This session occurred on 2/24/2016 and is the 4th Didactic session of the Concussion/Ortho LC. This session focused on the Knee and our speaker was Dr. Heyworth from Boston Children's.

1. Didactic Session 4: Knee Injuries
February 24, 2016
Bringing Basic Orthopedic and
Concussion Care to the Pediatric
Medical Home:
A PPOC/CHICO Learning Community
& Integration Program
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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We have no financial relationships with
commercial entities producing, marketing, re-
selling, or distributing health care goods or
services consumed by, or used on, patients
relevant to the content we are planning,
developing, presenting, or evaluating.
Disclosure
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Learning Community Schedule
Webinars
7:30am – 8:30am
Date Content
Thursday, June 11, 2015 Concussion
Wednesday, September 9, 2015 Foot and Ankle
Wednesday, December 16,
2015
Hand and Wrist
Wednesday, February 24, 2016 Everything Knee
Date
Wednesday, July 15, 2015
Thursday, August 13, 2015
Thursday, October 29,
2015
Thursday, March 24, 2016
Wednesday, April 27, 2016
Didactic Webinars
7:30am – 9:00am
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
In-Person Sessions
7:00am – 9:00am, BCH Waltham
Date Content
Wednesday, January 20, 2016 Practical Session
Wednesday, May 25, 2016 Practical Session

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Barry Zallen, MD
CHICO Chief Medical Officer
Louis Vernacchio, MD, MSc
PPOC Director of Research and Analysis
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
Madeleine Kuhn, MPH
CHICO Program Coordinator
Faculty
Benton Heyworth, MD
Orthopedic Surgeon at Boston Children's Hospital

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Schedule
Welcome and Review
Evaluating Knee Injuries
Case Discussion
Coursework and Wrap-up

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Watch our knee exam on YouTube
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
Search on YouTube:
Pediatric Physician’s
Organization at Children’s

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Knee Injuries
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Ben Heyworth, MD
Clinical Instructor in Orthopaedic Surgery, Harvard Medical School
Attending Orthopaedic Surgeon, Orthopedic Center
Division of Sports Medicine, Boston Children’s Hospital
Pediatric & Adolescent Knee:
Chronic Conditions
& Acute Injuries
An Algorithmic Approach to
Diagnosis & Early Management

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BCH – Dept Orthopaedic Surgery
22 Pediatric Orthopaedic Surgeons
• Pediatric & Young Adult Hip Center – 5 open & arthroscopic surgeons
• Cerebral Palsy (CP) Center – 3 surgeons, 2 physiatrists
• Pediatric Hand Surgery – 4 dual-fellowship trained surgeons
• Lower Extremity, Growth & Deformity Division – 4 surgeons
• Pediatric Sports Medicine – 6 dual-fellowship trained surgeons, 12 primary care
sports medicine fellowship trained MDs
• Spine Service – 6 surgeons
Daily (Mon-Fri) Urgent Ortho Clinics & Sports Medicine Clinics
• Boston, Waltham, Peabody (2-3d/week), Weymouth (1-2d/week), Lexington
• All MLPs supervised by Orthopaedic Surgery Attending MD
• Wednesday Evening Urgent Ortho Clinic (Waltham)
• Saturday Urgent SM Clinic – Sports Medicine MD (Boston)

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Outline
Anatomy & Physical Exam
• Gait – walking, jogging
• Standing – alignment, swelling, squat, single leg hop
• Supine (include hip)
Infectious/Inflammatory Knee Conditions
• Septic Knee vs. Lyme
• Prepatellar Bursitis: Aseptic vs. Septic
Acute Knee Conditions
• Anatomic, mechanism-based Approach to DDx
• Early Management, Approach to Referral
Chronic Knee Conditions
• Anatomic, age-based Approach to DDx
• Early Management, Approach to Referral

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Outline
Anatomy & Physical Exam
• Gait – walking, jogging
• Standing – alignment, swelling, squat, single leg hop
• Supine (include hip)
Infectious/Inflammatory Knee Conditions
• Septic Knee vs. Lyme
• Prepatellar Bursitis: Aseptic vs. Septic
Acute Knee Conditions
• Anatomic, mechanism-based Approach to DDx
• Early Management, Approach to Referral
Chronic Knee Conditions
• Anatomic, age-based Approach to DDx
• Early Management, Approach to Referral

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Anatomy
tendon

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Anatomy

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Physical Exam
• Gait – walking, jogging
• Standing – alignment, swelling, squat,
single leg hop
• Supine - include hip!
• Hip ROM
• Obligate ER, pain w/ ROM (XRs: R/o hip
pathology, e.g. SCFE)

