Injuries and Medical Problems in Children and Adolescents Flashcards
Why are the differences in MSK anatomy in children/adolescents
- epiphysial plates (and its junction) where growth occurs
- growth spurts
- bone malleability
- apophysites present
- articular cartilage is different
- muscle developement
- variety in sports play when younger
what are the 3 anatomical subsections that compromise a long bone?
- epiphysis
- metaphysis
- diaphysis
What is present in the developing skeleton
- epiphyseal plates
- to allow for bone growth
- site of weakness
- can be susceptible to fractures and sheer forces
What occurs during a growth spurt?
- bone length changes and then soft tissue length adapts to that
- leads to changes in coordination and biomechanics
- effects energy levels
what part of the bone is softer in developing bone? what is the impact of this
metaphysis
absorbs greater energy
suscpetable to different forms of fracture
generaly, developing bones are less dense/more porous
What is an apophysis?
Bony attachment site of a tendon (where muscle attaches to bone via tendon)
eg ASIS for rectus femoris muscle
What is the site of development and remodelling of adolescent bone?
The articular cartilage
- thicker and greater ability to remodel than in adults
What can happens if articular cartilage is damaged?
osteochondritis dessicans- disruption to blood supply to cartilage –> ischaemia and necrosis
Why are joints less stable in children and adolescents?
- muscle development not optimal/fully maturated, reducing core stability
- reduced cross bridges in ligaments leading to increased laxity
- joint stability relies less on muscle stability than in adults
Principles of managing injuries in children/adolescents
- Remember they are not mini adults
- manage physiological processes
- identify causes
- rehabilitate with emphasis on casual factors- more scope to address than in adults
- important to address biomechanics
Factors to take into account when addressing sporting injuries
- holistic approach
- CVS changes
nutritional - psychosocial
- enivornmental
- ethical considerations
- player development
Factors to take into account when addressing sporting injuries
- holistic approach
- CVS changes
nutritional - psychosocial
- enivornmental
- ethical considerations
- player development
CVS changes in children/adolescents
- lower SBP
- lower SV
- increased MHR
- lower CO
increased RR - less anaerobic power
- screening for any congenital issues
children/adolescents environmental consideratinos
- greater body surface area to mass- more susceptable to extreme conditions
- lower sweating rate
- more SA:VR
- lower rate of heat acclimatisation
- issues in hot and cold environments
children/adolescents environmental consideratinos
- greater body surface area to mass- more susceptable to extreme conditions
- lower sweating rate
- more SA:VR
- lower rate of heat acclimatisation
- issues in hot and cold environments
Common injury complaints in children/adolescents
- fractures
- hip and groin complaints
back pathology
traction apophysitis - joint instability
These relate to the physiological differences between adults and children/adolescents
Why are fractures managed differently in children/adolescents?
- greater capacity to heal
- bones contain growth plates
Why are fractures managed differently in children/adolescents?
- greater capacity to heal
- bones contain growth plates
How are growth plate fractures classified?
Salter Harris classification:
- type 1: epiphysis completely separated from end of bone, vital portion of growth plate remain intact. require cast but will be normal bone growth once healed
- type 2: most common. epiphysis and growth plate partially separate from metaphysis which is cracked. Typically have to be surgically put in place and immobilised.
- type 3: rare. Usually distal tibia. fracture runs through epiphysis and separates part of epiphysis and growth plate from metaphysis. surgery may be necessary. good prognosis if blood supply to separated portion is intact, no displacement, and bone regrows
- type 4: requires surgery to align growth plate. If this isnt achieved then prognosis for future growth is poor
- type 5: end of bone is crushed and growth plate is comrpessed. prognosis is poor, growth likely to be stunted
damage to growth plate will reduce future growth at that portion leading to biomechanical imbalances
Factors affecting severity of growth plate fractures
- severity
- age
- type of growth plate involved
Greenstick fracture
- one side broken and the other is bent
- reduced and cast over 6 weeks
occur in metaphysis
Buckle fracture
- incoplete fracture when bone buckles without distrupting one side of the bone
- common due to soft skeleton
- persistent pain more than a few hours, usually from falling onto wrist
- 5-11yr
- Quicker healing time
- 3 week cast
Causes of hip and groin pain in children/adolescents
- traumatic
- apophyseal injuries
- avascular necrosis of hip
- Perthe’s disease
- slipped upper femoral epiphysis
Groin pain in children/adolescents prognosis
80% heal in 3 weeks
Perthe’s disease aka
avascular necrosis of the hip
Blood supply of femur heads through the neck of the femur and supplies the head. Anything disrupting this can cause articular cartilage necoriss, changing the shape of the femoral head. Flattening of the head occurs causing hip pain
most common in boys from 5-12yrs causing limp
causes of slipped upper femoral epiphysis
sheer forces through the epiphysis between femoral head and neck results in a change in the anatomy
femoral head slips off femoral neck and this is a weak sight in children/adolescents that isn’t present in mature skeleton
causes of avascular necrosis of the hip
trauma:
- NOF fracture
- dislocation
- ETOH
systemic cortisone
what happens to the femoral head in avascular necrosis
flattening of the femoral head
management of avascular necrosis
generally conservative
may need surgical intervention
Perthe’s disease presentation
- painful hip
- limp
- 5-12yr
- boys more commonly
causes of slipped upper femoral epiphysis
- femoral head slips posteriorly
- due to weakness of growth plate
during periods of accelerated growth
gait in slipped upper femoral epiphysis
antalgic
Ddx back pain in young athletes
Less common than in adults.
