Injuries Unique to the Adolescent Athlete - Westchester Health Pediatrics

INJURIES UNIQUE TO
THE ADOLESCENT ATHLETE
Michael A. Gott MD
Director of Sports Medicine, Yorktown Orthopedic Institute
Westchester Health Associates
March 31, 2016

OVERVIEW
 Fractures
 Salter-Harris fractures
 Fractures unique to adolescents
 Overuse injuries
 Injuries in Throwers
 Hip Disorders in children
 SCFE
 Spine Injuries
 Spondylolysis/Spondylolisthesis

Fractures
 Growing bone is composed of
 Diaphysis
 Metaphysis
 Physis
 Epiphysis
 Injury in pediatric patients
bypasses relatively stronger
ligaments
  energy exits the weakest
link

SALTER-HARRIS CLASSIFICATION
1963
 I - through the physis
 II - physis and metaphysis
 III -physis and epiphysis
 IV - metaphysis and
epiphysis
 V - compression injury of
the physis
 VI - injury to periosteum/
perichondral ring

Buckle fractures
• Cast or splint for 4 weeks
• No sports or gym for 8 weeks

MANAGEMENT
 Salter-Harris I & II
 Anatomic physeal
reduction without inducing
growth arrest is the goal
 Closed vs open reduction
 Immobilization +/- fixation
depending on stability
 Thick periosteum can be
interposed at the fracture
site and blocks reduction
 Distal tibia physeal fxs
 Healing time is half the
time of mature bone injury
in same location

MANAGEMENT
 Salter-Harris III & IV
 Require anatomic reduction
(articular injuries)
 Likely need internal fixation
to maintain reduction
 Salter-Harris V & VI
 Keep high index of
suspicion- x-rays may be
unremarkable or subtle
 Suspect if there is a
compression injury
 Risk of physeal arrest
increase with Salter class
 Follow long term for
growth problems

Complications
 Avoid growth arrest
 Need frequent radiographic
at 4 month intervals
 Consider epiphysiodesis
or corrective osteotomies
if necessary
 Bowen et al report
expected 7 degree
correction/yr at distal femur
and 5 degree correction for
distal tibia with
hemiepiphysiodesis
 Guided Growth for the Correction of
Pediatric Lower Limb Angular
Deformity
**Saran et al JAAOS 2010

Fractures Unique to
Adolescents
 Patellar sleeve
 Tibial tubercle avulsion
 Tibial eminence
 Triplane fractures distal tibia

Sleeve Fracture of Patella
 Avulsion of distal
cartilaginous portion
of patella
 Age 8-12 yo
 Patella alta on exam
and xray
 Small fragment
separated from distal
patella on
radiographs
 MRI if dx
questionable
 Nondisplaced cast
 Displaced Tension
band or excision and
tendon repair

AVULSION OF TIBIAL TUBERCLE
 Tibial tubercle is anterior
and distal extension of
proximal physis
 Age 13-16 yo
 typically just prior to
physeal closure
 Classification
 Type I – through distal
ossification center
 Type II – through jxn.
tubercle and tibial centers
 Type III- involves articular
surface

AVULSION OF TIBIAL TUBERCLE
 Treatment
 Closed only for
nondisplaced
 ORIF to achieve
anatomic reduction
 Type III injuries
restore articular
congruity
 Complication
 Compartment
syndrome- anterior
tibial recurrent artery
 Growth arrest- rare

Tibial Eminence Fracture
 Avulsion of ACL
 Age 8-14 yo
 Hyperextension or
direct blow
 May have ACL stretch
with fracture  mild
residual instability
 Meniscus (medial)
may block reduction
 Loss of extension
biggest complication

Classification
 Meyers and McKeever
 Type I – Minimally displaced
○ Immobilize in cylinder cast 4-6 wks
 Type 2 – Displaced and hinged
posteriorly
○ Attempt casting with 10-20 degrees
flexion to reduce fragment
○ Internal fixation if closed reduction
fails
 Type 3 – Completely displaced
○ Internal fixation

