Disclosures Head to Toe: Common Sports Injuries in Kids

Transcription

1 Disclosures Head to Toe: Common Sports Injuries in Kids None R. Jay Lee MD Director Pediatric Orthopaedic Fellowship Assistant Professor Pediatric Orthopaedics Johns Hopkins / Bloomberg Children s Objectives Describe prevention strategies for patients before an injury Manage the acute pediatric sports injury, workup, and initial treatment Explain the concepts behind returning a young patient to sports and activity Prevention The Pre-Injury Approach Describe prevention strategies for patients before an injury for the Pediatric Athlete Counseling Cross Training Pre-season Physical Warm Up Rest Healthy Diet Hydrating Variety of Sports Protective Equipment Proper Technique Recognize injury and Address Counseling Guidance from parents, coaches, and the medical team Reinforcing healthy participation in sports 1

2 Cross Training Be active in a variety of things Mix up your routines and your activities Recommendation: do not participate in one sport year round Sports Physical - Musculoskeletal Body habitus Neck ROM Shoulder: shrugs, abduction to 90, internal and external rotation. Forearms: supinate, pronate Hands: open, close, spread, look for deformities Lower extremity: duck walk, toe and heel walk Knees: ROM and patellar tracking. Spine toes to check for scoliosis. Warm Up For injury prevention Both static and dynamic stretching Proper Rest Between Events or Sports Lack of sleep predisposes to injury Muscle fatigue predisposes to injury Plan an off season Maintain a Healthy and Well Balanced Diet Disordered Eating Supplements Steroids Stay Hydrated, Especially in the Summer Heat Illness 2

3 Enjoy a variety of sports, do not specialize too early Over use injuries Wear proper and well fitting protective equipment Helmets Pads Shoes Emphasize proper technique in all activities Concussion and tackling Throwing Recognize injury and respond in a timely manner Pain free participation Acute Pediatric Sports Injuries Chronic or Overuse Injuries Manage the acute pediatric sports injury, workup, and initial treatment Explain the concepts behind returning a young patient to sports and activity Characteristics / Symptoms Can present acutely +/- Acute trauma/injury Pain increases with activity Recurrent swelling Changes in form or technique Decreased interest in activity 3

4 Chronic or Overuse Injuries Little Leaguer's Shoulder Found Everywhere Arm Thrower s Shoulder of Proximal Humeral Physis Thrower s Elbow of Medial Epicondyle of Distal Humerus Gymnast s Wrist of Distal Radius Leg Traction Apophysitis involving Patella and Achilles Proximal Humerus Growth Plate Injury Common adolescent pitchers Repetitive Microtrauma Torque, Breaking Pitches Little Leaguer's Shoulder Little Leaguer's Shoulder Pain with throwing, velocity and control loss Pain to palpation over growth plate Widening of growth plate Treatment Rest 2-3 months no pitching with widening Physical Therapy, stretching/motion, RC muscles, core, scapulo-thoracic conditioning Slow Progression to Full Return Little Leaguer's Elbow Little Leaguer's Elbow Medial sided elbow injury Growth Plate Injury Apophysitis, avulsion More Common Adult Pattern Injury UCL strain/tear Repetitive Microtrauma Breaking Pitches Pain with throwing, velocity and control loss Pain along medial elbow, pain with stress of elbow Widening of physis 4

5 Little Leaguer's Elbow Little Leaguer's Elbow Treatment Rest 2-3 months no pitching Physical therapy Slow Progression Prevention Mechanics, pitch counts, no breaking balls Treatment Rest 2-3 months no pitching Physical therapy Slow Progression Prevention Mechanics, pitch counts, no breaking balls Prevention of Thrower s Injuries - Mechanics and Form Prevention of Thrower s Injuries - Pitch Counts Prevention Proper mechanics, pitch counts, no breaking balls Gymnast s Wrist Distal Radius Physeal Stress Syndrome Distal Radius Growth Plate Injury Common in gymnasts Repetitive Microtrauma Use of joint for weight bearing Gymnast s Wrist Distal Radius Physeal Stress Syndrome Wrist Pain Pain to palpation radial wrist Swelling and possible limit to ROM Widening of growth plate Chronic, physeal closure, positive ulnar variance 5

