Transcript Slide 1

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
Apophyseal
Muscles
Tendons
Anatomy Of Pediatric Bone

Epiphysis

Physis (Epiphyseal
plate)

Metaphysis

Diaphysis
Age Of Physeal Closure
 Average
– Girls
age of physeal closure
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
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
Distal tibia
Distal humerus
Phalanges (fingers)
Proximal humerus
Phalanges (toes)
Distal femur
Distal fibula
Proximal femur
Proximal tibia
114
60
56
41
27
21
17
15
9
8
98
59
28
39
22
11
18
21
7
6
1096
238
332
Total cases
368
301
2085
72
28
302
0
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
Sprains & Strains
R
I
C
E
Rest
Ice
Compress
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
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
a.
b.
c.
d.
e.
f.
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