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