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ABSTRACT: PURPOSE: The purpose of this study was to assess athletic activities associated with spondylolysis in children and adolescents in a New York metropolitan tertiary referral center. METHODS: We retrospectively evaluated 137 consecutive cases of symptomatic spondylolysis presenting to one of two pediatric orthopedic spine surgeons. Ten patients who did not participate in any organized athletics were excluded, leaving 127 children for analysis. Data regarding spondylolysis and athletic participation were gathered for analysis. RESULTS: One hundred and twenty seven patients were analyzed (mean age 13.9 ± 2.2 years). All patients had initial x-rays with nearly all obtaining further higher level imaging to confirm the diagnosis of spondylolysis. MRI was obtained in 42.5% of cases, limited CT scan in 29.1% of cases, and SPECT scan in 23.6% of cases. The most common location of spondylolysis was at the L5 level (74%), of which 43.6% were bilateral. 2.4% of the overall cohort had spondylolysis at multiple levels. The most common athletic activities associated with spondylolysis in this cohort were soccer (19.3%), basketball (17.2%), and lacrosse (9.4%). CONCLUSION: While previous reports have implicated participation in various sports in the development of symptomatic spondylolysis in children, lacrosse and baseball have rarely been associated with spondylolysis. We found that in the New York metropolitan area, soccer, basketball, lacrosse, baseball, tennis and football were most commonly associated with spondylolysis. Therefore, we emphasize consideration of spondylolysis in these children if they present with low back pain. These results may be used to counsel parents and young athletes about the possibility of spondylolysis as an etiology of lumbar back pain and in educating coaches, teachers, school nurses, and primary care providers.
Medicine and science in sports and exercise 04/2013; · 3.71 Impact Factor
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ABSTRACT: Intrasubstance tears of the anterior cruciate ligament (ACL) were once considered a rare injury in skeletally immature athletes but are now observed with increasing frequency. Treatment strategies have evolved as recent studies have identified unique considerations specific to the skeletally immature patient. The current literature now supports the trend toward early operative treatment to restore knee stability and prevent progressive meniscal and/or articular cartilage damage, but the optimal approach to ACL reconstruction in this age group remains controversial. Despite the reported clinical success of transphyseal reconstruction, iatrogenic growth disturbance secondary to physeal damage remains a genuine concern. The reluctance to place drill-holes across open physes has led to the development of numerous "physeal-sparing" reconstruction techniques using anatomic femoral and tibial footprints that have adequately restored anteroposterior and rotational knee stability in biomechanical studies but have demonstrated mixed results in the clinical setting. The intent of this review is to (1) highlight the unique anatomic considerations pertaining to ACL reconstruction in the skeletally immature athlete, (2) discuss preoperative clinical and radiographic assessment of the pediatric patient with a suspected ACL injury, (3) review transphyseal and physeal-sparing reconstruction techniques and highlight surgical technical considerations, (4) present clinical outcomes according to patient and technique-specific factors, and (5) review age-specific injury prevention treatment strategies and a novel treatment algorithm based on skeletal maturity. ACL reconstruction in the skeletally immature athlete typically results in a successful clinical outcome, yet the optimal surgical technique is still controversial. This review will help guide the management of ACL injuries in the pediatric athlete.
The Journal of Bone and Joint Surgery 03/2013; 95(5):e281-13. · 3.27 Impact Factor
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ABSTRACT: Subtle variations in acetabular morphology have been implicated in several pathologic hip conditions. Although it is understood that the acetabulum forms at the junction of the ilium, ischium, and pubis at the triradiate cartilage, the ossification and development pattern of the posterior wall of the acetabulum is unknown. Standard radiographs and computed tomographic scans used in evaluation of the adolescent hip do not allow a complete assessment of the non-ossified portions of the developing acetabulum. The purpose of this study was to define the currently unknown ossification pattern and development of the posterior wall of the acetabulum and to determine when conventional imaging, with use of computed tomography and radiographs, is appropriate.
One hundred and eighty magnetic resonance imaging examinations in patients who were four to fifteen years old were evaluated by a musculoskeletal radiologist for ossification patterns of the posterior wall of the acetabulum and triradiate cartilage. Correlations were made with available radiographs.
