Musculoskeletal injuries in the pediatric and adolescent athlete

Point-of-care ultrasound detection of anterior inferior iliac spine avulsion fracture in an adolescent: A case report

Purpose

This study presents a rare case of avulsion fracture of the anterior inferior iliac spine, typically occurring in adolescents engaged in physical activities. The purpose of this study is to emphasize the diagnostic challenges and conservative treatment options available for this condition.

Method

We describe the case of a 14-year-old healthy adolescent who suffered from an avulsion fracture following pelvic trauma after participating in a short-distance sprint. Initial physical examination and X-ray imaging were inconclusive, showing no apparent fractures. Due to parental refusal of a Computerized Tomography (CT) scan by concerns over the potential risks associated with radiation exposure, a diagnostic ultrasound was performed, which confirmed the presence of an avulsion fracture at the anterior inferior iliac spine.

Results

The ultrasound findings led to a conservative treatment approach, involving rest, and unloading of the affected limb. Follow-up assessments indicated significant pain relief within four weeks and enabled the resumption of partial physical activity after six months.

Conclusion

This case highlights the utility of ultrasound as an effective alternative diagnostic tool in situations where CT scans are not permissible. Additionally, it demonstrates that conservative management can be successful in treating avulsion fractures of the anterior inferior iliac spine in adolescents, leading to satisfactory recovery and return to activity.

Rotator Cuff Repair in Pediatric and Adolescent Athletes: Indications and Outcomes

Rotator cuff (RC) tears in pediatric and adolescent athletes are rare events. In these patients, RC tears are more likely to be traumatic or related to overuse among overhead. Repeated movements of abduction and external rotation are frequent mechanisms of injury. The supraspinatus is the most commonly involved tendon and the articular-sided tears are more common than the bursal side. Magnetic resonance imaging is considered the gold standard for diagnosing RC tears. Conservative treatment, arthroscopic, and open repair are all effective treatment methods depending on the type of injury. The risk of growth plate injury in these patients should be always considered when planning surgical interventions. Return to sport for competitive-level throwing athletes represents the greatest challenge in the treatment of these injuries.

Treatment of avulsion fractures of the pelvis in adolescent athletes: A scoping literature review

Avulsion fractures of the pelvis and hip region are typical injuries in adolescent athletes. Avulsion sites include the muscle tendon origin or insertion, and treating these injuries surgically or conservatively remains a debated issue. The main goals of this review were to assess and summarize injury types and sites, treatment-related clinical outcomes, and return to sport for adolescent patients with a pelvis avulsion fracture and to provide support for making treatment decisions. The PubMed database was searched in November 2021 to identify all published articles from 2000 to 2021 that reported the outcome and return to sport after conservative or surgical treatment. Eighteen studies with 453 patients were included in this review. The age range was 13.6-16.8 years. The most common injury site the was anterior superior iliac spine (37%), followed by the anterior inferior iliac spine (31%), ischial tuberosity (14%), lesser trochanter (9%), iliac crest (8%), and superior corner of the pubic symphysis (1%). Overall complications were lower in the surgical group compared to the conservative group. The rate of return to pre-injury activity level was greater in patients who underwent surgical treatment (p < 0.05). In conclusion, surgery is preferred for major dislocation and fragment size, providing a better return-to-sport rate and decreasing the risk of complications.

Running-related injuries in middle school cross-country runners: Prevalence and characteristics of common injuries

BACKGROUND

Understanding the prevalence and factors associated with running-related injuries in middle school runners may guide injury prevention.

OBJECTIVE

To determine the prevalence of running-related injuries and describe factors related to a history of injury.

DESIGN

Retrospective cross-sectional study.

SETTING

Survey distributed online to middle school runners.

METHODS

Participants completed a web-based survey regarding prior running-related injuries, training, sleep, diet, and sport participation.

MAIN OUTCOME MEASUREMENTS

Prevalence and characteristics differentiating girls and boys with and without running-related injury history adjusted for age.

PARTICIPANTS

Youth runners (total: 2113, average age,  13.2 years; boys: n = 1255, girls: n = 858).

