Should 13 Yo Have Meniscus Repaired

MENISCAL INJURIES IN CHILDREN AND ADOLESCENTS

CHARLES J. ODGERS, 4, MD, Resident, Orthopaedic Surgery

BRIAN GALINAT, Doctor, Attending Orthopaedic Surgeon

May 8, 1996

CLINICAL CASE PRESENTATION

ORTHOPAEDIC DEPARTMENT

THE ALFRED I. DUPONT INSTITUTE

WILMINGTON, DELAWARE

Case HISTORY:

A thirteen-year-old boy presented with left knee pain after sustaining an injury while wrestling three months prior to this visit. The patient stated that his left genu was in a hyperflexed position when it was twisted.

He felt a "popular" associated with pain on the lateral attribute of his knee. He stated that he had minimal knee swelling which had resolved, simply his pain persisted. He had taken Advil for a few days subsequently his injury which helped command the pain.

PHYSICAL Test: On concrete examination he had full range of motion of his left knee joint with a trace effusion. At that place was lateral articulation line tenderness, and he described a 'clunky' sensation as his knee was brought into extension from a hyperflexed position. There was a negative Lachman test and no instability to varus or valgus stress. Neurologic exam was normal.

IMAGING STUDIES: An MRI of his left knee showed no evidence of cruciate ligament injury. The lateral meniscus was not fairly visualized equally the MRI was of poor quality. Plain radiographs were non obtained.

DISCUSSION:

Epidemiology

5% of meniscal injuries involve patients < 15 years of historic period
Both menisci are equally vulnerable to injury
Slightly higher incidence of lateral meniscal tears in youths because of high numbers of discoid menisci in the earlier studies
Usually associated with loftier energy activities such as football, soccer, and basketball game

Clinical Presentation

The Problem

Hard to diagnose meniscal tears in children- bad historians
Clinical findings often subtle and nonspecific
Frequently leads to delay in diagnosis and misdiagnosis

History

Oftentimes draw a twisting event
A 'pop' may be heard or felt
Pain is commonly meaning with the majority of adolescents recalling a specific injury

Clinical Presentation

Symptoms

Hurting, intermittent swelling, locking, limping, and clicking
Vahvanen and Aalto- serial of 41 menisectomies in children- 95% presented with hurting, 71% had intermittent effusions, 66% had snapping sensation, 63% giving way, 54% intermittent locking, and seven% with a locked knee

Concrete Findings

Most common signs- joint tenderness and effusion
Chronic tears- often accept quadriceps wasting
Ligamentous laxity in children can crusade false positive McMurray's test

Demographics

Most common meniscal lesions - longitudinal vertical and peripheral tears
Saucepan handle tears common in older adolescents
Radial and parrot-beak tears ofttimes associated with ACL injuries
ACL injuries with meniscal injuries- need to evaluate for both

Differential diagnosis

Discoid meniscus- presents as 'snapping articulatio genus syndrome' with pain and popping from lateral articulation line- may be due to mechanical impingement of the thickened meniscus or a tear in the meniscus
Popliteus tendinitis- diagnosis fabricated clinically by tenderness over fibular collateral ligament with the human knee in 'figure of iv' position
Plica syndrome- can cause pseudolocking with the knee in semiflexed postion and pain with any motion
Patellofemoral pain- oftentimes localized to anteromedial joint line
Osteochondritis dessicans- routine radiographs can usually identify this

Evaluation

Radiographs helpful to rule out OCD, bony tumor, or osseous loose trunk
MRI- written report of choice in detecting meniscal pathology

Noninvasive and painless- fabricated arthrogram substantially obsolete
Frequently demand sedation for children
Indications- when clinical evaluation is inconclusive
Can miss lateral meniscal tears, especially in children

Diagnostic Arthroscopy- Indications

Persistent pain and instability
Recurrent effusions
Obvious ACL injury or meniscal tear by clinical exam

Treatment

Decision based on patients age, duration of symptoms, pattern of meniscal injury, and presence of concurrent injuries
Meniscectomy

Mainly of historical importance
Nearly follow-up studies- poor consequence with progressive and clinical deterioration over time
Fairbaink's radiographic changes later on total meniscectomy- squaring of the edge and flattening of the condyle, and narrowing of the joint space .

Partial Meniscectomy

Principle is to preserve as much of functioning rim of meniscus as possible
McGinty et al- compared 89 total with 39 fractional meniscectomies with 5.half dozen year follow-up- improve results with partial meniscectomy- too presently to tell
Indications- Tear patterns not acquiescent to repair-tears in avascular zone, small radial tears, and parrot-beak tears

Meniscal Repair

Collagen healing is possible in capsular third of meniscus- area where almost meniscal injuries occur in children
Repairing tear in young individuals when technically feasible is prudent when considering the natural history of alternative treatments

Practical trouble- Prolonged rehabilitation and fourth dimension abroad from sports compared to fractional meniscectomy

REFERENCES:

Busch MT: Meniscal injuries in children and adolescents. Clin Sports Med ix:661, 1990
DeHaven KE, Linter DM: Able-bodied injuries: Comparing by age, sport, and gender. Am J Sports Med 14:218-224, 1986.
Fairbank TJ: Human knee joint changes after meniscectomy. J Bone Joint Surg 4B:664-670, 1948.
Jackson JP: Degenerative changes in the knee after meniscectomy. Br Med J two:525-527.
King AG: Meniscal lesions in children and adolescents: a review of the pathology and clinical presentation. Injury 15:105-108, 1985.
McGinty JB, Geuss LF, Marvin RA: fractional or full meniscectomy. J Bone joint Surg 59A: 763-766, 1977.
Medlar RC, Manidberg JJ, Lyne ED: Meniscectomies in children- report of long term results. Am J Sports Med 8:87-92, 1980.
Ritchie DM: Meniscectomy in children. Aust NZ J Surg 35:239-241, 1965.
Vahvanen Five, Aalto K: Meniscectomy in children. Acta Orthop Scand 50:791-795, 1979.