Pediatric Athletic Injuries



Pediatric Athletic Injuries


Eric W. Edmonds, MD, FAAOS


Dr. Edmonds or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America.





Introduction

Pediatric athletic injuries are steadily increasing, especially as a result of early sport specialization. It is important to discuss the prevalence of these injuries and be aware of the most common types of injuries to implement prevention strategies and to provide the best method of management.


Prevalence of Injury

Injury prevalence in the pediatric athlete appears to be increasing over recent years, and it is believed to be, at least in part, because of youth athletes’ specialization.1 A 2020 systematic review found that the mean age of an injured athlete was 14.5 years, and that sport specializers were at significantly higher risk than those who were only sampling a sport. However, other factors related to age may play a role in both the risk for type and pattern of injury seen in this group,2 particularly during periods of rapid growth. Injuries associated with sports participation in children often occur in the shoulder, elbow, knee, and ankle.


Shoulder


Little Leaguer’s Shoulder

When young athletes sustain an injury that is a result of overuse, they are most often engaged in an activity involving overhead throwing. Proximal humeral epiphysiolysis, or Little Leaguer’s shoulder, is a common childhood sports injury that tends to occur in children ages 13 to 16 years, and the treatment is always nonsurgical. Recognizing the condition and how to prevent it from occurring can be difficult.

A 2020 study that prospectively enrolled 10- to 12-year-old baseball players and followed them over time found that approximately 60% of them had positive dominant shoulder MRI findings not present in their nondominant shoulder.3 Factors that appeared to contribute to the MRI changes included year-round play (P = 0.016), increased number of innings pitched (P = 0.046), spending rest innings as the catcher (P = 0.039), and a higher pitch count (P = 0.033). Singlesport athletes were significantly more likely to have abnormal MRI findings (P = 0.043) when compared with multisport athletes.

Although it is important to recognize epiphysiolysis and treat patients appropriately to reduce the risk of physeal closure, it is even more important to educate families on how to avoid overuse of the arm, thus preventing the injury. One study demonstrated at 2 months of rest that one-fifth of the athletes still reported the presence of pain.4 For those who did return to sport, 43% completely resumed play, 33% partially resumed play, and 24% failed to return to sport. After 6 months, 25% of the participants had a recurrence of pain in the shoulder. Factors associated with poor outcomes included longer period from initial presentation
to throwing prohibition and poor shoulder flexibility. Therefore, recommendations for management include complete rest from throwing as soon as the pathology is identified and the initiation of an upper body stretching program before resumption of throwing at 2 months.


Anterior Shoulder Instability

Shoulder instability in the young athlete is understood to be a complex problem, with many factors playing into both the etiology and the outcomes. Because one-fifth of all shoulder dislocations occur in people younger than 20 years, it is important to understand the natural history of this pathology in children.5 A 2019 review highlighted that several systematic reviews reported the recurrence rate for young patients to be higher than 70%.5 The authors indicated that even though the historical approach to treatment for patients with first-time dislocations has been nonsurgical, there is a current shift in the literature advocating for early surgery in this high-risk population because of the high risk of joint damage with recurrent instability.

There may yet be room for a more conservative approach to management if there is a better understanding of underlying pathology. A 2020 study attempted to describe the concept of functional shoulder instability.6 Through a robust investigation that included a pathology-specific questionnaire, standardized clinical scores, clinical examination, psychological evaluation, video and dynamic fluoroscopy MRI, the authors proposed that most of the functional instability (78%) was based on certain positions of the shoulder and that 72% was not controllable. Moreover, most patients (approximately 78%) had posterior instability, with only 17% having anterior instability and 6% showing multidirectional instability. It was also noted that there were often glenoid shape alterations or hyperlaxity that may have contributed to the findings of functional instability.

Some factors that play into outcomes are not all based on physiology. A 2020 study explored the effect of insurance status as a potential barrier to successful outcomes in children with shoulder instability.7 The study authors found that privately insured patients were both evaluated and obtained magnetic resonance images at a rate of about four to five times faster (P < 0.001) than publicly insured patients. Presumably because of the delay in care, the publicly insured patients were twice as likely to have secondary bony injuries (P = 0.016). The risk of recurrent instability, even after stabilizing surgery, was still significantly greater in the publicly insured patients (P = 0.022), indicating that even after establishing care and initiating treatment these patients are still at a higher risk for poor outcomes.