RESULTS

Running-related injuries were more prevalent in girls (56% vs. 50%, p = .01). Ankle sprain was the most common injury (girls: 22.5%, boys: 21.6%), followed by patellofemoral pain (20.4% vs. 7.8%) and shin splints (13.6% vs. 5.9%); both were more prevalent in girls (p < .001). Boys more frequently reported plantar fasciitis (5.6% vs. 3.3%, p = .01), iliotibial band syndrome (4.1% vs. 1.4%, p = .001) and Osgood-Schlatter disease (3.8% vs. 1.2%, p = .001). Runners with history of running-related injuries were older, ran greater average weekly mileage, ran faster, had fewer average hours of sleep on weekends, skipped more meals, missed breakfast, and consumed less milk (all p < .05). Girls with history of running-related injuries reported higher dietary restraint scores, later age of menarche, more menstrual cycle disturbances, and higher likelihood of following vegetarian diets and an eating disorder diagnosis (all p < .05). Runners with no history of running-related injuries were more likely to have participated in ≥2 years of soccer or basketball (p < .001).

CONCLUSIONS

Most middle school runners reported a history of running-related injuries and certain injuries differing by gender. Modifiable factors with the greatest association with running-related injuries included training volume, dietary restraint, skipping meals, and less sleep. Sport sampling, including participation in ball sports, may reduce running-related injury risk in this population.

Rotator Cuff Repair in the Pediatric Population Displays Favorable Outcomes: A Systematic Review

Purpose

To systematically review the literature to determine the injury mechanisms, presentation, and timing of diagnosis for pediatric patients with intratendinous rotator cuff tears and to determine the efficacy of surgical intervention for affected patients.

Methods

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus were searched. Studies were included if they involved only pediatric patients, soft-tissue rotator cuff injuries managed surgically, and reported outcomes. Patient characteristics, injury mechanisms, physical examination and imaging findings, time to diagnosis, surgical technique, and treatment outcomes were extracted. Findings were descriptively analyzed with weighted means and proportions.

Results

Twenty-one studies comprising 78 patients were included. The age range was 8 to 17 years and 57 were male. The supraspinatus (n = 56) was the most injured tendon. American football was the most reported sport played at the time of injury. Most patients were diagnosed within 6 months of injury via magnetic resonance imaging. Arthroscopic management was undertaken in 68 patients. Forty-six of 51 patients for whom data were available returned to sports at a range of 2.5 to 12 months postoperatively. Repair failure occurred in three patients.

Conclusions

The extant literature regarding rotator cuff tears in pediatric patients is limited to reports of low methodological quality. Qualitative synthesis of this low-level literature reveals that rotator cuff tears are mostly reported in male collision sport athletes but may also occur in female athletes and/or throwing athletes. These injuries are often successfully managed via arthroscopic repair, and patients and their families can be reassured that the majority of patients return to sports following surgery.

Level of Evidence

Level IV, systematic review of level IV studies.

Hip apophyseal injuries in soccer players: can MRI findings be useful to define when to return to play?

OBJECTIVE

To describe magnetic resonance imaging (MRI) findings in professional soccer players with acute apophyseal injury of the hip and to assess their relationship with return to sports.

MATERIAL AND METHODS

Adolescent soccer players with diagnosis of apophyseal injury in the anterosuperior and anteroinferior iliac spine were retrospectively evaluated between 2008 and 2016. All athletes underwent hip MRI examination within 4 days after onset of clinical complaint. Images were independently analyzed by two radiologists. Medical records were reviewed to obtain clinical data.

RESULTS

Mean displacement of the apophysis was 4.8 ± 4.6 mm. Bone edema was present in 82% of athletes and muscular edema in 41%. The mean time to return to sports was 37.3 ± 14.7 days. The difference between the measurements of the two radiologists was close to zero with agreement limits below 1.0 mm (p < 0.001). There was a significant correlation between displacement of the apophysis and return to sports, as well as between both and the presence of muscular edema. A displacement of the apophysis of 3.0 mm might serve as a parameter to predict return to sports/activity before 40 days, with a sensitivity of 92% and specificity of 96%, considering conservative physiotherapy treatment.

