation

Physical Exam She reports the knee is much more swollen overnight Inspection - shows large right knee effusion Knee ROM knee flexed slightly, patient unwilling to extend or flex knee. No palpable defect in quad or patella tendon Palpation - Diffusely tender over medial femoral condyle and medial pole of patella Manipulation Knee stable to varus and valgus stress in extension. Cannot flex knee to examine Difficult to assess Lachman or drawer test because patient too uncomfortable

Imaging

Differential diagnosis? Likely Diagnosis? Treatment? Counsel Patient/Expected Course?

Patella Dislocation Treatment? Likely course?

Teaching Points How to distinguish the patella dislocation from other knee injuries Discuss risk factors for patella instability and patellofemoral pain Discuss hypothetical case of tibial tubercle fracture or sleeve fracture and how you can avid missing these injuries Briefly discuss treatment options

Same patient 13 y.o. female soccer player with no history of knee problems She is in the open field making a change in direction when her knee gives out from under her. She feels and hears a loud pop. She is unable to rise under her own power. She is unable to complete the game and the knee begins to swell. The next morning, the knee is more swollen but not massively swollen, she cannot bend or straighten it. She comes to your office for evaluation

Physical Exam Inspection - Moderate Joint effusion Knee ROM - Patient permits only 30 degrees of passive flexion to gravity Palpation - Knee is tender diffusely but very tender over medial femoral condyle and along joint line Patient is guarding during stress maneuvers of knee Knee stable to varus and valgus stress at 0 and 30 degrees Lachman test does not show firm endpoint, contralateral knee is equivocal too Cannot flex knee enough for anterior/posterior drawer test or to palpate joint line

Imaging

Additional history? Exam? Differential diagnosis? Likely Diagnosis?

Additional Studies MRI?

Diagnosis : ACL tear with concomitant meniscal tear Treatment? Counsel Patient/Expected Outcome?

Teaching Points Discuss ACL injuries Epidemiology widening epidemic Can we prevent these injuries? Can we prevent reinjury in these patients? ACL injuries frequently associated with meniscal injuries Do all mensical injuries require surgery?

Case 4 18 month old toddler Presents to office for well child visit Parents concerned about the child s leg alignment No other significant developmental concerns Your evaluation of the child is normal Weight, height, language Physical exam of head, eyes, ears, neck, lungs, heart, abdomen, back, upper extremities are normal

Lower extremity exam Childs gait shows stable, fluid, consistent gait pattern with 5 degrees internal foot progression on left and 10 degrees internal on right In stance and during gait child has a problem with global alignment of the legs Knees have mild varus alignment Medial femoral condyle of knees 4cm separated when ankles placed together Prone exam shows Hip int rotation 50 degrees Ext rotation 70 degrees Thigh foot angle is 10 degrees internal bilaterally

Differential Diagnosis Likely cause? How do you advise these parents? When do you treat torsional problems?

Teaching Points Lower extremity alignment issues are a frequent cause of angst for parents (and grandparent) but it rarely requires intervention Panel will discuss when to worry about alignment abnormalities Panel will discuss when imaging is appropriate for management Frequent concern that there is something wrong with the hips. Panel will review and discuss what findings should raise a concern about hip pathology Panel will discuss how neurologic problems may present as gait abnormalities

Case 5 14 yo lacrosse player 14 yo lacrosse player presents to office complaining of chronic pain in the left ankle. Pain began 4 months ago during basketball season. She does not recall any specific injury that led to the onset of this pain. Patient reports occasional catching in the ankle. The ankle swells most days with activity but is better on off days. She has not missed any time from lacrosse yet but the pain is getting worse.

Physical Exam Inspection - Mild joint effusion Ankle ROM 30 dorsiflexion 50 plantarflexion (normal ROM), Subtalar range of motion 30 varus 20 valgus (normal), Palpation mild tenderness to compression across the anterior ankle joint, more tender when ankle plantar flexed medial deltoid ligament, syndesmosis, and lateral ligaments complexes nontender Manipulation anterior drawer test of ankle negative Double leg jump shows no apprehension Single leg hop elicits mild discomfort and he cannot jump as high

Additional information? Additional Imaging

Additional Imaging

Diagnosis? Management?

Teaching points Osteochondirits dissecans of the knee or talus will present with chronic pain May have mechanical symptoms Plain film imaging will usually reveal diagnosis this is usually the diagnosis we order to x-rays to rule out. MRI often necessary to stage the lesion and recommend treatment Many children with open growth plates may be managed nonoperatively but if lesion fails to heal surgery may be necessary Surgical results not always good Displaced osteochondral fractures usually require surgery Can review hypothetical offshoots of this case

Case 6 13 year old female twisted her ankle while playing volleyball. She has been unable to bear weight since the injury occurred. She reports pain primarily on the lateral side of her ankle She presents to your office hopping into the exam room Your inspection shows significant swelling over the lateral part of the ankle She cannot bear weight on the leg She is tender laterally over the ankle, medial deltoid and syndesmosis nontender The active and passive ankle range of motion is limited due to pain

Imaging 3 views of the ankle (AP, lateral, and mortise view)

Differential? Diagnosis?

Ankle Sprain Anterior Talofibular Ligament Management Types of immobilization When to use physical therapy? When can they return to play? Long term concerns Multiple recurrent sprains?

Panel Questions-Objectives Review with panel which ankle injuries raise a higher level of concern How are chronic problems managed differently Questions for panel Do you use Ottawa ankle rules? How do you differentiate an ankle sprain from a non-displaced Salter I/II of distal fibula? Does it matter for how you treat? When do you use an air cast, a boot, a cast?

Langiappe A little something extra 11 year old boy has difficulty running. Tires easily and has some pain in his left leg. Grandparents think his gait looks abnormal but they can t figure out exactly why. His past medical history is noncontributory Physical exam shows a significant valgus deformity of the left knee.