Jeffrey Mikutis, DO Bio: Pediatric orthopaedic surgeon Expertise in pediatric sports medicine and pediatric fracture care Served 21 years in the Air Force, with 12 years as an orthopaedic surgeon at Wright-Patterson Air Force Base, “I've always enjoyed working with my hands and building things, from erecter sets to scale models of aircrafts, ships and buildings. I felt that I could translate my perfectionist tendencies in building things into fixing people.”

Lower Extremity Physeal Injuries in the Pediatric Athlete 22nd Annual Pediatric Orthopaedic Symposium Jeffrey L. Mikutis, D.O. Pediatric Orthopaedic Surgery Dayton Children’s Hospital

disclosure I have no disclosures related to the following topic.

Increasing number of pediatric patients participating in year-round single sports This group of patients susceptible to chronic repetitive stress of both upper and lower extremities At the knee: well known conditions such as Anterior knee pain Osgood-Schlatter’s Disease Sinding-Larsen-Johnanssen Syndrome

Sports included: Basketball Football (kicker) Gymnastics Tennis Soccer

Reports of physeal stress injuries at the knee in high level competitive sports Cincinnati Children’s in 2005 reported on six pediatric athletes ages 8 yr to 15 yr with chronic knee pain and radiographic physeal widening of the femur and/or tibia per x-ray and MRI (Laor et al, 2005) Lateral Physis

MRI’s showed: Chondrocyte invade metaphysis 5 out of 6 children were compliant with rest/immobilization and improved symptomatically and radiographically at 3 months 1 out of 6 – Non-compliant patient continued to have pain and developed genu varum at 50 months (patient had distal femur and proximal tibial involvement)

2 cases of rapidly progressive knock-kneed deformity without injury or disease history (Zhang, et al, 2008) Both patients were overweight adolescent females Plain films, MRI’s revealed growth disturbance of distal lateral femoral physes Unlike juvenile Blount’s disease that affects the medial tibial physis during growth spurts and causing genu varum Both of these patients showed similar MRI’s to Blount’s and patients in previous article of cartilage invasion of the metaphysis

Treatment in both cases required corrective osteotomy and epiphysiodesis to prevent further deformity

Holloway et al in 2017 reported on “An unusual cause of genu valgum and persistent instability” in a 16 year old football player Initial injury was a valgus force to his knee during a tackle MRI demonstrated an MCL injury and patient was treated with bracing and PT

After return to football, patient sustained another valgus injury and was unable to return to sports Patient gradually developed a valgus right knee and progressive medial instability

MRI revealed finding consistent with Salter V injury of distal lateral femoral physis (crush injury of physis)

Patient was treated with osteotomy and medial reconstruction with excellent functional result

Demperwolf et al in the current JAAOS Global Research Review Reported on three year-round kicking athletes, mean age 14.2, with knee pain in the kicking leg and unilateral genu valgum All three had x-rays and MRI abnormalities in the distal lateral femoral physis

All patients had surgery with medial tension band plates with 2 out of 3 attaining correction and the oldest patient requiring osteotomy

Summary It is necessary for physicians, coaches, trainers and parents to be aware of risk factors for chronic physeal injuries, particularly in the year-round/kicking athlete or an athlete who has sustained a significant knee injury Non-athletic overweight adolescent patients need to be monitored for lower extremity deformity from chronic physeal injury

References Laor, T. et al. Physeal Widening in the Knee Due to Stress Injury in Child Athletes. AJR:186, May 2006; 1260-1264 Zhang, A; Exner, U; Wenger, D. Progressive Genu Valgum Resulting from Idiopathic Lateral Distal Femoral Physeal Growth Suppression in Adolescents. Journal of Pediatric Orthopaedics. Vol 28:7, October-November 2008; 752-756 Holloway E, et al. An Unusual Cause of Genu Valgum and Persistent Instability. Journal of Surgical Case Reports, 2017;8, 2-4 Dempewolf, M. et al. Youth Kicker’s Knee: Lateral Distal Femoral Hemisphyseal Arrest Secondary to Chronic Repetitive Microtrauma. JAAOS Glob Res Rev 2009;3:e079