Are classic metaphyseal lesions pathognomonic for child abuse? Two cases of motor vehicle collision-related extremity CML and a review of the literature.

Long bone fractures at the infant growth plate, known as classic metaphyseal lesions (CMLs), raise a strong suspicion for abusive injury. CMLs persist as a hallmark for inflicted injury although a handful of documented cases of CMLs created by other, non-abusive mechanisms within various healthcare settings are scattered throughout the past few decades of medical literature. The forces required to sustain a CML are typically defined as a combination of tensile, compressive, or rotational energy applied to the metaphyseal regions of an infant's long bones. Recently, two separate child protection teams each encountered a case of CML discovered after reported motor vehicle collisions (MVC). This provoked a critical appraisal of the medical literature to inform clinical practice regarding MVCs as a potential mechanism for this fracture type and to remind clinicians that there is no single injury pathognomonic for abuse.

The Association of Finger Growth Plate Injury History and Speed Climbing in Youth Competition Climbers.

INTRODUCTION: Finger growth plate injuries are the most common injury among youth climbers, and the association between these injuries and speed climbing, a mandatory discipline in the 2021 Olympics, has not been examined previously. Our primary purpose was to examine the demographic and training characteristics of adolescent competition climbers who reported a history of a finger growth plate injury compared to those who did not report a history of a finger growth plate injury. Our secondary purpose was to determine whether training characteristics differed between adolescent competition climbers who did and did not report speed climbing. METHODS: Our study was a cross-sectional study design. We surveyed adolescent climbers who competed in the 2017 USA Climbing Sport and Speed Youth National Championships. Questions assessed climbing injury history and current rock-climbing training characteristics. RESULTS: Two-hundred sixty-seven adolescent competition climbers, 14±3 (9-18) y of age (mean±SD with range), completed the survey. Those with a history of a finger growth plate injury reported greater approximate time spent speed climbing throughout the year (ß=1.28, 95% CI 0.11-2.46, P=0.032) and training regularly on the International Federation of Sport Climbing speed wall (adjusted odds ratio=3.95, 95% CI 1.14-13.7, P=0.031). CONCLUSIONS: Training regularly at practices on the speed wall was associated with a self-reported history of finger growth plate injuries among elite youth competition climbers. Speed climbing should be limited, especially during periods of rapid growth.

Low Energy, Lateral Ankle Injuries in Pediatric and Adolescent Patients: A Systematic Review of Ankle Sprains and Nondisplaced Distal Fibula Fractures.

BACKGROUND: Lateral ankle injuries are one of the most common musculoskeletal injuries sustained by pediatric and adolescent athletes. These injuries can result in significant time lost from competition, affect performance when returning to play, and represent a significant burden on the health care system as a whole. The purpose of this study was to systematically review the literature on the diagnosis, treatment, and prevention of acute lateral ankle injuries and their chronic effects in pediatric and adolescent athletes (younger than 19 y). METHODS: This systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines between September and December 2018. PubMed and Google Scholar were systematically searched using the search terms: ("distal fibula fracture" OR "ankle sprain") AND ("youth" OR "pediatric" OR "adolescent"). All authors participated in article review (N=172) for relevance and age restrictions in which 30 met the inclusion criteria. RESULTS: Thirty articles met inclusion criteria [Levels of Evidence I to IV (I: n=4, II: n=16, III: n=9, and IV: n=1)] including distal fibula fracture diagnosis and treatment, and risk factors, prevention, and chronic sequela of lateral ankle injuries in pediatric and adolescent patients. CONCLUSIONS: Low-energy, lateral ankle injuries are common in pediatric and adolescent patients, yet underrepresented in the medical literature. There is a lack of high-quality literature on diagnosis, treatment, and outcomes after Salter-Harris I distal fibula fractures. Available literature, however, suggests that there remains over diagnosis and over treatment of presumed Salter-Harris I distal fibula fractures. Adolescent ankle sprains dominate the available literature likely due to the high recurrence rate. Youth athletes and coaches should address risk factors and engage in injury prevention programs to prevent and minimize the effect of acute lateral ankle injuries. LEVELS OF EVIDENCE: Level III-Systematic review.

Traumatic Posterior Hip Dislocation and Epiphysiolysis in a High School Football Player with Successful Outcome at 4 Years Follow-up: A Case Report.

CASE: We describe a case of posterior hip dislocation in a 13-year-old boy after a contact football injury with attempted closed reduction resulting in complete separation of the epiphysis from the femoral neck metaphysis with associated femoral head fracture and posterior dislocation of the femoral head. Treatment was emergently performed with a greater trochanteric osteotomy, open reduction internal fixation using cannulated screws, and additional small diameter drill holes in the femoral head to promote blood flow. The patient did well postoperatively and at over 4 years follow-up had no evidence of avascular necrosis and returned to full athletics participation. CONCLUSION: Particular attention should be taken when reducing hip dislocations in the adolescent population who may be predisposed to epiphysiolysis. Preservation of periosteal soft-tissue attachments and the use of small diameter drill holes to promote femoral head blood flow may have contributed to the excellent outcome.

Salter-Harris Type III Fracture in a Football Player.

A 15-year-old high school football player sustained direct impact to his anteromedial left knee by a teammate's helmet during practice. The physician referred the athlete immediately to an after-hours clinic for imaging to rule out a fracture. Radiographs of the knee showed a nondisplaced Salter-Harris type II fracture. The treating physician also ordered magnetic resonance imaging, the results of which allowed for a more specific diagnosis of the fracture as a Salter-Harris type III fracture of the left femur.J Orthop Sports Phys Ther 2019;49(3):209. doi:10.2519/jospt.2019.7984.

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.

Distal radius nonunion after epiphyseal plate fracture in a 15 years old young rider.

BACKGROUND AND AIM OF THE WORK: Radius and ulna fractures are the most common long bone fractures in children and adolescents. The majority of these injuries involve the distal metaphyseal portion of the radius associated or not to physeal plate injuries. Because of the high remodelling potential of the distal radius in growing children most injuries heal without complication after closed reduction and immobilization in a long arm cast. Nonunions of closed distal radius fracture are an extremely rare occurrence especially in paediatric population. Methods: In this report, we describe a rare case of distal radius fracture nonunion in a 15-years old male rider treated conservatively with cast immobilization. Eight months later he underwent surgical closed reduction and fixation with kirschner wire and cannulated screw. Results: Follow-up at 2 years showed satisfying radiological and functional outcomes. The patient ultimately returned to ride 3 months following surgery. Conclusions: Nonunion is rarely seen in distal radius fractures in healthy children and adolescents, and there are few studies in the literature. Treatment of the nonunion must be individualized and the results are not entirely predictable.

Paediatric Salter-Harris type IV injury of distal tibia with talus fracture.

Fracture of talus with Salter-Harris injury of the distal end of tibia is a rare injury in paediatric age group. The authors report a case of a 13-year-old male child who sustained type IV Salter-Harris injury to the medial malleolus with coronal spilt along with spilt and depressed fracture of the neck of talus and fracture of the lateral process of talus with stable compression fracture of spine sustained due to fall from 6 meters height. CT scan delineated the morphology of fracture pattern and helped in preoperative planning. Talar articular fracture was reduced and fixed arthroscopically while distal tibial fracture was fixed under image intensifier. We observed favourable outcome following arthroscopic reduction at 4-year follow-up.

Overuse Physeal Injuries in Youth Athletes.

CONTEXT: Despite rising awareness of the risks associated with sports participation, overuse injuries continue to increase in youth athlete populations. Physeal injuries are one type of overuse injury exclusive to pediatric populations that are often sustained during athletic practice or competition. Overuse physeal injuries are, in theory, preventable; however, little consensus has been reached surrounding the risk factors, prevention, and treatment strategies. OBJECTIVE: This systematic review summarizes the best available evidence concerning overuse physeal injuries in youth and adolescent athletes. It can be used to develop prevention and treatment programs specific to this population. DATA SOURCES: PubMed and Academic Search Complete (EBSCOhost) were explored using the keyword physeal injuries from January 1950 through May 2015 to identify 24 studies. STUDY SELECTION: Original research studies of athletic populations with mechanisms of injury related to sport were chosen. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 3. DATA EXTRACTION: Data were extracted as available from 24 eligible studies. Study quality was rated using the Oxford Centre for Evidence-based Medicine (OCEBM) guidelines. RESULTS: Risk factors for injury include periods of accelerated growth, chronological age, body size, training volume, and previous injury. Injury prevention strategies currently emphasize participation limitations and sport-specific training programs in skeletally immature athletes. The most effective treatment after an overuse physeal injury was an extended period of active rest and joint immobilization when necessary. CONCLUSION: Overuse physeal injuries are multifactorial in nature. Muscular imbalances after accelerated growth periods predispose young athletes to overuse injuries. Modifiable risk factors such as flexibility, strength, and training volume should be regularly monitored to prevent these injuries.