1 Which sports are associated with the highest injury rates in children? What are the most common types of injuries seen?

In boys, the most injuries are seen with football. In girls, soccer accounts for the highest injury rates. Other sport activities that commonly lead to the emergency department evaluation of pediatric injuries include basketball, baseball/softball, inline skating, and hockey.

The most common types of ac ute injuries are soft tissue injuries, including sprains, strains, and contusions. Fractures and lacerations occur less frequently. However, in adolescents, overuse injuries are more common than acute injuries.

Patel DR, Nelson TL: Sports injuries in adolescents. Med Clin North Am 84:983–1007, 2000.

Taylor BL, Attia MW: Sports-related injuries in children. Acad Emerg Med 7:1376–1382, 2000.

2 What are overuse injuries? How are they managed?

Overuse injuries are chronic injuries that are related to constant high levels of physiologic stress without sufficient recovery time. These injuries are characterized by repetitive microtrauma and the development of inflammation that lead to significant pain and loss or limitation of function.

Overuse injuries are treated with rest and supportive bracing. Additionally the athlete should partake in proper training regimens that emphasize flexibility and stretching.

3 What is “Little League shoulder”? How does it present?

“Little League shoulder,” also known as proximal humeral epiphysitis, is most often seen in high-performance pitchers between 11 and 16 years of age. It may also be seen in tennis players, swimmers, and gymnasts. It is caused by overuse and subsequent inflammation of the proximal humeral physis. The chief complaint is gradual pain localized to the proximal humerus during the act of throwing or serving. The physical examination may be negative, or there may be tenderness to palpation of the proximal humerus. Radiographs may reveal a widening of the proximal humeral physis. Treatment is almost always nonsurgical and includes a rest period of 2 to 3 months, along with physical therapy.

Walter KD, Congeni JA: Don’t let little league shoulder or elbow sideline your patient permanently. Contemp Pediatr 21:69–92, 2004.

4 What is “Little League elbow”?

“Little League elbow”, or medial epicondylar apophysitis, results from stress to the medial epicondyle of the humerus. It is most commonly seen in children between the ages of 9 and 12 years who are baseball pitchers, infielders, or tennis players. An excessive number of pitches thrown and a sidearm pitching style have both been implicated as causes. The athlete presents with gradual onset of pain in the medial elbow and proximal forearm while throwing. Radiographs may be normal or reveal medial epicondylar apophyseal widening. Treatment is complete rest from throwing activities, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy.

Saperstein AL, Nicholas SJ: Pediatric and adolescent sports medicine. Pediatr Clin North Am 43:1013–1033, 1996.

5 Why is the early identification of “gymnast’s wrist” important?

Left untreated, “gymnast’s wrist,” a stress injury to the distal radial physis, may lead to premature fusion of the physis, growth arrest, and radial shortening. These patients present with activity-related pain of the dorsal aspect of the wrist, especially with floor exercises and vaulting, where there is an excessive load on a dorsiflexed wrist. There is tenderness over the distal radius, and radiographic findings may be normal or exhibit widening, beaking, or an indistinct appearance of the physis. Treatment is rest for 2–4 weeks. If there are radiographic changes, immobilization may be necessary.

Patel DR, Nelson TL: Sports injuries in adolescents. Med Clin North Am 84:983–1007, 2000.

6 Name the two types of apophysitis syndromes that occur surrounding the patellar tendon

Ganley TJ, Lou JE, Pryor K, et al: Sports medicine. In Dormans JP, Bell LM (eds): Pediatric Orthopedics and Sports Medicine: The Requisites in Pediatrics. St. Louis, Mosby, 2004, pp 278–279.

7 Which is the most common overuse injury in the young athlete?

Osgood-Schlatter disease commonly affects adolescents during periods of rapid growth. Symptoms include tenderness and a prominence at the tibial tubercle, with pain worsened by high-impact sports, kneeling, or squatting. The diagnosis is usually made clinically. However, plain radiographs will demonstrate enlargement or fragmentation at the anterior tibial tubercle due to the traction force at the insertion of the patellar tendon. Management includes rest, ice, NSAIDs, and stretching regimens to increase flexibility of the quadriceps and hamstrings. The problem usually resolves with closure of the physis, but children rarely may develop ossicles within the patellar tendon that require surgical removal.

