Working Diagnosis:
ACL tear, medial meniscus tear, lateral meniscus tear, grade 1 MCL sprain, hemarthrosis, and posterior capsular sprain with strains of the popliteus and gastrocnemius of left knee.

Treatment:
This patient was referred to orthopedic surgery, and arthroscopic surgery was agreed upon. ACL reconstruction was also discussed but the patient's family and orthopedist agreed to delay repair until the patient reached skeletal maturity.

Operation- A partial medial and lateral meniscectomy, and complete ACL tear debridement of the left knee was performed.

Outcome:
The patient was referred to physical therapy for strengthening and range of motion liberation and was given an ACL brace. He was instructed to progress to full activity as tolerated, advised to avoid pivoting activities and full time brace wear while awake.

Author's Comments:
This case highlights the unique ACL tear treatment strategies that are specific to the skeletally immature patient. With younger athletes engaging in more extreme sports, the incidence of injuries including cruciate ligament tears may increase, as opposed to the more common avulsion injuries seen in the pediatric population.

Editor's Comments:
1This case highlights the difficulties in performing a physical examination in an invidiual with intra-articular pathology. Exam findings may be limited by patient guarding.
2. This case is further complicated by the patient's age, as examinations of the pediatric patient may be limited by the patient's age-related fears
3. The case highlights the different course of management for skeletally mature vs skeletally immature patients, for whom surgical repair is complicated by growth and development concerns.

References:
1. Arbes S, Resinger C, Vecsei V, Nau T. The functional outcome of total tears of the anterior cruciate ligament (ACL) in skeletally immature patient. Int Orthop. 2007;31:471-475.
2. Finlayson CJ, Nasreddine A, Kocher M. Current concepts of diagnosis and management of ACL injuries in skeletally immature athletes. Phys Sportsmed. 2010;38(2):90-101.

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