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

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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.