Traumatic Injuries of the Pediatric Knee: Imaging

Perspective
Poster No.:

C-0263

Congress:

ECR 2015

Type:

Educational Exhibit

Authors:

E. Flaherty, D. Stedman, M. Chen, G. Bean, R. Loredo; San

Antonio, TX/US

Keywords:

Musculoskeletal joint, MR, Conventional radiography, CT,

eLearning, Trauma

DOI:

10.1594/ecr2015/C-0263

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Learning objectives
The aims of this pictoral essare are to:

Familiarize the audience with the pathophysiology and clinical presentation

of pediatric knee injuries
Discuss the imaging features of pediatric knee injuries as seen on
conventional radiography and cross sectional imaging
Understand how imaging plays a role in guiding treatment

Background

Knee pain secondary to trauma is one of the most common musculoskeletal complaints
in the pediatric population. Skeletal immaturity and intense physical activity increase
the risk of injury. Youth participation in organized sports has steadily increased over
the past 4 decades - 45 million children participate in scholastic or community-based
sports activities. There is a worldwide phenomenon of progressively younger athletes
participating in high performance competitions. Early sports involvement combined with
lack of physical preparedness predisposes the pediatric population to injury. Many
sports (basketball, volleyball, and soccer) are characterized by significant muscle-tendon
overload, high impact, and high training frequency without proper training conditions or
adequate supervision.
This pictoral essay describes many traumatic injuries of the knee sustained by pediatric
patients, some of which are unique to their population. A brief overview of each condition
is provided, along with it's imaging findings and management options.

Findings and procedure details

PATHOPHYSIOLOGY
Moderate physical activity benefits children and adolescents by inducing an increase in
growth hormone, preventing obesity, increasing insulin sensitivity, normalizing the lipid
profile, and regulating blood pressure. Intense physical activity leads to an increase in
inflammatory cytokines and a reduction in anabolic mediators, resulting in alterations in

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white blood cells. Knee injuries in growing bodies initiate changes in body composition,
including increased BMI and body fat percentage
While many injuries in the pediatric population are similar to those seen in adults, injury
patterns in children oftentimes differ from those in adults:

Young children are predisposed to physeal and apophyseal injuries - typically

ages 5 - 12 years
Overuse injuries (i.e. stress fractures, osteochondritis dissecans) are common
in older children - ages 13 - 17 years
Ligaments may be stronger than bones in young children, leading to less midsubstance ligamentous tears and more avulsion injuries

Due to decreased muscle strength, increased joint and ligamentous laxity, and altered
biomechanics (i.e. increased external tibial torsion), female athletes are at an increased
risk for injury during periods of rapid growth - particularly patellar maltracking and stress
fractures.
DIAGNOSIS
History and physical exam are critical in diagnosing traumatic knee injuries. Patients
present with pain, swelling, refusal to bear weight, bruising, decreased range of motion,
and locking of the knee. Conventional radiography remains the initial imaging of choice.
Many serious injuries will not be apparent on plain radiographs, including occult fractures,
internal derangement, and vascular injuries. Cross-sectional imaging, particularly MRI
given its lack of ionizing radiation, high resolution, and soft tissue contrast, is often
necessary to fully evaluate traumatic injuries.
TRAUMATIC INJURIES:
SALTER-HARRIS FRACTURES (Figs. 1 and 2)
The physeal cartilage is the weakest portion of the immature skeleton, and the ligaments
and capsular attachments are up to 5 times stronger. Distal femoral and proximal SalterHarris fractures (SHF) are uncommon, accounting for 1.6 and 0.8% of physeal fractures,
respectively.
SHF types

Type 1 - involves only the physis

Type 2 - involves the physis and metaphysis

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Type 3 - involves the physis and epiphysis

Type 4 - involves the physis, metaphysis, and epiphysis
Type 5 - crush injury of the physis

SHF of the knee are high risk for associated growth disturbances

Likely secondary to the violent injury mechanisms occurring at the knee

Subsequent abnormal growth is less common with lower grade fractures

Role of cross-sectional imaging

Most SHF of the knee are apparent on conventional radiography

Detect radiographically occult fractures and associated soft tissue injuries
Evaluate complications precluding closed reduction, such as interposed
periosteum or soft tissue
Detect early physeal closure

Management

40% of distal femoral and 16% of proximal tibial SHF require surgical repair

STRESS FRACTURES (Fig. 3)

