The Adolescent
Case 5.8 Left Knee Pain and Swelling
166 The Adolescent
OBJECTIVE
General: No apparent distress.
Vital s igns: Height: 5 ft 4 inches; weight: 115 lbs; temperature: 98.2; pulse: 76; respirations: 12; BP:
110/72.
Cardiac: RRR S1/S2; no murmurs, clicks, gallops, or rubs.
Respiratory: CTA bilaterally.
Musculoskeletal: Left knee with moderate effusion; no signifi cant ecchymosis. Skin is intact. Leg is in slight external rotation (equal bilaterally). No visible misalignment of patella. No muscle atrophy apparent. Range of Motion ( ROM ) from about 10 – 120 degrees, 5 + strength with hamstring and quad- riceps testing. Equivocal fl exion pinch test. Questionable anterior and posterior joint - line tenderness, both laterally and medially. No tenderness over the patella. Negative sag test; some laxity with varus and valgus testing at 0 degrees, but no laxity with varus and valgus testing at 30 degrees; some laxity with anterior drawer and Lachman testing.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Radiograph
___Urinalysis/urine culture ___Rapid strep test
___Complete blood count with differential ___Blood urea nitrogen/creatinine
___Magnetic resonance imaging (MRI) ___Antinuclear antibody
___Lumbar puncture ___C - reactive protein
___Lyme titer/western blot/ELISA
What is the most likely differential diagnosis and why?
___Lyme disease ___Meniscus tear
___ Anterior cruciate ligament ( ACL ) tear ___Rheumatoid arthritis
___Osgood - Schlatter disease ___Patellofemoral syndrome What is your plan of treatment?
What is your plan for follow - up care?
Are any referrals needed?
Does the patient ’ s psychosocial history impact how you might treat this patient?
What if this patient was male?
What if this patient was over age 18 or under age 13?
What if the patient was also diabetic or hypertensive?
What if the patient lived in a rural, isolated setting?
Left Knee Pain and Swelling 167
What kind of education should you provide to the patient regarding future injury prevention to protect against recurrence or injury to the contralateral side?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests:
• A radiograph shows a moderate joint effusion.
• The MRI shows a full thickness tear of the ACL with a partial thickness tear of the Medial Collateral Ligament ( MCL ).
• Antinuclear antibody is within normal limits.
• C - reactive protein is mildly elevated.
• Lyme tests are all negative. (IgG is elevated but IgM is within normal limits indicating a previ- ous — but not current — infection with Lyme disease).
What is the most likely differential diagnosis and why?
Tear of the ACL:
Regardless of the test results, one can be fairly confi dent that the diagnosis is an ACL tear. It may be harder to determine the certainty of concurrent MCL tear. However, the history of sudden onset knee pain during a high - risk activity with recurrent “ giving out ” and decrease in pain is classic for an ACL injury. The physical exam is also typical for ACL injury.
What is your plan of treatment?
Recommend that Maria continue rest, ice, compression, and elevation ( RICE ) therapy until she is seen by the orthopedist. Prescribe crutch use. (Note: Some providers will recommend use of an immobiliz- ing brace, but this practice varies. Know the preference of the orthopedist to whom you are referring the patient.) Instruct Maria about exercises to work on ROM (especially extension) and quadriceps strengthening. Provide educational materials (Heffron & Daley, 2010 ), including some frequently asked questions with answers and a guide to other useful resources. The orthopedist ’ s plan for Maria is likely to include a recommendation that she undergo ACL reconstruction surgery to repair the torn ligament. The recommendation for the specifi c type of surgical procedure and graft type will vary both by surgeon but also based on the skeletal maturity — or status of growth plate closure and esti- mation of remaining growth potential — for the particular patient.
What is your plan for follow - up care?
You should see Maria again after she has seen the orthopedist to review her options and answer any questions. If possible, provide a network of patients who have been through this experience so that Maria can talk to others with similar experiences. Provide psychosocial support through- out the pre - surgery, surgery (if undertaken), and rehabilitation process. Consider talking to Maria ’ s coach(es) about incorporating an ACL injury prevention program into the regular routine for their team(s).
