Robert L. Cloutier
Despite our nation’s obesity epidemic, the number of children participating in sports has continued to climb, and pediatric athletes frequently present to the emergency department (ED) after an injury. More than 20% of pediatric injury-related visits involve a sports-related injury. More than 30 million, or half, of all children and adolescents participate in organized sports, and many others participate in unorganized sports such as skateboarding and bicycling. The most common sports injuries evaluated in the ED are fractures, dislocations, sprains, strains, head injuries, contusions, and lacerations. ED physicians also need to be familiar with sports-specific injuries such as avulsion fractures, overuse syndromes, and brachial plexus injuries. The presentations are rarely life-threatening, but the conditions can result in chronic morbidity if not recognized and treated properly.
Overall the most common sports injuries are fractures and dislocations. Fractures may involve the diaphysis, metaphysis, or physis. Fractures surrounding the physis are common since the adjacent physis itself, not its surrounding ligamentous structure, is the weakest component. As a result, physeal fractures occur when forces are transmitted across the joint from the stronger ligaments to the weaker areas of physeal bone. This is in contrast to similar injuries in adults where sprains occur because weaker ligaments tear while pulling on stronger, mature bone. Most physeal fractures seen in sports are classified as Salter–Harris I or II. However, once the physis begins to close during adolescence, unique patterns such as the Salter–Harris III and IV fractures emerge. The adolescent suffers more ligamentous sprains, similar to adults, because of the maturing skeleton. It is helpful to remember the adage that “the younger the child, the more likely a sports injury will result in a fracture.”
Dislocations are common in adolescent athletes, but are very rare in athletes younger than 10 to 12 years. The most frequent dislocations associated with sports involve the proximal interphalangeal (PIP) joints of the hand. PIP dislocations occur when the fingertip is hyperextended during contact sports or when catching a ball. Other common dislocations involve the patella and the glenohumeral joint of the shoulder. Patella dislocations occur with a twisting mechanism on a partially flexed knee, and they are almost always lateral dislocations. Glenohumeral shoulder dislocations occur with contact sports such as wrestling and football when forces are applied to an abducted, externally rotated arm. Ninety percent of glenohumeral dislocations are anterior.
Avulsion injuries occur when stronger muscle tendons adhere to weaker areas of bone called secondary ossification centers or apophyses. When a strong muscular contraction occurs, the tendon may pull the bony apophysis away from the larger bone. As the force of muscular contraction increases in adolescence, these injuries increase in number. The most common site for avulsion injuries is the pelvis, where the iliac crest, anterior inferior iliac spine, anterior superior iliac spine, or the ischium can be avulsed. Another example is the tibial spine (or eminence) avulsion resulting from hyperextension of the knee. The tibial tubercle, greater trochanter, lesser trochanter, and phalanges may also be avulsed.
Overuse injuries are increasing in children with the advent of year-round training and overtraining. Overuse injuries come in many varieties and often present to the ED because of an acute exacerbation of chronic pain, such as in a stress fracture. The most common stress fractures involve the proximal to middle third of the tibia, but the metatarsals, femur, and humerus may also be affected. Spondylolysis is a stress fracture through the pars interarticularis of the vertebrae, and is common in young athletes with lumbar back pain. Little League shoulder is a Salter–Harris I injury of the proximal humerus in overhand-throwing athletes such as baseball pitchers; Little League elbow is a constellation of elbow pain, medial condyle tenderness, and a subtle flexion contracture from the repetitive valgus stress of throwing. Overuse conditions in the lower extremities include Osgood–Schlatter disease and Sinding–Larsen–Johansson syndrome (“jumper knee”), which present as tenderness of the tibial tubercle and tenderness at the distal pole of the patella, respectively. Sever disease is an inflammation of the calcaneal physis where it joins the Achilles tendon. Severs tends to develop and flare during growth spurts; while painful, it is a temporary condition that will resolve with rest and symptomatic treatment. Medial tibial stress syndrome (MTSS or “shin splints”), which appear frequently with running sports, is a diffuse area of tenderness over the middle to distal third of the posterior-medial tibia. The diffuse tenderness of MTSS can be contrasted with the point tenderness of tibial stress fractures.
Ligamentous injuries are the topic of some debate because of the adage that “kids don’t get sprains.” However, the incidence of ligamentous injury (sprain) increases as patients approach adolescence. Sprains are becoming more apparent in young athletes, but they must still be carefully distinguished from the more common physeal fracture. Sprains are classified as mild (grade I), moderate (grade II), or severe (grade III). Ankle sprain is the most common joint injury in all of sports. The ankle is typically injured laterally owing to an inversion mechanism, and this mechanism may result in injury to the lateral ankle ligaments or the physis of the distal fibula.
Anterior cruciate ligament (ACL) knee injuries appear to be increasing, most likely because of improved recognition in addition to higher participation rates in sports. The usual mechanism of ACL injury is hyperextension, and this mechanism may result in either an ACL sprain or the previously mentioned tibial spine avulsion.