Stress fractures in the pediatric population are typically the result of repetitive trauma on
normal bone (fatigue fracture). In the skeletally immature population, the proximal tibia
is the most common site of stress fracture (followed by the fibular and then the proximal
femur). The "female athlete triad" consists of stress fractures in adolescent females with
eating disorders, osteoporosis, and amenorrhea.
The cardinal presenting symptom is activity-related, insidious onset of pain

Initially, the pain is relieved with rest

In time, the intensity of pain increases, with associated functional
deterioration and limitation of activity

Imaging Findings

Only 10 - 25% of stress fractures are apparent on initial radiographs

MRI demonstrates linear low T1/T2 signal intensity with surrounding increased
T2 signal intensity
Three-phase nuclear bone scan can detect a stress fracture 3 - 5 days after
the onset of pain

Management

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Responds well to conservative management

Typically heal in 6 - 10 weeks

OSGOOD-SCHLATTER'S DISEASE (Fig. 4)

Osgood-Schlatter's disease is a common cause of knee pain in children, and is
associated with growth. OSD is thought to be secondary to chronic forceful contractions of
the quadriceps tendon at the tibial tubercle apophysis, leading to avulsion of the anterior
cartilage and bone
Most commonly affects girls aged 10 - 12 years, and boys 12 - 15 years

More common in boys

30% bilateral

Patients present with gradual onset of pain and edema localized to the tibial tuberosity,
aggravated by running, jumping, and kneeling
Imaging Findings

Lateral radiographs demonstrate fragmentation of the tibial tubercle

ossification center, overlying soft tissue swelling, partial obliteration of the
retrotendinous fat pad, and patellar tendon thickening

Management

Typically conservative
Up to 10% will be symptomatic in adulthood

LIGAMENTOUS INJURIES (Figs. 5 - 7)

Ligamentous injuries are more common in adolescent children than preadolescent
children, owing to the weak physis and physiologic ligamentous laxity in the immature
skeleton. However, the incidence of ligamentous injury in younger children is on the rise,
secondary to increasing participation in high level sports at younger ages. The incidence
of ACL injuries in skeletally mature children is reaching frequencies seen in adults.
The ACL is the most common ligament injured, and is more common in females due to
hormones, valgus alignment, joint laxity, intercondylar notch morphology, and earlier age
of skeletal maturity.

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PCL injuries are uncommon, but may occur with hyperextension or severe multiligamentous injuries.
Isolated collateral ligament injuries are rare.
Imaging Findings

The radiologic appearance of ligamentous injuries is similar to adults

Increased intrasubstance fluid signal and dysmorphic morphology; abnormal
lie or discontinuity of the ligament
In young children, the ligament may appear normal, but osseous contusions
in a pattern typically associated with ligamentous injuries may be seen (i.e.
contusions of the central lateral femoral condyle and posterolateral tibial
plateau that occur with ACL injuries)

Management

The PCL and collateral ligament injuries are usually treated conservatively,
as they tend to heal spontaneously; surgical repair is required in the setting
of a posterolateral corner injury associated with a PCL tear, or multiligamentous injury
Treatment of ACL injuries depends on skeletal maturity
Skeletally mature patients with closed physes undergo reconstruction in the
same manner used in adults
Skeletally immature patients with significant growth potential undergo partial
transphyseal reconstruction or all-epiphyseal reconstruction to minimize
iatrogenic disruption of the physes and subsequent growth disturbance
Studies have shown that delayed operative and non-operative treatment
result in poor outcomes, including persistent instability, progressive cartilage
degeneration, meniscal damage, and early osteoarthrosis

MENISCAL INJURIES (Figs. 8 and 9)

Meniscal injuries are in children with open physes. Most meniscal injuries prior to age 10
are secondary to discoid menisci.
Discoid menisci are large, dysplastic mensci lacking the normal semi-lunar shape.

