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Special Considerations For Injuries In Young Athletes

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Special Considerations For Injuries In Young Athletes

Special Considerations For Injuries In Young Athletes

Schmidt and Hollwarth compared the frequency of sportsinjuries in children with their physical location.91 They found that almost 44% of all injuries involve the upper extremities, 16% involve the head, and 34.5% involve the lower extremities. The peak incidence for injuries is age 12. In general, sprains, contusions, and lacerations account for most injuries. In the lower extremities, the knee joint is the most commonly injured area.51,74

Epiphyseal Injuries

The ligaments and articular capsule are firmer than bone and the epiphyseal plate in children.92 As a result, trauma to this region of the maturing skeleton usually injures the cartilaginous epiphyseal plate.4 These injuries result from shearing and avulsion forces as well as compression. The cartilaginous cells of the epiphysis may be damaged, resulting in premature closure of the epiphyseal plate and disturbance in bone growth. (See Figure 14 )

Upper-Extremity Injuries

The clavicle is the most commonly fractured bone in children.81 Most of these fractures are greenstick injuries of the midshaft clavicle. Associated neurovascular injury is rare. However, as in adults, posterior displacement of the clavicle from the sternoclavicular joint can cause compression of the trachea or mediastinal vessels. Treatment is sling of the shoulder and analgesia.

GH dislocations are unusual before physeal closure. As in adults, most dislocations are anterior. Diagnosis and treatment are the same. Orthopedic referral is essential, as many of these patients can develop chronic instability.

More than 50% of elbow fractures are supracondylar and occur as a result of a fall on an outstretched arm with hyperextension at the elbow. Direct vascular injury is uncommon, but the pulse may be diminished secondary to arterial spasm. Neurologic deficits are usually transient but can be due to direct nerve injury. Emergent orthopedic consultation is usually required for these injuries. Forearm compartment syndrome is a feared complication.

The elbow is dislocated more often than any other major joint in children and  adolescents, but it is still an unusual injury. Associated fractures are common. Neurovascular examination is important to evaluate for ulnar nerve and brachial artery injury.81

Hip/Pelvis Injuries

The presence of unfused epiphyses predisposes the pediatric hip and pelvis to traction injuries. Large fragments of bone can be avulsed with sudden and unexpected loads. The anterior superior iliac spine can be avulsed during football when the kicking foot is suddenly blocked or tackled. The psoas muscle can also avulse off of the lesser trochanter. The whole apophyseal plate of the ischium can separate via a pull of the hamstrings. This can be caused by overstretching the leading leg while running. Treatment for any of these injuries is conservative, and surgery is rarely needed.55

Knee Injuries

An avulsion injury may mimic a tear of the ACL. The ACL remains intact, but a large piece of the proximal tibia is avulsed secondary to flexion, twisting, or hyperextension.

In pediatric knee injuries, radiographs may be normal, but be suspicious of a significant injury if the knee is unstable. An unwary emergency physician may mistake a tibial tubercle for an avulsion fracture. Meniscal problems in this age group are uncommon.55

Physeal fractures in the region of the knee may be associated with ligamentous injuries.4 Immobilization and prompt orthopedic referral are mandatory.

Ankle Injuries

The twisting injuries that cause a fracture in adults produce a different pattern of injury in the immature skeleton. Inversion trauma to the ankle of a skeletally immature patient frequently causes separation of the distal fibular physis and spares the lateral ligaments. Physeal fractures are commonly misdiagnosed as ankle sprains, because spontaneous reduction usually occurs and radiographs reveal no bony abnormality.43 In general, ankle fractures in children are minimally displaced. However, when they involve the articular surface, they may require surgery.

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