Ed Mulligan, PT, DPT, OCS, SCS, ATC

Advanced Physical Therapy Practice: Clinical Orthopedic Residency

Education Series 2014

Pediatric Orthopedic Management

Children and Adolescents

Child = 2 years to puberty Adolescent = onset of puberty to cessation of growth, 

epiphyseal closure, and attainment of adult stature– Adolescent Growth Spurt 

Girls 10‐11  Boys 12‐13 

– Epiphyseal Fusion  Girls 15 Boys 17

Determining Musculoskeletal (vs. chronological) AgeTanner Stages of Physiologic Maturity

STAGE MALE FEMALE

I No pubic hair No breast development

II Minimal pubic hair Breast budsMinimal pubic hair

III Pubic hair over penisVoice changes

Enlargement of breastPubic hair on monsAxillary hair

IV Adult pubic hairAxillary hair

Areola enlargementAdult pubic hair

V Adult Adult

GIRLS BOYS

Determining Musculoskeletal (vs. chronological) Age

Greulich/Pyle Atlas

Greulich/Pyle Atlas– X‐ray of left hand– Available as iPad app

Anatomical and Physiological Differences in Pediatric Patient

Structure/System Pediatric Adult

Skeletal Sites of primary and secondary growth centers

Greater vascularity and porosityStronger periosteumHigher levels of circulating hormones

Fully ossified and closed growth centers

Less likely to completely remodel from a fracture

Soft Tissue Greater tissue pliabilityPredominance of type III collagenLess force productionLoss of flexibility and coordination during growth spurts

Greater tissue stiffnessPredominance of type I collagenGreater muscular force production

Metabolic Greater energy expenditure during activityPoor thermoregulation, longer to acclimatize to heat

Great mechanical efficiencyEfficient temperature regulation

What you see … What I seeWhat you see … What I see

Adolescent Injuries

Participation in athletics is high– 55% participation (59% male vs. 41% female) according                                            

to 2011 survey of National Federation of State High School Associations– Texas has the most (10% of U.S. population)

Overuse injuries accounted for 10% of injuries in 1980, now 50% Traumatic injury rate relatively unchanged

– 6% will sustain traumatic sports injuries that require medical care  in 1980; 7% more recently

Injury rate increases as age increases– 3% injury rate in elementary school, 7% in junior high, and 11% in high 

school

Injury Source

40% in unorganized sports 38% in physical education class 15% in organized school sport 7% in community sponsored sports

Highest injury rates occurred in football, gym games, and speed augmented sports (roller and skate boards)

Musculoskeletal Risk Factors

Structural qualities are different in children as comparedto adults, therefore healing responses also differ

Immature Musculoskeletal System

The weak link is the growth plate (epiphyses) and the area of tendon attachment (apophysis)           

The growth plate is vulnerable                                                            to abnormal mechanical                                                         pressures/forces and alterations                                                        in the timing, direction, and                                                            magnitude of the force

Unique Adolescent Risk Factors

Pliable bones Articular cartilage is soft and has 

decreased resistance to repetitive loading

Ligaments 2‐3 x stronger than centers of bone growth

At greater risk for apophyseal avulsion and tendon inflammation rather than muscular strain or tendonitis

Rapid Growth

Bone elongation is faster than muscle elongation resulting in inflexibility

Muscle imbalance predisposes to sprains, strains, and overuse injuries

Differential growth rate of bone and soft tissue during periods of growth creates imbalances that can lead to injury

Somatotype

• Inconclusive evidence linking body type to incidence of injury

• Some studies suggest                                                           that heavier or obese                                                         athletes tend to be                                                           injured more often

Adolescent Flexibility

Some investigators believe flexibility has on effect on risk of injury – others do not

“abstract” ideal along the continuum                                                of flexibility

Joint hyperlaxity (especially knee                                                       and shoulder) have been implicated                                                  as risk factors

“Tight” adolescents are at higher                                                       risk for apophyseal and soft tissue injuries

Adolescent Strength

Researchers do agree that increased muscle                                       strength is important in averting injury