The abnormal morphology allows for repetitive stress during extension

On MRI, there is > 50% coverage of the tibial plateau on coronal and sagittal
images
Discoid menisci are typically lateral
Prone to tear and intrasubstance degeneration

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Adolescents typically have concomitant ligamentous injuries, and 80 - 90% of patients

are involved in athletic activities. Patients present with pain, clicking, and locking (more
common with discoid menisci).
Imaging Findings

Pediatric meniscal injuries have a similar appearance as those in adults increased T2/PD weighted signal intensity extending to the free edge
Increased tear complexity is seen in the male and obese populations
Longitudinal tears and peripheral detachment are the most common meniscal
injuries in pediatric patients

Management

Meniscal injuries may be managed conservatively with free edge fraying or

small tears
Surgical debridement and/or saucerization is required with more complex
tears

OSTEOCHONDRITIS DISSECANS (Figs. 10 and 11)

Osteochondritis dissecans (OCD) describes the separation of a cartilaginous
subchondral bone segment from the remaining articular surface. It is divided into juvenile
and adult forms, with juvenile OCD affecting children and young adolescents with open
physes, and adult OCD affecting older adolescents and young adults.

Juvenile OCD is most common in athletic youths between 10 and 20 years

Twice as common in males
Bilateral in 30 - 40% of cases

The exact etiology is unknown, but OCD is thought to be caused by repetitive microtrauma
that interrupts the tenuous epiphyseal blood supply. Patients present with knee pain that
is exacerbated by activity and relieved by rest, swelling after activity, decreased range
of motion, joint grinding/locking. Accurate diagnosis is important, as patients develop
juvenile osteoarthritis when OCD is improperly treated.
Imaging Findings

Radiographs demonstrate a lucent subchondral lesion with a sclerotic rim

MRI is critical in evaluating lesion stability, as stability is the single-most
important prognostic indicator for determining conservative versus operative
management

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Signs of stability - fragment < 1 cm; continuity of the lesion with the parent
bone
Signs of instability in juvenile OCD - high T2 weighted intense rim that is the
same signal intensity as the surrounding joint fluid, which is surrounded by
an outer rim of low T2 weighted signal intensity or has multiple breaks in the
subchondral bone plate; cysts surrounding the lesion only if they are multiple
or large in size
Signs of instability in adult OCD - high T2 weighted signal intensity rim or
cysts surrounding the lesion; displaced fragment; high T2 weighted signal
fracture in the articular cartilage
The most common locations affected in order of decreasing frequency are
medial femoral condyle (representing 75% of lesions), lateral femoral condyle
(20% of lesions), trochlea, and patella

Management

Treatment is dependent on the age of the patient, size of the fragment, location
of the fragment, and fragment stability
Stable lesions in skeletally immature patients are amenable to conservative
management
Juvenile OCD has a higher rate of spontaneous healing

TRANSIENT PATELLAR DISLOCATION (Fig. 12)

Transient patellar dislocation results from the quadriceps applying lateral tension on the
patella when the knee is flexed and twisted. It is most common in adolescents aged 14
- 20 years participating in sporting activities, and is slightly more common in females.
Predisposing factors include patellar tilt, patellar alta, trochlear dysplasia, and patellar
subluxation.
Patients present with anterior and/or medial knee pain and swelling. Spontaneous patellar
relocation occurs in 50 - 75% of patients.
Imaging Findings

Plain radiographs and CT rarely demonstrate persistent patellar dislocation;

joint effusion is common
MRI demonstrates bone contusions in the inferomedial patella and
anterolateral aspect of the lateral femoral condyle; chondral injuries at the sites
of osseous contusions; disruption of the medial retinaculum; osteochondral
fragments and intraarticular loose bodies in 42%

Management

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Conservative management is usually sufficient, especially with solitary events

Surgical treatment to include lateral retinacular release, medial retinalcular
plication, and osteotomy may be necessary for severe or recurrent dislocations

SINDING-LARSEN-JOHANSSON SYNDROME (Figs. 13 and 14)

Sinding-Larsen-Johansson Syndrome is caused by forceful contraction of the quadriceps
and repetitive traction on the lower pole of the patella by the patellar tendon. It is most
common in children 10 - 14 years, and is more prevalent in males. Patients present with
pain localized to the lower pole of the patella which increases with flexion, infrapatellar
edema, and decreased range of motion.
Imaging Findings

Thickening of the proximal patellar tendon (typically with increased T2

weighted signal intensity), irregular morphology and/or increased T2
weighted marrow signal intensity within the inferior pole of the patella,
surrounding soft tissue edema, and occasionally bursitis
Typically occurs in isolation without known associated injuries to the major
stabilizing structures of the knee

Management

Treatment is conservative, with recovery occurring in 6 - 12 months with rest

and quadriceps flexibility exercises

PATELLAR SLEEVE AVULSION FRACTURE (Fig. 15)

Patellar fractures in skeletally immature patients are uncommon, accounting for 1 - 6%
of all pediatric fractures.

