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Stress Injuries of Bone in the Pediatric Athlete

Stress Injuries of Bone in the Pediatric Athlete. Christopher Couture, MD Victory Sports Medicine May 8, 2012. Key Concepts. Skeletal Maturity Critical vs. Non-Critical Fractures. Skeletal Maturity. In skeletally mature, overuse of bone leads to stress fracture

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Stress Injuries of Bone in the Pediatric Athlete

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  1. Stress Injuries of Bonein the Pediatric Athlete • Christopher Couture, MD • Victory Sports Medicine • May 8, 2012

  2. Key Concepts • Skeletal Maturity • Critical vs. Non-Critical Fractures

  3. Skeletal Maturity • In skeletally mature, overuse of bone leads to stress fracture • In bones with open physes, the injury occurs at the physis

  4. Common Features

  5. Historical Features • Insidious onset activity-related pain that gradually worsens with time • Pain generally well localized • Pain relieved with rest, although over time can continue to occur at rest

  6. Physical Exam • Localized tenderness • Rarely warmth, erythema, edema or (for fractures) palpable callus • Pain w/vibratory stimulus inconsistent • Special clinical tests specific to body area • i.e. “hop test” for femoral neck stress fx, “stork test” for pars intraarticularis stress fx

  7. Radiographs • Very specific; not very sensitive • Usually negative early in course • 2/3 initially negative, only ½ of these become positive • Onset of pain can precede positive film by 2-3 months • Characteristic findings: • Skeletally immature: physeal widening, sclerosis or closure • Skeletally mature: periosteal thickening, radiolucent line formation

  8. Triple-Phase/SPECT Scan • Very sensitive; not very specific • Can confirm diagnosis 2-8 days after sx onset • Can help to differentiate between other etiologies of symptoms (ex. medial tibial stress syndrome) • Characteristic findings: positive area of intense uptake on all three phases of scan

  9. MRI • Best combination of sensitivity and specificity • Promising in grading progressive stages of severity • Can localize site of injury and differentiate from other entities such as tumor, osteomyelitis, bony infarct, etc.

  10. Principles of Management • REDUCE ACTIVITY BELOW THRESHOLD FOR SYMPTOMS • Cessation or reduction of inciting sport • Immobilization • Non-weight-bearing • Orthotics (?) • Alternative training to maintain aerobic fitness, muscle tone, stamina • Other • Ice massage, NSAIDs, stretching/strengthening • “Invasive” treatment for displaced or nonhealing fractures

  11. Bone Stress Injuries in the Skeletally Immature Athlete

  12. Physis (epiphyseal plate; pressure epiphysis): the segment of the bone that is responsible for lengthening • Apophysis (traction epiphysis): growth center at point where muscle can attach (tibial tubercle, calcaneus); contribute to bone shape but not length

  13. Repetitive loading alters metaphyseal perfusion • Interferes with mineralization of hypertrophied chondrocytes • Hypertrophic zone continues to widen • Ischemia can lead to osseous necrosis & deformity • Can lead to localized, asymmetric growth or complete cessation of growth • ...although most stress injuries resolve without growth complications

  14. Physeal injuries of Long Bone • Proximal humerus • Distal radius • Distal femur • Proximal tibia • Metatarsals • ANY long bone...

  15. Proximal Humerus (Little Leaguer’s Shoulder) • Sequelae of repetitive traction/rotational forces across physis • Baseball pitchers, swimmers, gymnastics, volleyball • “Adolescent athlete’s shoulder”

  16. Distal Radius • Gymnasts: Most commonly reported physeal stress injury • Radiographically widened physis especially on metaphyseal side • Usually recover with rest & do not experience abnormal growth

  17. Where’s the Abnormality?

  18. Apophyseal Injuries • Osgood-Schlatter • Sindig-Larsen-Johansson • Sever’s (calcaneal “apophysitis”) • Little Leaguer’s elbow (medial epicondyle) • Panner’s (osteochondrosis of capitellum) • Pelvic apophyses (ASIS, AIIS, iliac crest)

  19. Reasons for Concern • Uninformed coaches and parents of children & adolescents • Increasing incidence of lower extremity stress injuries