Surgical Fixation

 Surgical Treatment
 Open or arthroscopic
 Small intraepiphyseal screws (rarely possible)
 Suture through or around fragment using ACL
tibial guide tied over anterior tibia
 Over-reduce slightly to combat ACL stretch and
loss of extension
 Early ROM with stable fixation
 Excision and ACL reconstruction if unable to
reduce or fix or if residual instability due to
stretch

Etiology
 Forceful muscle
contraction during
eccentric loading
 Point of failure at
site of apophysis
rather than muscle-
tendon junction

Displaced fracture AIIS – Rectus femoris

AVULSION FRACTURE
Hip/Pelvis
 Treatment: Rest, crutches for 2 weeks,
progressive rehabilitation to return to
sports activity; position extremity to
relax involved muscle group
 Progressive rehab program
 Complete healing in 6 weeks-several
months
 Ischial Tuberosity - Open reduction and
internal fixation of large fragments
displaced more than 2 cm

Introduction
 Overuse injuries are very common in
pediatric/adolescent population
 Etiologies vary but physiology is
unchanged
 Overload or repetitive microtrauma strains the
musculotendinous unit until its unable to
withstand additional loading
 Continued stress  collagen cross-links break
 shear forces cause the collagen fibril to slide
 Overload at tendon insertion site =
Apophysitis
 Overload on bone  stress fracture

Stress Fractures
 Practical causes
 Sudden increase in
intensity
 Multiple high intensity
work-outs without rest
 Poor footwear
 Lack of arch support
 Improper fitting shoes
 Biomechanical factors
related to training
surfaces
 Pavement vs trails

High Risk Stress Fractures
 Tension side of
femoral neck
 Patella
 Medial malleolus
 Tibia diaphysis
 Talar Neck

Tibial Stress Fractures
 Discontinuation of inciting activity
 Rest, ice, limited weight bearing, NSDAIDs
 If no relief in 2-4 weeks, consider NWB
or cast treatment
 Slow resumption of activity
 Cross-training
 Gradual resumption of sport
 May take 8-16 weeks for full training

Stress Fractures
 Femoral neck stress
fractures
 5-10% of all stress
fractures
 Runners and military
recruits
 Compression sided
fractures =
Conservative Tx
 Tension sided fractures
= ORIF
 Address BEFORE
displacement can be
catastrophic in young
person

APOPHYSEAL CONDITIONS
 Osgood-Schlatter
 Sinding-Larsen-Johansson
 Sever’s Disease
 Iselin’s Disease

Pathophysiology
 During the rapid growth surrounding
puberty
 apophyseal line appears to be weakened further
because of increased fragility of calcified
cartilage.
 Microfractures are believed to occur because of
shear stress leading to the normal progression of
fracture healing
 Clinical picture and the radiographic
appearance of resorption, fragmentation,
and increased sclerosis leading to eventual
union

APOPHYSEAL CONDITIONS
Osgood-Schlatter
 Separately described by Osgood and
Schlatter in 1903
 Age of onset in boys 10 – 15 & girls 8 – 13
 Traction apophysitis of the tibial tubercle
caused by repetitive microtrauma from a
contracting extensor mechanism
 Incidence as high as 20% in athletic
children
 ~5% in non-athletic population
 Occurs bilateral in 20 to 30% of cases
 Most common in basketball, volleyball,
soccer, and gymnastics

Osgood Schlatter
 Symptoms
 Acute Phase
 Pain and tenderness over tibial tubercle
 Pain accentuated with palpation and resisted
knee extension
 Localized edema, warmth
 Pain increased with squatting, jumping
 Healed phase
 Asymptomatic Anterior knee mass
 10% adults remain symptomatic due to
secondary ossicle formation
 Pain can be associated with increased activities

APOPHYSEAL INJURY
Osgood-Schlatter
 Radiographic
Findings
 Prominence of the
tibial tubercle
 Fragments of
secondary
ossification center of
tibial tubercle may be
displaced slightly
anteriorly and
superiorly

