Intended for healthcare professionals

Endgames Case Review

Traumatic knee pain in a child

BMJ 2018; 362 doi: (Published 05 July 2018) Cite this as: BMJ 2018;362:k2497
  1. Oliver Beaumont, CT1 surgery1,
  2. Robert Miller, CT2 surgery2,
  3. Henry Claireaux, academic F2 in trauma and orthopaedics3,
  4. Jakob van Oldenrijk, consultant orthopaedic surgeon4
  1. 1Musgrove Park Hospital, Taunton, UK
  2. 2Chelsea and Westminster Hospital, London, UK
  3. 3Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK
  4. 4Erasmus University Medical Centre, Rotterdam, Netherlands
  1. Correspondence to: O Beaumont oliver.beaumont{at}

A 12 year old boy presented to the emergency department with his parents after falling from a motocross bike. The child was unable to describe the precise history of the event or injury mechanism, but he described experiencing immediate and progressive pain in the left knee and was unable to fully extend the knee or bear weight on that side after the injury.

He sustained no other injuries and was haemodynamically stable. On examination, a large effusion in the joint was noticed. Flexion was limited to between 20° and 90°, but the collateral knee ligaments were stable in extension and in 30° of flexion. Anterior drawer and Lachman test suggested grade 1 instability. The pivot shift test was not possible because of patient apprehension. The limb was neurovascularly intact and the boy’s calves were soft and non-tender. Radiographs of the knee were taken (figs 1, 2).

Fig 1

Anteroposterior plain radiograph of the child’s knee taken shortly after arrival in the emergency department

Fig 2

Lateral plain radiograph of the left knee


  • 1. What is the diagnosis

  • 2. How would you manage this injury?

  • 3. What soft tissue injuries may be associated with this injury?


What is the diagnosis?

The plain radiographs show a fracture of the tibial spine (aka intercondylar eminence) (figs 3, 4). These are bony avulsion fractures of the anterior cruciate ligament (ACL) along with part of its attachment to the intercondylar eminence of the tibia.

Fig 3

Anteroposterior radiographs of the child’s knee, with arrow pointing …

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