30th Annual Winter Update Indiana Osteopathic Association Hyatt Regency Hotel December 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/year Most 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 satisfaction Socialize and be with friends Excessive energy outlet Helps develop lifelong fitness patterns Learning teamwork & fair play

Uniqueness Of The Immature Musculoskeletal System Open growth plates- provides growth Thicker periosteum- more vascular, faster healing Long bones more porous- buckle fx’s common Long 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 System Greater vascularity of menisci of the knee (better healing potential) Increased ability to remodel fractures The younger the better The closer to the physis the better Best when fractures are in the plane of motion

Pediatric And Adolescent Injury Patterns Skeletal injuries Soft tissues Epiphyseal 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

Estimated age of closure 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 Facts Physis is the weakest area of bone Ligaments are 300% stronger than the physeal area in the Tanner stage 3 child Different 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 59 238 Distal humerus 56 28 332 Phalanges (fingers) 41 39 Proximal humerus 27 22 72 Phalanges (toes) 21 11 Distal femur 17 18 28 Distal fibula 15 21 302 Proximal femur 9 7 Proximal tibia 8 6 0 Total cases 368 301 2085 Ogden : 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 Fracture Most common type Fracture 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 reduction Increased potential for growth arrest

Salter V Fracture Severe crush injury to the physis Potential for increase risk of growth arrest (partial or complete) May be difficult to differentiate between Salter I and V

Salter-Harris Fractures Any Salter-Harris type fracture can cause growth arrest Difficult 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 Spine Spondylolysis Spondylolisthesis (secondary to pars interarticularis stress fracture)

Spondylolysis Usually a stress fracture of the pars interarticularis A result of axial loading of the spine in extension Commonly at L4, L5 Seen frequently in gymnasts and interior football lineman

Spondylolysis Diagnosis Plain radiographs Bone scan SPECT scan (single-photon emission computed tomograms) MRI

Fracture usually heals with fibrous union Spondylolysis Treatment 1st diagnose it Usually rest until comfortable May need TLSO NSAID’s Exercises 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 spondylolysis May be completely asymptomatic (incidental finding on x-ray)

Spondylolisthesis Treatment Asymptomatic Usually Grade I-II No activity restrictions Abdominal strengthening Hamstring stretches Interval X-rays to monitor for progression

Spondylolisthesis Treatment Symptomatic Usually > Grade II Modify activities based on symptoms Abdominal strengthening Hamstring stretches Antilordotic brace +/- Surgery

Pediatric And Adolescent Injuries Hip and Pelvis Avulsions Apophysitis Slipped-Capital Femoral Epiphysis (SCFE) Osteitis Pubis

Apophyses Are 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 AIIS Greater trochanter Lesser trochanter Ischium

Hip And Pelvis Avulsions Iliac Crest (Ext Oblique muscle of the abdomen) ASIS- (Sartorius) AIIS- (Rectus femoris) Lesser Trochanter- (Iliopsoas) Ischium- (Hamstrings) Greater Trochanter- (Gluteus Medius)

Slipped Capital Femoral Epiphysis Most common hip disorder in adolescents 2-10 per 100,000 Males 2-3x more common

Slipped Capital Femoral Epiphysis Males 9-16 y/o Females 8-15 y/o Exact 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 gradual AP & frog leg lateral X-ray is usually diagnostic

Slipped Capital Femoral Epiphysis

Slipped Capital Femoral Epiphysis Treatment Surgical stabilization with cannulated screw fixation