- spondylolysis (Pars defect)- relatively common
- spondylolisthesis
- scoliosis
- scheuermann’s disease
- osteomyelitis
- congenital abnormalities
- ankylosing spondylitis
- juvenile RA
- Malignancy
Spondylolysis aka
Pars defect = defect on pars interarticularis
epidemiology spondylolysis
6% gen pop
50% sporting back pain
due to repetitive hypertextension
more common in males
which vertebrae are commonly affected by sponylolysis/pars interarticularis
L4/5 or L5/S1
sports causing spondylolysis
those causing repetitive spinal extension:
- football
- crickets
- gymnastics
- weightlifting
common presentation spondylolysis
- sport related pain
- worst on activity
also ask:
- multiple joint pain/swelling
- night pain
- morning stiffness
- neuro/systemic Sx
common presentation spondylolysis
- sport related pain
- worst on activity
- pain on lumbar extension
specifically single leg extension or extension combined with rotation
other Q to ask someone with suspected spondylolysis
- multiple joint pain/swelling
- night pain
- morning stiffness
- neuro/systemic Sx
Ix for spondylolysis
- Xray- AP, lat, oblique
- SPECT/CT- determine the reactivity of lesion and whether it is acute or chronic
- MRI first point of call although difficult to tell if chronic or acute
Treatment for spondylolysis
- relative rest from aggravating activties
- analgesia
rehab: - core
- flexion avoid extensino
hamstring stretches to reduce tension - aerobic fitness
- sports specific
- bracing in an extreme example
traction apophysitis
areas in the developing skeleton where the tendon attaches onto the bone and can become painful and inflamed
More common in children because the area is not yet hardened
associated with a lot of growth in short time
Extreme consequence of traction apophysitis
avulsion fracture
The area of bone that it attaches to it softer than adult skeleton
common examples of sites of traction apophysitis
- osgood schlatters (tibial tuberacle) patella tendon
- Severs (calcaneum) achilles tendon
- Sinding Larsen Johansson (inf. pole patella), pat tendon
- Little league elbow (med. epicondyle) wrist flexor
- Iselins (5th metatarsal) peroneus brevis
most common traction apophysitis
Osgood schlatters
inflammation at the site of patella tendon attachment at the tibial tubercle
Osgood schlatters-clinical findings
- TOP tibial tubercle
- protruded tibial tubercle
- Pain on resisted knee extension/squatting
- pain on passive knee flexion
- restricted hamstring flexibility
Biomechanical risk factors for osgood schlatters
- Poor quad/hamstring flexibility
- growth spurt
- increased Q angle
- patella alta (sits high in trochlear groove)
overpronated feet - knee valgum
increases traction occurring at tibial tuberosity
Severs Disease- clinical findings
Traction apothysitis where achilles attaches to calcaneus
- TOP calcaneal growth plate
- Pain and restriction on DF stretch
- Pain on resisted PF/calf raise
Biomechanical factors predisposing to severs disease
- overpornation/valgus at the ankle
- stiff forefoot
Mx traction apophysitis
- relative rest (change in activity)
- treatment of inflammation
- address biomechanical factors
- improve movement patterns
why is there increased risk of dislocation in children and adolescents
cross bridges of ligaments not fully formed and stability provided by muscle development is not optimised
Patello-femoral stability mechanism
- patellar alignment is maintained by fibrous structures
- these provide medial and lateral pull (vastus medialis and IT and vastus lateralis providing tension)
subluxation vs dislocation
subluxation is partial loss of joint congruity
dislocation is complete loss
What must fail in order for dislocation to occur?
One of the medial structures will fail either by:
- medial patella femoral ligament detaching at femoral attachment
- avulsion fracture at chondro-osseous junction
This allows lateral structures to pull kneecap out of the trochlear groove
Biomechanical risk factors for patella instability/dislocation
- shallow femoral trochlear
- hypoplastic lateral femoral condyl
- patella shape
- patella alta
- poor VMO strength
injury prevention concepts
- anthropometric measurements
- load management
- generic warm up
- functional movement screening
- injury prevention exercise programmes
Aims of the warmup
- graduated physiological preparation for exercise
- turn on neurological pathways for muscle activation ‘proprioception’
- physical and mental rehearsal of sports-specific movements
FIIT principle
frequency intensity time and type
part of load management
current concepts of injury prevention
- hamstring/gluteal/adductor/gastrocnemius strengthening
postural/core stability training
proprioceptive training
myofascial release
