The Differences Between a Child’s and Adult’s Knee Injury

Dr. Miller: Knee injuries and knee surgery in kids is different than it is in adults, and we're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm Dr. Tom Miller, and I'm here with Dr. Stephen Aoki, and Dr. Aoki is the Professor of Orthopaedics Surgery here at the University of Utah in the Department of Orthopaedics.

Steve, what's the major difference between injuries in kids and adults? I mean, you would think that they'd have some similar injuries, but I gather they're different.

Dr. Aoki: A lot of the injuries that we see in kids are very similar with regards to the mechanism of injury. We see ACLs in kids, we see patellar dislocation, we see meniscus tears, we see cartilage injuries. So the pathology is the same as what we see often times in adults, it's just that we have to treat them sometimes a little bit differently because we're dealing with a problem of growth and so kids are still growing and . . .

Dr. Miller: We're talking about kids, what age ranges are we talking about? What ages?

Dr. Aoki: So typically the growth plates are open, can be open up until about the age of 16. Everyone's a little bit different.

Dr. Miller: And for the audience, what's a growth plate?

Dr. Aoki: Growth plate is a little line in the bone, and that line of bone, it's the area in your bones that allows for that growth. And so that area, the growth plate is the area where the body . . . it allows your bones to get larger. And so when we injure ourselves around the knee, those growth plates are still open in kids that are still growing.

Dr. Miller: And so if they're open, they're a little softer than they would be as an adult and they would be more prone to damage?

Dr. Aoki: Not necessarily, it's a center that with surgery or with injuries can get injured. And if growth plates get injured, then we can have a problem where there's a growth disturbance. And so that's the major difference between kids and adults as far as injuries around the knees. We have to be a little more careful because we don't want to have a growth disturbance.

Dr. Miller: So it sounds like the surgery has to be more meticulous to avoid damaging their growth plate, and that's something that you specialize in?

Dr. Aoki: Sure. Often times when someone is growing, and there's a difference between the person that's growing but has very little growth left, and the person who's extremely young and has a lot of growth potential left. There's more risk with a person that has a lot more growth available. And so there's a little bit of an increased concern and worry, and we as physicians have to worry about potential problems with injuries and surgeries. And so the techniques that we have available often times have to be changed just a little bit from what we would do with a standard adult, because we want to try to minimize injury to the growth plates.

Dr. Miller: So kids are running and jumping and playing and chasing and falling and doing all kinds of crazy stuff. Do you tend to see more injuries of the knee in children than you do in adults?

Dr. Aoki: Knee injuries tend to be a little more common in kids. I think a lot of it has to do with just their activity level. You look at kids and what they do, most of them are nowadays playing competitive sports and they're playing year-round sports and activities. And so the exposure hours that they have to be exposed to at-risk activities probably tend to be a little bit higher than in my case for instance. I exercise to stay healthy . . .

Dr. Miller: Stay in shape?

Dr. Aoki: Yeah, and . . .

Dr. Miller: Not to make goals?

Dr. Aoki: Exactly. And kids they're doing a little bit more twisting, pivoting, jumping, more excessive activity, and so just the exposure hours that they have to at-risk sports tend to be a little bit riskier.

Dr. Miller: So you mentioned earlier about the different types of injuries. What's the most common injury that you see with the knee?

Dr. Aoki: I think from my standpoint in my practice, the typical injuries that I see, number one, overuse injuries that often times can be treated without surgeries and they can unfortunately it takes a little bit of time to just let things rest and . . .

Dr. Miller: And kids don't like to rest.

Dr. Aoki: Yeah, and kids don't like to rest and parents don't like their kids to be pulled out of their competitive sports either. But from a surgical standpoint, some of the more common issues that I deal with are ACL tears, patellar dislocations, cartilage injuries, meniscal tears.

Dr. Miller: One of the questions I have is, at what age do you begin to see ACL tears? Now obviously kids as young as 6 or 7 are playing soccer, but I don't imagine you see these types of injury until they're a little big or a little heavier. So I don't know, is that true?

