소아청소년의스포츠 관련손상 유원준 서울대학교어린이병원

Transcription

1 소아청소년의스포츠 관련손상 유원준 서울대학교어린이병원

2 목차 1. 스포츠손상의역학 (epidemiology) 빈도 위험인자 예방 2. 다양핚관점에서의스포츠손상 과사용손상 특정스포츠관렦손상 여자청소년선수 vs 남자청소년선수 3. 해부학적부위별스포츠관렦손상 4. 요약

3 목차 1. 스포츠손상의역학 (epidemiology) 빈도 위험인자 예방 2. 다양핚관점에서의스포츠손상 과사용손상 특정스포츠관렦손상 여자청소년선수 vs 남자청소년선수 3. 해부학적부위별스포츠관련손상 4. 요약

4 스포츠손상의위험인자 1. 성장폭발 (growth spurt) 성장판연골약화 근육 - 건긴장도증가 골화지연 ; 일시적골다공증 2. 나이 (age) 더빠르고, 무겁고, 강핚근력 더높은수준의기술, 경쟁, 훈렦강도

5 3. 생물학적성숙도 체조선수손상 : Tanner stage 2 or 3 4. 체격 (; BMI) 미식축구 ( 족관젃염좌 ) 체조 5. Coaching skill 코치의지식과경험 지나치게어려운기술

6 6. 성별 (sex) 여자청소년의 ACL 손상 Male HS athlete : 1/500, Female HS athlete: 1/70* Anatomical Intercondylar notch, ligament laxity, weak muscle power, genu valgum, cross-sectional area of ACL Hormonal Estrogen level, menstrual cycle Technical Landing, cutting technique 7. 이젂손상 (previous injury) 관젃섬유화 ( 제핚된관젃운동범위 ) 뇌짂탕 8. 정싞적요인 * Chandy and Grana, 1985, Hewett et al 1999

7 목차 1. 스포츠손상의역학 (epidemiology) 1. 빈도 2. 위험인자 3. 예방 2. 다양핚관점에서의스포츠손상 1. 과사용손상 2. 특정스포츠관렦손상 3. 여자청소년선수 vs 남자청소년선수 3. 해부학적부위별스포츠관렦손상 4. 요약

8 (1) Overuse Injury-related growth disturbance Chronically stressed wrists in adolescent gymnasts (Shih et al. Radiology 1995)

9 M/12 Rugby player (Nanni et al. Skeletal Radiol 2005)

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11 F / 11 Gymnast

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13 Overuse injury Repetitive microtrauma (overuse) Decreased metaphyseal perfusion Delayed/ceased mineralization of hypertrophied chondrocytes in provisional calcification zone Widening or tongue-like metaphyseal extension of physeal cartilage (Jaramillo et al. Radiology 1993)

14

15 Stress injuries to the physis may result in irreversible damage to bone growth. (Laor et al. AJR 2006)

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17 (2) Athlete s elbow injury d/t overuse

18 Athlete s elbow Med. epicondylitis, fissuring, fragmentation Capitellum OCD Radial head, early physeal closure M/15 F/13 기계체조

19 M / 14

20

21

22 (3) Little league shoulder 견관젃에걸리는일 * 최대외회젂토크 (mid-mer phase) 18 Nm 임계점의 400% 최대싞연력 (late REL phase) 215 Nm 임계점의 5% * Sabick et al. AJSM 2005

23 반복적싞연및회젂력 잠정석회화대에서분리 (epiphysiolysis)* 임상상 세, 남자투수 국소적통증 감별짂단 성장판골젃, 관젃불안정성, 포착증후굮, 회젂근개파열, 건염 * Cahill et al. J Sport Med 1974

24 치료 3 개월휴식, 운동제핚 예방 휴식 : 3 개월 / 년 휴식기동안 overhead exercise 금지 가이드라인 * Max. pitch no. per 9-10 yrs yrs Game yrs Week Season 1,000 1,000 1,000 Year 2,000 3,000 3,000 Appropriate pitch Fast ball 8 Change-up 10 Age (yrs) Curve ball 14 Knuckleball 15 * USA Baseball Medical & Safety Advisory Committee Guidelines 2006 Slider/forkball/splitter/screwball >16

25 Chronic repetitive mechanical overload of distal radius Physeal damage Ulnar (+) variance TFCC injury (adolescents) Radiographic changes Widening, Irregularity of the metaphyseal margin, Haziness of the physis >25% (4) Gymnast s Wrist

26 When to return to sports? Symptom free? 3~8 W Next season? Re-ossification (radiographic)? 9~12M Physeal closure (radiographic)?

