The Pediatric Athlete
Mininder S. Kocher, MD, MPH
Theodore J. Ganley, MD1
Michael T. Busch, MD1
1Gurus:
Pediatric Sports Medicine
THE GURU SAYS…
PRISM’s successful system of multidisciplinary multicenter research collaboration has already served as a model for other research groups and organizations.
THEODORE J. GANLEY
Pediatric sports medicine is an emerging subspecialty that is a hot field! It is hot in orthopaedic surgery, with new subspecialty organizations such as PRISM (Pediatric Research in Sports Medicine) and study groups such as ROCK (osteochondritis dissecans), PLUTO (pediatric ACL), and JUPITER (patellofemoral instability). Pediatric sports medicine sessions are now regular occurrences in orthopaedic meetings, including AAOS, POSNA, AOSSM, IPOS, AAP, and AANA. Most children’s hospitals have established sports medicine programs. Orthopaedic trainees interested in pediatric sports medicine are often pursuing dual fellowship training in both pediatric orthopaedics and sports medicine, or they are pursuing a single fellowship that has a large pediatric sports medicine component. A recent review of 14,636 pediatric sports medicine cases submitted by candidates for Part II certification by the American Board of Orthopedic Surgeons from 2004 to 2014 showed a large increase in the number of cases performed by dual pediatric and sports medicine fellows from 2.1% to 21.4% over a 10-year period.1
THE GURU SAYS…
One of the real challenges of sports medicine is understanding all of the ways in which overuse and sports injury can create musculoskeletal maladies in youngsters, but we must never forget to consider tumor, infection, and congenital problems as a potential source of what seems to be an ordinary sports-related complaint.
MICHAEL T. BUSCH
Pediatric sports medicine is also a hot field for patients and families. More than 30 million children and adolescents are participating in youth sports in the United States. With increased participation in competitive sports at a young age come increasing rates of injury. More than 3.5 million children 14 years old and younger receive treatment annually for youth sports injuries. Children 5 to 14 years old account for 40% of sports-related injuries in emergency rooms. Recent trend in youth sports includes professionalization, early sports specialization, and increasing rates of burnout and dropout. Youth sports has become a big business, estimated as a $17 billion market. Young athletes are specializing in a single sport year-round at early ages.2,3 With increasing competition, pressure, and specialization come increasing rates of burnout. Almost 45% of children aged 6 to 12 played a team sport regularly in 2008, and now only 37% do. And 70% of adolescents are dropping out of sports by age 13. These children and adolescents leaving youth sports may forgo the health and psychosocial benefits of being physically active.
THE GURU SAYS…
To help avoid overuse injuries, I recommend at least one rest day from the athletes sport each week, one rest week-end each month, and 1 week off sports between each school season.
THEODORE J. GANLEY
Trouble comes in many forms when caring for the young athlete. Although the conditions are not as grave as tumors, serious infections, and trauma, the acute and overuse injuries that affect the young, active child are very common. Sports medicine, like much of pediatric orthopaedics, is the treatment of low-energy trauma or repetitive microtrauma. Demographic evaluations now show that although the total number of children involved in organized sports decreases as the children get older, the intensity of the competition, and training for that competition, increases—and with it, many injuries.4
THE GURU SAYS…
Some young athletes are on two or three teams at a time during individual sea-sons throughout the year. That volume of participation warrants discussions about activity modification, balancing levels of exercise and rest, proper hydration, and proper nutrition and other measures to enhance fitness and minimize the chance of overuse injuries.
THEODORE J. GANLEY
Sources of trouble caring for the pediatric athlete are both clinical and psychosocial. The orthopaedic surgeon will have frequent contact with the overzealous sports parents. Managing these interactions is a key to staying out of trouble. NEWSFLASH! These families often have heavily invested both financially and psychosocially in their child’s sports. Often, the parents are living vicariously through the child’s athletic accomplishments or projecting their athletic insecurities on the child (Fig. 14-1). Other times, parents are simply doing what they think is best for their children, and the whole family structure is focused around the children’s sports activities. Parents may have dreams of their child becoming a professional athlete or getting an athletic scholarship to college, even though the odds of this are exceedingly unlikely. Or parents may simply want their child to excel in one dimension, be popular and respected, or get special consideration
for college admission. Just as treating any child with a medical condition, when treating the child athlete, you must consider the whole family. Beware the “crazy sports parents.” These are parents, who have overly invested in the kid’s sports: devastated at injury, pushing to get them back as soon as possible, and always telling you how great an athlete the child is. These crazy sports parents may require an approach that focuses on putting the injury in perspective and the long-term health of the child. And they may require a clinic visit that lasts longer than 15 minutes.