Dr. Aoki: That's probably true. I think luckily the majority of ACL injuries that we see, tend to be in kids that are more in their teenage years. And so from a standpoint of growth, they are maybe less risky than the person who comes in who's 7, 8, 9 years old. When they start to be that real young, pre-pubescent child, they have a lot of growth left in. And so those injuries are not very common, but we do see them and they happen. It's certainly a little bit more of a problem to injure at such an early age. But there are certainly options that are available if the knee still feels unstable, which is the typical complaint that we have with ACLs.

Dr. Miller: So for the parent of the active 13 or 14-year-old playing soccer, how would they know if that child had an injury such as an ACL tear or a meniscal tear? Would it just be pain or . . . because kids minimize things so they continue doing what they want to do.

Dr. Aoki: Most individuals that tear their ACL have a very distinct injury, they're planting, they're cutting, twisting, pivoting, they jump, they land wrong, they feel a pop, and usually what happens is that knee swells up and it blows up like a balloon. And so the knee gets stiff, it gets swollen. That's a typical picture of what we see with an ACL. It's very uncommon to injure your ACL and not get swelling.

Dr. Miller: So then they should seek out their own pediatrician or what would your advice be to that parent who assumes there is a problem with the joint, with the knee?

Dr. Aoki: I always think that it's important to at least touch base with your pediatrician because they're the individual that is taking of all of your medical issues. And so it's not a bad idea to touch base with them first. They may want to see you. They may quickly get you over to see an orthopedist or someone specializing in sports medicine. But I think that in general it's always a good, at least it's a good idea to at least touch base with your pediatrician.

Dr. Miller: Now, you're careful, you're going to protect that growth plate when you're doing surgery. After surgery is the recovery longer than it would be in an adult because of the growth plate, or is it a faster recovery?

Dr. Aoki: No, kids probably heal a little bit faster than adults, and so the recovery process may be a little bit shorter. Although I treat my kids from a rehab standpoint very similar to the way that I treat my adults, mainly because for my kids I think it's worth taking that extra time to give it every chance to heal, give it every chance to . . . for that graft to take and that rebuild or that ligament to take. And so giving that extra time. I don't necessarily, while I do think that there's sometimes a rush to get back to competitive sports, I think often times it's in the best interest to take a step back and not rush things when you're so young because you have the rest of your life to look forward to.

Dr. Miller: It sounds like you have that conversation with both the child that you're going to operate on, and the parent before you even do the surgery.

Dr. Aoki: Sure. And I think it's really important to have that discussion of expectations as to when you can return to sports because that is important to kids and it's important to parents who want to get their kids back to sports and they show promise and they are real competitive. I think it goes to both the adult and the child. Everyone wants to see your child succeed.

Dr. Miller: So for the child athlete who is following instruction, who's going through physical therapy, are we talking about a month, two months, three months before they're back on the playing field?

Dr. Aoki: Depends on the injury, it depends on what problem we're talking about. So I would say in general when we talk about ACL injuries, we're looking at a 6 to 12-month recovery process of gradually increasing that activity. It's not that you're sitting in bed and at six months you're just hopping out and going at full sports. This is gradual progression of activity. Starting easy, working with therapy, getting stronger, getting your motion, it's this process of gradually increasing the activity until you get to the point where you're strong enough, you feel stable enough, you get your confidence back.

And I usually tell parents that the first year back to competitive sports is really a catch up year. It's that year that kids are a little nervous about getting back, they're not quite sure of their knee, they just need to get their feet back underneath them.

Dr. Miller: So the surgery is just a few hours in the recovery process. I mean, you go in, you repair the joint, you're careful with the growth plate, you reattach a ligament. And then it's really all about their participation in the recovery process, it's about involving them in the physical therapy and the gradual return to full potential?

Dr. Aoki: Sure. I would look at the surgery aspect as being a little blip in the big picture. While it's an important aspect of the whole process, the time afterwards and being patient about letting things recover. I tell families and kids that it's sort of like gluing a model airplane. At some point if you play with it too early, it's going to come apart. You need to let the glue dry. And part of the whole process of going through this rehab is just not letting there be too much stress to what we fixed because if you stress it too early, it's going to loosen up.

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