CONCLUSION

Displacement of the apophysis and presence of muscular edema evaluated by MRI showed a significant correlation with return to sports in athletes with acute apophyseal injuries of the anterosuperior and anteroinferior iliac spines.

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Shoulder: An Orthoregeneration Network (ON) Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFβ), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.

Understanding the undulating pattern of the distal femoral growth plate: Implications for surgical procedures involving the pediatric knee: A descriptive MRI study

INTRODUCTION

Operative procedures near the distal femoral physis can result in iatrogenic damage if one is not familiar with the complex anatomy of the growth plate. The purpose of this study was to use physeal-specific MRI sequences to delineate the anatomic dimensions of the distal femoral physis.

MATERIALS AND METHODS

Sixty patients underwent physeal-specific spoiled gradient 3-D fat saturated (SPGR) MRI analysis of a single knee. Three age groups (eight to 10, 11-13, and 14-16 years) comprised of equal numbers (n = 20) of boys and girls were evaluated. Using the SPGR coronal sequence, the distance of the physis to the femoral articular cartilage was recorded at the medial, mid-medial, notch, mid-lateral and lateral margins of the knee. Coronal measurements were recorded at four locations along the sagittal sequence, as the anteroposterior dimension of the knee was divided into equal quartiles.

RESULTS

While little variation in shape was observed in the anterior quartile, the remaining quartiles demonstrated significant variability that increased moving posteriorly (p < .001), therefore reflecting a more concave shape in the posterior aspect of the femur. These observations were statistically significant for age at the posterior two quartiles.

CONCLUSION

These MRI data suggest that while the physis is linear in the anterior part of the femur, it possesses a more concave shape in the posterior aspect of the medial and lateral condyles. Findings were preserved across gender and age. Ultimately, these data can aid in preoperative planning and should be considered when performing operative procedures in the skeletally immature knee.

Pediatric Sports Injuries

With increasing pediatric participation in organized sport and the early specialization of children in single sports, the number of injuries seen in the pediatric and adolescent athletic population continues to increase. Children experience acute traumatic injuries during practice and competition as well as chronic overuse injuries secondary to the repetitive stress on their developing bodies. The unique nature of the pediatric patient often requires a different diagnostic, prognostic, and treatment approach to sports injuries compared with their adult counterparts.

Injury-Free Children and Adolescents: Towards Better Practice in Swedish Football (FIT project)

This interdisciplinary research project will produce evidence-based recommendations on how injuries in Swedish youth football (soccer) can be prevented. Fewer injuries will positively impact athlete health, performance and career longevity and have the potential to promote life-long physical activity and wellbeing.

Injury pattern research demonstrates that injuries are a significant problem in (Swedish) youth sport. Football has a higher traumatic and overuse injury rate than many contact/collision sports (e.g., field hockey, basketball). In research on youth football, the incidence of overuse training injuries was measured as high as 15.4 injuries per 1000 training hours, and the incidence of traumatic and overuse match injuries was 47.5 injuries per 1000 match hours. The injury frequency is alarming and applies to the 54% of children aged 7-14 and the 39% of youths aged 15-19 years who participate in Swedish organised sports. A large body of research identifies injury risk factors and preventative strategies; however, as the recent IOC consensus statement on youth athletic development points out, the existing, mostly bio-medical knowledge does not provide effective evidence-based injury prevention strategies. To address this deficit, interdisciplinary and context-driven knowledge on injury development in youth sport is needed.

The proposed project will produce scientific evidence through four consecutive studies: a) Questionnaire to register the types, frequency and management of injuries; b) Laboratory testing of biomechanical, clinical and training-specific parameters to establish individual physical and sport-specific dispositions; c) Observation of sporting contexts to understand sporting cultures, coaching methods and coach-athlete relationships; and d) Interviews with coaches and players to recognize knowledge that shapes coaching and training. The sample of youth players will be recruited from Sweden’s most popular and injury-prone sport: football. Each of the four studies will conduct its own data production and analyses, and a collective analysis will produce integrated evidence. Concrete recommendations for best sporting practice will be developed, which will serve sporting federations, sport education institutions, coaches, sport support staff and players.

