Pediatric and Adolescent Sports Traumatology

268 Pages·2014·9.84 MB·English

by  Cosimo Tudisco

vincenzo guzzanti
editor
Pediatric and
Adolescent Sports
Traumatology
foreword by
carl l. stanitski
1 3
Pediatric and Adolescent Sports
Traumatology
Vincenzo Guzzanti
Editor
Pediatric and
Adolescent Sports
Traumatology
123
Editor
Vincenzo Guzzanti
Universityof Cassino
BambinoGesùChildren’s Hospital
Rome
Italy
ISBN 978-88-470-5411-0 ISBN 978-88-470-5412-7 (eBook)
DOI 10.1007/978-88-470-5412-7
SpringerMilanHeidelbergNewYorkDordrechtLondon
LibraryofCongressControlNumber:2013951125
(cid:2)Springer-VerlagItalia2014
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Thisbookisaffectionatelydedicatedtomydaughter,Valentina,
who, through her vigorous participation in volleyball, skiing
and swimming kept alive in me a passion for sport; to Rossella,
whowaitedwithinfinitepatienceandunderstandingduringthis
project; and to my parents who allowed me a place to design,
write andeditthe chapters ofthe book inthe peace andquiet of
my country home.
Foreword
Organized orthopaedic sports medicine’s emergence began in earnest in
the US in the 1970s. At that time, emphasis was placed on information
presented by team physicians for elite collegiate and/or professional
teams, especially American football. Societies were formed, courses
developed, and journals initiated to accommodate the burgeoning
interest in this newly organized field. Non-orthopaedic disciplines such
as exercise physiology, sports psychology, nutrition, athletic training,
and physical therapy quickly became incorporated in efforts to define
new areas of investigation. In 1964, Dr. Bob Jackson, following his
return from studying arthroscopy in Japan, introduced to North
America the use of arthroscopy as a diagnostic tool for knee disorders.
Commercial interestsdevelopedanappropriatesized camera,fiberoptic
lightsource,andoperativeinstrumentswhichledtoincreasedinterestin
and use of the procedure in the mid-1970s in the US. This advance in
minimally invasive surgery progressed from diagnostic abilities to true
surgical procedures with arthroscopic guidance. This endoscopic
method not only revolutionized orthopaedic surgery but the entire field
of surgery and its subspecialties. The American Academy of Ortho-
paedic Surgeons provided highly popular courses in arthroscopy and a
generation of arthroscopists incorporated these procedures into their
practices and education programs. I performed my first knee arthro-
scopic surgery in 1975. Internationally, similar efforts began with
worldwide collaboration. Fellowships in orthopaedic sports medicine,
often dominatedbyarthroscopicsurgeries,wereestablished.IntheUS,
in1991,therewere19orthopaedicsportsmedicinefellowshipsbasedon
an apprentice model. In 2000, there were 58 fellowships. This number
almost doubled (93) by 2009 with 224 fellows that year. Forty-three
percent of current US graduating orthopaedic residents take ortho-
paedicsportsmedicinefellowships.ACertificateofAddedQualification
examination in orthopaedicsports medicine was initiated a decade ago.
In addition to orthopaedic sports medicine fellowships, there are
accredited sports medicine fellowships in Internal Medicine, Rehabili-
tation, Emergency Medicine, Pediatrics and, Family Medicine, the one
with the largest percentage (80 %) of such fellowships. The field of
pediatric and adolescent sports medicine was essentially ignored for
some time due to the then held notions that ‘‘children do not get
significant sports injuries’’ and, ‘‘children heal any injury without
vii
viii Foreword
difficulty’’. It always seemed to this author that scholastic athletes
accountedforthelargestnumberofathletesinthecountryandathletes
inthisvastpopulationdoindeedgetsportsinjuries,usuallynotserious,
but enough did have injuries, especially about the knee, that had long-
termnegativeoutcomes.Thisviewwasnotincorporatedintothegeneral
orthopaedic sports medicine milieu at that time nor was treatment of
theseyoungathletesconsideredbypediatricorthopaedicsurgeonstobe
true pediatric orthopaedics, e.g., treatment of club foot, scoliosis or
Perthes’ disease. In 1972, in the US there were 4 million senior school
(grades 9–12) athletes. In 2010, there were an estimated 25 million
athletes, the major increase reflecting the governmental Title IX pro-
gram requiring equal opportunities for participation in sports by girls/
women as for boys/men. Sports were readily embraced by girls and
women.Awidevarietyofindividualandteamsportsarenowavailable
for this group of athletes. Twenty million pediatric and adolescent
athletes take part in community based programs, primarily in soccer,
baseball, basketball, swimming, and softball. There has been a signifi-
cant rise in individual youth ‘‘extreme’’ sports with skate boards, bicy-
cles,snowboards,andskis.Sportsrelatedinjuriesinpatients\18years
old as extrapolated from emergency room visits in the US were esti-
mated to be *1.2 million injuries in 2008–2009.
