Me d i c i n eT o d a y PEER REVIEWED ARTICLE POINTS: 2 CPD/1 PDP Sports injuries in childre n The number of children with sports injuries seen in sports medicine practices is increasing. The usual outcome is full recovery, but the consequence of a missed diagnosis of a more serious condition may be significant for the child. The important issue of encouraging children to be injuries seen in sports medicine practices appears more active in an effort to improve their overall to be actually increasing.1 , 2 health is a complex public health problem.1 , 2 Fortunately, many of the sports injuries that Childhood sports participation in Australia has occur in children are self-limited and full recovery unfortunately declined over the past few decades. is the usual outcome. However, more serious con- Some 86% of children aged 5 to 14 years were ditions may occasionally occur and the conse- active in sport in 1985, but by 2003, the level of quence of a missed diagnosis, especially during the participation had fallen to 54% for girls and 69% rapid pubertal growth phase, may be significant for boys.1 During this time period, the number of for the child. overweight and obese children has been increas- Pain in a child should not be dismissed as ‘grow- TOM CROSS ing. At the other end of the spectrum, more active ing pains’. If an informed systematic approach FACSP, MBBS, DCH children are training more intensively and for is followed, the clinical assessment of a child will longer periods of time in one or several sports. be rewarding and straightforward and significant Dr Cross is Consultant Sports In turn, the number of children with sporting pathology will hopefully not be missed. Physician, North Sydney Orthopaedic and Sports Medicine Centre, Sydney, NSW. • The number of overweight children is increasing. However, children who are more active are training more intensively and for longer periods of time in one or several s p o r t s . • There are significant differences in the types of injuries that are sustained by children and adults and this is due to the physiology of growing bones. • Osteochondroses are conditions characterised by disordered endochondral ossification of the epiphyseal growth centre. Osgood–Schlatter’s disease and Sever’s disease are two relatively common types of osteochondroses. This article describes a less common osteochondrosis, osteochondritis dissecans. • The aphorism that ‘not everything that presents as a sports medicine problem should be strictly regarded as a sports injury’ is true in both adults and children. Differential diagnoses, such as tumours, infection, inflammatory conditions and serious hip pathologies masquerading as knee pain, should be considered in patients with atypical signs and symptoms. • There are general guidelines that should be followed for training the young athlete and also more specific guidelines for particular sporting activities. X X M e d i c i n eT o d a y y June 2007, Volume 8, Number 6 M e d i c i n eT o d a y y June 2007, Volume 8, Number 6 X X Sports injuries in children continued distal femoral epiphyseal p l a t e p a t e l l a e p i p h y s i s proximal tibia epiphyseal tibial tubercle p l a t e apophysis (site of attachment m e t a p h y s i s of patella tendon) diaphysis of tibia distal tibia epiphyseal p l a t e calcaneal apophysis (site of attachment of Achilles tendon) Figure 1. Proximal right humerus greenstick fracture (arrow) in a 9-year-old girl. Figure 2. Growth cartilage about the knee and ankle region. This article discusses the common paediatric The growing skeleton sports medicine conditions and highlights the There are significant differences in the types of significant differences in the types of injuries that injuries that are sustained by children compared are sustained by children and adults. with adults. These are due to the physiology of growing bone. For example, the metaphysis in H i s t o r y children is more elastic than in adults and hence The initial clinical approach to examining a child fractures are often incomplete (e.g. greenstick frac- (especially a young child) requires emphasis ture; see Figure 1). on establishing rapport with the child so that Both the metaphysis and the epiphysis, the areas an adequate history and examination may be either side of the growth plate (also known as the p e r f o r m e d . epiphyseal plate or physis) are vulnerable to injury The opportunity to observe a young child in the (including macrotraumatic and microtraumatic waiting room and when he or she walks into your events; see Figure 2). Isolated ligament injury is rare office should be taken. A detailed history of a young in children younger than 14 years as the ligaments child should be taken from his or her parents. Spe- are stronger than the physes and epiphyses in this cific questions should address developmental mile- age group.4 For example, avulsion of the tibial spine stones and also any relevant family history.3 If a bony origin of the anterior cruciate ligament (ACL) parent accompanies an older child, the clinician is may occur in a child (Figures 3a and b), whereas advised to direct questions to the child first to the same mechanism of injury in an adult will develop rapport, and then to clarify any points at a disrupt the ACL in its midsubstance. Therefore, later stage with the parent(s). it should be remembered that trauma resulting in X X M e d i c i n eT o d a y y June 2007, Volume 8, Number 6 M e d i c i n eT o d a y y June 2007, Volume 8, Number 6 X X Sports injuries in children continued Figures 3a (left) and b (right). Anteroposterior and lateral views of avulsion of the tibial Figure 4. Supracondylar femoral fracture tubercle (arrows) of the anterior cruciate ligament (right knee) in a 13-year-old boy. (arrow; Salter-Harris II) in a 14-year-old boy. ligament injuries in adults might, in chil- therefore different in children compared physeal plate. It is relatively weak, particu- dren, result in bone or growth plate frac- with adults (see Table).1 - 7 larly during the pubertal growth phase, tures (Figure 4) or ligamentous bony The apophysis, the site of tendon and is known as the ‘weakest link’ in the a v u l s i o n s .2 , 4 - 6 The spectrum of both macro- attachment to bone, is a cartilage site with musculo-tendinous unit in children. Injury traumatic and microtraumatic injuries is a growth plate that is separate from the often occurs at this site and is caused by Table. Different types of sporting injuries in children and adults R e g i o n M e c h a n i s m Injury in child Injury in adult Examples of mechanism of injury K n e e T w i s t i n g / v a l g u s Avulsion of the tibial spine origin of Anterior cruciate ligament Side step in football and f o r c e the anterior cruciate ligament, disruption, +/- meniscal injury n e t b a l l fracture distal femoral or proximal tibial epiphysis K n e e O v e r u s e Osgood–Schlatter’s disease or Patellar tendinopathy Running and jumping Sinding–Larsen–Johannson disease2 S h o u l d e r F a l l Fracture distal clavicle epiphysis Acromio-clavicular joint disruption Football and skiing S h o u l d e r F a l l Fracture proximal humeral epiphysis Dislocated gleno-humeral joint Football and skiing T h u m b Valgus force Fracture proximal phalangeal epiphysis Ulnar collateral ligament disruption F o o t b a l l P e l v i s / h i p Acute flexor/ Apophyseal avulsion of anterior Quadriceps or hamstring strain Running and jumping extensor strain inferior iliac spine or ischial tuberosity H e e l O v e r u s e Sever’s apophysitis Achilles tendinopathy Running and jumping X X M e d i c i n eT o d a y y June 2007, Volume 8, Number 6 M e d i c i n eT o d a y y June 2007, Volume 8, Number 6 X X Sports injuries in children continued either a macrotraumatic event, such as an tendinous unit (e.g. a proximal hamstring acute injury that causes avulsion to a por- muscle strain).2 , 4 , 5 Another example of tion of the apophysis or repeated micro- injury to the apophyseal area in children traumatic events, such as repetitive overuse includes avulsion of the medial humeral to the apophyseal area, which is termed epicondyle (see Figures 6a to c). a p o p h y s i t i s .4 Microtraumatic events are more common than macrotraumatic O s t e o c h o n d r o s e s events. An example of such an injury in Osteochondroses are conditions charac- children includes avulsion of the ischial terised by disordered endochondral ossifi- tuberosity of the pelvis (see Figure 5). cation of the epiphyseal growth centre. However, the same mechanism of acute The articular cartilage and the epiphyses Figure 5. Left ischial tuberosity avulsion injury in adults might result in a muscle of long bones are affected. There are over fracture (arrow) in a 14-year-old male sprinter.