Pediatric and adolescent injury in rodeo

High injury potential in rodeo is well recognized but the injury data for pediatric and adolescent rodeo athletes remain sparse. A systematic review of the literature published between 1990 and 2017 was conducted to assess the incidence and determinants of rodeo-related injuries in this population and to suggest injury prevention measures. Three of the 10 included studies reported event frequency and exposure data while the other seven pertained to particular injuries and/or rodeo events. Although each study documented cases of severe injuries, the limited epidemiological data indicated the majority of pediatric and adolescent athletes sustained minor injuries, such as sprains, strains, and contusions. Most injuries resulted from the impact of a fall or animal contact with the head being the most reported injury site. Owing to an unpredictable nature of this sport, injury prevention is challenging but there is evidence that helmets reduce the incidence and severity of head injuries.

Operative treatment of pelvic apophyseal avulsions in adolescent and young adult athletes: a follow-up study

INTRODUCTION

Pelvic apophyseal avulsion can limit young athletes' performance for months and may result in permanent disability. Nonoperative treatment is most commonly preferred, while surgical management with reduction and fixation is reserved for selected cases. Our aim was to evaluate outcomes of operative management of pelvic apophyseal avulsions in a series of adolescents and young adult athletes.

MATERIALS AND METHODS

Operative room registries and medical records were reviewed to identify patients who received surgical treatment for pelvic apophyseal avulsions who were younger than 24 years and with a minimum of 12 month follow-up.

RESULTS

Thirty-two patients (16.8 years ± 2.6) were identified. The most common avulsion sites were anterior inferior iliac spine (34.4%, N = 11) and ischial tuberosity (34.4%, N = 11). Other avulsions were five cases (15.6%) of the pubic apophysis, four cases (12.5%) of the anterior superior iliac spine apophysis and one case of the iliac crest apophysis. Seventeen cases (53.1%) underwent surgery early, i.e., during the first 3 months after the acute injury. Twenty-two cases (68.8%) involved reduction with internal fixation, and six cases (18.8%) involved resection of the fragment. Twenty-six athletes (81.3%, N = 26) reported good outcomes and were able to return to preinjury sports level. Six patients (18.8%) had moderate outcome and reported activity limitations during high-level sports. Large displacement (> 20 mm) or delayed (> 3 months) surgery was not associated with inferior outcomes (P = 0.690 and P = 0.392, respectively). Injury side (P = 0.61) or gender (P = 0.345) did not affect outcomes.

CONCLUSIONS

Operative management of pelvic apophyseal avulsion results in return to the preinjury sports level in more than 80% of the cases. However, while both acute surgery for large displacement and delayed intervention for failed nonoperative treatment are generally successful in improving sports function in these cases, comparative studies are required to refine criteria for surgery.

LEVEL OF EVIDENCE

Case series, IV.

The anatomy of E-Learning tools: Does software usability influence learning outcomes?

Reductions in laboratory hours have increased the popularity of commercial anatomy e-learning tools. It is critical to understand how the functionality of such tools can influence the mental effort required during the learning process, also known as cognitive load. Using dual-task methodology, two anatomical e-learning tools were examined to determine the effect of their design on cognitive load during two joint learning exercises. A.D.A.M. Interactive Anatomy is a simplistic, two-dimensional tool that presents like a textbook, whereas Netter's 3D Interactive Anatomy has a more complex three-dimensional usability that allows structures to be rotated. It was hypothesized that longer reaction times on an observation task would be associated with the more complex anatomical software (Netter's 3D Interactive Anatomy), indicating a higher cognitive load imposed by the anatomy software, which would result in lower post-test scores. Undergraduate anatomy students from Western University, Canada (n = 70) were assessed using a baseline knowledge test, Stroop observation task response times (a measure of cognitive load), mental rotation test scores, and an anatomy post-test. Results showed that reaction times and post-test outcomes were similar for both tools, whereas mental rotation test scores were positively correlated with post-test values when students used Netter's 3D Interactive Anatomy (P = 0.007), but not when they used A.D.A.M. Interactive Anatomy. This suggests that a simple e-learning tool, such as A.D.A.M. Interactive Anatomy, is as effective as more complicated tools, such as Netter's 3D Interactive Anatomy, and does not academically disadvantage those with poor spatial ability. Anat Sci Educ 9: 378-390. © 2015 American Association of Anatomists.

