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Evaluation and Management of Sports Injuries in Children Michelle Sirak, MD Division Director Pediatric Physical Medicine and Rehabilitation Goryeb Children s Hospital – PowerPoint PPT presentation

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Title: Evaluation%20and%20Management%20of%20Sports%20Injuries%20in%20Children

Evaluation and Management of Sports Injuries in
  • Michelle Sirak, MD
  • Division Director
  • Pediatric Physical Medicine and Rehabilitation
  • Goryeb Childrens Hospital

  • None

Learning Objectives
  • Identify acute and chronic sports injuries in the
    child athlete
  • Evaluate and triage acute and chronic sports
  • Discuss issues and concerns that are unique to
    the child athlete

Common Acute Sports Injuries
  • Bruises/Contusions
  • Injury after a fall or a bump
  • Swelling and inflammation of soft tissue, muscle,
  • Abrasion
  • Injury after a scrape
  • Injury to skin/cut
  • Basic first aid
  • Laceration
  • Tearing/breaking of skin
  • Medical Attention

Common Acute Sports Injuries
  • Sprain
  • Ligament
  • Bone to Bone
  • Overstretched/partially torn
  • Strain
  • Muscle
  • Irritation/Inflammation/Partial Tear with in
  • Ligament Tear
  • Dislocation
  • Bone moves out of joint
  • Fracture
  • Broken Bone
  • Growth Plate Injuries Fractures

  • Situation Safety
  • Immobilize
  • Cervical Spine
  • Limb
  • Talk to the child
  • Once over
  • Above and below suspected injury

Management - RICE
  • R Rest
  • Rest the injury
  • Encourage activity with uninjured parts
  • Alternate sports
  • I Ice
  • 48 hrs
  • 15 20 min on/45 60 min off
  • Ice after activity/end of day x several months
    until symptoms gone
  • C Compression
  • Bandage, taping, brace
  • Early
  • When weight bearing
  • E Elevation
  • Above the heart to prevent pooling and swelling
  • 4 5 x/day while icing

Case 1
  • A 13 year old girl complains of "twisting" her
    left ankle while playing field hockey. She was
    running on the field towards the goal. She does
    not recall exactly in which direction her ankle
    twisted. She did not feel or hear any "snaps,"
    "pops," or "clicks." She denies sustaining any
    other injuries and has not sustained any previous
    injury to her left ankle.
  • On exam she is able to bear some weight on the
    ankle but it is starting to swell and is painful.
    Distally, her toes are pink, with brisk capillary
    refill and intact sensation to light touch.
    Tenderness can be elicited by palpation over the
    anterior aspect of the ankle joint.

Lateral Ankle Sprain
  • Rolling over the ankle
  • Stretch or tear of 1 or more ligaments in the
    ankle joint
  • Graded I, II, III based on severity

  • Weight Bear
  • Range of Motion
  • Pulses Capillary Refill
  • Anterior Draw gt5mm
  • Talar Tilt gt5-10 degrees

  • Higher Up the Leg
  • Syndesmosis Injury
  • Maisonneuve Fracture

Lateral Ankle Sprain
  • RICE
  • Crutches until weight bear without pain
  • Early Mobilization
  • X-ray?
  • Conservative
  • Physical Therapy
  • ROM, Strength, Pain Free activities
  • Grade 3 Surgical

Case 2
  • A 15 year old boy complains of sharp pain in the
    back of his right leg. He was running towards
    the goal while playing soccer. He felt a pop
    and burning sensation in the leg at the time of
    the injury. It is worse when he tries to actively
    bend his knee and with walking.
  • On exam he is able to bear weight on his right
    leg. The back of his thigh is tender to
    palpation. Pain is elicited when trying to
    stretch the right leg and when actively bending
    the right knee against resistance.

Hamstring Strain
  • Forceful hamstring contraction (concentric) or
    knee extension (eccentric)
  • Stretch or tear of muscle or tendon
  • pulled muscle
  • Grade I strain Grade III complete tear

  • Swelling
  • Bruising
  • Tenderness to palpation over muscle belly
  • Pain when stretching the muscle
  • Pain with resisted contraction of the muscle

Hamstring Strain
  • RICE
  • Weight-bearing reduction if needed
  • Imaging
  • Gentle Stretching
  • Strengthening
  • Thigh Wrap for support

Case 3
  • A 16 year old girl complains of sharp pain in the
    left knee. She was cutting to the left to
    avoid her opponent when she felt and heard a loud
    painful pop in her knee. Her knee immediately
    began to swell and feels stiff. When she tries to
    bear weight on her left leg she feels that the
    knee will give way.
  • On exam she has visible swelling of the left
    knee. There is tenderness along the joint line
    of the knee. She is unable to fully bend or
    straighten her knee.

