Developing Physically Active and Sporty Kids - Injuries Specific to Children and Teenagers

Original Editor - Jess Bell based on the course by Tracy Prowse
Top Contributors - Jess Bell, Naomi O'Reilly, Kim Jackson, Wanda van Niekerk, Lucinda hampton and Aminat Abolade

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Introduction

While physical activity levels are declining in children generally, there are still large numbers of children and teenagers who participate in organised sports. And, as is discussed here, participation in formal sports can lead to injuries and burnout. Thus, when working with children and adolescents, it is important to consider how children’s injuries are different to those seen in adults.

Know Your Child’s Age

There are a number of "ages" which must be considered when working with children, including their:

• Developmental age
• Skeletal age
• General training age
• Sport-specific training age
• Relative age

It is also useful to monitor a child’s growth. This might include regular (e.g. quarterly) height measurements in standing, crook sitting and arm span. This monitoring can help to identify peak velocity height (i.e. the time when the child is growing the fastest), which is relevant to some of the conditions discussed below. Table 1 shows typical growth per year.

Table 1. Typical growth in height per year

Age (years)	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20
Height (cm)	5	4.8	5	4.8	5	4.8	8.6	12	7.7	3.3	2.3	1.9	1.3	0.9	0.5

Common Injuries in Children

Figure 1. Paediatric knee x-ray.

Why are Injuries in Children Different to those in Adults?

Figure 2. Anatomy of a long bone.

The injuries observed in children are often different to those seen in adults for the following reasons:

• Weak attachment site (causing avulsion fractures):
  • Growth plate cartilage in children is less able to resist stress when compared to articular cartilage in adults. It is also less resistant to shear and tension forces than the surrounding bone. This can lead to a failure of the physis (see Figures 1 and 2) when increased stress is applied. Thus, in incidents where adults experience a complete tear of a ligament or joint dislocation, children might experience a growth plate separation. Children appear to be more prone to growth plate injuries during periods of rapid growth (see Table 1).
• A mismatch between bone growth and muscle growth, which leads to incoordinated movements, and thus fracture
• Physis is weaker, which can lead to fracture (see above)
• Greenstick fracture - i.e. a partial thickness fracture - the cortex and periosteum are disrupted on one side of the bone only. They are unaffected on the other side. They are most common in children aged under 10 years, although they can occur at any age.
• Premature growth plate fracture = stress fracture

Types of Injuries

Apophysitis:

• Caused by traction injuries to the cartilage and bony attachment of tendons

• Often related to overuse in children who are growing
• More common in the lower limb

Osteochondrosis:

• Less common, but osteochondroses are a group of conditions that affect the epiphysis (see Figures 1 and 2)

• They occur when there are degenerative changes in the epiphyseal ossification centres of growing bones
• Caused by a temporary disruption of blood supply at the bone-cartilage complex, rather than traction
• They tend to resolve spontaneously, but should be monitored (surgery rarely required)

Metaphyseal fractures:

• Fractures that affect the metaphysis of tubular bones
• Occur most often in the forearm and lower leg

Avulsion fractures:

• Occur when there is a failure of the bone - a bone fragment is: “pulled away from its main body by soft tissue that is attached to it.”

During periods of rapid growth in children, bone lengthens before the muscles and tendons have time to stretch and develop the necessary strength and coordination to control this new longer bone. This can lead to awkwardness in a child’s movement patterns.

• Traumatic injuries lead to fractures of the bone or growth plate

• Strong incoordinated contractions of the muscles lead to avulsion fractures, rather than a tear of the muscle or tendon

Table 2 lists common growth plate injuries / osteochondroses. These injuries tend to be treated conservatively except for those which affect the hip and the knee.

Table 2. Common growth plate injuries / osteochondroses.

Non-Articular (related to overuse)	Articular	Physeal
Osgood-Schlatter's disease - tibial tubercle	Perthes disease - femoral head (ages 4 to 10)	Scheuermann’s disease - thoracic spine
Sinding Larsen Johansson syndrome - inferior pole of the patella	Kienbock’s disease - lunate wrist (more common in individuals aged 20 to 30 years)	Blount’s diease - proximal tibial growth plate (obese children aged 9 to 10 years)
Sever’s disease - calacaneus	Kohlers - navicular (ages 2 to 8, more commonly 4 to 6 years)	Triangular fibrocartilage complex (TFCC) impingement
	Osteochondritis dessicans: Medial femoral condyle of the knee Talar dome Capitellum elbow - loose bodies - common in gymnasts and throwers

Table 3 lists common fractures found in children.

Table 3. Common types of fractures found in children.

Metaphyseal Fracture	Avulsion Fracture	Growth Plate Fractures
Mostly occur in the forearm and lower leg	Musculotendinous, with common sites including: ASIS (sartorius) AIIS (rectus femoris) Ischial tuberosity (hamstrings) Lesser trochanter of the femur (iliopsoas) Ligamentous (ACL to tibia)	Salter-Harris fractures: Types I and II These injuries tend to heal well Examples include  Slipped Capital Femoral Epiphysis (SCFE)- most common in boys aged 12 to 15 years who are overweight Types III and IV These involve the joint surface and complications can occur NB: even if an x-ray is normal, a history of severe rotational or shear force with localised swelling, bony tenderness and loss of function can indicate a growth plate fracture.

Take Home Message

When a child presents with a traumatic injury, fracture should be considered. When pain appears related to overuse, or is long-term, growth plate injuries should be considered rather than tendinopathy, ligament sprain, tendon or muscle tear.

Management of Injuries in Children

Avulsion fractures:

• Musculotendinous avulsion fractures are treated conservatively (i.e. the same as a grade III muscle tear)
• Ligamentous avulsion fractures are often treated with surgery, so the child will need to be assessed by a specialist

Metaphyseal fractures:

• Must be immobilised
• Tend to heal quickly (3 weeks)

Growth plate injuries:

• Usually require conservative management / load management, especially in children who present with Osgood-Schlatter's disease and Sever's disease
• If pain levels are high and the child has difficulty weight-bearing, they may require crutches for a time (1 to 2 weeks)
• Load is then gradually reintroduced
  • A graded exposure approach to load can be adopted so that the system starts to accommodate and build up a tolerance to load

Osteochondosis / osteochondritis dissecans:

• The child should be referred to a specialist who can determine if immobilisation / surgical intervention is required