Lecture 4: The Young Athlete

Question 1

Where does long bone grow?

Answer 1

Long bone growth occurs at each end around the epiphyseal (growth) plates

Question 2

Apophysis

Answer 2

traction epiphysis

where tendons attach to bones

Question 3

Epiphyseal plate

Answer 3

where long bone growth occurs (at ends of long bone)

• 2-5x weaker than surrounding bone
• 15-30% of all childhood fractures are growth plate fractures

Question 4

Major differences between the bones of growing children and adults

Answer 4

• increased vulnerability of the epiphyseal plate
• tendon/ligament attachment sites (apophyses) are weak cartilaginous plates that are predisposed to avulsion injuries
• metaphysis/diaphysis in children is more resilient when compared to mature bones
• during rapid growth phases, bone lengthens before muscles and tendons are able to stretch

Question 5

Increased vulnerability of epiphyseal plate

Answer 5

Junction btwn growth plate and metaphysis

• typically due to shear/rotation force and compression. Most resistant to tension
• physis is 2-5x weaker than adjacent capsule or ligament (more common injury at bone than tendon/ligament)
• periosteum is a major support
• injury can be acute or from repeated force
• common acute fracture: distal radius, humerus, distal tib, fib, femur

Question 6

Salter-Harris Fracture

Answer 6

Fracture at epiphyseal plate

Question 7

Type I Salter-Harris

Answer 7

Complete separation of epiphysis from metaphysis WITHOUT any bone fracture

Question 8

Type II Salter-Harris

Answer 8

MOST COMMON - TRIANGLULAR shaped metaphyseal fragment

line of separation extends along growth plate then through portion of metaphysis

does not go thru jt.

Question 9

Type III Salter-Harris

Answer 9

INTRA-articular and extends from jt. surface to growth plate and extends along plate to its periphery

Question 10

Type IV Salter-Harris

Answer 10

Fracture extends from jt. through epiphysis, across whole growth plate and through part of metaphysics

COMPLETE split

Question 11

Type V Salter-Harris

Answer 11

COMPRESSION

Relatively uncommon

Question 12

Salter Harris Classifications

Answer 12

S- Straight Across
A - Above
L - Lower or beLow
T - Two or Through
ER - ERasure of growth place or cRush

Question 13

Little League Shoulder

Answer 13

Stress fracture of proximal epiphyseal plate of humerus (11-16 year olds)

• lower tolerance for rotational stress at epiphyseal plate

Pain in dominant shoulder of athlete (baseball, tennis, volleyball)
- during and after throwing
- decreased speed and control
- recent increase in FITT

• Treatment: abstinence from activity fo 4-6 weeks
• healing occurs uniformly

Question 14

Slipped Capital Epiphysis

Answer 14

Pressure epiphysis

• Femoral head stays in place and femoral neck slips up
• Occurs in children btwn 12-15 years (overweight males, late maturers)

Question 15

Clinical Clues for Slipped Capital Epiphysis

Answer 15

• decreased hip abduction and internal rotation
• shortening and external rotation of leg
• surgical emergency (pin placement)

Question 16

Apophyses as weak cartilaginous plates

Answer 16

Predisposes to avulsion injuries

• repetitive submaximal forces
• increase FITT
• growth patterns (more muscle-tendon tightness during growth spurts)

We typically injure 2-jt. muscles (ex. rectus femoris, sartorius)

Question 17

Common sites of avulsion around pelvis

Answer 17

Ischial Tuberosity > AIIS > ASIS

Ischial tuberosity: hamstrings attach
AIIS: rectus femoris attaches
ASIS: sartorius attaches

Question 18

Mode of Injury of avulsions around the pelvis

Answer 18

Running
Kicking
Slip

Question 19

Clinical clues for avulsion around pelvis

Answer 19

• athlete usually reports “pop” or tearing followed by pain at site (or poorly localized groin pain for AIIS)
• pain on palpation over site (ASIS displaces inferiorly over AIIS)
• pain with passive stretch and resisted flexion of muscles