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Physical Exam
• Supine Knee Exam
• Effusion = ACL vs. meniscus vs. chondral injury vs. contusion
• Knee ROM
• Pain w/ hyperextension, hyperflexion = ? Meniscus tear
• Ligaments
• Lachman (ACL)
• Varus/valgus (LCL/MCL vs. distal physeal fracture)
• Ant/post drawer (ACL/PCL)
• Posterior sag (PCL)
• Lateral patellar apprehension test (MPFL/patellar
instability)

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Physical Exam
• Supine Knee Exam
• JLT, Macmurray
• Other TTP
• Tibial tubercle (Osgood
schlatter vs. tibial tubercle fx)
• Inferior ple of patella (patellar
tendinitis vs. SLJS)
• MFC (OCD vs. plica)
• LFC (OCD, ITB syndrome)

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Outline
Anatomy & Physical Exam
• Gait – walking, jogging
• Standing – alignment, swelling, squat, single leg hop
• Supine (include hip)
Infectious/Inflammatory Knee Conditions
• Septic Knee vs. Lyme
• Prepatellar Bursitis: Aseptic vs. Septic
Acute Knee Conditions
• Anatomic, mechanism-based Approach to DDx
• Early Management, Approach to Referral
Chronic Knee Conditions
• Anatomic, age-based Approach to DDx
• Early Management, Approach to Referral

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DDx: Atraumatic Swelling
Sepic Arthritis
• #1 = pain w/ passive ROM
• Effusion
• Erythema
• Fever
• Other: immunosuppressed, recent
illness
Lyme Arthritis
• Minimally/non-painful effusion
Inflammatory Arthritis
• Morning stiffness
• May be first presentation of
rheumatologic joint disorder
Aseptic Prepatellar Bursitis
• Anterior/prepatellar soft tissue swelling
• Contusion
• Tx = Ice, compression, activity
modification
Septic Prepatellar Bursitis
• Erythema
• TTP
• Pain w/ ROM
• Abrasion, laceration
• Wrestlers, other athletes
• Tx = IV abx

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Prepatellar Bursitis

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Outline
Anatomy & Physical Exam
• Gait – walking, jogging
• Standing – alignment, swelling, squat, single leg hop
• Supine (include hip)
Infectious/Inflammatory Knee Conditions
• Septic Knee vs. Lyme
• Prepatellar Bursitis: Aseptic vs. Septic
Acute Knee Conditions
• Anatomic, mechanism-based Approach to DDx
• Early Management, Approach to Referral
Chronic Knee Conditions
• Anatomic, age-based Approach to DDx
• Early Management, Approach to Referral

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DDx
ACL Tear
• Most common cause of pediatric knee
hemarthrosis
• Dx: MRI = standard of care
Patellar Dislocation/Instability
• Dislocation vs. subluxation
• MRI: R/o chondral injury, assess anatomic
risk factors, pre-op planning
• Primary vs. recurrent
Meniscus Tear
• Medial
• Lateral
• Acute presentation of chronic discoid?
Other Ligamentous Injury
• PCL, MCL, LCL
• Multiligamentous rare (other than ACL/MCL)
Contusion
• Direct blow (flexed knee) vs. collision
• Age 7-12 y/o: ↑↑ apprehension
Distal Femur Physeal Fracture
• ‘Pediatric equivalent’ of MCL/LCL injury
• Salter Harris I vs. II (III, IV more rare)
Patella Fracture
• Patellar Sleeve
• Patella (Transverse, comminuted)
Proximal Tibial Fracture
• Plateau (impaction injury)
• Physeal Fracture
• Cozen’s Fracture = metaphyseal

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Pediatric ACL

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Pediatric ACL: Non-Operative Tx
Principles
• Bracing
• PT
• Activity Modification
• Patient Counseling
• Parental Counseling

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Pediatric ACL Insufficiency
Natural History
Pediatric population
with no ACL
(attempted non-
operative tx)
Unacceptable rates
of meniscal,
chondral injuries
(often unrepairable)

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Pediatric ACL: “Physeal Sparing”

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Pediatric ACL: “Physeal Sparing”

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Pediatric ACL: “Physeal Sparing”
• Mean 5.3yr f/u:
• 2 pts w/ graft failure
– 4.7yr, 8.3 yr post-op
• 44pts w/ no failure:
– Mean IKDC 96.7
– Mean Lysholm 95.7
– Lachman: 23 nl, 18 near-nl, 1 abnl
– Pivot-shift: 31 nl, 11 near-nl
• 23 concurrent meniscus repair
– 4 repeat repair/debride
• No LLD, deformity
– Mean growth 21.5cm