Weak Neck ‐ cervical spine and soft tissue injuries Weak Rotator Cuff ‐ shoulder subluxation and tendinitis Weak Trunk ‐ low back and hamstring injuries Weak Quads ‐meniscal and patellofemoral injuries Weak Lower Leg ‐ ankle sprains, “shin splints”, and Achilles injuries 

Resistance Training in Children/Adolescents

Safe and effective if age appropriate guidelines followed– Most injury occurs with improper techniques, excessive 

weight/resistance, and lack of adult supervision

Strength changes and muscular hypertrophy will not be distinguishable until post‐puberty

During preadolescence strength changes are related to neurological mechanisms– Increased motor unit activation– Motor unit coordination/recruitment– Intrinsic adaptations 

Weight Training General Guidelines

Teach proper technique with minimal loads or resistance Supervision/instruction from qualified fitness                                 

or medical professional Provide exercise variety of all major muscle                                   

groups Particular attention to the core muscles                                     

(hips/trunk)

Consider Periodization– systematically varied over time

Weight Training General Guidelines

No ideal combination of sets/reps/frequency– 2‐3 x wk, nonconsecutive days– 2‐3 sets of 10‐15 reps

Intensity– Training intensity of 75% of 1 RM                      

or 6‐7 on perceived exertions scale Velocity – moderate General Design

– Incorporate balance and coordination– Emphasize functional movement and multi‐

directional exercise

Unique Considerations in Pediatric Orthopedic Examination

Growth status (height/weight change) Parental involvement Intellectual Capacity, Level of Attention, Fear level, etc Child activity level and interests Posture/Postural Habits Different expectations regarding                          strength/flexibility

Functional assessment whenever                                     possible

Congenital Orthopedic Issues

Congenital Orthopedic Problems

Developmental Dysplasia of Hip Legg‐Calves‐Perthes Disease Slipped Capital Femoral Epiphysis Tibial Varum (Blount’s Disease) Talipes Equinovarus (Club Foot) Metatarsus Adductus Scoliosis Torticollis Start with Normal Physiologic Development

Normal Physiologic Pediatric Development

Femoral Version

Angular difference between axis of femoral neck and transcondylar axis of the knee

40° anteversion and decreases progres‐sively to normal of 8‐15° by the age of 8

Assessed by Craig’s test and/or asymmetry in IR and ER of the hip

Treatment usually unnecessary due to spontaneous de‐rotation but can address impairments that promote in‐toeing

Angular difference between transmalleolar axis and the transcondylar axis of the knee

External tibial torsion increases from about 5° at birth to 15‐20° at skeletal maturity

Assessment:  — Evaluate amount of posterior displacement of

lateral malleolus compared to medial malleolus with the knee flexed to 90°

Osteotomies generally only considered when deformity is + 3 S.D. — > 10° internal torsion or > 35° external torsion

Normal Physiologic Pediatric Development

Tibial Torsion

Natural Development of Coronal Plane Knee Alignment

Bowlegs:  up to age 1½‐2 yrs and straightening by 2½ years Knock‐Knees: up to 4 yrs and straightening by 6 years

When to be concerned:– Delayed motor milestones– Marked unilateral asymmetry– Persistence of normal variation                                                             

beyond age when usually resolved– Red Flags:  difficult birth, prematurity

Developmental Dysplasia of Hip (DDH)

Hip anomalies  with predisposition to instability and dislocation

Incidence– 1 per 100 – subluxation – 1 per 100 – dislocation– 6:1 female‐to‐male ratio

Etiology– Multifactorial– small intrauterine space, breech delivery, hormone laxity

DDH

Additional Risk Factors– White and Navajo Indian– First Born– Female– Breech delivery

Requires post‐birth US screening

Complications if untreated– Pain– Waddling gait with decreased agility– Early onset hip OA

