Forest
Common pitfalls in the diagnosis of pediatric sports injuries
Pitfalls…..
How things get missed • Inadequate training • Inadequate time • Inadequate information gathering • Inadequate interpretation
Inadequate interpretation • • • •
Context Biases Time Experience
Forest
Remedies • Training • Time • Information gathering • Interpretation
Diagnostic pitfalls: categories • Unique susceptibilities due to skeletal immaturity • Anatomic variants mimicking injury • Developmental conditions that may or may not be symptomatic • Medical conditions presenting as injury
Common pitfalls: Outline • Foot/ankle • Knee • Hip, pelvis, back, hamstring • Elbow • Wrist
Heel pain • Hx: Hx: 12 y.o y.o.. soccer player; heel pain with running • PE: tender over posterior calcaneus near Achilles
Heel pain: Differential diagnosis • Achilles tendonitis • Plantar fasciitis • Bursitis • Stress fracture • Bone bruise
Heel pain in children
Sever’s disease
Achilles tendon
Calcaneal apophysis Plantar fascia
Sever’s disease (calcaneal apophysitis) • 9-12 year olds • Heel pain with running • Tender over apophysis • Shoes with poor heel cushion • Tight calf muscles
Lateral foot pain • Hx: 14 y.o. soccer player; rolled ankle; developed lateral foot pain and swelling • PE: tender, swollen Vth metatarsal
Sever’s disease: treatment • Limit impact activity • Ice, NSAIDs? • Stretch calf/hamstrings • Heel cups
Lateral foot pain: xx-ray
Lateral foot pain
Iselin’s disease (Apophysitis of Vth metatarsal)
Differential diagnosis
Injured side
Accessory ossification centers
Comparison view
A
B
Accessory navicular
C
D
Os vesalianum
Os trigonum
Tarsal coalition Key features • Lateral pain/instability without lateral ligamentous laxity • Peroneal spasm • Non Non--supple flat foot • Fibro Fibro--osseous bridge that becomes more rigid with maturation
Osgood-Schlatter Osgooddisease • 13 13--16 y.o. males • History of running, jumping, squatting, and/or recent increase in activity • Tenderness, swelling over tubercle; tight hamstrings
Ankle pain
Anterior knee pain: Differential diagnosis • Patellofemoral pain syndrome • Iliotibial band syndrome • Patellar tendinitis • Prepatellar bursitis • OsgoodOsgood-Schlatter disease
Anterior knee pain • Hx: 9 y.o. gymnast with infrapatellar pain • PE: tender over patellar tendon origin
Anterior knee pain: xx-ray
Sinding-Larson SindingLarson--Johanssen syndrome • Traction apophysitis at inferior patellar pole • 8-12 yrs.; M>F • Treatment similar to OsgoodOsgood-Schlatter
Anterior knee pain • Hx: 14 y.o. cross country runner with anterior knee pain; worse with running on hills • PE: tender over lateral patellar border
Anterior knee pain: xx-ray
Bipartate patella
Chronic knee pain
• SuperiorSuperior-lateral pain (rather than inferior--medial) inferior • Bony tenderness • Trauma insufficient to cause fracture
• 15 y.o. boy with swelling, clicking, and mild instability of knee • No history of injury • Small effusion on exam; restricted flexion; stable ligaments
Bipartate patella
Avulsion fracture
Chronic knee pain: which side is abnormal?