Posterior acetabular wall ossification lags behind anterior wall ossification throughout development. On average, the posterior wall of the acetabulum began to ossify at the chronological age of eight years, followed by a discrete rim of posterior calcification (posterior rim sign) at the patient age of twelve years, just prior to the fusion of the posterior acetabular wall elements to the pelvis. This preceded the closure of the triradiate cartilage in all subjects. On average, male patients had fusion of the posterior wall of the acetabulum one to 1.5 years after female patients.
The ossification of the posterior wall of the acetabulum is completed in a predictable manner prior to closure of the triradiate cartilage.
Prior to closure of the triradiate cartilage (typically at the age of twelve years in girls and fourteen years in boys), magnetic resonance imaging, rather than radiographs and computed tomography, should be used to evaluate a child with hip pain or to measure and characterize acetabular morphology when cross-sectional imaging is indicated. This study characterizes a secondary ossification center along the edge of the posterior wall of the acetabulum that becomes ossified just prior to fusion. This secondary rim ossification center should not be confused with pathologic conditions such as labral avulsion or posterior acetabular wall injury.
The Journal of Bone and Joint Surgery 02/2013; 95(3):230-6. · 3.27 Impact Factor
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ABSTRACT: : Many surgeons utilize preoperative multiplanar imaging for surgical planning before fusion surgery using pedicle screw instrumentation. Computed tomographic (CT) scan is often used but limited by non-weight-bearing images and high-ionizing radiation. The purpose of this study was to compare pedicle length and width measurements using a multiplanar fluoroscopic imaging system and CT with gross measurements to validate the accuracy of multiplanar fluoroscopic imaging and compare relative radiation exposure between techniques.
: Thirteen intact cadaveric lumbar spine segments were imaged using multiplanar fluoroscopic imaging and conventional CT scan using a low-dose pediatric protocol. At each level and each imaging modality, the 26 pedicles were measured digitally for width and pedicle screw length in accordance with typical presurgical planning procedures. All images were independently measured by 3 observers. After measurement, the specimens were sectioned using a microsurgical saw to facilitate anatomic measurements using calipers. Measurements of the multiplanar fluoroscopic imaging and CT were compared with direct anatomic measurements to quantitate and compare measurement accuracy of CT and fluoroscopic imaging. At the time of image acquisition, radiation exposure from each modality was quantified to allow for comparison of radiation exposures.
: CT and multiplanar fluoroscopy had similar agreement with gross measurements with respect to pedicle width and length, with κ values for comparison of CT and fluoroscopy with gross measurements falling between 0.61 and 0.73. Both modalities underestimated pedicle width (by 1.9 mm for both modalities) and length (5.5 mm for CT, 6.6 mm for fluoroscopy). Interobserver reliability was higher for fluoroscopy versus CT. High-dose fluoroscopic imaging used 31% of the radiation exposure for CT.
: Multiplanar fluoroscopic imaging provides comparable diagnostic preoperative planning to CT scan in an experimental cadaveric model. The use of multiplanar fluoroscopic imaging resulted in between 69% and 85% less radiation exposure than conventional CT scan using pediatric settings. CLINICAL EVIDENCE:: This study demonstrates similar results from simulated preoperative templating using fluoroscopic imaging compared with CT scan but with less radiation exposure.
Journal of pediatric orthopedics 12/2012; 32(8):e67-71. · 1.23 Impact Factor
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ABSTRACT: Femoral trochlear dysplasia is an anatomic deformity that predisposes patients to patellar instability, including patellar subluxation and dislocation, and can lead to severe patellofemoral joint degeneration if left untreated. Femoral trochlear dysplasia leading to recurrent bilateral patellar dislocation has rarely been reported as having a familial association. Orthopedic surgeons who encounter patients presenting with chronic patellar instability with no underlying disease or syndrome should be aware of the presence of femoral trochlear dysplasia leading to recurrent bilateral patellar dislocation. Although femoral trochlear dysplasia remains uncommon, the presence of bilateral recurrent patellar dislocation in multiple members of the same family is highly suggestive of genetic inheritance.This article describes 3 patients from 1 family who presented with femoral trochlear dysplasia leading to recurrent bilateral patellar dislocation. To our knowledge, this is the second article to describe a familial form of femoral trochlear dysplasia associated with recurrent bilateral patellar dislocation and is the first article in English. A lower threshold for screening and early intervention for symptomatic family members may be indicated to prevent the long-term effects of chronic patellar subluxation, dislocation, and patellofemoral arthritis.
