BACKGROUNDPosterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population.AIMTo identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients.METHODSThis descriptive prospective study at a tertiary children’s hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up.RESULTS35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94).CONCLUSIONThis is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.
Background: Segond fractures (avulsion fractures of the proximal lateral tibia) are highly associated with anterior cruciate ligament (ACL) tears in adult patients. This large case series of pediatric Segond fractures describes the associated intra-articular knee injuries to determine if these fractures have a high incidence of ACL tears or its equivalent injury in young patients. Methods: Institutional review board approved retrospective study at a tertiary children's hospital of patients under 19 years who were diagnosed with a Segond fracture between 2009 and 2019 was conducted. Demographics, clinical data, imaging features, associated injuries, and treatment information were collected. Results: Fifty-three patients (44 males and 9 females) with median age 15.4 (11.8 to 19) years with Segond fractures of the proximal tibia on radiographic imaging were included. Diagnosis of associated injuries was established based on clinical examination, radiology report, and arthroscopic findings. Median Segond fracture size was 2.0×9.0 mm measured on standard anteroposterior knee radiographs. Magnetic resonance imaging (MRI) was obtained in 49/53 (92.5%) patients. Associated injuries included ACL tears (39 patients, 73.6%), tibial spine fractures (9, 17.0%), and other injuries (5, 9.4%). 37/53 (69.8%) patients had meniscal injury. Three (5.7%) patients sustained multiligament injuries. All associated injuries were confirmed by either MRI/computerized tomography or direct operative examination. Among Segond fractures found with ACL tears, 12 (30.8%) were contact injuries, 30 (76.9%) were sports injuries. In associated tibial spine fractures, 7 (78%) injuries were contact in nature and were sports related. There was a statistically significant difference (P = 0.013) in age, patients with tibial spine fractures (median 13.6 y) being younger than those with ACL tears (median 15.4 y). 12/53 (22.6%) had associated articular cartilaginous injuries, 3 of which were treated surgically. Overall, 81.1% of patients were treated operatively for associated intra-articular injuries. Conclusions: This large case series of Pediatric Segond fractures suggests a high association with intra-articular injuries, specifically, ACL tears and its equivalent injury, that is, tibial spine fractures, the later more common in the younger patient population. An MRI is recommended in patients with a Segond fracture for characterizing the exact intra-articular injury to help plan the appropriate management. Level of Evidence: Level IV-prognostic.
Background: Segond fractures (avulsion fractures of the proximal lateral tibia) are considered to be pathognomonic for anterior cruciate ligament (ACL) tears in adult patients. Purpose: To describe the largest case series of pediatric Segond fractures and associated intra-articular injuries of the knee to determine if these fractures are pathognomonic for ACL tears in young patients. Methods: IRB-approved retrospective study of patients under 20 years who presented with Segond fracture to a tertiary children’s hospital between 2009-2019. Demographics, clinical data, imaging features, associated injuries, and treatment information were collected. Results: 55 patients (46 males, 9 females) with mean age 15.2 years (11.8-19.1) with Segond fractures of the proximal tibia on radiology imaging were identified (Fig.1.2). Diagnosis of associated injuries was established based on clinical examination, radiology report and findings during arthroscopy. Average Segond fracture size was 2.7 x 9.5mm as measured on standard knee radiographs. Magnetic resonance imaging (MRI) was obtained in 49/55(89%) patients. Associated injuries included anterior cruciate ligament (ACL) tears (39 patients, 70.9%), tibial eminence fractures (9, 16.4%), and all other injuries (7, 12.7%) (Table 1.1). Among Segond fractures found with ACL tears, 12 (30.8%) were contact injuries, 30 (76.9%) were sports injuries. In associated tibial spine fractures, 7 (78%) injuries were contact in nature and were sports related. When age was compared between the patient group with ACL tears (mean 15.7 years) to the ones with tibial spine fractures ( mean 13.9 years), there was a statistically significant difference(p=0.007). 12/55 (21.8%) had associated articular cartilaginous injuries, 3 of which required surgical intervention. 37/55 (67.3%) patients had meniscal injury. 3 (5.5%) patients suffered multi-ligament injuries. Overall, 87.2% of the patients required surgical management for associated intra-articular injuries of the knee. Conclusion: The Segond (tibial avulsion) fracture is associated with intra-articular injuries the pediatric population, most commonly ACL tears and meniscus tears. However, the largest case series in the pediatric population suggests that they are not pathognomonic for ACL tears as a notable proportion of patients, especially the ones who are younger in age, have tibial eminence fractures or no ACL tears. [Table: see text][Figure: see text]
Background: Posterior ankle impingement (PAI) is a known cause of posterior ankle pain in athletes performing repetitive plantarflexion motions, such as in soccer. Even though it is well-described in adults, literature on PAI in pediatric patients is scarce. Purpose: The purpose was to describe prospective outcomes after arthroscopic management of posterior ankle impingement in pediatric and adolescent patients. Methods: An IRB-approved prospective study was performed at a tertiary children’s hospital from 2016-2020. Patients <18 years of age who were diagnosed with posterior ankle impingement and underwent posterior ankle arthroscopy with minimum 3-month post-operative follow-up were included. Data collected included pre-operative demographics and sporting activities, clinical and radiologic findings. Visual Analogue Scale (VAS) scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were collected at the initial and follow-up visits. Results: A total of 50 patients (65 ankles; 28 females), were included with mean age 13.3 years. Football and soccer were the most commonly implicated sports. All patients underwent initial conservative management including relative rest, immobilization and/or physical therapy for an average period of 44 weeks. The indication for surgery was failure of conservative management to improve symptoms. All patients underwent posterior ankle arthroscopy with arthroscopic confirmation of impingement pathology followed by debridement. The pathology was predominantly bony (Os trigonum, Stieda process) in 54%, and predominantly soft tissue (low flexor hallucis longus belly, ganglion cyst in the ankle, hypertrophied posterior ankle ligaments) in 46%. All 50 patients (100%) returned to sports at an average 8.5 ± 4.1 weeks. 51 ankles had radiographs done at 1 years post-operatively which did not show recurrence or any new osseous abnormalities. At mean follow up of 26 months, there was a statistically significant improvement in VAS scores (7.0 to 0.53, p<0.05) and AOFAS scores (63.9 to 95.6, p<0.05) from pre- to post-operative final follow-up. Complications included numbness over lateral part of the heel (sural nerve distribution) in 1 patient. Conclusion: The first prospective study on pediatric PAI demonstrates that arthroscopic treatment, after failed conservative management, allowed patients to return to prior level of activity and sports, and resulted in improved pain relief and higher functional parameters. Complications associated with this procedure were minimal.
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