Sports injuries involving muscle are either contusions or strains. Contusions result from direct blows to the muscle, most of which are mild. However, complications can arise with hematomas in large muscle groups such as the quadriceps. A rare complication of contusions with intramuscular hematomas is myositis ossificans, a benign proliferation of bone and cartilage that appears weeks after a large contusion. Muscle strains occur when a sudden contraction of a muscle results in stretching or tearing of muscle fibers. Strains usually occur at the point where muscle and tendon fibers join. The classic muscle strain is that of the hamstrings, where the individual cannot bear weight after experiencing a “pop.”
Brachial plexus injuries (“stingers” or “burners”) result from trauma to the neck and shoulder region. The nicknames for brachial plexus injuries come from the burning or stinging sensation that tends to radiate down one arm in a nondermatomal pattern. The differential diagnosis includes spinal cord injury, which must be excluded in any patient with bilateral upper extremity symptoms or radicular symptoms into the legs.
ED EVALUATION
Most sports injuries involve an injured extremity, and a standardized approach to evaluation is recommended. Adequate pain control prior to physical examination or radiographs cannot be overemphasized. The injured extremity should be fully exposed to reveal any erythema, ecchymoses, or swelling, and the region should be palpated closely for any point tenderness. Exposing the injured extremity for comparison is often helpful. Adjacent joints should be assessed for both active and passive range of motion. The Ottawa knee and ankle rules have been found to be highly sensitive in school-age children and should be applied when deciding whether radiographs are indicated. Adequate visualization requires at least two views, and often three.
Patients with brachial plexus injuries may have unilateral weakness of the deltoid, biceps, or rotator cuff. A positive Tinel sign at the supraclavicular fossa also suggests a plexus injury. Close inspection of the cervical spine is necessary to rule out a cervical spine injury.
KEY TESTING
• Radiographs are necessary to evaluate for fractures in children or adolescents
ED MANAGEMENT
The keys to ED management of sports injuries are pain control, injury recognition, proper immobilization, and appropriate consultation. Pain control is best provided prior to any detailed examination or imaging and permits a better physical examination, better radiographs, and less patient discomfort. The majority of sports injuries can be immobilized and seen by an orthopedist or sports medicine physician within 5 days. The exceptions to this rule are limb-threatening injuries, intra-articular fractures (Salter–Harris III and IV), markedly displaced fractures, and dislocated joints that cannot be successfully reduced. Proper immobilization does not differ from that employed with other musculoskeletal injuries. Ideally, the joints proximal and distal to an injury are immobilized. If this cannot practically be done, immobilization techniques should provide for stabilization and protection from further injury.
Dislocations require prompt recognition and pain control. After appropriate radiographs, procedural sedation is recommended for reduction. Numerous techniques exist for reducing dislocations, and ED physicians need to be familiar with the different approaches. After successful reduction, postreduction radiographs and immobilization are indicated.
Avulsion injuries of the lower extremities and pelvis are managed with crutches and non-weight bearing until follow-up. The management of ligamentous and tendinous injuries depends upon their severity. More severe injuries require immobilization until follow-up. Stress fractures also require immobilization, but most other overuse injuries merely require a cessation of the related activities. If there is any doubt, the best plan is to immobilize the affected area and arrange for close follow-up in 3 to 5 days.
Brachial plexus injuries without progressive symptoms require minimal ED management once the diagnosis is made, but any focal findings suggestive of intracranial bleeding or cervical spine injury require emergent imaging. Chronic symptoms or persistent neurologic deficits are best evaluated with MRI.
CRITICAL INTERVENTIONS
• Emergent consultation for any injury with suspected neurovascular compromise or compartment syndrome
• Prompt reduction of any dislocated joint using analgesia and procedural sedation
• Emergent imaging for suspected cervical spine injury
DISPOSITION
Disposition and discharge instructions need to be emphasized in sports injuries. All of these patients need the classic “PRICE” discharge instructions covering the basics of protection, rest, ice, compression, cast/splint care, and elevation. Modifying this to “PRICE-FM” emphasizes follow-up, medications, and mobility for ideal management. Follow-up should be scheduled for 3 to 5 days with an orthopedist, sports medicine physician, or primary physician. Opioids should be provided if necessary, although this should be rare. More commonly, nonsteroidal anti-inflammatory drugs suffice. Mobility and range of motion are emphasized for ligamentous and muscle injuries. Return-to-play decisions are best left to the physician who will be monitoring the patient’s condition on follow-up.
Common Pitfalls
• Assuming that the young athlete with a sports injury has a sprain. The younger the athlete, the more likely an injury will result in a fracture.
• Forgetting to emphasize the importance of proper follow-up and rehabilitation.
ACKNOWLEDGMENT
The author gratefully acknowledges the contributions of Greg Canty to the content of this chapter.
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