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Medscape Orthopaedics & Sports Medicine eJourn. 2001;5(2) 

In This Article

Types of Injuries

Children sustain injuries unique to their physical and skeletal immaturity and to their specific physical characteristics. With intensive training, however, they now sustain injuries previously seen almost exclusively in adults.

Epiphyseal Injuries

Epiphyseal injuries, which have no adult counterpart because they occur at the epiphyseal growth plates, are usually caused by shearing and avulsion forces. However, compression also plays a significant role. The cartilaginous cells of the epiphysis may be damaged, producing premature closure of the epiphyseal plate and bone growth disturbance with subsequent deformity. Some injuries may involve the articular aspect of the epiphysis, with no direct trauma to the growth plate. In such cases, the fracture must be accurately reduced and internally fixed to prevent secondary osteoarthritis (Figure 1).

Figure 1.

Osteochondral fracture of the medial femoral condyle in a 12-year-old basketball player who fell and twisted her knee after jumping for the ball.

Upper Limb Injuries

Elbow injuries in sports are common. Damage to major vessels or nerves may occur, some children require operative treatment, and plain x-ray films of children are often difficult to interpret because of the presence of multiple ossification centers. The elbow is likely to develop posttraumatic stiffness, and damage to the growth plate can result in subsequent deformity.

Dislocation of the elbow is common in gymnastics and can be associated with fractures of the medial epicondyle of the humerus, fractures of the neck of the radius, or injury to the median or ulnar nerve. At all ages, dislocations require prompt reduction. Rehabilitation should be gradual, and sporting activities should not be resumed before 8 to 12 weeks. The child should have regained a full range of movement before resuming full sporting activity.

Overuse Injuries

In gymnasts, divers, wrestlers, and hockey players, traction apophysitis occurs at the insertion of the triceps into the olecranon epiphysis. Athletes complain of local pain and tenderness around the insertion of the triceps tendon that is exacerbated by supporting their body weight with their arms. X-ray films may show marked fragmentation of the epiphysis but are difficult to interpret because of normal variants in this region. Treatment consists of a rest from upper limb activities, and symptoms usually resolve within 3 months. Long-term problems are rare.

Osteochondritis dissecans of the humeral capitellum is well documented[1,4] and can occur in nonathletic children. The dominant arm is affected in baseball pitchers due to valgus loading of the elbow during pitching, which leads to repeated compression of the lateral side of the joint. In gymnasts, compression and rotation during weight bearing by the arm and loading of the lateral side of the elbow (increased by the physiological valgus of the elbow) affect the joint surface. Athletes present with minimal elbow pain and some swelling and are often unable to fully extend the elbow, which is often tender laterally. X-ray films are often diagnostic, but early diagnosis may require magnetic resonance imaging (MRI) or computed tomography (CT). The damaged area of the articular epiphysis can break away to form an intra-articular loose body.

If recognized early, conservative management of osteochondritis dissecans may be successful, with proscription of weight bearing on the upper limbs and of stressing the elbow. Loose bodies should be removed surgically or arthroscopically. Because the articular surface is damaged and the joint not congruous, early osteoarthrosis can ensue. Disease of the radial head is rarer, but diagnosis and treatment follow the same rules as for osteochondritis dissecans of the humeral capitellum.

The entire epiphysis of the humeral capitellum is affected in Panner's disease, probably as a result of more generalized circulation impairment. Pain, swelling, and limitation of motion of the elbow are evident, and diagnosis is radiological. The lesion will heal, but when a deformity is present, there will be incongruity of the joint with the risk of later osteoarthrosis.

Epiphyseal Growth Plate Overuse Injuries

The epiphyseal growth plate may fail because of repeated microtraumas. In particular, stress fractures through the olecranon epiphysis, which present with pain in the posterior aspect of the elbow with local tenderness over the olecranon with decreased elbow extension, have been reported[5] in adolescent baseball players, gymnasts, and wrestlers. The growth plate is widened, and conservative treatment is recommended.

