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Polousky ortho
This document provides guidance on recognizing and managing common pediatric sports injuries. It discusses injuries of the upper extremity including shoulder dislocations, AC joint injuries, clavicle fractures, Little League shoulder, and finger injuries. For the lower extremity, it covers knee sprains, ACL tears, meniscus tears, ankle sprains, and osteochondritis dissecans lesions. It emphasizes the importance of early referral for injuries like ACL tears. Key referral criteria mentioned include persistent symptoms despite rest/physical therapy and positive radiographic findings. Clinical pearls provided include obtaining x-rays for injuries with pain, swelling and effusion and recognizing that not all injuries are just sprains.
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Polousky ortho
- 1.
- 2. Objectives • Recognize common pediatricsports injuries • Discuss ambulatory management when appropriate • Identify when to refer to orthopedics
- 3. About Our Practice •24 Providers – Various subspecialties including hand, sports, and spine surgery • Locations – Akron, North Canton, Boston Heights, Medina, Mahoning Valley, Mansfield, Norwalk • Same-day appts – Available Monday-Friday • 330-543-3500
- 4. A FEW SPORTSINJURY MANAGEMENT PEARLS
- 5. • Injury +pain + swelling/effusion – Obtain an x-ray – Immobilize – Refer early • Radiographs may be negative but there may be… – Occult fractures (growth plate/scaphoid) – Ligamentous or other injuries (ACL/ meniscus tear)
- 6. • It’s notalways “just a sprain” • Clinical deformity – Urgent referral/ER • Unsure? – Contact our office
- 7.
- 8. Shoulder Dislocation • Mechanismof Injury – Direct blow or fall • Epidemiology – More common in adolescent males over age 10 – Anterior dislocation most common • Physical exam – Swelling, tenderness to palpation, clinical deformity
- 9. • Treatment – Earlyrecognition, referral to ED, reduction • Pre and post-reduction radiographs to confirm reduction and identify Hill-Sachs/Bony Bankhart lesions – Immobilization (sling and swathe) – PT after initial immobilization – Activity restrictions (8-12 weeks depending)
- 10. • When torefer – Within to 2 weeks post injury – Ability to promptly obtain MR arthrogram (labral pathology) – Discussion of possible surgical intervention • 50-90% re-dislocation rate in skeletally mature patients
- 11. AC Joint Injuries •Mechanism of Injury – Direct blow or fall • Epidemiology – More common in athletes and males • Physical exam – Swelling, tenderness to palpation, asymmetry
- 12. • Treatment – Dependentupon displacement • Simple sprain vs. dislocation – Surgical intervention may be warranted – Immobilization (sling and swathe) – Activity restrictions (8-12 weeks depending) • When to refer – Asymmetry – Promptly (prior to 2 weeks post injury)
- 13. SC Joint Injuries• Mechanism of injury – High energy trauma (contact sports/MVA) – Subluxation (atraumatic – arm elevation) • Physical exam – Anterior Dislocation/Fracture • Swelling, prominence, TTP – Posterior Dislocation/Fracture • Asymmetry, TTP • Upper extremity paresthesia • Diminished pulse compared to contralateral side • Dysphagia, dyspnea, tachypnea, stridor
- 14. • Treatment – Anterior •Immobilization (sling and swathe) • Activity restrictions (8-12 weeks depending) • Some require surgical treatment (acute dislocations) – Posterior • Conservative care versus urgent surgical reduction • When to refer – Emergent referral to ED • Concern for posterior displacement and vascular/pulmonary compromise – Promptly (prior to 2 weeks post injury)
- 15. Clavicle fractures • Mechanismof injury – Fall or direct trauma • Epidemiology – More common in active males – Most common are shaft fractures • Physical exam – Medial, distal, shaft – Swelling, ecchymosis, asymmetry, tenderness to palpation – Skin tenting (impending open fracture)
- 16. • Treatment – Conservativecare in the majority of cases • Sling and swathe • Activity restrictions (up to 12 weeks due to high risk of refracture) – Operative • Controversial – Open, impending open fractures – >2cm shortening • When to refer – Emergent referral to ED • Concern for impending open fracture • Neurovascular compromise – Promptly (prior to 2 weeks post injury)
