Pediatric sports injuries in foot and ankle Poster No.: P-0013 Congress: ESSR 2014 Type: Scientific Poster Authors: Y. Kobashi 1, T. Mogami 1, S. Yamazoe 1, A. Baba 2, S. Ogiwara 1 ; 1 2 Chiba/JP, Tokyo/JP Keywords: DOI: Musculoskeletal bone, Musculoskeletal joint, MR, Education, Trauma 10.1594/essr2014/P-0013 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 18
Purpose To know what kind of sports injuries in both children and adolescents. To know the difference of sports injuries between children and adolescents. Page 2 of 18
Methods and Materials When we diagnose the sports injuries in both of the children and adolescents by CT and MRI, we realize that we lack of those knowledge. We limited them to only the sports injuries of the foot and ankle, and evaluated them with regard to the type and location of injuries and diagnosis. We retrospectively reviewed medical records, CT and MR images of 20 ankles and 3 feet of 23 pediatric athletes (21 males and 2 females; mean age 14.5 years; range 9-18 years). Sports history of each patient was as follows: twelve of 21 patients had history of football, 3 of them did marathon running, 2 of them did gymnastics competition, 2 of them did judo, and each one of them did baseball, kendo, skating, and basketball. All of 21 patients evaluated MR and/or CT images to judge which part there was an injury in. Page 3 of 18
Results Three of 21 patients who were under 12 years old and who played football showed obstacles peculiar to children: growth plate injury, sever disease, and os subfibulare. Children of the age 13 years or older and played football came to have high ratio to be fractured, such as stress fracture of distal tibia, metatarsal and talus (osteochondral lesion). The stress fracture of navicular, cuboid, calcaneus and talus was recognized sporadically except for football mainly. Only one of 21 patients were 16 years old and had anterior talofibular ligament tear. None of all patients had tendon rupture. Page 4 of 18
Images for this section: Table 1: Category of sports Twelve of 22 patients played football. Male are more dominant than female about foot and ankle trauma. Page 5 of 18
Table 2: Category of football injuries Under 12 year old patients, there was no evidence of stress fracture or ligament tears. Osteochondral lesion of talus was more prominent than other traumatic lesions. Over 13 year old patients, stress fracture and ligament tear (ATFL tear) was present. Page 6 of 18
Fig. 1: Footballer's trauma (under 12 years old) Sever disease (10 year old mal) a.lateral view of ankle X ray: separation of calcaneal apophysis consisted with calcaneal apophysitis is demonstrated (arrow). b.t1 weighted sagittal image: There is evidence of low signal intensity area suggestive of bone marrow edema at the calcaneal apophysis (arrow). c.stir sagittal image: bone marrow edema is also visualized. This finding is typical for Sever disease (arrow). Page 7 of 18
Fig. 2: Os subfibulare (12 year old male) a.ap view of plain ankle X ray: focal radiolucent area suggestive of bone marrow edema and small rounded bony fragment are visualized at tip of lateral malleolus (arrow). Soft tissue swelling is demonstrated in the ankle joint (arrowheads). b.mr of ankle, STIR sagittal image: bone marrow edema is visualized in the os subufibulare and lateral malleolus (arrow). Soft tissue swelling is seen adjacent to lateral malleolus (arrowhead). Page 8 of 18
Fig. 3: Growthplate injury (11 year old male) a.lateral view of ankle X ray: widening of growthplate is visualized (arrow). There is no fracture in the tibial epiphysis and metaphysis. This growthplate injury is consistent with Salter-Harris classification type I. b.ct of ankle, MPR sagittal image: widening of distal tibial growthplate is demonstrated (arrow). Tibial shaft is sifted toward anterior side. Page 9 of 18
Fig. 4: Footballer's trauma: over 13 years old Stress fracture of medial malleolus and 3rd-4th metatarsal. a.16 year old male : vertical low signal linear intensity consisted with stress fracture is visualized at medial malleolus (arrow). b.13 year old male: there is evidence of cortical thickening at the 3rd metatarsal (arrow). Fracture line is indistinct on this study, however from his history; this finding is consisted with stress fracture with callus formation. c.13 year old male (different from b): bony fracture is visualized at proximal aspect of 4th metatarsal with bone marrow edema (arrow). Page 10 of 18
