Injuries Unique to the Adolescent Athlete - Westchester Health Orthopedics & Sports Medicine
1. INJURIES UNIQUE TO
THE ADOLESCENT ATHLETE
Michael A. Gott MD
Director of Sports Medicine, Yorktown Orthopedic Institute
Westchester Health Associates
March 31, 2016
2.
3. OVERVIEW
Fractures
Salter-Harris fractures
Fractures unique to adolescents
Overuse injuries
Injuries in Throwers
Hip Disorders in children
SCFE
Spine Injuries
Spondylolysis/Spondylolisthesis
4. Fractures
Growing bone is composed of
Diaphysis
Metaphysis
Physis
Epiphysis
Injury in pediatric patients
bypasses relatively stronger
ligaments
energy exits the weakest
link
5. 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
7. 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
8. 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
9. 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
11. 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
12. 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
13. 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
14. 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
15. 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
17. Tibial Eminence Fracture
Surgical Treatment
Open or arthroscopic
Small intraepiphyseal screws (rarely possible)
Suture through or around fragment using ACL
tibial guide tied over anterior tibia
Over-reduce slightly to combat ACL stretch and
loss of extension
Early ROM with stable fixation
Excision and ACL reconstruction if unable to
reduce or fix or if residual instability due to
stretch
21. AVULSION FRACTURE
Hip/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
23. 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
24. 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
25. High Risk Stress Fractures
Tension side of
femoral neck
Patella
Medial malleolus
Tibia diaphysis
Talar Neck
27. 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 activity
Cross-training
Gradual resumption of sport
May take 8-16 weeks for full training
28. 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
30. Pathophysiology
During the rapid growth surrounding
puberty
apophyseal 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
31. APOPHYSEAL CONDITIONS
Osgood-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
32. 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
35. APOPHYSEAL INJURY
Osgood-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
36. 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
38. 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
39. APOPHYSEAL INJURY
Sever’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)
40. 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
42. Physeal Injury In Throwers
Little Leaguer’s Shoulder
Little Leaguer’s Elbow
43. PHYSEAL INJURY
Little 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
44. PHYSEAL INJURY
Little 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
45. PHYSEAL INJURY
Little 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
46. PHYSEAL INJURY
Little 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
47. PHYSEAL INJURY
Little Leaguer’s Elbow
Describes group of injuries due to
valgus throwing stress
Medial epicondyle apophysitis
Medial epicondyle avulsion fx
OCD Capitellum/Panner’s dz
Olecranon apophysitis
Radial head osteochondrosis
48. PHYSEAL INJURY
Little 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 throwing
Strong contraction of the flexor-pronator muscle
attachments as the arm is started forward
Valgus moment with throwing
Lateral side- compression at radiocapitellar joint
Medial side- traction at epicondyle and UCL
Posterior shear
49.
50. PHYSEAL INJURY
Little 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
51. PHYSEAL INJURY
Little 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
52. PHYSEAL INJURY
Little Leaguer’s Elbow
Treatment
If 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
54. Medial Epicondyle Avulsion
Forceful throwing acute injury
Tension from UCL and pull by flexor-
pronators
Nondisplaced and stable
Cast 2-3 wks
Begin ROM and gradual return to activity
ORIF indications – Cannulated screws
Displaced fragment (? 5mm - ? Less in throwers)
More aggressive with throwers
Instability
Incarcerated fragment
Ulnar nerve dysfunction
56. 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
57. 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
58. 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
59. OCD Capitellum
X-rays – Irregular ossification center
Rarefaction within a crater
Loose bodies
MRI – may help locate loose bodies
Define OCD lesion
60. 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
61. OCD Capitellum
Surgical Indications
Persistent pain
Symptomatic loose body
Locked elbow
Elbow Arthroscopy
Remove loose bodies
Debridement to healthy subchondral bone
May consider OATS for noncontained defects
Guarded 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.
62. 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
63. SCFE
Epidemiology
Obese
Positive FH
African American
Boys 60% , Girls
40%
Mean age at onset
Boys 13.5yo
Girls 12yo
18-63% Bilateral
64. SCFE
Presentation
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
65. SCFE
Classification - Loder
Stable – Able to weight bear
with or without crutches
None developed osteonecrosis
Unstable – Unable to weight
bear without crutches
Up 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!
68. SCFE
Treatment
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??
69. SCFE
Atypical patients
age <11
small 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
72. 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
73. SPONDYLOLYSIS
Pathophysiology
Caused by repetitive
microtrauma to the
spine
Repetitive extension
and rotation
Continuum of
disease from stress
reaction to
spondylolytic defect
Most commonly
unilateral
76. 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
77. 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 )
79. SPONDYLOLYSIS
Bone 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
81. SPONDYLOLYSIS
Treatment:
Asymptomatic athlete – Observe and allow full
participation
Symptomatic
○ Stress Reaction – Acute process with the ability to
heal
Brace 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 flexibility
Physical therapy and activity restriction
Rarely TLSO for 6-8 weeks
82. 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
83. SPONDYLOLISTHESIS
Olisthesis = movement
Refers to slipping
forward of one vertebra
on the next caudal
vertebra
Most common L5-S1
Classification by Wiltse
85. 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
86. SPONDYLOLISTHESIS
Presentation
Back pain
Hamstring tightness
“Pelvic waddle” gait
Limited Lumbar ROM
Occurrence usually by 4-6 yo
May become symptomatic at any age
88. SPONDYLOLISTHESIS
Treatment
Low Grade (I-II)
Usually nonoperative
Activity modification and PT
Grade I may return to contact sports when
asymptomatic
Grade II restricted from football and gymnastics
Progression rare
X-ray f/u q 6 mo x 2yrs then yearly to maturity
Surgery for failure conservative or documented
progression – in situ fusion
○ R/O other causes LBP – tumor, infx, HNP
89. SPONDYLOLISTHESIS
Treatment
High Grade (III-V)
May have radiculopathy or cauda equina
L5-S1 causes L5 radiculopathy
Children recommend prophylactic fusion
Often need L4-S1
Decompression/nerve exploration for
neurologic symptoms
Reduction 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
90. Conclusions
Many injuries seen in adolescents are
unique to this age group
Physeal injuries
Apophyseal injuries
Some injuries occur in adults as well
Stress fractures
Spondylolysis/spondylolisthesis