DDH Signs/Symptoms

Clinical Examination– Newborn

5‐10° asymmetry or limitation of hip ROM Asymmetric thigh or gluteal folds

– Older children  exhibit trendelenberg or waddling gait Unequal femoral length

Special Tests 

DDH Special Tests

New Borns Ortolani Test

– From FLEX/ADD  ABDUCT hip– + test = clunk

Barlow Test– From FLEX/ABD ADDUCT hip with post glide– + test = dislocation/clunk

3 months or older Galeazzi’s Test

– One knee lower than the other

Barlow Maneuver Ortolani Maneuver

DDH Treatment

• Initial treatment is a Pavlik harness that maintains hips in flexion (90‐100°) and abduction (45‐50°) with                                    neutral rotation – the “M” position

• Parental educational regarding hip extension                                 and adduction avoidance

• Children over 6 months are usually to                                               large to tolerate harness

• 80% success rate• If unsuccessful, periacetabular osteotomy                                       

to improve the acetabular orientation

Legg Calves Perthes - coxa plana

Axial non-enhanced CT scan through the hip clearly shows the loss of structural integrity of the right femoral head.

avascular necrosis resulting in a flattening of the femoral head

LCP Disease

Stages1. Avascular phase – blood supply stops2. Collapse (fragmentation) phase – acetabulum collapses3. Revascular phase – blood supply restored4. Healing (reossification) phase – flattened femur replaced 

with new bone5. Healed phase – formation of femur completed (18‐24 mo.); 

shape may continue to round until end of skeletal maturity

• Prevalence: 1:1200 kids (males > females)

• Self limiting disease with spontaneous healing as necrotic bone is replaced by new bone formation over 1‐4 years

• Can have residual effects from incon‐gruency and persistent hip abductor weakness

Legg-Calves-Perthes Disease

Signs and Symptoms:– Usually a gradual onset in boys (4:1) between the age of 4‐8– More typical in small for age, hyperactive kids– Mild limp (trendelenburg) following activity with vague hip and groin 

pain; symptoms usually relieved by rest– Limitations in Abduction and Internal Rotation

Management:– Rest (reduced activity), crutches prn, maintain ROM (especially 

abduction), NSAIDs, – Surgery indicated if over 8 (femoral or pelvic osteotomy)

Legg-Calves-Perthes Disease

Slipped Capital Femoral Epiphysis (SCFE)

Femoral head slips in a posteromedial direction on the femoral neck

Acute:  sudden onset of pain/disabilityChronic:  > 3 week onset of pain/disabilityAcute‐on‐Chronic:

SCFE Onset

Acute — sudden onset of pain/disability with significant trauma, resulting in restricted hip abd and IR

Acute‐on‐Chronic — aching pain in hip/thigh/knee for weeks or months as a result of a chronic slip, followed by trauma causing acute symptoms

Chronic — > 3 weeks of pain and disability with history of limp and losss of hip abd and IR ROM

Signs/Symptoms– Obese males between 9‐15 YO (periods of rapid growth spurt)

– BEWARE of lateral knee pain– Limited and painful hip internal rotation with hip often held in flexion secondary to psoas spasm

– Leg Length Discrepancy; involved limb shortens

Post‐op Management– 4‐6 weeks of NWB; followed by gradual resumption      of weight‐bearing and ADL activities

Slipped Capital Femoral Epiphysis

SCFE has more limitation in flexion SCFE symptoms are usually more severe Evidence of slippage evident on radiograph

Clinical Evidence of Slippage Stable 

– vague knee/hip pain;– antalgic limp with toe out gait

Unstable– hip flexion accompanied by ext. rotation– unable to walk without crutches

Differentiation of SCFE and LCP

Tibia Vara (Blount’s Disease)

Infantile < 3; Juvenile 4‐10, Adolescent; > 11 yo Radiograph evidence

– Varus angulation secondary to ossification in the medial aspect of the tibial metaphysis resulting in tibial adduction and internal rotation

– Hip‐knee‐ankle line Knee joint falls outside that line  (bow leg)

Differential Diagnosis– Other skeletal dysplasia, rickets,  Vit D deficiency, 

physiologic genu varum

> 1% prevalence that increases to 2.5% in obese and/or African‐American children.