Therefore, surgical stabilization in this younger cohort, in its current state, may not solve the issue of recurrent instability. Two studies demonstrated evidence that recurrence may be as high as 50% in the adolescent population after surgery, especially as the patients are followed for more than 10 years8 or if they participate in a contact sport such as rugby.9 There may be an association with age, with a particular cutoff at approximately 16 years of age for the recurrence seen in contact sports (P = 0.0002).9 These same study authors noted a higher incidence of Hill-Sachs lesions (P = 0.0002) and bony Bankart lesions (P = 0.009) compared with adult control patients; however, they concluded that age was a more significant contributor to recurrent instability after surgery than the presence of bone loss. Specific to youth rugby players, it was concluded that at the time of index surgery, those younger than 16 years would have 2.2 times the risk of further instability with a potential recurrence rate as high as 93%.

In contrast to the previous study, another study published in 2021 that evaluated the risk factors for recurrence in those with early failure (<2 years) compared with a matched cohort without recurrent shoulder instability during that early time frame (mean follow-up, almost 5.5 years) found that bone loss, morphology, and patient age were factors significant to outcomes.10 The study authors found with univariate analysis that increased glenoid bone loss (P = 0.039), decreased glenoid retroversion (P = 0.024), and more than one instability event before surgery (P = 0.017) were risk factors for subsequent recurrent instability after surgery. A multivariate regression analysis revealed values that could predict future recurrence, independent of each other: glenoid retroversion less than 6°, skeletal immaturity, and more than one prior instability event. Interestingly, the risk of recurrence increased threefold in patients with two of those independent risk factors and increased fourfold in patients with all three risk factors.

Although contact sports have been implicated in the risk for recurrent instability, as noted previously, another study from 2019 with findings of recurrent instability in one-third of patients studied less than 4 years after stabilization surgery did not find that type of sport was associated with risk for recurrent instability in this adolescent age group.11 Although contact sport participation trended to be important, it was not significant. However, the study authors did find that 89% of those who redislocated the shoulder had a Hill-Sachs lesion (P = 0.048). In conjunction with the previous study, the associated osseous pathology seen in this age group may be the more predictive factor. Another study that
compared the outcomes of remplissage performed in adolescents with anterior instability with a matched control cohort found a significantly higher rate of recurrence in patients undergoing Bankart repair only (47%) compared with patients undergoing Bankart repair plus remplissage (13%, P = 0.04).12 It was concluded that the addition of the remplissage procedure to a Bankart repair may not only fill the Hill-Sachs defect, but it may also augment stability through a mechanism of posterior capsulorrhaphy (Figure 1).

Another approach to minimize the risk for recurrence after surgery is the conversion to open repair versus the current mainstay of arthroscopic Bankart repair.13 With shorter follow-up (minimum 2 years), the adolescent patients in this cohort had no instability events and excellent outcome scores. The only poor outcome in the group, attributed to the open surgical approach, was a small loss of external rotation. Therefore, the authors recommended that an open stabilization procedure was a better treatment option in the contact athlete than in the overhead or throwing athlete.

With such high rates of recurrent instability after primary surgery in these young athletes, it is important to consider possible courses of management for recurrence. A 2020 review highlighted that surgery is still an option (just the same as in adult patients) with particular focus on revising the Bankart repair but further treating all the bony pathology even to the point of considering a Latarjet procedure.14 The rate of recurrence after a repeat stabilization surgery remains at approximately one-third of those undergoing the second procedure. However, in a systematic review published in 2019, it was found that despite the high rate of recurrent instability and revision surgery, approximately 80% of adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability return to their preinjury level of play.15







Elbow


Little Leaguer’s Elbow

The spectrum of this pathology can range for the classic medial epicondyle apophysitis (edema and widening), fragmentation of the medial epicondyle, edema of the distal humeral metaphysis, and partial disruption of the ulnar collateral ligament.16 Management tends to be conservative in nature and twofold: education with an intent to prevent pathology (such as applying pitchcounts to youth baseball) and modifications of activity once the symptoms start (no throwing, casting, and/or
medial scapular stabilizing physical therapy). Surgery is rarely indicated.

