Children and abdolescents:

exercise & sports

H. Mellerowicz

Klinik für Kinderorthopädie

und Traumatologie
HELIOS Klinikum Emil von Behring
Stiftung Oskar - Helene - Heim
Moving and exercise is healthy - but what is the
reality?
Overweight in Germany:

BMI > 30

20,5% of men
21,1% of women

500g more weight per person [Nationale Verzehrstudie II, 2008]

per year
USA 2008:
900g more weight yearly in average on every US-citizen
204kg - Berlin’s fattest boy
- after all: he already lost 7kg
 Obese children -
special findings at the locomotor system

M. Wiener et al., Dtsch. Z. Sportmed. 50 (1999)

Orthopedic exam. of obese (overweight>50%)-
in comparism to 22 normal weight children

- hyperlordosis and kyphosis of the spine

- knocked & flat feet, hallux valgus
- shortening of muscles (pelvic & leg muscles)
- weakening of abdominal muscles
- X-legs (≥5 cm IAD)
Even though
- pain mainly at the spine & knees my brother
and sister
eat the same
amount as me
they are like
starvelings
 How flabby are our children really?
D. Brettschneider, Physical Education 49 (2000), 340

status of health of children today

n. Ketelhut, K. u. Bittman, F., 2000

- 20-40% overweight
(NBP 91, Haue et al., 99)
- 30% not ready for school
(Anders, 99)
- 17% higher level of cholesterol
(NBP 91, Hurrelmann, 99)
- 8-12% high blood pressure
(NBP 91)
- 40-60% weakness of posture,
- coordination and
concentration
(Buchholz 99, Hurrelmann 99)
girls and boys 10-13 years old

from: der Spiegel 2000

OMSELS, 1998:
primary school:
30-60 min. daily
exercise and sports

KLEINE, 1997:
8-13 year old
children:
109 min. television
time in 1994/95
 Structural changes from
reduction of moving / exercise
muscules -atrophy -dysbalance
(type II fibres)

tendons -atrophy -shortening

-rupture

joints -instability -luxation

chondropathia
arthrosis

coordination -reduction of age -injury

related -overuse
coordination -chronic back pain

(from: Bittman et al., 1989, Küster 2004)

 State of health in children

children on the way to be chronic patients –

loss of posture
20-30% overweight (epidemic of obesity (Graf))

20-50% weakness of posture and coordination

25% weakness of heard & circulation

13-25% weakness of foot muscles

more than 40% recommendation of training and practise

of muscles & coordination
acc. to Mellerowicz et al. 1993
Glass 1999
Reeg, Mellerowicz et al. 2003
Ziroli u. Döring 2004
Woweries 2004
Graf 2010
 State of the Art
lumbar back pain

70-80% of the adults

7-72% in children and abdolescents
(Jeffries et al., 2007)

22% english pupils (Murphy et el., 2005)

30.4% american pupils (Olsen et el., 1992)
58.9% danish pupils (Harreby et al., 1999)

correlation to later chronic back pain in adults

(Brattberg 1994 Harreby et al., 1995, Leboeuf-Yao et al., 1998)
 Incidence of unspecific back pain
in pupils in China
Yao et al., Guangzhou, China, Spine 2011

cross-section study n = 2083 age 10-18 years

2 basis schools and 4 superior schools

questionaire I. demographic data: age, class, living

anthropometric factors: size, weight

II. prevalence of pain within 3 months

characterization:
frequence
duration
pain scale
Influence on daily life
causes
excercise & sports
consultation of a physican
missing school time
 Incidence of unspecific back pain
in puplis in China
Results: 29,1% (24,7% boys, 33,1% girls)

Age: 21,5% 10-14 year of age

38,2% 15-18 year of age

pain / BMI 19,53 / 19,23

pain character:
girls > boys (p = 0,000)
more than 2x (girls > boys, 46,4%>34,4%, p<0,01)
duration: 60,8% min., 19,8% hours, 15,1% days, 4,3% weeks
11% irradiate pain
18% pain in the morning
33.1% sitting in school
25.7% sitting in front of television
24.4% excercise & sports (26,1% ♂ > 23,2% ♀)

