Revista de Medicina Desportiva (English) May 2018 - Page 26

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
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 treat- ment can be conservative (more fre- quent) or surgical (clearance greater than 2cm or conservative treatment failure). 5 At an early stage, the symp- tomatic control should be made with sports rest and unload of the limb, followed by a phase of rehabilita- tion and muscular reeducation and, finally, the return to sports, with specific sports activities. The recom- mended 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. Defini- tion 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 mus- culoskeletal 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. 24 may 2018 www.revdesportiva. ً܈‘\YYZ\KSY[\˂ܝYXKܝ˂HP\\H[[[[\]O•HX]Y[و[\[܈ܝXX]BY[Y[ P H[\Y\[XZ[B[[HHܝYX\[ۂ[KY\\وHX\قH\X[Y\KH[[\[\H[[]\٘XܞK[[Y[Hو MIHوK\\\H\›؜\Y[\Y\HX^HXXH[[[]Y[ [\ BYX\K[Y][ۋ[XܛX[[B[X]X[HۙYHY\\\HقHP[[\]\\H[B]Z]Hٝ[]YK[X[YX\Š L LJKHYۚYX[[ܙX\BوH][X]X[\Y\وHP\XܙY NIJK\[\[H\و\X[XۜXB[ۜو\Y[Y[ JH[[[X]\H[][H[]YX[ˈB[ܙX\[[Y[HوP\\\š\][YXܚX[ ]H[ܙX\Y[X\و[[\X\][›ۈY \\ܛX[Hܝ[]H[ܙH\YH[\X^HHB\YX][ۋH\Xܜ[[^\H[[^Y[Z[[˜ۜY\][ۈ\[H][X][ۂو[[[X]\H[][H]]KH[X][ۜ[\X[X B\]Y\܈\ܛ\و]Y[œ[H[]YX[^Y [H\B]Y[]H\X[\[]ZX[\X\\XۛH[[][ۂH[\[܈ܝXX]HY[Y[][][[H\\[B[X[܈ܛ HX\[ۂ܈ۜ\]]H܈\X[X] BY[\[۝ݙ\X[ \H\˜H[[H܈\X[X]Y[X]\Hۜ\]]HX]Y[]\\ ˍ[Y\[ܙH[X[[X[]H[ L[Y\[ܙH[KBY\وH[\[Y[\\ˈ܈BX\[ۈX]H\HوX] BY[H\ܛYY HܜXXYۛ\\H\[[H[]\[^\X\[Hݙ\YKH\X[^[Z[][ۈ\ٝ[[Y܈XYۛ\]\BY[Y[^]Hو\HYHܛ\]Y[[[[ZY[\]BYHXˈH\X[^[Z[KB[ۈ[HۙHۈۙY\˜[HZYو]X\X\BܝۙYH\[]XH  K[H[[܈HYXYۛ\قH[\K\H\H]\[\X[X\]Y\[HX\[ۈ[ZH[ۜY\][ۈH[8&\™ܛ[X[ Y\X[B]Y[8&\YH[[\&\\YXKB[ۋH\X[X\]Y\]\\\X[[^H8$\\\X[^][ۈ\HH[[B[][H[ܙH[[X]\H]Y[˂]Y[]]Hܛ[BX[[HX]Y\X[H\˜Y[][[\]Y\Y\[HX\]YH]\H\XY X\H\Hو^܈[ۂܘY ܘX[\[[Z][[\B[H[[]\H\YY][\\[X[\\XHH\\]K]\Y\ B\وH\X[X\]Y\\Y \ܙ\[HۈHܛوB\[X[^X[^\]X][ۜŠ\\܈[\H[\[Z\]\H\[[\ YBHY[Y[HوZ[\H]\\HوHܘY HZ[ܘKBY[]^KX\X[\[\\œ[HۜY\Y Y\ LYX\›وYKH[[\H]Y[ HܙX]\H\و\\KB]Y[[H[Z[HY[X\œ[[^\Y\[Z[]BXZ[ؚX]HوX]Y[\Bۙ]\H\\][ۈوH[[H]\ܝ \[[HۜY\YXۙ\H[H^X][ۜ[HX[\X˜X]H[[ۘ[\[˂[\]YHۙ\˂ܝYXK]0[Y[\\[\K]•HY[\\\\ۜXH܈B[Z\[ۈوYXܜ[ۂوYX[ۈوH[\X[^][ۈ[XX][ۂوHۙYH[ HY\YY[HZ]\HYH[Y\HBZY LLH[HY[\B\]HH\XHو L LLH H\\H\ MKLHH [