Fig. 5: Nonunion of stress fracture of 5th metarsal (13 year old male) a.oblique view of foot X ray: there is evidence of bony fracture in the proximal aspect of 5th metatarsal (arrow). The fracture line is clearly visualized. b.t1 weighted sagittal image: bone marrow edema is not demonstrated at bony fragment. No bony fusion is seen (arrow). Page 11 of 18
Fig. 6: Osteochondral lesion of talar dome (15 year old male) T2 weighted coronal image: focal signal change is visualized at medial aspect of talar dome (arrow). Cortical irregularity of talar dome is also visualized. Osteochondral lesion of talar dome is suspected. Page 12 of 18
Fig. 7: Traumatic lesions of non-football player Stress fracture of navicular and cuboid a.stress fracture of navicular, STIR axial image (15 years old male: judo palyer): navicular shows high signal intensity suggestive of bone marrow edema (arrow). b.stress fracture of cuboid, STIR sagittal image (15 years old male: kendo player): bony fracture is demonstrated in the cuboid. Fracture line is clearly visualized (arrow). Bone marrow edema is seen. Page 13 of 18
Fig. 8: Stress fracture of calcaneus and talus c.stress fracture of calcaneus, T1 weighted sagittal image (10 years old male: baseball player): fracture line is visualized at posterior aspect of calcaneus (arrow). d.stress fracture of talus, CT of ankle, MPR coronal image (18 years old male). Radiolucent line consisted with fracture is visualized at talus (arrow). Page 14 of 18
Fig. 9: Anterior talofibular ligament tear T2 weighted axial image (16 years old female): There is evidence of rupture of ATFL (arrow). Localized fluid collection is visualized in front of lateral malleolus. Page 15 of 18
Conclusion Pediatric sports injuries are different from adults them because pediatric bone and joint are immature and weak as compared to the adults. In children under the age of 12, growthplate is particularly thick and epiphyseal nucleus includes thick cartilage. Therefore, their sports injuries are prominent with abnormality of growthplate and epiphyseal nucleus such as sever disease and os subfibulare. In children at age of 13, exercise capacity and muscle volume are increased and frequency of stress fracture is elevated. Location of stress fracture is various from each sports. In football, we need to focus on 5 th metatarsal stress fracture. Footballers do many feints, e.g.; body feints, scissors, matthew feints and so on. These movements are more characteristic of football than other sports and may cause a strong tension from peroneal tendon to proximal aspect of 5th metatarsal. Of course, footballers are running and dribbling for a long distance in one game. We should consider that all-round exercise of footballers is caused various foot traumas at all time. Japanese sports, kendo and judo are prone to stress fracture of tarsal such as cuboid and navicular. Both of judo and kendo are sports that perform barefoot. Their basic lower limb position is raising heels. And judo and kendo players attack the opponent quickly. These may give repetitive forces which occur to stress fracture to tarsal. Only one patient who was 16 years old female had ATFL tear in our study. This patient's growthplate is closed and it suggests that the bone becomes mature. Therefore, ATFL tear may occur. Conclusion We reviewed pediatric foot and ankle sports injuries. Various sports occurs various foot and ankle injuries; however, football players are more prominent than other sports. According to patients under the age of 12, we should consider their immature bones. Footballers, especially over the age of 13 often occur stress fracture in their feet. When the growthplate is closed, ATFL and other ligament tears may be visualized. Page 16 of 18
References 1. Smita Rao, Jody Riskowski, Marian T. Hannan. Musculoskeletal conditions of the foot and ankle: assessments and treatment options. Best Pract Res Clin Rheumatol. 2012; 26(3): 245-268 2. P Wong, Y Hong. Soccer injury in the lower extremities. Br J Sports Med. 2005; 39(8): 473-482 3. Sharon R. Sharpe. Joseph Knapik, Bruce Jones. Ankle braces effectively reduce recurrence of ankle sprains in female soccer players. J Athl Train. 1997; 32(1): 21-24. Page 17 of 18
Personal Information Yuko Kobashi, MD, PhD. 5-11-13 Sugano Ichikawa city, Chiba 272-8513 JAPAN Phone: +81 47-322-8513 Email: ykobashi@jikei.ac.jp Page 18 of 18