A Complex Knee Injury in an Adolescent Football Player

Abstract

HISTORY: A 18-year-old senior HS football player presented to the University of Chicago Sports Medicine clinic with a chief complaint of 4 days of severe left knee pain. His injury occurred during a football game when he was tackled around his left ankle causing his foot to be effectively planted, he fell back with his knee extended then turned to the right resulting in a painful “pop”. Preliminary radiographs in the ED were read “no fracture”. He was discharged NWB with crutches and an immobilizer. In clinic he still had severe pain, swelling, limited motion and was unable to bear weight. PMH: healthy MEDS: Tylenol #3's prn and ibuprofen 800 mg po tid SPORTS: Pt signed a full ride college scholarship for football 1 week prior. PHYSICAL EXAMINATION: On examination the patient was 6 feet tall, 250 lbs. He had a 3+ joint effusion and a 15 degree flexion contracture with 20 degrees of motion. MCL, LCL anteromedial and anterolateral joint lines were tender. He could not perform a quad set. DIFFERENTIAL DIAGNOSIS: ACL tear with or without associated injuries Fracture of femur and/or tibia Meniscal tear with possible mechanical block Osteochondral injury with or without loose body Quad tendon tear TEST AND RESULTS: AP, lateral and oblique left knee radiographs from the ED were interpreted in clinic as a displaced tibial spine avulsion fracture. The radiologist interpretation was a “loose body”. FINAL WORKING DIAGNOSIS: Displaced Tibial Spine Avulsion with ACL deficiency TREATMENT AND OUTCOMES: The patient had a knee arthroscopy performed 9 days post-injury. Findings included ACL insufficiency, tibial spine avulsion fracture, an impaction fracture of the posterior lateral tibial plateau, a bucket handle tear of the lateral meniscus and a complex vertical 1.5 cm medial meniscal tear. Multiple bone fragments, cartilage pieces, and frayed ligament tissue were removed. The meniscal tears were debrided and repaired. An ACL reconstruction using a bone-patellar-bone graft was performed. The impaction fracture site was debrided. Full ROM noted in the OR. Post-op therapy is progressing with the hope of playing football next season. Discussion points of this case include age-related complications of ACL injury including tibial spine injuries as well as indications for early surgical intervention and treatment options.