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IntroductiontoPediatricSportsInjuries:TheLowerExtremity
Dr.MichaelPriolaPediatricOrthopedicSurgeon
MinnesotaChapteroftheAmericanAcademyofPediatrics
Disclosures:None
Objectives
Followingthispresentation,themotivatedlearnerwillbeabletounderstand:• Therisks&howlowerextremityinjuriesinpediatricsportsinjuriesoccur• Thetreatmentofspecificlowerextremitypediatricsportsinjuries• Preventionstrategies
WhoIsParticipating?
• Over45millionchildrenages6-21engageinasportsprogramheldoutsideofschool(6)
• 75%ofU.S.familieshaveatleastonechildinahighschoolsport(6)
PositiveImpactofSports• Physicalactivity• TheCDCestimatesapproximately50%ofchildrenareengagedinregularexercise• Morethan1/3ofchildrenbornafter2000willdevelopdiabetes• Childhoodobesityhastripledinlast40years• Childhoodobesityisagoodpredictorofadultobesity• Diminishedqualityoflife:socialdiscrimination,heartdisease,decreasedself-confidence
Merkel,DonnaL.YouthSport:PositiveandNegativeImpactonYoungAthletes.OpenAccessJSportsMed.2013;4:151-160.
PositiveImpactofSports
• ImprovedAcademicAchievement• In2010,theCDCreportedapositivecorrelationwithsportsparticipationandhighergrades;obesitycorrelatedwithlearningdifficulties
• DecreasedHigh-RiskActivities• Smoking• Illicitdruguse• Carryingaweapon
• Bingedrinkingtheexception
Merkel,DonnaL.YouthSport:PositiveandNegativeImpactonYoungAthletes.OpenAccessJSportsMed.2013;4:151-160.
PositiveImpactofSports• OverallHealthBenefitsforGirls
• Decreasedriskfordeveloping:• Breastcancer• Osteoporosis• Futureobesity• Heartdisease
• Decreasedratesof:• Teenpregnancy• Unprotectedsexualintercourse• Smoking• Druguse• Depression• Suicide
Merkel,DonnaL.YouthSport:PositiveandNegativeImpactonYoungAthletes.OpenAccessJSportsMed.2013;4:151-160.
PositiveImpactofSportsPsychologicalBenefits
• Socialsupport• Friendships• Peerinteractions• Goalsetting• Timemanagement• Emotionalcontrol• Leadership• Wisdom• Socialintelligence• Cooperation• Self-exploration• Increasedself-esteem• Lessanxiety• Decreasedriskofdepressionandsuicide
Merkel,DonnaL.YouthSport:PositiveandNegativeImpactonYoungAthletes.OpenAccessJSportsMed.2013;4:151-160.
PressuretoPerform
•42%ofinjuredyouthathleteshideordownplaytheinjurysotheycancontinueplaying• Pressurefromparents• Pressurefromcoaches• Pressurefromteammates
NegativeImpactofSports• TheSports-MedicalIndustry• The8mostcommonrecreationalactivitiesaccountedfor2.24millionmedically-treatedinjuriesofthemusculoskeletalsysteminchildrenages5-14(3)• Morethan3millionemergencyroomvisitseachyearforages5-24fromsports-relatedinjuries• AccordingtotheNationalCenterforSportsSafety,3.5millionchildrenunderage14receivesomesortofmedicalcareforsports-relatedinjurieseachyear
• The“IndustryCostModel”?...(3)• $2billion(2001)
Risks
•Whichsporthashighestfrequencyofinjury?
• Girlscrosscountry• Football•Wrestling• Girlssoccer• Boyscrosscountry
Coaches
• Fazarale etal• 73%ofcoachesreportedtheyfollowedtherulesforpitchingregulationandrestrequirments• However,theycouldonlyanswer43%ofquestionsregardingpitchingrules
• Yukutake etal• Only40%ofcoacheshadaccurateknowledgeoftheguidelines• 28%reportedcompliance
Fazarale JJ,Magnusssen RA,Pedroza AD,etal.Knowledgeofandcompliancewithpitchcountrecommendations:asurveyfo jouth baseballcoaches.SportsHealth.2012;4:202-204Yukutake T,YamadaM,AoyamaT.AsurveyexaminingthecorrelationsbetweenJapaneselittleleaguebaseballcoaches;knowledgeofand compliancewithpitchcountrecommendationsandplayerelbowpain.SportsHealth.2013;5:239-245
NegativeImpactofSports• Injuries• Increasedtensilestrengthacrossgrowingbonesduringgrowthspurts• Growthoccursatthephysis• Injuriesoccuratdifferentanatomicstructurescomparedtoadults
Merkel,DonnaL.YouthSport:PositiveandNegativeImpactonYoungAthletes.OpenAccessJSportsMed.2013;4:151-160.
SportsInjuries
• Injuriesduringadolescentyears• Decreasedflexibility• Decreasedcoordination• Decreasedbalance
NegativeImpactofSports•Mostinjuriesaresustainedfromrepetitivetrauma
• Rest(themostimportant),ice,andnon-steroidalanti-inflammatorydrugs(NSAIDS),e.g.aspirin,ibuprofen,naproxen,willnormallyalleviatetheproblem
NegativeImpactofSports• Thespecializationofsports•Moreandmoreyoungathleteschoosingtostaysportsspecific• Increases• Sports-relatedinjuries• Peerisolation• Burnout• Psychosocialproblems• Attrition
NegativeImpactofSports
• Earlierstart• Numerousstudiesshow“athleticperformanceatanearlyageisunreliableinpredictingfutureabilitytoperformsuccessfullyinachosensport”
• Theearlierachildisidentifiedasbeingtalentedforaparticularsport,themoreuncertainthepredictionforfuturesuccessinthatsport
NegativeImpactofSports
• Undiagnosedanduntreatedinjuriescanleadtolong-terminjuriesthatwillaffectthechildwellintoadulthood• Recurrentshoulderinjuryleadingtonormalanatomyalteration• Recurrentelbowinjuryleadingtochronicelbowinstability• Recurrentanklesprainsleadingtochronicankleinstability
Osgood-Schlatter Disease
•Apophysitis ofthetibial tubercle• Rest• Ice• Compression• NSAIDs
Osgood-Schlatter Disease
•Canresultinpatellaalta• Riskforpatelladislocationandotherpatellofemoraldisease
Osteochondritis Dessicans• “Adevelopmentalconditionofthejointinwhichthearticularcartilageandunderlyingboneareinvolved”• Occursbeforephysealclosure• Exactetiologyunknown,butmostlikelymultiplefactors• Mechanicaltraumaorstressinhighlyactivechildren
OsteochondritisDessicans• Patientcomplainsofactivity-relatedkneepain• Non-specificlocation• Alsomaycomplainofgivingway,locking,etc.
• Tendernessoverthecondyle• PositiveWilson’sTest
OsteochondritisDessicans• AP,lateral,tunnel, andsunrise/Merchantview• 2/3oflesionsonmedialcondyle• MRIusedtodetermineextentofarticularcartilageinvolvementandstabilityofthelesion
OsteochondritisDessicans• Outcomebetterin• Stablelesions• Medialfemoralcondylelesions• Lessactivepatients
• Stablelesionsdidbetterwithconservativetreatment• Unstablelesionsdidbetterwithsurgery
OsteochondritisDessicans
QuadricepsContusion
QuadricepsContusion• Blunttraumatoanteriorthighsevereenoughtoresultinmusclehemorrhage• Thighswelling,pain,lossofkneeflexion
• Overnextfewweeks,granulationtissueforms• Canmatureintoadensecollagenousscarandleadtosignificantdisability
QuadricepsContusion• Treatment
• RICE• KIandcrutchesinitially• Whenpainandspasmsubside,gentleAROM• PassivestretchingtoincreaseKFnotpermitted;willexacerbatebleedingandscarformation
• Progressivestrengtheningandexercisespermittedafter90° ofKFisobtained
• Moderatetosevere:4-6weeksbeforereturntoplay• 120° offlexion• 80%strengthofoppositeleg• Functionalgait
• IflossofKFandpain,surgicalexcisionafter6months
QuadricepsContusion• AnteriorCompartmentSyndrome• Rare• Severethighswellingandpain(canalsooccurifbleedingdisorderpresent)• Causesmusclenecrosis• SURGICALEMERGENCY
QuadricepsContusion• MyositisOssificans• Bodydevelopsbonytissueinsteadofmuscletissue• Surgicalexcisionafter6months
AcutePatellarDislocation• Occursinages14-20,high-levelathletes• Usuallyunderlyinganatomicalabnormality• MPFLmostimportantstabilizingstructureofthepatella• Mechanism:Indirectforceappliedtokneecausestheinjury• Aninternalrotationmomentisappliedtothefemurwhilethefootisplanted,kneeflexedandinvalgus• Basketball,football,baseball,
gymnastics
AcutePatellarDislocation• Patientusually describestwistinginjury• Kneeoften swollen• Patellaisalmostalwaysreduced• Ifnotreduced,thekneewillusuallybeflexedandpatellawillbelateral• Passivelyextendkneeandgentlyapplymedialforcetothepatella• Usuallyunderlyinganatomicalabnormality
RecurrentPatellarDislocation• AnatomicFactors• IncreasedQangle
• Normalis<10degrees• Excessiveexternaltibialtorsion• Femoralcondylardysplasia• Patellaalta• Generalizedligamentouslaxity
AcutePatellarDislocationKneeEffusion
NoYes
KneefilmsandpossiblyanMRIChondral DefectPresent?
3-4Occurrences?
Yes NoYes No
LookatOccurrence
Rate
Surgery BriefImmobilizationRigorousRehab
Surgery
AcutePatellarDislocation• Rehab
• Briefimmobilizationthenrehab• Aimedatresolvinghemarthrosis,reducingpain,improvingROMandincreasingquadricepsandhamstringstrength
• Useofpatellarstabilizingbracerecommended
• Afterrehab,returntosportspermitted,ifnoeffusionandapprox.80%ofstrength
• 50-60%ofpatientswillnothavearecurrence
• Surgery• Arthroscopicsurgeryrequiredtoremoveloosefragment(<2cmwithlittleornosubchondral bone)orfix(>2cmwithsubchondral bone)
• AcuterepairofmedialstructuresorMPFLreconstruction
RecurrentPatellarDislocation
• Surgery• 3-4recurrencesofpatelladislocationandtheinstabilityaffectslifestyle• Mustcorrectanatomicvariantifpresent
• Procedures• Lateralretinacular release• MPFLreconstruction• Vastus medialis advancementwithlateralmedialreefingorsemitendinosustenodesis• Distalrealignment
MeniscalTears
• Developmatureanatomicrelationsby3monthsgestation• Mostlytype1collagenwithfibersincircumferentialpattern• Bloodsupplycomesfromperiphery• Byage1,innerthirdisavascular• Adultvascularpatternpresentat10yrs• Red-red,red-white,white-white• Importantforhealing
MeniscalTears• Rareinchildrenandadolescents• UsuallyoccurwithACLtearsoriftearisabnormalinshape• Discoidmeniscus
• Incidenceincreaseswithage• Medialmeniscus>lateralmeniscus• 30%arerepairable• Occurwithtwistingorpivotingmotionduringsports
• Basketball,soccer,football
MeniscalTears• Symptoms
• Painalongjointline
• Effusion
• Swelling
• Givingway
• Locking
MeniscalTears• Acutetreatment:RICE• Rest• Ice• Compression• Elevation
MeniscalTears• Mostsymptomaticmeniscaltearsinchildrenrequiresurgicaltreatment• Arthroscopicinside-outorall-insiderepair• Red-redzoneorred-whitezone
• Overallresultsexcellent
ACLTears• Dodwell etalreporteda190%increasefrom1990-2009inrateofACLreconstructionsper100,000,ages3-20,inNewYorkstate(1)
• A2012studyshowedACLinjuriesrepresentnearly25%ofallhighschoolkneeinjuries(12)
IntrinsicRiskFactorsforACL• Females2-9xhigherrateofnon-contactACLinjury• Decreasedfemoralnotchwidth• DecreasedACLvolume• Increasedposteriorslope• IncreasedQangle• Increasedanteversion• Greatergeneralizedligamentouslaxity• Quadricepsdominantmusculature• Weakcoreandhipstrength
ExtrinsicRiskFactorsforACL• Pivotingandcuttingsports• Footwear•Weatherconditions• Playingsurfaces
PreventionFemales• Tendtobeonelegdominant• Valguswithlanding• Onekneerelativelystraight• Mostweightononeleg• Trunktiltedsocenterofmassisshiftedoutsideoffeet
TibialEminenceFractures• Peakage8-14• Controversystillexistsoverinjurymechanism• Classicallyoccurredfromfalloffabicycle• Usuallyoccurswithhyperflexionorhyperextensionforce,withorwithoutvarus orvalgus,andarotationalmoment
• TheACLisstretchedorattenuatedpriortofracture• Swelling,pain,positiveACLtests
TibialEminenceFractures• AcuteTreatment• Rest• Ice• Compression• Elevation
• Symptoms• Pain• Swelling• Inabilitytoperformstraightlegraisetest
TibialEminenceFractures• MeyersandMcKeever
TibialEminenceFractures• Treatmentbasedondisplacementandabilitytoreducewithkneeinextension• Type1:10-30° ofkneeflexionrecommended
• Cylindercastfrom4-6weeks• Type2thatwon’treduceandallType3:Surgery
• Usuallyduetoentrappedmeniscus• Numerousfixationmethods
• Fracturepatternandsurgeonexperience
TibialEminenceFractures• Closedtreatment• 3-4weeksincast• ActiveROMexercisesandstrengtheningstartedimmediatelyaftercastisremoved
• Surgery• ProtectedWBfor6weeks• ReturntosportsafterfullROMandmoststrengthreturns(3-4months)
• UsuallyresiduallaxityinACLbutdoesnotcorrelatewithsubjectivesymptoms
AnkleSprain• Halfofallanklesprainsoccurduringathleticactivity•Morecommoninadolescents• Childrenmorelikelytodamagedistalfibularphysis• Growthplatesinchildrenweakerthanligaments
AnkleSprain• Mechanismofinjury:plantarflexionandinversion• Lateralligaments(anteriortalofibular,calcaneofibularandposteriorfibularligaments)areinjured• Canalsodamagedeltoidligament(mechanismofinjuryispronation-abduction,pronation-externalrotationandsupination-externalrotationofthefoot)
AnkleSprain• Differentiatebetweenphysealinjuryandligamentousinjurybasedonanatomiclocationofthepainandtenderness• Erronsideofcaution• Swelling,tenderness,followedbysomebruising
AnkleSprain
AnkleSprain
• Interosseousligamentsprain• Inassociationwithdeltoidligament
• Squeezingfibulaandtibiatogetherproximallycausespain
AnkleSprain
AnkleSprain
AnkleSprainRehab• PhaseI
• Restandprotection(brace,cast,splint,crutches,icewrap)
• Controlofswelling(compression,elevation• Earlyweightbearing
• PhaseII• ReduceresidualswellingandrestoreROMandstrength
• Followwithlowimpactaerobictraining• PhaseIII
• Proprioceptiveexercisesandsports-specificskills(running,jumping,cutting)withgradualreturntosports
• Maywearanklestabilizingbraceortapeankletopreventfurtherinjury
AnkleSprain• Ifcontinuingsymptoms(uncommon),refer• Chronicankleinstability;couldbedisorderofproprioception,musclecontrol,andligamentousstability,orcouldbeincompetentstabilizingligament• Mayrequiresurgery
• OCDoftalardome• Mayrequiresurgery
GeneralPreventionStrategies• Don’tstartsportsuntilage6• Accurateassessmentofeachchild’sreadiness• Amismatchinskillstosportscanresultinanxiety,stressandlossofinterestincontinuedparticipation
Murphy,Esme.TheHighCostofCompetitivepre-H.S.Sports.February16,201510:36PM.http://minnesota.cbslocal.com/2015/02/16/the-high-cost-of-competitive-pre-h-s-sports/.AccessedNovember11,2016
GeneralPreventionStrategies• Pre-participationphysical• AmericanAcademyofFamilyPractice,AmericanAcademyofPediatrics,AmericanCollegeofSportsMedicine,AmericanMedicalSocietyofSportsMedicine,AmericanOrthopedicSocietyofSportsMedicine,andAmericanOsteopathicAcademyofSportsMedicine• Screeningtool• Identifyproblemsthatmayrequirefurtherinvestigation:heart,lungs,neurologic,etc.• Educateathletesonnutritionandunhealthybehavior
GeneralPreventionStrategies• Theremaybeanunderlyingproblemthatpredisposesachildtoinjury,soitisimportanttofullyevaluatethepatientbeforezeroinginononeacuteinjury• Ex:multiplepatellardislocations• Ehlers-Danlos syndrome• Malignantmalalignment• Increasedtibialtubercle-trochleargroovedistance• Dysplastictrochlea• PatellaAlta• IncreasedQ-angle
GeneralPreventionStrategies•Collaboration• Parents,coaches,players• Parentsandcoachesshouldnotencouragetheyoungathletetoplaythroughpainandshouldfollowsports-specificguidelines
GeneralPreventionStrategies• Payspecialattentiontotheimmatureskeleton• Appropriateexercisevolumesduringpractice,games,andrehabilitation
• Timeoff• Atleast1dayoffperweekandatleast1monthoffperyearfromtrainingforaparticularsport;thebodyneedstorecover
• ProperEquipment• Pads(neck,shoulder,elbow,chest,knee,shin)• Helmets• Mouthpieces• Faceguards• Protectivecups• Eyewear
GeneralPreventionStrategies• StrengthenMuscles• Stretch(afterthegame)•Usepropertechnique•Payattentiontothetemperature•Drinkplentyoffluids
• STOP IFTHEREISPAIN
RemembertheGoals…•Havefun!
•Beactive
•Practicefundamentalskills
• Learn
Network of 22 Shriners Hospitals for Children• Networkof22healthcarefacilitiesspecializingin
pediatricorthopedics,burncare,cleftlip&palateandspinalcordinjuries.
• TwinCitieshospitalspecializesinpediatricorthopaedics• ClosestShrinersburnhospitalisinCincinatti• Spinalcordinjuries&cleftlip/palatecanbetreatedinChicago
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OurMission
• Toprovidethehighestqualitymedicalandsurgicalcaretochildrenwithorthopedicneedswithinacompassionate,family-centeredandcollaborativecareenvironment.
• Toprovidethehighestqualitycarewithoutregardtotheabilityofapatientorfamilytopay.
AcceptingInsurance• Acceptingmostmajorinsurance
carriers,includingMedicaid.
• Noinsurance?Noproblem!
ConditionsTreatedFootandankledisorders
• Bunions
• Cavus feet
• Clubfoot/talipes equinovarus (pre-postnatal)
• Congenitalfootdeformities
• Pes planus (flatfeet)
• Tarsalcoalition
• Toewalking
• Verticaltalus
Handandtoedisorders
• Constrictingbandsofdigits,armsandtoes
• Supernumerarydigits
• Polydactyly andsyndactyly ofdigits
Hip,kneeandlegdisorders
• Genuvalgum /varum
• Hipdysplasia
• Intoeing
• Legg-Calve-Perthes disease
• Leglengthdiscrepancy
• Osgood-Schlatter disease
• Slippedcapitalfemoralepiphysis
• Traumareconstruction
Muscular/neuromusculardisorders
• Cerebralpalsy/encephalopathy
• Charcot-Marie-Tooth
• Spinalmuscularatrophy
• Musculardystrophy
• Myelodysplasia (spina bifida)
ConditionsTreatedContinuedRheumatology
• Dermatomyositis
• Juvenileidiopathicarthritis
• Lupus
• Osteogenesis imperfecta
• Scleroderma
Shoulderdisorders
• Erb’s palsy
Specialorthopaedic disorders
• Arthrogryposis
• Bonelesions(nooncology)
• Limbdeficiency– upperandlowerextremityprostheses
• Metabolicbonedisease(rickets)
• Skeletaldysplasia
SpinalDisorders
• Congenitalspinedisorders
• Kyphosis/lordosis
• Scoliosis
• Spondylosisandspondylolisthesis
• Tetheredcords
Specializedplasticsurgery
• Birthmarks
• Breastreduction
• Earreconstruction
• Hemangioma
• Burnscarreleases(noacuteburncare)
HolisticApproachtoCare
Camps PROM
Services• SpecialtyClinics• SurgeryServices• InpatientCare• Rehabilitation(Occupational&PhysicalTherapy)• Orthotics(Bracing)&Prosthetics(ArtificialLimbs)• Radiology(X-Rays)
ReferralGuidelines• Children&adolescents18yearsandyounger• StabilizeatER/URandthenproceedtoapediatric orthopaedicsurgeonforcasting,surgery,therapyandfollow-up• Fracture&sportsinjurieswillbeseensamedayornextday• Financialassistanceavailable– allchildrenwillbetreatedregardlessofabilitytopay• Transportationisavailableuponrequest
ToSchedule:Urgent:612-269-7021
Non-Urgent:612-596-6105Fax:612-596-6102
THANKYOU
References• Murphy,Esme.TheHighCostofCompetitivepre-H.S.Sports.February16,201510:36PM. http://minnesota.cbslocal.com/2015/02/16/the-high-cost-of-
competitive-pre-h-s-sports/.AccessedNovember11,2016.• Merkel,DonnaL.YouthSport:positiveandnegativeimpactonyoungathletes.Openaccessjournalofsportsmedicine4(2013):151.• WillisRB.SportsMedicineintheGrowingChild.In:Morrissy RT,WeinsteinSL,ed.LovellandWinter’sPediatricOrthopaedics. 6th ed.Philadelphia,PA:
LippincottWilliams&Wilkins;2006;1407-1411.• Koval KJ,ZuckermanJD.PediatricShoulder.HandbookofFractures.2nd ed. Philadelphia,PA:LippincottWilliams&Wilkins;2002:296-309.• Shea K,PfeifferRP,Apel PJ.OveruseInjuriesinPediatricandAdolescentAthletes.In:AbelM,ed.Orthopaedic KnowledgeUpdate:Pediatrics3.3rd ed.
Rosemont,IL:AmericanAcademyofOrthopaedic Surgeons;2006:23-31.• Gottschalk,A.W.andAndrish,J.T.,2011.Epidemiologyofsportsinjuryinpediatricathletes.Sportsmedicineandarthroscopyreview,19(1),pp.2-6.• Andrish,J.T.,1990.Upperextremityinjuriesintheskeletallyimmatureathlete.NicholsJA,GILL&MICHEll,422,pp.673-688.
• Fazarale JJ,Magnusssen RA,Pedroza AD,etal.Knowledgeofandcompliancewithpitchcountrecommendations:asurveyfo jouth baseballcoaches.SportsHealth.2012;4:202-204
• Yukutake T,YamadaM,AoyamaT.AsurveyexaminingthecorrelationsbetweenJapaneselittleleaguebaseballcoaches;knowledgeofand compliancewithpitchcountrecommendationsandplayerelbowpain.SportsHealth.2013;5:239-245
• Boykin,RobertE.,etal."CorrelationbetweentheChildHealthQuestionnaireandtheInternationalKneeDocumentationCommitteescore inpediatricandadolescentpatientswithananteriorcruciateligamenttear."JournalofPediatricOrthopaedics 33.2(2013):216-220.
• Morrissy,RaymondT.,andStuartL.Weinstein,eds.LovellandWinter’sPediatricOrthopaedics.SixthEd.LippincottWilliams&Wilkins,2006.
• Kaeding,ChristopherC.,DavidFlanigan,andChristopherDonaldson."Surgicaltechniquesandoutcomesafteranteriorcruciateligamentreconstructioninpreadolescentpatients."Arthroscopy:TheJournalofArthroscopic&RelatedSurgery 26.11(2010):1530-1538.
• InformationonCollegeSportsandAthleticScholarships.http://www.scholarshipstats.com/default.htm.AccessedNovember11,2016.
• Merkel,DonnaL.YouthSport:PositiveandNegativeImpactonYoungAthletes.OpenAccessJSportsMed.2013;4:151-160.
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