30th AnnualWinter Update
IndianaOsteopathicAssociation
Hyatt Regency HotelDecember 2-4,2011
COMMON PEDIATRIC SPORT INJURIES
David C. Koronkiewicz, D.O.IU Goshen Orthopedics and Sports Medicine
30th Winter Update
Indiana Osteopathic Association
CHILDREN AND ADOLESCENTS ARE
NOT “LITTLE ADULTS”
Participation In Sports
35 million participants between ages 6-21 in organized nonscholastic sports
6-8 million participate in organized scholastic sports (ages 6-21)
Unknown number playing unorganized sports for fun and exercise
Injuries In Sports*
1/3 of all childhood injuries are sports related
Estimated 3.5 million injuries/yearMost common injuries are sprains and
strains
*National SAFE KIDS Campaign & American Academy of Pediatrics
Benefits Of Sport Participation
Fun (most important)Attain self-confidence & personal
satisfactionSocialize and be with friendsExcessive energy outletHelps develop lifelong fitness patternsLearning teamwork & fair play
Uniqueness Of The Immature Musculoskeletal
System Open growth plates- provides growthThicker periosteum- more vascular,
faster healingLong bones more porous- buckle fx’s
commonLong bones can absorb more energy- can
bend but may not break
Uniqueness Of The Immature Musculoskeletal
System
Different injury patterns at different ages- depends on strength of adjacent structures
Thicker articular cartilage-children and adolescents can develop chrondral or osteochondral fragmentation from overuse
Uniqueness Of The Immature Musculoskeletal
SystemGreater vascularity of menisci of the knee
(better healing potential)Increased ability to remodel fractures
The younger the betterThe closer to the physis the betterBest when fractures are in the plane of
motion
Pediatric And Adolescent Injury Patterns
Skeletal injuries Soft tissuesEpiphyseal Muscles
Apophyseal Tendons
Anatomy Of Pediatric Bone
Epiphysis
Physis (Epiphyseal plate)
Metaphysis
Diaphysis
Age Of Physeal Closure
Average age of physeal closure– Girls
Bone age of 14.5*– Boys
Bone age of 16.5*
*It may not be chronological age
Age Of Physeal Closure
Estimated age of closure– Medial clavicle (25)– Prox. humerus (18-21)– Distal radius (17-19)– Prox. femur (16-18)– Distal femur (16-19)– Prox. tibia (16-20)– Distal tibia (17-18)
Physeal Injury Rates
FactsPhysis is the weakest area of boneLigaments are 300% stronger than the
physeal area in the Tanner stage 3 childDifferent injury patterns and locations
based on age of the child
Incidence Of Physeal Injuries
Ogden Peterson Neer
Distal radius 114 98 1096
Distal tibia 60 59 238Distal humerus 56 28 332Phalanges (fingers) 41 39Proximal humerus 27 22 72 Phalanges (toes) 21 11Distal femur 17 18 28Distal fibula 15 21 302 Proximal femur 9 7Proximal tibia 8 6 0
Total cases 368 301 2085Ogden : Skeletal Injuries in the Child. Lea & Lebiger, 1982
Salter Harris Fracture Classification
Salter I Fracture
Injury through the physis
Easily reducible (when needed)
More common in younger children
Commonly found in birth related injuries
Salter II FractureMost common typeFracture line extends thru
the physis with a small fragment of triangular metaphyseal bone that is accompanying the epiphyseal fragment
Frequently in children ages greater than 10
Salter III Fracture
Fracture line extends from the joint thru the epiphysis thru the physis and then along the physeal plate dislodging a segment of epiphysis
Usually requires anatomic reduction
Salter IV Fracture
Fracture extending from the joint thru the epiphysis thru the physis then thru the adjacent metaphysis
Fracture usually migrates towards the diaphysis
Needs anatomic reductionIncreased potential for
growth arrest
Salter V FractureSevere crush injury
to the physisPotential for increase
risk of growth arrest (partial or complete)
May be difficult to differentiate between Salter I and V
Salter-Harris FracturesAny Salter-Harris type fracture can
cause growth arrestDifficult to determine the amount of
crush or damage to the physes at the time of the original injury
Growth arrest– Type I – least risk – Type V- highest risk
Is Type I really a Type V ?????
Injuries and
Conditions
Pediatric And Adolescent Injuries
Sprain & Strains
Sprains & Strains
R Rest
I Ice
C Compress
E Elevate
Pediatric And Adolescent Injuries
SpineSpondylolysisSpondylolisthesis (secondary to pars
interarticularis stress fracture)
SpondylolysisUsually a stress fracture
of the pars interarticularis
A result of axial loading of the spine in extension
Commonly at L4, L5Seen frequently in
gymnasts and interior football lineman
Spondylolysis DiagnosisPlain radiographsBone scanSPECT scan (single-photon emission
computed tomograms)MRI
Spondylolysis
Treatment1st diagnose itUsually rest until comfortableMay need TLSONSAID’sExercises
Fracture usually heals with fibrous union
Spondylolisthesis
When stress fracture does not heal nor does a stable nonunion develop the fracture separates
The anterior vertebral body slides forward leaving the posterior elements in normal position [Grade I ( 25%) to Grade IV (100%)]
Spondylolisthesis
This is a progression of spondylolysisMay be completely asymptomatic
(incidental finding on x-ray)
Spondylolisthesis Treatment
AsymptomaticUsually Grade I-IINo activity restrictionsAbdominal strengtheningHamstring stretchesInterval X-rays to monitor
for progression
Spondylolisthesis Treatment
SymptomaticUsually > Grade IIModify activities based on symptomsAbdominal strengtheningHamstring stretchesAntilordotic brace +/-Surgery
Pediatric And Adolescent Injuries
Hip and PelvisAvulsionsApophysitisSlipped-Capital Femoral Epiphysis
(SCFE)Osteitis Pubis
ApophysesAre specialized growth centers of the
immature skeleton that occur around joints.
Major muscle or muscle groups take origin or insert into these areas.
Areas prone to variety or injuries in youths participating in sports (overuse & avulsions).
Usually contributes to the size of the bone not the overall length.
Apophysitis
Common disorder of the immature skeleton that represents a fatigue type fracture or strain to the attachments at the growing apophyses.
Results from a microtrauma at the musculotendinous origin or insertion site
Represents tendonitis in adults
Avulsions Or Apophysitis
Iliac crest ASIS AIISGreater trochanterLesser trochanterIschium
Hip And Pelvis Avulsions
a. Iliac Crest (Ext Oblique muscle of the abdomen)
b. ASIS- (Sartorius)
c. AIIS- (Rectus femoris)
d. Lesser Trochanter- (Iliopsoas)
e. Ischium- (Hamstrings)
f. Greater Trochanter- (Gluteus Medius)
Slipped Capital Femoral Epiphysis
Most common hip disorder in adolescents
2-10 per 100,000Males 2-3x more
common
Slipped Capital Femoral Epiphysis
Males 9-16 y/oFemales 8-15 y/oExact cause of SCFE is still unknown Prevalence of bilateral SCFE is 21-80%Contralateral SCFE occurs within 18
months of diagnosis of the 1st hip
Slipped Capital Femoral Epiphysis
Red Flags for Diagnosis– Older children especially male– Obesity– Limp– Pain in thigh, groin, or knee
Onset sudden or gradualAP & frog leg lateral X-ray
is usually diagnostic
Slipped Capital Femoral Epiphysis
Slipped Capital Femoral Epiphysis
Treatment Surgical stabilization with cannulated
screw fixation