Anterior Cruciate Ligament (ACL) Tear
  • Most commonly injured knee ligament in athletics
  • One of major ligaments in middle of the knee
  • Connects femur to tibia
  • Keeps the knee stable
  • Cutting, deceleration, hyperextension

ACL Tear
  • Noncontact injuries most common
  • Contact injuries may involve other structures
  • MCL
  • Medial Meniscus
  • Increased
  • Female
  • Lax ligaments
  • Knock Knee

  • Swelling
  • Tenderness along the joint lines of the knee
  • Range of Motion
  • Anterior Drawer test

ACL Tear
  • RICE
  • Partial Weight Bearing
  • Imaging
  • Physical Therapy
  • Surgery?
  • Physical Therapy
  • Goal complete rehab in 1 year

Case 4
  • A 14 year old boy presents to the emergency room
    having jammed his middle finger during a
    basketball game.
  • There is significant swelling at his PIP joint
    with displacement of his middle phalanx in
    relation to the proximal phalanx. He is unable to
    flex or extend his finger secondary to pain.
    Sensation on the medial and lateral border of the
    digit is intact with normal capillary refill.

  • Moves out of joint
  • Finger
  • Jammed force to end of joint
  • Twisting
  • Hyperextension
  • Immediate pain

Shoulder Knee/Patella
  • Deformity
  • Unable to bend/straighten dislocated joint

Finger Dislocation
  • X-ray
  • Dislocation
  • Fracture
  • Realignment
  • Splint/Buddy Tape 3 6 weeks
  • RICE
  • Occupational Therapy
  • Stretching/ROM
  • Strengthening

Case 5
  • A 17 year old girl slides into second base while
    playing softball and collides with the second
    baseman. She immediately hears a snap and feels
    pain in her leg.
  • She is unable to stand or weight bear on the leg
    and there is an obvious deformity of the lower
    leg. She has sensation throughout the leg but is
    unable to move the leg.

  • Broken Bone Emergency Care
  • Severe Pain
  • Hear/feel snap
  • Difficult to move/weight bear on injured part
  • Injured part moves unnaturally
  • Visible Deformity
  • EMS/9-1-1
  • Splint AS IS

  • Simple
  • One fracture line, bone is broken into 2 pieces
  • Comminuted
  • More than one fracture line with more than 2 bone
    fragments at the fracture site
  • Closed
  • Skin in fracture area is not broken, break is not
    exposed to the outside
  • Open (Compound)
  • Skin over the fracture is broken, exposing the
    broken bone

Growth Plate Injuries/Fractures
  • Where bone is growing
  • Weakest during growth spurt
  • Female 10 11 yo ? 15 17 yo up to 3/yr
  • Male 11 -12 yo ? 16 17 yo up to 4/yr
  • Cessation of growth
  • Limb length discrepancies

Acute Injuries
  • Eye Injury
  • Cover with Paper Cup
  • Doctor/ED
  • Dental Emergency
  • Lost/Broken tooth
  • Sterile gauze moisten with saline/milk
  • Out from socket
  • Rinse with saline/milk
  • Place back in socket

Chronic Injuries
  • Overuse
  • Repetitive action with too much stress on
    musculoskeletal system without adequate recovery
  • Newer Phenomenon
  • Used to play different sports/season
  • Now year round training

Causes of Overuse Injuries
  • 1Training Errors
  • Too much, too soon, too fast
  • Problem with equipment - growth
  • Environmental Conditions
  • Hot
  • Dehydration ? muscle dehydrated increase risk
    of injury
  • Cold
  • Decrease blood flow to muscle

Causes of Overuse Injuries
  • Poor Nutrition
  • Inadequate Hydration
  • Anatomic Misalignment
  • Knock kneed, bow legged, flat feet, high arches
  • Muscle Imbalance
  • Growth Spurt
  • Tighter muscles decrease flexibility
  • Prior Injury
  • Deconditioning or Out of Shape!

Shin Splints
  • Microscopic tearing of muscle attaching to bone
    on shins
  • Pain, inflammation irritation along leg
  • Repeated running on hard surface/hills
  • Tx
  • RICE
  • Arch Support
  • Stretching
  • Strengthening
  • Decrease mileage

Osgood-Schlatter Disease
  • Pain at Tibial Tuberosity where tendon attaches
    from patella
  • Rapid growth 10 15 years old
  • Overuse
  • Tight quads, hamstring, calf muscles
  • Painful bump below knee

Osgood-Schlatter Disease
  • RICE
  • Pain Free Activities
  • Strengthening
  • Stretching
  • 6 24 months from start of pain to resolve
  • Return when
  • Bump not painful
  • Pain free ROM
  • Jog, sprint, cut, jump pain free

