Evaluation of pediatric sports injuries 高雄醫學大學附設醫院 骨科 陳建志 d830191@yahoo.com.tw, 0975356619 Epidemiology of Sports Injuries in Children ◼ male > female Bijur PE, Arch Pediatr Adolesc Med. 1995 Watkins J, J Sports Med Phys Fitness. 1996. ◼ About half the injuries were acute, and half were chronic. Axe MJ, Del Med J. 1991 ◼ ◼ football accounted for the largest proportion The most common causes of injury: generally caused by overuse. ◼ ◼ ◼ Anatomic malalignments lead to abnormal stresses. Motor strength imbalance can result in muscular strains and overuse. Skeletal growth leads to tight musculotendinous units, which are, in turn, associated with muscle strains Gender Issues in Young Athletes ◼ ◼ ◼ ◼ ◼ In childhood (prepuberty), boys and girls are practically equal in their athletic abilities After puberty, physiologic parameters may affect the ability of both sexes to compete on an "equal" level Perhaps the anatomic site most affected by gender variation is the knee. Patellofemoral problems are much more common in females than in males Female athletes also appear to be at increased risk for ACL injuries Bone Growth https://classconnection.s3.amazonaws.com/748/flashcards/3764748/png/endochondral_ossification-141290A54D73166CCA3.png Primary Ossification Center Forms http://classconnection.s3.amazonaws.com/816/flashcards/844816/png/primary_ossification_center1319085805869.png Secondary Ossification Center Physis (Growth Plate) https://plasticsurgerykey.com/wp-content/uploads/2016/02/B9781437717334006303_f030-001-9781437717334.jpg Time of Appearance of Secondary Ossification Center http://www.rch.org.au/uploadedImages/Main/Content/fractureeducation/figure14_timing.jpg Time of physis closure Apophysis VS Epihysis The apophysis 1. A secondary ossification center 2. A site of tendon or ligament attachment, -- in the non-weight-bearing part 3. Most fuse during the 2nd decade of life, → delayed fused especially in female athletes. 4. also called 'traction epiphysis‘, as compared to the epiphysis https://miro.medium.com/max/1200/1*1BRun5VpvzZ1lyhwGk_HQ.png Common Injuries by Type in Adolescent and Preadolescent Athletes ◼ ◼ ◼ Overuse Injuries Strains, Contusions, and Sprains Fractures in the Child Athlete Overuse Injuries the repetitive application of submaximal stresses to otherwise normal tissues ◼ ◼ ◼ ◼ Stress fracture Periostitis Inflammation of an apophysis Cartilage injury Stress fracture ◼ ◼ ◼ most frequently in the tibia, fibula, and pars interarticularis in young athletes Focal tenderness in a singular site on the bone is common The vibration of a tuning fork →frequently exacerbates the pain Stress fracture ◼ ◼ ◼ Tc 99m bone scans MRI Treatment includes activity modification, immobilization with splinting or casting, and rest. https://www.aspetar.com/journal/upload/images/201992683932.jpg http://www.drdavidgeier.com/wp-content/uploads/2015/05/Tibialstress-fx-FI.jpg Periostitis: inflammation of the periosteum Acute Infection Autoimmune ◼ s/s ◼ intense pain difficulty bearing weight on the affected limb pus formation, fever, chills swelling Chronic Repeated stress on your bones ◼ jump run lift heavy weights Periostitis (Shin splints) ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ Traction forces on the periosteum from the muscles Pain is usually diffuse Bone scan may show diffuse uptake along the shin. Overpronation or oversupination of the feet Inadequate footwear Increasing training too quickly Running on hard surfaces Decreased flexibility at the ankle joint Inflammation of an apophysis or epiphysis Traction --Apophysis Vs Compression---Epiphysis 拉力過分使用症狀群 ( overuse) 脛骨節結軟骨炎 Osgood-Schlatter syndrome ◼ 跳躍者的膝 Sinding-Larsen-Johansson syndrome (Jumper’s knee) ◼ 跟骨節結軟骨炎 Sever’s Disease ◼ 副舟狀骨軟骨炎 Accessory navicular bone ◼ 脛骨節結軟骨炎 Osgood-Schlatter syndrome Sinding-Larsen-Johansson syndrome (Jumper’s knee) 跟骨節結軟骨炎 Sever’s disease 副舟狀骨軟骨炎 Accessory Navicular bone 副舟狀骨軟骨炎 壓力過分使用症狀群 ( overuse) ◼ 舟狀骨軟骨炎 Kohler Disease ◼ 第二蹠骨軟骨炎 Freiberg Disease ◼ 肱骨外髁軟骨炎 (少棒) Panner Disease 舟狀骨軟骨炎( Kohler Disease) 舟狀骨軟骨炎 第二蹠骨軟骨炎 Freiberg Disease Avuscular necrosis of left 2nd metatarsal head Little League elbow Repetitive valgus extension forces can lead to ◼ ◼ ◼ ◼ irritation of the medial epicondyle osteochondritis of the capitellum, premature closure of the proximal radial epiphysis a pitcher who has pain during the acceleration phase of throwing 肱骨外髁軟骨炎 (少棒) Panner Disease 剪力過分使用症狀群 ( overuse) ◼ ◼ 股骨頭骨骺滑脫 slipped capital femoral epiphysis 剝離性軟骨炎 Osteochondritis Dissecan 股骨頭生長板分離 剝離性軟骨炎 Osteochondritis Dissecan 剝離性軟骨炎 剝離性軟骨炎 Strains, Contusions, and Sprains ◼ ◼ The athlete with open physeal plates is less susceptible to ligament and