Adirim TA, Cheng TL: Overview of injuries in the young athlete. Sports Med 33:75–81, 2003.

Ganley TJ, et al: Sports medicine. In Dormans JP, Bell LM (eds): Pediatric Orthopedics and Sports Medicine: The Requisites in Pediatrics. St. Louis, Mosby, 2004, pp 278–279.

8 What is the recommended management for Sever disease?

Sever disease, an apophysitis resulting from repetitive stresses on the calcaneal ossification center by the Achilles tendon, is often seen in young runners. The athlete will report heel pain and often has had a recent growth spurt and increase in activity level. Management includes rest, NSAIDs, Achilles tendon stretching, and the use of heel cups in cleats or sneakers. It usually resolves in 2–4 months without the need for surgery.

Ganley TJ, et al: Sports medicine. In Dormans JP, Bell LM (eds): Pediatric Orthopedics and Sports Medicine: The Requisites in Pediatrics. St. Louis, Mosby, 2004, pp 273–298.

Simons SM, Sloan BK: Foot injuries. In Birrer RB, Griesemer BA, Cataletto MB (eds): Pediatric Sports Medicine for Primary Care. Philadelphia, Lippincott Williams & Wilkins, 2002, pp 443–444.

9 List the most common locations for stress fractures in pediatric athletes

Coady CM, Micheli LJ: Stress fractures in the pediatric athlete. Clin Sports Med 16:225–238, 1997.

10 In which sports are participants most likely to sustain stress fractures?

Saperstein AL, Nicholas SJ: Pediatric and adolescent sports medicine. Pediatr Clin North Am 43:1013–1033, 1996.

11 Describe the most likely diagnosis in a gymnast who reports gradual-onset, recurrent, activity-associated, midline low back pain

The most likely diagnosis is spondylolysis, a defect of the pars interarticularis that occurs with repetitive axial loading of the lumbar spine. The most common site is at L5. Radiographs may be normal or may show a pars defect in the oblique view, often described as a “Scotty dog with a collar” appearance. Treatment requires restriction of activity and an aggressive rehabilitation regimen that includes abdominal strengthening and flexion exercises. Bracing is reserved for athletes who are unresponsive to these measures.

Herman MJ, Pizzutillo PD, Cavalier R: Spondylolysis and spondylolisthesis in the child and adolescent athlete. Orthop Clin North Am 34: 461–476, 2003.

12 What is the most dreaded complication of returning to sports too soon following a concussion?

Second impact syndrome. This results from acute brain swelling when a second head trauma is sustained prior to full recovery from an initial concussion. Second impact syndrome is thought to occur because the athlete reinjures the head during a period of disordered cerebral autoregulation following the initial head injury. The American Academy of Neurology guidelines on return to sports (Table 61-1) theoretically allow for this critical time period to pass and for the vascular autoregulatory mechanisms in the brain to heal and regain their normal function. Second impact syndrome, though quite rare, is not treatable and almost universally fatal.

Table 61-1 Summary of Recommendations For Management Of Concussion in Sports

From Quality Standards Subcommittee, American Academy of Neurology. www.aan.com/;professionals/;practice/;guidelines/;concussion_sports

Centers for Disease Control and Prevention: Sports-related recurrent brain injuries—US. MMWR Morb Mortal Wkly Rep 46:224–227, 1997.

Cantu RC: “Second impact syndrome.” Clin Sports Med 17:37–44, 1998.

13 Does posttraumatic seizure (the occurrence of a seizure directly after head trauma) increase the risk of intracranial injury?

Posttraumatic seizure (PTS) can be divided into three categories based on when they occur in relation to the injury: Immediate (within seconds), early (within 1 week), and late (> 1 week). Most PTSs occur within 24 hours of injury, and they substantially increase the risk of intracranial injury. Computed tomography (CT) of the head is indicated in these patients to evaluate for traumatic brain injury. There is debate as to whether children with negative CT scans and normal neurologic examinations may safely be discharged to home. Immediate PTSs rarely recur, whereas early PTSs and late PTSs are more likely to recur.

Holmes JF, Palchak MS, Conklin MS, Kupperman N: Do children require hospitalization after immediate post-traumatic seizure? Ann Emerg Med 43:706–710, 2004.

Schutzman SA: Injury—head. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine. Philadelphia, Lippincott Williams & Wilkins, 2000, pp 332–333.

