The Young Athlete Flashcards
What are some differences between Adult and Growing Bone?
- Articular cartilage of growing bone is thicker and can remodel
- Junction between epiphyseal plate and the metaphysis is vulnerable to disruption, especially shearing forces
- Tendon attachment sites - apophyses - provide a relatively weak cartilaginous attachment, predisposing avulsion injuries
- Metaphysis of long bones in children is more resilient and elastic, predisposing to greenstick fractures
- During growth spurt, epiphyseal plate is more fragile leading to increased incidence of physeal fractures in pubescence
What are the three most common types of fractures seen in the young athlete?
- Metaphyseal
- Epiphyseal Growth Plate
- Apophyseal Avulsion Fractures
What is the most common metaphyseal fracture in young athletes
- Buckling in either forearm or lower leg
- Known as greenstick
What is the treatment for greenstick fractures?
- If no growth plate involvement
- Immobilization, heals in three weeks
- Sometimes angular or rotational deformity requires ORIF
Name the Site of Osteochondrosis associated with: Perthes, Kienbocks, Kohlers, Freibergs, and Osteochondritis Dissecans (Articular)
- Femoral Head
- Lunate
- Navicular
- Second Metatarsal
- Medial Femoral Condyle, Capitellum, talar dome
Name the site of Osteochondrosis associated with Osgood Schlatter, Sinding Larsen Johansson, and Severs lesions (Non Articular)
- Tibial Tubercle
- Inferior Pole of Patella
- Calcaneus
Name the site of Ostechondrosis associated with Sheurmanns and Blounts Lesions (Physeal)
- Thoracic Spine
- Proximal Tibia
Describe the Salter Harris Classification of Growth Plate Fractures (Physeal)
- S - Slipped
- A - Above (growth plate)
- L - Lower
- T - Through
- ER - Erasure (of growth plate, crushed)
How well do the different classifications of Salter Harris Fractures Heal?
- 1 and 2 heal well
- 3 and 4 involve joint surface and growth plate and have high complication rate
What history best describes growth plate fracture?
- Severe rotational or shear force with accompanying localized swelling, bony tenderness, and loss of function
- Orthopedic referral mandatory
What type of avulsion fracture can occur in children accompanying ACL injury?
- Avulsion of tibial spine or the Distal Femoral Attachment
What is the most commonly reported acute apophyseal sports injury in the upper extremity? In the Spine?
- Injury to the olecranon and medial epicondyle of humerus
- in Spine it is the vertebral ring apophysis
How are avulsion fractures in the young athlete treated?
- Same as grade 3 tears of muscle
- Reduce pain and swelling
- Restore full ROM with passive stretching and active ROM as symptoms settle
- Graduated return to strength training
- Reattachment is rarely necessary
Are dislocations of the glenohumeral joint common in the younger child?
- No, but common in the adolescent
What are the radiographic signs of Stress fracture of the proximal humeral epiphyseal plate?
- Widening of the proximal humeral epiphysis
- Metaphyseal sclerosis and demineralization or fragmentation of the epiphysis
- Most improve with rest and return to sport
What causes shoulder impingement in the younger athlete?
- Secondary to atraumatic instability
- Because of repetitive stress to anterior capsule of the shoulder
- Also occur in swimmers where excessive IR causes a tendency to impinge
What types of elbow pathology may be caused by forceful valgus stress in pitching?
- Medial stretching, Lateral Compression, and Posterior Impingement can cause:
- Apophysitis of the epicondyle
- Chronic strain of medial (ulnar) collateral ligament
- Avulsion fracture of the medial epicondylar apophysis
- Ulnar Nerve damage
- Lateral compressive forces in particular may damage articular cartilage of the capitellum or radial head
Which individuals experience Osteochondritis Dissecans of the Capitellum? Treatment?
- Gymnasts
- Pitchers
- Early stages respond well to rest
- Loose bodies (if any) need surgery to remove
- Results of surgery are variable
Describe a Panners Lesion
- Occurs in younger child (under 11 years)
- Self limiting
- Fragmentation of the entire ossific center of the capitellum
- No loose bodies, no surgery required
What is a common cause of dorsal wrist pain in the young gymnast?
- Compromise of blood supply of the distal radial physis
- Aggravated by weight bearing
- On radiographs: widening, irregularity, haziness, or cystic changes within growth plate
- Other causes include scaphoid impaction syndrome, dorsal impingement, TFCC tear, stress fractures
What is a Kienbocks Lesion?
- Osteochondrosis of lunate
- Usually in older patients (over 20)
What is treatment for stress injuries of the distal radial physis in the young athlete?
- Rest
- However, premature closure can occur resulting in positive ulnar variance
What is the most common postural abnormality of the spine in the younger athlete?
- Scheuermanns Lesion
What is a Scheuermanns Lesion?
- Excessive kyphosis of the spine due to osteochondrosis
- Usually in thoracic spine but also at thoracolumbar junction
How is the radiologic diagnosis of Scheuermans Lesion Made?
- Presence of wedging of 5 degrees or more on 3 adjacent vertebrae
What is the management of Scheuermans Lesion in the young athlete?
- Aimed at preventing progression
- Joint mobilization, massage, stretching of hamstrings and abdominal strengthening
- Brace may be worn
- Surgery indicated if kyphosis greater than 50 degrees or signs of spinal cord irritation are present
What are the sites of apophysitis around the hip joint?
- ASIS - Sartorius
- AIIS - Rectus Femoris
- Lesser Trochanter - Iliopsoas
Describe Perthes Disease and its presentation
- Osteochondrosis of femoral head
- Ages 4-10
- Presents with limp or low grade ache in the thigh
- Unilateral
- Limited Abduction and Internal Rotation
- More common in males
- Radiographs show increased density and flattening of the femoral capital epiphysis
What is management of Perthes Disease?
