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Overview
Epidemiology
Unique pediatric anatomy
Upper and lower extremity overuse
injuries and growing pains
Sport specific injuries
Treatment
Sports Injuries
Estimated 4.3 million
injuries per year
Sports injuries account for
1/3 of all injuries in this age
group
Half of pediatric sports
injuries are due to overuse
Etiology
Paradigm Shift
Increasing participation in organized athletics
among skeletally immature athletes
Younger ages & increasing intensity of participation
Specialization & Year-Round Focus
Shift in Etiology
Macrotrauma
Fractures & Dislocations
Repetitive Microtrauma
Increasing Prevalence of
Overuse injuries
Longer seasons
Increased preseason training
Sports camps
Select teams
Rapid transition between sports
Emphasis on competition
Poor coaching
Extremely Fit
Athlete
A condition caused
by submaximal
stress to previously
normal tissues
Young Athletes
The growing athlete is not merely a
smaller version of the adult
There are marked differences in
coordination, strength, and stamina
In young athletes, bone-tendonmuscle units, growth areas within
bones, and ligaments experience
uneven growth patterns, leaving them
susceptible to injury.
Pediatric Anatomy
Epiphysis:
bone between joint and
the growth plate
Physis:
Growth plate: cartilage
layer which allows growth
in length
Apophysis:
attachment site for tendon
to bone
Pediatric Growth
Puberty
Growth spurts begins
Age 9 for girls with peak height velocity at 11-12
Age 11 for boys, with peak height velocity at 13-14
Classic Presentation
Treatment
Return to Throwing:
Predicated on:
complete resolution of symptoms &
absence of tenderness on physical examination
Documented radiographic healing is not essential for return to athletics
Gradual return = Critical Strict throwing program emphasizing proper mechanics
Swimmers Shoulder
Repetitive motion of swimming can cause
rotator cuff impingement
Pressure on the rotator cuff from part of the
shoulder blade or scapula as the arm is lifted
Can result from fatigue and weakness of the
rotator cuff and muscles surrounding the
shoulder blade
Treated with physical therapy,
strengthening exercises
Radiographic Findings
Persistence of olecranon apophysis +/- widening
Must compare to opposite elbow
Case #3
Operative
Indications
Persistent symptoms > 3-6 months of
conservative treatment
Radiographically documented failure of
apophyseal closure despite conservative mgmt
Single screw
OCD
Osteochondritis Dessicans
Focal injury to subchondral bone resulting
in loss of structural support for the
overlying cartilage
OCD
Non-Surgical Treatment
Stable Lesions:
STOP THROWING
NSAIDs
early splinting for acute symptoms
maintain range of motion
periodic radiographic follow-up
gradual return to activity when
asymptomatic and healed
OCD
Surgical Treatment
Unstable Lesions may require surgery
Arthroscopic
Drilling
Removal of loose bodies
Fixation
Pelvic Apophysitis
Occurs in runners 8-15
Iliac crest apophysitis
Pain at the top of the pelvis,
occurs bilaterally with trunk
rotation
Ischial apophysitis
Pain localized to ischial
tuberosity or sitting bone
Onset insidious
Treatment
Rest, ice, NSAIDS, stretching
Osgood-Schlatter Syndrome
Traction apophysitis of tibial
tubercle
1903: Osgood and Schlatter
published independent papers
on this clinical syndrome
Athletes 10-15 years of age
Jumping sports
Boys > girls (? Historic sports
participation)
Bilateral 25-50% of cases
Osgood-Schlatter Syndrome
Clinical Features:
Pain, swelling, tenderness
directly over tibial tubercle
Symptoms worse with running,
jumping, stairs
Wax and wane with time
Severity spectrum of pain only
after activity to constant pain that
limits sports and daily activity
Osgood-Schlatter Syndrome
Radiographic Features:
X-rays not required, usually are
normal
X-rays can show fragmentation
of tubercle or loose ossicle
separate from tuberosity
Osgood-Schlatter Syndrome
Natural History:
Self-limited over a period of 1224 months
Pain usually remits at skeletal
maturity
Prominence of tibial tubercle
persists
Small percentage of patients
have painful ossicle : surgical
excision very successful
Management of OsgoodSchlatters
Reassurance and teaching of natural history
Patients can play sports as tolerated
Treat symptomatically: relative rest , ice, hamstring
and quad stretching, neoprene knee sleeves,
NSAIDS
Corticosteroid injections are not recommended
Rarely, 2-4 week course of immobilization is