for college admission. Just as treating any child with a medical condition, when treating the child athlete, you must consider the whole family. Beware the “crazy sports parents.” These are parents, who have overly invested in the kid’s sports: devastated at injury, pushing to get them back as soon as possible, and always telling you how great an athlete the child is. These crazy sports parents may require an approach that focuses on putting the injury in perspective and the long-term health of the child. And they may require a clinic visit that lasts longer than 15 minutes.
THE GURU SAYS…
For many of these sports families, childhood sports is not just about the child’s athletic accomplishments. The entire family’s social group may be with the families of the other young athletes on a team. Their child having to drop out of a team might then mean disrupting these contacts and friendships. What appears to be crazy behavior might simply be a reflection of the loss the entire family is facing.
MICHAEL T. BUSCH
▶ Red Flags for Crazy Sports Parents
▶ Parents talk more than the child.
▶ Parents say “we got injured” or “our injury.”
▶ Parents are wearing the uniform or clothing of their child’s sports team.
▶ Parents who say that their child is “elite” or “being recruited” when their child is less than 14 years old.
▶ Parents whose first question is “When can she get back to sports?”
▶ Parents who can recite their child’s sports statistics from memory.
▶ Parents who have multiple videos of their child’s sports on their phone.
▶ Parents with radar guns to measure their pitch velocity.
▶ Parents who tell you their child has a “high pain threshold.”
▶ Parents whose whole social life and family vacations are tied around youth sports tournaments.
THE GURU SAYS…
Sometimes kids only want their parent to speak but part of our job is to get young athletes to tell us their story and what’s important to them.
THEODORE J. GANLEY
Regardless, the young athlete themselves is often also very invested in their sport. Often their identity and peer group is tied to their sports. Their psychosocial functioning is closely associated with their identity as an athlete. When injured, they may lose this identity and experience psychosocial stress. They may become distraught or cry when you diagnose them with an anterior cruciate ligament (ACL) tear. As pediatric orthopaedic surgeons who have treated patients with osteosarcoma, cerebral palsy, myelodysplasia, or skeletal dysplasia, it can be hard for us to appreciate the impact that a sports injury can have on a young athlete and their family. Although it may seem minor compared to children with
more severe conditions, we still must realize how real and devastating the news is to them. When giving bad sports injury news such as a torn ACL, it can often be helpful to pause and let the family digest the diagnosis and circle back to them in clinic to discuss treatment and outcome since they may be in “shock” from the initial diagnosis with poor retention of information thereafter. Sometimes, even scheduling another clinic visit later in the week can be helpful. Tell the family that you appreciate what bad news this is for them, but let them know that this is a common injury and emphasize the good prognosis in terms of return to sports. There will be time later in the treatment pathway to lay crepe with discussions of reinjury, graft failure, complications, and long-term arthritis.
more severe conditions, we still must realize how real and devastating the news is to them. When giving bad sports injury news such as a torn ACL, it can often be helpful to pause and let the family digest the diagnosis and circle back to them in clinic to discuss treatment and outcome since they may be in “shock” from the initial diagnosis with poor retention of information thereafter. Sometimes, even scheduling another clinic visit later in the week can be helpful. Tell the family that you appreciate what bad news this is for them, but let them know that this is a common injury and emphasize the good prognosis in terms of return to sports. There will be time later in the treatment pathway to lay crepe with discussions of reinjury, graft failure, complications, and long-term arthritis.
Watch for the young athlete who is not coping well from their injury. Initially, many patients and families go through the Kubler-Ross stages of denial, anger, bargaining, depression, and acceptance. However, some patients may experience a true adjustment disorder or major depression that they are unable to cope with. Having had a handful of high-level youth athletes who committed suicide or attempted suicide at some point after their sports injuries, I think it is very important to be proactive and vigilant regarding depression. I let patients know that this injury can have a large psychosocial impact on them. I suggest they talk about how they are feeling, stay connected with their team, redirect their athleticism and training to physical therapy (PT), and focus on the goal of returning to sports. It can be helpful to talk to friends or teammates who have recovered from a similar injury. While it is normal to feel bummed out from being out of sports, if they are having difficulty coping or feeling depressed, then they should seek help. It can be hard to talk to their parents, or teammates, in the limited time we have in the clinic about these issues. We work closely with sports psychologists within our sports medicine program and sports psychologists in the community. Working with a “sports” psychologist has less of a stigma than working with other mental health professionals.