- 17. Little League Shoulder •Mechanism of injury – Overuse injury in skeletally immature child • Epidemiology – Proximal humeral epiphysiolysis – Overhead athletes (pitching/tennis) – Most common in males 9-15 years of age • Physical exam/history – Decreased pitch velocity/pain with throwing – Mild swelling possible – Tenderness over proximal humerus physis – Pain/limited ROM (especially internal rotation)
- 18. • Treatment – Obtainradiographs • Contralateral if uncertain – Sling for comfort, PRN NSAIDs – Rest with no pitching (up to 3 months) – Physical therapy with progressive throwing program • When to Refer – Persistent symptoms/positive radiographs – Discussion of long-term complications of physeal growth arrest and possible deformity
- 19. Little League Elbow •Mechanism of Injury – Overuse/injury in skeletally immature child • Epidemiology – Medial elbow injury/stress • Medial apophysitis, stress fracture, UCL injury, flexor pronator mass strain – Repetitive valgus elbow stress/microtrauma (pitching) • Physical exam – Mild swelling possible – Tenderness over medial elbow – Limited ROM – Laxity with valgus stress testing
- 20. • Treatment – Obtainradiographs – Dependent upon diagnosis • Sling for comfort, PRN NSAIDs • Rest with no pitching (up to 3 months) • Physical therapy with progressive throwing program • Surgical intervention • When to Refer – Persistent symptoms – Radiographic abnormality • Medial epicondyle widening, avulsion fracture, capitellar abnormality – Concern for UCL injury
- 21. Wrist Sprain/Fractures • Mechanismof Injury – Fall, direct blow • Physical exam – Swelling, tenderness to palpation, limited ROM, clinical deformity • Treatment – Gross deformity • Refer to ED – Splint – Refer +/- radiographs • When to Refer – Positive radiographs/concern for occult fracture – Within 1 week of injury
- 22. Finger Injuries/Sprains • Mechanismof Injury – Fall, direct blow, “stoved finger” • Physical exam – Swelling, tenderness to palpation, limited ROM, clinical deformity – Nail plate deformity, bleeding from the base of the nail bed Non-bony mallet
- 23. • Treatment – Grossdeformity +/- open injury • Refer to ED – Splint – Refer +/- radiographs • When to Refer – Positive radiographs/concern for occult fracture or non- bony ligamentous injury – Within 1 week of injury if closed – Urgently if concern for open injury Bony mallet
- 24. Seymour Fracture • Mechanismof Injury – Crush or direct trauma • Physical exam – Nail plate lying above eponychium with bloody drainage/scabbing – Swelling, tenderness to palpation, limited ROM – Clinical deformity • Flexion at the DIP joint with inability to fully extend finger This is an OPEN fracture!
- 25. • Treatment – Acute(within 24-48 hours) • Refer to ED for I&D, nailbed repair • Possible surgical pinning dependent upon deformity • Oral antibiotics – Chronic • Refer to Orthopedics • Complications – Nail/finger deformity – Chronic osteomyelitis
- 26.
- 27. Spondylolysis/Spondylolisthesis • Overview – Parsinterarticularis fracture and potential progression to slip (spondylolisthesis) • Epidemiology – Adolescent athletes (gymnasts, cheerleaders, football linemen, weight- lifters) • Physical exam/history – Low back pain +/-radiculopathy – Pain with back extension – TTP lower lumbar spine/paraspinal musculature
- 28. • Treatment – Obtainradiographs • PA/lateral only (no need for obliques) • May be negative with spondylolysis only – Rest, PT, as needed otc NSAIDS, stretching (hamstrings) – Injections – Operative (fusion) • When to Refer – Persistent symptoms despite rest/PT – Spondylolisthesis on radiographs
- 29.
- 30. Avulsion Fractures • Overview –Indirect trauma with a sudden forceful muscle contraction “snap or pop” • Epidemiology – Adolescent athletes at puberty – Sprinting, kicking a ball, swinging a bat • Physical exam – Swelling, tenderness over affected tendon attachment – Weakness of affected muscle – Difficulty with weight bearing/limping
- 31. • Treatment – Obtainradiographs – Protective weight bearing with crutches – Early ROM – Physical therapy – Surgical intervention for significantly displaced avulsion fractures-extremely uncommon. • When to Refer – Positive radiographs
- 32.
