Today we're going to talk about common sports-related injuries. I have no relevant disclosures. The learning objectives today are diagnosis and treatment of common sports-related injuries to the spine, upper extremity, and lower extremity. While concussion is very common sports injury, this will be addressed in another module. Today's lecture is going to focus on musculoskeletal injuries that occur. So common injuries to the spine. Pelvis avulsion fractures. They're unique to adolescents age 13 to 14 years of age and females and 15 to 17 years of age and males. This is due to the fact that the secondary centers of ossification have not yet fused to the pelvis. This is seen in high-level competitive sports such as track and field with sprinting and jumping as well as soccer and football. The incidence is rising due to increased participation in competitive level sports. Most result from a sudden violent muscular contraction while the ipsilateral extremity is static causing the muscular tendon to be ripped from the apophysis or secondary ossification center. This most commonly occurs at the ischial tuberosity from sprinting due to a sudden powerful contraction of the hamstring muscle when the hip is flexed and the knee is extended. Avulsions from the ASIS or the AIIS are caused by strong contractions of the rectus femoris and sartorius muscles. ASIS injuries can also occur with kicking. Pelvic avulsion fractures for exam. They're going to have point tenderness and swelling over the involved apophysis. Weakness with active hip motion due to pain. Imaging, you want to compare bilaterally. For treatment, conservatively you're going to do bed rest until the pain subsides followed by two to six weeks of crutch walking with a gradual increase in weight bearing as pain will allow. So therefore you're going to do a careful reconditioning that facilitates a safe return to full activity usually within six to ten weeks. Ospondylolosis. There's going to be vertebral defect most commonly seen in children and adolescents. It's going to be at the L5 vertebral level. This occurs at the pars inter interarticularis and it can lead to ospondylolisthesis. This occurs during hyperextension forces that can be seen in gymnastics and football. They're going to complain of localized back pain that is exacerbated by hyperextension, standing and lying prone. The pain is relieved with flexion. Their neurological exam should be normal. On imaging, oblique x-rays will show the pars defect or the classic Scotty dog decapitation. Bone scan may be positive five to seven days later. CT or MRI may be used as well. Treatment consists of relative rest and eliminating aggravating activities. Bracing may be used if they have increased pain. They may also require surgical correction in severe cases. Next we're moving on to common upper extremity injuries. Upper extremity injuries are common in pediatric athletes. They typically present due to an acute or overuse etiology as a result of skeletal immaturity. Injury patterns in pediatric patients are different than adults. Most of these sports injuries respond well to conservative measures including modification of the activity and physical therapy. Adolescents experience injuries more typical of an adult as they reach skeletal maturity. Identification of the injury and appropriate surgical interventions or indications are key to preventing complications and returning athletes to competition safely. In many sports athletes use their arms to brace themselves during falls leading to an upper extremity injury. Examples include sliding headfirst into base, diving to make a catch, and tumbling during gymnastics and sparring in martial arts. Fractures. Fractures are described in terms of anatomic location, direction of the fracture line, type of fracture, and degree of angulation and displacement. When the growth plate is involved use of the Salter-Harris classification system is recommended. An estimated 15% of all fractures in children involve the growth plate. Because the adjacent epithelial plate is not ossified in the young children and therefore is invisible on radiograph, the fracture may be mistaken for a minor sprain or missed altogether only to manifest itself at a later date in the appearance of slowed or failure longitudinal limb growth or in a development of an angular abnormalities. Even if diagnosed and properly treated fesial injuries may still result in longitudinal or angular abnormalities. Fractures of the feces are unique to children and have implications not seen in the adult population. Robert Salter and Robert Harris came up with an effective classification system that describes these injuries and has general prognostic implications. A type 1 Salter-Harris fracture you'll see complete separation of the epithesis from the metaphysis without any bony injury. Reduction is usually straightforward and patients have a good prognosis. Type 2 is going to be the most common type of fracture. You're going to see a portion of the feces extending into the metaphysis. The growing cells on the feces are intact and attached to the epithesis leading to an excellent prognosis. Type 3 is going to be an intra-articular where the fracture line extends from the articular surface to the physicist and out to the cortex. Anatomic reduction of the articular surface is critical. The prognosis is good as long as the blood supply to the epithesis is intact. Type 4 the fracture extends from the articular surface through the physicist and into the metaphysis producing a complete split. Anatomic reduction of the joint and physicist is critical. Open reduction is often necessary if there is any displacement. And then the type 5 Salter-Harris fracture is the result of a severe crushing force to the physicist. Since displacement is unusual the injury is often missed on initial x-rays. The