Orthopedics 04/2012; 35(4):e574-9. · 2.66 Impact Factor
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ABSTRACT: The cause of adolescent idiopathic scoliosis (AIS) is unknown and is currently believed to be multifactorial. AIS is a largely asymptomatic condition and many adolescents with AIS are involved with organized athletics and physical activity. To date, no data exist indicating predictors of return to physical activity after posterior spinal fusion for AIS. In this cohort study, adolescents who underwent posterior spinal fusion for AIS were evaluated to determine what clinical, surgical, and demographic variables predicted rate of return play in organized athletics.
Forty-two athletically active adolescents who underwent posterior spinal fusion for AIS at a single tertiary care academic orthopaedic institution by a single surgeon were analyzed for clinical, surgical, and demographic predictors of return to presurgical activity levels. Data were collected by chart review, patient interview, and completion of postoperative SRS-22 outcomes score.
At an average of 5.5 years follow-up, 25 patients (59.5%) had returned to sports at an equal or higher level of physical activity. Three variables were independently associated with return to athletic activity postoperatively. The relationship between distal level of fusion and rate of return to play demonstrated a statistically significant stepwise decline from T11 to L4. Lenke classification and final SRS-22 score were also predictive of return to activity. No complications related to return to play were reported.
In this retrospective cohort study, distal level of fusion, Lenke classification, and postoperative SRS-22 score were each independent predictors of rate of return to preoperative level of athletic activity after posterior spinal fusion for AIS.
Prognostic Level II: retrospective Study.
Journal of pediatric orthopedics 04/2012; 32(3):259-65. · 1.23 Impact Factor
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ABSTRACT: To provide the pediatrician with a comprehensive overview of the orthopedic considerations and potential issues in a child with Charcot-Marie-Tooth (CMT) disease. CMT is not one disease but rather a myriad of genetic and biochemical processes that manifest in a final common pathway of physical impairment with cardinal orthopedic elements.
This review incorporates the most current research on CMT, including its orthopedic elements, and the opinion of specialists in pediatric orthopedics specifically in the areas of foot and ankle, hip dysplasia and spinal deformity.
This article provides a framework for pediatricians to understand the complex and variable natural history of CMT with regard to neurologically produced musculoskeletal changes.
Current opinion in pediatrics 12/2011; 24(1):50-6. · 2.01 Impact Factor
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ABSTRACT: To summarize recent literature regarding long-term follow-up after spinal fusion for patients with adolescent idiopathic scoliosis. In particular, this review includes a review of research which provides insight into long-term results after fusion using pedicle screw stabilization, a relatively new technique for which long-term follow-up is only recently available.
The literature increasingly uses patient-derived questionnaires to report outcomes. Minor residual scoliosis after fusion does not adversely affect outcomes and is well tolerated by patients without causing functional limitations. In contrast, patients who are leaning forward after fusion ('positive sagittal balance') do worse as measured by validated outcomes instruments. Although patients who undergo long fusion have higher rates of disc degeneration on magnetic resonance imaging compared with the general population, this degeneration is most often clinically silent.
The best available evidence suggests that most patients do well after posterior fusion for adolescent idiopathic scoliosis, although outcomes are adversely affected if patients develop positive sagittal balance. Continued surveillance will determine whether accelerated degeneration at unfused levels becomes symptomatic at longer-term follow-up or remains clinically silent.