14 What is commotio cordis?

Commotio cordis is a sudden cardiac arrest in a patient without preexisting heart disease following a relatively minor blow to the chest. The pathophysiology involves the mechanical force of the blow leading to a depolarization of the myocardium on the T-wave of the cardiac cycle, precipitating cardiac arrest. It is the second leading cause of sudden death in the young athlete and occurs most frequently in the sport of baseball. In animal models, commotio cordis is seen most often with balls thrown between 30 and 50 miles per hour, the speed of most Little League pitches. Chest protectors and softer-core balls have been marketed in an attempt at prevention, but most leagues do not mandate their use.

Maron BJ: Sudden death in young athletes. N Engl J Med 349:1064–1075, 2003.

15 Why are children at greater risk for commotio cordis than adults?

Children are more vulnerable than adults because of their thin and flexible chest walls and their lower agility.

16 What is the most common cause of sudden death in the young athlete?

Hypertrophic cardiomyopathy. This condition is a congenital heart deformity resulting in left ventricular outflow obstruction with asymmetric septal hypertrophy. It predisposes the athlete to arrhythmias that are likely to cause syncope or death. Unfortunately, most athletes are asymptomatic before the development of the lethal event, and preparticipation screening examinations (even with electrocardiography) may be normal.

Maron BJ, Epstein SE, Roberts WC: Causes of sudden death in competitive athletes. J Am Coll Cardiol 7:204–214, 1986.

17 What are some clinical characteristics of burners/stingers?

A stinger is a brachial plexus injury following a traumatic stretching or compression force on the neck. Symptoms include unilateral arm pain or burning especially in the C5–C6 nerve root distribution. There may be associated weakness. The symptoms often resolve within minutes but may persist. Of note, if the symptoms are persistent or bilateral, involve the lower extremities, or are accompanied by neck pain, more significant spinal cord injury may have occurred.

Vegso JJ, Lehman RC: Field evaluation and management of head and neck injuries. Clin Sports Med 6:1–15, 1987.

18 What is the most commonly injured nerve in acute shoulder dislocation?

The axillary nerve, which innervates the upper arm, must be carefully examined with acute shoulder dislocation. Shoulder dislocation is most likely to occur when the arm is abducted and externally rotated, is far more likely anterior than posterior, and is often recurrent.

Ganley TJ, et al: Sports medicine. In Dormans JP, Bell LM (eds): Pediatric Orthopedics and Sports Medicine: The Requisites in Pediatrics. St. Louis, Mosby, 2004, pp 283–284.

19 Describe the mechanism of injury in gamekeeper’s thumb

Gamekeeper’s thumb, also known as skier’s thumb, is a sprain of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. The injury is the result of a forced abduction and extension of the thumb that occurs when falling on an outstretched hand or colliding with an object. Patients with this injury exhibit point tenderness over the ulnar collateral ligament and may have no radiographic findings. Treatment includes immobilization and compression with a thumb spica splint. If the patient has an open physis, this mechanism of injury will produce a Salter-Harris III fracture of the proximal phalanx.

Garrick JG, Webb DR: Sports Injuries Diagnosis and Management, 2^nd ed. Philadelphia, W.B. Saunders, 1999, pp 183–187.

20 What is the difference between a mallet finger and a jersey finger?

See Table 61-2.

Table 61-2 Mallet Finger Vs. Jersey Finger

21 How do pelvic avulsion fractures occur?

Avulsion fractures (Fig. 61-1) result from sudden muscular contractions and are usually associated with vigorous running or jumping. These are seen in sports that require rapid acceleration or deceleration, or quick changes of direction.

Figure 61-1 Avulsion fracture of the left anterior superior iliac spine.

Kim SS, Thomas M: A football player with thigh pain. Pediatr Emerg Care 17:267–268, 2001.

22 What are the most common locations of pelvic avulsion fractures? What muscle attachment contributes to the fracture?

See Table 61-3.

Table 61-3 Pelvic Avulsion Fractures

23 A running football player was struck in the thigh by another player’s helmet. Radiographs are negative, yet the patient has marked pain at the site of the injury and with ambulation. What is the likely diagnosis, and what treatment should be initiated?