Are any referrals needed?
A referral to orthopedics is warranted. Potentially, a referral to a counselor, psychiatrist, or psycholo- gist (especially one involved in sports psychology and/ or experienced with pediatric patients) may be helpful. However, Maria has seen a psychiatric mental health nurse practitioner before, so she may already be comfortable with this professional. A referral for physical therapy may be appropriate, depending on the provider ’ s relationship with the pediatric orthopedist to whom she is referring the patient and the orthopedist ’ s preference for management during the acute post - injury phase.
Does the patient ’ s psychosocial history impact how you might treat this patient?
In this case, there is not any difference in treatment based on psychosocial history; but, given Maria ’ s struggles with anxiety, it is important to make sure that she feels like she is knowledgeable and
168 The Adolescent
empowered to make decisions and manage her care. It is important to gauge the patient ’ s response to the situation and determine the need for a mental health referral.
What if this patient was male?
These injuries are less common in males, but similar treatment considerations regarding skeletal maturity would apply.
What if the patient was over age 18 or under age 13?
If the patient was over age 18, she ’ d likely be at skeletal maturity; and standard adult reconstruction procedures could be used. If she was under 13, she ’ d be more likely to have wide open physes; and perhaps delayed surgical reconstruction would be the most appropriate treatment option.
What if the patient was also diabetic or hypertensive?
Standard procedures should be used for any diabetic or hypertensive patient undergoing surgery (i.e., extra insulin to compensate for the stressful situation).
What if the patient lived in a rural, isolated setting?
This might limit access to a pediatric orthopedic specialist but should not otherwise impact the plan or care.
What kind of education should you provide to the patient regarding future injury prevention to protect against recurrence or injury to the contralateral side?
The patient is likely to have many questions. An information sheet may help the patient with an ACL injury based on some commonly asked questions (Heffron & Daley, 2010 ).
Are there any standardized guidelines that you should use to assess or treat this case?
The major guiding principle in the management of ACL injuries is the importance of skeletal maturity.
Skeletal maturity will help determine the appropriate treatment modality for a particular patient with an ACL tear. Different surgical techniques have been developed to try to prevent growth disturbance that may result from the use of standard adult reconstruction procedures; and in adolescents with wide open physes, delayed surgical intervention may be the most appropriate modality.
REFERENCES AND RESOURCES
Griffi n , L. Y. ( 2005 ). Essentials of musculoskeletal care ( 3rd ed. ). Rosemont, IL : American Academy of Orthopaedic Surgeons .
Griffi n , L. Y. , Albohm , M. J. , Arendt , E. A. , Bahr , R. , Beynnon , B. D. , Demaio , M. , et al. ( 2006 ). Understanding and preventing noncontact anterior cruciate ligament injuries: A review of the Hunt Valley II meeting, January 2005 . The American Journal of Sports Medicine , 34 ( 9 ), 1512 – 1532 . Doi: 10.1177/0363546506286866.
Heffron , P. M. , & Daley , A. M. ( 2010 ). Anterior cruciate ligament injuries in adolescent girls: The primary care provider ’ s guide. Unpublished manuscript, New Haven, CT : Yale University School of Nursing .
Magee , D. J. ( 2008 ). Knee . In D. J. Magee (Ed.), Orthopaedic physical assessment. (pp. 727 – 843 ). St. Louis : Saunders Elsevier .
Paletta , G. A. , Jr. ( 2003 ). Special considerations. Anterior cruciate ligament reconstruction in the skeletally imma- ture . The Orthopedic Clinics of North America , 34 , ( 1 ), 65 – 77 . Retrieved from MEDLINE.
Schachter , A. K. , & Rokito , A. S. ( 2007 ). ACL injuries in the skeletally immature patient . Orthopedics , 30 ( 5 ), 365 – 370 . Retrieved from MEDLINE.