prognosis is poor due to the high rate of premature physio closure. Here is just a picture with an easy way to remember the different types. So type 1 through type 5 you can remember as Salter. S meaning straight across. A for above the growth plate. L for lower meaning below the growth plate. TE meaning through everything both above and below the growth plate. And then R for crush for type 5. Pediatric distal radio fractures are common injuries. They are either complete by cortical injuries or incomplete fractures. Incomplete fractures such as a torus or buccal fractures are failures of the compression cortex. Greenstick fractures involve cortical failure of the tension side. Incomplete fractures are considered stable injuries and are treated with immobilization using a short arm cast usually plaster or fiber cast for three weeks. Incomplete fractures with deformity closed reduction should be attempted. In children an acceptable reduction is considered a coronal or sagittal plane deformity of less than 15 degrees or less than one centimeter of shortening. These fractures tend to completely heal on average in six weeks and are remodeled by eight months. In the picture you see a green stick fracture. Surgical fixation with smooth pins is indicated for failure to achieve or maintain an acceptable closed reduction. Open reduction is often necessary if patients present two to three weeks post injury due to rapid healing in children. Next are scaphoid fractures. They are uncommon in children. Ossification of the scaphoid begins around age 4 to 5 and is complete around age 13 to 15. It can result from a direct compression force or indirectly from forced dorsiflexion. These kids are going to present with pain over the anatomic snuff box or directly over the distal pole of the scaphoid. You can also get stress fractures of the scaphoid bone. 3% of fractures do not appear on radiograph until one to two weeks from the initial injury. If there is a high clinical suspicion and negative radiographs, MRI or CT is recommended. Stress fractures of the scaphoid bone can occur due to repetitive microtrauma and forearm muscle fatigue. This occurs in athletes with repetitive loading of the wrist in a dorsiflex position such as occurs in gymnasts, divers, or tennis players. Scaphoid impaction syndrome can occur with forced dorsiflexion of the wrist that may cause the contact between the scaphoid against the dorsal rim of the radius. These patients can present with pain along the dorsal radial aspect of the wrist with dorsiflexion. Initial management of scaphoid fracture should be with a long arm thumb spica cast to immobilize a very active pediatric population. A short arm spica cast is indicated for incomplete or avulsion fractures. In two weeks, the long arm spica cast may be continued or transitioned to the short arm thumb spica cast. Risk fractures are at higher risk for non-union and further immobilization with a long arm spica cast or even surgical management are indicated. Despite excellent outcomes with non-operative management, surgical management should be considered in patients near or at skeletal maturity with displaced fractures and in those with a non-union fracture. Next are other carpal fractures. So there can be isolated fractures of the hamate. However, it's very uncommon in children. It can be as a result to a direct blow to the hand. If suspicion is high for a hamate fracture on radiographs, MRI is an effective diagnostic tool. Conservative treatment in a short arm cast is recommended for at least three weeks. Treatment with K-wire fixation may be indicated if there is significant displacement or dislocation. Pissiform fractures can occur but they are also rare. The center of ossification appears between 7.5 to 10 years of age and is the last carpal bone to ossify. The bone is fully developed by age 12 but prior to this there may be multiple sites of ossification. This can give the pissiform a fragmented appearance which should be distinguished from fracture. Radiographs or MRI are useful to make this distinction. Metacarpal fractures can also occur. This can occur in the head, neck, and shaft or base of the metacarpal. Depending on where the fracture is in the metacarpals, treatments should be splinting, closed reduction, or open reduction. The most common site is usually the base of the metacarpal fracture. Phalanx fractures can also occur. They can occur proximal, middle, or distal. Climbing related middle phalanx fracture. This is due to repetitive stresses from intense rock climbing and have been associated with fracture of the dorsal part of the middle finger epiphysis. The full crimp position which is the DIP extension with PIP flexion produces excessive loading in this part of the hand leading to physio overload, consolidation, partial necrosis, and eventual growth plate fracture. Treatment for this consists of immobilization, finger therapy, and a cessation of rock climbing for several months. Montagia fracture is a displaced fracture of the proximal ulna that is accompanied by dislocation of the radial head. This results from a fall on the outstretched hand with the elbow extended and forearm rotated radially producing a varus stress. Rotator cuff tears not going to go into great detail as this is a common injury seen in adults but I am going to point out the differences that seen with children. So rotator cuff tears are not common in children however they can occur usually resulting from an overhead throwing motion so seen in like pictures. Rotator cuff lesions may be under reported and or inaccurately reported among pediatric patients. Pediatric patients with operative rotator cuff tears should be expected to have associated injuries with complete and thorough arthroscopic visualization identifying these injuries, most commonly involving the labrum. Rotator cuff tears in