APOPHYSEAL INJURY
Osgood-Schlatter
 Treatment:
 Reassurance
 Many able to tolerate mild symptoms and continue play
 Typically spontaneous resolution with closure of the
physis; though may have residual tenderness with
kneeling
 Pad or cho-pat strap may be helpful
 Ice/NSAIDS
 Quadriceps and hamstring stretching
 Restriction of activities
 If painful after physeal closure, may be ossicle that is
symptomatic
 May predispose to risk of tubercle avulsion

Sinding-Larsen-Johansson
Syndrome
 Anterior knee pain at distal pole of
patella from
 pull of the quadriceps extensor
mechanism on an apophysis
 Common in boys ages of 11-13 yrs
 Symptoms
 Aggravated by
 Running
 jumping
 stair climbing
 kneeling
 Irregular areas of ossification that
coalesce and incorporate into the
patella.
 Rarely, a separate ossicle persists
that may remain symptomatic

APOPHYSEAL INJURY
Sinding-Larsen-Johansson
 Differential Diagnosis:
 Patellar tendonitis
 Patella fracture
 Sleeve fracture of patella
 Treatment:
 Self-limited disease
 Spontaneous resolution in 12
– 18 months
 Reassurance
 Modification of activities
 Ice/NSAIDS
 Lower extremity stretching
program (quadriceps,
hamstrings, and heel cords)
 Patella knee sleeve

Severs Disease
 Inflammation of calcaneal
apophysis
 Described by Sever in 1912
 Age
 9-10 yrs
 Sex
 Males most commonly
 Bilateral 60% +
 Symptoms
 Posterior heel pain
aggravated by running &
jumping activity
 Diff DX: calcaneal stress
fracture

APOPHYSEAL INJURY
Sever’s Disease
 Treatment:
 Self limited
 No long term sequelae
 Heel cord stretching/strengthening
 Heel cups or shock-absorbing inserts
 Responds well to therapy, usually able to
return to sports in 6 - 8 weeks
 Differentiate from calcaneal stress fracture
(medial lateral compression test)

Iselin’s Disease
 Inflammation at apophysis of 5th
metatarsal
 Seen commonly in soccer, basketball,
gymnast and dancers
 Age 8-13 yrs
 Painful lateral border of foot
 May walk on medial border of foot
 Improves with rest, activity
modification

Hip & Pelvis Apophysitis
 ASIS
 Sartorius
 AIIS
 Rectus femoris
 Ischial tuberosity
 Semitendonosis
 Biceps femoris
 Treatment
 Rest, Activity Modification, Stretching

Physeal Injury In Throwers
Little Leaguer’s Shoulder
Little Leaguer’s Elbow

PHYSEAL INJURY
 First described in 1953 by Dotter
 Described in literature as
 osteochondrosis of the proximal humeral epiphysis
 proximal humeral epiphysiolysis
 stress fracture of proximal humeral epiphyseal plate
 rotational stress fracture
 Typically males, 12 - 15 years of age
 Average duration of symptoms before treatment is
approximately 7 months
 Associated with quantity and intensity of pitching,
age at which pitching started

PHYSEAL INJURY
 Chief complaint:
 Pain localized to the proximal humerus
during the act of throwing
 Occurs during various phases of throwing
 Gradual onset of pain
 Usually no inciting event
 Playing ability diminishes with pain
 Loss of velocity

PHYSEAL INJURY
 Clinical Findings:
 Tenderness proximal humerus / shoulder
 Weakness in external rotation
 Pain with resisted internal rotation
 Rarely swelling
 Normal strength and ROM
 Radiographs: AP external rotation
 Widening and irregularity of proximal
humeral physis
 Metaphyseal fragmentation
 Comparison views helpful
 Demineralization of metaphysis
 Sclerosis of metaphysis
 Bone scan may be normal

PHYSEAL INJURY
 Treatment:
 Rest from throwing 6 weeks to 3
months on average
 May be up to 1 year
 If asymptomatic, may begin
throwing program
 Widened proximal humeral physis
seen radiographically can take
several months to remodel
 Some recommend non-pitching
position until physis closes
 Monitor mechanics
 No known long term sequelae