THE GURU SAYS…
It’s important to have everyone treating these athletes—including nutritionists, NPs, PAs, medical and surgical specialists—understand warning signs such as the examination and outcome measures to collectively provide patients with the best referrals and overall clinical care.
THEODORE J. GANLEY
Also be alert for the child athlete who is looking to you or their injury to rescue them from overbearing athletic expectations. They may have played a sport for a long time, but now it is no longer fun or they are not as good as they were. An injury is a “safe” way to drop the sport. This is could be a swimmer with shoulder pain, a gymnast with back pain, or a dancer with patellofemoral pain. They may not be getting better with regular treatment and have negative imaging examinations. Be wary of a pain syndrome, such as chronic regional pain syndrome (CRPS). In fact, many cases of CRPS are diagnosed in the sports medicine clinic.5 But sometimes these are patients trying to leave their sport. Telling them that they need a break from their sport or redirecting to another sport may come as a relief to the athlete and gradual acceptance by the parents. Unfortunately, the higher the level of the athlete, the more difficult such issues are to sort out.
Staying Out of Trouble as a Team Physician
Many sports medicine surgeons and physicians are team physicians. Being a team physician can be an incredible fun and rewarding experience. It can also be a source of stress, pressure, and time sink. I am a team physician for two local high schools, supervise coverage at the Boston Public Schools, am head team physician at a Division 3 college, am the orthopaedic consultant for a Division 1 college, and also cover a number of other events such as the Boston Ballet, the Boston Marathon, USA Track & Field, and the US Ski Team. Being on the sideline at a high school football game, the wings at a ballet performance, or the finish at a ski race allows you to appreciate the athlete in their native environment. It also gives
you a sense of the demands on the athlete and injury mechanisms. Working with athletic trainers at the high school or college level as a well-functioning team is essential. Respect the trainer’s experience and judgment. Let them run out onto the field first and call you over when they need you. Don’t assert your medical credentials as they often know the athlete better than you and may have seen more of a certain injury than you! NEWSFLASH! Being a team physician takes time and energy. The commitment is commensurate with the level of sport. Being a professional team physician sounds glamorous but can be completely time consuming and stressful. As pediatric orthopaedic surgeons, we have unique expertise as high school team physicians and in youth sports leagues. Also look for undercovered sports such as gymnastics, figure skating, running, and dance. These sports may greatly appreciate the attention and can become very devoted to your practice.
you a sense of the demands on the athlete and injury mechanisms. Working with athletic trainers at the high school or college level as a well-functioning team is essential. Respect the trainer’s experience and judgment. Let them run out onto the field first and call you over when they need you. Don’t assert your medical credentials as they often know the athlete better than you and may have seen more of a certain injury than you! NEWSFLASH! Being a team physician takes time and energy. The commitment is commensurate with the level of sport. Being a professional team physician sounds glamorous but can be completely time consuming and stressful. As pediatric orthopaedic surgeons, we have unique expertise as high school team physicians and in youth sports leagues. Also look for undercovered sports such as gymnastics, figure skating, running, and dance. These sports may greatly appreciate the attention and can become very devoted to your practice.
THE GURU SAYS…
Injuries in these athletes can be at times underappreciated relative to those in collision sports. Remembering the exceptional focus and grit demonstrated by these young athletes during extended hours of training can help us to better detect, treat, and prevent over-use injuries.
THEODORE J. GANLEY
Being a capable team physician requires a knowledge base beyond pediatric orthopedics and sports surgery. ORTHOPAEDICS 101: A good team physician has an understanding of concussion, heat-related illness, dehydration, the female athlete, infectious diseases, nutrition, the adaptive athlete, and sports psychology. Look for this in your fellowship training. After training, look to acquire or maintain these skills through team physician courses or becoming involved in organizations such as ACSM and AMSSM.