Consequences: 4,6% missing school time

20,3% ♂ > 12,3% ♀ consulting a physician
Conclusion for the practise
unspecific back pain is more frequent
in children and abdolescents

within characteristic differences of back pain

in gender, reasons and behaviour
for prevention of chronification and recurrances
in adulthood
an intervention in the behavior within
exercise & sports, daily activities
food & drinking is necessary
Incidence of unspecific back pain
in puplis in China

Discussion
 Injuries in sports and age
McHugh Br. J. Sports. Med. 2009;44:45-49

- risk of young athletes in relation to the bodyweight

- prevalence (under 18 years):
• USA: 10-15% obese, 35% overweight
• Europe: 7% obese, 30% overweight
- reduction of physical active young people < 18 years: 15-25%
- higher risk
- insuffizient posture survey
- too much weight
in relation to height
 23,5 billion SMS/year.
Yeah!

400-700 m !!

20,000 m / day 400-700 m / day

[Bitkom / Bundesnetzagentur 2007]

 Exergames
the controller makes the difference
 Exergames
the controller makes the difference

Nintendo Wii Balance Board / Controller

 more new national diseases

• Gameboy finger
• SMS thumb
• Smartphone acne
• mobile elbow
• i-Phone shoulder
• Phubbing to Smombie
• phantom vibration syndrome
ring xiety
vibran xiety
textraphrenie

• tangst
• coma writer, post writing stress syndrome
 new national disease
Smartphone neck
• headache
• neck pain
• tingling in the arms and hands
• digestive and breathing troubles
 Current trend
and
risk sports
in children and abdolescents
 State of the Art
Epidemiology
trampoline: 1997-2002 600% increase of injuries,
50% increase per year, (Premtis 2004),
2009: 31,9/100,000 children

inflatable castles: 1990-2010: 64.657 injuries, 15x increase

5,28 injuries / 100.000 children

Scateboards: 8,1% of injuries (Zalavras 2005)

ATV (Quad): 2005: 767 dead, 120 (10%) children,

136.700 injuries
41.000 (30%) children
1997-2006: 476% increase

spine injuries !
paraplegia !
 accidents on trampoline

Royal Society
for Prevention of Accidents
(2007/2009):

trampoline accidents

-multiple users
-supervisors
-safty net
-injury pattern
 accidents on trampoline
in children and abdolescents
Loder et al. Indianapolis, USA J. Pediatr. Orthop. 2014
Königshausen et al. Bochum, Germ. Sportverl. Sportschad. 2014
Berger et al. Murnau, Germ. Unfallchirurg. 2014

methods
- explorative study about fractures from
US-national database (NEISS) 2002-2011
n = 1.002.735 ᴓ 9,5 years (51.7% ♂)
288.876 (29%) fractures, statistics

- retrospective study about injury patterns,

causes and incidence 1999-2013
n = 195 (93 ♂, ♀ 102), ᴓ 10,3 years (2-16),
statistics

- retrospective study about injury patterns,

causes, incidence and prevention
2002-2010, n = 268
 accidents on trampoline
in children and abdolescents

results
- 29% fractures:
upper extremity: 60% (lower arm: 37%, elbow: 19%)
lower extremity: 35,7% (lower leg: 40%, ancle joint: 31,5%)
spine: 4,4% (cervical spine: 36,5%, lumbal spine: 24,7%)
scull / face: 1%
ribs / sternum: 0,5%

- 95,1% outpatient, 9,9% clinical treatment

- all expenses (in- and outpatient care) 10y: 1.002 Bill. US $, fractures: 408 Mill US $

- 1999-2006: n = 73 / 2006-2013 n = 122 (+67%) *

- 90% at home, 10% under supervision
- 39% fractures, OP: 42%, 3x ACL lesions
- upper extr. 26% (fractures and luxations 77,5%, 20% OP)
- lower extr. 52% (≥ distorsions and fractures 22% leg length, ancles) 34%
OP
- head / spine 22% (1x cervical spine OP)
 Trampolin injuries in children and
abdolescents
2002-2006: 1%
since 2007: 3,2% injuries
75% several children
28% injuries with safety installation
heavy (nets, mats, water)
injuries 28,6 without safety installation
31,7% safety nets
25% without safety net

from: Berger et al. 2014

 Conclusion for the practise
Trampolin injuries in children and abdolescents

- USA: epidemic increase with economic importance

- safety installations on the trampolin can not prevent injuries

- risk: several children on the trampolin

- prevention by warmup and information

to parents, schools and clubs

- trampolin is high risk sport !