The immature patella is surrounded by a thick layer of protective cartilage

Patellar sleeve fractures are the most common patellar fractures, typically occurring
between ages 8 and 12. The inferior pole is more commonly affected, with only 15 cases
of superior pole patellar sleeve avulsion fractures reported.
Sleeve fractures are osteocartilaginous lesions of the patellar pole caused by powerful
contraction of the quadriceps when the knee is flexed or sustains a direct anterior blow.
Imaging findings

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Radiographs demonstrate a small osseous avulsion fracture, joint effusion,

and patella alta/baja
MRI is the study of choice to fully evaluate the extent of cartilage damage
and to evaluate the extensor mechanism

Management

Conservative management (casting in extension) is reserved for nondisplaced fractures with an intact extensor mechanism - may result in
extensor weakness, patella alta/baja, and ossification of the patellar tendon
Open surgical reduction is performed for displaced fractures, with
concomitant reconstruction of the extensor apparatus

Images for this section:

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Fig. 1: A 7 year old male status post motor vehicle collision with a knee deformity. (a,b) AP
and lateral radiographs of the knee demonstrate a comminuted fracture through the distal
femoral physis with full shaft width anterior dislocation. Diminished pulses were noted
on physical examination. (c,d) On CT angiography, a comminuted Salter-Harris type II

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fracture was identified (red arrow), with occlusion of the popliteal artery (blue ellipse)
noted at the level of the fracture.

Fig. 2: An 11 year old male with knee pain after falling while playing basketball. (a,b) AP
and lateral radiographs of the knee demonstrate are suggestive of a possible proximal
tibial fracture. (c) Coronal T1 weighted MR image definitively shows a non-displaced
Salter-Harris type II fracture of the proximal tibia (yellow arrow).

Fig. 3: A 15 year old male cross country runner with knee pain. (a) A frontal view
of the knee demonstrates a linear focus of sclerosis within the medial aspect of the
proximal tibial metaphysis (blue arrow), compatible with a stress fracture. (b,c) Coronal
T1 weighted and T2 weighting MR images of the knee again demonstrate a stress fracture
(yellow ellipse), with surrounding edema, as evidenced by low T1 and high T2 signal
intensity.

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Fig. 4: A 15 year old male with knee pain after playing basketball. (a,b) Lateral knee
radiograph and sagittal PD weighted MRI image demonstrate fragmentation of the tibial
tubercle (red arrows). (c) Sagittal T2 weighted MR image shows soft tissue edema
overlying the tibial tubercle (blue arrow), as well as thickening of the distal tibial tendon
(yellow arrow).

Fig. 5: Sudden knee pain in a 16 year old female while playing volleyball. (a) Lateral
radiograph of the knee demonstrates a deep lateral femoral notch (yellow arrow) and
a joint effusion (red arrow). (b,c) Sagittal T2 weighted MR images show increased T2
signal intensity throughout the ACL (blue ellipse) and an abnormal horizontal orientation
of the ligament (green arrow), compatible with a complete ACL tear. Additionally, kissing
contusions of the lateral femoral condyle and posterolateral tibial plateau are visualized
(purple arrows).

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Fig. 6: A 16 year old female with knee pain after an MVC. (a,b) AP and lateral radiographs
demonstrate an avulsion fracture of the posterior tibial plateau (blue ellipse). (c) Sagittal
PD weighted MR image shows osseous avulsion of the tibial insertion of the PCL (yellow
arrow). (d) Sagittal T2 weighted image of the knee demonstrates increased T2 signal
intensity within the fibers of the PCL, consistent with interstitial tearing (red arrow).

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Fig. 7: A 17 year old male who suffered a direct blow to the lateral aspect of the knee
while playing football. (a) Coronal T2 weighted MR image demonstrates a complete tear
of the medial collateral ligament at the level of the proximal tibia (yellow ellipse), with
associated traction and laxity (blue arrow). (b) An additional coronal T2 weighted image
demonstrates partial thickness tearing of the medial collateral ligament at the level of the
femoral epicondyle (red arrow). Significant edema is noted in the surrounding soft tissues.

Fig. 8: A 14 year old male soccer player with chronic knee pain. Plain radiographs were
normal. (a,b) Coronal and sagittal T2 weighted MR images demonstrate a non-coapted,
complete radial tear of the anterior horn-body junction of the lateral meniscus (yellow
arrows).

