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Ligament tears rare when children injure their knees

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By Dr. Jeff Daniels EBS Medical Columnist

As we near the end of the ski season, I’ve been looking back at some of the more interesting injuries we’ve had in the clinic. Most injures have been minor tragedies for those involved, and luckily, there have been very few major tragedies. It’s hard not to let every injury we see affect us in some way.

Of all the injuries that come through, the ones that get to me the most are when kids get hurt. They are only a small percentage of patients we treat, and none this season resulted in a long-term tragedy. Most often the patient’s concern is, “How will I play baseball (or hockey, or lacrosse) with my broken wrist when I get home?” But there were some I remember for one reason or another.

Unlike adults, kids between 5 and 15 rarely injure their knees the way adults do. We see many adults who come in with a torn anterior cruciate ligament, more commonly known as an ACL, but this rarely happens in children. When it does, it presents in several ways and poses some unusual problems.

Most kids are small enough not to generate the amount of torque it takes to tear the ACL. Either that, or they are built with ACLs that are more resistant to tearing, possibly because the part of the tibia that the ACL attaches to gives and breaks before the ligament has a chance to tear.

This patient came to the Big Sky Medical Clinic with a knee injury this winter. When kids injure their knees, they rarely tear the anterior cruciate ligament because they don't often generate enough force to separate the ligament. PHOTO BY DR. JEFF DANIELS

This patient came to the Big Sky Medical Clinic with a knee injury this winter. When kids injure their knees, they rarely tear the anterior cruciate ligament because they rarely generate enough force. PHOTO BY DR. JEFF DANIELS

Kids who present with this injury are usually brought in by the ski patrol with their injured leg wrapped in a brace. Even through ski clothing, we can tell that the knee is very swollen. Most haven’t heard the “pop” that adults hear, or sense, when they tear their ACL. Also, most kids won’t attempt to stand on the injured leg, while most adults are in denial and will try to get up and ski down with the immediate realization that the leg is unstable and they had better call ski patrol.

When an adult comes in with a torn ACL, I can usually move their knee around, often painlessly, and get a feel for the damage done. With kids, you can’t even breathe on the injured knee; they just won’t let you near it! So we have to rely on the clinical presentation, and then X-rays to get to the diagnosis.

Most kids who injure the ACL haven’t torn it, but have pulled apart the surface of the tibia where the ACL attaches. This is usually obvious on the X-rays. The tibia can have several different types of fractures associated with this injury. Sometimes we see a thin band of bone floating inside the knee joint. In others, we see a fracture line through the entire tibial spine complex, a ridge of bone where the ACL attaches. Whatever we see, we know we are dealing with a significant injury, and it’s going to take a long time to heal. Surgery is also an option.

The close of this season marks my 23rd ski season at Big Sky taking care of the injured and the sick on the mountain. Brad Poore and Myra Lemke on my office staff have chalked up their 21st ski seasons. Our physician assistant Cary Wilson, who has been in Big Sky longer than I have, just completed his third ski season as a provider of health care—prior to that, he helped injured skiers as a ski patroller. Kathryn Cody, Josie Gunderson, Katie Daniel and Yasmin Irazabal on my office staff, along with volunteers Greg Erickson and Johnny Perez, have kept the office running smoothly.

The program I created in 1998 for senior medical students, residents and sports fellows has helped the clinic provide the best care to all who’ve sought treatment here. This season, more than 60 health care professionals participated in this program, contributing to a total of more than 800 in the past 19 years.

I hope to continue this service to the Resort and to the Big Sky community, in one way or another, for many years to come.

Dr. Jeff Daniels was the recipient of the 2016 Big Sky Chamber of Commerce Chet Huntley Lifetime Achievement Award and has been practicing medicine in Big Sky since 1994, when he and his family moved here from New York City. A unique program he implements has attracted more than 800 medical students and young doctors to train with the Medical Clinic of Big Sky.

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