Paediatric ACL repair reinforced with temporary internal bracing

PURPOSE

Instability following non-operative treatment of anterior cruciate ligament (ACL) rupture in young children frequently results in secondary chondral and/or meniscal injuries. Therefore, many contemporary surgeons advocate ACL reconstruction in these patients, despite the challenges posed by peri-articular physes and the high early failure rate. We report a novel management approach, comprising direct ACL repair reinforced by a temporary internal brace in three children.

METHODS

Two patients (aged 5 and 6 years) with complete proximal ACL ruptures and a third (aged seven) with an associated tibial spine avulsion underwent direct surgical repair, supplemented with an internal brace that was removed after 3 months.

RESULTS

Second-look arthroscopy, examination and imaging at 3 months confirmed knee stability and complete ACL healing in all cases. Normal activities were resumed at 4 months, and excellent objective measures of function, without limb growth disturbance, were noted beyond 2 years.

CONCLUSION

ACL repair in young children using this technique negates the requirement and potential morbidity of graft harvest and demonstrates the potential for excellent outcome as an attractive alternative to ACL reconstruction, where an adequate ACL remnant permits direct repair.

LEVEL OF EVIDENCE

IV.

Common sports-related musculoskeletal injuries presenting to the emergency department

Young athletes are specialising in sports at a younger age, placing the developing musculoskeletal system under considerable stress. Overuse injuries such as apophysitis are chronic in nature and account for a large proportion of musculoskeletal injuries suffered by young athletes; however, with an increased emphasis on success in sport, tendinopathy and fatigue fractures are now being reported with increasing frequency, in the adolescent population. Correct diagnosis and early protection, rest, ice, compression and elevation therapy is critical, along with supervised rehabilitation an expert in paediatric and adolescent sports medicine. Acute traumatic knee injury and ankle sprain account for most acute injuries. Although most are soft tissue in nature, radiography may be useful in specific situations before early initiation of protection, rest, ice, compression and elevation therapy. These injuries will also require follow-up by an expert in paediatric and adolescent sports medicine to confirm the diagnosis and instigate ongoing rehabilitation and/or orthopaedic referral. Many of these injuries are preventable and due consideration should be given to simple prevention strategies.

Epidemiology of Elbow Dislocations in High School Athletes

BACKGROUND

The elbow is the second most commonly dislocated major joint in the general population. Previous studies that focused on emergency department populations indicate that such injuries occur most frequently among adolescent athletes.

PURPOSE

To describe the epidemiological rates and patterns of sports-related elbow dislocations in high school athletes.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Sports-related injury data for the 2005-2006 through 2013-2014 academic years from a national convenience sample of high schools participating in the National High School Sports-Related Injury Surveillance Study (High School Reporting Information Online [RIO]) were analyzed.

RESULTS

Certified athletic trainers participating in High School RIO reported 115 of 1246 (9.2%) elbow injuries as elbow dislocations. A total of 30,415,179 athlete exposures (AEs) were reported during the study period, resulting in a dislocation rate of 0.38 per 100,000 AEs. The majority of the dislocations resulted from boys' wrestling (46.1%) and football (37.4%). Elbow dislocation rates were higher in competition than in practice. Also, 91.3% of dislocations occurred in boys' sports. Among both boys (60.4%) and girls (88.9%), the majority of injuries occurred during varsity sports activities. Contact with another person was the most common injury mechanism (46.9%), followed by contact with the playing surface (46.0%). Dislocations more commonly resulted in removal from play for more than 3 weeks (23.4% vs 6.9%, respectively) or medical disqualification (36.9% vs 7.0%, respectively) compared with other elbow injuries. Dislocations were also more likely to result in surgical treatment than other elbow injuries (13.6% vs 4.7%, respectively).

