Lecture 4: The Young Athlete Flashcards
Where does long bone grow?
Long bone growth occurs at each end around the epiphyseal (growth) plates
Apophysis
traction epiphysis
where tendons attach to bones
Epiphyseal plate
where long bone growth occurs (at ends of long bone)
- 2-5x weaker than surrounding bone
- 15-30% of all childhood fractures are growth plate fractures
Major differences between the bones of growing children and adults
- increased vulnerability of the epiphyseal plate
- tendon/ligament attachment sites (apophyses) are weak cartilaginous plates that are predisposed to avulsion injuries
- metaphysis/diaphysis in children is more resilient when compared to mature bones
- during rapid growth phases, bone lengthens before muscles and tendons are able to stretch
Increased vulnerability of epiphyseal plate
Junction btwn growth plate and metaphysis
- typically due to shear/rotation force and compression. Most resistant to tension
- physis is 2-5x weaker than adjacent capsule or ligament (more common injury at bone than tendon/ligament)
- periosteum is a major support
- injury can be acute or from repeated force
- common acute fracture: distal radius, humerus, distal tib, fib, femur
Salter-Harris Fracture
Fracture at epiphyseal plate
Type I Salter-Harris
Complete separation of epiphysis from metaphysis WITHOUT any bone fracture
Type II Salter-Harris
MOST COMMON - TRIANGLULAR shaped metaphyseal fragment
line of separation extends along growth plate then through portion of metaphysis
does not go thru jt.
Type III Salter-Harris
INTRA-articular and extends from jt. surface to growth plate and extends along plate to its periphery
Type IV Salter-Harris
Fracture extends from jt. through epiphysis, across whole growth plate and through part of metaphysics
COMPLETE split
Type V Salter-Harris
COMPRESSION
Relatively uncommon
Salter Harris Classifications
S- Straight Across
A - Above
L - Lower or beLow
T - Two or Through
ER - ERasure of growth place or cRush
Little League Shoulder
Stress fracture of proximal epiphyseal plate of humerus (11-16 year olds)
- lower tolerance for rotational stress at epiphyseal plate
Pain in dominant shoulder of athlete (baseball, tennis, volleyball)
- during and after throwing
- decreased speed and control
- recent increase in FITT
- Treatment: abstinence from activity fo 4-6 weeks
- healing occurs uniformly
Slipped Capital Epiphysis
Pressure epiphysis
- Femoral head stays in place and femoral neck slips up
- Occurs in children btwn 12-15 years (overweight males, late maturers)
Clinical Clues for Slipped Capital Epiphysis
- decreased hip abduction and internal rotation
- shortening and external rotation of leg
- surgical emergency (pin placement)
Apophyses as weak cartilaginous plates
Predisposes to avulsion injuries
- repetitive submaximal forces
- increase FITT
- growth patterns (more muscle-tendon tightness during growth spurts)
We typically injure 2-jt. muscles (ex. rectus femoris, sartorius)
Common sites of avulsion around pelvis
Ischial Tuberosity > AIIS > ASIS
Ischial tuberosity: hamstrings attach
AIIS: rectus femoris attaches
ASIS: sartorius attaches
Mode of Injury of avulsions around the pelvis
Running
Kicking
Slip
Clinical clues for avulsion around pelvis
- athlete usually reports “pop” or tearing followed by pain at site (or poorly localized groin pain for AIIS)
- pain on palpation over site (ASIS displaces inferiorly over AIIS)
- pain with passive stretch and resisted flexion of muscles
Management of avulsion around pelvis
Immediate
- ice
- support w/ protected gait (crutches)
- refer for imaging
early rehab
- early core stability (transversus abdominus)
- static balance
- maintain cardio - UBE (upper body ergometer)
- progressive ROM and strengthening
late rehab
- progress functional strength and power
Total time of recovery for avulsion around pelvis
Ischial Tuberosity: 3-4 months
ASIS and AIIS: 6-8 weeks
Resilience of metaphysis/diaphysis in children
Metaphysis/diaphysis in children is more resilient when compared to mature bones
- withstands greater deflection w/o fracture
Children have Greenstick type fractures
- incomplete fracture (like trying to break green tree branch)
- usually the fracture is on the side OPPOSITE to bending force
- common WRIST injury but can be anywherw
Clincal clues for Greenstick fractures
- may not have “typical” pain
- tender on palpation mid shaft
- swelling or may have “bump” due to bend in bone
- may have decreased ROM or pain w/ weight bearing
Management of Greenstick fractures
- refer for X-ray
- standard immobilization
- heals quickly 3-4 weeks
Rehab following:
- regain ROM and strength
Apophysitis
- injury to apophysis (aka traction epiphysis)
- due to bone lengthening before muscles and tendons can stretch
- this is an over-use injury due to repetitive motion during rapid growth
minimal muscle-tendon injuries in this age group
Little League Elbow
Apophysitis of medial epicondyle
- due to forces during cocking and early acceleration (may also cause avulsion injury)
Clinical Clues for Little League Elbow
- medial elbow pain and decreased velocity and control
- tenderness over medial epicondyle
- pain w/ resisted wrist flexion and pronation (b/c wrist flexors attach at medial epicondyle)
- valgus stress of elbow is PAINFUL
- may have tenderness on lateral side (compression on lateral side)
Managament of Little League Elbow
Immediate
- ice
- support w/ protected brace or splint
- refer for imaging
early rehab
- complete local rest for min of 4-6 weeks
- maintain lower extremity and core
late rehab
- throwing program starts 6-8 weeks
- start long toss then non-competitive pitches w/ emphasis on form
- stop for 2-3 days w/ any pain
Osgood-Schlatter/Sinding-Larsen-Johansson
- continuous contraction or stretch of quadriceps may cause softening or partial avulsion of apophysis
- most common during growth spurts and w/ high level of activity (running and jumping)
Osgood-Schlatter
at tibial tubersoity
Sinding-Larsen-Johansson
at inferior pole of patella
Clinical Clues of Osgood-Schlatter/Sinding-Larsen-Johansson
Slow onset tenderness
- tibial tuberosity in OS (girls 8-13 and boys 10-15)
- inferior patella in SLJ (children 10-15)
Tightness of surrounding muscles (quadriceps, hamstrings)
Excessive pronation
Management of Osgood-Schlatter/Sinding-Larsen-Johansson
- self limiting conditions
- settles w/ bony fusion
- OS may be left w/ a prominence of tibial tubercle
- Activity modification (no need to rest completely)
- cryotherapy
- address imbalances (stretch/strengthen) - quads and hamstrings
Sever’s Disease
Calcaneal Apophysitis is a traction apophysitis of the insertion of Achilles
- usually seen in boys between 8 and 12 years of age
- 2nd most common site of apophysitis (secondary to OS)
- usually w/ increase in activity or during growth spurt
- seen in children w/ shortened gastrocnemius-soleus muscle complex
Clinical Clues of Sever’s Disease
- tenderness over the posterior aspect of the heel
- decreased dorsiflexion ROM (plantar flexors are tight)
- over pronation
Management of Sever’s Disease
Early rehab
- insert heel raise to decrease pain in early rehab
- stretch of plantar flexors
Progress to
- strengthens plantar flexors and dynamic stablizers when pain free
- correct/manage over-pronation
- condition settle in 6-12 months (max 2 years)
Traumatic Plate Injuries
- will have appropriate mechanism of injury
- pain on palpation of growth plate
- replication of stress causes increase in plate pain
- requires immediate medical attention
Chronic Growth Injuries
- pain w/ activity (especially after increase in FITT)
- pain subsides w/ rest
- deformity
- swelling
- pain on palpation
