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