  20. Countermeasures • Individualized training & skill development • Delay progressions in periods of rapid growth • Variety - avoid repetition • Quality over volume • Periodic physical exam; directed studies • Physical conditioning • Trained personnel (certified athletic trainers) • Periodization • Appropriate assessment of physical maturity for expected demands

  21. A Child Should Never Be Expected to “Work Through the Pain”

  22. Bone Stress Injuries in the Skeletally Mature Athlete

  23. Wolff’s Law • Bone will remodel itself in response to mechanical stress (or more accurately, strain) • Sources of strain include muscle contraction & ground stresses • Bone responds by increasing its rate of remodeling • Resorption by osteoclasts precedes replacement by osteoblasts • Lag time – weaker structure during this period

  24. How Does This Lead To Fracture? • If sufficient recovery time allowed, stronger bone results • If repeated application of stress, microdamage can accumulate • Compensatory remodeling is thought to be able to repair this microdamage, but if repetitive loading continues and remodeling cannot maintain integrity of bone, stress fractures develop • Influenced by number of repetitions, frequency of repetitions, amount of load

  25. Risk Factors • ~ 60% of patients w/stress fracture have had prior stress fracture • Participation in sports involving running and jumping • Rapid increase in physical training program • Poor preparticipation physical condition • Female gender • Hormonal or menstrual disturbances • Decreased bone density • Decreased thickness of cortical bone • Nutritional deficiencies (including dieting) • Extremes of body size and composition • Running on irregular or angled surfaces • Inappropriate or worn-out footwear • Inadequate muscle strength • Poor flexibility • “Type A” behavior

  26. Training Errors • Substantial, sudden increase in training intensity, duration or distance • Sudden change in training surface • Harder, uneven surfaces • Acquisition of new (“inadequate”) footwear • Or keeping old footwear too long (500 mi. rule)

  27. Critical stress fractures require specific attention due to increased rates of nonunion • Include anterior tibia, medial malleolus, talus, navicular, 5th metatarsal, sesamoids • Usually treat nonweightbearing 6+ weeks • Noncritical stress fractures can be treated with a short period of immobilization or relative rest • Include medial tibia, fibula, 2nd–4th metatarsals • Usually return to play in 6-8 weeks

  28. Non-Critical Stress Fractures

  29. Medial Tibia • Posteromedial border of distal 1/3 of tibia • Association with high-arched feet or excessively flat feet • Walking boot • May begin gradual return to activity after tenderness disappears; usually full return to play in 8-12 weeks

  30. Fibula • Minimal role in weight bearing • Stress fractures arise from muscle traction and torsional forces • Usually distal 1/3 • Treat with weight-bearing rest (4-6 weeks), perhaps with short period in walking boot

  31. Metatarsals • Mets 1,3,4 and distal 2 usually uncomplicated and treated with relative rest; walking boot • Gradual return to sport program after tenderness resolved

  32. Base of 2nd Metatarsal • Common among ballet dancers • Can be treated with weight-bearing rest but patients must refrain from training for 6 weeks

  33. Calcaneus • Localized tenderness over medial or lateral aspects of calcaneus, usually at upper posterior margin • Treat: 6-8 weeks weight-bearing rest with soft heel cushion

  34. Cuboid & Cuneiforms • Rare - usually considered non-critical • Treat: weight-bearing rest with short period in walking boot

  35. Coronoid Process • From repeated impact in trapshooting • Presents with nonspecific aching in shoulder • Pain with palpation and resisted active adduction/forward flexion • Axillary view XR • Avoid shooting 6-8 weeks

  36. Humerus • Proximal fractures, medial epicondyle fractures seen in throwers, gymnasts and pole vaulters • Midshaft fractures seen in throwers and workers doing heavy lifting • Pain with throwing or lifting may involve entire upper arm • Treat: rest 6-8 weeks

  37. Radius • Uncommon location - reported in military personnel and tennis, volleyball and softball players, gymnasts and cheerleaders and football offensive linemen • Pain in shaft of radius with exertion; pain with weight-bearing on wrist or active wrist extension • Treat with 6 weeks immobilization

  38. Ulna • Reported in softball pitchers, rodeo riders and volleyball players, racquet sports and football offensive linemen • Pain with underhand maneuvers • Treat with relative rest and modification of biomechanics if necessary