This patient probably sustained a quadriceps contusion. Initial treatment involves halting the hemorrhage and preventing spasm by rest, ice, compression, and elevation for 24–48 hours. Bracing with 90 ° of knee flexion may be needed in cases of severe swelling. The patient should then undergo progressive isometric strengthening and active range-of-motion exercises. Vigorous massage and passive stretching should be avoided because both have been associated with myositis ossificans, a condition in which heterotopic bone growth occurs within the quadriceps muscle.

24 What is the typical mechanism for an injury to the anterior cruciate ligament in children?

As in adults, injury to the anterior cruciate ligament (ACL) results from a sudden deceleration accompanied by hyperextension and a rotatory force on a planted foot. This is often accompanied by a popping sensation and the acute onset of hemarthrosis. Whereas adults and older adolescents will probably tear the ligament itself, younger children may avulse a bony segment of tibia at the ACL insertion site. Plain radiography followed by magnetic resonance imaging is used to delineate the specifics of the injury. Management of the ACL injury is complicated by the open physes in skeletally immature children, requiring careful consideration of operative versus nonoperative treatment plans by the orthopedist.

Bernhardt DT: Knee and leg injuries. In Birrer RB, Griesemer BA, Cataletto MB (eds): Pediatric Sports Medicine for Primary Care. Philadelphia, Lippincott Williams & Wilkins, 2002, pp 409–410.

Ganley TJ, et al: Sports medicine. In Dormans JP, Bell LM (eds): Pediatric Orthopedics and Sports Medicine: The Requisites in Pediatrics. St. Louis, Mosby, 2004, pp. 288–290.

25 What is the rate of recurrence of acute patellar dislocation?

Approximately 1 in 6 pediatric patients with patellar dislocation will be affected by recurrent patellar instability. The patient most prone to recurrence will have an increased Q angle. The Q angle is created by two lines drawn from the anterior superior iliac spine to the center of the patella, and from the center of the patella to the center of the tibial tubercle. Q angles greater than 20 ° predispose to instability by increasing the lateral force of the patella during knee extension.

Ganley TJ, et al: Sports medicine. In Dormans JP, Bell LM (eds): Pediatric Orthopedics and Sports Medicine: The Requisites in Pediatrics. St. Louis, Mosby, 2004, pp 285–287.

26 What are the limitations to the Ottawa Ankle Rules in children?

The Ottawa Ankle Rules are criteria developed for predicting ankle fractures based on examination features in adults with the goal of reducing unnecessary radiographs. They allow, however, for “insignificant fractures” (such as small avulsion fractures) to be undiagnosed. They are not universally applicable to the pediatric population because of the questionable significance of Salter-Harris I and avulsion fractures on children’s future growth and development. Though studies have attempted to validate them in children, they have been limited by small sample size and debate as to whether any fracture can be considered “insignificant” in a child.

Clark KD, Tanner S: Evaluation of the Ottawa Ankle Rules in children. Pediatr Emerg Care 19:73–78, 2003.

Plint AC, Bulloch B, Osmond MH, et al: Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med 6:1005–1009, 1999.

27 What are some unique characteristics of young athletes that make them more prone to heat-related illness than the adult?

The larger body surface area of a child allows them to absorb more external heat, and they have a limited ability to produce sweat as compared to adults. They are also less able to cognitively appreciate the need to adequately hydrate and may not ask for hydration breaks often enough. Other risk factors for heat illness include obesity, dehydration, deliberate water restriction in order to “make weight,” use of laxatives, practices early in the season without adequate acclimatization, and the use of dark clothing or heavy equipment (such as padding).

Gambrell RC: Environmental conditions and youth sports. In Birrer RB, Griesemer BA, Cataletto MB (eds): Pediatric Sports Medicine for Primary Care. Philadelphia, Lippincott Williams & Wilkins, 2002, pp 95–96.

28 What measures can be used to prevent pediatric sports injuries?

A thorough preparticipation sports evaluation by a physician should be conducted to detect potential risks and determine possible medical contraindications to participation in certain sports. A carefully planned conditioning regimen should start 6–8 weeks before the athletic season begins. This should emphasize overall fitness rather than focusing on skills specific to only one athletic activity. The athletes should slowly adapt to increases in intensity and frequency of exercise. Equipment and playing sites must be of appropriate size and satisfactory condition.

Christopher NC, Congeni J: Overuse injuries in the pediatric athlete; evaluation, initial management, and strategies for prevention. Clin Pediatr Emerg Med 3:118–128, 2002.

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