Will She Still Make the WNBA? Sports Injuries & Fractures

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1 Will She Still Make the WNBA? Sports Injuries & Fractures Aharon Z. Gladstein MD Pediatric Orthopaedic Surgery Pediatric Sports Medicine Sports Injuries Chronic (overuse) Acute Who can be treated in PCP office Who needs to be referred Bad actors we can t miss 1

2 30 million Epidemiology children participate in organized sports in the U.S. 10+ office visits per million 3sports injuries per year in U.S. 70% from million youth sports Pediatrics 2001 year from injuries ~¼ of all injuries 2

3 Benefits of Youth Sports Washington et al. (Pediatrics 2001) Physical activity present/future Acquire motor skills Teach goal setting Learn social skills Good sportsmanship Have fun Enhance bone geometry Trends in Youth Sports Participation National Council of Youth Sports million 6-18 y/o children participate in organized athletics 44 million participate in more than one sport Most do not limit their participation to one season but participate year round Sports specialization starts at a very young age 3

4 Why is the Immature Skeleton at Risk? Increased susceptibility of immature skeleton to repetitive stress Physeal plate injury Apophyseal cartilage injury Biomechanical differences in stress Bone quality decreased during rapid growth Adaptations to repetitive stress with growth Muscular tightness and imbalance Physeal Nomenclature Diaphysis Shaft (thick cortices) Metaphysis shaft side of the physis adjacent to the physis (flare and thinned cortical bone) Epiphysis End of the long bone Physis growth plate Apophysis ossification center at site of muscular or ligamentous insertion 4

5 Apophys itis Chronic repetitive distractive force Damage accumulates Widening of the physis More susceptible to acute injury Sports Injury Types Acute Injury Single supramaximal stress Can be contact or non-contact injuries Chronic Injury (Overuse) Microtrauma Repetitive submaximal stress Not enough rest }CUMULATIVE Can t remember when it started 30-50% of pediatric sports related injuries 5

6 Prevalence of Overuse Injuries Little quality research on the incidence or prevalence of overuse injuries in children and adolescents Overuse injuries represent about 50% of all injuries Prevalence likely underestimated in the literature DiFiori et al. Overuse Injuries and Burnout in Youth Sports. Clin J Sport Med 2014;;24:3-20 Imaging Need an x-ray Acute effusion Bony asymmetry Unable to bear weight Not resolving Parental/Physician reassurance Need an MRI Almost never as first line Mechanical block to motion 6

7 Shoulder Overuse Little Leaguer s Shoulder Multidirectional instability Acute Fracture Dislocation Thrower s Shoulder aka Little Leaguer s Shoulder Epiphysiolysis Proximal Humerus Etiology: Repetitive torsional stress, widening of the physis Treatment Activity restriction Gradual return to throwing Adherence to pitch counts 7

8 Little Leaguer s Shoulder Pain with throwing Tender at proximal humerus Xray Widened growth plate Txt No throwing 3 months Growth deformity rare Limit pitching Multidirectional Instability Shoulder dislocation without acute event Multiple subluxations Spontaneous reduction +/- pain Cool trick Common in swimmers 8

9 Multidirectional Instability Can pop shoulder in and out on command Doesn t hurt Diffuse ligamentous laxity Systemic Collagen disorder? History of trauma? Treatment PT muscle strengthening Acute Shoulder Injury Fracture Refer Sling until pain-free Rarely needs surgery Amazing remodeling capability 9

10 Acute Shoulder Injury Dislocation Refer Acute injury Traumatic Severe pain +/- spontaneous reduction Internal derangement Redislocation common Surgery Elbow Overuse Injuries Medial Epicondylitis Capitellar Osteochondritis Acute Injuries Medial epicondyle avulsion Elbow dislocation rare 10

11 Thrower s Elbow / Medial Epicondylitis aka Little Leaguer s Elbow Apophysitis medial epicondyle Medial epicondyle MUCL Flexor Pronator origin Thrower s Elbow / Medial Epicondylitis Valgus stress at the elbow close to ultimate strength of MUCL during throwing Risk Factors Year-round baseball Tournament play Multiple leagues Over pitch counts Poor biomechanics (pitching technique) Shoulder tightness / GIRD 11

12 Capitellar Osteochondritis Throwers Valgus-extension overload Lateral elbow compressive force Repetetive microtrauma Avascular necrosis Loose body Too much throwing Not enough rest Capitellar Osteochondritis Hurts to throw Lateral elbow pain/tenderness Popping +/- swelling X-ray fragmentation Txt Rest, PT, NSAID Referral if locking 12

13 Acute Elbow Injury Medial Epicondyle Avulsion Acute injury while throwing Fracture through growth plate Often acute event after chronic overuse Pop Severe pain/swelling X-ray fracture Refer cast vs surgery Knee Overuse Patellofemoral syndrome Osgood-Schlatter Sinding-Larson-Johansson Syndrome Osteochondrits Dessicans Acute ACL tear Meniscal tear Tibial Tubercle Avulsion Growth plate fracture 13

14 Patellofemoral Syndrome Anterior knee pain Extremely common! Running, jumping, squatting Patellofemoral articulation Cartilage, synovium, muscle, bone Lower extremity malalignment Valgus Rotational Patellofemoral Syndrome Spectrum Normal alignment, pain Txt Rest, PT, refer if recalcitrant Patella Maltracking Txt Rest, PT refer if recalcitrant Patella Dislocation Txt Brief immobilization, PT surgery if recalcitrant 14

15 Osgood Schlatter Tibial Tubercle apophysitis Most common overuse injury in knee Traction Inflammation at tendon-bone interface Pre-teen age Osgood-Schlatter s Disease Radiographs: Widening or fragmentation of tibial tubercle apophysis Treatment Activity restriction Stretching (quads, hams, heels) PT for hip & core strengthening Will get better eventually 15

16 Osgood-Schlatter Swelling + pain at tibial tubercle Tenderness to palpation No joint effusion Tight hamstrings/quads Xray prominent tibial tubercle Txt Rest, PT for stretching Symptoms resolve with growth plate closure Normal growth plate Bump does not go away Sinding Larsen Johansson Synd Apophysitis of Inferior pole of patella Same mechanism as O-S Pain/Tenderness at bottom of patella Swelling but no effusion Xray - +/- fragmentation Txt Rest, PT for stretching 16

17 Osteochondritis Dessicans Fragment of bone and cartilage partially or completely separates from joint Etiology: Overuse? Pain + swelling +/- locking Xray - fragmentation Acute Knee Injuries Knee instability Patellofemoral Tibiofemoral Swelling Acute event X rays to rule out fracture and confirm joint effusion Refer for evaluation 17

18 Acute Knee Injuries: Physeal Fractures Present like ligamentous injuries Critical not to miss Often require immobilization or surgery Proximal tibia or distal femur Pain can be acute or chronic May present as hip or knee pain Critical not to miss Must get lateral x ray SCFE Proximal femur physeal injury Can be acute or chronic (or both) May present with hip or knee pain Can progress if diagnosis or treatment delayed Lateral x-ray critical for dignosis 18