 Epidemiology
Steffen et al., Br. J. Sports. Med of 2010.; 44: 485-9

 systematic analysis of the literature

 athletes 14-18 years
 national and international competitions
 13 investigations, 10 prospective
 injury rate variation per year about 5 and 70 injuries
per 1,000 hours exposition
 2-4 injuries per athlete / saison
 hockey > soccer > badminton > gymnastics > rowing
 amount of datas do not permit final conclusions
 Typical injury pattern
acc. Gaulrapp 1997, Jung et al. 2008, Wood et al. 2010

• contusions of soft tissue

• fractures
(metaphys. compression, diaphys. green
stick fractures, epiphyseal lesions,
transition fractures)

• apophysial lesions

• osteo- chondral ligament

injuries

• joint lesions

• head & brain injuries

 long lasting effects after sports injuries in
children
Mafulli et al., Br. J. Sports. Med 2010; 44:21-25.

- few data only:

- stress-fractures, osteochondrosis, ACL ruptures
- epiphyseal fractures n=2157
38,3% sports
14,9% growing disturbance
- premature closing of the epiphyseal growing plate
without trauma:
gymnastics
soccer
rugby (american football)
tennis
basketball
 Cartilage
(mod. from JANI, 1992)

hyaline cartilage: higher elastic, growing potential,

even regeneration

epiphys. cartilage: reduced mechanical resistance

possible: growing disturbance
and trauma

apophys. cartilage: red. mechan. resistance

higher elastic
 Epiphyseolysis in exercise
& sports
reduced and longer STH & androgene hormones

muscle power epi- & apophyseal. resistance

epiphyseolysis capitis fem.

(Morscher 1961,1967)

growing zone (apophyseolysis / spine growing

disturbance)
(acc. Jucker 1990, Segesser et al. 1995, Joung et al. 2008)
 Incidence of 
epiphysiolysis capitis femoris
Wirth, T. Stuttgart,GER Orthop./ Unfallchir. up2date 2011
Peck, D. Novi,USA Am. Fam. Phys. 2010
Lehmann, C.L. New York,USA J. Pediatr Orthop. 2006
 

3,78 % 1981 adipositas (BMI > 85%)  

9,66 % 2000  
 2×
  
10,8 % 2006 2005
 

♂ Ø 13,5 12,6 years 58,0% li > re 60,4%

♀ Ø 12,2 11,6 years 41,2% 

acc. to. Wirth 2011

 "pain on the knee
--- never forget the hip !"
Hefti 2009
Hefti 2009
time delay for the diagnosis
of
epiphyseolysis capitis femoris
 
orthopedic surgeon: 4,5 weeks
other: 9,1 weeks
 
knee pain: 10,3 weeks
x-ray: 13,3 weeks
hip pain: 4,9 weeks
x-ray: 3,2 weeks
 
  3,1 weeks  → 30° 
  7,5 weeks  → 30 - 50°
19,9 weeks  → 50°
acc.to Wirth 2011
 State of the Art
Epiphysiolysis capitis femoris (ECF)
- stability
- symptoms: walking ability (Loder et al., 1993)
- time: - acute (<3 weeks)
- acute on chronic (intermit. = 3 weeks.)
- chronic (> 3 weeks)
(Fahey O'Brien 1965, Aronsson et al., 1996)

- avascular necrosis of pelvic head

(AVN) 4,6 - 58%
(Boyer et al., 1981, Dedance et al., 2010)