PHYSEAL INJURY
 Describes group of injuries due to
valgus throwing stress
 Medial epicondyle apophysitis
 Medial epicondyle avulsion fx
 OCD Capitellum/Panner’s dz
 Olecranon apophysitis
 Radial head osteochondrosis

PHYSEAL INJURY
 Initially used in 1960 by Brodgon and Crow
 Most common in 9 to 14 y/o
 Injuries on medial elbow primarily occur during the
acceleration phase of throwing
 Strong contraction of the flexor-pronator muscle
attachments as the arm is started forward
 Valgus moment with throwing
 Lateral side- compression at radiocapitellar joint
 Medial side- traction at epicondyle and UCL
 Posterior shear

PHYSEAL INJURY
 Chief Complaint:
 Location of pain
○ Deep or lateral – capitellar OCD
○ Medial – tension problems
 Onset of pain
○ Abrupt – avulsion of medial epicondyle,
epiphyseal fracture, or UCL injury
○ Gradual – Lateral compression with OCD
capitellum or radial head osteochondrosis
○ Abrupt with locking - OCD

PHYSEAL INJURY
 Clinical Findings:
 Tenderness over medial epicondyle
 Hypertrophy of medial epicondyle
 Flexion contracture
 Valgus deformity
 Radiographic Findings
 Typically normal
 May reveal widening of medial epicondyle
apophysis, fragmentation of medial epiphysis,
capitellar OCD

PHYSEAL INJURY
 Treatment
 If apophysis not significantly displaced:
○ Rest 2 - 3 weeks
○ Isometric strengthening, stretching, resistive
strengthening
○ Gradual return to throwing after 6 - 12 weeks
 Throwing program
○ Good prognosis with rest
○ If pain returns  out until next season

Medial Epicondyle Avulsion
 Forceful throwing acute injury
 Tension from UCL and pull by flexor-
pronators
 Nondisplaced and stable
 Cast 2-3 wks
 Begin ROM and gradual return to activity
 ORIF indications – Cannulated screws
 Displaced fragment (? 5mm - ? Less in throwers)
 More aggressive with throwers
 Instability
 Incarcerated fragment
 Ulnar nerve dysfunction

Panner’s disease
 Younger age < 4-8 yo
 Osteochondrosis of capitellum
 Comparable to Legg-Calve-Perthes
 Irregular ossification center
 Self limiting
 Loose bodies rare
 Complete resolution with reconstitution
of capitellum

OCD Capitellum
 Fragmentation of
subchondral bone
 Adolescent age > 10
yo
 Repetitive
compression may
disturb blood
supply
 Entire blood supply
from posterior
aspect of humerus
 No collateral flow

OCD Capitellum
 Pain with throwing
 Tender at
radiocapitellar joint
 10-20 degree flexion
contracture
 Early detection
crucial
 MRI helpful
 May prevent
progression with
activity change

OCD Capitellum
 X-rays – Irregular ossification center
 Rarefaction within a crater
 Loose bodies
 MRI – may help locate loose bodies
 Define OCD lesion

OCD Capitellum
 Treatment
 Rest, Ice, NSAIDs
 Gradually begin ROM and strengthening
when pain subsides
 Interval program for return to activity when
strength and ROM normal 3-6 months
 Many delay until following season
 Evaluate/change throwing technique
 Position change- away from
pitching/catching
 Guarded prognosis - DJD

OCD Capitellum
 Surgical Indications
 Persistent pain
 Symptomatic loose body
 Locked elbow
 Elbow Arthroscopy
 Remove loose bodies
 Debridement to healthy subchondral bone
 May consider OATS for noncontained defects
 Guarded prognosis – worse for noncontained
*Osteochondritis Dissecans of the Capitellum: Current Concepts David E.
Ruchelsman, MD, Michael P. Hall, MD and Thomas Youm, MD
J Am Acad Orthop Surg, Vol 18, No 9, September 2010, 557-567.