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Fig. 9: Knee pain in a 13 year old male while playing football. (a) Lateral radiograph
demonstrates a large suprapatellar effusion (blue arrow). (b-d) Sagittal and coronal T2
weighted MR images demonstrate a discoid lateral meniscus (yellow arrow) with an
associated complex tear (red ellipses). Contusion of the lateral tibial plateau and a large
effusion are also noted.

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Fig. 10: A 14 year old female with knee pain after playing basketball. (a) A frontal
radiograph demonstrates a lucent lesion with a sclerotic rim within the medial femoral
condyle articular surface (blue arrow), consistent with OCD. (b,c) Coronal and sagittal
T2 weighted images of the knee in this patient again show a nondisplaced 1.9 cm
subchondral fragment within the medial femoral condyle (red arrow). A rim of T2 weighted
hyperintense signal intensity is visualized (yellow arrows), without signs of instability.

Fig. 11: A 14 year old male with chronic knee pain while playing football and basketball.
(a) A frontal radiograph demonstrates a lucent lesion with an associated sclerotic border
(blue ellipse) within the lateral femoral condyle articular surface, compatible with OCD.
(b,c) Coronal and sagittal T2 weighted MR images show a nondisplaced fragment (yellow
arrows) with a rim of high T2 weighted signal intensity (green arrows) and an outer rim of
low T2 weighted signal intensity (green arrows), consistent with an unstable lesion. He
subsequently underwent arthroscopy and drilling.

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Fig. 12: A 14 year old female volleyball player with sudden onset knee pain. (a) Axial T2
weighted MR image demonstrates kissing contusions and compaction fractures involving
the medial patellar facet and lateral femoral condyle (blue arrows). There is a tear of
the medial patellar retinaculum (yellow ellipse). The trochlea is shallow (red arrow). (b)
Coronal T2 weighted MR image shows intra-articular loose bodies (green ellipse), thought
to arise from the medial patella.

Fig. 13: A 15 year old female cheerleader with chronic knee pain. Conventional
radiographs demonstrated no abnormalities (a,b) Sagittal and axial T2 weighted MR

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images of the knee demonstrate mild cortical irregularity of the inferior patellar pole
with associated minimal marrow edema (blue arrow). Thickening of and increased T2
weighted signal intensity within the proximal patellar tendon are also seen (yellow arrow)
on the sagittal image. Mild edema is visualized in the surrounding soft tissues (red
arrows).

Fig. 14: Knee pain in a 9 year old male who plays basketball. (a,b) Sagittal and axial T2
weighted MR images of the knee demonstrate elongation of and increased T2 weighted
signal intensity within the inferior pole of the patella (yellow arrows). Additionally, there is
mild thickening of, and increased T2 weighted signal intensity within the proximal patellar
tendon (red ellipse).

Fig. 15: A 15 year old male soccer player with knee pain. (a) Lateral radiograph
demonstrates an avulsion fracture of the inferior pole of the patella (blue ellipse).
(b) Sagittal PD weighted MR image re-demonstrates the patellar avulsion fracture
(yellow arrow), which extends to the osteochondral junction (red arrow). The extensor

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mechanism (patellar tendon) is intact (purple ellipse). (c) Patellar marrow edema is
evident on the axial T2 weighted MR image (green arrow).

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Conclusion

The incidence of pediatric knee injuries is on the rise with increasing participation in
organized sports. Imaging plays an important role in the characterization of these injuries
and aids in treatment decision-making. Proper management is necessary in preventing
the development of early osteoarthrosis.

Personal information
References

1. Orth RC. The pediatric knee. Pediatr Radiol. 2013 Mar 1;43(1):90-8.
2. Brenner JS, American Academy of Pediatrics Council on Sports Medicine and Fitness.
Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics.
2007 Jun;119(6):1242-5.
3. Cuff S, Loud K, O'Riordan MA. Overuse injuries in high school athletes. Clin Pediatr
(Phila). 2010 Aug;49(8):731-6.
4. Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries
among United States high school athletes: 2005-2007. Am J Sports Med. 2009
Sep;37(9):1798-805.
5. De Lucena GL, dos Santos Gomes C, Guerra RO. Prevalence and associated factors
of Osgood-Schlatter syndrome in a population-based sample of Brazilian adolescents.
Am J Sports Med. 2011 Feb;39(2):415-20.
6. Diederichs G, Issever AS, Scheffler S. MR imaging of patellar instability: injury patterns
and assessment of risk factors. Radiographics. 2010 Aug;30(4):961-81.