Remember that youth sports has become a big industry. As a result, you will be faced with questions regarding nutritional supplements, performance enhancement, strength and conditioning training, and specialized equipment. Children don’t need extra nutrients to perform athletically. Supplemental vitamins and minerals for the pediatric athletic are usually expensive and unnecessary. Performance-enhancing substances are a major source of trouble for young athletes.6,7 Chances are very good that if you care for many young athletes, you care for a population that is taking a performance-enhancing substance.6 It has been estimated that 10% to 20% of adolescent athletes (depending on the sport) use some kind of performance-enhancing substance. Although anabolic steroids are the most risky and have received the most attention, creatine, diuretics, amphetamines, and other stimulants can also be problematic.
Children and adolescents are at risk for heat injury and dehydration just as pro athletes are, maybe more so. Children are less efficient at regulating heat because they perspire less when they are hot. Children also make more metabolic heat per body mass than do adults. As a team doctor, you must be proactive in preventing heat injury. You can recommend and enforce a policy that includes mandatory periodic water drinking, cancellation or modification of practice in unsafe weather, and the discouragement of weight loss through water loss (e.g., wrestlers). Helmets should be removed when children are not in contact situations, so heat loss can occur through the head. Daily weights may be done before and after practice to monitor fluid loss.
THE GURU SAYS…
Be aware that the principles of preventing heat injury and dehydration applies year-round rather than just during summer months.
THEODORE J. GANLEY
Sometimes as a team doctor you have to speak up for young athletes who are put in dangerous situations due to limited budgets. You should also insist on proper fitting equipment that is in good repair. Sports equipment and playing fields should be age and size appropriate. Have discussions with the coaches and trainers regarding injury prevention and proper warm-up. Although coaches are loath to give up practice time, emphasizing performance benefits and keeping players on the field can be a convincing argument for warm-up. The medical team should practice simulated cervical spine injury protocols using a backboard and collar. Equipment to remove the facemask of helmets should be readily accessible. Protocols to access emergency medical services (EMS) should be reviewed.
THE GURU SAYS…
During the warm-up time, coaches can address flexibility, strength, and neuromuscular training with programs such as “Ready, Set, Prevent” and the Micheli Center Prevention Program. They are both exercise and injury-prevention programs tailored to pediatric athletes and can be included in prepractice or team practice routines.
THEODORE J. GANLEY
Recent news headlines have exposed team physicians who have sexually assaulted young athletes. Being a team physician means that you are in a position of trust and a position of power. Respecting the moral and ethical obligations of this position is essential. Team physicians should not put themselves in a position where they could be compromised or accused of inappropriate behavior. Examining the athlete should be done with appropriate clothing and ideally with others observing.
THE GURU SAYS…
Most problems in youth sports are nonoperative and really a part of primary care. Most primary care physicians are particularly talented at taking thorough histories, understanding the big picture, and communicating with families.
MICHAEL T. BUSCH
THE GURU SAYS…
We encourage our sports practitioners to contact at least one pediatrician per day and text or call every orthopaedic surgeon who refers a patient. Our athletic trainers who work in the clinic are critical to keeping the lines of communication open with the physical therapists and trainers associated with their patients.
MICHAEL T. BUSCH
How to Build A Pediatric Sports Medicine Practice
You need credibility as both a pediatric orthopaedic surgeon and a sports medicine surgeon. This may mean dual fellowships in pediatric orthopaedics and sports medicine. If you do only a pediatric orthopaedic fellowship, then the local sports medicine surgeons may not respect you as a sports surgeon. Also, ABOS board certification (CSQ) in sports medicine may be required for sports privileges. If you do only a sports medicine fellowship, then the pediatric orthopaedic surgeons may not think you understand growth and the pediatric patient.
Sports medicine is more than sports injury surgery. Strive to understand the medical issues of the whole athlete: concussion, nutrition, psychology, cardiac issues, the adaptive athlete, female athlete triad, biomechanics, etc.
Work closely with medical sports medicine physicians, ideally in your practice. This is a synergistic relationship. Treat them with respect and understand their skills. There are conditions such as back pain, concussion, and patellofemoral dysfunction for which they may have a more effective therapeutic approach. They can also make your practice more surgically efficient by seeing acute injuries and if they need surgery, involving you. In addition, they may be proficient in ultrasound-guided office injections. Incorporation of medical sports medicine physicians, sports psychologists, athletic trainers, and sports nutritionists allows you to provide holistic sports medicine care. Patients and referring providers appreciate this and this may be a competitive advantage in your market.