Slipped Capital Femoral Epiphysis
 Slippage through the
hypertrophic zone of
physis
 Femoral head remains
reduced
 Neck displaces
anterosuperior & external
rotation
 Etiology
 Idiopathic – most common
 Endocrinopathy
 Renal failure
 Prior radiation therapy

SCFE
Epidemiology
 Obese
 Positive FH
 African American
 Boys 60% , Girls
40%
 Mean age at onset
 Boys 13.5yo
 Girls 12yo
 18-63% Bilateral

SCFE
Presentation
 Hip, thigh, or knee
pain
 Limited internal
rotation
 Out-toeing gait
 Initial pain may be
vague
 Key to classification
is the ability of the
child to ambulate

SCFE
Classification - Loder
 Stable – Able to weight bear
with or without crutches
 None developed osteonecrosis
 Unstable – Unable to weight
bear without crutches
 Up to 50% developed
osteonecrosis
○ *Slipped Capital Femoral Epiphysis: Current
Concepts David D. Aronsson, MD, Randall T. Loder, MD,
Gert J. Breur, DVM, PhD and Stuart L. Weinstein, MD . J
Am Acad Orthop Surg, Vol 14, No 12, November 2006,
666-679
Old description
acute and
subacute!

SCFE
Radiographic Evaluation
 AP and frog leg
 Loss of lateral
overhang of ossific
nucleus (Klein’s line)
 Varus appearance

SCFE
Treatment
 In situ pinning
 Avoid forceful reduction
– AVN
 Percutaneus with one or
two 6.5 screws
 Start anterior on neck
and aim at center of
head
 Goal – physeal closure,
prevent further slippage
 Osteotomy – late for
residual
deformity/AVN
 Roll for ORIF??

SCFE
 Atypical patients
 age <11
 small size  Endocrine workup
 Prophylactic pinning contralateral hip
controversial
 usually for age < 11 or endocrinopathy
 RTP delayed until after physis begins
closure & patient asymptomatic
 Screw removal controversial in athletes

SCFE
Complications
 Osteonecrosis
 Chondrolysis
 DJD
 Pistol grip
deformity
 Subtrochanteric
femur fracture

SPONDYLOLYSIS
 Spondylos = Vertebra
Lysis = Break
 Defect in the pars
interarticularis without
displacement of
vertebral bodies
 Incidence of
spondylolysis: 4 - 6%
 Most often L5 level
(up to 95%)
 2-4 times more common
in men

SPONDYLOLYSIS
Pathophysiology
 Caused by repetitive
microtrauma to the
spine
 Repetitive extension
and rotation
 Continuum of
disease from stress
reaction to
spondylolytic defect
 Most commonly
unilateral

SPONDYLOLYSIS
 High risk Sports
 Gymnastics
 Diving
 Football
○ Interior linemen
 Rowing

SPONDYLOLYSIS
 Differential Diagnoses
 Lumbar disc herniation
 Spondylolisthesis
 Intervertebral diskitis (fever, elevated ESR)
 Osteoid osteoma (night pain, pain relieved with
NSAIDs, abnormal scan)
 Spinal cord tumor (sensory findings, upper motor
neuron signs)
 DDD

SPONDYLOLYSIS
 Clinical Presentation
 Insidious aching back pain exacerbated by
strenuous activity with occasional radiation to
the buttocks
 Rising to an upright posture against resistance
elicits pain
 Pain exacerbated by hyperextension & rotation
 Hamstring tightness in 80% of patients
 Tenderness in lumbar spine to palpation and
percussion

SPONDYLOLYSIS
 Radiographic Findings:
 Stress reaction = sclerosis without radiolucency
 Spondylolytic defect = sclerosis with radiolucency
 A thickening or stress reaction of the pars may be
visible on a lateral or oblique radiograph 3 to 6
weeks after development of back pain
 Lateral x-ray reveals 80% (most sensitive)
 Oblique an additional 15% - neck of Scottie dog (most
specific )