In addition to the technological developments that led to improved
arthroscopicsystems,otheraspectsofmedicaltechnologybegantoplay
increasing roles in sports medicine. Imaging techniques using CT and
MRI became revolutionary aids in diagnosis. Anesthetic methods in
pain management led to a huge increase in out-patient/same day dis-
chargesurgeries.Rehabilitationprotocolswhichemphasizedaccelerated
recoverywithresultantdiminishedreturntoplaytimeweredevelopedto
stem the negative effects of misuse and disuse.
Establishment of a sports medicine clinic devoted to pediatric and
adolescentathleteswasapioneeringeffortbymymentor,colleague,and
friend, Dr. Lyle Micheli, who began such a venue in the mid-1970s at
Boston’s Childrens’ Hospital. This clinic became a model for a multi-
disciplinary approach to care, clinical and epidemiologic research, and
injury prevention program development. Since that time, other clinics
with such a focus have arisen throughout the country and the world.
Therearenowmultiplenationalandinternationalcoursesandsymposia
as well as textbooks which address this subspecialty area. A core of
young US orthopaedic surgeons who are fellowship educated in pedi-
atric orthopaedics and orthopaedic sports medicine will provide the
leadership for future endeavors.
The initial reported overuse sports injury was a pediatric one, ‘‘little
league elbow’’, described by Adams in 1965 in young boy baseball
pitchers in California. Numerous overuse injuries occur at various
anatomic sites. These are associated with intrinsic factors—gender,
laxity, flexibility, strength, anatomic alignment and, extrinsic factors—
training methods/coaching/supervision,practice and competition times,
equipment/venues. The overuse conditions are often manifestations of
Foreword ix
rapid growth at junctional tendon-bone interfaces, e.g., Osgood–
Schlatter’s Disorder, Sever’s calcaneal apophysitis.
Majorinjuriesoccurwithincreasingfrequencywithageoftheathletes
given their increased size and speed. Senior schools athletes’ injuries
accounted for *40 % of sports injuries with 15 % of those requiring
surgical treatment. In the junior school group of athletes, which repre-
sented *15 % of injuries, only 5 % necessitated surgicalmanagement.
Growth must be considered as the pediatric orthopaedic surgeons
‘‘fourth dimension’’ given its impact on normal development and
responsetoinjury.Thisisespeciallyimportantabouttheknee,themost
commonsignificantinjurysite,wherephysealandintra-articularinjuries
occur. Musculoskeletal growth is variable in its onset, magnitude,
intensity, and duration. Attendant with growth are changes in the ath-
lete’s co-ordination, strength, flexibility, and endurance. In assessing
immature athletes, one must consider the physiologic age of the patient
and not their chronological age. Negligence of this leads to lack of
distinction between a child who is 100 pounds of mustache and muscle
versus another child who is 100 pounds of facial peach fuzz and baby
fat.Thisisespeciallytrueinthe‘‘never–neverland’’ofadolescence.Itis
importanttoassesstheproblemsoftheearlymaturingathleteversusthe
late maturer, each of whom will have issues regarding choice of sports.
In the US there is a major emphasis on sports requiring throwing,
catching, and hitting a ball. The young athlete who does not excel in
these skills may consider themself an athletic failure. Directing such an
athlete into sports such as soccer, track and field, swimming, wrestling,
or crew will provide a venue for achievement.
Structured, organized team sports beginning at ages 6–7 have
replaced unstructured free play for many children in the US. There are
now earlier competitions with prolonged seasons, sports camps, elite
travelteams,andfocusonasinglesportyeararound.Incontrasttothis
team regimen, extreme sports appeal to individuals. In response to the
intense, competitive atmosphere surrounding some youth sports pro-
grams, there is a move afoot in the US of non-competitive sports pro-
gramswithnoscoresbeingkeptandnoonedeclaredawinnerorlooser
but all a ‘‘participant’’. Children readily see through this by ages 9–10
and very much know who won or lost.
Sports are big business with massive finances driven by media con-
tractsatelite collegiateathleticprogramsandintheprofessionalranks.
Mediacoveragehasincreasedtheawarenessofinjuriessustainedbythese
celebrityathletesandtheirrecoveryfromthemorthelackoftheathlete’s
returntopriorsuperstardom.Thepublic’sexpectationsoftreatmentand
outcomes following injury in the scholastic athlete are often based on
thesecases.Suchhighprofilerolemodelsoftendriveparentsandyoung
athletestofeelalmostassuredthatthey(theathlete),too,canhavesuch
success leading to the development of ‘‘premature professionals’’ with
exaggerated expectations. Such attitudes cause a loss offocus and pur-
poseofyouthsports.IntheUS, *5 %ofseniorschoolathletesgoonto
participate in collegiate athletics and of those, only 2 % do so on an
x Foreword
athletic scholarship. Of the collegiate athletes, between 1 % and 9 %
become professional athletes. Despite such daunting data, many youth
sportathletesinsistthattheirfutureliesinprofessionalathletics.