Page 21 of 23

7. Eismann EA, Pettit RJ, Wall EJ, Myer GD. Management strategies for osteochondritis
dissecans of the knee in the skeletally immature athlete. J Orthop Sports Phys Ther.
2014 Sep;44(9):665-79.
8. Frank JS, Gambacorta PL. Anterior cruciate ligament injuries in the skeletally immature
athlete: diagnosis and management. J Am Acad Orthop Surg. 2013 Feb;21(2):78-87.
9. Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester D. Avulsion fractures of the
knee: imaging findings and clinical significance. Radiographics. 2008 Oct;28(6):1755-70.
10. Greenberg EM, Greenberg ET, Ganley TJ, Lawrence JTR. Strength and functional
performance recovery after anterior cruciate ligament reconstruction in preadolescent
athletes. Sports Health. 2014 Jul;6(4):309-12.
11. Hill BW, Rizkala AR, Li M. Clinical and functional outcomes after operative
management of Salter-Harris III and IV fractures of the proximal tibial epiphysis. J Pediatr
Orthop B. 2014 Sep;23(5):411-8.
12. Kessler JI, Nikizad H, Shea KG, Jacobs JC, Bebchuk JD, Weiss JM. The
demographics and epidemiology of osteochondritis dissecans of the knee in children and
adolescents. Am J Sports Med. 2014 Feb;42(2):320-6.
13. Kijowski R, Blankenbaker DG, Shinki K, Fine JP, Graf BK, De Smet AA. Juvenile
versus adult osteochondritis dissecans of the knee: appropriate MR imaging criteria for
instability. Radiology. 2008 Aug;248(2):571-8.
14. Lin S-Y, Lin W-C, Wang J-W. Inferior sleeve fracture of the patella. J Chin Med Assoc.
2011 Feb;74(2):98-101.
15. Merrow AC, Reiter MP, Zbojniewicz AM, Laor T. Avulsion fractures of the pediatric
knee. Pediatr Radiol. 2014 Nov;44(11):1436-45; quiz 1433-6.
16. Moksnes H, Engebretsen L, Eitzen I, Risberg MA. Functional outcomes following
a non-operative treatment algorithm for anterior cruciate ligament injuries in skeletally
immature children 12 years and younger. A prospective cohort with 2 years follow-up. Br
J Sports Med. 2013 May;47(8):488-94.

Page 22 of 23

17. Patel DR. Stress fractures: diagnosis and management in the primary care setting.
Pediatr Clin North Am. 2010 Jun;57(3):819-27.
18. Sanchez R, Strouse PJ. The knee: MR imaging of uniquely pediatric disorders. Magn
Reson Imaging Clin N Am. 2009 Aug;17(3):521-37, vii.
19. Shieh A, Bastrom T, Roocroft J, Edmonds EW, Pennock AT. Meniscus tear patterns
in relation to skeletal immaturity: children versus adolescents. Am J Sports Med. 2013
Dec;41(12):2779-83.
20. Stracciolini A, Casciano R, Levey Friedman H, Meehan WP, Micheli LJ. Pediatric
sports injuries: an age comparison of children versus adolescents. Am J Sports Med.
2013 Aug;41(8):1922-9.
21. Stracciolini A, Casciano R, Levey Friedman H, Stein CJ, Meehan WP, Micheli LJ.
Pediatric sports injuries: a comparison of males versus females. Am J Sports Med. 2014
Apr;42(4):965-72.
22. Strouse PJ. MRI of the knee: key points in the pediatric population. Pediatr Radiol.
2010 Apr;40(4):447-52.
23. Thapa MM, Chaturvedi A, Iyer RS, Darling SE, Khanna PC, Ishak G, et al. MRI
of pediatric patients: Part 2, normal variants and abnormalities of the knee. AJR Am J
Roentgenol. 2012 May;198(5):W456-65.
24. Valentino M, Quiligotti C, Ruggirello M. Sinding-Larsen-Johansson syndrome: A case
report. J Ultrasound. 2012 Jun;15(2):127-9.
25. Bates DG, Hresko MT, Jaramillo D. Patellar sleeve fracture: demonstration with MR
imaging. Radiology. 1994 Dec;193(3):825-7.

Page 23 of 23