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Complications of ACL-R in Children

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Patellar Instability:
A Pediatric/Adolescent Phenomenon

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Risk Factors

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Associated Injuries
– Rates of intra-articular injury: (arthroscopic or open assessment)
– 95% articular cartilage injuries

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Non-Operative Tx
• Physical Therapy (mainstay)
– Quadriceps Strengthening (VMO)
 Isotonic > Isometric
 Closed and/or Open Chain effective
 Isokinetic, Eccentric a/w 
patellar contact Forces
 Aquatic Therapy
• Bracing, Taping (adjunctive)
– Questionable value in recent literature

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Operative Tx
• Arthroscopy
– Diagnostic
 Assessment of MPFL insertion, mid-
substance (injury)
 Presence of loose bodies, OC fragments
– Primary MPFL Repair (vs. Open)
 Suture anchors
– Medial retinacular plication (Altchek)
• Proximal (Soft Tissue) Realignment
– MPFL Reconstruction
– Proximal Medial Reefing
– (Insall: Pants-over-vest)
• Distal (Bony) Realignment
– TTO  Medialization (Elmslie-Trillat) vs.
Anteromedialization (Fulkerson)
• Early Procedures
– Soft Tissue (Skel Immature)
 Galleazi (Semi-T
through patella)
 Goldthwaite (patellar
tendon partial transfer)
– Bony/TTO (Skel Mature)
 Distalization
 Anteriorization (Maquet
- 2cm)
 Posteromedialization
(Hauser)
– Bony/TG (Skel Mature)
 Trochleoplasty

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Treatment Algorithm

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Pediatric Fractures About the Knee
Contusion, MCL/LCL ‘Sprain’
• Direct blow (flexed knee) vs.
Valgus/varus direct blow
• Age 7-12 y/o: ↑↑ apprehension
Distal Femur Physeal Fracture
• ‘Pediatric equivalent’ of MCL/LCL injury
• Salter Harris I vs. II (III, IV more rare)
Patella Fracture
• Patellar Sleeve
• Patella (Transverse, comminuted)
Proximal Tibial Fracture
• Plateau (impaction injury)
• Physeal Fracture
• Cozen’s Fracture = metaphyseal

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Pediatric Fractures About the Knee
Contusion, MCL/LCL ‘Sprain’
• Direct blow (flexed knee) vs.
Valgus/varus direct blow
• Age 7-12 y/o: ↑↑ apprehension
Distal Femur Physeal Fracture
• ‘Pediatric equivalent’ of MCL/LCL injury
• Salter Harris I vs. II (III, IV more rare)
Patella Fracture
• Patellar Sleeve
• Patella (Transverse, comminuted)
Proximal Tibial Fracture
• Plateau (impaction injury)
• Physeal Fracture
• Cozen’s Fracture = metaphyseal

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Pediatric Fractures About the Knee
Contusion, MCL/LCL ‘Sprain’
• Direct blow (flexed knee) vs.
Valgus/varus direct blow
• Age 7-12 y/o: ↑↑ apprehension
Distal Femur Physeal Fracture
• ‘Pediatric equivalent’ of MCL/LCL injury
• Salter Harris I vs. II (III, IV more rare)
Patella Fracture
• Patellar Sleeve
• Patella (Transverse, comminuted)
Proximal Tibial Fracture
• Plateau (impaction injury)
• Physeal Fracture
• Cozen’s Fracture = metaphyseal

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Outline
Anatomy & Physical Exam
• Gait – walking, jogging
• Standing – alignment, swelling, squat, single leg hop
• Supine (include hip)
Infectious/Inflammatory Knee Conditions
• Septic Knee vs. Lyme
• Prepatellar Bursitis: Aseptic vs. Septic
Acute Knee Conditions
• Anatomic, mechanism-based Approach to DDx
• Early Management, Approach to Referral
Chronic Knee Conditions
• Anatomic, age-based Approach to DDx
• Early Management, Approach to Referral

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Overuse Injuries of the Knee