Stress-induced changes in the distal radial epiphysis are well recognized in gymnasts who present with wrist pain associated with some swelling and local pain on weight bearing and rotation of the wrist. X-ray films demonstrate widening of the growth plate, with failure of the zone of calcification. The prognosis of these changes is good. With rest, the epiphysis recovers. However, growth can be impaired, and the child may develop a slight shortening of the radius compared with the ulna.

Lesions of and Around the Hip Joint

Various sites around the hip are weak because of the presence of unfused epiphyses. Large fragments of bone can be avulsed with sudden unexpected loads. The anterior inferior iliac spine tends to fail when the kicking foot is suddenly blocked. More often, when the foot hits the ground, the anterior inferior iliac spine is pulled off by the reflected head of the rectus femoris. In similar circumstances, the psoas muscle can avulse the lesser trochanter. The whole apophyseal plate of the ischium can separate following the powerful pull of the hamstrings. This can happen in cross-country running when a wider-than-expected ditch is jumped, causing overstretching of the leading leg. More rarely, the anterior superior iliac spine can be avulsed by the action of the sartorius in a bad gymnastics vault landing. The entire iliac crest apophysis can also be pulled by the abdominal muscles, although displacement is uncommon.

Typically, the young athlete gives a history of severe, immediate and well-localized pain, and x-ray films confirm the diagnosis. Because the avulsions are deep, cryotherapy is unhelpful, and pharmacological analgesia is the preferred option for pain relief, with rest and gradual return to activity as pain permits. Immediate surgery is usually not indicated, and late surgery is occasionally required despite occasional dramatic radiographic changes.

In the child, the epiphyseal plate is weaker than the ligaments, and valgus and varus stresses injure the growth plate instead of tearing the medial and lateral collateral ligaments. The knee may be unstable, and plain x-ray films appear normal, but stress x-ray films, taken under anesthesia if the pain is severe, will reveal the epiphyseal lesion. Management consists of immobilization for 4 weeks and controlled mobilization thereafter. Some authors recommend percutaneous or internal fixation for particularly unstable injuries.[6,7]

A similar imbalance between muscle and ligaments and epiphyseal strength may produce the classic anterior cruciate ligament (ACL) lesion in nonathletic children. The mechanism of injury is a flexion, twisting, or hyperextension injury, with immediate pain and hemarthrosis. In these cases, the ligament itself remains intact, but a large piece of the proximal tibia is avulsed. Following x-ray examinations, an arthroscopic washout of the joint is performed, and a small cannulated screw is used to fix the bone fragment back into place. Even following anatomical reduction, some laxity and lack of full extension are commonly experienced.

Although children were once considered at low risk for midsubstance tear of the ACL, an increasing number of such lesions, often associated with a lesion of the medial collateral ligament, are being reported.[4,6] MRI can assist in this diagnosis, because its sensitivity and specificity are relatively low; however, arthroscopy should still be considered the "gold standard" for diagnosis. If the ACL is torn, operative reconstruction can prevent secondary meniscal tears and articular cartilage injuries. Reconstruction provides good results, with a low subsequent risk of growth abnormalities.

Meniscal problems in children are unusual, are generally associated with a discoid lateral meniscus with a painless "clonking" noise before the tear, and warrant arthroscopy. Similarly, the extensor apparatus above the patella is rarely injured in children. In sleeve fractures of the patella, the periosteum is stripped downward in continuity with the tendon. The diagnosis is usually missed until the bone grows again in the empty pouch, producing the double patella appearance. At this stage, it is too late to operate.

Osteochondritis dissecans is often due to intense physical activity and high-level sport, with the possibility of degenerative changes secondary to loose body formation or residual deformity of the joint surface. The most commonly affected areas in the lower limb are the lateral aspect of the medial femoral condyle, the femoral head, and the talus (Figure 2).[2] Management of osteochondritis dissecans depends on the state of the lesion and the age of the athlete. In the appropriate joints, arthroscopy is the procedure of choice. Nonoperative treatment in skeletally immature young athletes may allow resolution of circumscribed stable lesions. However, surgical or arthroscopic removal of symptomatic loose bodies resulting from late disease is recommended.

