| Edward Staub, M.D. drstaub.com |
Orthopaedic Surgeon, Sports Medicine, Knee, Hip, Shoulder, Ankle, Spine
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| PEDIATRIC ORTHOPEDIC PROBLEMS By Edward Staub, M.D. |
OVERUSE SYNDROME IN CHILDREN
With the fitness explosion, I have seen more and more injuries in children. Most of these are “overuse” injuries
resulting from overstressing the body. It’s usually thought that these occur only in the poorly-conditioned adult
athlete. However, children are also quite prone to these injuries, frequently for different reasons. With great numbers
of children participating in athletic programs, leagues, special summer camps, etc., it’s useful for parents to
understand why certain injuries can occur and how they might be prevented.
GROWING CARTILAGE
Children differ from adults in that they have growing cartilage cells in their bones and around their joints. The
cartilage is a soft white substance that covers the bone ends at the joint. (You commonly see cartilage on chicken
bones.) A child’s cartilage is thicker and perhaps more susceptible to shear injury than in adults. As a result, small
fractures of the joint surface are more common in children.
Another location of cartilage is in the growth plate near each end of the bone. The growth plate is a zone of immature
cartilage cells which eventually calcify and form bone. The growth plate is responsible for lengthwise growth of a
bone. It has long been known that injuries, such as fractures of the growth plate, may produce growth disturbances.
Furthermore, it has been suggested by some medical researchers that the repetitive trauma of certain athletic
activities may produce subtle injuries to the growth plate, thus potentially causing growing deformities.
A third location of growth cartilage is in the area where a tendon attaches onto bone. This area is called “apophysis ”
( see diagrams below). Between the bone and tendon end, there is a mound of cartilage. Eventually the cartilage
transforms into bone, but until it does, it represents a weak link between tendon and bone. Therefore, it’s prone to
injury. Traction on the tendon can pull off or avulse the apophysis, resulting in a fracture. Lesser trauma results in
an inflammation or “apophysitis.” Osgood-Schlatter’s disease of the knee is the best known of these conditions, but
apophysitis can also occur at the heel or pelvis and can be painful. The treatment is usually rest.
GROWING PAINS:
Growth of the bones also produces growing pains. As the bones grow in length, there must also be associated
growth of muscles and ligaments. During periods of rapid childhood growth—the growth spurts—the muscle growth
may have difficulty keeping up with bone growth. Thus, joint tightness and loss of flexibility may result.
It’s at the time of this growth spurt that children may be first exposed to repetitive training and conditioning programs.
This can lead to “overuse” injuries which produce sprains of tight muscles.
Overuse injuries—literally ailments as a result of overdoing the activity or overtaxing the body—are probably the most
common reasons why children who participate in sports complain of pain. Growth and immature bones, as discussed
above, are two reasons for overuse injuries in children. Other causes include training errors, (such as abrupt
increases in activity, intensity or duration), improper footwear, unfavorable playing surfaces (such as concrete) and
anatomic mal-alignment problems of the lower extremities (such as bowlegs, knock-knees, or flat feet).
Children, like adults, who participate in sports will always risk injury, such as fractures or sprains. However, overuse
injuries can frequently be prevented. When a child is in a growth spurt, initiating supplementary muscle flexibility
exercise programs or decreasing intensity training may help alleviate muscle injuries. It’s hoped that future medical
studies will help us realize the effects of repetitive and strenuous exercise on growing bones and will help determine
both the maximum levels of athletic training during childhood. Until that time, it’s best to advise some caution when
children are involved with sports requiring repetitive actions, such as jogging, pitching, or gymnastics.
GROWTH PLATE FRACTURES
The end of the bone at the joint in a growing child is called the epiphysis. Below and adjacent to this area is the
growth plate or epiphysial plate. Because this plate is cartilage, it is weaker than bone and, thus, more prone to
fractures. Nearly fifty, years ago, two orthopedists-Salter and Harris- classified these fractures with reference to
prognosis and treatment.
Some of these fractures can be potentially serious as a joint displacement or growth injury in a growing child can lead
to future arthritis, deformity, or stunted growth. Therefore fractures need to be recognized and treated meticulously.
Salter Type 1
A fracture line goes across the growth plate, parallel to the line of the plate. These are usually non-displaced
and not initially seen on an x-ray. Suspicion occurs from the injury and local tenderness at the end of the bone.
Treatment is with a cast-sometimes at the risk of overtreatment.
If I am initially unsure that it is a fracture rather than a sprain or bruise, I may splint the limb, and re-check a few days
later. If still very painful,I assume a fracture and apply a cast.
A few weeks later new bone formation or callus is evident on x- rays - confirming the fracture.
Salter Type 2
The fracture line runs along the plate and up into the adjacent bone—away from the joint.
Treatment is a cast. If the fracture is displaced or angulated, it needs to be set. This is usually easy.
Salter Type 3
The opposite of type 2. The fracture goes along the plate and then shears into the epiphysis and into the joint.
If non-displaced, these are treated with a cast.
If dislaced, the position cannot be accepted as the joint surface can be disrupted and result in arthritis.
Therefore, displaced fractures require surgery and pinning.
Salter Type 4
The fracture runs vertically across the epiphyseal plate and into the joint.
Like type 3 above, the position must be perfect. If it iis displaced, surgical pinning is required to prevent deformity
or growth plate damage.
Salter Type 5
Rare. The plate is subjected to a crush type injury –usually in the knee or ankle. Initial x-rays may look normal and the
injury may be overlooked. Prognosis is poor as the damage is done at the time of the injury.
Growth disturbances may occur.
The prognosis is excellent for types 1 and 2 as long as the displacement if any is corrected and protected with a cast
until the fracture heals. The prognosis for types 3 and 4 are also good-albeit maybe a bit more guarded than the first
two- as long as the fractures are in excellent position or replaced in excellent position by surgical pinning.
The prognosis for type 5 is not good, but fortunately, these are not common injuries.
Moreover, parents need to realize that damage to the growth plate occurs at the very time of the injury and the die is
cast then, so to speak. Therefore however excellent and meticulous the medical treatment, growth disturbances can
still occur.
OSTEOCHONDROSES
These are common problems related to growing cartilage and bone injuries –probably as a result of blood supply /
circulatory problems. The most serious of these are Legg-Perthes disease of the hip which can result in permanent
hip joint damage. Less serious forms affect the foot (Kohler’s Disease); metatarsal or instep (Freiberg’s Disease);
or the heel ( Sever’s Disease ).
The most common overuse syndrome is Osgood-Schlatter Disease. This is similar to an osteochondrosis but it is
probably more appropriately associated with a tendonitis or apophysitis (above). It affects the patella tendon(kneecap
tendon. Below the kneecap is a normal bump on the upper leg. This is called the tibial tubercle. The patella tendon
attaches here. Stress and overuse either causes a tendonitis or slightly pulls the growing tubercle off of the bone.
This occurs because full bone has not quite formed from the growing cartilage mound and the tubercle is therefore
weaker than the tendon. There could also be some localized bony damage as x-rays frequently show clumping of the
immature tubercle.
Clinically, the child complains of knee pain and soreness. There is frequently local swelling and tenderness over the
tubercle.
The condition is benign and not serious. Treatment consists of rest, medicine like advil for a short time, and a brace
to rest the knee. It frequently recovers with rest and time—the only problem may be getting an active child or teen to
rest.
I have never operated on this, but I suppose that surgery would be indicated in a rare, severe case in which the
tubercle is completely displaced or avulsed off of the bone.
MORE CONTENT AND DIAGRAMS TO COME IN THE NEAR FUTURE
With the fitness explosion, I have seen more and more injuries in children. Most of these are “overuse” injuries
resulting from overstressing the body. It’s usually thought that these occur only in the poorly-conditioned adult
athlete. However, children are also quite prone to these injuries, frequently for different reasons. With great numbers
of children participating in athletic programs, leagues, special summer camps, etc., it’s useful for parents to
understand why certain injuries can occur and how they might be prevented.
GROWING CARTILAGE
Children differ from adults in that they have growing cartilage cells in their bones and around their joints. The
cartilage is a soft white substance that covers the bone ends at the joint. (You commonly see cartilage on chicken
bones.) A child’s cartilage is thicker and perhaps more susceptible to shear injury than in adults. As a result, small
fractures of the joint surface are more common in children.
Another location of cartilage is in the growth plate near each end of the bone. The growth plate is a zone of immature
cartilage cells which eventually calcify and form bone. The growth plate is responsible for lengthwise growth of a
bone. It has long been known that injuries, such as fractures of the growth plate, may produce growth disturbances.
Furthermore, it has been suggested by some medical researchers that the repetitive trauma of certain athletic
activities may produce subtle injuries to the growth plate, thus potentially causing growing deformities.
A third location of growth cartilage is in the area where a tendon attaches onto bone. This area is called “apophysis ”
( see diagrams below). Between the bone and tendon end, there is a mound of cartilage. Eventually the cartilage
transforms into bone, but until it does, it represents a weak link between tendon and bone. Therefore, it’s prone to
injury. Traction on the tendon can pull off or avulse the apophysis, resulting in a fracture. Lesser trauma results in
an inflammation or “apophysitis.” Osgood-Schlatter’s disease of the knee is the best known of these conditions, but
apophysitis can also occur at the heel or pelvis and can be painful. The treatment is usually rest.
GROWING PAINS:
Growth of the bones also produces growing pains. As the bones grow in length, there must also be associated
growth of muscles and ligaments. During periods of rapid childhood growth—the growth spurts—the muscle growth
may have difficulty keeping up with bone growth. Thus, joint tightness and loss of flexibility may result.
It’s at the time of this growth spurt that children may be first exposed to repetitive training and conditioning programs.
This can lead to “overuse” injuries which produce sprains of tight muscles.
Overuse injuries—literally ailments as a result of overdoing the activity or overtaxing the body—are probably the most
common reasons why children who participate in sports complain of pain. Growth and immature bones, as discussed
above, are two reasons for overuse injuries in children. Other causes include training errors, (such as abrupt
increases in activity, intensity or duration), improper footwear, unfavorable playing surfaces (such as concrete) and
anatomic mal-alignment problems of the lower extremities (such as bowlegs, knock-knees, or flat feet).
Children, like adults, who participate in sports will always risk injury, such as fractures or sprains. However, overuse
injuries can frequently be prevented. When a child is in a growth spurt, initiating supplementary muscle flexibility
exercise programs or decreasing intensity training may help alleviate muscle injuries. It’s hoped that future medical
studies will help us realize the effects of repetitive and strenuous exercise on growing bones and will help determine
both the maximum levels of athletic training during childhood. Until that time, it’s best to advise some caution when
children are involved with sports requiring repetitive actions, such as jogging, pitching, or gymnastics.
GROWTH PLATE FRACTURES
The end of the bone at the joint in a growing child is called the epiphysis. Below and adjacent to this area is the
growth plate or epiphysial plate. Because this plate is cartilage, it is weaker than bone and, thus, more prone to
fractures. Nearly fifty, years ago, two orthopedists-Salter and Harris- classified these fractures with reference to
prognosis and treatment.
Some of these fractures can be potentially serious as a joint displacement or growth injury in a growing child can lead
to future arthritis, deformity, or stunted growth. Therefore fractures need to be recognized and treated meticulously.
Salter Type 1
A fracture line goes across the growth plate, parallel to the line of the plate. These are usually non-displaced
and not initially seen on an x-ray. Suspicion occurs from the injury and local tenderness at the end of the bone.
Treatment is with a cast-sometimes at the risk of overtreatment.
If I am initially unsure that it is a fracture rather than a sprain or bruise, I may splint the limb, and re-check a few days
later. If still very painful,I assume a fracture and apply a cast.
A few weeks later new bone formation or callus is evident on x- rays - confirming the fracture.
Salter Type 2
The fracture line runs along the plate and up into the adjacent bone—away from the joint.
Treatment is a cast. If the fracture is displaced or angulated, it needs to be set. This is usually easy.
Salter Type 3
The opposite of type 2. The fracture goes along the plate and then shears into the epiphysis and into the joint.
If non-displaced, these are treated with a cast.
If dislaced, the position cannot be accepted as the joint surface can be disrupted and result in arthritis.
Therefore, displaced fractures require surgery and pinning.
Salter Type 4
The fracture runs vertically across the epiphyseal plate and into the joint.
Like type 3 above, the position must be perfect. If it iis displaced, surgical pinning is required to prevent deformity
or growth plate damage.
Salter Type 5
Rare. The plate is subjected to a crush type injury –usually in the knee or ankle. Initial x-rays may look normal and the
injury may be overlooked. Prognosis is poor as the damage is done at the time of the injury.
Growth disturbances may occur.
The prognosis is excellent for types 1 and 2 as long as the displacement if any is corrected and protected with a cast
until the fracture heals. The prognosis for types 3 and 4 are also good-albeit maybe a bit more guarded than the first
two- as long as the fractures are in excellent position or replaced in excellent position by surgical pinning.
The prognosis for type 5 is not good, but fortunately, these are not common injuries.
Moreover, parents need to realize that damage to the growth plate occurs at the very time of the injury and the die is
cast then, so to speak. Therefore however excellent and meticulous the medical treatment, growth disturbances can
still occur.
OSTEOCHONDROSES
These are common problems related to growing cartilage and bone injuries –probably as a result of blood supply /
circulatory problems. The most serious of these are Legg-Perthes disease of the hip which can result in permanent
hip joint damage. Less serious forms affect the foot (Kohler’s Disease); metatarsal or instep (Freiberg’s Disease);
or the heel ( Sever’s Disease ).
The most common overuse syndrome is Osgood-Schlatter Disease. This is similar to an osteochondrosis but it is
probably more appropriately associated with a tendonitis or apophysitis (above). It affects the patella tendon(kneecap
tendon. Below the kneecap is a normal bump on the upper leg. This is called the tibial tubercle. The patella tendon
attaches here. Stress and overuse either causes a tendonitis or slightly pulls the growing tubercle off of the bone.
This occurs because full bone has not quite formed from the growing cartilage mound and the tubercle is therefore
weaker than the tendon. There could also be some localized bony damage as x-rays frequently show clumping of the
immature tubercle.
Clinically, the child complains of knee pain and soreness. There is frequently local swelling and tenderness over the
tubercle.
The condition is benign and not serious. Treatment consists of rest, medicine like advil for a short time, and a brace
to rest the knee. It frequently recovers with rest and time—the only problem may be getting an active child or teen to
rest.
I have never operated on this, but I suppose that surgery would be indicated in a rare, severe case in which the
tubercle is completely displaced or avulsed off of the bone.
MORE CONTENT AND DIAGRAMS TO COME IN THE NEAR FUTURE
| The following medical articles are intended only for general patient information and education. They are not necessarily specific to any one patient's needs and, therefore, should not be construed as formal medical advice or treatment. Obviously, if you have a similar medical problem, you should consult a physician and not rely on these articles in lieu of treatment. If you reside in Dr. Staub's area, he will be delighted to accept you as a patient, but his ultimate opinion and recommendations will be based on his personal examination of you. |