CONCLUSION

In high school athletes, elbow dislocations result in longer removal from play and are more likely to require surgical treatment than nondislocation-associated elbow injuries. Rates and patterns of elbow dislocations vary by sport. In high-risk sports, focused sport-specific prevention strategies may help to decrease the rates and severity of elbow dislocation injuries.

Evidence-based guidelines for wise use of electronic games by children

Electronic games (e-games) are widely used by children, often for substantial durations, yet to date there are no evidence-based guidelines regarding their use. The aim of this paper is to present guidelines for the wise use of e-games by children based on a narrative review of the research. This paper proposes a model of factors that influence child-e-games interaction. It summarises the evidence on positive and negative effects of use of e-games on physical activity and sedentary behaviour, cardio-metabolic health, musculoskeletal health, motor coordination, vision, cognitive development and psychosocial health. Available guidelines and the role of guidelines are discussed. Finally, this information is compiled into a clear set of evidence-based guidelines, about wise use of e-games by children, targeting children, parents, professionals and the e-game industry. These guidelines provide an accessible synthesis of available knowledge and pragmatic guidelines based on e-game specific evidence and related research.

Lower extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment

Paralleling the growing popularity of organized sports among pediatric athletes, the stress and intensity of training regimens has escalated the frequency and severity of pediatric overuse injuries. It is essential that radiologists have a thorough knowledge of the pathogenesis of these injuries and of their characteristic patterns with different imaging techniques in order to appropriately diagnose overuse injuries in the pediatric skeleton. Knowledge of the classification, mechanism, clinical and imaging manifestations of acute and chronic overuse injuries of the lower extremities common among pediatric athletes can assist in imaging-based diagnosis and characterization of injury.

The increasing incidence of paediatric diaphyseal both-bone forearm fractures and their internal fixation during the last decade

BACKGROUND

The incidence of children's forearm fractures is increasing worldwide. This is different from the declining trend observed in the overall injury rate, and the reason for the increase is not known. Diaphyseal forearm fractures comprise 3-6% of all paediatric fractures, and they offer a challenge to their treatment. The purpose of this study was to evaluate the incidence of diaphyseal both-bone forearm fractures in children during the last decade in Northern Finland. Another objective was to study the background factors, treatment, and re-displacement of these fractures.

MATERIALS AND METHODS

All 168 children (<16 years) admitted to our paediatric trauma centre due to diaphyseal both-bone forearm fractures during 2000-2009 were included. The type of injury, background factors, radiographics, treatments and re-dislocations were reviewed. The age-related incidence rates were evaluated.

RESULTS

The incidence of diaphyseal both-bone forearm fractures increased 4.4-fold (95% CI 2.0-10.8; P<0.001) between 2000 (8.2/100000) and 2009 (35.9/100000). The increase in the incidence was accelerating (P<0.001) and the overall increase was 338%. The incidence of surgical treatment for diaphyseal fractures increased 4.2-fold (95% CI 1.9-10.4, P=0.001), which is in relation to increasing number of fractures. However, internal fixation increased from 13.3% in 2000-2001 to 52.7% in 2008-2009 (P=0.015), as an alternative to conservative treatment. The re-displacement rate was high (29.9%) amongst the patients with conservative treatment compared to those who were invasively operated (1.4%) (P<0.001). The mean age of the patients increased by 2.4 years in the study period (P=0.019). Trampoline was the most important and still increasing reason for the fractures. At the beginning of the study, there were no trampoline-related fracture, but towards the end of the study 30-41% of the fractures were caused by a trampoline injury (P=0.004).

CONCLUSIONS

There was an accelerating increase in the incidence of paediatric diaphyseal both-bone forearm fractures during the last decade. Trampoline was the most important and still increasing reason for these fractures. The mean age of the patients was increasing. Increasing proportion of diaphyseal both-bone forearm fractures was treated operatively. Re-displacement was unusual amongst operated cases.

