The Pediatric Athlete
Amanda Weiss Kelly
Each year, 20-30 million children participate in organized athletic programs (20).
There were over 7.6 million high school-age adolescents participating in organized competitive sports in 2009-2010 (17).
About three million pediatric sports injuries occur annually in the United States (13).
High school athletes account for an estimated 2 million injuries, 500,000 doctor visits, and 30,000 hospitalizations annually (19).
Twenty-five to thirty percent of these injuries occur during participation in organized sports, and 40% occur in unorganized sports (13).
SPORT-RELATED CONCUSSION IN THE PEDIATRIC ATHLETE
The Centers for Disease Control and Prevention (CDC) estimate that traumatic brain injuries in children 14 years old and younger result in 435,000 emergency department (ED) visits annually, with approximately half of these injuries being sports related (8). Because many athletic and play activities in this age group are unmonitored and a high proportion of injuries do not result in ED visits, the actual incidence of head injury is likely much higher.
Concussion Management and Return to Play
Because of the longer recovery time and greater risk for long-term neurologic sequelae in pediatric athletes (4), concussion should be co-managed with the assistance of a sports medicine physician and/or neurologist experienced in the management of pediatric concussion.
The current international guidelines for this management are reflected in the consensus statement of the Third International Conference on Concussion in Sport, held in Zurich, Switzerland in November 2008 (16).
At this time, the consensus is that any pediatric athlete suspected of having suffered a concussion should be immediately removed from that game or activity with no return to that activity that day.
The consensus outlines a return-to-play protocol consisting of six rehabilitation stages: 1) no activity until symptom free (complete physical and cognitive rest); 2) light aerobic exercise; 3) sport-specific exercise; 4) noncontact training drills; 5) full-contact practice; and finally, 6) return to play. There should be 24 hours between each stage, and if any return of concussion symptoms occurs during a rehabilitation stage, the patient returns to the previous stage and level of rehabilitation.
Many experts recommend neuropsychological testing prior to full return to play, whereas the Zurich consensus emphasizes that this testing should be used as an informational aid to the clinician rather than being the sole basis for return-to-play decisions.
There is significant variability in concussion management for athletes younger than age 18 years in the number of symptom-free days with no activity between the injury and the beginning of stage 2. This varies among different practices from a minimum of 1 day to 30 days.
A vital point for clinicians to remember is that children may still demonstrate deficits during neuropsychological testing for a period of time after they are “symptom free.” The safest approach in athletes who have had baseline testing and the protocol currently used in many high schools across the United States is to begin stage 2 when their postconcussion neuropsychological testing returns to baseline level (with an age-standardized baseline level for athletes who had no prior testing). An important caveat to this treatment strategy is that current computer-based neuropsychological testing is only valid down to age 10.
There is no consensus regarding when an athlete with a history of multiple concussions should be restricted from further participation in contact sports. Our understanding of the long-term sequelae of different levels of traumatic brain injury is still evolving. With this lack of complete evidence, a conservative approach to management is appropriate. Evaluation for disqualification from further contact sport activities for a pediatric athlete should be considered on an individual basis. The younger the athlete, the lower the threshold should be for minimizing the risk of further brain injury.
FRACTURES IN THE PEDIATRIC ATHLETE
The physis is the weakest structure in the growing skeleton, making it more susceptible to injury than the surrounding muscles, tendons, and ligaments.
The Salter-Harris classification is the most widely used method of describing physeal fractures:
Type I: Through the physis
Type II: Through the physis and metaphysis
Type III: Through the physis and epiphysis (therefore involves the articular surface)
Type IV: Through the metaphysis, across the physis, through the epiphysis, and involving the articular surface
Type V: Crush injury to the physis
Type VI: Injury to the perichondrium
Type I fractures have the best prognosis, with minimal risk for growth arrest in these fractures.
In type II fractures, growth arrest may occur, especially at specific sites, such as the distal femoral physis.
In type III injuries, growth arrest is rare, but since the joint surface is involved, anatomic reduction must be maintained to ensure articular cartilage congruity and prevent future joint degeneration.
In type IV injuries, there is concern for both growth arrest and articular cartilage congruity.
Type V injuries are usually diagnosed retrospectively after growth arrest or angular deformity has occurred.
Finally, in type VI injuries, angular deformities may occur if a bony bridge develops in the perichondrium on one side of the physis.
Salter-Harris fractures can usually be diagnosed with plain films, but magnetic resonance imaging (MRI) and computed tomography (CT) are sometimes used to more accurately delineate physeal injuries.
Apophyseal Avulsion Injuries
Apophyses are growth plates that add shape and contour, rather than length, to a bone. They are often sites for muscle attachment.
Apophyseal avulsions typically occur as a result of violent contraction of the attached muscle (23).
The pelvis is a common site for avulsion fractures. The anterior superior iliac spine (ASIS) can be avulsed by the sartorius muscle with violent flexion of the hip, such as when a sprinter is accelerating in the first few strides from the starting block.
Violent flexion of the hip or extension of the hip when combined with knee extension can also lead to avulsion of the anterior inferior iliac spine (AIIS) by the rectus femoris.
Diagnosis of both injuries can be made with plain radiographs. Treatment is conservative including symptom-limited weight bearing until pain free, followed by rehabilitation and gradual return to activities.
Recovery from an avulsion injury of the AIIS injury is typically more prolonged than that of an ASIS injury.
Abrupt contraction of the abdominal muscles or tensor fascia lata (muscle of the iliotibial band), as with a rapid direction change, can lead to avulsion of the iliac crest. Direct trauma can also fracture the iliac crest apophysis. This commonly occurs when an athlete is tackled in football. Plain radiographs may not be as useful for diagnosis in this injury, because displacement may be minimal. MRI may be helpful in diagnosing iliac crest avulsion. Treatment is conservative and includes protected weight bearing until the athlete is not in pain followed by rehabilitation and progressive return to activity.