SPONDYLOLYSIS
 Bone Scan with SPECT: increased uptake at the
area of the pars interarticularis
○ SPECT can miss chronic injuries
 SPECT (single photon emission computed tomography)
 MRI: Best to rule out disc herniation and nerve
root compression in pt’s with neuro deficits
 CT: Best to identify bony anatomy
○ Must order thin slices (3 mm)
 SPECT or CT scan best to identify if x-rays
negative

SPONDYLOLYSIS
 Treatment:
 Asymptomatic athlete – Observe and allow full
participation
 Symptomatic
○ Stress Reaction – Acute process with the ability to
heal
 Brace immobilization TLSO 6-12 weeks or until
asymptomatic followed by PT and return to sport
○ Spondylolytic defect – no potential for healing
 Treatment goals are pain relief and increased flexibility
 Physical therapy and activity restriction
 Rarely TLSO for 6-8 weeks

SPONDYLOLYSIS
 Surgical Intervention
 Considered for patients with
stress reactions or
spondylolytic defects that have
failed 6-12 months of
conservative Tx
○ L1-L4 – Direct repair of the
spondylolytic defect
○ L5 – L5-S1 Posterolateral
fusion vs. Direct repair

SPONDYLOLISTHESIS
 Olisthesis = movement
 Refers to slipping
forward of one vertebra
on the next caudal
vertebra
 Most common L5-S1
 Classification by Wiltse

SPONDYLOLISTHESIS
 Meyerding
Classification
 Grade 1 = 1-25% slip
 Grade 2 = 26-50% slip
 Grade 3 = 51-75% slip
 Grade 4 = 76-100% slip
 Grade 5 =
spondyloptosis

SPONDYLOLISTHESIS
 Etiology is unknown except in traumatic
types
 Incidence 4.4% at 6yo & 6% at 18yo
 Higher incidence in males
 Natural History
 Harris et al – 18 yr f/u Meyerding Grade 3&4
○ 36% asymptomatic
○ 55% occasional back pain
○ 45% neurologic symptoms
 Beutler et al – 45 yr f/u Meyerding Grade 1&2
○ Followed a course similar to general population

SPONDYLOLISTHESIS
 Presentation
 Back pain
 Hamstring tightness
 “Pelvic waddle” gait
 Limited Lumbar ROM
 Occurrence usually by 4-6 yo
 May become symptomatic at any age

SPONDYLOLISTHESIS
Treatment
 Asymptomatic slips observed
 Avoid repetitive activity
 Patients with asymptomatic 30% slip can
play contact sports and be followed for
progression

SPONDYLOLISTHESIS
Treatment
 Low Grade (I-II)
 Usually nonoperative
 Activity modification and PT
 Grade I may return to contact sports when
asymptomatic
 Grade II restricted from football and gymnastics
 Progression rare
 X-ray f/u q 6 mo x 2yrs then yearly to maturity
 Surgery for failure conservative or documented
progression – in situ fusion
○ R/O other causes LBP – tumor, infx, HNP

SPONDYLOLISTHESIS
Treatment
 High Grade (III-V)
 May have radiculopathy or cauda equina
 L5-S1 causes L5 radiculopathy
 Children recommend prophylactic fusion
 Often need L4-S1
 Decompression/nerve exploration for
neurologic symptoms
 Reduction controversial – monitor L5
 *Spondylolysis and Spondylolisthesis in Children and Adolescents: I.
Diagnosis, Natural History, and Nonsurgical Management: Ralph Cavalier,
MD, Martin J. Herman, MD, Emilie V. Cheung, MD and Peter D. Pizzutillo, MD.
J Am Acad Orthop Surg, Vol 14, No 7, July 2006, 417-424

Conclusions
 Many injuries seen in adolescents are
unique to this age group
 Physeal injuries
 Apophyseal injuries
 Some injuries occur in adults as well
 Stress fractures
 Spondylolysis/spondylolisthesis

Injuries Unique to the Adolescent Athlete - Westchester Health Pediatrics

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Injuries Unique to the Adolescent Athlete - Westchester Health Pediatrics