Current opinion in pediatrics 12/2011; 24(1):68-75. · 2.01 Impact Factor
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ABSTRACT: STUDY DESIGN:: Cadaveric Study. OBJECTIVE:: To compare a fluoroscopic imaging system with computed tomography (CT) and radiographs in detection of spondylolysis and radiation exposure in a cadaver model. SUMMARY OF BACKGROUND DATA:: Lumbar spondylolysis is defined as a defect or fracture of the pars interarticularis and occurs with or without anterior spondylolisthesis. CT scan is the gold standard imaging study for spondylolysis but is limited by the supine position, which may cause reduction of anterolisthesis and by ionizing radiation, which limits the frequency of follow-up scans. METHODS:: Thirteen intact cadaveric lumbar spine segments with 26 pars were randomized to be left intact or to undergo simulated fracture using a 1.3 mm oscillating microsurgical saw. Fifteen pars underwent simulated fracture and 11 pars were left intact. Lumbar spine segments were imaged using plain radiographs, multiplanar fluoroscopic imaging, and conventional CT scan. The images were interpreted by 3 observers blinded to the number and location of defects. Radiation exposure and doses were recorded from all imaging units. RESULTS:: Average radiation doses were 0.0025 mSv for each radiograph, 0.23 mSv (low dose) and 0.47 mSv (high dose) for fluoroscopic imaging, and 1.5 mSv for conventional CT imaging (pediatric dose setting). Evaluation of radiographs for spondylolysis had sensitivity of 98% and specificity of 97%. Evaluation using low-dose fluoroscopic images, high-dose fluoroscopic images, and CT scan images correctly identified the status of all pars based on multiplanar images; sensitivity and specificity were 100%. Kappa analysis demonstrated a value of 0.89 for radiographic interpretation indicating excellent agreement. Kappa values describing agreement for image interpretation for fluoroscopic imaging and CT scan were equal to 1.0, representing perfect agreement. CONCLUSIONS:: Three-dimensional fluoroscopic imaging provides comparable diagnostic imaging with CT scan in an experimental cadaveric model of spondylolysis using up to 85% less radiation than conventional CT scan.
Journal of spinal disorders & techniques 12/2011; · 1.21 Impact Factor
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ABSTRACT: Avulsion of the tibial spine is functionally equivalent to rupture of the anterior cruciate ligament in an adolescent athlete. It therefore presents to general orthopaedists as well as a wide variety of orthopaedic subspecialty surgeons, including traumatology sports medicine, and pediatrics. Restoration of normal knee kinematics is dependent on anatomic reduction and fixation of the avulsed fragment. Because this injury is typically sustained by the skeletally immature patient, epiphyseal fixation is ideal to avoid physeal injury, which can lead to angular limb deformity. We present a case, the first report to our knowledge, of coronal plane deformity in a lower extremity after open reduction and internal fixation of a tibial spine avulsion fracture. A successful treatment plan using hemiepiphysiodesis and guided growth is used with 20-month follow-up to skeletal maturity.
Journal of orthopaedic trauma 08/2011; 25(12):e115-9. · 1.78 Impact Factor
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ABSTRACT: This case report documents a rare cause of block to reduction in association with an anterior traumatic dislocation of the radial head in children. The radial head dislocations described were not reducible with a closed reduction secondary to "button holing" of the radial head through the anterior joint capsule. Open reduction was required to release the capsule and reduce the radial head. After reduction, the elbow was immobilized in flexion and the forearm in mild supination for 3 weeks. Postoperatively, all patients demonstrated full elbow function and range of function.
Journal of orthopaedic trauma 04/2011; 25(4):e38-41. · 1.78 Impact Factor
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ABSTRACT: Patellar dislocation is a common traumatic injury in the pediatric and adolescent population. The primary constraint to lateral subluxation and dislocation of the patella is the medial patellofemoral ligament (MPFL), which serves to resist lateral translation of the patella. Injury to the MPFL may predispose to recurrent dislocation but the anatomic site of injury is poorly characterized in children and adolescents.
The authors addressed 2 questions: (1) What is the zone of injury to the MPFL in a pediatric/adolescent population after primary patellar dislocation? (2) What is the location of the femoral attachment of the MPFL with respect to the growth plate?
Cohort study (prevalence); Level of evidence, 2.
Patients were eligible if they were ≤18 years of age and suffered a recent patellar dislocation characterized by magnetic resonance imaging (MRI) findings of high T2-signal intensity in the lateral femoral condyle. Patients were excluded if they had a history of prior dislocations, prior knee surgery, or congenital dislocation. Two musculoskeletal radiologists and an orthopaedic resident reviewed MRI scans of 43 children. The MPFL was divided into 3 zones: patellar insertion, femoral insertion, and midsubstance. The zone of injury was confirmed by the presence of associated soft tissue edema on short tau inversion recovery sequences and the distance from the MPFL insertion to the medial distal femoral growth plate was measured. Associated injuries were noted and the Insall-Salvati ratio was measured.
The MPFL injury was isolated to the patellar attachment in 61% of patients and to the femoral attachment in 12%. Twelve percent of patients had injury at both the patellar and femoral attachments. Six percent had no identifiable MPFL injury and 9% had combinations of midsubstance and either patellar or femoral attachment injuries. The kappa value for injury determinations was 0.71, indicating substantial concordance. The MPFL insertion site averaged 5 mm distal to the medial physis. Eighty-six percent of patients had an MPFL insertion distal to the growth plate, 7% had an insertion at the physis, while only 7% had a proximal insertion. The incidence of associated chondral injuries, the value of the Insall-Salvati ratio, and the location of MPFL insertion did not vary significantly with location of MPFL injury. Sixteen patients (36%) had MPFL insertions that were within 5 mm (either proximal or distal) of the growth plate.
