Abstract
HISTORY: A 12-y/o high school soccer player sustained a left knee injury during a game in mid July (unknown mechanism of injury). Player used crutches for 1 week. Player returned to action early August and reinjured the same knee during a cutting motion while kicking the ball. After the trauma, the player felt significant pain on the lateral aspect of his knee; left the field and applied ice. PHYSICAL EXAMINATION: At the orthopedic consultation (1 month after injury), patient presented with joint effusion, limited range of motion (ROM) 0-80° and tenderness at palpation of the postero-medial and -lateral joint line. Specific tests: positive Lachman and ADT, grade II pivot shift and grade I varus stress test at 30°. Posterolateral drawer and Dial tests were negative. DIFFERENTIAL DIAGNOSIS: 1. PL corner sprain 2. ACL tear 3. Fracture of the tibial eminence 4. Meniscal tear 5. Patellar dislocation 6. Osteochrondritis dissecans (OCD) TEST AND RESULTS: Left knee AP, lateral and tunnel view radiographs: - No sign of fracture or OCD; open growth plates: bone age of 13.5-y/o (Greulich and Pyle) Left knee MRI - Complete ACL tear, posteromedial horn meniscal tear, and evidence of a mild sprain of the posterolateral corner 3D knee biomechanical assessment during gait - During stance, patient shows important transverse internal tibial rotation excursion (7°) and a knee flexum (16°) to stabilize the joint FINAL WORKING DIAGNOSIS: Left ACL rupture and medial meniscal tear in a 12-y/o boy with open growth plates TREATMENT AND OUTCOMES: 1. ACL reconstruction with 2 strand hamstrings tendon graft - Hamstring harvest proximally and kept attached distally - Transphyseal tibial tunnel and transepiphyseal femoral tunnel - Double graft fixation on the femur 2. Leg extension brace for 3 weeks and standard physio protocol initiated 3. Follow-ups done at 2, 6, 12, 26 and 52 weeks 4. After clinical, biomechanical and strength assessments 1-year post op, player returned to pivoting sports with hinge brace - Clinical assessment: no thigh atrophy, no effusion, full ROM (0-140°), Lachman and ADT negative, and grade I pivot-shift test - 3D knee biomechanical assessment: knee flexum still present during stance (13°) but tibial internal rotation excursion was stabilized (2°) 5. Further rehab should address biomechanical deficiencies for full functional recovery
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