6 Gymnast s Wrist Distal Radius Physeal Stress Syndrome Treatment Rest 3-6 months NSAIDS Slow Progression to Full Return Surgical Resection of Physeal Bars Ulnar shortening osteotomy Traction Apophysitis of the Lower Leg Due to repetitive pull of a tendon Inferior Patella / Sinding Larsen Johansson Proximal Tibia / Osgood Schlatter Calcaneus / Sever s Pain over a growth center or tendon insertion Pain stops with growth plate closure Patellar Tendon Related SLJ and Osgood Traction Apophysitis Inflammation at a patellar tendon attachments Stress from extensor mechanism / patella tendon Jumpers (basketball, volleyball), Sprinters Patellar Tendon Related SLJ and Osgood Pain with palpation, with stretch of tendon Irregularity and fragmentation Rule out other diagnoses X-ray not diagnostic Patellar Tendon Related SLJ and Osgood Rest NSAIDs, Ice, Activity Modification Straps PT for stretching Sports when pain controlled. Inflammatory Osteochondritis Dissecans Quadriceps Tendonitis 6

7 Acute Pediatric Sports Injuries Manage the acute pediatric sports injury, workup, and initial treatment Explain the concepts behind returning a young patient to sports and activity Acute Injuries: Shoulder Dislocations Young athletes have a high tendency to have recurrent dislocation Surgery If associated bony, soft tissue pathology on MRI Consider for collision sport athletes nearing skeletal maturity High Incidence of Recurrence 12 years old High Incidence of Recurrence 16 years old Acute Injuries: Shoulder Dislocations Xrays to confirm reduction of dislocation Shoulder AP and Axillary view Rest and Immobilization Physical therapy Strengthen dynamic stabilizers Referral Especially for collision sport athletes nearing skeletal maturity Recurrent dislocations Acute Injuries: Elbow Injuries 7

8 Acute Injuries: Elbow Injuries Acute Injuries: Elbow Injuries Monitor Near full ROM Look for limited flexion for nursemaids, or occult fracture Xrays normal Look for a fat pad sign Rest and Immobilization Posterior splint and follow up in 1 week. Repeat xrays if tender Fat pad sign Suggests hemoarthrosis or effusion Normal Elbow Injury Acute Injuries: Wrist Injuries Acute Injuries: Wrist Injuries Monitor Near full ROM Xrays normal Rest and Immobilization Cock up wrist brace or resting splint and follow up in 1 week. Repeat xrays if tender Occcult fractures, scaphoid Scaphoid Fractures Uncommon, but often hard to visualize Acute Injuries: Wrist Injuries Scaphoid Fractures Uncommon, but often hard to visualize Acute Injuries: Hip / Pelvis Injuries Clinical exam can help localize pain Look out for knee pain, that is hip pain Log roll of leg, internally and externally rotate Xrays AP and lateral of the hip Injury 2 months 2 months 8

9 Acute Injuries: Hip / Pelvis Injuries Xrays AP and lateral of the hip SCFE can be missed on single AP views Acute Injuries: Hip / Pelvis Injuries Normal Pelvis Avulsion Fracture Pelvis Avulsion Fracture Acute Injuries: Hip / Pelvis Injuries Pelvis Avulsion / Hamstring Rest 3-4 weeks Crutches for pain free ambulation No sports Stretching and rehab with PT for return to activities Acute Injuries : Knee Injury Monitor bumps and bruises Get better with time Can have focal swelling Acute Injuries : Knee Injury Acute Injuries : Knee Injury Refer Mechanical symptoms: catching, locking, giving way, buckling Ligament tears Swelling, Mechanical symptoms Meniscal tears +/- swelling, mechanical issues Chondral injuries swelling, mechanical issues OCD early, ongoing pain without relief Differential Ligament injury (ACL, PCL, MCL, LCL) Patellar Dislocation Bony/cartilage Fracture Meniscus Tear 9