- 33. Pediatric Non-traumatic KneePain • Overview – Associated with growth, new activity, or overuse – Knee pain without concerning symptoms such as swelling/mechanical symptoms – Often bilateral, very common! • Physical exam – Often tender over patellar/quad tendons – May have limited ROM – Normal exam otherwise • Treatment – Obtain radiographs (AP, lateral, notch, sunrise) – Conservative care (rest, ice, stretching, PRN otc pain meds – Physical therapy • Refer – Postiive radiographs – Failure of PT/Conservative care
- 34. Knee Sprains • Overview –Stretch, tear, or full tear of a ligament in the knee – Twisting injury or direct blow to the knee • Epidemiology – Adolescent athletes at puberty – Sprinting, kicking a ball, swinging a bat • Physical exam – Pain, swelling or effusion, limited ROM – Limping – Laxity/pain with varus (LCL), valgus (MCL) stress testing or anterior (ACL), posterior (PCL) drawer testing
- 37. • Treatment – Obtainradiographs – Rest, ice, immobilization, compression, as needed otc pain medications – Activity restrictions – Physical therapy • When to Refer – Persistent symptoms despite rest/PT – Significant/persistent effusion – Laxity on exam
- 38. ACL Tear • Mechanismof Injury – Non-contact hyperextension injury +/- rotation or valgus force – Pivoting with partially flexed knee – “Popping” sensation may be noted • Epidemiology – ACL provides anterior and rotational stability – Becoming more common (year-round/younger sport participation) • Physical Exam – Effusion, tenderness to palpation, limited ROM – Antalgia – Positive Lachman/Anterior drawer/Pivot shift
- 40. • Treatment – Radiographs •Typically negative but may show Segund fracture – Immobilization, protected weight bearing – Prompt referral! • We will see as a same-day appointment or within a couple days • We will obtain prompt MRI – Surgical management plus PT and activity restrictions (9 months) • Non-operative treatment leads to functional instability, secondary meniscal/cartilage damage, and likely early osteoarthritis
- 41. Tibial Spine Fracture •Overview – Avulsion of the ACL off the tibial spine – Non-contact hyperextension injury +/- rotation or valgus force – Pivoting with partially flexed knee – “Popping” sensation may be noted • Epidemiology – Childhood equivalent of an ACL tear – Most common between 8-14 years of age • Physical Exam – Effusion, tenderness to palpation, limited ROM (lack extension) – Antalgia/inability to bear weight
- 42. • Treatment – Radiographs –Immobilization, protected weight bearing – Prompt referral! • Within 1 week – Management dependent upon fracture displacement • Casting versus surgical management • May have associated ACL laxity
- 43. Tibial Tubercle Fracture •Mechanism of Injury – Non-contact injury when quadriceps muscle is contracted during jumping/knee extension • Epidemiology – Adolescent males near skeletal maturity • Physical Exam – Effusion, tenderness to palpation over tibial tubercle – Inability or extensor lag with straight leg raise – Inability to bear weight
- 45. • Treatment – Radiographs •May be subtle • Patella alta – Immobilization, crutches – Prompt referral! • Within 1 week – Management dependent upon fracture displacement • Casting versus surgical management • Activity restrictions • Physical therapy
- 46. Meniscus Tears • Mechanismof injury – Most occur from twisting, non-contact injury • Epidemiology – Lateral tears most common – May have associated ligamentous injury • History – Pain, swelling, reported mechanical symptoms (locking, catching, “gives out”) • Physical Exam – Effusion – Limited ROM – Tenderness along the joint line – Positive McMurray or Thessaly testing McMurray Testing
- 47. • Treatment – Obtainradiographs and refer early • Typically normal – Activity restriction – Ice, rest, as needed otc pain medication – Treatment dependent upon type of tear • Physical therapy/bracing • Surgical intervention frequently recommended – Mensicectomy versus meniscal repair – Typically result in good outcomes in pediatric patients • When to Refer – Promptly (within 1-2 weeks) – Ortho can initiate MRI
