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Pediatric/skeletally immature w/ possible ACL tear
Focused hx/exam [S] + imaging - Hx: injury mechanism, popping/locking/catching, swelling, ability to weight-bear/return to play
- Exam: neurovasc (esp tibial/peroneal n.),1 joint line tenderness, step-off/deformity, effusion, varus/valgus laxity @ 0° and 30° extension, AP/rotational laxity, Lachman test2
- Image: AP/lateral XR knee 1st to r/o fx/dislocation, [C] then MRI if needed to r/o internal knee pathology [S]
Consider ACL repair [L] vs conservative mgmt options: - Initial conservative mgmt if Δ laxity of IL vs CL knee3 <5-7 mm and pt less active4 [L] w/ delayed repair if recurrent instability [L], goal <5mo postinjury [M]
- Initial operative mgmt, esp if Δ laxity of IL vs CL knee3 >5-7 mm and pt active4 [L]. Techniques: tibial-independent/transtibial approach [M], single/double bundle [S], autografts or allografts5 OK [S]
- If repair ACL, also fix assoc meniscal tear [L], esp. if locked knee [C], but not assoc incomplete MCL tear [L]
- Post-op: No brace if isolated ACL [M]. Prevent future ACL tear via NM training6 [M], not brace [L]. Initiate post-op PT7 [M]. Return to play based on clinical judgment, not time/fxn criteria [L]
Footnotes 1 Tibial n. controls ankle plantar flexion, toe flexion, provides foot sole sensation. Peroneal n. controls ankle dorsiflexion, toe extension, provides shin/top of foot sensation.
2 Lachman: w/ pt supine, knee flexed @ 20° to 30°, place 1 hand behind tibia (thumb on tibial tuberosity), other on pt’s thigh. Pull anteriorly on tibia to assess ACL injury: >10 mm ant. mvmt or >2 mm more ant mvmt than CL knee suggests ACL tear.
3 Laxity definition >5-7 mm increased laxity of IL vs. CL knee on KT-1000 (quantifies ant translation of knee w/ joint flexed between 20° to 30°); normal knees have ≤3 mm laxity difference between sides.
4 Active: variably defined as >50-199 h jumping and/or cutting sports/year.
5 Autografts may be preferred over allografts in the young, active population. Patellar tendon bone-to-bone and hamstring-tendon autograft techniques both recommended.
6 NM training: eg, plyometrics, strengthening, instructor feedback component; often coach-led.
7 Early, accelerated, and nonaccelerated PT programs recommended.
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Adult/skeletally mature w/ possible ACL tear
Active (>50-199h jumping/cutting sports/yr) adult Focused hx/exam [S] + imaging - Hx: injury mechanism, popping/locking/catching, swelling, ability to weight-bear/return to play
- Exam: neurovasc (esp tibial/peroneal n.),1 joint line tenderness, step-off/deformity, effusion, varus/valgus laxity @ 0° and 30° extension, AP/rotational laxity, Lachman test2
- Image: AP/lateral XR knee first to r/o fx/dislocation [C], then MRI if needed to r/o internal knee pathology [S]
Surgical reconstruction for acute ACL tears [M] - Tibial-independent or transtibial approach [M]; single/double-bundle technique recommended [S]; autografts or allografts3 OK [S]
- Also fix assoc meniscal tear [L], esp if locked knee [C], but not assoc incomplete MCL tear [L]
- Post-op: No post-op brace if isolated ACL [M]. Prevent future ACL tear via NM training4 [M], not brace [L]. Initiate post-op PT5 [M]. Return to play based on clinical judgment, not time/fxn criteria [L]
Footnotes 1 Tibial n. controls ankle plantar flexion, toe flexion; provides foot sole sensation. Peroneal n. controls ankle dorsiflexion, toe extension; provides shin/top-of-foot sensation.
2 Lachman: w/ pt supine, knee flexed @ 20° to 30°, place 1 hand behind tibia (thumb on tibial tuberosity), other on pt’s thigh. Pull anteriorly on tibia to assess ACL injury: >10 mm ant mvmt or >2 mm more ant mvmt than CL knee suggests ACL tear.
3 Autografts may be preferred over allografts in the young, active population. Patellar tendon bone-to-bone and hamstring-tendon autograft techniques both recommended.
4 NM training: eg, plyometrics, strengthening, instructor feedback component; often coach-led.
5 Early, accelerated, and nonaccelerated PT programs recommended.
Less active (<50-199h jumping/cutting sports/yr) adult Focused hx/exam [S] + imaging - Hx: injury mechanism, popping/locking/catching, swelling, ability to weight-bear/return to play
- Exam: neurovasc (esp. tibial/peroneal n.),1 joint line tenderness, step-off/deformity, effusion, varus/valgus laxity @ 0° and 30° extension, AP/rotational laxity, Lachman test2
- Image: AP/lateral XR knee first to r/o fx/dislocation [C], then MRI if needed to r/o internal knee pathology [S]
Consider ACL repair [L] vs conservative mgmt options: - Initial conservative mgmt, esp if Δ laxity of IL vs CL knee3 <5-7 mm (if <50h/yr of jumping/cutting sports) or <5 mm (if 50-199h/yr) w/ delayed repair if recurrent instability [L], goal <5mo postinjury [M]
- Possible initial operative mgmt, esp if Δ laxity of IL vs CL knee3 >5-7mm. Techniques: tibial-independent/transtibial approach [M], single/double bundle [S], autografts or allografts4 OK [S]
- If repairing ACL, also fix associated meniscal tear [L], esp if locked knee [C], but not incomplete MCL tear [L]
- Post-op: No post-op brace if isolated ACL [M]. Prevent future ACL tear via NM training5 [M], not brace [L]. Initiate post-op PT6 [M]. Return to play based on clinical judgment, not time/fxn criteria [L]
Footnotes 1 Tibial n. controls ankle plantar flexion, toe flexion and provides foot sole sensation. Peroneal n. controls ankle dorsiflexion, toe extension, provides shin/top-of-foot sensation.
2 Lachman: w/ pt supine, knee flexed @ 20° to 30°, place 1 hand behind tibia (thumb on tibial tuberosity), other on pt’s thigh. Pull anteriorly on tibia to assess ACL injury: >10 mm ant mvmt or >2 mm more ant mvmt than CL knee suggests ACL tear.
3 Laxity definition: >5-7mm increased laxity of IL vs CL knee on KT-1000 (quantifies ant translation of knee w/ joint flexed between 20° to 30°); normal knees have ≤3 mm laxity difference between sides.
4 Autografts may be preferred over allografts in the young, active population. Patellar tendon bone-to-bone and hamstring-tendon autograft techniques both recommended.
5 NM training: eg, plyometrics, strengthening, instructor feedback component; often coach-led.
6 Early, accelerated, and nonaccelerated PT programs recommended.
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