Blount’s Disease Management

Bracing for infantile onset Surgery may be necessary for 

failed bracing, delayed diagnosis, or marked deformity (> 13°)

Surgical Choices– Guided growth (hardware on 

health side to allow injured side to catch up)

– Tibial Osteotomy

Talipes Equinovarus (Club Foot)

Common (1/1000) idiopathic congenital deformity – Twice as common in boys and 50% of cases are bilateral– Extremely disabling foot position– Ankle plantarflexed, rearfoot inverted,                                           forefoot in adduction, plantarflexed 1stray resulting in disadvantageous foot                                             position  and mobility necessary for                                                weight‐bearing

Club Foot Treatment – Ponseti Method

Needs to begin within 1‐2 weeks of birth to maximize outcome Precise sequence of manipulations that lead to deformity 

correction– Foot manipulated at weekly intervals to                                         

maximize corrected position followed by                                          casting to maintain position 

– Usually followed by Achilles lengthening surgical procedure

After correction of deformity child wears “boots                                               “and bar” orthotic continuously for 3  months                                               and then during naps until the age of 4– abducted, ext. rotated, and dorsiflexed position

Metatarsus Adductus

Forefoot curved medially with rearfoot in slight valgus position

Treatment– Mild (or flexible) – stretching, cast‐immobilization, and shoe 

therapy (straight and/or reverse last)

– Severe (or structural) – manipulation; serial                                                   casting, and/or surgical correction

Surgical Correction includes rearfoot realignment,                                               tendoachilles lengthening, and medial cuneiform                                                opening/cuboid closing osteotomy

Scoliosis

3‐D deformity with > 10° deviation in coronal plane Idiopathic prevalence 1‐3% Three Types

– Congenital ‐ abnormally formed vertebrae– Syndromic – neuromuscular disorder– Idiopathic – unknown cause; most common variety with onset > 10 years old

Structural  – Fixed, rotary component with trunk flexion– Named for location and direction – “C” or “S” curves

Non‐structural– Corrects with lateral bending and curve (postural scoliosis) not present in 

forward bending

Right Thoracic

Left Lumbar

Adam’s Forward Bend Test

Scoliosis screening – assessment of rib prominence

Presence of LLD

Pelvis/Waist line                                                                 obliquity

Shoulder/Scapular                                                               obliquity

Cobb Angle – Standing Radiograph

Scoliosis

Cobb Angle• < 25° ‐monitor• 25‐40° nonsurgical treatment• > 40° consider surgical intervention

Curve Progression• Healthy child unlikely to progress if curve is < 30° at maturity 

• > 50° progresses even after growth is finished

Scoliosis Treatment

Goals:– Maintain (or halt) curvature progression– Address weakness and flexibility impairments 

strengthen convex, stretch concave– Pain Management

Systematic review:– Effectiveness of bracing is controversial– Exercise therapy can retard curve progression 

and offer improvement in impairments

Exercise Approaches

Schroth Method – intense in‐house multi‐discipline program consisting of active strengthening, auto‐

correction exercise,  therapist facilitation, bracing, ADL counseling, and behavioral therapy

DoboMed – active 3‐D auto‐correction exercise in ‐CKC, rib mobilization and respiration training

Side Shift Program – self lateral shifts and tilt exercise combined with hitch exercise (lifting and holding 

the limb on the convex side)

SEAS Program (Lyon Method) – auto‐elongation exercises with emphasis on deep spinal stabilization training, 

behavioral modification, and family involvement

Fusco C, et al, Exercise Systematic Review, Physiother Theor Prac, 2011

Torticollis (Wry Neck)

Congenital Muscular Torticollis Shortening of SCM

– Laterally flexed toward and rotated away from shortened side Facial asymmetry  Plagiocephaly – flattening of the skull

Etiology (usually presents in first month)– Intrauterine constraint (e.g. breech presentation)– Birth trauma (e.g. difficult delivery)