The pediatricians can be your greatest allies. The pediatrician manages the pediatric and adolescent patient, often until they complete college in their early 20s. As such, they often control and recommend referrals. Pediatricians will appreciate your emphasis of pediatric sports medicine. They say, “The child is not a little adult.” Your mantra should be, “The child athlete is not a little adult athlete!”
If your practice and/or hospital environment limits patients that you can see to 18 years old, you will be limited. This may skew your practice to nonoperative treatment. If you can treat college age patients, this allows you to see similar injuries as older adolescents, follow your high school athletes through college, become a college team physician, and skew toward operative cases. If the pediatricians are seeing the patients through college, you can make the practical case and business case to your hospital administrators. Remember, as an orthopaedic surgeon you are a large net revenue producer for the hospital and ancillary services.
Tip O’Neill said that “all politics are local.” Similarly, develop strong local roots. Become a high school team physician. Coach your kids’ sports and sponsor their team. Give talks to pediatricians, physical therapists, athletic trainers, and parents. Interface with youth sports organizations. The national and international talks that you give are important, but don’t neglect your local connections. These build the bulk volume of your practice.
The number one complaint of referrers is lack of communication! This holds for pediatricians, primary care physicians, other orthopaedic surgeons, physical therapists, and athletic trainers. Get back to them. Your electronic medical record (EMR) may claim that it automatically sends notes to the referrer, but EMR has glitches, the person listed as the referrer may not actually be who referred the patient to you, and a computerized EMR note may be hard to wade through for the bottom line. Send them an email or a text. You will automatically become the most communicative and accessible orthopaedic surgeon they have ever encountered!
Physical therapists can also be your great allies. If possible, try to send patients to local therapists in their community. It is easier for them and it builds local relationships. Give talks to therapists. Appreciate their skills. Learn their language: neuromuscular facilitation, Graston, McConnell taping. After a surgery or an injury, they are often spending much more time with the patient than you are. If a therapist raises a concern about a patient, take it seriously. Soon the therapists will be recommending you to injured athletes and even to patients who are not improving under care of another provider. If a therapist refers a patient to you, refer them back to the therapist for nonoperative or postoperative treatment. It upsets a therapist who refers you a patient to then have that therapist referred to therapy within your system.
Look for underrepresented sports. Everyone wants to cover high school football and in some communities, there is fierce competition to be the team physician. Being a high school team physician does not guarantee that the injured athlete will be treated by you. In point of fact, the patient will be referred by their pediatrician or primary care physician. Figure skating, gymnastics, running clubs, and dance are often undercovered and thrilled to have a physician interested in their unique issues. They tend to be very vibrant communities that will be faithful to your practice.
THE GURU SAYS…
The average high school football team has one or less operative injuries per year. Being a team physician is a true dedication, and not a shortcut to a busy operative schedule.
MICHAEL T. BUSCH
Sports Injuries
Many of the acute injuries that occur to the pediatric athlete are fractures covered elsewhere in this text. This section emphasizes the most commonly encountered pediatric athletic injuries, with the focus on staying out of trouble as you help these young athletes return to sports.
SHOULDER INJURIES
Typical shoulder injuries in young athletes include sternoclavicular (SC) joint injuries, clavicle fractures, acromioclavicular (AC) joint injury, glenohumeral instability, and little league shoulder.
Sternoclavicular Joint Injury
SC joint injuries, although still uncommon, are being seen with increased frequency. Posterior SC joint injuries are usually traumatic resulting from a direct blow to the medial clavicle.8 There is deformity and pain at the SC joint. There may be hoarseness, difficulty swallowing, or vascular insult from posterior displacement of the medial clavicle toward the important mediastinal structures of the esophagus, trachea, and large vessels (Fig. 14-2A). Staying out of trouble with SC joint injuries includes not missing the diagnosis. These injuries are notoriously difficult to view on plain X-ray, including the serendipity view. Three-dimensional imaging (CT or MRI) is required to make the diagnosis and to characterize the injury (Fig. 14-2B). Although traditional teaching is that these injuries are usually medial clavicle physeal fractures since the medial clavicle physis closes late, a recent study showed that nearly half of these injuries in adolescents are true joint dislocations.9 Treatment should be urgent and in the operating room with vascular/cardiac surgery backup. Rare cases have been reported of serious blood loss from reduction of a posterior SC joint dislocation. Stay out of trouble and inform your vascular surgeons. Don’t do this case at the surgery center! Closed reduction has been described with abduction of the shoulder in the horizontal plane with a beanbag between the shoulder blades and percutaneous reduction with a towel clamp. Because closed or percutaneous reduction may redislocate or is often unsuccessful, I tend to operate on posterior SC joint dislocations. This involves open reduction, repairing the intra-articular disk if torn, repairing the periosteal
tube, and stabilizing the medial clavicle and sternum with heavy suture. Ligament reconstruction is not typically needed.