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DDx
Patellar Tendinitis
• Inferior pole patella TTP
• Skeletally mature (>12y/o)
Osgood-Schlatter Syndrome
• Tibial tubercle TTP (apophysitis)
• 10-16 y/o athletes
Sinding Larsen Johannsen Syndrome
• Inferior pole patella TTP
• 8-12 y/o athletes > non-athletes
Other causes of anterior knee pain
• Patellar maltracking
• Patellar chondrosis
• Patellar osteochondritis dissecans
(OCD)
• “Patellofemoral pain syndrome (PFPS)”
• “Runner’s knee”
Inflamed Plica Syndrome
• Anteromedial TTP, +/- palpable
snapping
• Adolescents > other populations
Osteochondritis Dissecans (OCD)
• Vague, non-specific pain +/- effusion
• XRs: 4 views (AP, lateral, tunnel/notch,
sunrise/skyline)
• MFC > LFC >> Trochlear > Patellar
Iliotibial band (ITB) syndrome/bursitis
• Adolescents, young adults
• Another form of “runner’s knee”
• Ober test
Lateral Discoid Meniscus
• Clicking/clunking knee, lateral JLT
• 2-10 y/o >> 11-18 y/o
ANTERIOR MEDIAL, LATERAL

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ANTERIOR
PAIN,
TENDERNESS

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Adolescents/Adults: Patellar Tendinitis
(“Jumper’s Knee”)

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Osgood-Schlatter’s Dz/Syndrome

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Sindig-Larsen-Johannsen Dz/Syndrome

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MEDIAL/ANTEROMEDIAL
PAIN,
TENDERNESS

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Inflamed Plica Syndrome

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Osteochondritis Dissecans (OCD):
An Overuse Phenomenon?

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Osteochondritis Dissecans (OCD):
What is it?
“Osteochondritis dissecans is a condition or injury affecting a focal region of subchondral bone, in
which progressive changes can occur in the overlying articular cartilage if the affected bone fails
to heal, including softening, swelling, fissuring, partial separation, and finally, complete
detachment of the chondral or osteochondral fragment.”

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Osteochondritis Dissecans (OCD):
Can we cure it?
Research in OsteoChondritis of the Knee (ROCK)
Evolution of a multi-center disease-specific study group
- 2008: small group of founding members
- 2012: 13 centers, 15 surgeon-investigators
- 3 pediatric musculoskeletal radiologists from 2 centers
- 1 Physical Therapist
- 1 Ph.D. Researcher

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LATERAL/ANTEROLATERAL
PAIN,
TENDERNESS

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ITB Syndrome/Bursitis

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Lateral Discoid Meniscus

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Lateral Discoid Meniscus

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Chronic/Overuse Injuries of the Knee
– Age-dependent, location-specific
– Anterior, skeletally mature
– Patellar tendinitis/tendinosis (inferior pole TTP)
– Patellar tilt vs. maltracking vs. chondrosis
– Anterior, skeletally immature
– Osgood-Schlatter (distal, tibial tubercle apophysitis)
– Sinding-Larsen-Johannsen (proximal/inferior pole)
– Deep/vague vs. Anteromedial (MFC)/Anterolateral (LFC), skeletally immature
– OCD
– Anteromedial, +/- palpable snapping, adolescent
– Plica
– Lateral
– Lateral discoid meniscus (usually skeletally immature, +/- clicking/clunking,
LJLT)
– ITB Syndrome/Bursitis (adolescent runner, tight ITB/+Ober test)

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Chronic/Overuse Injuries of the Knee
Treatment = 4-Pronged Approach
1) “Relative rest”
• Families decide
• No rest = exacerbate condition, slow
recovery
2) Cryotherapy
• 30 min on, 30 min off
• 4-5x/day: ‘more smart than crazy’
3) NSAIDS
• Tx-Dose Regimen x3-4 wks
• Weight-based dosing
4) PT
• Underlying biomechanical deficits
(tightness > weakness)
• Period of peak growth
• Harder they work = faster return

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Orthopedic Advice and Urgent Access
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
Answered live between 7:00AM and 5:00PM, Monday through Friday
Appointments will be made in Boston or a BCH satellite
based upon the patient’s location, day of week and urgency

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Stepped Care Approach – Knee
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Stepped Care Approach – Knee
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Orthopedics ED Coursework
1. Cases sent by email and on
Blackboard
2. Select at least 3 cases to
review
3. Complete the case review
form using information from:
• Your EHR
• MyPatients (if applicable)
• Other visit documentation
you may have access to
4. Return to Madeleine Kuhn by
March 17, 2016
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Meeting Evaluation
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Please take a moment to fill out the session evaluation
survey and provide us with your feedback so that we
can continue to improve and meet your expectations
and for CME Credits!
A recording of this session will be emailed tomorrow
with the follow-up email.
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Thank You!
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu