Download - Injuries Unique to the Adolescent Athlete - Westchester Health Orthopedics & Sports Medicine
INJURIES UNIQUE TOTHE ADOLESCENT ATHLETE
Michael A. Gott MDDirector of Sports Medicine, Yorktown Orthopedic InstituteWestchester Health Associates
March 31, 2016
No Disclosures
OVERVIEW Fractures
Salter-Harris fracturesFractures unique to adolescents
Overuse injuries Injuries in Throwers Hip Disorders in children
SCFE Spine Injuries
Spondylolysis/Spondylolisthesis
Fractures Growing bone is
composed ofDiaphysisMetaphysisPhysisEpiphysis
Injury in pediatric patients bypasses relatively stronger ligaments energy exits the
weakest link
SALTER-HARRIS CLASSIFICATION 1963
I - through the physis II - physis and metaphysis III -physis and epiphysis IV - metaphysis and
epiphysis
V - compression injury of the physis
VI - injury to periosteum/ perichondral ring
Buckle fractures
• Cast or splint for 4 weeks• No sports or gym for 8 weeks
MANAGEMENT Salter-Harris I & II
Anatomic physeal reduction without inducing growth arrest is the goal
Closed vs open reduction Immobilization +/- fixation
depending on stability
Thick periosteum can be interposed at the fracture site and blocks reduction Distal tibia physeal fxs
Healing time is half the time of mature bone injury in same location
MANAGEMENT Salter-Harris III & IV
Require anatomic reduction (articular injuries)
Likely need internal fixation to maintain reduction
Salter-Harris V & VI Keep high index of suspicion-
x-rays may be unremarkable or subtle
Suspect if there is a compression injury
Risk of physeal arrest increase with Salter class
Follow long term for growth problems
Complications Avoid growth arrest
Need frequent radiographic at 4 month intervals
Consider epiphysiodesis or corrective osteotomies if necessary Bowen et al report
expected 7 degree correction/yr at distal femur and 5 degree correction for distal tibia with hemiepiphysiodesis Guided Growth for the Correction of
Pediatric Lower Limb Angular Deformity
**Saran et al JAAOS 2010
Fractures Unique to Adolescents
Patellar sleeve Tibial tubercle avulsion Tibial eminence Triplane fractures distal tibia
Sleeve Fracture of Patella Avulsion of distal cartilaginous portion of patella
Age 8-12 yo Patella alta on exam
and xray Small fragment
separated from distal patella on radiographs
MRI if dx questionable
Nondisplaced cast Displaced Tension
band or excision and tendon repair
AVULSION OF TIBIAL TUBERCLE Tibial tubercle is anterior
and distal extension of proximal physis
Age 13-16 yo typically just prior to
physeal closure Classification
Type I – through distal ossification center
Type II – through jxn. tubercle and tibial centers
Type III- involves articular surface
AVULSION OF TIBIAL TUBERCLE Treatment
Closed only for nondisplaced
ORIF to achieve anatomic reduction
Type III injuries restore articular congruity
Complication Compartment syndrome-
anterior tibial recurrent artery
Growth arrest- rare
Tibial Eminence Fracture Avulsion of ACL Age 8-14 yo Hyperextension or
direct blow May have ACL
stretch with fracture mild residual instability
Meniscus (medial) may block reduction
Loss of extension biggest complication
Classification Meyers and McKeever
Type I – Minimally displaced○ Immobilize in cylinder cast 4-6
wks Type 2 – Displaced and hinged
posteriorly○ Attempt casting with 10-20
degrees flexion to reduce fragment
○ Internal fixation if closed reduction fails
Type 3 – Completely displaced○ Internal fixation
Tibial Eminence FractureSurgical Fixation
Tibial Eminence Fracture Surgical Treatment
Open or arthroscopicSmall intraepiphyseal screws (rarely possible)Suture through or around fragment using ACL
tibial guide tied over anterior tibiaOver-reduce slightly to combat ACL stretch
and loss of extensionEarly ROM with stable fixationExcision and ACL reconstruction if unable to
reduce or fix or if residual instability due to stretch
Apophyseal Fractures
Etiology Forceful muscle
contraction during eccentric loading
Point of failure at site of apophysis rather than muscle-tendon junction
Displaced fracture AIIS – Rectus femoris
AVULSION FRACTUREHip/Pelvis Treatment: Rest, crutches for 2 weeks,
progressive rehabilitation to return to sports activity; position extremity to relax involved muscle group
Progressive rehab program Complete healing in 6 weeks-several
months Ischial Tuberosity - Open reduction and
internal fixation of large fragments displaced more than 2 cm
Overuse syndromes
Introduction Overuse injuries are very common in
pediatric/adolescent population Etiologies vary but physiology is unchanged
Overload or repetitive microtrauma strains the musculotendinous unit until its unable to withstand additional loading
Continued stress collagen cross-links break shear forces cause the collagen fibril to slide
Overload at tendon insertion site = Apophysitis
Overload on bone stress fracture
Stress Fractures Practical causes
Sudden increase in intensity
Multiple high intensity work-outs without rest
Poor footwear Lack of arch support Improper fitting shoes
Biomechanical factors related to training surfaces Pavement vs trails
High Risk Stress Fractures Tension side of
femoral neck Patella Medial malleolus Tibia diaphysis Talar Neck
Radiographs
Tibial Stress Fractures Discontinuation of inciting activity
Rest, ice, limited weight bearing, NSDAIDs
If no relief in 2-4 weeks, consider NWB or cast treatment
Slow resumption of activityCross-trainingGradual resumption of sport
May take 8-16 weeks for full training
Stress Fractures Femoral neck stress
fractures 5-10% of all stress
fractures Runners and military
recruits Compression sided
fractures = Conservative Tx
Tension sided fractures = ORIF
Address BEFORE displacement can be catastrophic in young person
APOPHYSEAL CONDITIONS
Osgood-Schlatter
Sinding-Larsen-Johansson
Sever’s Disease
Iselin’s Disease
Pathophysiology During the rapid growth surrounding
pubertyapophyseal line appears to be weakened
further because of increased fragility of calcified cartilage.
Microfractures are believed to occur because of shear stress leading to the normal progression of fracture healing
Clinical picture and the radiographic appearance of resorption, fragmentation, and increased sclerosis leading to eventual union
APOPHYSEAL CONDITIONSOsgood-Schlatter Separately described by Osgood and
Schlatter in 1903 Age of onset in boys 10 – 15 & girls 8 –
13 Traction apophysitis of the tibial tubercle
caused by repetitive microtrauma from a contracting extensor mechanism
Incidence as high as 20% in athletic children~5% in non-athletic population
Occurs bilateral in 20 to 30% of cases Most common in basketball, volleyball,
soccer, and gymnastics
Osgood Schlatter Symptoms
Acute Phase Pain and tenderness over tibial tubercle Pain accentuated with palpation and resisted knee
extension Localized edema, warmth Pain increased with squatting, jumping
Healed phase Asymptomatic Anterior knee mass 10% adults remain symptomatic due to secondary ossicle
formation Pain can be associated with increased activities
Osgood-Schlatter
APOPHYSEAL INJURYOsgood-Schlatter
Radiographic Findings Prominence of the
tibial tubercle Fragments of
secondary ossification center of tibial tubercle may be displaced slightly anteriorly and superiorly
APOPHYSEAL INJURYOsgood-Schlatter Treatment:
Reassurance Many able to tolerate mild symptoms and continue play Typically spontaneous resolution with closure of the physis;
though may have residual tenderness with kneeling Pad or cho-pat strap may be helpful Ice/NSAIDS Quadriceps and hamstring stretching Restriction of activities If painful after physeal closure, may be ossicle that is
symptomatic May predispose to risk of tubercle avulsion
Sinding-Larsen-Johansson Syndrome
Anterior knee pain at distal pole of patella from pull of the quadriceps extensor mechanism
on an apophysis Common in boys ages of 11-13 yrs
Symptoms Aggravated by
Running jumping stair climbing kneeling
Irregular areas of ossification that coalesce and incorporate into the
patella. Rarely, a separate ossicle persists that
may remain symptomatic
APOPHYSEAL INJURYSinding-Larsen-Johansson
Differential Diagnosis: Patellar tendonitis Patella fracture Sleeve fracture of
patella
Treatment: Self-limited disease Spontaneous resolution in 12
– 18 months Reassurance Modification of activities Ice/NSAIDS Lower extremity stretching
program (quadriceps, hamstrings, and heel cords)
Patella knee sleeve
Severs Disease Inflammation of calcaneal
apophysis Described by Sever in 1912
Age 9-10 yrs
Sex Males most commonly Bilateral 60% +
Symptoms Posterior heel pain aggravated
by running & jumping activity Diff DX: calcaneal stress
fracture
APOPHYSEAL INJURYSever’s Disease Treatment:
Self limited No long term sequelae Heel cord stretching/strengthening Heel cups or shock-absorbing inserts Responds well to therapy, usually able to
return to sports in 6 - 8 weeks Differentiate from calcaneal stress fracture
(medial lateral compression test)
Iselin’s Disease Inflammation at apophysis of 5th
metatarsal Seen commonly in soccer,
basketball, gymnast and dancers Age 8-13 yrs Painful lateral border of foot
May walk on medial border of foot Improves with rest, activity
modification
Hip & Pelvis Apophysitis ASIS
Sartorius AIIS
Rectus femoris Ischial tuberosity
SemitendonosisBiceps femoris
TreatmentRest, Activity Modification, Stretching
Physeal Injury In ThrowersLittle Leaguer’s ShoulderLittle Leaguer’s Elbow
PHYSEAL INJURYLittle Leaguer’s Shoulder First described in 1953 by Dotter Described in literature as
osteochondrosis of the proximal humeral epiphysis
proximal humeral epiphysiolysis stress fracture of proximal humeral epiphyseal
plate rotational stress fracture
Typically males, 12 - 15 years of age Average duration of symptoms before
treatment is approximately 7 months Associated with quantity and intensity of
pitching, age at which pitching started
PHYSEAL INJURYLittle Leaguer’s Shoulder Chief complaint:
Pain localized to the proximal humerus during the act of throwing
Occurs during various phases of throwing
Gradual onset of pain Usually no inciting event Playing ability diminishes with pain
Loss of velocity
PHYSEAL INJURYLittle Leaguer’s Shoulder
Clinical Findings: Tenderness proximal humerus / shoulder Weakness in external rotation Pain with resisted internal rotation Rarely swelling Normal strength and ROM
Radiographs: AP external rotation Widening and irregularity of proximal
humeral physis Metaphyseal fragmentation
Comparison views helpful Demineralization of metaphysis Sclerosis of metaphysis Bone scan may be normal
PHYSEAL INJURYLittle Leaguer’s Shoulder
Treatment:
Rest from throwing 6 weeks to 3 months on average May be up to 1 year
If asymptomatic, may begin throwing program
Widened proximal humeral physis seen radiographically can take several months to remodel
Some recommend non-pitching position until physis closes
Monitor mechanics No known long term sequelae
PHYSEAL INJURYLittle Leaguer’s Elbow Describes group of injuries due to
valgus throwing stress
Medial epicondyle apophysitisMedial epicondyle avulsion fxOCD Capitellum/Panner’s dzOlecranon apophysitisRadial head osteochondrosis
PHYSEAL INJURYLittle Leaguer’s Elbow Initially used in 1960 by Brodgon and Crow Most common in 9 to 14 y/o Injuries on medial elbow primarily occur during
the acceleration phase of throwingStrong contraction of the flexor-pronator
muscle attachments as the arm is started forward
Valgus moment with throwingLateral side- compression at radiocapitellar
jointMedial side- traction at epicondyle and UCLPosterior shear
PHYSEAL INJURYLittle Leaguer’s Elbow Chief Complaint:
Location of pain○ Deep or lateral – capitellar OCD○ Medial – tension problems
Onset of pain○ Abrupt – avulsion of medial epicondyle,
epiphyseal fracture, or UCL injury○ Gradual – Lateral compression with OCD
capitellum or radial head osteochondrosis
○ Abrupt with locking - OCD
PHYSEAL INJURYLittle Leaguer’s Elbow
Clinical Findings: Tenderness over medial epicondyle Hypertrophy of medial epicondyle Flexion contracture Valgus deformity
Radiographic Findings Typically normal May reveal widening of medial epicondyle apophysis,
fragmentation of medial epiphysis, capitellar OCD
PHYSEAL INJURYLittle Leaguer’s Elbow
TreatmentIf apophysis not significantly displaced:
○ Rest 2 - 3 weeks○ Isometric strengthening, stretching, resistive
strengthening○ Gradual return to throwing after 6 - 12 weeks
Throwing program○ Good prognosis with rest○ If pain returns out until next season
Medial Epicondyle Fracture
Medial Epicondyle Avulsion Forceful throwing acute injury Tension from UCL and pull by flexor-
pronators Nondisplaced and stable
Cast 2-3 wksBegin ROM and gradual return to activity
ORIF indications – Cannulated screwsDisplaced fragment (? 5mm - ? Less in throwers)More aggressive with throwersInstabilityIncarcerated fragmentUlnar nerve dysfunction
ORIF
Panner’s disease Younger age < 4-8 yo Osteochondrosis of capitellum Comparable to Legg-Calve-Perthes Irregular ossification center Self limiting Loose bodies rare Complete resolution with
reconstitution of capitellum
OCD Capitellum Fragmentation of
subchondral bone Adolescent age >
10 yo Repetitive
compression may disturb blood supply
Entire blood supply from posterior aspect of humerus No collateral flow
OCD Capitellum Pain with throwing Tender at
radiocapitellar joint 10-20 degree
flexion contracture Early detection
crucial MRI helpful May prevent
progression with activity change
OCD Capitellum X-rays – Irregular ossification center
Rarefaction within a craterLoose bodies
MRI – may help locate loose bodiesDefine OCD lesion
OCD Capitellum Treatment
Rest, Ice, NSAIDs Gradually begin ROM and strengthening
when pain subsides Interval program for return to activity
when strength and ROM normal 3-6 months
Many delay until following season Evaluate/change throwing technique Position change- away from
pitching/catching Guarded prognosis - DJD
OCD Capitellum Surgical Indications
Persistent painSymptomatic loose bodyLocked elbow
Elbow ArthroscopyRemove loose bodiesDebridement to healthy subchondral boneMay consider OATS for noncontained defectsGuarded prognosis – worse for noncontained*Osteochondritis Dissecans of the Capitellum: Current Concepts
David E. Ruchelsman, MD, Michael P. Hall, MD and Thomas Youm, MD J Am Acad Orthop Surg, Vol 18, No 9, September 2010, 557-567.
Slipped Capital Femoral Epiphysis Slippage through the
hypertrophic zone of physis
Femoral head remains reduced
Neck displaces anterosuperior & external rotation
Etiology Idiopathic – most
common Endocrinopathy Renal failure Prior radiation therapy
SCFEEpidemiology
Obese Positive FH African American Boys 60% , Girls
40% Mean age at onset
Boys 13.5yo Girls 12yo
18-63% Bilateral
SCFEPresentation Hip, thigh, or
knee pain Limited internal
rotation Out-toeing gait Initial pain may
be vague Key to
classification is the ability of the child to ambulate
SCFEClassification - Loder Stable – Able to weight bear
with or without crutchesNone developed osteonecrosis
Unstable – Unable to weight bear without crutchesUp to 50% developed
osteonecrosis
○ *Slipped Capital Femoral Epiphysis: Current Concepts David D. Aronsson, MD, Randall T. Loder, MD, Gert J. Breur, DVM, PhD and Stuart L. Weinstein, MD . J Am Acad Orthop Surg, Vol 14, No 12, November 2006, 666-679
Old description acute and subacute!
SCFERadiographic Evaluation
AP and frog leg Loss of lateral
overhang of ossific nucleus (Klein’s line)
Varus appearance
Radiographic Grading
SCFETreatment
In situ pinning Avoid forceful
reduction – AVN Percutaneus with one
or two 6.5 screws Start anterior on neck
and aim at center of head
Goal – physeal closure, prevent further slippage
Osteotomy – late for residual deformity/AVN
Roll for ORIF??
SCFE Atypical patients
age <11small size Endocrine workup
Prophylactic pinning contralateral hip controversial usually for age < 11 or endocrinopathy
RTP delayed until after physis begins closure & patient asymptomatic
Screw removal controversial in athletes
SCFEComplications
Osteonecrosis Chondrolysis DJD Pistol grip
deformity Subtrochanteric
femur fracture
Spine Pathology
SPONDYLOLYSIS Spondylos = Vertebra
Lysis = Break Defect in the pars
interarticularis without displacement of vertebral bodies
Incidence of spondylolysis: 4 - 6%
Most often L5 level (up to 95%)
2-4 times more common in men
SPONDYLOLYSISPathophysiology
Caused by repetitive microtrauma to the spine Repetitive extension
and rotation Continuum of
disease from stress reaction to spondylolytic defect
Most commonly unilateral
SPONDYLOLYSIS High risk Sports
GymnasticsDivingFootball
○ Interior linemenRowing
SPONDYLOLYSIS Differential Diagnoses
Lumbar disc herniation Spondylolisthesis Intervertebral diskitis (fever, elevated ESR) Osteoid osteoma (night pain, pain relieved with
NSAIDs, abnormal scan) Spinal cord tumor (sensory findings, upper motor
neuron signs) DDD
SPONDYLOLYSIS
Clinical Presentation Insidious aching back pain exacerbated by
strenuous activity with occasional radiation to the buttocks
Rising to an upright posture against resistance elicits pain
Pain exacerbated by hyperextension & rotation Hamstring tightness in 80% of patients Tenderness in lumbar spine to palpation and
percussion
SPONDYLOLYSIS Radiographic Findings:
Stress reaction = sclerosis without radiolucency
Spondylolytic defect = sclerosis with radiolucency
A thickening or stress reaction of the pars may be visible on a lateral or oblique radiograph 3 to 6 weeks after development of back pain Lateral x-ray reveals 80% (most sensitive) Oblique an additional 15% - neck of Scottie dog (most specific
)
SPONDYLOLYSIS
SPONDYLOLYSISBone Scan with SPECT: increased uptake at
the area of the pars interarticularis○ SPECT can miss chronic injuries
SPECT (single photon emission computed tomography)
MRI: Best to rule out disc herniation and nerve root compression in pt’s with neuro deficits
CT: Best to identify bony anatomy ○ Must order thin slices (3 mm)
SPECT or CT scan best to identify if x-rays negative
SPONDYLOLYSIS
SPONDYLOLYSIS Treatment:
Asymptomatic athlete – Observe and allow full participation
Symptomatic○ Stress Reaction – Acute process with the ability
to healBrace immobilization TLSO 6-12 weeks or until
asymptomatic followed by PT and return to sport○ Spondylolytic defect – no potential for healing
Treatment goals are pain relief and increased flexibilityPhysical therapy and activity restrictionRarely TLSO for 6-8 weeks
SPONDYLOLYSIS Surgical Intervention
Considered for patients with stress reactions or spondylolytic defects that have failed 6-12 months of conservative Tx○ L1-L4 – Direct repair of
the spondylolytic defect○ L5 – L5-S1
Posterolateral fusion vs. Direct repair
SPONDYLOLISTHESIS Olisthesis =
movement Refers to slipping
forward of one vertebra on the next caudal vertebra
Most common L5-S1
Classification by Wiltse
SPONDYLOLISTHESIS Meyerding
Classification Grade 1 = 1-25% slip Grade 2 = 26-50%
slip Grade 3 = 51-75%
slip Grade 4 = 76-100%
slip Grade 5 =
spondyloptosis
SPONDYLOLISTHESIS Etiology is unknown except in traumatic
types Incidence 4.4% at 6yo & 6% at 18yo Higher incidence in males Natural History
Harris et al – 18 yr f/u Meyerding Grade 3&4○ 36% asymptomatic○ 55% occasional back pain○ 45% neurologic symptoms
Beutler et al – 45 yr f/u Meyerding Grade 1&2 ○ Followed a course similar to general population
SPONDYLOLISTHESIS
PresentationBack painHamstring tightness“Pelvic waddle” gaitLimited Lumbar ROMOccurrence usually by 4-6 yoMay become symptomatic at
any age
SPONDYLOLISTHESISTreatment Asymptomatic slips observed
Avoid repetitive activity Patients with asymptomatic 30% slip
can play contact sports and be followed for progression
SPONDYLOLISTHESISTreatment Low Grade (I-II)
Usually nonoperativeActivity modification and PTGrade I may return to contact sports when
asymptomaticGrade II restricted from football and
gymnasticsProgression rareX-ray f/u q 6 mo x 2yrs then yearly to
maturitySurgery for failure conservative or
documented progression – in situ fusion○ R/O other causes LBP – tumor, infx, HNP
SPONDYLOLISTHESISTreatment High Grade (III-V)
May have radiculopathy or cauda equinaL5-S1 causes L5 radiculopathyChildren recommend prophylactic fusionOften need L4-S1Decompression/nerve exploration for
neurologic symptomsReduction controversial – monitor L5
*Spondylolysis and Spondylolisthesis in Children and Adolescents: I. Diagnosis, Natural History, and Nonsurgical Management: Ralph Cavalier, MD, Martin J. Herman, MD, Emilie V. Cheung, MD and Peter D. Pizzutillo, MD. J Am Acad Orthop Surg, Vol 14, No 7, July 2006, 417-424
Conclusions Many injuries seen in adolescents
are unique to this age groupPhyseal injuriesApophyseal injuries
Some injuries occur in adults as wellStress fracturesSpondylolysis/spondylolisthesis
Thank You