Much higher prevalence of hip dysplasia

Torticollis Management

Feeding– Chin should have to rotate towards side of 

involvement 

Positioning/Carrying– Hold so that child has to tilt and rotate to 

see environment– Encouraging play toward direction of 

limitation

Daily manual stretching Surgery may be necessary if not 

improved after 6‐12 months

Right Shortened SCM

Overuse Injuries

Pathogenesis– Natural process of healing is unable to keep up with breakdown of tissue

– If stress repeats before rebuilding                                               and recovery – inflammatory                                                     response  may occur

– Tissue progressively weakens and                                                may fail

Factors Contributing to Overuse Injury

Factors contributing to overuse

Injuries

Condition of the Athlete Inadequate

Rest Poor Technique

Inappropriate Training

Previous Injury

Equipment

Playing Surface

Adult Peer Pressure

Maturity Level

Self-Esteem

Body Morphology

Muscle Imbalances

Anatomic Alignment

Inflexibility

Menstrual Status

Instability-Laxity

Growth Plate Status

Apophyseal Injury

Musculotendinous units pulling on                                            developing insertional areas– Cause traction injury with bony change

Therapy typically starts after 2‐4 wks rest– Flexibility (pain free range)– Strengthening

Progression from concentric to eccentric – Slow, careful progression to prevent avulsion

Sites for Hip Apophysitis

Iliac Apophysitis

Mechanism of Injury– gradual onset of apophyseal in‐flammation at the ossification center of the growth plate 2ary to repetitive contractions by the oblique abdominals, gluteus medius, TFL, and hamstrings

– particularly common in adolescent runners, soccer players, or jumpers

ASIS

Lesser Trochanter

Ischial Tuberosity

Signs/Symptoms– pain over the growth plate at the muscular insertions

– increased pain with resisted contractions 

Management    – 4‐6 weeks of rest with gradual resumption of training activities

– work on running and jumping mechanics

Complications: Avulsion fractures

Hip Apophysitis

Osgood-Schlatter Syndrome

Activity related traction apophysitis at the tibial tubercle

20% prevalence in sports; 5% in non‐sporting child

Self‐limiting (by musculoskeletal maturity)and spontaneous recovery in 90% over 1‐2 year period 

Radiographic Findings

Apophyseal irregularity with separation from the tibial tuberosity in early stages 

fragmentation in the later stages

persistent bony ossicle may be visible in a few cases after fusion of the tibial epiphysis 

Differential Diagnosis

Sinding – Larsen – Johansson Syndrome– traction apophysitis at inferior                                          pole of patella

Hoffa Syndrome– fat pad syndrome

Tibial Tubercle Avulsion Fracture– Violent, forceful quad contraction (single event)

OS Signs/Symptoms

Pain/swelling at patellar tendon insertion Limited and painful quad activation Painful kneeling

Athletically active with increased plyometric load

Osgood-Schlatter Syndrome

Subacute Care– Quadricep and Hamstring stretching– Bubble pad with infrapatellar strap during activity– Quad isometrics and SLRs

Acute Care– Ice massage to tibial tubercle– Aspirin prn– Selective rest from irritating activities 

avoid total immobilization minimize running/jumping activities

Sinding-Larsen-Johansson

Inferior pole of patella– Differentiate from OS via palpation

Similar presentation to Osgood‐Schlatter– Pain specific to inferior pole

Most common in 10‐12 y.o. males

Managed similar to OS

Sever’s Disease (Calcaneal Apophysitis)

tight Achilles tendon (particularly in the rapidly growing athlete) pulls on the calcaneal epiphyseal attachment producing a disruption of circulation and possible fragmentation of the calcaneus

common with cleated shoe wear or rapid alterations in the heel height of the athletic shoe– Ground reaction forces dissipated through 

less surface area (contact area directly under cleated area more concentrated)

Sever’s Disease

SIGNS/SYMPTOMS– young athlete (8‐11yo)– pain on the posterior heel at the insertion

of the achilles tendon  and positive heel squeeze test

– aggravated by activity and relieved by rest– Self‐limiting condition ends at skeletal 

maturity when the growth plate closes

TREATMENT – judicious rest and the insertion of bilateral 

heel lifts  to alleviate injurious stresses– gastroc/Soleus stretching

Little League ElbowMedial Epicondyle Apophysitis

Traction apophysitis of medial epicondyle in adolescents from valgus overload

Graded according to severity of symptoms and degree of displace‐ment or avulsion

Throwing faults– Open up to soon (arm behind body)