- pre- osteoarthritis (OA) deformity → hip OA

(Engelhardt 1994, Weinstein 1997, a.m.o.)
 Femuro-acetabular
CAM impingement (FAI)
 Epiphysiolysis capitis femoris
in exercise & sports
Segesser B., Morscher E.: Perimed Verlag München 1987
Murray R.O., Duncan C.: J. Bone Jt. Surg 53 (1971) 406 - 409
Schmitt H.: Pressemitteilung DGSP 2011

„tilt deformitiy" in sports: 24% > 9% (20- 31%)

sports:
2,5 x more frequent
soccer: studs on soccer‘s shoes
ski: stem movements
gymnastics: hurdle sit
athletics: hurdle sit

hip arthritis sports hip arthritis no sports

n = 44 n = 36
ECF lenta 25 = 57% 8 = 22%
proved 20 proved 3
probably 5 probably 5

→ sport medicin survey of the hips

in growing age!
 Epi- and apophyses

from Pförringer / Rosemeyer 1987 from v. Laer et al. 2013

- reduced bending- and rupture stability

- higher plastic expansion capicity
from: Jani 1992
case 1
14 years old boy
rotation trauma with ancle sprain
on the left side after sakateboarding
Diagnosis? further examinations?
distally proximally
6 weeks after surgery
6 months after surgery
 case 2
9 year old boy - distal lower leg fracture
conservative treatment

from v. Laer et al. 2013

„Kadi“-lesion ! Salter III lesion med. malleolus

with bridging and progressive false
growing into varus position
epiphyseolysis
metaphys. epiphys. oblique fracture compression
wedge wedge throught meta-& of the epiphysis
epiphysis

from Gritsbach 2014

 Epi- and apophyseal lesions in
children and abdolescents

methods:

- own results
- new literature 2012-16:
84 studies

epiphysis: 70
apophysis: 14
 Distal tibia fractures
Chai et al. China Orthopedics 2015
Podesewa & Mubarak Dallas, USA J. Pediatr. Orthop. 2013

methods:

- retrospective study n=286 (202 ♂, 84 ♀) Ø11,7 years

<2mm dislocation: conservative, long leg cast
>2mm dislocation: ORIF, Kw or screws

- review
 Distal tibia fractures

Results: - follow up Ø 6,4 years

>2mm dislocation: complications:
premature closure of epiphys. gap n=40 (152)
varus / valgus n=16 (38%)

- risk: fibula fracture

long leg cast at Salter / Harris III / IV fracture

-> 3mm dislocation: periostal infold!

SH-typ III-IV: ORIF
 Reliability and indication / necessity for CT exam. for
distal epiphyseal fractures
Thawrani et al. Wilmington,USA J. Pediatr. Orthop. 2011
Blackburn et al. Burlington, USA J. Bone Jt. Surg. Am 2012

methods: - x-ray and CT, Salter-Harris classification (SH)

OP indication n=50, 5 radiol., surgeons

results: - classif. of dislocation: x-ray sufficient

(CT not better intraobserv. reliance)

- CT: OP indication 26%

fracture anatomy 55% -75% CT
planing (screw posit.) 56%

- OP: if fracture gap >2mm SH III / IV

from: Schmitt Sportorthopädie und –traumatologie im

Kindes- und Jugendalter 2014
 Distal tibia fractures
does surgery reduce the risk of premature
closing of the epiphyseal gap?
Russo et al. San Diego, USA J. Pediatr. Orthop. 2013

methods: retrospektive study

- n=96 Ø 12,6 years

- closed reduction / long leg cast (LLC)
- group 1: dislocation <2mm: LLC
- group 2: dislocation 2-4mm: LLC
- group 3: dislocation 2-4mm: ORIF (incl. interposition)
- group 4: dislocation > 4mm: ORIF (incl. interposition)

follow up min. 6 months

CT in cases of suspected bone bridge ( „bony bar" (BB) /
premature closure of growing zone (PEC)
 Distal tibia fractures
does surgery reduce the risk of premature
closing of the epiphyseal gap?
Russo et al. San Diego, USA J. Pediatr. Orthop. 2013

results:

- premature epiphys. closure (PEC): 43%!

- group 1: (n = 14) <2mm PEC: 29%, OP 7%
- group 2: (n = 33) 2-4mm conserv.: PEC: 33%, OP 15%
- group 3: (n = 11) 2-4mm ORIF: PEC: 33%, OP 15%
- group 4: (n = 38)> 4mm ORIF: PEC: 55%, OP 23%
(p=0,19) (p=0,57)

no signif. differences / PEC:

age, sex, cause of injury, time to surgery, heigh,
init. disloc., number of reposit. trials, methode of surgery
 Trampoline injuries
Loder et al. Indianapolis,USA J. Pediatr. Orthop. 2014
Königshausen et al. Bochum Sportmed. Sportverl. 2014

- complete expenses (in- and outpatient) 10y:

1.002 Bill. US $, fractures: 408 Mill US $.

- 95,1% outpatients, 9,9% inpatient

- 29% fractures:
upper extr.: 60% (forearm: 37%, elbow: 19%)
lower extr.: 35,7% (the trampoline knee: crus antecurvatum after
Salter Harris II + V, lower leg: 40%, ancle: 31,5%,spec.trampol.ancle
=varus)
spine: 4,4% (cervical: 36,5%, lumbar: 24,7%)
skull / face: 1%
ribs / sternum: 0,5%
 The „trampoline ankle joint“
-- heavy injury of the med. malleolus with several jumpers

Blumetti et al. Ottawa, Canada J. Pediatr. Orthop. 2016

methods:
- retrospekt. case study n=11 Ø11,8 years (8-13) (7♀, 4♂)

follow up Ø17,8 months (2-72)

 The „trampoline ankle joint“
- heavy injury of the med. malleolus in a several jumpers
results:

- several jumpers: n=9 (impact 80 kg/ 25kg ≥ fall from 2,80m)

(Minelaus et al. 2011)
- Salter-Harris typ III n=7, non dissloc. n=6
- bimale. n=6, med. malleolus n=5
- OP n=6
- med. bony bridge / stop of growing / varus n=2
 The amount of Salter / Harris I epiphyseolysis in
children‘s fibula- and- ancle injuries
- a prospective MRI study
Hofsli et al. Odense, Dänemark J. Pediatr. Orthop. B 2016

methods: n= 38/391 (18 ♂, 13 ♀) Ø10 ± 2,36 years

MRI 6,9 ± 2,87 days after trauma

results: NO Salter / Harris I epiphyseolysis!

- bone contusion („bone bruise")
- joint effusions
- cartilage- / ligament / subcutan edemas
- apophyseal lesions / bony-cartilage flakes
 Triplane fractures
-widening of the medial joint space
Gourrnent u. Gupta Oak Lawn, USA J. Orthop Trauma 2011

methods: retrospect. control study, n=22, 24 fractures

results: 86% 1-9mm widening

linear to the dislocation
complete anat. correction  regular med. joint space
 no complications

from: Gritzbach in Schmitt

Sportorthopädie
und –traumatologie im Kindes-
und Jugendalter 2014
 "Two- and triplane„ fractures
-functional results after closed reduction/
percut. fix. and fracture gap <2-2,4mm
Choudhry et al. Cincinnati, USA J. Pediatr. Orthop. 2015
Crawford Cincinnati, USA J. Pediatr. Orthop. 2012

methods: n=78, triplane (58), twoplane (n=20)> 2 years

results: - triplane: younger (p=0,01), -♀ +♂, ♀ younger (p<0,001)

- <2-2,4mm gap same functional scores /no relation:
fracture gap distance
- 2-4 years = 4-10 years results (same reposition)
- percut. fixation sufficient

from Gritzbach in Schmitt

Sportorthopädie
und –traumatologie im Kindes-
und Jugendalter 2014
case 3

11 year old boy - knick against a soccer‘s goal frame

Salter III fracture prox. bone dig.I of the foot

case 4

14 year old boy

sudden pain without trauma left knee

9 month after lower leg spiral fracture

conservative therapy

rotational wrong position

bronchitis - pertussis - antibiotics

begin. pseudarthrosis

fix. extern -completely cured

remobilisation
 overuse / stress fractures

- more common than in adults (Jani,1991)