Recent evidence regarding Little Leaguer’s elbow is discussed in a 2020 study.17 MRI findings in a single season were reviewed in another study by the same authors.3,16 The natural history of those findings with repeat MRI after 3 years was reviewed. The authors discovered that in 58% of the children studied, MRI revealed pathology of the dominant arm, with 80% demonstrating either progressive lesions or new lesions (43%). Year-round play was a significant predictor of tenderness to elbow palpation (P = 0.027), and during that 3-year period, 12% of the players required active treatment for elbow pain (including casting for pain). The authors also noted that in the cohort that continued to play baseball, there was a statistically significant change in the dominant arm’s internal and external rotation compared with that of the nondominant arm.


Medial Epicondylar Avulsion

The management of medial epicondylar fracture of the humerus has evolved over the past decade or so, as radiographic assessment and potential risk to outcomes have been studied. A recent discrete choice experiment evaluating preferences for management via clinical case vignettes identified that associated elbow dislocation and the amount of fracture displacement were the only attributes that significantly influenced surgeons’ decision to perform surgery.18 The study found that for every 1-mm increase in displacement, surgeons tended to favor a surgical approach by a factor of 0.09. One-half of the surgeons in the study preferred a surgical approach for all the clinical vignettes. Interestingly, for the other half, the decision to perform surgery was significantly based on the degree of fracture displacement but without standardization regarding how much displacement would affect patient outcomes. An association with dislocation is considered by some to be an appropriate indication to achieve relative elbow stability with bone fixation in the setting of surrounding soft-tissue disruption, but the validity of this indication remains untested.

Many publications have highlighted the inability to accurately define the true amount of displacement on standard AP and lateral elbow plain radiographs, so attention has been directed to better evaluation of this fracture and its displacement.19 A 2019 study attempted to validate findings using an axial radiographic view to identify the anatomic orientation of the medial elbow epicondylar physis in children. On average, the medial epicondylar apophysis was angled distally 36° and posteriorly 45° relative to the distal humerus, which is helpful in understanding the orientation for surgical reduction. Moreover, the authors confirmed that the AP radiograph significantly underestimated displacement relative to the axial radiograph at all displacements greater than 5 mm.

Perhaps more important than recognizing the ability of plain radiographic views to assess this fracture is the ability of CT to change the treatment decision according to a 2019 study.20 First, the authors confirmed the aforementioned failure of the AP radiograph to accurately represent the amount of displacement for medial epicondylar fractures, with significant differences from measures on the axial CT scans. Second, treatment plans were changed because of the increased amount of displacement seen on CT scans compared with plain radiographs. The findings of past studies evaluating the inadequacy of plain radiograph and the potential benefit of three-dimensional imaging should prove valuable in attempts to understand forthcoming studies comparing outcomes related to the amount of displacement on an AP radiograph, because it is now understood that the direction of displacement is not truly observable on an AP radiograph (Figure 2).

With improved understanding of medial epicondylar fracture patterns and displacement have come advances in fracture management. A 2020 biomechanical and clinical study recently compared three different fracture fragment fixation methods in children because the physis and the fracture pattern can dictate the need to use something other than a screw, such as Kirschner wires or suture anchors.21 The study authors found that from a biomechanics standpoint (via a pig model), screws were stronger and stiffer, and this reached statistical significance. However, all three fixation strategies resulted in radiographic union, and only a single patient (in the screw group) lost reduction. Of note, the suture-anchor group was less likely to require a second surgery for implant removal (P < 0.05), which was calculated to be a cost savings of 10% compared with screw fixation.

In another study, the ability of washers to affect the outcome of medial epicondylar fracture fixation was assessed.22 It is thought that the washer-screw construct may prevent fracture fragmentation and penetration, but concerns exist that it will increase the rate of secondary surgery for implant removal for painful prominence. The study authors found that 31 of 137 children (23%) underwent implant removal; this group did not have a washer nor were they athletes. Moreover, the addition of the washer did not affect subsequent recovery of elbow range of motion. Therefore, the recommendation is to use a washer-screw construct when risk of fragmentation is noted in preoperative planning.







A 2021 study compared the patient position (supine versus prone) in the management of medial epicondylar fractures, with the understanding that prone positioning improves exposure of the fragment (as a posterior structure) but with the need for extensive repositioning.23 The positioning process added an average of approximately 30 minutes to each case (P < 0.001), but with no difference in actual tourniquet time. Despite a statistical difference of 1 mm in the ability to achieve a reduction being noted, with better results with prone positioning, it remains to be seen whether that statistical difference is clinically meaningful.

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May 1, 2023 | Posted by in ORTHOPEDIC | Comments Off on Pediatric Athletic Injuries

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