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Anterior Cruciate Ligament Injuries in

the Skeletally Immature Athlete :

Diagnosis and Management
Jeremy S. Frank, MD
Peter L. Gambacorta, DO

Reviewer : Muhammad Pringgo Arifianto


1. Chronicity
2. Mechanism of injury ( Contact Vs
3. Nearly half of all ACL injuries are
associated with a hemarthrosis
between 6 and 12 hours after
Physical Examination

O Visualization To detect any underlying effusion

O Palpation
O ROM : injury to the meniscus and/or
cartilage should be considered
O Lachman test : to assess anterior
tibial translation and end point
O The Pivoy Shift test is benefical in
reproducing the sense of instability
O MRI has 95 % sensitivity for
detecting ACL tears in pediatric
O MRI is not absolutely indicated for :
- positive and asymmetric Lachman
and pivot shift examination
- No additional ligamentous laxity
- Full Knee ROM
O Nonsurgical Management
O Activity modification
O Functional bracing
O Physical rehabilitation

O Surgical Management
Surgycal management is guided by :
- Patients skeletal
- Physiologic maturity
- Chronologic maturity
nner Stages of Physiologic Maturity
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Growth 5-6cm/y 5-6cm/y 7-8cm/y 10 cm/y None
Testes, penis Testes : <4ml Testes : 4ml or Testes : 12 mL Testes : 4.1- Testes fully
or <2.5cm 2.5-3.5cm; or 3.6 cm; 4.5 cm; mature in
penis usually enlargement, increased size shape and
not yet lengthening of and breadth of size
enlarged penis penis
Pubic hair None Sparse. At Pubic hair Adult-like, but Fully mature in
base of penis over pubis; over a smaller type and
darker, area quantity,
coarser, and extending to
more curied the thighs
Growth 5-6 cm/y 7-8cm / y 8cm/y 7cm / y None
Breasts No Buds Elevation and Areolae and None Mature
development aerolar Papillae form
enlargement secondary
Pubic hair None Sparse, on On mond Adult-like, but Fully mature in
labia; slightly pubis; darker, over a smaller type and
pigmented coarser, and area quantity,
more curled extending to
the thighs
Algorithm for anterior cruciate ligament reconstruction in the
skeletally immature patient
ACL tear in skeletally
immature patient

( <50% fibers Complete

Prepubesc Adolescents Older

ent with growth Adolescents
Tanner remaining with closing
stage 1 or Tanner stage physes
2 3 or 4 Tanner stage
Males <12 Males <13-16 5
y y Males > 16 y
Females < Females < 12- Females > 14
11 y 14 y y
Physeal-sparing Transphyseal Adult-Type
Activity modification combined extra reconstruction anatomic ACL
Physical therapy and intra-articular with autogenous reconstruction
Bracing reconstruction quadrupled with hamstrings
with autogenous hamstring or patellar tendon
iliotibial band tendons and ( autograf
metaphyseal preferable )
O Weight-bearing and activity
O Bracing
O Progressive physical therapy protocol
emphasizing ROM
O A gradual and measured return to
sport-specific maneuvers
Thank You