– Excessive ER

Examination

Position(s) played, number of throws/week, and pitch type Palpation for area of tenderness Special Tests

– Valgus Stress Test at 30°– Moving Valgus Test– Milking Sign– Valgus Extension Overload

Elbow Flexor/Pronator Strength Axioscapular/Scapulohumeral Strength

Management

Minimum 4‐6 weeks rest Icing Flexor/Pronator Training Throwing biomechanics analysis Parental/Coach Education:

– For the average pitcher age 8 to 13 years, mastering the fastball and change‐up pitches alone will allow a thrower to remain highly competitive

What do you see?

Classic radiographic signs are physeal widening on standard AP X‐rays,  lateral fragmentation or calcification, sclerosis, demineralization, and cystic changeAnton C, Pediatr Radiol, 2010

Would it help to know this is 13 year-old boy who plays baseball

Widening of the proximal humeral physis on the right while normal physis on the left

Little League Shoulder Proximal Humeral Epiphysiolysis

epiphysiolysis is thought to resemble that of a stress fracture or Salter–Harris type‐I injury (growth plate separation)

Most common in high performance pitchers from ages 11‐16

Caused by large rotational torque and poor  throwing mechanics 

Palpation tenderness at proximal/lateral humerus that is aggravated by throwing

GIRD is usually present (GHL IR ROM Deficit)

Little League Shoulder Proximal Humeral Epiphysiolysis

Little League Shoulder

Rehab– Provide early rest (6‐12 wks duration)– Scapular stabilization training– Progress to isotonic RC strengthening– Implement proprioceptive techniques– Must complete pain‐free interval throwing program prior to 

return 90% are asymptomatic after 3 months of rest

Carson WG, Am J Sports Med, 1998

What is the critical intervention strategy?

Protect the Young Throwing Athlete

Watch and respond to signs of fatigue 4 months/year off Adhere to pitch count limits and days rest 

recommendations (nexttwoslides) Avoid pitching on multiple teams with overlapping seasons Avoid using radar guns Learn good throwing mechanics emphasizing fast balls and 

change‐ups A pitcher should not also be a catcher for his team  If a pitcher complains of pain – get an evaluation from a 

sports medicine physician  Inspire fun and encourage multiple‐sport                          

participation

Daily Limits on Number of Pitches

Age 2006 USA Baseball Guidelines 2010 Little League Baseball Regulations

17‐18 NA 105/day

15‐16 NA

13‐14 75/game 95/day

11‐12 75/game 85/day

9‐10 50/game 75/day

7‐8 NA 50/day

Guidelines for Pitch Volume and Rest

Age 2006 USA Baseball Guidelines 2010 Little League Baseball Regulations

13‐14 125/wk ‐ 1000/season ‐ 3000/yr

11‐12 100/wk ‐ 1000/season ‐ 3000/yr

9‐10 75/wk  ‐ 1000/season ‐ 2000/yr

All ages21‐35 pitches  1 day rest36‐50 pitches 2 days rest51‐65 pitches  3 days/rest66+ pitches 4 days/rest

OCD Introduction

Osteochondrosis is a joint disease occurring in rapidly growing children and adolescents characterized by interruption of the blood supply to the bone, in particular to the epiphysis, followed by localized bony necrosis. 