Involvement in athletics may have negative effects on some partici-
pants including psychological ‘‘burn-out’’, eating disorders, and use of
performance enhancing medications. The overall effects of sports par-
ticipation in the appropriate setting are, however, highly positive and
include improved physical health with lower rates of obesity, diabetes,
heart disease and osteoporosis, and enhanced psychosocial health as
seen with lower rates of teen pregnancy, recreational drug use, and
higher self-esteem.
Injury prevention is a necessary part of all orthopaedic sports med-
icineprogramsandincludesassessmentofintrinsicandextrinsicfactors
as etiologic agents of injury. The focus of youth sports programs needs
to remain on learning skills, teamwork, fair play, and fitness while
enjoying the sport. Despite a large number of youth who remain
involved in organized sport, the significant drop out rate (*70 %) of
youth sports participants in the US by *13 years of age needs to be
reversed by innovative programs. Adoption of the European model of
the non-school-based community sports club which provides life-long
opportunities for sport and fitness and an active life style would go a
long way to provide athletic longevity and health in the US.
The above commentary represents reflections on over 60 years of
involvementinpediatricandadolescentsports.Thishasbeenasaplayer
(littleleague,seniorschool,college),acoach(seniorschool),aparentof
3 high level collegiate athletes, an official/referee, and a sports ortho-
paedic surgeon and team physician for little leaguers, scholastic, colle-
giate, andprofessionalathletes.Italsoincorporatesinformationgained
during years of interactions with sports medicine practitioners in
numerous fields during faculty participation in national and interna-
tional meetings and courses. Major changes have occurred over these
past6decadesindiagnosisandmanagementofsportsrelatedinjuriesas
well as the establishment of sports medicine as a recognized field of
study. The emergenceof pediatric andadolescent sportsmedicine asan
acknowledged sub-specialty is gratifying to see.
Ithankmycolleague,academiccollaborator,andfriend,Dr.Vincenzo
Guzzanti,forthehonor ofpresentingthis informationandthese obser-
vations. I congratulate him for bringing his more than two decades of
experience in pediatric and adolescent sports medicine to the develop-
ment,alongwithothersportsmedicineexperts,ofthisexcellenttextbook.
This monograph will serve as a valuable reference and overview of the
fieldaswellasastimulustothereadersforadditionalstudyinthisfield.
Carl L. Stanitski
Emeritus Professor of Orthopaedic Surgery
Medical University of South Carolina
Charleston, SC, USA
Preface
Attheendingofaclinicalandacademiccareer,onereflectsonwhatone
has done and also asks if one left a mark in their field. This text was
designedtogivewitnessofmystudyandofresearchinsportsinjuriesin
young athletes. Some topics in the book reflect a personal experience.
Other chapters arepresented by colleagues selected for their recognized
international standing in clinical and scientific expertise.
Over the past 20 years, an increased number of children and ado-
lescentsbecameinvolvedinawidespectrumofsports.Fortheseathletes
immersedinbeginningorcompetitivelevelsofsport,thereisaneedfor
available information to reassure parents of the children’s physical,
mental, and social development and to provide sports medicine spe-
cialistswithdataforprevention,diagnosis,andmanagementofathletic
disorders to prevent delayed or unsuitable treatment. It is also impor-
tanttonothavesportsassociationslosethemajorfocusofdevelopment
of young athletes, that is, in addition to learning and enjoying the
game(s), and to generate interest in long-term fitness and participation
in sports. The various demands on the young, developing athlete must
be understood on the basis of normal growth and development of the
skeletallyimmatureindividualonthewaytoadulthood,especiallyinthe
physiologic ‘‘never-never land’’ of adolescence.
Itiswellknownthatveryyoungchildrenhavemusclefibernumbers,
types, and distribution ratios similar to adults. Since growth can be
characterized by a protein anabolic state to support tissue synthesis,
children’s musculoskeletal systems are much more dynamic than in
adults. Developing tissues—bone, articular cartilage and, especially,
bone–tendon junctions—are more susceptible to such developmental
dynamics. At particular risk is the immature physis. Physeal and
epiphyseal damage may cause damage of greater consequences because
of the potential negative impact of prolonged growth at the site of
injury. More specific discussion of various injuries will be presented in
subsequent chapters.
Controversy exists regarding management of capsular and ligamen-
tous tears about the knee and ankle and the consequences of non-
operativeorsurgicaltreatmentonlaterjointstabilityanddevelopment.
Specific chapters are devoted to algorithms for diagnosis and treatment
xi