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