Treating anterior cruciate ligament tears in skeletally immature patients

PURPOSE

To systematically review the current evidence for conservative and surgical treatment of anterior cruciate ligament (ACL) tears in skeletally immature patients.

METHODS

A systematic search of PubMed, CINAHL, EMBASE, CCTR, and CDSR was performed for surgical and/or conservative treatment of complete ACL tears in immature individuals. Studies with less than six months of follow-up were excluded. Study quality was assessed and data were collected on clinical outcome, growth disturbance, and secondary joint damage.

RESULTS

We identified 48 studies meeting the inclusion criteria. Conservative treatment was found to result in poor clinical outcomes and a high incidence of secondary defects, including meniscal and cartilage injury. Surgical treatment had only very weak evidence for growth disturbance, yet strong evidence of good postoperative stability and function. No specific surgical treatment showed clearly superior outcomes, yet the studies using physeal-sparing techniques had no reported growth disturbances at all.

CONCLUSIONS

The current best evidence suggests that surgical stabilization should be considered the preferred treatment in immature patients with complete ACL tears. While physeal-sparing techniques are not associated with a risk of growth disturbance, transphyseal reconstruction is an alternative with a beneficial safety profile and a minimal risk of growth disturbance. Conservative treatment commonly leads to meniscal damage and cartilage destruction and should be considered a last resort.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Running-related injuries in school-age children and adolescents treated in emergency departments from 1994 through 2007

Running for exercise is a popular way to motivate children to be physically active. Running-related injuries are well studied in adults but little information exists for children and adolescents. Through use of the National Electronic Injury Surveillance System database, cases of running-related injuries were selected by using activity codes for exercise (which included running and jogging). Sample weights were used to calculate national estimates. An estimated 225 344 children and adolescents 6 to 18 years old were treated in US emergency departments for running-related injuries. The annual number of cases increased by 34.0% over the study period. One third of the injuries involved a running-related fall and more than one half of the injuries occurred at school. The majority of injuries occurred to the lower extremities and resulted in a sprain or strain. These findings emphasize the need for scientific evidence-based guidelines for pediatric running. The high proportion of running-related falls warrants further research.

Arthroscopic management of osteochondritis dissecans of the capitellum: mid-term results in adolescent athletes

BACKGROUND

The optimal treatment of osteochondritis dissecans (OCD) of the capitellum in adolescent athletes remains challenging. The purpose of this study was to investigate the mid-term results of arthroscopic treatment of OCD of the capitellum in a series of adolescents.

METHODS

We identified 25 consecutive patients at our institution that underwent arthroscopic treatment for OCD of the capitellum since 1999. Ten elbows were treated by arthroscopic debridement and drilling alone, whereas 12 elbows required additional mini-arthrotomies for bone grafting or the removal of large loose bodies after arthroscopy. The clinical charts and operative reports of these patients were retrospectively reviewed for relevant clinical information including age, sport, character of symptoms, preoperative and postoperative range of motion, return to sport, and postoperative complications. Twenty-one patients (22 elbows) were reached to determine their current elbow function and athletic activity using the Single Assessment Numerical Evaluation score.

RESULTS

The average age of the patients in our series was 13.1 years. All patients participated in organized athletics that involved the upper extremity and had undergone an average of 10.2 months of nonoperative treatment before surgery. At a mean follow-up of 48 months, the patients gained an average of 17 degrees of extension and 10 degrees of flexion after surgery. Both the improvement in flexion and extension were statistically significant compared with the preoperative range of motions (P=0.001, P=0.01). When patients were asked to rate their elbow function from 0% to 100% using the Single Assessment Numerical Evaluation score, the average rating was 87%. Eighteen of 21 patients (86%) returned to participate in their sport at their preinjury level.

CONCLUSION

Arthroscopic management of capitellar OCD in adolescent athletes results in significantly improved range of motion and a high rate of return to athletics. Accompanying arthrotomy may be required for large loose body removal or bone grafting.