The zone of MPFL injury in a pediatric population after primary patellar dislocation was predominantly isolated to the patellar attachment (61%), in contrast to previous literature. Twelve percent of patients had injury only at the femoral attachment, while 12% of patients had injury to both the patellar and femoral attachments. The remaining 15% had injury at multiple locations or no identifiable injury. The MRI finding that the anatomic insertion of the MPFL is distal to the physis in 93% of patients and that the MPFL is more likely to be injured at the patellar attachment has important implications in the surgical reconstruction of the MPFL in pediatric or adolescent patients.
The American journal of sports medicine 03/2011; 39(7):1444-9. · 3.61 Impact Factor
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ABSTRACT: Retrospective cohort study.
To describe long-term clinical and imaging results focusing on the uninstrumented lumbar spine after posterior spinal fusion for adolescent idiopathic scoliosis.
Although previous studies found rates of low back pain after long fusion for adolescent idiopathic scoliosis which are comparable to rates found in the general population, many surgeons believe that the long lever arm associated with the fusion mass will result in increased stress at uninstrumented caudal intervertebral discs and accelerated degenerative changes.
This is a retrospective chart and imaging review of adolescent idiopathic scoliosis patients treated with posterior fusion and segmental instrumentation. Patients completed follow-up examination, outcome questionnaires, radiographs, and magnetic resonance (MR) imaging. MR images were scored for evidence of degeneration of lumbar discs below the level of the fusion.
Twenty patients participated in the study, providing 90 discs below fusions for evaluation. The average follow-up was 11.8 years. The distal level of fixation was at L1 on average. The major curve averaged 55° ± 11° before surgery and was corrected to 25° ± 10° at follow-up. Follow-up MR imaging demonstrated new disc pathology in 85% of patients enrolled. Only one patient demonstrated significant degenerative disc disease at the junctional level, whereas most pathology was seen at the L5-S1 disc. The average Pfirrmann grade at uninstrumented levels deteriorated from 1.1 before surgery to 1.8 at follow-up. The greatest degree of degeneration was seen at the L5-S1 disc space where average degenerative scores increased from 1.2 before surgery to 2.3 after surgery. Three patients with severe disc disease were taking nonsteroidal anti-inflammatory drugs for pain, but no narcotics. Only mild scoliosis research society (SRS) and Oswestry changes were noted in this severe degeneration group.
Despite demonstrating an accelerated rate of L5-S1 disc degeneration, our study group has good functional scores and maintenance of correction over 10 years postfusion. In this long-term MR imaging follow-up study, disc degeneration was found remote to the lowest instrumented vertebra.
Spine 02/2011; 36(23):1948-54. · 2.08 Impact Factor
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ABSTRACT: Spondylolysis is a common cause for back pain in the adolescent athlete. Increased awareness of the presentation of this subset of patients can aid in optimal outcomes. This paper aims to review the typical presentation of spondylolysis in the adolescent with specific focus on the adolescent athlete. We review current controversies in diagnosis and management and aim to provide a thorough review to aid the pediatrician in making clinical decisions for this subset of patients.
The optimal algorithm for diagnostic imaging is controversial. Single positron emission computerized tomography can provide good sensitivity but poor specificity for spondylolysis. Computerized tomography can be useful as a follow-up exam to visualize the bony anatomy and osseous healing but has the concern of high radiation exposure. MRI may be a useful tool for diagnosis and follow-up examination, which may have significant advantages over traditional imaging techniques. Brace use is controversial and most likely functions as an adjunct for limiting motion to promote activity restrictions.
Spondylolysis in the adolescent athlete is a common problem. MRI is a good study for diagnosis, although further studies need to be done in order to show its advantages over traditional diagnostic methods. Brace wear is encouraged as a method for promoting activity modification, although its efficacy in promoting healing and success in treating spondylolysis is controversial.
Current opinion in pediatrics 02/2011; 23(1):68-72. · 2.01 Impact Factor
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ABSTRACT: As physician involvement in health policy grows, there will be an increasing need for future leaders in orthopedics. Interested orthopedic residents may be unaware of opportunities for leadership involvement in professional and subspecialty organizations. This article investigates whether national and subspecialty organizations offer membership to residents, allow residents to participate in committees, and provide opportunities for scholarly activity and mentorship. The authors surveyed 20 national orthopedic professional and subspecialty societies to evaluate the availability and cost of resident membership, meeting attendance and participation, research funding, committee membership, and mentorship opportunities. Each society's Web site was reviewed, and societies were contacted by phone if further inquiry was needed. Of the 20 orthopedic societies surveyed, 11 allowed resident membership. Five of 20 societies allowed residents to serve on committees, with a total of 14 total positions for residents. Four organizations provided formalized mentorship programs to residents. Although opportunities for resident involvement in subspecialty and professional societies are available in the majority of groups surveyed, the Orthopaedic Trauma Association and American Society for Surgery of the Hand provided the most comprehensive collection of opportunities. Residents should also pursue involvement in other organizations that may be more readily accessible, such as local, state, and regional orthopedic and medical societies. Increased resident participation in these organizations may help in increasing the 14 nationally available committee positions for orthopedic residents. Our orthopedic profession and societies should encourage motivated residents to pursue involvement and leadership at the national level.
Orthopedics 01/2011; 34(10):e669-73. · 2.66 Impact Factor
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ABSTRACT: Animal cadaveric biomechanical study.
We hypothesized that increasing bony destabilization of a bovine cadaveric sacrum by anterior pedicle screw penetration and bilateral alar decortication would decrease the amount of load necessary for failure of the construct and result in failure through the decortication sites.
Fusion to the sacrum has become commonly used for treatment of neuromuscular scoliosis and fusions in osteoporotic patients. Fixation failure after attempted fusion to the sacrum may be attributed to iatrogenic causes such as S1 screw penetration and sacral ala decortication.
Sixteen fresh-frozen 6- to 8-week-old calf spines were tested after instrumentation with pedicle screws and bilateral rods from L2 to S1 using four constructs: (1) S1 screws with posterior-only purchase; (2) S1 screws with bicortical purchase; (3) S1 screws with bicortical purchase and sacral alar decortication; and (4) S1 screws with bicortical purchase, decortication, and iliac fixation. A destructive flexural bending load was applied at L2 to each construct. Ultimate failure moment (Nm) was compared among the four groups, using a one-way analysis of variance combined with Holm-Sidak post hoc test.
No significant difference in failure moment was found among groups 1, 2, and 3. The addition of iliac fixation (group 4) significantly increased bending load to failure (P < 0.01), and iliac screw dislodgement was the dominant mechanism of failure. All specimens in group 3 failed with fractures extending through the decortication site. Groups 1 and 2 specimens failed by fracturing through the S1 body.
Sacral alar decortication and anterior pedicle screw purchase did not decrease the failure moment in long instrumentation to the sacrum. Pattern of failure was affected, with alar decortication being the site of fracture in each construct in which it was performed. Iliac fixation increased the failure moment under catastrophic loading conditions even when combined with sacral alar decortication and bicortical pedicle screw purchase.
Spine 01/2011; 36(6):E388-92. · 2.08 Impact Factor
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ABSTRACT: The young throwing athlete is susceptible to medial elbow injury due to valgus overload. We hypothesized that this injury can occur during the throwing motion with an acute episode of medial elbow pain resulting in an inability to effectively participate in throwing activities. In addition, appropriate treatment of acute, medial epicondyle avulsion fractures in baseball players can result in an asymptomatic elbow with subsequent return to play within a year of injury.
A case series of all youth baseball players with medial epicondyle avulsion fractures that occurred while throwing were identified. We studied several variables, including demographics, adherence to USA Baseball youth pitching recommendations, clinical history, radiographic findings, treatment, and outcome.
Eight skeletally immature baseball players, who were a mean age of 13 years (range, 11-15 years), presented with medial epicondyle fractures that occurred while throwing. All 8 players experienced sudden pain during throwing, and all 5 players with appropriate age and position qualifications did not conform to the USA Baseball youth pitching recommendations. Anteroposterior radiographs documented average fracture displacement of 5.1 mm (range, 2.5-10 mm). Five of 8 players had 5 mm or less of displacement and were selected for nonoperative treatment. Three of 8 players had more than 5 mm of displacement and underwent open reduction and internal fixation. All players were able to return to play at an average of 7.6 months (range, 4-10 months).