- Rest
- ROM exercises to maintain Abduction and IR
- If severe may require arthroscopic chondroplasty and loose body removal
- Main long term concern is Osteoarthritis due to irregularity of the joint surface
Describe Slipped Capital Femoral Epiphysis and its presentation
- Ages 12-15
- Usually in overweight boys who tend to be late maturing
- Most common presenting symptom is limp, sometimes pain in the knee
- Shortening and External Rotation of the affected leg
- Hip Abduction and IR are reduced
- Bilateral Involvement common
- Radiographs show widening of growth plate
What is treatment of Slipped Capital Femoral Epiphyses?
- Gradually progressing slip is indication for surgery
- Acute severe slip is surgical emergency
- Can lead to Avascular Necrosis
What may be an anatomical predisposing factor to the development of Osgood Schlatter?
- Excessive Subtalar Pronation
What is a Sinding Larsen Johannson Lesion?
- Apophysitis of inferior patellar pole
- Prevalent in junior basketball players
- Self limiting and treated with rest
Describe Osteochondritis Dissecans of the Knee
- Presents with intermittent pain and swelling of gradual onset
- May present as acute painful and locked knee (Associated with hemarthrosis and loose bodies)
- Radiographs reveal defect at lateral aspect of Medial Femoral Condyle
- Ortho referral for fixation of loose fragment or removal of detached fragment
Describe Stills Disease
- Juvenile Rheumatoid Arthritis of the knee
- Persistent intermittent effusion with increased temperature and limited ROM
- May be family history of RA
- Needs serological examination including Rheumatoid factor, ESR, and maybe examination of joint aspirate
- Treatment is activity modification
Describe Diagnosis of Acute Rheumatic Fever?
- May or may not be history of sore throat and Carditis
- Must maintain high index of suspicion
- Investigations include markers of inflammation (ESR, C reactive protein), Serology for Streptococci, and echocardiography
- Treatment is Oral Penicillin and Aspirin
Describe a Discoid Meniscus
- May cause persistent knee pain and swelling in the adolescent athlete
- Marked Joint Line Tenderness
- History of clunking in the younger child (4 years)
Describe Adolescent Tibia Vara (Blounts Disease)
- Affects proximal tibial growth plate
- Affects tall, obese children around the age of 9
- Usually Unilateral
- Radiographs show a reduced height of the medial aspect of the proximal tibial growth plate
- May require surgery to correct mechanical abnormality
What are some Risk Factors for Females tearing an ACL?
- Being in pre-ovulatory phase of menstrual cycle vs post-ovulatory phase
- Decreased intercondylar notch width
- Increased knee abduction moment on impact on landing
When is non operative management suggested for children with ACL injury?
- Children who have not yet reached skeletal maturity (Tanner stages 1 and 2, Prepubescents)
- Poor Outcome
When is surgery recommended for children with ACL injury?
- Children who are non compliant with management
- Demonstrating functional instability with ADLs
- Associated Meniscal Pathology
- Usually use Autologous IT Band graft
What is a Severs Lesion?
- Apophysitis of the Calcaneus at the insertion of the achilles
- Patient complains of localized pain with activity
- Tenderness at insertion of achilles
- May be tightness of gastrocnemius or soleus
- May be limited dorsiflexion
What is management of Severs Lesion?
- Activity Modification
- Heel Raise
- Calf Stretching
- Strengthening to plantar flexors when pain free and symptoms permit
What are common Tarsal Coalitions?
- Most common form is a bony or cartilaginous bar between the navicular and calcaneus
- Second is between calcaneus and talus
- Calcaneocuboid is least common
What is presentation of Tarsal Coalition?
- Midfoot pain after recurrent ankle sprains or after repetitive running and jumping
- May have a limp
- Restriction of Subtalar Joint Motion
- Radiographs taken at 45 degree oblique may confirm
- If negative but clinical suspicion is high, MR or CT
What is treatment of Tarsal Coalition?
- Orthotic Therapy
- Surgical excision in younger patient with severe symptoms
- Coalition may recur after surgery
What is a Kohlers Lesion? Presentation?
- Osteochondrosis affecting navicular bone in young children
- Ages 2 to 8
- Pain over medial aspect of navicular
- Radiographs show increased density and narrowing of navicular bone
What is treatment of Kohlers Lesion?
- Waling Cast for Six Weeks to accelerate relief
- Orthoses if biomechanical abnormalities are present
Describe Apophysitis of the Tarsal Navicular Bone
- May cause pain on the medial aspect of the tarsal navicular at insertion of tibialis posterior tendon
- Often associated with the presence of an accessory navicular or prominent navicular tuberosity
- Management includes activity modification, NSAIDs, and orthoses to control excessive pronation if present
Describe Apophysitis of the Fifth Metatarsal
- Traction apophysitis at insertion of Peroneus Brevis at base of fifth metatarsal
- Localized tenderness and pain on resisted eversion of the foot
- Manage with activity modification and stretching and strengthening of the peroneals
Describe Freibergs Lesion
- Osteochondrosis causing collapse of the articular surface and adjacent bone on the metatarsal head
- Second Metatarsal most commonly involved (ballet dancers)
- Most frequently in adolescents over age of 12
- Standing on forefoot aggravates pain
- Tenderness and swelling around second metatarsal joint
- Radiographs reveal a flattened head of metatarsal with fragmentation of the growth plate
What is treatment of Freibergs Lesion?
- If caught early, activity modification, padding under metatarsal, and footwear modification to reduce pressure over metatarsal heads
- If symptoms persist, surgery
