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Paediatric knee

GROWTH & DEVELOPMENT OF THE KNEE

At Birth   

Femoral nucleus present

3m   

Prox tibia present

3-5m   

Patella

7-9m   

Tibial tubercle

Knee growth accounts for two thirds of lower limb growth

Normal children have genu varum < 2yrs age, which progresses to valgus by 4yrs.

Meniscii are discs in the fetus & become semilunar with development. The medial meniscus is "C shaped", whereas lateral meniscus is is "O shaped" and is more sharply curved.


CONGENITAL KNEE DISLOCATION

Incidence:

2 per 100,000 general population; 1 per 100 DDH patientsCongenital knee dislocation

Female > Male 10:3 ratio, One-third bilateral, equal right and left

Aetiology:

1. Environmental: Fetal position, increased in Breech

2. absence or hypoplasia of cruciate ligaments

3. quadriceps fibrosis acquired

Heredity: Associated with Larson's syndrome

Associated deformities:

  • DDH in 45% of patients 
  • Foot deformity in 31%, clubfoot most common
  • Elbow 10%
  • Cleft palate, spina bifida, hydrocephalus, harelip, imperforate anus, facial paralysis
  • Also associated with: Arthrogryposis, myelodysplasia and Down's Syndrome
Pathology:
  1. Quadriceps fibrosis and contracture
  2. Anterior subluxed tibia
  3. Hamstrings and ilio-tibial band anterior
  4. Absence suprapatellar pouch
  5. Underdeveloped or absent patella
  6. Hypoplastic or absent cruciates
  • Severity:
  1. Grade I: minimum subluxation, knee 15-20 degrees. hyperextended, 45-90 degrees Flexion
  2. Grade II: displaced moderate, tibia anterior on femur, knee in 25-45 degrees hyperextension, flex to neutral
  3. Grade III: total displacement of tibia epiphysis, no contact, hip flexed, foot at mandible

DIAGNOSIS:

1. Hyperextended knee, limited flexion

2. Tibia dislocated anterior to femur

3. Tight quadriceps

4. May be valgus & lateral displacement of tibia

3. Ossification proximal tibia, distal femur hypoplastic or absent

TREATMENT:

  • The knee is usually too stiff for splintage or manipulation 
  • Surgical treatment usually at 3 to 6 months of age:
    1. Perform before weight bearing
    2. Ant-medial approach
    3. Inverted V in rectus femoris or tongue flap
    4. Medial and lateral parapatellar incision
    5. Free fibrosed quads, patella and tendons from bone
    6. Possible release anterior knee capsule, IT band and lateral septum
    7. Possible reconstruct cruciates if absent: semitendinosous for ACL
    8. Hip spica x 6 weeks, then night splint


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