tube, and stabilizing the medial clavicle and sternum with heavy suture. Ligament reconstruction is not typically needed.
THE GURU SAYS…
By contrast, posterior displaced fractures that do not compromise the airway or vessels can be allowed to heal and often remodel without surgery.
MICHAEL T. BUSCH
Anterior SC joint injuries are different than posterior SC joint. Although some are traumatic, many are atraumatic and associated with ligamentous laxity. Some cases are asymptomatic: they have a pop that is not painful, have full motion, and have full function. These can be observed. Cases that are symptomatic will require surgery: open reduction and ligamentous reconstruction. I usually use allograft gracilis tendon through drill holes in the medial clavicle and sternum weaved in a figure-of-8 fashion (Fig. 14-3). Stay out of trouble by drilling carefully in the mediastinum. Chucking up the drill so it can only extend a few millimeters from the tissue protector and connecting the drill holes with an angled curette saves some angst.
Clavicle Fracture
Clavicle fractures are common in sports. Special considerations in athletes include time to return to play and shoulder function. Open reduction internal fixation (ORIF) of displaced clavicle fractures has gained enthusiasm in adolescents extrapolating from treatment trends in adults (Fig. 14-4). However, recent studies have shown similar results in terms of function with nonoperative treatment. Children and younger adolescents have greater remodeling potential. Some sports
parents may push surgical treatment for a sooner return to play. However, in contact sports this may be 6 to 12 weeks with surgery compared with 12 to 16 weeks with nonoperative treatment. Avoid trouble by adopting a shared decision-making approach erring toward nonoperative treatment.
parents may push surgical treatment for a sooner return to play. However, in contact sports this may be 6 to 12 weeks with surgery compared with 12 to 16 weeks with nonoperative treatment. Avoid trouble by adopting a shared decision-making approach erring toward nonoperative treatment.
THE GURU SAYS…
The most definitive indications for surgery are open fracture, impending skin necrosis, and neurovascular compromise. The dominant shoulder in a late adolescent upper extremity athlete, with significant shortening or angulation, is probably a reasonable indication.
MICHAEL T. BUSCH
Acromioclavicular Joint Injuries
Most AC joint injuries in children and adolescents are sprains without substantial displacement (types 1-3) that are treated nonoperatively. Even displaced AC joint injuries (types 4 and 5) in children and early adolescents may be treated nonoperatively. Unlike in adults, the ligaments are rarely disrupted. Instead, the periosteum remains attached to the intact ligaments, allowing excellent healing—sometimes so abundant that the callus is mistaken for a tumor (Fig. 14-5). Avoid trouble by simply watching these injuries recover in most children.
THE GURU SAYS…
Distal clavicle injures in youths are fractures until proved otherwise.