Patellofemoral Pain Syndrome(Runners Knee)
  • Pain around/behind the kneecap
  • Walk, run, sit long period of time, downhill,
  • Intermittent knee swelling
  • RICE
  • Knee Brace/Shoe Orthotic
  • Physical Therapy
  • Strengthen VMO

Growth Plate Overuse Injuries
  • Little Leaguers Shoulder
  • Proximal Humeral Epiphysitis
  • Overuse of growth area of the humerus with
    widening of growth plate
  • Little Leaguers Elbow
  • Medial Apophysitis
  • Medial epicondyle pain
  • Muscles that bend the wrist attach to medial

Stress Fracture
  • Lower Body
  • Shin
  • Foot
  • Toes
  • Injury without insufficient recovery
  • Avoid Impact
  • Boot to quicken healing
  • Back (Spondylolysis)
  • Fracture of pars interarticularis
  • Hyperextension
  • Twisting
  • Gymnastics, dancing, skating, football
  • Bracing 3 9 months
  • PT

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  • Re injury most common injury
  • Return to sport before sufficient healing and
    recovery is not complete
  • Increase risk of injury to adjacent body part
  • Proper warm up/stretching
  • Pace self, ease back into sport
  • Proper Equipment
  • Safe playing surface
  • Adequate adult supervision safety
  • Prepare child for sport
  • training/conditioning

  • Trust Body Cues
  • Pain/sore
  • Listen to Im Tired
  • Rest Days
  • Vary intensity of the workout
  • Vary the type of physical activity
  • Hydration
  • 8 oz. beyond thirst prior to game
  • 4 8 oz. every 15-30 min during activity

? Concussion ?
  • 18 yo Female falls off bicycle
  • 17 yo Male falls off skateboard and lands on
  • 16 yo Female hits head on metal bed frame
  • 10 yo Male is hit in the head with
  • books when opening his locker

Does your management change if
  • Feels totally fine
  • Is dizzy, but really wants to play because today
    is the final practice before decision is made on
    who makes the team
  • Feels fine, but on exam balance is terrible
  • Mom is standing right behind you giving you the
    stink eye

  • May be caused by a direct blow to the head, face,
    neck or elsewhere on the body with an impulsive
    force transmitted to the head

Biokinetics of Concussion
  • Acceleration-deceleration and rotational forces
  • Helmet?

  • Typically results in the rapid onset of
    short-lived impairment of neurologic function
    that resolves spontaneously
  • May result in neuropathological changes, but the
    acute clinical symptoms largely reflect a
    functional disturbance NOT a structural injury

Pathophysiology of Concussion
  • Brain obligate aerobic organ fueled by glucose
    delivered via blood circulation
  • Brain activity increases blood flow to brain
  • Coupled relationship of oxygen and glucose

  • Mismatch of metabolic supply and demand may
    cell dysfunction, increased cell vulnerability to
    second traumatic insult/stress
  • Each insult need to consider if insult initiated
    above chemical cascade
  • No abnormality on STANDARD structural
    neuroimaging studies is seen
  • Newer imaging is showing evidence of injury
  • Functional MRI

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Classification of Concussions
  • Consensus Statement Zurich 2012
  • ABANDONED Simple vs. Complex Grading
  • Majority 80 90 resolve in a short (7 10 day)
  • Recovery time frame may be LONGER in children and

  • 8.9 of all reported high school athletic
  • F gt M in similar sports
  • ? F weaker neck muscles and smaller head mass?
  • ? M more reluctant to report injury?
  • Football, F Soccer, M Lacrosse, M Soccer, F
    Basketball, Wrestling, F Lacrosse, Softball, M
    Basketball, M F Volleyball, Baseball

Pre-season Baseline Testing
  • Standard Pre-participation Sports Physical
  • Concussion History including any head, face, or
    cervical spine injuries where concussions may
    have been missed
  • Identify athletes that fit into a high risk
    category education/prevention opportunity
  • Neurocognitive Testing - baseline

My cats OK I can play, I got my cat scanned
  • Immediate
  • Headache
  • Dizziness
  • Double Vision
  • Nausea
  • Light/Sound Sensitivity
  • Feeling Foggy
  • LOC
  • Amnesia
  • Behavioral Changes
  • Cognitive Impairment
  • Sleep Disturbance

On-field/Sideline Evaluations
  • Cervical Assessment on Field
  • Address first aid issues
  • Any Suspicion of concussion
  • NFL Docs eye in the sky
  • SCAT3 rapid sideline screening
  • http//achieves.gmu.edu/assets/docs/achieves/SCAT_
  • Serial monitoring for deterioration over next few

  • Physical and Cognitive REST until symptom
  • Do NOT need to awaken throughout the night,
    observe for normal breathing pattern
  • Cocoon Therapy AKA a whole list of what you
    CANNOT do
  • VS.
  • Do what you can tolerate/does
  • not worsen symptoms
  • fastest way to recovery and stop spending time
  • with me is to listen to your symptoms.
  • You cannot push through a concussion

