Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete…: Journal of AAOS(February 2013)

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Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management

Jeremy S. Frank, MD and Peter L. Gambacorta, DO

Abstract

Intrasubstance anterior cruciate ligament (ACL) injuries in children and adolescents were once considered rare occurrences, with tibial eminence avulsion fractures generally regarded as the pediatric ACL injury equivalent. However, with increased single-sport focus, less free play, and year-round training at younger ages, intrasubstance ACL injuries in children and adolescents are being diagnosed with increased frequency. As in the adult, a knee devoid of ligamentous stability predisposes the pediatric patient to meniscal and chondral injuries and early degenerative changes.

Management of ACL injuries in skeletally immature patients includes physeal-sparing, partial transphyseal, and complete transphyseal ACL reconstruction. Complications include iatrogenic growth disturbance resulting from physeal violation.

In the past 20 years, sports injuries in pediatric and adolescent athletes have dramatically increased. Approximately 38 million young athletes participate in organized sports annually in the United States. Of these, nearly 2 million high school students and almost twice as many athletes aged <14 years are treated for a sports-related injury each year. This new epidemic of sports-related injuries can be partially attributed to the dramatic surge in the number of participants since the passage of Title IX, along with increased emphasis on year-round competition, single-sport concentration, and more intense training.

Summary

ACL ruptures in skeletally immature patients are becoming more common with increased single-sport concentration, year-round participation, and less time spent in free play. It is the role of pediatric sports medicine providers to properly diagnose and manage these injuries. Nonsurgical management, including activity modification, bracing, and physical therapy, is best used for patients with partial tears involving <50% of the ACL diameter. In patients with complete ruptures, chronologic, physiologic, and skeletal maturity must be assessed to appropriately address the injury. Treatment options are predicated on assessment of the patient’s maturity and include physeal-sparing, partial and complete transphyseal, and adult-type anatomic ACL reconstruction. Postoperative management includes weight-bearing and activity modifications, bracing, and a progressive physical therapy protocol emphasizing ROM, closed-chain strengthening, and a gradual and measured return to sport-specific maneuvers. Surgical complications are rare.

Journal AAOS © 2013 (February)


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