  39. Ribs • First rib: Seen in baseball pitchers and basketball players • Pain with arm motion over supraclavicular area • Other ribs: Seen in softball players, golfers and rowers • Pain with rotation of the trunk • Noncritical: treat with relative rest and gradual return to activity

  40. Spondylolysis • Pars intraarticularis stress fractures • Common in gymnasts, cheerleaders and weightlifters; L4-5 most common levels • Usually involved in repetitive extension load activity • Ultimately complains of significant back spasms (often coinciding with growth spurt) – often misdiagnosed as lumbar strain • Pain with one- or two-leg standing extension tests; gait abnormality 2ndary to hamstrings tightness • Plain XR usually negative; obliques - “collar on the Scottie dog” • Bone scan helpful; SPECT scan or MRI more sensitive • Treatment: controversial – rest +/- corset brace (thoracic lumbosacral orthosis); often requires 3-6 months

  41. bilateral L5 spondys

  42. Spondylolisthesis • Bilateral pars defects allowing slippage of vertebral bodies • Graded depending on amount of slippage • Lateral view XR • High-grade may have radiculopathy • Treatment: Grade 1 or older adolescents with Grade 2 - intensive treatment similar to spondylolysis • Surgical stabilization if progressive, persistent pain or radiculopathy, younger children with Grade 2, all Grade 3-4 (L4-S1 fusion)

  43. Critical Stress Fractures

  44. Femoral Neck • Seen in runners and dancers, especially older athletes • Critical - complications can be severe including AVN, nonunion, deformities and displacement • Present with pain in groin, anterior thigh or knee; aching pain usually precipitated by weight-bearing activity and brought about by significant change in training • Differentiate compression from traction lesion • Treatment: often surgery, especially for all tension lesions; compression lesions can be treated conservatively if mild but often requires bed rest (non-weight-bearing mandatory)

  45. Anterior Cortex of Tibia • Prone to delayed union, nonunion and progression to complete fracture • Vulnerable to nonunion b/c poor vascularity and increased mechanical tension • “Dreaded black line” • Treatment programs include prolonged rest (4-6 months), bone stimulators/TENS; consideration of IM nailing immediately

  46. Medial Malleolus of Tibia • Usually present with weeks of mild discomfort punctuated by acute episode • Excessive ankle pronation with accomp. tibial rotation distribute excessive forces to med mall • Nondisplaced fractures can be treated conservatively with pneumatic leg brace for 6 weeks • Displaced fractures or nonunions require surgery

  47. Tarsal Navicular • Central 1/3: relative avascularity, shear forces in the region • Mild symptoms; vague dorsal pain in midfoot • Critical exam: pain to palpation in “N” spot • Advanced imaging should be pursued early if suspected • 6 weeks non-weight-bearing immobilization; if still tender, another 2 weeks; use physical therapy • If no response or displaced, surgery (screw fixation +/- bone grafting)

  48. Talus • Usually involve lateral body; neck fractures rare • Often present with prolonged pain following ankle sprain despite adequate rehab • Excessive subtalar pronation allows lateral impingement of the lateral process of the calcaneus on the posterolateral corner of the talus • Treat: non-weight-bearing x 6 weeks • Nonunion: surgical excision of lateral process of talus

  49. Proximal 5th Metatarsal • Tuberosity avulsion fracture • Usually result of acute inversion injury • Uncomplicated; treated with brief immobilization for pain relief followed by progressive activity • Jones fracture • Occurs at junction of metaphysis and diaphysis • Acute vs. chronic • Chronic: critical and prone to nonunion • Treated with 6-10 weeks of non-weight-bearing rest • Failure to heal or displaced: fixation screw (early?) • Diaphyseal stress fracture • As for chronic Jones fracture

  50. Sesamoids • Medial and lateral sesamoids at 1st MTP act to increase mechanical advantage of FHB tendon and absorb weight-bearing stress on medial forefoot • Medial sesamoid more commonly affected • Usually requires advanced imaging; need to differentiate bipartite sesamoid from true fracture • Critical: prone to non-union • Treat: non-weight-bearing rest for 6 weeks • If nonunion or splintered, surgical excision

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