Shoulder and Elbow Injuries in the Adolescent Throwing Athlete.

Shoulder and elbow injuries in the adolescent population can be generally divided into skeletally immature and skeletally mature. Skeletally immature injuries refer to damage to the open growth plate (physis) in the young athlete, which have distinct differences in long-term risks if not managed correctly due to the potential for growth disturbance. Skeletally mature injuries occur in athletes with closed growth plates and are less likely to limit growth potential. It is important to recognize these different types of injuries, as well as the patients most at risk for each type because treatment may vary significantly between the two groups. The main skeletally immature injuries covered by this review will include: medial epicondyle apophysitis ("Little Leaguer's elbow), medial epicondyle fractures, olecranon stress fractures, capitellar osteochondritis dissecans (OCD), and proximal humeral apophysitis ("Little Leaguer's shoulder"). The skeletally mature injuries discussed will include: valgus extension overload syndrome (VEOS), ulnar collateral ligament (UCL) tear, shoulder instability, and superior labral anterior-posterior (SLAP) tears. We will review the history and presentation of the injuries as well as different treatment strategies and return to play guidelines for both primary care sports physicians as well as orthopedic surgeons.

Growth Disturbance Following Intra-articular Distal Radius Fractures in the Skeletally Immature Patient.

INTRODUCTION: The purpose of this study was to characterize the incidence of growth disturbance following intra-articular distal radius fractures in skeletally immature patients and to assess early radiographic and functional outcomes. METHODS: A retrospective investigation of pediatric patients with intra-articular distal radius fractures between 1997 and 2012 at a single institution was performed. Pathologic fractures and fractures in patients with closed physes were excluded. In total, 28 patients (24 males, 4 females), with a mean age of 13.8 years and mean follow-up of 31.7 months, met inclusion criteria. Fractures were categorized according to the Salter-Harris classification, and all radiographs were assessed for evidence of physeal disturbance. Information regarding treatment and early clinical results were obtained from a medical record review. Functional outcomes using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Modified Mayo Wrist Score (MMWS) were collected. Fisher exact test was used to compare the incidence of physeal arrest in the study population to previously published rates of physeal arrest in extra-articular fractures involving the distal radius. Because the data were not parametrically distributed, the Mann-Whitney-Wilcoxon test was used to compare those who did and did not develop physeal arrest. RESULTS: Of the 28 patients, 9 (32%) sustained Salter-Harris III fractures and 19 (68%) sustained Salter-Harris IV fractures. Growth disturbance occurred in 12 (43%) patients, comprised of 3 Salter-Harris III fractures and 9 Salter-Harris IV fractures; 7 of these patients underwent surgical intervention to address deformity. All 4 children age 10 years or younger had growth arrests that underwent subsequent procedures for a skeletal rebalancing of the wrist. No significant differences in DASH or MMWS were seen in the short term between patients who did or did not have physeal arrest. CONCLUSIONS: Intra-articular distal radius fractures in skeletally immature patients have a considerably higher rate of physeal growth arrest than extra-articular physeal fractures. Following acute management aimed at restoring and preserving anatomic physeal and articular alignment, follow-up radiographs should be obtained to evaluate for physeal arrest in skeletally immature children. Patients and families should be counseled regarding the high rate of growth disturbance and the potential need for deformity correction in the future, particularly in younger children. LEVEL OF EVIDENCE: IV-case series.

Outcome of 3.5-mm Anatomical Locking Plates for the Treatment of Proximal Tibia Fractures Involving the Meta-Diaphyseal Junction.

The clinical and radiological outcomes of proximal tibia fractures involving the meta-diaphyseal junction treated with unilateral 3.5-mm locking precontoured anatomical plates are reported. Thirty-nine patients (41 proximal tibia fractures) who had proximal tibia fractures with complete meta-diaphyseal dissociation were enrolled in the study. For all patients, immediate postoperative and final follow-up simple radiographs were evaluated to determine the quality of the reduction by assessing coronal and sagittal alignment. In cases of intra-articular involvement, articular reduction quality and condylar width were additionally assessed. Clinical outcomes were assessed by knee range of motion and Lysholm knee score at final follow-up. Immediate postoperative radiographs showed satisfactory results: medial proximal tibial angle within 87°±5° in 87.8% (36 of 41), posterior tibia slope within 9°±5° in 85.4% (35 of 41), less than 2-mm articular step or gap in 79.3% (23 of 29), and a condylar width difference within 5 mm compared with the femoral condyles in 93.1% (27 of 29). All reductions but 1 were found to have satisfactory maintenance of the initial reduction. At final follow-up, the mean knee range of motion and Lysholm knee score were 122.5° (range, 100°-135°) and 75.8 (range, 50-100), respectively. A single lateral 3.5-mm plate fixation for proximal tibia fractures involving the meta-diaphyseal junction offers mechanically stable fixation with satisfactory clinical and radiological outcomes. [Orthopedics. 2018; 41(6):e777-e782.].

The Role of the Basement Plate in Physeal Bar Formation.

BACKGROUND: Physeal fractures and resultant physeal bars can pose significant problems in skeletal development for the injured growing child. Although now well-recognized, only a small body of experimental literature covering this problem is available. The goal of this study was to help further develop an understanding of the different regions of the physis and the way in which each region responds to injury/fracture. METHODS: This Institutional Animal Care and Use Committee (IACUC)-approved study assessed bar formation using radiologic and histologic methods and measured leg lengths of skeletally immature rats. The right tibia was used as the control to measure leg length discrepancy (LLD), and the left tibia received either a fracture only (F), an epiphyseal scrape (ES), an epiphyseal drilling procedure (ED), or metaphyseal drilling (MD). Radiographs and LLD measurements were obtained at postoperative days 0, 21, and 56. RESULTS: A significant LLD was present at day 56 in the ED group (P=0.01). Radiographic identification of bars showed significant evidence of bar formation for the ES and ED groups at 21 days and the ED group at 56 days (P<0.05). Histologic examination showed a high incidence of histologic physeal bar formation in the ES, ED, and MD groups at 21 and 56 days. CONCLUSIONS: Findings showed that the physis was able to continue to grow following an injury to the physis' hypertrophic region. MD produced little effects with few physeal bars and little LLD. By postoperative day 56, ED animals showed greater LLD than ES animals. Penetration of the basement plate was more likely to lead to bar formation/growth retardation than was ablation of the epiphyseal region of the physis (including resting cells). CLINICAL RELEVANCE: Data presented here provides insight into the importance of different regions of the physis and its repair/continued growth after physeal fracture. We suggest that a better understanding of the physiological cause of physeal arrest after physeal fracture will be important for the development of treatments to prevent physeal arrest or to treat physeal arrest after it occurs.

Consequences Following Distal Femoral Growth Plate Violation in an Ovine Model With an Intramedullary Implant: A Pilot Study.

BACKGROUND: Retrograde femoral nailing in skeletal immature patients would broaden the surgical options for fracture care and reconstructive procedures but involves violation of the open, active distal femoral physis with the potential for growth disturbance. The tolerance for putting a large diameter metal implant across the physis is largely unknown. The purpose of this pilot investigation was to define the upper limit of cross-sectional violation with a metal implant before causing premature growth arrest or inhibition using a sheep model. METHODS: Eighteen sheep underwent placement of a retrograde, intramedullary implant at 3-months of age through an open distal femoral physis. The cross-sectional area of the physis was measured preoperatively and implants were selected that violated 3% to 8% of the cross-sectional area of the physis. Growth across the distal femoral physis was examined radiographically following surgery. Following euthanasia, both operative and no operative femurs were removed to compare differences in maximal lengths. RESULTS: The distal femora grew an average of 10.6±2.2 mm radio graphically after implantation. When compared with control specimens, only operative specimens with 8% of physeal violation demonstrated significant growth discrepancy with operative femurs measuring <2.1 mm in length compared with the contralateral control femur. Histologic analysis did not demonstrate any significant physeal bars formation. CONCLUSION: Distal femoral growth continues across the physis when 3% to 7% of the cross-sectional area of the physis is violated using a retrograde intramedullary implant. Specimens with 8% of growth violation demonstrated significant growth inhibition. As such, retrograde nailing through the distal femoral physis appears safe up to 7%. On the basis of previous anatomic data in humans and average nail sizes, violations of >6% of the physis with pediatric retrograde nailing would be uncommon. These findings suggest that retrograde nailing may be a viable option and merits further study. LEVEL OF EVIDENCE: Level IV-case series.

[Fractures of the lower extremities in childhood : Part 2: lower leg and ankle fractures]. / Frakturen der unteren Extremität im Kindesalter : Teil 2: Unterschenkel- und Sprunggelenksfrakturen.

The treatment of pediatric patients in trauma surgery is a special situation in every aspect. For deciding on the correct treatment of fractures of the lower leg and ankle joint, various parameters, such as residual growth rate, skeletal age and height of the patient are decisive. The differences between fractures in children and adolescents are the open epiphyseal plate and the resulting residual growth. The bones of young children have a higher healing tendency and a greater potential for correction than in adolescents. Especially in the lower leg and the ankle joint, the potential for correction is decisive for the healing of fractures and for possible development of growth disorders. The limits of tolerance concerning axial malalignments and the expected spontaneous potential for correction must play an essential role for further treatment with conservative or operative therapy. This article deals with the special features of pediatric fractures of the lower leg and ankle joint.