Osteochondritis dissecans is a painful variety of osteo‐chondrosis where the articular cartilage softens and the  bone is inflamed with a creation of a flap of cartilage that further dissects away from its underlying subchondral attachments

OCD

Location1. Knee: most commonly affected; 

intercondylar region of MFC2. Elbow:  capitellum of baseball pitchers3. Talus:  athletic teenagers, especially males

Signs/Symptoms– Joint effusion, pain– Knee pathology:  antalgic gait or “locking” 

due to loose body

Knee OCD

Wilson’s Test– IR leg and extend knee from full flex, repeat with ER– (+) when IR is painful and ER is not

Treatment– Non‐displaced, mild/moderate cases

Short period of immobilization; quad strengthening, and gradual return to activity

– Loose fragments/skeletally mature adolescent Fragment < 5 mm:  simple excision Fragment > 5mm:  internal fixation

Kohler’s Disease

Osteochondrosis of navicular bone

Incidence – rare; in children 6‐9 yrs old Signs/Symptoms

– Localized pain in area of navicular bone– Antalgic gait with weight bearing shifted laterally

Treatment– Generally resolves with time– May need brief period of casting if severe pain                                              

with ambulation

Juvenile KyphosisScheuermann’s Disease

Definition– Osteochondrosis of thoracolumbar vertebrae resulting in kyphosis of > 40° that is not corrected by active hyperextension

– Anterior wedging of 3+ adjacent vertebral bodies resulting in decreased intervertebral space and LBP

Incidence– Boys > girls (0.05% prevalence) in 13‐16 yo– Concurrent scoliosis present in 30‐40%

Juvenile KyphosisScheuermann’s Disease Treatment

Trunk extensor strengthening

Thoracolumbar passive trunk extension stretching

Core training of deep postural muscles and gluteals

LE stretching (hamstrings)

Orthotic bracing and/or surgery                       in more severe cases

Broken Bones

Pediatric Fractures are Unique

Immature Bone

– Thick  fibrous periosteum is strong and not easily torn at time of injury

Ligaments are often stronger than                                                     growth plates 

– Physeal (growth plate) fracture                                             is more common than ligament                                                    sprains or joint dislocations

Pediatric Fractures are Unique

Fractures heal more rapidly (than in adults)

– Ex: adult femoral shaft fracture takes 5 mo. to heal while it takes 3 wks in newborn

– Non‐union fractures are rare in children

– Significant remodeling can occur at fracture site allowing some malunion deformities to correct spontaneously

– Complications include osteomyelitis or growth disruption

Saltar-Harris Fracture Scale

Type Description

I Follows course along physis

II Runs along physis and through metaphysis

III Runs along physis and through epiphysis

IV Travels through metaphysis and epiphysis, transecting physis

V Crush fracture

Salter-Harris Physeal Fracture Mnemonic

Common Fracture Types

Torus fractures (“buckle fractures”)– One side of the bone is compressed 

causing the other side to bend away from the growth ; stable with no separation or displacement (no fracture line)

– Common areas:  distal radius and ulna– Heal quickly  in 3‐4 wks with cast or splint

Greenstick fracture– Fracture line through one side of the bone 

causing it to bend away– Common area: clavicle

Supracondylar Fracture

Mechanism:– Usually in children (under 12) from a FOOSH

Signs/Symptoms– appears to be a dislocation with distal                    

humerus and olecranon displaced backwards and proximal humeral shaft displaced forward                                                    

Miscellaneous:  – Injury treated as an orthopedic  emergency– 4‐6 wks immobilization before focusing on 

regaining extension ROM– Complications include Volkman's ischemic 

contracture

Spondylolysis

Stress fracture or defect of the pars interarticularis due torepetitive movements of  rotation and extension

Spondylolisthesis

Forward slip of vertebrae

– Grade I       25% slippage

– Grade II 25‐50% slippage

– Grade III     50‐75% slippage

– Grade IV     > 75% slippage

Spondy Signs/Symptoms

Insidious onset of unilateral low back pain

Pain with active movement testing – extension— Accentuated with hyperextension and ipsilateral 

rotation in single limb stance

Hyperlordotic posture with possible step off sign– Tight hamstrings– Short torso with flat buttocks– Rib cage appears low and iliac crests high– Vertical sacrum; lacking full hip extension

Athletic Populations at Risk for Spondy

Activities that require or have emphasis on repetitive lumbar hyperextension Gymnasts (43% elite; 63% Olympic) Football Offensive Lineman Divers Pole Vaulters Weight Lifters Wrestlers Dancers High Jumpers Swimmers (butterfly)