indicated for severe cases that resists simple
activity modification
Temporarily improves symptoms, does not alter
natural history
Sinding-Larsen-Johansson
Lesion
Closely related to Osgood-Schlatter
Occurs at the opposite end of the
patella tendon at attachment to patella
No apophysis is involved, tendon
attaches to patella directly
With repetitive tension, periosteum
becomes inflamed and lays down more
bone
Sinding-Larsen-Johansson
Lesion
Similar complaints of activity
related pain but located at
the end of the patella
Slightly younger patient
population ages 8-12
Treatment
Rest, ice, analgesia
Usually self-limiting
No evidence that having had OS or SLJ as a child
predisposes adults to patella or quad tendinopathy
Examination
Diffuse peripatellar
tenderness
Normal knee mechanics
No joint swelling
Normal gait
Normal radiographs
Shin Splints
Medial Tibial Stress Syndrome
Shin pain that produces pain
and discomfort due to repetitive
running
Pain along posteromedial border
of the tibia
Treatment: rest/ ice/ NSAIDS/
stretching
Recurrence common if return to
activity too quickly
Stress Fractures
Stress Fractures
Stress Fractures
Occasionally occur in
prepubescent pediatric
athletes
More common in
adolescent or high school
age athletes
Running sports higher risk:
Cross country, soccer,
basketball
Stress Fractures
Diagnosis often delayed
13.4 wks (1-70)
Vague complaints of pain
Examination
Local tenderness 65.7%
Swelling 24.6%
Pain with single leg jump
Imaging
Xrays: only 9.8% abnormal @ presentation, but usually positive if
more than 3 or 4 weeks of symptoms
Bone scan and MRI positive 100%
Stress Fracture
Usually heals with 612 weeks of rest
Some require
crutches/ brace
treatment
Usually means
missing that season
2 weeks
8 weeks
Stress Fractures
Some high risk stress fractures fail to
heal or risk progression to a complete
fracture and need surgery
Juvenile Osteochondritis
Dissecans (JOCD)
Acquired condition of the joint that affects the
articular surface and subchondral bone in pts
with open growth plates
Most commonly presents w/ vague knee pain
that is poorly localized, without history of
recent trauma
80% symptoms more than 15 months
Osteochondritis Dissecans
Skeletally immature athletes with an OCD lesion and
an intact articular surface have a potential for healing
by stopping repetitive impact loading
May require immobilization, crutches for 6-12 weeks
May take 6-18 months to heal
Skeletally mature athletes with an OCD lesion have a
poorer prognosis
Natural History
If healing does not occur
Subchondral fracture
Fragmentation of
cartilage
Full thickness defect
Ultimately loss of
fragment stability and
loose bodies
Operative Treatment
Indications
Loose bodies
Failure to improve over 6
months
Unstable lesion
Approaching skeletal maturity
Surgery
Drilling and or Fixation
Wright RW, McLean M, Matava MJ, Shively RA: Osteochondritis dissecans of the knee: Long-term results of excision of the fragment. Clin Orthop 2004;424:2
Recognizing Injuries
Athletes should pay close attention to
the physical limitations of their bodies
by quickly responding to pain and
allowing rest when needed
It is important to recognize injuries at
their earliest stages and to diagnose
and treat them appropriately so that
play is not impeded
Current Recommendations
810
50
1112
65
1314
75
1516
90
1718
105
recommendations were modified with permission from the USA Baseball Medical & Safety Advisory
Committee in Petty et al. Ulnar Collateral Ligament Reconstruction in High-School Baseball Players
AJSM, 2004.
Current Recommendations
1 Day of
Rest
2 Days of
Rest
3 Days of
Rest
4 Days of
Rest
810
20
35
45
50
1112
25
35
55
60
1314
30
35
55
70
1516
30
40
60
80
1718
30
40
60
90
aRecommendations were modified with permission from the USA Baseball Medical & Safety Advisory Committee in
Petty et al. Ulnar Collateral Ligament Reconstruction in High-School Baseball Players AJSM, 2004.
Current Recommendations
Age, y
Fastball
Change-up
10
Curveball
14
Knuckleball
15
Slider
16b
Forkball
16b
Splitter
16b
Screwball
17b
aReprinted
with permission from the USA Baseball Medical & Safety Advisory Committee.1
Ages reflect results from a survey by the USA Baseball Medical & Safety Advisory Committee. Petty et al.
believe that these pitches should not be thrown before the player is 18 years old.
b
Healthy diet
Calcium, vitamin D
www.STOPSportsInjuries.org
STOP Sports Injuries
Keeping Kids in the Game for Life