MICHAEL T. BUSCH
Glenohumeral Instability
Shoulder instability is seen frequently in adolescent athletes and can be classified as anterior instability, multidirectional instability (MDI), and posterior instability.10 Anterior instability is usually traumatic and often results in anteroinferior capsulolabral disruption (Bankart lesion). The risk of recurrent dislocation is high in patients 18 years of age and younger, probably over 70%. Fixing the first-time dislocator versus fixing the recurrent dislocator is controversial. A one-size-fits-all approach does not work. I find an MRI helpful to delineate the extent of injury. In the acute setting, an MRI arthrogram is not necessary due to the arthrogram effect of the hemarthrosis. If there is a more extensive labral tear, ALPSA (anterior labral periosteal sleeve avulsion) lesion, HAGL (humeral avulsion of the glenohumeral ligament) lesion, or loose body, then surgery may be indicated initially. I find, however, that most patients can be managed nonoperatively and have surgery if they dislocate again. If the shoulder has dislocated two or three times, the patient and family usually appreciate that the shoulder is dysfunctional preoperatively. If you operate on a first-time dislocator, the shoulder was “normal” to the family before you operated. Stay out of trouble by adopting a shared decision-making process in these cases. Some families are risk averse and want to avoid surgery. Others are more averse to recurrent instability that may take the athlete out of sports and want to have it fixed initially. Also, the timing of the season may impact decision-making. A patient with a dislocated shoulder in the beginning or middle of the football season can often return to sports and have it fixed at the end of the season. I usually do an arthroscopic labral repair and capsulorrhaphy (Fig. 14-6). Open stabilization may be indicated for instability after prior arthroscopic surgery. However, open surgery has potential complications of subscapularis rup ture or losing external rotation. Latarjet coracoid transfer has become very popular in adults and is being performed more frequently in adolescents. Indications for Latarjet include glenoid bone loss, large engaging Hill-Sachs lesion, and “off track” lesions. However, the Latarjet procedure is a larger operation than arthroscopic stabilization and has substantial risks such as nerve injury, nonunion, and stiffness.
THE GURU SAYS…
Before adopting a 70% failure rate as an absolute indication for surgery, you have to ask if it could also be viewed as a 30% rate of unnecessary surgery. Instead of being an absolute indication for surgery, the high failure rate of nonoperative treatment should simply be one of the factors used in making individualized recommendations that the parents use in this shared decision making. Perhaps we also have to look harder at our nonoperative treatment regimens.
MICHAEL T. BUSCH
THE GURU SAYS…
Adolescents seem to have good quality bone and don’t seem to have as many indications for a Latarjet as young and middle-aged adults.
MICHAEL T. BUSCH
THE GURU SAYS…
I have found the remplissage procedure to be useful for the dislocator with a large Hill-Sachs impaction fracture and an intact glenoid labrum.
THEODORE J. GANLEY
MDI is very different from anterior instability. The direction of instability is usually posteriorly and inferiorly. The pathology is usually capsular laxity, not
a labral tear. The typical patient is a ligamentously lax adolescent female. Look for Ehlers-Danlos syndrome and refer to genetics if appropriate. Do a Beighton score. Staying out of trouble means the initial treatment should be PT. Identify shoulder therapists who like to work with these patients as both physical and mental therapist. The shoulder PT for MDI should address strengthening, scapular mechanics, scapular winging, shoulder posture, snapping scapula, and pain control. Beware of the voluntary dislocator with psychiatric overlay. Although I try to avoid surgery in MDI patients, some patients fail PT and have instability that impairs activities of daily living (ADLs). In these patients, shoulder stabilization can be performed by arthroscopic capsulorrhaphy or open capsular shift. I favor open inferior capsular shift in patients with Ehlers-Danlos syndrome or generalized ligamentous laxity as it reduces capsular volume to a greater extent than arthroscopic capsulorrhaphy.11 Be careful of operating in overhead athletes with MDI such as swimmers, throwers, and gymnasts. If their symptoms are with sports but not ADLs, then they may have difficulty returning to sports because of loss of motion and they may be unhappy. If they are having difficulty with ADLs, then I think surgery is reasonable, and I tell them that return to sports is possible but not assured.
a labral tear. The typical patient is a ligamentously lax adolescent female. Look for Ehlers-Danlos syndrome and refer to genetics if appropriate. Do a Beighton score. Staying out of trouble means the initial treatment should be PT. Identify shoulder therapists who like to work with these patients as both physical and mental therapist. The shoulder PT for MDI should address strengthening, scapular mechanics, scapular winging, shoulder posture, snapping scapula, and pain control. Beware of the voluntary dislocator with psychiatric overlay. Although I try to avoid surgery in MDI patients, some patients fail PT and have instability that impairs activities of daily living (ADLs). In these patients, shoulder stabilization can be performed by arthroscopic capsulorrhaphy or open capsular shift. I favor open inferior capsular shift in patients with Ehlers-Danlos syndrome or generalized ligamentous laxity as it reduces capsular volume to a greater extent than arthroscopic capsulorrhaphy.11 Be careful of operating in overhead athletes with MDI such as swimmers, throwers, and gymnasts. If their symptoms are with sports but not ADLs, then they may have difficulty returning to sports because of loss of motion and they may be unhappy. If they are having difficulty with ADLs, then I think surgery is reasonable, and I tell them that return to sports is possible but not assured.