Spondy Treatment Principles

• In absence of neurologic symptoms, Grade I & II respond well to conservative interventions

• Restriction from aggravating activities• Non‐rotational hyperextension or axial loading 

movements

• Thoracolumbosacral bracing to limit or  prevent lumbar extension (physician preference)

• Anti‐lordotic postural training: • Core/Abdominal strengthening • Hamstring /Hip Flexor stretching

Spondy Prognosis

Bony Union— 29% patients with bilateral spondy healed completely— 100% patients  with unilateral healed completely (Sys et al, Eur Spine J, 2001)

Return to full activity at about 4 months

If resolution of symptoms does not occur, surgery indicated — usually wait 9‐12 months before recommendation for surgery

III and IV may require surgery (particularly if athlete is still growing)— posterior lateral fusion(most common)— decompressive laminectomies (more severe slips)— 82% post op were able to return to sport (Debnath et al, JBJS, 2003)

“Nursemaid’s” or Pulled Elbow

Definition– Radial head subluxation

Cause– Radial distraction when swinging a child by the arms or pulling up by arm

Signs/Symptoms– Elbow pain at radial head– Elbow held in slight flex

1. Pressure on radial head

2. Grasp wrist and apply slight traction

3. Supinate the forearm while flexing the elbow to 90°

May need 2‐3 weeks of casting if recurrent

Pulled Elbow Reduction

Adolescent ACL Injuries

The risk of surgical management to prevent further joint deterioration in the young athlete probably outweighs the concern for growth plate arrest from drilling the surgical tunnels for graft passage  

Additionally, we have good retrospective data that indicates that bracing and activity modification have a poor likelihood of allowing returning to pre‐injury activity levels

Post-Op Rehab Consideration for

Adolescent ACL Reconstruction

Surgeon may drill a more vertically oriented tunnel to minimize growth plate arrest

Because of the more vertical graft placement– therapists should expect more difficulty in attaining 

post‐op flexion ROM.  

Post‐op rehab is modified from the typical adult perspective – Despite the lack of evidence for post‐op bracing it 

is a needed reminder to the adolescent that they had recent major knee reconstruction

Adolescent ACL Reconstruction

• Surgical technique is dictated by the physiological bone age • Physis is avoided in pre‐pubescent's (ITB tenodesis or physeal‐sparring) • Transphyseal graft passage is safe for those within 3 years of bony maturity

Immature ACL Injury

> 6 years Growth Remaining

ITB TenodesisExtra-articular

> 3 Years Growth Remaining

Tanner Stage I‐IIMales < 12; Females < 11

Physeal SparingAll-EpiphysealTunnels and Fixation

< 3 years Growth remaining

Tanner Stage III‐IVMales 13‐16; Females 12‐14

Trans-physealTunnels and Fixation

At MaturityTanner Stage VClosing tubercle with < 6 months bone growth remaining

Patellar Autograft

Surgical Decision-Making Algorithm

Injury Prevention

According to the AAP and NATA ‐ 50% sports related injuries are avoidable Pre‐participation Screening  C Preseason Conditioning A Adult Supervision with Educated Coaches and Medical Personnel A Wear the right equipment (that fits) C Improve Biomechanical Factors (use good technique) C Improve strength (core) and flexibility A Time off (at least one day/week and 3 months/year) C Multi‐sport emphasis with delayed specialization C Reduce Training Error – Gradual increase in training IDF C Reduce emotional stress!!

Excellent Resource

Journal of Athletic Training 2011;46(2):206‐220

The Right Focus

Not — did you win?— did you play well?— did you do your best? ….

but

Did you have fun!

Why youth sports are “good”

You learn how to compete You learn how accept criticism You learn how be a teammate You learn how to be healthy You learn how to win …

and you learn how to lose

www.stopsportsinjuries.com

The Sports Trauma andOveruse Prevention sports Injuries campaign was initiated by the AOSSM in early 2007

Excellent resources for coaches, parents, athletes and health care providers