muscle-tendon injuries than to avulsion fractures and growth plate injuries Nevertheless, strains and sprains, and more commonly contusions, do occur in the young athlete. Strains an injury to the muscle, near the musculotendinous junction ◼ more common after the growth spurt ◼ 3 degrees of severity of strains The first : mild tenderness, pain with passive stretch of the muscle The second : spasm of the involved limb The third : a complete tear of the musculotendinous junction with a palpable defect. ◼ highly associated with improper warm-up before sports, fatigue, and previous injury. ◼ Contusions ◼ ◼ ◼ ◼ ◼ ◼ ◼ Contact sports, such as soccer and football Severe injuries with large hematomas and loss of motion increased risk of short-term complications and long-term disability immobilized under significant stretch for a short period → stretch reduces the degree of bleeding and edema Early mobilization after the injury → reduce scar tissue formation and provide a more rapid recovery of tensile strength active range-of-motion exercises, with restriction from vigorous activity Massage therapy, ultrasound, and heat may cause further bleeding and damage and are contraindicated Ligament Sprains in Skeletally Immature Athletes ◼ ◼ ◼ Sprains are ligamentous injuries less frequently in children because of the higher degree of elasticity of ligaments in children and because the adjacent epiphyseal plates are "the weak link." Adolescents who are undergoing or have undergone the growth spurt are more prone to ligamentous injury. 生長板骨折 發生率 男:女=2:1 男 : 12 到 14 歲 女 : 11 到 12 歲 The Growth Percentage of the Physis Salter-Harris Classification https://rebelem.com/wp-content/uploads/2019/03/Salter-Harris-FractureClassification.png Salter-Harris Classification https://healthjade.com/wp-content/uploads/2019/05/Salter-Harris-fracture-types.jpg Type I: Separated growth plate Type II above growth plate Type III below growth plate Type IV: through growth plate Type IV: through growth plate Type V erasure of the growth plate ◼ ◼ Severe crushing force applied through the epiphysis to an area of the physis Since no fracture or displacement observed, it is virtually impossible to diagnose when it occurs 小兒骨折 ➢並非小號的成人骨折 ➢常遭到不當治療 延誤治療的原因 ➢ 被忽視 ➢ 叛逆性強 ➢ 在坊間，接受不當治療 生長停滯 ➢ 全面性停滯 ➢ 部分性停滯 長短腿 彎曲變形 斷骨延長術 將長骨一端行緻密骨切開術 (corticotomy), 經1-2星期讓骨痂行程後,再利用延長器一 每日四次,每次0.25 mm的速度拉長,待達 到預設長度後,經3-4個月待骨痂骨化後拆 除延長器 骨痂切除術條件 ◼ 成長期 > 1 年 ◼ 骨痂面積< 50% 長短腿 ◼ 二公分以上須治療 ◼ 二公分~五公分:在長腿著手 ◼ >五公分:在短腿著手 長 短 腿- 差值預測 長 短 腿- 差值預測 生長板吻合術 Sports-Specific Injuries Baseball ◼ ◼ ◼ ◼ Little Leaguer's shoulder is a term that describes pain due to a stress fracture of the physis or due to capsular laxity and instability Little Leaguer's elbow, also called pitcher's elbow between the ages of 12 and 16 valgus extension overload: traction stresses on the medial aspect of the elbow, the medial collateral ligament, and the medial epicondyle compression stresses on the lateral aspect of the joint, leading to osteochondritis dessicans of the capitellum, loose bodies, and radial head overgrowth Shoulder pain in young swimmers and throwing athletes ◼ ◼ ◼ ◼ exacerbated by repetitive overhead activities rotator cuff weakness, scapular motor weakness, and apprehension The most common diagnosis is instability Treatment is physical therapy Basketball ◼ ◼ ◼ ◼ high frequency of twisting and cutting movements a high incidence of knee injuries increased stresses on the ACL and menisci Ankle sprains: Eversion sprains in this age group may be more serious than the more common inversion injuries, because they are more likely to affect the mortise and open distal tibial growth plate Gymnastics ◼ ◼ ◼ ◼ ◼ ◼ high demands on the upper extremity gymnast's wrist: premature closure of the growth plates or other growth disturbances → undergrowth of the radius, and a resultant ulnar-plus variance Lumbar spine injuries are common → stress fractures of the pars interarticularis Disk herniation Cheerleading ◼ ◼ ◼ athleticism of gymnastics, the power of weight lifting, and the coordination of dance The most common cause of injuries is partner stunts followed by gymnastic tumbling runs. Injuries of the ACL, overuse injuries of the wrist and shoulder, foot and ankle injuries Tennis ◼ ◼ the repetitive overhead upper extremity use and the twisting and cutting demands on the lower extremity and torso Compared with adult tennis players, young tennis players have a reduced incidence of chronic overuse injuries Conclusion ◼ ◼ ◼ Child athletes are not just little adults. Understanding of injury mechanisms, types, and distribution Awareness of injury variations particular to child athletes → Early diagnosis and prevention of injury