Medial epicondyle avulsion fractures can occur with a characteristic acute presentation while throwing in youth baseball players. Prevention may be possible when conforming to established USA Baseball youth pitching recommendations. Once an acute medial epicondyle avulsion fracture occurs, these injuries may be managed using published treatment algorithms, with successful return to play in less than 1 year.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 10/2010; 19(7):951-7. · 1.93 Impact Factor
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ABSTRACT: When operative stabilization of forearm fractures in older children is necessary, the optimal method of fixation is controversial. This study compared the radiographic and functional outcomes of intramedullary nailing to plating of forearm fractures in children between 10 and 16 years of age.
Thirty-one patients who underwent operative fixation of midshaft radius and ulna fractures were divided into nailing and plating groups and were compared retrospectively according to perioperative data and patient outcome measures (fracture union at 3 and 6 months, loss of forearm rotation, restoration of radial bow magnitude and location, and complication rates).
The nailing group had 19 patients, with a mean age of 12.5 years (range, 10-14.6 years), and the plating group had 12, with a mean age of 14.5 years (range, 11.9-16 years). Groups were similar for sex, arm injured, fracture location, Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association classification, and number of open fractures. Duration of surgery and tourniquet use were significantly shorter in the nailing group (P = 0.037 and 0.001, respectively). No differences were found between the groups for fracture union at 3 or 6 months. At latest follow-up, radial bow magnitude was similar for the 2 groups and restored to normal in both. Radial bow location in the nailing group was significantly different from the reported normal values (P = 0.001). Despite this, there was no difference in loss of forearm rotation between groups. Complication rates were also similar between groups, with 1 ulna nonunion, 1 compartment syndrome, and 2 refractures in the nailing group and 1 radius and ulna nonunion, 1 broken plate, and 2 refractures in the plating group.
Based on similar functional and radiographic outcomes, nailing of length-stable forearm fractures remains an equally effective method of fixation in skeletally immature patients 10 to 16 years of age when compared with plating and is our treatment of choice.
Therapeutic level III--retrospective comparative study.
Journal of Pediatric Orthopaedics 06/2008; 28(4):403-9. · 1.16 Impact Factor
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ABSTRACT: Adolescent back pain poses a distinct diagnostic challenge to the physician due to skeletal maturity and activity levels seen in adolescent patients. The purpose of this review is to focus on the musculoskeletal causes of adolescent back pain and to review the current literature on the etiology, diagnosis and treatment options.
Etiologies of adolescent back pain include a vast differential diagnosis, including traumatic, morphologic, infectious and neoplastic etiologies. Recent literature has focused on spondylolysis, back pack-related pain, disc herniations and back pain in adolescent athletes. Recent anatomic studies have demonstrated a distinct morphology to spondylytic spines attributing the etiology of spondylolysis in part to morphologic predispositions.
Increasing numbers of active adolescents will lead to increasing complaints of back pain seen by the primary care physician. Recent epidemiological studies have suggested a correlation between adolescent back pain and adult-onset back pain. A systematic approach to the adolescent with back pain is for arriving at a clear diagnosis and guiding appropriate treatments.
Current Opinion in Pediatrics 03/2008; 20(1):37-45. · 2.83 Impact Factor
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ABSTRACT: To familiarize primary care pediatricians with basic detection and treatment strategies of lower extremity stress fractures, while highlighting new research related to improving diagnosis and management approaches for pediatric and adolescent athletes.
Young age appears to be a risk factor for the development of stress fracture, but this difference may be secondary to differences in activity levels, for which most studies have not controlled. While use of radiographs and bone scan may be important to rule out other entities, MRI has emerged as the gold standard for definitive diagnosis of stress fractures. Since abnormal lower extremity biomechanics can have an etiological role in stress fracture, gait re-training may be an important feature of treatment of some patients. In addition, athletes with open physes appear to be predisposed to different sites and mechanisms of stress fractures than their skeletally mature counterparts, and may have poorer outcomes than previously reported in tibial shaft fractures.
As participation in competitive youth sports continues to increase, prospective studies are needed to enhance our understanding of epidemiological factors and optimal treatment strategies for pediatric and adolescent athletes.
Current Opinion in Pediatrics 03/2008; 20(1):58-61. · 2.83 Impact Factor