- 48. Ankle Sprains • Mechanismof injury – Most occur from a rotational, non- contact injury • Epidemiology – Lateral sprains most common – High ankle sprain versus low – Grade 1-3 (stretch -> complete tear) • Physical Exam – Pain, inability to weight bear, antalgic gait – Ecchymosis, swelling – Limited ROM – Tenderness around affected ligament – Positive anterior drawer testing
- 49. • Treatment – Considerradiographs – Immobilize, mobility assistance if need be (crutches) – Rest, ice, compression, as needed otc pain meds – Bracing – Physical therapy • When to Refer – Positive radiographs – Persistent symptoms/instability despite conservative care/PT – Recurrent sprains
- 50. Osteochondritis Dissecans (OCD)Lesions • Overview – Articular cartilage/subchondral bone lesion • Epidemiology – Most common in the knee but may also affect the elbow and ankle – More common in adolescence • History – Pain, swelling, reported mechanical symptoms (locking/catching), limited ROM of affected joint – Activity related pain • Physical Exam – Effusion – Limited ROM – Tenderness over affected bone
- 52. • Treatment – Obtainradiographs – Refer early – Dependent upon stability of OCD lesion based upon radiographs/MRI • Stable – Activity restriction, as needed otc pain medication, immobilization, restricted weight bearing • Unstable – Surgical debridement, microfracture, +/- fixation • When to Refer – Promptly (within 1-2 weeks) – Ortho can initiate MRI
- 53. A FEW ORTHO REFERRALPEARLS
- 54. Scoliosis • Ifobtaining x-rays PA of the entire spine (lateral if first imaging) • Refer early and for scoliometer readings > or = 5 degrees • Low dose radiation x-rays available in Akron (EOS)
- 55. Developmental Dysplasia ofthe Hip • Do not obtain US prior to 6 weeks of age (corrected for prematurity) – Physiologic immaturity of the hip • Frank + Barlow/Ortolani – Refer promptly/do not wait for an US as we will promptly initiate treatment (Pavlik harness)
- 56. References Deitch J, etal. Traumatic Anterior Shoulder Dislocation in Adolescents. Am J Sports Med. Sept-Oct, 2003;31(5):758- 763 Ghanem IB, Rizkallah M. Pediatric avulsion fractures of pelvis: current concepts. Curr Opin Pediatr. 2018 Feb;30(1):78- 83. doi: 10.1097/MOP.0000000000000575. PMID: 29176354. Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the Presentation, Management, and Outcomes of Little League Shoulder. Am J Sports Med. 2016 Jun;44(6):1431-8. doi: 10.1177/0363546516632744. Epub 2016 Mar 16. PMID: 26983458. Klingele, K.E., Kocher, M.S. Little League Elbow. Sports Med 32, 1005–1015 (2002). https://doi.org/10.2165/00007256200232150-00004 Shieh AK, Edmonds EW, Pennock AT. Revision Meniscal Surgery in Children and Adolescents: Risk Factors and Mechanisms for Failure and Subsequent Management. Am J Sports Med. 2016 Apr;44(4):838-43. Vanderhave KL, Moravek JE, Sekiya JK, Wojtys EM. Meniscus tears in the young athlete: results of arthroscopic repair. J Pediatr Orthop. 2011 Jul-Aug;31(5):496-500.
- 57. Krusche-Mandl I, KottstorferJ, Thalhammer G, Aldrian S, Erhart J, Platzer P. Seymour fractures: retrospective analysis and therapeutic considerations. J Hand Surg Am. 2013;38(2):258-64. Klingele, K.E., Kocher, M.S. Little League Elbow. Sports Med 32, 1005–1015 (2002). https://doi.org/10.2165/00007256200232150-00004 LaFrance, Russell M.; Giordano, Brian; Goldblatt, John; Voloshin, Ilya; Maloney, Michael Less: Pediatric Tibial Eminence Fractures: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 18(7):395-405, July 2010. Li X, et al. Management of Shoulder Instability in the Skeletally Immature Patient. J Am Acad Orthop Surg. 2013;21:529-537 Shieh AK, Edmonds EW, Pennock AT. Revision Meniscal Surgery in Children and Adolescents: Risk Factors and Mechanisms for Failure and Subsequent Management. Am J Sports Med. 2016 Apr;44(4):838-43. Vanderhave KL, Moravek JE, Sekiya JK, Wojtys EM. Meniscus tears in the young athlete: results of arthroscopic repair. J Pediatr Orthop. 2011 Jul-Aug;31(5):496-500.