pediatric population are most commonly articular-sided partial thickness tears of the supraspinatus muscle. Shoulder dislocations, separation of the proximal humeral epiphysis or major fracture dislocation are seen in younger children subjected to significant forces. Traumatic dislocations are rare in children under 10 years old accounting for less than 2% of dislocations but 20% of shoulder dislocations occur in patients under 20 years old. Anterior glenohumeral instability is most common direction of instability and more common in the younger population. Most literature focuses on treatment of adolescent skeletally mature shoulder dislocations due to their high reoccurrence rates. Most of these dislocations as stated already are anterior dislocations. Redislocation rates are reported anywhere from zero to 100% so highly variable. This is seen commonly in athletes such as pitchers and volleyball players who require repetitive over arm motions. Complications may include axillary nerve injury. They're gonna present with shoulder fatigue, pain, numbness and paresthesias. Shoulder may slip in and out when the arm is placed in the abduction and external rotation such as the throwing position. On exam, you're gonna test laxity, apprehension test, relocation test, anterior drawer test and anterior load and shift test. In skeletally immature patients, anterior inferior dislocations will present with slightly abducted externally rotated arm. The humeral head may be palpable with prominent acromion in thin patients. You also wanna do a thorough neurovascular exam including the axillary nerve. Images, you're gonna do an x-ray with AP, scapular Y and axillary views. Treatment, conservatively is gonna be a sling, immobilization, range of motion and strengthening of the shoulder girdle complex. Strengthening alone rarely works to prevent reoccurrence if there is sufficient capsular laxity and therefore you may have to go to surgical if rehabilitation fails. So prompt recognition and reduction of acute shoulder dislocations is imperative. Remember, the proximal humeral physicist closes between ages 14 to 17 years. So gentle constant traction should be reused for reductions in order to avoid injury to the proximal humeral physicist. Immobilization and adduction in internal rotation for one to six weeks is typical. Treatment after primary and recurrent dislocation is controversial. Current evidence favors non-surgical for primary dislocation in skeletally immature patients given lower recurrence rates than adolescent and adult patients. Physical therapy for gradual strengthening and return of range of motion can vary depending on the age of the patient. Surgical intervention is indicated for patients with recurrent dislocation who have failed non-operative management or primary dislocations at high risk of recurrence due to MRI findings or risk factors such as age, arm dominance, sport compliance, et cetera. Patients with multidirectional instability often require a labral repair, open arthroscopic assisted, and all arthroscopic techniques have been described in these cases. Next is medial apophysitis. This is also known as Little League's Elbow. Little League's Elbow is an overuse condition seen in adolescent baseball players, hence the name that can be a cause of pain located on the inside of the elbow. With too much repetitive throwing of a baseball, the growth plate on the inside of the end of the elbow known as the medial epicondyle becomes inflamed. Little League's Elbow is known as an apophysitis which refers to chronic inflammation of the growth plate commonly seen in ages nine to 14. Radiographs are always obtained to evaluate the growth plates around the elbow. In Little League's Elbow, there may be irregularity noted of the growth plate of the medial epicondyle. However, up to 85% of the time, the x-rays may be normal. It is also important to evaluate the elbow on radiographs to look for other signs of injury like stress fractures and injury to the growth plates and bones on the lateral sides of the elbow. While the majority of the cases, plain x-rays will suffice, an MRI can be obtained to look more closely at the growth plates and to evaluate for ligament injury when the findings on examination are unclear. Treatment mainstay is non-surgical, rest for four to six weeks minimum with strengthening and endurancing program. You can use ice and insets during the acute phase. Surgery is rarely needed in these cases. Complication may lead to osteochondritis, desiccans of the capitulum. Next is lateral epicondylitis. This is also known as tennis elbow. It rarely affects children, is more likely to be seen in adolescent and adult population. Painful inflammation of the tendons located along and attached to the lateral elbow. The cause is overuse of forearm muscles that causes micro tears and fraying of the tendons, usually due to improper technique in racket sports. Athletes engaged in activities that involve repetitive motions of the wrist and forearm, so this is golfing and racket sports, are at risk for developing this condition. With tennis in particular, stress is greatest on the outer elbow of the dominant arm during a backhand swing. Incorrect grip size, inappropriate string tension or swing mechanics can contribute to this injury. Athletes may complain of pain in the elbow during or after activity. There is typically no great swelling or redness and the onset of pain is gradual. Pain may travel down the forearm toward the wrist and improve with rest, but it often returns when the activity is resumed. Some athletes may also notice decreased grip strength in the affected arm. It's usually diagnosed through history and physical exam. X-rays are not needed. Treatment can be activity modification and rest, eccentric strengthening, bracing. The elbow with a counterforce strap or using a wrist