  • Wear sunglasses if photophobia
  • Sleep in a dark room as much as possible 2 3
    days, then try to resume normal sleep/wake hours
    and nap 15 20 minutes
  • Gradually increase exposure to telephone, music,
    TV by 15 minute intervals as long as symptom free
  • Feeling better danger zone
  • Light Activity
  • Over Sleeping

Management Medications
  • Avoid and let symptoms be your guide
  • Extreme headache Rx or OTC but avoid over use
  • Masking symptoms
  • Rebound headaches
  • Melatonin
  • Sleep
  • Headaches

School Considerations
  • Attendance
  • Visual Stimulus
  • Workload
  • Physical Exertion
  • Breaks
  • Audible Stimuli
  • Testing
  • Concussion Team at School?

Return to Play (RTP)
  • Symptom free off medication
  • Exception antidepressants
  • Neurocognitive Testing
  • Objectively evaluate condition, track recovery
  • Measures symptoms, verbal visual memory,
    processing speed, reaction time
  • Gradual RTP Protocol
  • Proceed 1 level at a time if asymptomatic at
    current level
  • 24 hrs per level 1 week to proceed through full
    rehabilitation protocol
  • Any symptoms drop down to asymptomatic level x
    24hrs before proceeding
  • May stretch out RTP if lt 13 years old

Pediatric Adolescent Considerations
  • All recommendations are for ages 10 up
  • Less than 10 years old, report symptoms
  • Need to include both child parent input as well
    as teacher and school input when appropriate
  • Neuropsychological testing Neuropsychologists
    may play a larger role for school
  • Learning disabilities ADHD
  • May take longer to symptom free prolonged RTP
  • NO same day RTP
  • Cognitive rest may require absence from school or
    modified work load
  • HUGE STRESSOR!!!!!!!!

PreventionHelmets Do Not Prevent Concussions!
  • Helmets/Headgear
  • New bike helmet following impact
  • Football helmets reduce impact force to head but
    not concussion incidence
  • Soccer head gear unclear utility, heading can be
    performed safe? avoidance does not prevent
  • Headgear increasing head injuries female
    lacrosse, soccer
  • Athletes, Parents, Coaches, Athletic
  • Trainers, Physicians, Health Care Providers,

Long Term Effects
  • Chronic Traumatic Encephalopathy
  • Seen in 18-year old multisport athlete with a
    history of concussions from football upon autopsy
  • New football, soccer
  • 3 or more concussions
  • Increased LOC, post-amnesia, confusion
  • 8 16 yo persistent deficits in processing
    complex visual stimuli
  • Athletes with 2 or more concussions who are
    concussion free x 6 months performed similarly on
    NP testing as athletes with 1st concussion in
    last week
  • 2 or more concussions lower GPA

Second-Impact Syndrome
  • Sustain an initial head injury then second injury
    before symptom free from first head injury
  • Cerebral vascular congestion ? diffuse cerebral
    swelling ? death
  • Pediatric Adolescents at higher risk for rare
  • All reported cases are of athletes lt 20 yo.
  • Catastrophic football head injuries 3x more
    likely in high school than in college athletes

Retirement From Sport
  • Consider when sustained 3 concussions in an
    individual season or more than 3 months of

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These Parents are Cray
Returning Too Soon
  • But I CANNOT fall behind in school!
  • But she HAS to take those tests tomorrow!
  • But its a REALLY important game!
  • But I am kinda a BIG DEAL!
  • The coach is going to KILL me!
  • The coach is going to kick her off the team!
  • If he misses this season how can he become a
    professional _______ and I can retire?!?!

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Talking the Students and Parents off the Ledge
  • If you are injured you are not going to perform
    your best
  • You are not going to be the best contribution for
    your team
  • You will take longer/not heal
  • It is easier to reinjure yourself
  • You are first a child then a student athlete
  • Your health is most important
  • Believe it or not the world will go on!

  • Kids Sports by Eric Small, MD
  • Mild Traumatic Brain Injury in Children and
    Adolescents by Michael W. Kirkwood Keith Owen
  • The Sports Medicine Patient Advisor Third Edition
    by Pierre Rouzier, MD
  • Consensus Statement on Concussion in Sport 4rd
    International Conference on Concussion in Sport
    Held in Zurich, November 2012
  • Physical Medicine and Rehabilitation Board Review
  • Sports-Related Cervical Spine Injuries On-Field
    Assessment Management
  • www.ImPACTTest.com
  • Effect of Amantadine on Post-Concussive Symptoms
    Poster Presentation
  • Clinical Report Sport-Related Concussion in
    Children and Adolescents
  • www.cdc.gov/concussion

Thank You!
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