“Multi-ligamentous” Injury Patterns of the Skeletally Immature Knee:

“Multi-ligamentous” Injury Patterns of the Skeletally Immature Knee:
A case series and review of existing literature
Raghav Badrinath MD, Erica Giles BSc, Cordelia W. Carter MD
Yale University, New Haven, CT
RESULTS
OBJECTIVES
There is little information available on multi-ligamentous knee
injuries (MKIs) in the skeletally immature population. As a result,
there is no consensus amongst treating surgeons regarding optimal
treatment for these rare injuries. Similarly, data are lacking
regarding clinical and functional outcomes for these patients. This
case series attempts to describe injury patterns and propose
treatment strategies for managing multi-ligamentous (combined
ACL-LCL/PCL/PLC) injuries in patients with open physes.
DISCUSSION
Case 2 is a 13 year-old male who presented with knee pain and swelling following a contact football
injury. Radiographs demonstrated a displaced tibial spine fracture and associated Segond fracture.
MRI revealed additional injuries of the distal lateral collateral ligament (LCL) and biceps femoris
insertions onto the fibular head. He was treated with arthroscopic-assisted reduction and internal
fixation of the tibial spine fracture using all-epiphyseal screws and open repair of his lateral injuries
using all-epiphyseal suture anchors. He had an uncomplicated postoperative course and at 6 months
after surgery was asymptomatic, had regained full knee ROM and had returned to unrestricted activity.
A.
B.
C.
D.
E.
1 1 4MR - D E l ati p s oH n ev aH w eN el aY
LAR ETAL DNA PA TF EL E ENK RX
TAL E ENK
M P 7 0: 9 5: 6 3 1 0 2/ 9/ 0 1
393267001E
------Dockery, Nathaniel B
MR1044273
2/8/2000
13 YEAR
M
Coronal T2-weighted MR image from Case 3,
demonstrating avulsion fractures of the ACL and LCL.
B l ei n a ht aN ,yr ekc oD
3 7 2 4 4 0 1RM
0 0 0 2/ 8/ 2
RA EY 3 1
M
Yale New Haven Hospital ED - RM411
XR KNEE LEFT AP AND LATERAL
KNEE AP
10/9/2013 6:57:27 PM
E100762393
-------
Dockery, Nathaniel B
Unit#:MR1044273
A cc#:E100763368
DO B:2/8/2000
M/13 YEA R
H
SMILO W 2 NP2
MRI KNEE LEFT WO IV C O NTRA ST
t2_tse_fs_C O R
10/10/2013, 8:32:33 PM
--LO
LOC
C:-0.09
:-0.09
THK:2.30 SP:2.30
FFS
METHODS
R
This study was performed in accordance with institutional IRB regulations. Three skeletally immature
adolescents who presented to our institution with MKIs between 2012 and 2013 were identified.
Patient records were retrospectively reviewed to obtain data on demographics, mechanism of injury,
physical exam, imaging, treatment and outcome.
RESULTS
Page: 1 of 2
Case 1 is a 13 year-old male who presented with multiple musculoskeletal injuries after being
struck by a car while on a scooter. In addition to open fractures of the left femur and ankle
requiring urgent surgical stabilization, he sustained bony avulsion of the ipsilateral left PCL from
the tibia, avulsion fractures of the LCL and popliteus from the femur, and intrasubstance tearing of
the anterior cruciate ligament (ACL). Surgical treatment included staged repair of the PCL using
transphyseal sutures; suture repair of the posterolateral corner injury using all-epiphyseal bone
tunnels; and subacute ACL reconstruction using physeal-respecting techniques. He developed
postoperative arthrofibrosis and required manipulation under anesthesia. At one year from surgery,
he had regained full knee ROM, was asymptomatic and had returned to unrestricted activity.
A.
Brewer, Taezhan
Unit#:MR443022
Acc#:E100510668
DOB:5/27/2000
M/13 YEAR
H
R
B.
SMILOWBrewer,
3 NP3 Taezhan
MRI KNEE LEFT WO IV CONTRAST
Unit#:MR443022
COR PD high_bw
Acc#:E100510668
7/12/2013, 2:54:02
AM
DOB:5/27/2000
M/13--YEAR
LOC:-43.99
THK:3 SP:3.60
FFS
A
--c:BO1,2;SP2,3
NEX:1
--Pix Bdwth:501
AQM:384\0\0\346
SE/TR:2500/TE:27/FA:170/ETL:6
Page: 18 of 29
H
L
--W:1578/C:566/Z:1.33
c:BO1,2;SP2,3
Phase Dir:COL
NEX:1
Phase FoV:100
--AFoV 159*159
Pix Bdwth:501
DFoV:16x16cm
AQM:384\0\0\346
Compressed
7:1
SE/TR:2500/TE:27/FA:170/ETL:6
IM:18
SE:817 of 33
Page:
cm
C.