brace may also help to decrease symptoms. Ice, insets and surgery is reserved for the most severe cases. Next is subluxation of the radial head, also known as nursemaid elbow. It's the most common elbow injury in childhood and one of the most common ligamentous injuries. Mechanism of action is a sudden traction applied to the extended arm. The annular ligament is torn at the site of attachment to the radius. This is predominantly seen in ages one through four. They will cry initially and then hold their arm close to the body with the elbow flexed and forearm pronated. Typical history is one of a parent suddenly pulling the child up by an arm. Could also occur by a child grabbing onto something as they fall. While this is not necessarily a sports related injury, it is a common injury, so I included it in this presentation. They may complain of elbow, forearm or wrist pain. On examination, child's gonna resist supination and the x-rays are usually normal. Treatment is reduction by supinating the forearm with the elbow in a flexed position while applying pressure over the radial head. You can also place the arm in a sling. Next is distal radial epiphysitis, also known as gymnastics wrist. This is due to forceful loads through an extended wrist during activities like tumbling and vaulting. Leads to inflammation and irritation of the growth plate. They're gonna complain of pain in the dorsal radial region of the wrist. The prevalence of wrist pain in pediatric gymnasts ranges from 56 to 67% in high quality studies. Gymnastics is a demanding sport necessitating forceful loads through an extended wrist during activities like tumbling and vaulting. This leads to inflammation, irritation of the growth plate. Patients usually have pain in the dorsal radial region of the wrist and the radiographic findings include enlargement and blurring of the distal radius physicist, metaphyseal bone cyst and distal wedging of the epiphysis. Treatment consists of insets and rest from impact activities for three to six months. Chronic cases can lead to development of long-term positive ulnar variants and bone bar formation in the distal radius physicist. Operative treatment in chronic symptomatic cases involves resection of the fesial bar and small closures or ulnar epiphysiodeus and shortening with or without radial osteotomy and large fesial closures. Next is a thumb ulnar collateral ligament injury. This is also known as skier's thumb. This occurs when the UCL is injured by forceful thumb abduction and hyperextension. This injury usually involves a Salto-Harris three fracture of the thumb and the proximal phalanx. If the fragment is displaced by less than two millimeters, non-surgical management is indicated. Fractures with more than two millimeters of displacement require open reduction internal fixation. Younger children may also suffer from Salto-Harris one and two proximal phalanx fractures, whereas adolescents can show avulsion fractures and rupture of the UCL as seen in adults. Next are boutonniere deformities. These result as traumatic avulsion of the central portion of the extensor tendon as it inserts on the middle phalanx. And usually it went unrecognized at the time of initial injury. The mechanism of injury is usually a blow to the tip of a finger that drives it into force flexion against resistance. Initially, there may be local tenderness over the dorsal aspect of the PIP joint without deformity. With time, however, the lateral bands of the extensor mechanism migrate bolerly, producing a flexion deformity of the PIP with a secondary extension deformity of the distal joint. Here's just showing a picture of the PIP joint inflection with the DIP and hyperextension, and there is a tear in the central slip. Treatment, if the injury is recognized early, healing may occur with splinting of the PIP joint into extension. Later, an open surgical repair may be necessary to improve function. Next, we have the mallet finger or swan neck deformity. These result of avulsion of the extensor tendon from its insertion at the base of the distal phalanx of a finger. It occurs as a result of a blow to the extended finger against resistance. The tendon alone or the portion of the distal phalanx into which it inserts may be involved. This can occur when a ball hits the tip of a finger, also called baseball finger. Clinical appearance is that of a dropped finger or flexion deformity of the distal interphalangeal joint with inability to actively extend the joint. Here just shows a picture of the disruption of the extensor tendon mechanism to the DIP joint, resulting inflection of the DIP. If not recognized and treated at the time of injury, the condition becomes chronic and contracture of the extensor mechanism may occur with a secondary hyperextension deformity of the PIP joint producing the swan neck deformity. Treatment is splinting the distal joint into an extended position. Open reduction will be required if a large fragment of bone is involved and surgical repair is also needed for chronic cases. Last but not least, we're gonna talk about common sports-related lower extremity injuries. First is ACL tear. It's a common adult injury, so it won't go into great detail, assuming it's going to be covered in the adult musculoskeletal modules. There are several factors that can make treating pediatric or adolescent ACL injuries more challenging. First of all, making an accurate diagnosis can be difficult as there is a spectrum of injuries, including tibial avulsions, partial ACL tears and complete tears. And there can be multiple barriers to performing an accurate examination in this patient population. ACL injuries are thought to be increasing in several pediatric populations, including both...

sports-related injuries

spine

upper extremity

lower extremity

musculoskeletal injuries

avulsion fractures

spondylolysis