Module 68, Pediatric Orthopaedist Level

This 11 year old female presented to Orthopaedic Clinic complaining of right knee pain . There was no history of trauma. This pain increased with activity and decreased at rest and had been present for approximately one year. A past history of osteomyelitis of the right tibial shaft at age two was elicited. This infection was treated with IV antibiotics and the child had no problems until the recent symptoms started one year ago. When asked to localize the pain the patient pointed directly to the tibial tubercle. Prominence of the right tibial tubercle was noted as compared to the left.. The tibial tubercle was warm, slightly red, swollen and tender to palpation. There was pain with resisted knee extension but no pain to passive knee range of motion. There was no joint line tenderness or effusion. The right knee had full range of motion with no hamstring or quadriceps tightness. There was no instability to varus or valgus stress. Lochman and MacMurray tests were negative. There was no pain to palpation over the infrapatellar ligament and patellar tracking was normal. An x-ray was obtained. The patient was sent for a physical therapy evaluation and training for stretching and isometric strengthening including a home exercise program. Anti-inflamatories were prescribed. A knee pad was recommended for sports and kneeling activities. Stretching before and after sports as well as application of ice was recommended.

Question 68A

Application of a leg cylinder cast would resolve the symptoms faster and more permanently.

Question 68B

The anterior ossicle will likely cause long term symptoms and as a young adult may need to be surgically excised.

Question 68C

If this girl is a high level athlete, injection of the tibial apophysis with steroid would be a good alternative to gain faster resolution of the symptoms rather than using oral anti-inflammatories.

Question 68D

This condition can cause a recurvatum deformity of the tibia.

Question 68E

This girl is at increased risk for an acute tibial tubercle fracture during her teenage years.