1. 30th Annual Winter Update
Indiana
Osteopathic
Association
Hyatt Regency Hotel
December 2-4,2011

2. COMMON PEDIATRIC SPORT INJURIES
David C. Koronkiewicz, D.O.
IU Goshen Orthopedics and Sports Medicine
30th Winter Update
Indiana Osteopathic Association

3. CHILDREN AND ADOLESCENTS ARE NOT “LITTLE ADULTS”

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Pediatric And Adolescent Injury Patterns
Skeletal injuries Soft tissues
Epiphyseal Muscles
Apophyseal Tendons

11. Anatomy Of Pediatric Bone
Epiphysis
Physis (Epiphyseal plate)
Metaphysis
Diaphysis

12. 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

13. 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)

14. 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

15. Incidence Of Physeal Injuries
Ogden Peterson Neer
Distal radius
Distal tibia
Distal humerus
Phalanges (fingers)
Proximal humerus
Phalanges (toes)
Distal femur
Distal fibula
Proximal femur
Proximal tibia
Total cases
Ogden : Skeletal Injuries in the Child. Lea & Lebiger, 1982

16. Salter Harris Fracture Classification

17. Salter I Fracture Injury through the physis
Easily reducible (when needed)
More common in younger children
Commonly found in birth related injuries

18. 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

19. 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

20. 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

21. 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

22. 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 ?????

23. Injuries and Conditions

24. Pediatric And Adolescent Injuries
Sprain & Strains

25. Sprains & Strains
R Rest
I Ice
C Compress
E Elevate

26. Pediatric And Adolescent Injuries
Spine
Spondylolysis
Spondylolisthesis (secondary to pars interarticularis stress fracture)

27. 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

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

29. 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

30. 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%)]

31. Spondylolisthesis This is a progression of spondylolysis
May be completely asymptomatic (incidental finding on x-ray)

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

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

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

35. 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.

36. 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

37. Avulsions Or Apophysitis
Iliac crest
ASIS
AIIS
Greater trochanter
Lesser trochanter
Ischium

38. 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)

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

40. 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

41. 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

42. Slipped Capital Femoral Epiphysis

43. Slipped Capital Femoral Epiphysis
Treatment
Surgical stabilization with cannulated screw fixation