Apply this knowledge into proper management strategies and referrals

Transcription

1 1 2 3 Lower Extremity Injuries Jason Kennedy, M.D. Disclosures I have no financial/ industry disclosures. Objectives Identify common lower extremity injury patterns in the child and adolescent Apply this knowledge into proper management strategies and referrals Explain how to prepare initial response to common injuries in the school or trainer setting Lower Extremity Injuries Minor Sprains - liagament injuries Strains - muscle injuries Overuse Simple Fractures Major Fractures Requiring a Cast Fractures Requiring Surgery Initial Management Check for associated injuries Head, neck, chest, abdominal, etc. Depends on mechanism Identify extremity Determine if a wound is present (open fracture) apply a clean dressing as soon as possible Stabilize the extremity, if able EMS helpful for femur fractures Overuse Injuries Lower Extremity Osteochondroses Tendinitis Stress reaction Exacerbation of anatomic condition Idiopathic anterior knee pain Osteochondroses Osgood-Schaltter s - tibial tubercle Sinding-Larsen-Johannsen - distal pole of patella Sever s - calcaneal apophysis Osgood-Schlatter s 1

2 Traction induced inflammation of the tibial tubercle apopphysis (growth plate) Self-limited Boys > girls ages Prominent tibial tubercle and characteristic x-ray findings of fragmented appearance Sinding-Larsen-Johannsen Similar to Osgood-Schlatter but at the distal pole of the patella Self-limited - ages Traction changes on x-ray from the patellar tendon Similar treatment with quad and hamstring stretching, ice massage, and activity modification Osteochondroses of Knee Sever s Inflammation of the Calcaneal apopphysis (growth plate) At the attachment of the Achilles tendon proximally and plantar fascia distally Ages 9-14 Boys > girls Achilles stretching, ice massage, +/- heel cups or orthotics, activity modification (may be necessary) Tendinitis Quadriceps/Patellar tendon Pes anserine (hamstrings) Achilles Flexor Hallucis, Peroneals, Tibialis Posterior No x-ray changes Patellar Tendinitis Very common in junior high athletes Girls > Boys Traction of tight quads, rapid growth and increased activity Responds well to stretching, activity modification and PT if they are deconditioned Pes Tendinitis/Bursitis Extremely common in adolescents in conjunction with patellar tendinitis Medial hamstring insertions Anteromedial proximal tibia pain/tennderness tenderness increased with resisted contraction of hamstrings Stretching, ice massage, activity modification, PT 2

3 SCFE Slipped Capital Femoral Epiphysis Consider in children with prolonged knee pain or hip pain growth plate of the hip slips off of the neck of the femur either gradually or acutely (Surgical Emergency) Overweight children most at risk but exists in thin patients AP and Frog pelvis (not individual hip) x-rays SCFE Pelvic Avulsion Fractures ASIS - Anterior Superior Iliac Spine (Sartorius) AIIS - Anterior Inferior Iliac Spine (Rectus femoris) Ischial tuberosity (Hamstrings) Many times sprinting injuries - acceleration or deceleration Pelvic Avulsions Lower Extremity Fractures Femoral Shaft Proximal Tibia Tibial Eminence Tibial Tubercle Tibia Shaft Distal Tibia Tillaux Triplane Lower Extremity Fractures Risk Year-round play - fatigue Overtraining Size differential - especially in Jr. High/Middle School age groups Femoral Shaft Fractures Treatments up to 5 years - Spica casting 5y - 12y - flexible nails maturity weight 100 lbs. fracture pattern 12y to mature rigid nail 3

4 sometimes younger - pediatric nail Femur - Flexible Nails Femur - Rigid Nail Hip Dislocations Size differential High Energy Mostly in Football ACL Proximal Tibia Tibial Spine/Eminence ACL attachment Tibial Tubercle Apophysis Tibial Eminence - Screw Tibial Eminence- Suture Tibial Tubercle Tibia Shaft Ankle Injuries < 8 years old generally a small fracture instead of sprain generally non-displaced at the lateral malleolus (outside) X-ray is worthwhile Treatment is boot versus cast early weight bearing Ankle Injuries 8-12 years Fractures and sprains present can still have non-displaced physeal (growth plate) fractures can begin to have special fractures related to growth Sprains - Lateral (ATFL and CF ligaments) Medial (Deltoid ligaments) Distal Tibia - Growth Plate Fractures Tillaux Triplane Distal Tibia Physis Closure Triplane Fracture Triplane Fracture Growth Arrest 4

5 Injury to the Physis (Growth Plate) Angular deformity Limb length inequality Distal Femur (at the knee) ~50% rate of closure 18-51% angular deformity Sports Injuries Total increasing with more participation Overuse continues to be a problem Injury prevention important Fracture types and complications differ in the growing skeleton Return to School Most elementary and middle school age children can return soon in a wheelchair to facilitate transport Independent toilet use can be an obstacle Most single bone fractures can be expected to rerun in 7-10 days some exceptions Return to Sport Most fractures can return when 95% strength compared to opposite side Most fractures 4-6 months before the feel strong Femur and tibia shaft take the longest Many ankle fractures can be doing well at 3 months (bony union at 6 weeks) Return to Sport ACL Inline running at 3 months Older adolescents some sports at 6 months Most younger children 9 months to 1 year In hopes of reducing re-tear/failure rate References Flynn JM, Skaggs DL, Waters PM, Rockwood and Wilkins Fractures in Children. 8 ed. Lippincott, Williams, & Wilkins. Philadelphia Ahmad CS. Pediatric and Adolescent Sports Injuries. AAOS Monograph Series AAOS.org POSNA.org Weinstein SL, Flynn JM. Lovell and Winter s Pediatric Orthopaedics, 7 ed. Vol. 2. Wolters Kluwer; 5

6 Philadelphia: