Adolescent Ortho

1. Adolescent Ortho Anthony Beutler, MD Primary Care Sports Medicine

2. Top 10 “The Caddie” Comments Dr. Brennan: “I think I’m going to drown myself in that lake.” Caddie: “Think you can keep your head down that long?

3. Objectives • Describe the unique role of “growth” as a risk factor for adolescent musculoskeletal overuse injures • Discuss the clinical presentation and management of common overuse injuries unique to adolescents

4. Epidemiology • Data Collection on injury rates in children and adolescents is very poor • Overload injuries are epidemic secondary to adult training regimens • “Growth” site injuries predominate with Osgood-Schlatter disease thought to be the most common • Young athletes complaining of pain generally “have something going on” and not just the aches and pain of athletic activity

5. Growth Cartilage • Growth Plate (epiphyseal plate) • Artic. Cartilage • Apophysis (tendon insertion)

6. Common Adolescent Overuse Injuries

7. Top 10 “The Caddie” Comments Dr. Howard: “I’d move heaven and earth to break 100 on this course.” Caddie: “Try heaven; you’ve already moved most of the earth!”

9. Osgood-Schlatter’s DiseaseClinical Features • History- Young Athlete complains of painful enlargement of the tibial tuberosity; pain worse with activity • Physical- Tender Tibial Tubercle; tight extensor mechanism • Imaging- May be fragmentation of the Anterior Tibial Tuberosity

10. Bilateral Xrays

11. Osgood-Schlatter’s DiseaseDifferential Diagnosis • Sinding-Larsen-Johansson Disease • Osteochondroma • Bi-partite Patella • Patellofemoral Pain Syndrome • Osteochondritis Dissecans • Tibial Tubercle Avulsion Fracture

12. Top 10 “The Caddie” Comments Dr. Nasin: “Do you think I can get there with a 5 iron?” Caddie: “Eventually.”

19. Osteochondritis DissecansClinical Description • Avascular Necrosis of Subarticular Bone probably secondary to repetitive trauma involving bone with a marginal blood supply • Most Commonly involves the lateral aspect of the medial femoral condyle • Males more commonly affected; disorder is frequently bilateral

20. Osteochondritis DissecansDifferential Diagnosis • Osteosarcoma • Discoid Meniscus • Osteochondral Fracture

21. Top 10 “The Caddie” Comments Dr. Ho: “Please stop checking your watch all the time. It’s a distraction.” The Caddy: “It’s not a watch – it’s a compass.”

23. Sever’s DiseaseClinical Description • Traction Apophysitis

24. Sever’s DiseaseClinical Features • History- Most Commonly seen in early adolescence; presents with heel pain in the morning and with activity • Physical- Tenderness over the Calcaneus; tight hamstrings and gastrocsoleus • Imaging- May see fragmentation or sclerosis of the calcaneus apophysis

26. Sever’s DiseaseDifferential Diagnosis • Stress Fracture • Reflex Sympathetic Dystrophy

27. Sever’s DiseaseTreatment • Activity Modification • Heel Cord Flexibility • Heel Lifts • Immobilization for 2-3 weeks

28. Top 10“The Caddie” Comments Dr. Meyering: “That can’t be my ball. It’s too old.” Caddie: “It’s been a long time since we teed off, Sir.”

32. Little League ElbowClinical Description • The most commonly recognized injury complex in the young throwing athlete • Throwing creates predictable force loads across the elbow • Tension across the Medial structures • Compression across the Lateral structures

33. Little League ElbowClinical Features • History- Insidious onset of pain; decreased performance, or loss of motion in the throwing athlete • Physical- Tenderness in the medial, lateral or posterior elbow; may demonstrate a mild flexion contracture • Imaging- Plain films may be nl; may need bone scan, CT and/or MRI

34. Little League ElbowDifferential Diagnosis • Panner’s Disease • Medial Apophysitis • OCD of Capitellum • Olecranon Apophysitis • Hypertrophy of Ulna • Normal Variant • Neoplastic Process • Neuropathy

35. Little League ElbowTreatment • Medial Stress Lesion- 4-6 weeks of activity modification • Lateral Lesions- Orthopedic Consultation • Pitching Program

36. Top 10“The Caddie” Comments Dr. Burkdall: “How do you like my game?” Caddie: “Very good, but personally I prefer golf.”

39. Little League ShoulderClinical Description

40. Little League ShoulderClinical Features • History- Insidious onset of activity related proximal arm/shoulder pain • Physical- Rotator Cuff weakness and impingment in young athlete • Imaging- Plain films may demonstrate widening of the epiphyseal plate

41. Little League ShoulderDifferential Diagnosis • Rotator Cuff Disorders • Glenohumeral Instability • Neoplastic Disease

42. Little League ShoulderTreatment • Sports Medicine Referral • No throwing for 3 months • Specialized rotator cuff and throwing rehab • Gradual return to throwing program (after 3 months)

43. Top 10 “The Caddie” Comments Dr. Howe: “This is the worse course I’ve ever played on!” The Caddie: “This isn’t the golf course. We left that an hour ago.”

46. Who gets it? Girls 9–15 yo, Boys 11–18 yo Most common in obese or rapidly growing What is it? Unstable growth plate fracture Most Common Hip Disorder in Adolescents Stable vs Unstable Slipped Capital Femoral Epiphysis Epidemiology

47. When do I think about it? ANY Adolescent with hip pain or ext. rotation, thigh pain or knee pain Hip exam with limited internal rotation or obligate external rotation with flexion Where do I send the patient next? Xray in wheelchair Klein’s Line on AP Hip Films Orthopedic Surgery – NON-WEIGHT BEARING, next 72 hours Klein’s Line on AP Normal Abnormal Frog Leg Slipped Capital Femoral Epiphysis When and What to Do

48. Slipped Capital Femoral EpiphysisImaging • Imaging- Frog Leg Pelvis; Bone Scan and/or CT if clinically suspicious

49. Slipped Capital Femoral Epiphysis Differential Diagnosis • Legg-Calve Perthes Disease • Stress Fracture