Pediatric emergency medicine trisk 0849 0849
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traumatizing the tendon’s insertion on the tibial tubercle during the child’s growth
spurt. The patients have localized tenderness and occasional swelling over the
tibial tubercle. The patient will refuse to extend the knee against force (e.g.,
perform a deep knee bend) and have difficulty going up or down stairs, although
they may have a normal gait on a level surface. To eliminate the possibility of a
neoplasm or a secondary avulsion if there is an acute change, the physician
should obtain radiographs. In Osgood–Schlatter disease, the radiographs will be
normal or show irregularity of the tubercle.
Patellofemoral dysfunction (PFD) or patellofemoral pain syndrome may be
caused by misalignment of the extensor mechanism of the knee. The vastus
lateralis, vastus intermedius, and rectus femoris pull the patella slightly laterally
and need to be balanced perfectly by the vastus medialis to keep the patella
tracking across the articular cartilage correctly. The patient with PFD may have
patellar pain with running and especially while going down inclines or stairs. The
patient may also have the sensation of the knee giving out when descending,
although an actual fall does not usually occur. The patient may describe pain
when sitting for a prolonged time with the knee flexed at 90 degrees (e.g., in
class). The pain disappears once the patient is ambulatory. On examination, the
patient may have a medially displaced patella, tenderness of the articular surface
of the patella, and a positive patellar stress test. This test is performed with the
patient in the supine position with the knee fully extended. The patient is asked to
relax the quadriceps so that the physician can move the patella. With the patella
pulled inferiorly, the physician should gently press down on it and ask the patient
to tighten the quadriceps. The patient should be asked to “push the knee into the
examination table.” This will move the patella superiorly as the physician
continues to press down. A patient with PFD will have acute pain with this
maneuver. Radiographs are normal.
Patellar tendonitis, or “jumper’s knee,” occurs in patients during their growth
spurt, especially those involved in jumping (knee extension) sports. The knee is
tender on the inferior pole of the patella and the adjacent patellar tendon, but not
on the tibial tubercle; radiographs are generally normal.
Prepatellar bursitis occurs after acute or chronic trauma to this bursa, which
overlies the patella. The patient will have swelling over the anterior aspect of the
knee, especially over the patella. A septic bursitis may need to be ruled out by
needle aspiration.
Osteochondritis dissecans (OCD) is the separation of a small portion of the
femoral condyle with the overlying cartilage. The patient is usually an adolescent
with a 1- to 4-week history of nonspecific knee pain. The physical examination