Differential diagnosis • • • •
Torn meniscus Discoid meniscus Plica syndrome Patellofemoral pain syndrome • Chondral fracture Right
Chronic knee pain
Right
Osteochondritis dissecans
Acute knee injuries: differential diagnosis • Anterior cruciate ligament sprain • Medial collateral ligament sprain • Meniscus tear • Patellar subluxation/ dislocation • Fracture
Left
Acute knee injury: Case I History • 15 y.o. FB player tackled from side • Medial pain, swelling • Restricted motion • Instability with lateral movements
Acute knee injury: Case I Radiographic findings
Acute knee injury: Case I Children vs. adults
Acute knee injury Physical examination • Tender over adductor tubercle and distal femur • 3+ medial instability • Negative Lachman
Acute knee injury Children vs. adults
Acute knee injuries: Case II • 11 y.o. gymnast • Knee “popped” after landing • Immediate swelling • Instability with pivoting
Acute knee injuries: Case II Physical examination • IntraIntra-articular effusion • Tenderness at posteriorposterior-lateral corner • Positive Lachman test
Case II Radiologic evaluation
Case II Radiologic evaluation
Hip pain • Fracture • Dislocation • Adductor or psoas strain • “Hip pointer” • SI or pubic symphysis sprain • SCFE
SCFE
Acute hip pain • Hx: 18 y.o. figure skater with acute anterior hip pain after landing from a jump; painful weight--bearing and weight hip flexion • PE: normal passive hip flexion and internal rotation
Acute “hip” pain
Apophyseal avulsion
Apophyseal injuries
Apophyseal avulsion
Hamstring/ buttock pain
Chronic hamstring pain
Ischial apophysitis
Chronic “hamstring” pain
• 15 y.o. female with 2 years of hamstring pain after jumping off a 3 foot wall • Pain is worse with sitting; better with standing, walking, and even running
Low back pain: Disc disease
Elbow pain in children
Little League elbow (medial epicondylitis)) epicondylitis
Medial epicondylitis: epicondylitis: complications
• Medial elbow pain with throwing • Tenderness over flexor tendon origin • Restricted elbow extension • Painful wrist flexion/pronation
“Little League elbow” • Differential diagnosis
Compression
Elbow pain in gymnast
Osteochondritis dissecans
Tension
Elbow pain in gymnast
Chronic wrist pain • • • •
Wrist pain in children
Tendinitis Stress fracture Arthritis Nerve entrapment
Radial epiphysitis: epiphysitis: risks
Acute wrist pain
• Positive ulnar variance • Arthritis
Unique responses to injury
Torus (metaphyseal (metaphyseal)) fracture
Pediatric sports injuries: Summary • Unique risks • Unique injuries
“Bummer of a birthmark, Hal”
Questions/comments?
Pitfalls…..
How things get missed • Inadequate training • Inadequate time • Inadequate information gathering • Inadequate interpretation
Inadequate interpretation • • • •
Context Biases Time Experience
Forest
Remedies • Training • Time • Information gathering • Interpretation
Diagnostic pitfalls: categories • Unique susceptibilities due to skeletal immaturity • Anatomic variants mimicking injury • Developmental conditions that may or may not be symptomatic • Medical conditions presenting as injury
Common pitfalls: Outline • Foot/ankle • Knee • Hip, pelvis, back, hamstring • Elbow • Wrist
Heel pain • Hx: Hx: 12 y.o y.o.. soccer player; heel pain with running • PE: tender over posterior calcaneus near Achilles
Heel pain: Differential diagnosis • Achilles tendonitis • Plantar fasciitis • Bursitis • Stress fracture • Bone bruise
Heel pain in children
Sever’s disease
Achilles tendon
Calcaneal apophysis Plantar fascia
Sever’s disease (calcaneal apophysitis) • 9-12 year olds • Heel pain with running • Tender over apophysis • Shoes with poor heel cushion • Tight calf muscles
Lateral foot pain • Hx: 14 y.o. soccer player; rolled ankle; developed lateral foot pain and swelling • PE: tender, swollen Vth metatarsal
Sever’s disease: treatment • Limit impact activity • Ice, NSAIDs? • Stretch calf/hamstrings • Heel cups
Lateral foot pain: xx-ray
Lateral foot pain
Iselin’s disease (Apophysitis of Vth metatarsal)
Differential diagnosis
Injured side
Accessory ossification centers
Comparison view
