clinics of apophysitis includes pain , with clinical findings similar to avulsions , but the inflammation of apophysitis has a smoother progress . Exams for diagnosis ( directed and also contralateral for comparision ) may be necessary . 3 Most of these pathologies can be diagnosed with X-ray , which should be used as a routine exam whenever an avulsion is suspected or there is a prolonged pain in the limb after acute injury . The ultrasound exam study also might be useful . The role of CT scan and MRI is not so well defined in acute lesions ; however , some patients may be subjected to these studies for evaluation of the trauma episode . 4 Finally , scintigraphy must be considered because it has a high sensitivity for detection of bone lesions and it has the possibility to conducting studies of the whole body . Briefly , we will say that treatment can be conservative ( more frequent ) or surgical ( clearance greater than 2cm or conservative treatment failure ). 5 At an early stage , the symptomatic control should be made with sports rest and unload of the limb , followed by a phase of rehabilitation and muscular reeducation and , finally , the return to sports , with specific sports activities . The recommended time to resume sports is six months and a regular radiological surveillance should be maintained for two years .
Bibliography
1 . Rossi F , Dragoni S . Acute avulsion fractures of the pelvis in adolescent competitive athletes : prevalence , location and sports distribution of 203 cases collected . Skeletal Radiol . 2001 ; 30:127-131 .
2 . White KK , Williams SK , Mubarak SJ . Definition of two types of anterior superior iliac spine avulsion fractures . J Pediatr Orthoped . 2002 ; 22:578-582 .
3 . Martinoli C , Valle M , Malattia C , Beatrice Damasio M , Tagliafico A : Paediatric musculoskeletal US beyond the hip joint . Pediatr Radiol 2011 ; 41 ( suppl 1 ): S113-S124 .
4 . Meyers AB , Laor T , Zbojniewicz AM , Anton CG : MRI of radiographically occult ischial apophyseal avulsions . Pediatr Radiol 2012 ; 42 ( 11 ): 1357-1363 .
5 . Ferlic PW , Sadoghi P , Singer G , Kraus T , Eberl R : Treatment for ischial tuberosity avulsion fractures in adolescent athletes . Knee Surg Sports Traumatol Arthrosc 2014 ; 22 ( 4 ): 893-897 .
Prof . Doctor João Espregueira-Mendes . Ortopedia , Porto .
The ACL rupture in children . When to operate ?
The treatment of anterior cruciate ligament ( ACL ) injuries remains a challenge to the orthopedic surgeon since , regardless of the success of the surgical procedure , the final results are still unsatisfactory . An incidence of 15 % of re-rupture is observed and this figure may reach 22 % in young patients ( under 25 years ). In addition , an abnormal kinematics in the knee after surgery of the ACL and osteoarthritis are still a quite often outcome . In recent years ( 2007-2011 ), a significant increase of the traumatic injuries of the ACL was recorded (+ 19 %), as well as in the number of surgical reconstructions of this ligament (+ 28 %) in immature skeletally individuals . The increasing incidence of ACL ruptures is multifactorial , but the increased number of children participating on high-performance sports and at a more lower age ranges may be a justification . The risk factors should always be analyzed and taken into consideration during the evaluation of an immature skeletally athlete . The indications and surgical techniques for this group of patients should be individualized , since these patients have particular anatomical characteristics , not only in relation to the anterior cruciate ligament itself , but also in the physis and the potential for growth . The decision for conservative or surgical treatment is still controversial . There is a tendency for surgical treatment because conservative treatment causes 33.7 times more clinical instability and 12 times more injuries of the internal meniscus . For the decision about the type of treatment to be performed , the correct diagnosis is the first challenge and it is not always so easily overcome . The physical examination is often enough for diagnosis ; however , the ligament laxity of these age group patients in can bring might generate
some doubts . The physical examination should be done on both knees and the aid of devices , such as the Port Knee Testing Device ( PKTD ), can be helpful for the right diagnosis of the injury . There are several surgical techniques and the decision should take into consideration the child ’ s growth potential , after checking the patient ’ s age and Tanner ’ s classification . The surgical techniques with epiphysial and extra – epiphysial fixation are the chosen in those skeletally more immature patients . Patients with little growth potential can be treated surgically as adults , but singularities regarding the technique must be respected , such as the use of flexor tendon grafts ( gracilis and semitendinous ) and the tunnels must be carried out in as perpendicular as possible to the physis plate . However , regardless of the surgical techniques used , discrepancy on the growth of the lower limbs and axial axis deviations ( varus or valgus ) can occur and their cause is not well understood . Due to the high incidence of failure with rupture of the graft , the reinforcement with extra-articular tenodesis should be considered . After 13 years of age , the younger the patient , the greater the risk of rupture . The patient and the family members should always keep in mind that the main objective of treatment is the long-term preservation of the joint and not the return to sport . This goal should be considered secondary and the expectations should be realistic about the functional results .
Dr . Henrique Jones . Ortopedia , Setúbal
Meniscus injury . What to do ?
The meniscus is responsible for the transmission of loads , absorption of shocks , reduction of the joint stress , stabilization and lubrication of the knee joint . The loads applied in the gait are three times the body weight ( 200-250 kg ) and the meniscus have a surface of 10-12 cm 2 , so the pressure is 15-25 kg / cm 2 . In the
24 may 2018 www . revdesportiva . pt