Anterior cruciate ligament tear in children and adolescents

Anterior cruciate ligament tear in children and adolescents

Introduction

The anterior cruciate ligament or ACL is one of the four major ligaments that connect the thigh bone (femur) to the lower leg bone (tibia). The ACL is very important and plays a crucial role in maintaining knee stability, especially during activities that include abrupt stopping or slowing down, quick change in direction or landing from a jump.

Picture of the knee anatomy or picture for a child twisting his/her knee

Injury to the ACL tear happened when the ACL separated in two pieces or turn off its bone attachment. ACL injury is a serious concern for active kids and teens, and we see increasing in the ACL injuries in the past 2 decades. The reason for that is the growing number of children and adolescents who is participating in professional and organized sports at an early age. ACL injuries are often accompanied by injury to other structure of the knee such as meniscus tears, cartilage damage, or another ligament tear.

Risk factors

The risk of ACL injuries among young athletes is influenced by multiple factors. Various studies have identified that females are at a heightened risk, along with individuals who have higher body weight and BMI, knee valgus deformities (commonly known as knock knees), certain severe forms of flat feet, and inadequate neuromuscular control in both the hip and knee regions.

How do ACL injuries in children differ from ACL injuries in adults?

A child's body is significantly different from an adult's body, not only in terms of size but also in anatomy. The main contrast lies in the growth process, as children have growth plates at the end of their long bones, known as physis, which are crucial for bone development. These growth plates are delicate and susceptible to damage during injury and treatment. This difference can have a major impact on the severity of injuries and the approach to treatment.
Another difference is the greater healing potential of injuries in the knee in children compared to adults.
Therefore, surgical techniques must be adjusted to safeguard the child's growth, and every effort should be made to repair the injured structures.

What are the symptoms of ACL injury in young athletes?

Some symptoms become apparent right after the injury, while others persist for a longer period. The immediate signs of an injury may involve sudden pain, a popping sensation, and significant swelling in the knee within a short time frame. The knee's mobility is often limited, and walking can be very uncomfortable. It is not unusual for individuals to underestimate the seriousness of the injury because the pain and swelling improve quickly in the following weeks. However, when attempting to return to sports activities, the knee may feel unstable and prone to giving out. Players may lack confidence in the knee or find it difficult to pivot on that side.

How can I know that my child has an ACL in injury?

Your pediatric orthopedic doctor will utilize various methods to diagnose an ACL tear in the child:

• Initially the doctor will ask about the patient's symptoms, the mechanism of injury, and the treatment received post-injury. Additionally, the doctor will ask about the child's involvement in sports, any prior knee injuries or symptoms, as well as the medical history.
• The doctor will also perform a physical examination to assess the child's range of motion, stability, and strength in the knee. They may perform specific tests such as the Lachman test or the pivot shift test to further evaluate the integrity of the ACL.
• X-ray is useful to rule out other injuries that may present similar symptoms to an ACL tear, such as fractures.
• MRI scans will be employed to confirm ACL damage and identify any other knee injuries like meniscus tears, cartilage damage, or other ligament injuries.
• To assess the child's remaining growth potential, the doctor may request information about the parents’ height and conduct bone age x-rays.

What treatment choices are available for a pediatric ACL tear?

Initial Treatment

Following the initial injury, it is crucial to decrease swelling and manage pain effectively. A useful approach for the initial treatment is RICE, which stands for Rest, Ice, Compression with elastic bandage, and Elevation the injured part
The physician may advise taking pain relievers or anti-inflammatory medications and suggest using crutches to aid in walking. Once the swelling goes down, it is essential to concentrate on restoring the movement, especially extension or straightening.

Determining If Your Child Requires ACL Surgery.

It is important for the doctor to discuss with both the parents and the child the appropriate treatment options that are available. This dialogue will help identify their requirements and hopes, all while weighing the potential risks and complications associated with each treatment method.

Surgical intervention is not always necessary. Surgery may be recommended if the patient:

• Is unable to engage in his/her preferred physical activities.
• Experiences instability that impacts daily tasks.
• Has a repairable meniscal tear or multiple torn ligaments in the knee.

Non-surgical treatment

For certain young athletes and their parents, opting for conservative or nonoperative management could still be a reasonable treatment choice. This approach should include:

• Using a knee brace
• Rehabilitation exercises
• Sports restrictions for an extended period until reaching skeletal maturity.

The conservative approach is typically appropriate for athletes participating in sports such as cycling or swimming, where there is minimal impact and no pivoting force on the knee. Conversely, athletes engaged in sports like basketball, soccer, and football, which require running, jumping, pivoting, or contact, will probably require ACL surgery to continue playing.
Continuing to play with an unstable knee caused by a torn ACL, can result in additional damage to the knee cartilage and meniscus.

It was recommended in the past to postpone the surgery until the child reaches skeletal maturity and growth plates have closed to prevent growth issues and bone deformities. However, new research suggests that early surgery is now favored, as postponing treatment can have detrimental effects in the future. Delaying surgery may result in meniscus tears, cartilage damage, and increasing the risk of developing arthritis at an early age.
Thanks to advances in technology and surgical approaches, it is no longer necessary to delay surgery until the child is done growing. In fact, delaying surgery can lead to more knee damage.

Surgical Approach

A completely torn ACL will not heal without surgery. While the majority of ACL injuries require surgery, some young athletes may choose to postpone the procedure until their bones have fully matured to reduce the likelihood of growth plate damage resulting from the surgery.

Advanced surgical techniques now allow for early ACL reconstruction in growing athletes with little to no impact on their growth plates. Parents contemplating surgery for their child should consult with a pediatric orthopedic surgeon specializing in sports medicine.

The pediatric orthopedic surgeon will select the most suitable surgical technique following a thorough assessment of the athlete's physical development (specifically puberty) and bone age determination through a pediatric endocrinologic consultation and x-ray of the left hand/wrist.

By assessing the athlete's physical maturity and bone age, the physician can tailor the surgical technique to ensure optimal outcomes and minimize the risk of complications. This personalized approach is essential in providing young athletes with the best possible care and support for their orthopedic needs.

If your child is experiencing severe pain and swelling or instability after a knee injury, it is likely that they have an ACL tear. It is important to seek assessment from a pediatric orthopedic specialist in sports medicine.
At American Hospital Dubai, our team is dedicated to evaluating your child's injury and providing guidance on the most effective treatment options. We specialize in treating ACL injuries in children and will create a personalized treatment plan that is best suited for you and your child.

Our pediatric orthopedic specialists have extensive experience in diagnosing and treating ACL tears in children, using the latest techniques and technologies to provide the most effective care. We understand the unique needs of young athletes and work closely with them to help them recover and return to their normal activities as quickly and safely as possible.