10 Acute Injuries : ACL Tear and Reconstruction Acute Injuries : ACL Tear and Reconstruction Previous Concepts Skeletally immature, so delay surgery until growth completed Activity Modification and Bracing More meniscus and cartilage damage present at time of delayed ACL reconstruction Acute Injuries : ACL Tear and Reconstruction 17 year old 10 year old Acute Injuries : ACL Tear and Reconstruction Adult ACL Reconstruction Acute Injuries : ACL Tear and Reconstruction Adult ACL Reconstruction Tunnels cross open growth plates Acute Injuries : ACL Tear and Reconstruction Current Concepts Avoid delay in ACL reconstruction in active individuals Growth plates disruption can be minimized but patients are followed until maturity 10

11 Current Treatment Options Pediatric ACL Reconstruction Tunnels spare open growth plates Acute Injuries : ACL Tear and Reconstruction Acute Injuries : Osteochondral Fracture and Repair Acute Injuries : Osteochondral Fracture and Repair Osteochondral Fractures Repair aggressively in anticipation of greater healing capacity than in an adult Acute Injuries : Meniscus Tear Acute Injuries : Tear of Discoid Meniscus Younger patients 10 years and younger Injury to abnormal meniscus Repair aggressively in anticipation of greater healing capacity than in an adult Older patients 10 years and older Injury to normal meniscus Discoid Normal 11

12 In Between: OCD Osteochondritis Dissecans or OCD Osteochondritis Dissecans Osteochondritis Dissecans Disease of the bone and cartilage Repetitive microtrauma in an area with poor blood supply Softening of cartilage Cartilage separation Detachment of Cartilage and Bone Elbow: gymnasts, pitchers Knee Ankle: recurrent sprains Pain Vague pain in joint, activity related Swelling, stiffness Catching, locking symptoms late signs (loose cartilage) Osteochondritis Dissecans Normal Knee Knee include Notch View Advance imaging MRI 12

13 Osteochondritis Dissecans In Between: Osteochondritis Dissecans Referral Early: Rest, activity modification Late: Surgery Prognosis best when growth plates widen open Acute Injuries : Ankle Sprains (physeal fracture?) Ankle sprains Most common reason for missing sport Tear of ankle ligaments Acute Injuries : Ankle Sprains (vs physeal fracture) Twist, roll, turning mechanism Pain over the lateral ankle Sprain >>> growth plate injury Acute Injuries : Ankle Sprain (vs physeal fracture) Rule Out Fracture AP/Lat/Mortise Ottawa Ankle Rules? Acute Injuries : Ankle If ankle sprain RICE Walking boot, walking cast, calm shell orthosis Home exercise vs physical therapy for strengthening, proprioception, functional brace 13

14 Acute Injuries : Fracture Acute Injuries : Fracture Often definitive for fracture if growth plates closing or closed Often definitive for fracture if growth plates closing or closed Acute Injuries : Fracture Acute Injuries : Ankle Often inconclusive if growth plates open If likely fracture or unsure Immobilize in splint, walking cast or boot Repeat radiographs in 10 days to look for signs of healing fracture Sever s Disease Sever s Disease Traction Apophysitis on Heel Stress from Achilles tendon, microtrauma Running and jumping sports Pain directly over posterior calcaneus, with stretch of Achilles, tight Achilles 14

15 Sever s Disease Sports Injuries Not Required Rest NSAIDs, Ice, Activity Modification Heel Cups PT for stretching Sports when pain controlled. Key for all is rest and gradual return to activity when symptom free Sports Injuries Thank You RLee74@jhmi.edu A safe return to sports post injury: Rest and recover Wait until pain free Rebuild motion, strengthen, function Increase gradually intensity, duration 15