Little League Shoulder
Little league shoulder is widening of the proximal humeral physis from repetitive rotational stress. This is often a cause of chronic shoulder pain in younger pitchers, whereas internal impingement is often the cause of chronic shoulder pain in older adolescent pitchers. Interestingly, proximal humeral physeal changes and acquired increased humeral retroversion is an adaptive change in pitchers to allow for the increased external rotation of the throwing arm seen in adult pitchers. The diagnosis can be made from history, physical examination, and comparison X-rays showing increased widening of the involved arm (Fig. 14-7). The treatment is nonoperative with activity restriction, PT, and pitching mechanics. Stay out of trouble by giving the family a realistic expectation for return to throwing at 4 months instead of 3 to 6 weeks.12 Emphasize PT and pitching mechanics to avoid recurrence. Try to find a biomotion lab that does pitching mechanics, physical therapists who like pitchers, and pitching coaches who understand pitching mechanics and injury.
THE GURU SAYS…
Attention to detail regarding a youth athlete’s core strengthening, hip strengthening, lower extremity balance training, and scapular stabilizers will help ensure that their entire upper extremity has an appropriate, stable platform. Stay out of trouble by strengthening the entire kinetic chain and do not focus solely on the involved joint.
THEODORE J. GANLEY
ELBOW INJURIES
Medial Epicondyle Fracture
Medial epicondyle fractures can occur in throwing or upper extremity weight-bearing athletes such as gymnasts. In throwers, there may be an antecedent history of medial elbow pain before the acute fracture. Whereas there is controversy regarding operative versus nonoperative treatment of displaced medial epicondyle fractures in a typical pediatric patient, I would recommend surgical fixation for the high-demand elbow athlete such as a baseball or softball thrower, or a gymnast (Fig. 14-8). ORTHOPAEDICS 101: The humeral origin of the UCL originates from the medial epicondyle, so the medial epicondyle must be important. Acute fixation followed by early mobilization typically leads to good results. If treated nonoperatively, this can lead to symptomatic nonunion with pain, valgus instability, and ulnar neuropathy. Fixing an established medial epicondyle nonunion is challenging in terms of scar, protecting the ulnar nerve, and mobilizing the fragment back to its base.13 Thus, staying out of trouble with this fracture in the athlete involves ORIF to avoid symptomatic nonunion.
THE GURU SAYS…
While the average kid may tolerate some loss of motion and a very delayed union, many dedicated athletes and families don’t.
MICHAEL T. BUSCH
Little League Elbow
Little league elbow describes injuries about the pediatric throwing elbow related to repetitive valgus loading.14 These injuries include medial injuries from repetitive distraction (medial epicondyle apophysitis), lateral injuries from repetitive compression (OCD [osteochondritis dissecans] of the capitellum), and posterior injuries from repetitive shear (olecranon apophysitis).
Medial epicondyle apophysitis is characterized by medial elbow pain, tenderness at the medial epicondyle, and widening of the apophysis on X-ray. Treatment is nonoperative and similar to little league shoulder: stop throwing, PT, pitching mechanics. Staying out of trouble is setting reasonable expectations regarding returning to throwing, usually in 6 to 8 weeks. If the child throws through medial elbow pain, they can sustain a medial epicondyle avulsion fracture (see above). This warning usually gets the families’ attention and facilitates compliance.
OCD of the Capitellum
Repetitive compressive loading of the capitellum can lead to OCD in throwers and gymnasts. OCD involves fragmentation of the subchondral bone with articular cartilage and can lead to instability and a loose fragment (Fig. 14-9). OCD can be suspected on X-rays and MRI is useful for staging the lesion. If detected early with intact articular cartilage, OCD can be treated nonoperatively with cessation of sports. Approximately 40% of lesions will heal in the elbow, which is lower than the knee (60%).15 Lesions that do not heal can be treated with arthroscopic drilling. Later-stage lesions are treated with either fragment removal and microfracture or cartilage resurfacing with OATS (osteochondral autograft transfer system) plugs from the knee. This can be done through a direct anconeus splitting approach in hyperflexion. High-demand athletes such as pitchers and high-level gymnasts may have better results with OATS. Staying out of trouble in OCD of the capitellum means trying to detect the lesions early where treatment is simpler.