Paediatric ACL tears and Tibial Spine Fractures

Courtesy: Prof Shital Parikh, Professor, Cincinatti Childrens Hospital, Cincinatti, Ohio, USA

Pediatric ACL Tears & Tibial Spine Fractures – High-Yield Notes

 Pediatric ACL Tear

 Natural History (IMPORTANT)

• Non-operative – poor outcomes
  •  instability
  •  meniscal tears
  •  return to sports
• Delay > 12 weeks – irreparable meniscus injury
  Conclusion: Early surgical management preferred

 Assessment of Skeletal Maturity

Methods:

• Tanner staging (unreliable clinically)
• Bone age (hand X-ray)
•  Distal phalangeal physis:
  • Open  >2 years growth remaining
  • Closing  <2 years growth

? Treatment Algorithm (VERY IMPORTANT)

1.  Prepubescent (Tanner I–II)

• Age: ~8–10 years
• Physeal-sparing (Extra-articular)
  • Iliotibial band technique (MacIntosh)

2.  Intermediate (Growth remaining >2 yrs)

• Epiphyseal ACL reconstruction
  • Tunnels within epiphysis (no physis violation)

3.  Near maturity (<2 yrs growth)

• Transphyseal ACL reconstruction
  • Principles:
    • Tunnel < 8 mm
    • Physeal damage < 5%
    • Soft tissue graft
    • Avoid hardware across physis

 Graft Choices

• Preferred: Hamstring / Quadriceps tendon
• Avoid:  Allograft ( failure in children)

 Return to Sports

• Minimum: 6 months
• Preferred: 9–12 months
• Add:
  • Functional testing
  • ACL brace (select cases)
  • Injury prevention programs

 Complications

• Growth disturbance (rare ~1.3%)
  • Valgus deformity
  • Limb length discrepancy
• Re-tear rate higher than adults

 Tibial Spine (ACL Avulsion) Fracture

 Classification (Meyers & McKeever)

• Type I – Undisplaced
• Type II – Hinged
• Type III – Completely displaced
• Type IV – Comminuted

 Management

 Type I

• Casting

 Type II–IV

Surgical fixation (preferred)

 Why Not Conservative

• Meniscal interposition common
• Malunion  extension block
• High arthrofibrosis risk with immobilization

 Fixation Options

1.  Screw fixation

• Strong fixation
•  Requires removal later

2.  Suture fixation

• No second surgery
• Useful in comminuted fractures

Outcomes: No major difference

 Surgical Principles

• Anatomical reduction
• Rigid fixation
• Early mobilization (to prevent stiffness)

 Complications

 Most important: Arthrofibrosis

• Prevention:
  • Early surgery
  • Early ROM
  • Stable fixation

Others:

• Residual laxity (due to ACL stretch)
• ~5–20% may need later ACL reconstruction

 Important Clinical Pearls ?

• Distal femur physis contributes:
  • 70% femoral growth
  • 37% limb growth
• ACL avulsion  always normal ACL
  May lead to future instability
• In children:
  Treat ACL early, don’t wait for maturity

 One-line Summary

• Pediatric ACL  early surgery + growth-respecting technique
• Tibial spine fracture  fix displaced, mobilize early