Technical Information about ACL Injuries in Children.

Introduction

What is the incidence rate of injuries of the anterior cruciate ligament (ACL) in children and adolescents?

Injuries of the anterior cruciate ligament (ACL) in children and adolescents were once felt to be infrequent. Less than 20 years ago, some accepted thinking was that complete ACL disruption occurs only after growth plate closure (1). This concept emerged from the observation that physeal injury occurs before ligament damage (2,3). Biomechanical studies have confirmed this clinical observation that the ligaments are generally stronger than the growth plate (4,5). There has also been postulation that the anatomic location of the insertion of knee ligaments in relation to the physis leads to the preferential injury to the physis (3).

More recently it has become recognized that ligamentous injury can occur in the pediatric population and in fact Cook et al have shown that the knee is the most frequently injured site in the child athlete (6). Avulsion injuries from the tibial spine (3,7,8), the femoral insertion (9,10), or both tibial and femoral insertions have been reported (11). More recently, there have been multiple reports of complete ACL tears in skeletally immature children (3,9,12-14), the youngest in a three year old (15).

Despite the above observations, ACL injuries in the skeletally immature are becoming more prevalent. DeLee (16) has identified three factors that have lead to an increased interest in children’s knee injuries:

1. a greater number of children participating in organized sports,
2. increased recognition of pediatric knee injuries by the medical community, and
3. improved methods for diagnosing ligamentous disruptions in all age groups.

Operative treatment of ACL injuries in children, ideally, would be postponed until physeal closure. This more conservative approach, however, may actually result in greater risk to the knee. Controlling the activities of children can be impossible given the immaturity of the athlete and the increasing pressure to excel at younger ages.

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