Residente De Ortopedia

Lower Extremity Injuries in the Skeletally Immature Athlete

Joshua B. Frank, MD Gregg J. Jarit, MD Jonathan T. Bravman, MD Jeffrey E. Rosen, MD

Dr. Frank is Orthopaedic Fellow, KerlanJobe Orthopaedic Clinic, Los Angeles, CA. Dr. Jarit is Resident, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases, New York, NY. Dr. Bravman is Resident, Department of Orthopaedic Surgery,University of Colorado School of Medicine, Denver, CO. Dr. Rosen is Assistant Professor and Director, Adolescent Sports Medicine, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly tothe subject of this article: Dr. Frank, Dr. Jarit, Dr. Bravman, and Dr. Rosen. Reprint requests: Dr. Rosen, NYU–Hospital for Joint Diseases, Department of Orthopaedic Surgery, Suite 1616, 301 E 17th Street, New York, NY 10003. J Am Acad Orthop Surg 2007;15:356366 Copyright 2007 by the American Academy of Orthopaedic Surgeons.

Abstract The heightened intensity of training and competition amongyoung athletes places them at increased risk for both acute and chronic injuries. Prompt recognition and treatment of such injuries are critical to prevent long-term functional disability and deformity. These injuries occur in patterns unique to the skeletally immature athlete, given their developing epiphyses and ossification centers and supporting ligamentous structures. Children and adolescentswho participate in recreational and organized sports are particularly susceptible to a broad spectrum of lower extremity injuries involving both the osseous and soft-tissue structures. Fundamental knowledge of the pathophysiology of injury helps the clinician in determining management. Early recognition of acute traumatic injuries, along with preventive regimens and knowledge of both nonsurgical andsurgical treatment protocols, has helped to restore and maintain normal lower extremity function in the skeletally immature athlete.

pproximately 30 million children participate in organized sports; approximately one third of school-age children who engage in organized sports sustain an injury requiring medical attention1 (Table 1). Children and adolescents are susceptible to sports injuriesfor numerous reasons. They have varying athletic abilities and many times engage in athletic activities while unsupervised. In addition, children and adolescents are still developing osseous structure and, compared with adults, they display unique biology (eg, speed of healing, higher strength of ligaments versus growth plates). Other contributing factors are the increase in intense training atyounger ages and participation in multiple sports. Athletics-related injuries result in an estimated $1.8 bil-

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lion annually in health care–related costs.1

Physiologic Factors in Children and Adolescents
Children are susceptible to athletic injuries because of a number of inherent developmental factors. They often lack fully developed complex motor skills and during puberty maydemonstrate a temporary decline in coordination and balance. Limb length, mass, and moments of inertia naturally change with age. Whereas limb length increases 1.4 times from age 6 to 14 years, limb mass increases by more than 3 times; this mismatch may lead to musculoskeletal imbalance.2 The large increase in mass requires the

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Journal of the American Academy of Orthopaedic Surgeons

Joshua B.Frank, MD, et al

muscles to generate greater force to move the limb, which in turn creates increased strain on the tendons, musculotendinous junctions, and apophyses. These factors place children and adolescents at increased risk during high-demand sports activity. Additionally, children have open physes, which may be more vulnerable to stress, placing young athletes at increased risk of...