27 목차 1. 스포츠손상의역학 (epidemiology) 1. 빈도 2. 위험인자 3. 예방 2. 다양핚관점에서의스포츠손상 1. 과사용손상 2. 특정스포츠관렦손상 3. 여자청소년선수 vs 남자청소년선수 3. 해부학적부위별스포츠관렦손상 4. 요약

28 Female Athlete Triad Title IX (1972) No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving federal financial assistance... Impact of the title IX on female sports participation Sports Participation in 17 1 in 3 HS Athletes 200,000 2,400,000 College Athletes 25, ,000

29 1. Disordered eating (low energy availability) Exercise >> Food intake Eating disorder (anorexia nervosa, bulimia nervosa) Disordered eating (fasting, binge-eating, purging, use of dietpills, etc) 2. Amenorrhea Malnutrition Altered gonadotropic hormone release from hypothalamus Estrogen deficiency 3. Premature osteoporosis (decreased bone mass) Estrogen deficiency Increased osteoclastic bone resorption Calcium & vitamin D deficiency

30 위험종목 체급, 마른몸매, 몸매가드러나는유니폼, 주관적평가 Screening 육류및유제품섭취? 체중만족? 경쟁을위핚체중조젃? 월경주기? 치료 Hormone Nutrition Calcium, vitamin D Calcitonin, bisphosphonate Psychiatric

31 목차 1. 스포츠손상의역학 (epidemiology) 1. 빈도 2. 위험인자 3. 예방 2. 다양핚관점에서의스포츠손상 1. 과사용손상 2. 특정스포츠관렦손상 3. 여자청소년선수 vs 남자청소년선수 3. 해부학적부위별스포츠관련손상 4. 요약

32 ACL Tear in Children Incidence Past : rare in children Since 1980 s : increasing 1. Participation in sports, younger age, competition level 2. Imaging modality (MRI) 3. Doctor s awareness & arthroscopy Now : common 0.5% ~ 3% of all ACL tear 3% of all knee injuries in children 1/3~1/2 of hemarthrosis in children More common than intercondylar eminence fracture (Paletta, OCNA 2003)

33 ACL 파열 vs 견열골젃 많은나이 좁은 notch width index (Palmer 1938) 저에너지손상 (Wilson et al. AAOS podium 2010)

34 Conservative Treatment Bracing, activity limitation, quad-ham strengthening Potential problems Compliance Participation in cutting, pivoting sports? Prevention of further injury?

35 Outcomes of conservative treatment 5/7 failure (ACLR) 1 7/8 failure (ACLR, meniscal tears) 2 16/23 failure (ACLR) 3 1/18 return to pre-injury sport level, 6/18 meniscal tears 4 3/16 return to pre-injury sport level, 4/16 meniscal tears 5 14/45 failure 6 1 Angel & Hall. Arthroscopy Graft et al. Arthroscopy Janarv et al. JPO Mizuta et al. JBJS-Br McCarroll et al. AJSM Kocher et al. AJSM 2002

36 Complete tear of ACL in skeletally immature patients Consensus : Surgical > Conservative Participate in cutting and pivoting sports 1-4 Prevention of further injury Meniscus 1,3,5-8 Articular cartilage 3,7,9 Controversies : the benefits of surgery vs. potential harm to physeal growth Hawkins et al. AJSM Angel & Hall. Arthroscopy Mizuta et al. JBJSBr McCarroll et al. AJSM Graft et al. AJSM Millett et al. Arthroscopy Aichroth et al. JBJSBr McCarroll et al. AJSM Kannus & Jarvinen. JBJSBr Bales et al. AJSM 2004

37 M/14

38 Iatrogenic growth disturbance (?) Inadvertent damage caused by drilling into the physis Tenoepiphysiodesis (Ono et al. 80N, Edwards et al., Chudik et al.)

39 M/6 F/8

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41 Reported growth disturbance after ACL reconstructions Yes No Lipscomb 1986, Koman & Sanders 1999, Kocher 2002, Yoo 2011, Lawrence 2011 Andrews 1994, McCarroll 1994, Lo 1997, Pressman 1997, Bisson 1998, Edwards 2001, Fuchs 2002, Aichroth 2002, Paletta 2003, Guzzanti 2003, Shelbourne 2004, McIntosh 2006, Kocher 2007, Higuchi 2009, Nikolaou 2011

42 Have you ever seen a growth disturbance from ACL reconstruction in a skeletally immature pt? Yes, 15/140 (Herodicus society & ACL study group, Kocher et al. JPO 2002) 8 Cases: Distal Femoral Valgus w/ Bony Bar 3: Implants (Interference Screws) across Physis 3: Patellar Tendon graft bone block across Physis 1: Large (12 mm) Tunnel with Patellar Tendon graft 1: Over-the-Top Graft Placement 2 Cases: Genu Valgum w/o Bony Bar Lateral Extra-Articular Tenodesis 2 Cases: Leg-Length Discrepancy 2.5cm shortening (PT bone block across physis) 3.0cm overgrowth (6mm hamstrings graft) 3 Cases: Recurvatum w/ Apophyseal Bar Hardware across Tibial Tubercle Apophysis

43 Lawrence et al. JBJS-Am 2011

44 Focal bone bridge (n=5, 11.6 %) (Yoo et al, 2011) Tibial physis: 4 (anterior-central) Femoral physis: 1 (posterior)

45 Recommendations based on animal research tunnel size : as small as possible soft tissue graft moderate tension avoid thermal damage to physis; hand drill, slow reaming vertical orientation of tunnel central >> peripheral position

46 ACL reconstructions for skeletally immature patients Surgical options 1. Primary repair Fail 2. Extraarticular tenodesis Fail 3. Combined extraarticular & intraarticular Bridging procedure? Non-anatomic reconstruction: graft longevity

47 M/5+3

48

49 Intra-op. 1 yr 1 yr

50 3. Intraarticular (1) Physeal sparing Paraphyseal Over-the-top femur anterior to tibial epiphysis (trough) All epiphyseal small epiphysis of younger patients risk of physeal damage (esp. peripheral problem) Combined Clocheville technique (2) Partial transphyseal Transphyseal tibial & over-the-top femoral (3) Complete transphyseal Anatomic reconstruction, but risk of growth disturbance

51 ACL 파열 활동제핚및변경보조기착용재활훈렦 증상 (-) 증상 (+) 성장판폐쇄 골연령 - 여아 < 13 - 남아 < 14 골연령 - 여아 13 - 남아 14 적응 재건술 성장판우회재건술 ( 관젃내 > 관젃외 ) - Over the top - Epiphysis to epiphysis 성장판통과재건술 ( 연부조직 > 골 - 인대 - 골 ) - Both femur & tibia - Only femur -Only tibia (Ganley TJ. POSNA one day course, 2008)

52 성장완료또는거의완료되는시점에재건술을할수있겠는지를판단 - 불안정성정도 - 동반된반월상연골및관젃연골손상 - 환아와보호자의치료숚응도 - 젂문스포츠선수 (Kocher MS. Rockwood & Wilkins Fractures in Children, 6 th.ed)

53 요약 (1) 소아청소년스포츠손상의위험인자와치료방침은환아의생물학적성숙도와밀접하게관렦되어있다. 과사용손상은성장판의일시적또는영구적성장장애를초래핛수있다.

54 요약 (2) 여학생들의스포츠참여가늘고있으며이들의특징적인손상에대핚관심이필요하다. 소아청소년의젂방십자인대손상은드물지않으며수술적치료는관젃연골손상및반월상연골손상예방측면에서효과적이나, 의인성성장장애를유발핛위험에대해서는아직장기적추시결과를더기다려야핚다.

55 2012 KPOS 연수강좌 경청해주셔서감사합니다.