Other sites of avulsion injury in the hip and pelvis include the greater trochanter (gluteus medius), lesser trochanter (iliopsoas), and ischial tuberosity (adductors, hamstrings). Diagnosis and treatment are similar to that mentioned for ASIS and AIIS injuries.
Tibial tubercle avulsions typically occur while an athlete is landing or jumping, as a result of a violent contraction of the quadriceps. Excessive bleeding and swelling can cause an anterior compartment syndrome, so a careful neurovascular examination is essential. Diagnosis can be made with plain radiographs. Long leg cast immobilization with the knee in extension for 3-4 weeks is adequate treatment for nondisplaced fractures. Open reduction with internal fixation (ORIF) is required if there is significant displacement of the fracture fragment.
Avulsions of the medial epicondyle are common in throwing athletes. The athlete typically reports feeling a snap or pop during the throwing motion. Anteroposterior (AP) radiographs will demonstrate the avulsion. Minimally displaced fractures can be treated with immobilization, whereas fractures displaced more than 5 mm should receive surgical referral (12).
Vertebral end-plate fractures are an avulsion of the ring apophysis of the vertebra. If the avulsion is from the posterior inferior portion of the vertebra, the apophyseal attachment of the associated disc and the apophysis can be displaced into the vertebral canal, causing neurologic symptoms. This injury can be difficult to distinguish from disc herniation. Plain radiographs can show the separated bony fragment, and MRI can demonstrate marrow edema. For symptomatic displacement of the apophysis into the vertebral canal, treatment is operative removal of the disc and bony fragment. Without neurologic symptoms, initial treatment is conservative management.
Torus or buckle fractures are compressive fractures that lead to failure of the bone at the junction of the metaphysis and diaphysis.
This type of injury only occurs in children and is possible because of the porous nature of their bones.
Torus fractures are stable and heal well. They can be treated with splinting or casting for comfort.
Another fracture that only occurs in children, the greenstick fracture, refers to an incomplete fracture in the shaft of a long bone. There is disruption of one cortex of the bone and bending of the other. The ability of the pediatric bone to plastically deform allows for the occurrence of this type of fracture.
Greenstick fractures with minimal angulation can be treated with immobilization.
Surgical intervention may be required for fractures with significant angulation.
Complete fractures are fractures through both cortices that are often displaced and/or angulated, requiring closed reduction or ORIF.
Wrist and forearm fractures are some of the most common fractures in children.
Most of these fractures can be treated with casting or splinting but may require reduction or ORIF.
Carpal navicular or scaphoid fractures can occur in children with open growth plates and have a high rate of nonunion.
Supracondylar fractures are very common among 3- to 11-year-old children.
Supracondylar factures are one of the pediatric fractures with the highest risk of complications, with neurovascular complications being particularly common.
These fractures are usually sustained from a fall on an outstretched hand, but can also occur as a result of direct trauma. A thorough neurovascular examination is imperative if a supracondylar fracture is suspected.
The diagnosis can typically be made with plain lateral radiographs of the elbow.
Any child with a supracondylar fracture should be referred for evaluation by a pediatric orthopedist, because many require surgical fixation.
Overuse injuries have become more common in children with the growth of competitive youth sports programs (9).
The risks of overuse are more serious in the pediatric/adolescent athlete because the growing bones of the young athlete cannot handle as much stress as the mature bones of adults (5).
The American Academy of Pediatrics (AAP) recommends encouraging athletes to incorporate 1-2 days per week of rest from competitive athletics, sports-specific training, and competitive practice to allow for children and adolescents to recover both physically and psychologically. The AAP also emphasizes that the focus of sports participation should be on fun, skill acquisition, safety, and sportsmanship.
Risk factors for overuse injuries are often divided into intrinsic and extrinsic factors.
Intrinsic Risks for Overuse Injuries
Some issues specific to immature skeletons contribute to the risk for overuse injuries in children. For instance, children have growth cartilage in several areas of the skeleton, and it is particularly susceptible to injury from repetitive stress.
Growth cartilage is found at the physes (epiphysis and apophysis).
Also, as children experience growth spurts, there are rapid changes in bone length, which can lead to a relative inflexibility of the muscle-tendon units that cross joints. This may predispose the growing athlete to muscular, joint, and physeal injury (9).
Abnormalities in alignment may also predispose an athlete to overuse injuries. Pes planus or cavus, overpronation, patellofemoral malalignment, tibial torsion, femoral anteversion, and leg length discrepancies may be related to increased risk for overuse injuries in athletes (9).
Extrinsic Risk Factors for Overuse Injury
Improper training technique can contribute to the risk for overuse injury.
Increasing intensity, duration, or frequency of training too quickly can lead to overuse injury.
In runners, injury may also result from persistently running the same direction around the track or on the same side of the street due to angulation of the running surface.
Also, parental and coaching pressures to increase the intensity of a child’s training can contribute to injuries.
Improperly fitting or worn out equipment may increase the risk of injury. For example, using worn out running shoes or adult-sized weight-training equipment may predispose the pediatric athlete to overuse injury.
Year-round participation in the same sport may increase the risk of overuse injury.
Common Overuse Injuries
A traction apophysitis occurs where a muscle group attaches to a secondary center of ossification.
It is caused by repetitive stress at these sites that can lead to pain and swelling.
The diagnosis of an apophysitis can usually be made on physical examination. In nonclassic cases, radiographs may help rule out other conditions.
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