Figure 2.

Osteochondritis dissecans of the talus in a 16-year-old soccer player with a history of 3 inversion injuries of the ankle during the previous 4 months. Excision of the fragment was necessary.

The Sinding-Larsen-Johansson lesion is a syndrome of tenderness and radiographic fragmentation localized to the inferior pole of the patella. This self-limiting lesion is a calcification tendinopathy in an avulsed portion of the patellar tendon. The pulling action by the patellar tendon on the ossification center of the tibial tubercle may cause inflammation and pain, which causes the clinical Osgood-Schlatter lesion associated with the Sinding-Larsen-Johansson lesion. Both lesions occur between the ages of 8 and 13 years in girls and 10 and 15 years in boys. Boys are nearly twice as commonly affected than girls, possibly because of their higher activity levels.[4,5]

Lesions of and Around the Ankle

The twisting injuries that cause a fracture in adults produce a different pattern of injury in the immature skeleton. In general, ankle fractures in children are minimally displaced. However, when involving the articular surface, they may require open reduction and internal fixation.

The foot is the site of stress lesions more commonly than usually realized. Sever's lesion presents with activity-related pain at the tip of the heel and radiographic fragmentation of the calcaneal apophysis. The lesion is probably a stress fracture, but there is often a similar asymptomatic x-ray film of the asymptomatic side. In these cases, clinical findings take priority, and the asymptomatic side should be left alone. The pain responds to rest and a shock absorber under the heel.

Kohler's disease is an idiopathic avascular necrosis of the tarsal navicular and is managed by rest and avoidance of jumping and hopping on the involved foot. Generally, this lesion takes 2 to 3 years to return to normal.

Chronic back pain in children is rare, except for Scheuermann's disease and spondylolysis (or spondylolysthesis). More serious explanations, such as fractures, infections, and tumors, should, therefore, always be considered. Adolescent athletes are more prone to disk prolapse, which is best diagnosed by MRI. The high-risk sports for acute spinal injuries are American football, diving, gymnastics, and trampolining. Sports injuries account for 18% of pediatric cervical spine fractures.[6]

Following trauma, fractures of the cervical spine are less common in children than in adults. Most spinal injuries in patients younger than 12 years involve the atlantoaxial or atlanto-occipital joints, although all levels are encountered.[2,6] Prevertebral soft tissue swelling greatly assists diagnosis on lateral films. Slight anterior vertebral wedging is normal in children because of incomplete ossification, and up to 2 mm of spondylolysis is acceptable in the upper cervical spine. Children's normally lax ligaments result in a greater prevalence of displacements than fractures. Children with Down's syndrome have such lax atlantoaxial ligaments that sports activity should be restricted if a lateral x-ray film shows the distance between the anterior aspect of the dens and the posterior aspect of the arch of the atlas to be greater than 4.5 mm. This laxity predisposes to atlantoaxial rotary subluxation, with abnormal displacement between the facet joints, presenting as torticollis. If this is suspected on plain radiographs, CT scanning with the head turned in both directions is required to assess whether this is fixed (a facet joint does not reduce with the head turned toward the direction of C2) or mobile. This is often seen in ballet due to rapid head rotation while pirouetting.

Gymnastics, dance, football, weight-lifting, and running are associated with spondylolysis, an osseous defect of the pars interarticularis between the superior and inferior facets of the vertebral body, and spondylolisthesis, the slippage of a superior vertebra on its inferior. Both can be related to hyperextension and axial loading, because there is an increased incidence in gymnasts (11%), ballet dancers, fast cricket bowlers, and American football players.[1] Spondylolysis is not always symptomatic.

A much less frequent cause of low back pain in adolescent athletes is lumbar disk protrusion, but the role of continuous microtrauma is not clear. Not all children with a lumbar disk protrusion report low back pain, but most develop sciatica. The role of acute trauma in the development of disk herniation in young patients has been stressed, but degenerative changes may play a leading role, with trauma acting only as a precipitating factor. This could explain the infrequency of the lesion in intensively trained young athletes.

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