Question 20

Management of avulsion around pelvis

Answer 20

Immediate
- ice
- support w/ protected gait (crutches)
- refer for imaging

early rehab
- early core stability (transversus abdominus)
- static balance
- maintain cardio - UBE (upper body ergometer)
- progressive ROM and strengthening

late rehab
- progress functional strength and power

Question 21

Total time of recovery for avulsion around pelvis

Answer 21

Ischial Tuberosity: 3-4 months
ASIS and AIIS: 6-8 weeks

Question 22

Resilience of metaphysis/diaphysis in children

Answer 22

Metaphysis/diaphysis in children is more resilient when compared to mature bones

• withstands greater deflection w/o fracture

Children have Greenstick type fractures
- incomplete fracture (like trying to break green tree branch)
- usually the fracture is on the side OPPOSITE to bending force
- common WRIST injury but can be anywherw

Question 23

Clincal clues for Greenstick fractures

Answer 23

• may not have “typical” pain
• tender on palpation mid shaft
• swelling or may have “bump” due to bend in bone
• may have decreased ROM or pain w/ weight bearing

Question 24

Management of Greenstick fractures

Answer 24

• refer for X-ray
• standard immobilization
• heals quickly 3-4 weeks

Rehab following:
- regain ROM and strength

Question 25

Apophysitis

Answer 25

- injury to apophysis (aka traction epiphysis) - due to bone lengthening before muscles and tendons can stretch - this is an over-use injury due to repetitive motion during rapid growth minimal muscle-tendon injuries in this age group

Question 26

Little League Elbow

Answer 26

Apophysitis of medial epicondyle - due to forces during cocking and early acceleration (may also cause avulsion injury)

Question 27

Clinical Clues for Little League Elbow

Answer 27

- medial elbow pain and decreased velocity and control - tenderness over medial epicondyle - pain w/ resisted wrist flexion and pronation (b/c wrist flexors attach at medial epicondyle) - valgus stress of elbow is PAINFUL - may have tenderness on lateral side (compression on lateral side)

Question 28

Managament of Little League Elbow

Answer 28

Immediate - ice - support w/ protected brace or splint - refer for imaging early rehab - complete local rest for min of 4-6 weeks - maintain lower extremity and core late rehab - throwing program starts 6-8 weeks - start long toss then non-competitive pitches w/ emphasis on form - stop for 2-3 days w/ any pain

Question 29

Osgood-Schlatter/Sinding-Larsen-Johansson

Answer 29

- continuous contraction or stretch of quadriceps may cause softening or partial avulsion of apophysis - most common during growth spurts and w/ high level of activity (running and jumping)

Question 30

Osgood-Schlatter

Answer 30

at tibial tubersoity

Question 31

Sinding-Larsen-Johansson

Answer 31

at inferior pole of patella

Question 32

Clinical Clues of Osgood-Schlatter/Sinding-Larsen-Johansson

Answer 32

Slow onset tenderness - tibial tuberosity in OS (girls 8-13 and boys 10-15) - inferior patella in SLJ (children 10-15) Tightness of surrounding muscles (quadriceps, hamstrings) Excessive pronation

Question 33

Management of Osgood-Schlatter/Sinding-Larsen-Johansson

Answer 33

- self limiting conditions - settles w/ bony fusion - OS may be left w/ a prominence of tibial tubercle - Activity modification (no need to rest completely) - cryotherapy - address imbalances (stretch/strengthen) - quads and hamstrings

Question 34

Sever's Disease

Answer 34

Calcaneal Apophysitis is a traction apophysitis of the insertion of Achilles - usually seen in boys between 8 and 12 years of age - 2nd most common site of apophysitis (secondary to OS) - usually w/ increase in activity or during growth spurt - seen in children w/ shortened gastrocnemius-soleus muscle complex

Question 35

Clinical Clues of Sever's Disease

Answer 35

- tenderness over the posterior aspect of the heel - decreased dorsiflexion ROM (plantar flexors are tight) - over pronation

Question 36

Management of Sever's Disease

Answer 36

Early rehab - insert heel raise to decrease pain in early rehab - stretch of plantar flexors Progress to - strengthens plantar flexors and dynamic stablizers when pain free - correct/manage over-pronation - condition settle in 6-12 months (max 2 years)

Question 37

Traumatic Plate Injuries

Answer 37

- will have appropriate mechanism of injury - pain on palpation of growth plate - replication of stress causes increase in plate pain - requires immediate medical attention

Question 38

Chronic Growth Injuries

Answer 38

- pain w/ activity (especially after increase in FITT) - pain subsides w/ rest - deformity - swelling - pain on palpation