SMILOW 3 NP3
MRI KNEE LEFT WO IV CONTRAST
SAG PD high_bw
7/12/2013, 2:49:21 AM
--LOC:-0.03
THK:3 SP:3.60
FFS
D.
Images A and B are coronal and sagittal MR images of the knee, demonstrating displaced avulsion fractures of the LCL from the
femur (A) and the PCL from the tibia (B) and an intrasubstance ACL tear (B). Image C is an intraoperative fluoroscopic image
demonstrating all-epiphyseal suture repair of the LCL. Images D and E are arthroscopic pictures demonstrating the appearance
of the PCL following suture repair and of the ACL and PCL following reconstruction using transphyseal tunnels.
F
F
G.
mc
cm
F
H.
S: 94
Z: 0.36
C: 648
W: 1049
Compressed 32:1
IM: 1001
Ultimately, there are many questions that remain unanswered in terms of structuring management
plans for skeletally immature patients with MKIs, including: surgical indications, optimal surgical
timing, appropriate surgical techniques, and effective rehabilitation guidelines. In addition to
addressing these knowledge gaps, future research should continue to attempt to delineate clinical
and functional outcomes for these patients.
W:1660/C
W:1660/C:776/Z:1.60
:776/Z:1.60
Phase Dir:C O L
Phase
Phase FoV
FoV:100
:100
A FoV 160*160
DFoV
DFoV:16x16cm
:16x16cm
C ompressed 7:1
IM:34
IM:34 SE:8
SE:8
cm
cm
I.
2 f o 2 : eg a P
Images A and B above are AP and lateral radiographs demonstrating avulsion fractures of the tibial spine and Segond fracture.
C is a coronal T2 MR image demonstrating associated injuries of the biceps and LCL at their fibular insertion. D and E are
postoperative films following all-epiphyseal fracture fixation.
Images F-I are arthroscopic images demonstrating (F) tibial spine fracture following removal of entrapped medial meniscus;
(G) following reduction and provisional fixation with K-wires; (H) Drilling prior to screw placement; (I) appearance of the
fracture following reduction and fixation.
E.
P
W:1651/C:844/Z:1.33
Phase Dir:COL
Phase FoV:100
AFoV 159*159
DFoV:16x16cm
Compressed 7:1
IM:17 SE:7
cm
F.
The three patients included in this small, retrospective case series were all in the early years of
adolescence, with open physes. Both male and female sexes were represented. High-energy
mechanisms of injury were commonly described. These skeletally immature patients presented
more commonly with ligamentous avulsion fractures than intra-substance ligamentous failure.
Because of the theoretical risk for iatrogenic physeal injury and resultant growth disturbance, the
surgical techniques employed were physeal-sparing, wherever possible. Complications reported in
adult patients such as arthrofibrosis also occurred in this population. Ultimately, return to sport was
an achievable goal for each patient.
L
--T:FL;BO 1,2
NEX:2
ITA P:p2
Pix Bdwth:200
A Q M:320\0\0\256
SE/TR:4420/TE:52/FA :160/ETL:13
Page: 34 of 54
0 1 1 :S
6 3. 0 :Z
846 : C
9401 : W
1: 2 3 d e s s er pm o C
2 0 0 1 :MI
Multi-ligamentous knee injuries (MKIs) are uncommon in skeletally immature patients, with little
formal research performed on this population. Clinical outcomes for adolescent patients with
combined ACL-MCL injuries have been reported in the literature to be similar to adults (Sankar et
al, JPO 2006); however, injury patterns, treatment algorithms, and clinical outcomes for other types
of MKIs remain largely undescribed for young athletes.
Case 3 is a 12 year-old female who sustained acute injuries of both lower extremities after being
struck by a car. The left knee was noted to be swollen and tender; radiographs and subsequent
MRI/ CT scans revealed tibial spine fracture and bony avulsion of the femoral attachments of
popliteus and LCL. She underwent arthroscopic-assisted reduction and suture fixation of the
tibial spine fracture and open repair of lateral injuries using all-epiphyseal bone tunnels. She had
an uncomplicated postoperative course and at 6 months after surgery was asymptomatic, had
regained full knee ROM and had returned to unrestricted activity.
CONCLUSIONS
This small case series is likely most useful in that it highlights gaps in our knowledge about
multi-ligamentous knee injuries in skeletally immature patients, and may therefore stimulate
discussion and focused research efforts amongst pediatric sports specialists.
Corresponding author information:
Cordelia W. Carter, MD
Assistant Professor of Orthopaedic Surgery
Yale University School of Medicine
Email: cordelia.carter@yale.edu