A
B
Accessory navicular
C
D
Os vesalianum
Os trigonum
Tarsal coalition Key features • Lateral pain/instability without lateral ligamentous laxity • Peroneal spasm • Non Non--supple flat foot • Fibro Fibro--osseous bridge that becomes more rigid with maturation
Osgood-Schlatter Osgooddisease • 13 13--16 y.o. males • History of running, jumping, squatting, and/or recent increase in activity • Tenderness, swelling over tubercle; tight hamstrings
Ankle pain
Anterior knee pain: Differential diagnosis • Patellofemoral pain syndrome • Iliotibial band syndrome • Patellar tendinitis • Prepatellar bursitis • OsgoodOsgood-Schlatter disease
Anterior knee pain • Hx: 9 y.o. gymnast with infrapatellar pain • PE: tender over patellar tendon origin
Anterior knee pain: xx-ray
Sinding-Larson SindingLarson--Johanssen syndrome • Traction apophysitis at inferior patellar pole • 8-12 yrs.; M>F • Treatment similar to OsgoodOsgood-Schlatter
Anterior knee pain • Hx: 14 y.o. cross country runner with anterior knee pain; worse with running on hills • PE: tender over lateral patellar border
Anterior knee pain: xx-ray
Bipartate patella
Chronic knee pain
• SuperiorSuperior-lateral pain (rather than inferior--medial) inferior • Bony tenderness • Trauma insufficient to cause fracture
• 15 y.o. boy with swelling, clicking, and mild instability of knee • No history of injury • Small effusion on exam; restricted flexion; stable ligaments
Bipartate patella
Avulsion fracture
Chronic knee pain: which side is abnormal?
Differential diagnosis • • • •
Torn meniscus Discoid meniscus Plica syndrome Patellofemoral pain syndrome • Chondral fracture Right
Chronic knee pain
Right
Osteochondritis dissecans
Acute knee injuries: differential diagnosis • Anterior cruciate ligament sprain • Medial collateral ligament sprain • Meniscus tear • Patellar subluxation/ dislocation • Fracture
Left
Acute knee injury: Case I History • 15 y.o. FB player tackled from side • Medial pain, swelling • Restricted motion • Instability with lateral movements
Acute knee injury: Case I Radiographic findings
Acute knee injury: Case I Children vs. adults
Acute knee injury Physical examination • Tender over adductor tubercle and distal femur • 3+ medial instability • Negative Lachman
Acute knee injury Children vs. adults
Acute knee injuries: Case II • 11 y.o. gymnast • Knee “popped” after landing • Immediate swelling • Instability with pivoting
Acute knee injuries: Case II Physical examination • IntraIntra-articular effusion • Tenderness at posteriorposterior-lateral corner • Positive Lachman test
Case II Radiologic evaluation
Case II Radiologic evaluation
Hip pain • Fracture • Dislocation • Adductor or psoas strain • “Hip pointer” • SI or pubic symphysis sprain • SCFE
SCFE
Acute hip pain • Hx: 18 y.o. figure skater with acute anterior hip pain after landing from a jump; painful weight--bearing and weight hip flexion • PE: normal passive hip flexion and internal rotation
Acute “hip” pain
Apophyseal avulsion
Apophyseal injuries
Apophyseal avulsion
Hamstring/ buttock pain
Chronic hamstring pain
Ischial apophysitis
Chronic “hamstring” pain
• 15 y.o. female with 2 years of hamstring pain after jumping off a 3 foot wall • Pain is worse with sitting; better with standing, walking, and even running
Low back pain: Disc disease
Elbow pain in children
Little League elbow (medial epicondylitis)) epicondylitis
Medial epicondylitis: epicondylitis: complications
• Medial elbow pain with throwing • Tenderness over flexor tendon origin • Restricted elbow extension • Painful wrist flexion/pronation
“Little League elbow” • Differential diagnosis
Compression
Elbow pain in gymnast
Osteochondritis dissecans
Tension
Elbow pain in gymnast
Chronic wrist pain • • • •
Wrist pain in children
Tendinitis Stress fracture Arthritis Nerve entrapment
Radial epiphysitis: epiphysitis: risks
Acute wrist pain
• Positive ulnar variance • Arthritis
Unique responses to injury
Torus (metaphyseal (metaphyseal)) fracture
Pediatric sports injuries: Summary • Unique risks • Unique injuries
“Bummer of a birthmark, Hal”
Questions/comments?