- more often (Hulkko u. Orava,1987;Yngve,1990;Saperstein u. Nicolas,1996)

local: cause:

tibia 48%running 24%

fibula 20% basketball 13%
spine 15% gymnastics 21%
foot 8% scating 15%
femur 3% soccer 9%

from: Kasten,P. Stressfrakturen 2014

 Differential
Differential diagnoses
diagnoses of
of
bone-
bone- and
and bone
bone marrow
marrow changes
changes

osteosarcoma
chondrosarcoma
Ewing-sarcoma
fresh bone infarct
bone bruise (trauma)
 Intraepiphyseal
Intraepiphyseal stress
stress injuries
injuries
of
of the
the prox.
prox. tibia
tibia epiphysis
epiphysis
MRI-findings
Tony et al. Staffordshire, UK Eur. J. Radiol. 2014

n=4
Intraepiphyseal
Intraepiphyseal stress
stress injuries
injuries
of
of the
the prox.
prox. tibia
tibia epiphysis
epiphysis
MRI-findings

from: Tony et al. 2014

Intraepiphyseal
Intraepiphyseal stress
stress injuries
injuries
of
of the
the prox.
prox. tibia
tibia epiphysis
epiphysis
MRI-findings

from: Tony et al. 2014

Intraepiphyseal
Intraepiphyseal stress
stress fraktures
fraktures of
of the
the prox.
prox.
tibia
tibia epiphysis
epiphysis
MRT-findings
Tony et al. Staffordshire, UK Eur. J. Radiol. 2014

3-6 m 1-5 y 10-12y 14-16y

pressure loadat normal load,

activity and max. area of impact
from: Tony et al. 2014
case 4

14 years old soccer player

flex.- rot. trauma without contact
knee pain - no ability of standing and walking

Diagnosis? further examination?

Apophysis- underestimated in theory and practise
 Epidemiology of
apophyseal lesions
2-50% of the fractures in abdolescents (Wirth 2016)
(68-90% ♂, 10-32% ♀) (Singer et al. 2014)
 Apophyseal injuries
"The apophysis is the weak point in the
locomotor system of young athletes" (Franke, K.
Traumatologie des
Sportes 1980)

chron. traction „apophysitis"

avulsion injury small disloc.

(abruptly max. muscle tension) apophyseal
direct trauma large fractures
 localisation
• Anterior superior iliac spine (3)

• Anterior inferior iliac spine (1)

• Ischial tuberosity (2)

• trochanter

• lesser trochanter
Division of apophyseal lesions in
different activities of sports
n=21

Anterior inferior iliac spine

et superior

• soccer 6
• sprint (start) 4
• doing long splits 2
• fall backwards
from a swing 2
• others (handball,
fall by scating, etc.) 3
 Diagnostics
- case history (anamnesis)

- clinical examination
(swelling, functional deficits)

- sonography

- x-ray

- MRI

- CT
 Apophyseal lesions
nearly - always conservative treatment

Aderholt 1971
Clancy v. Foltz 1976
Micheli 1983
Ogden 1981
Riemer 1981
Steinbrück 1985
Susard 1983
Krahl et al. 1997
Lini et al. 2000
v. Laer 2001
Nehrer 2005
Lau et al. 2008
Wirth 2016
Avulsions- / apophyseal
fractures
"Avulsion fractures of the spina iliaca ant. sup.
may provoke persistent pain syndromes
and even decades after prim. trauma imitate
pseudotumors, which could be treated
with surgical refixation with good results.“
Knobloch et al.
Sportverl. Sportschad. 2007
Spina iliaca anterior superior
 Spina iliaca anterior
inferior

Apophysis of m. rectus fem. is affected in

¾ of all cases
 Caution

cranio-post. pillar
separate bone core

➩ x-ray:
30°oblique exposure
 Therapy
most common: conservative

antiphlogistic drugs

follow up with sonography

mobilisation with crutches

sport rehabil.- training only

after min. 6 weeks
from: Wirth, Orthopäde 2016, 45, 213-218
trochanter major
Development of the growing area of the prox. femur
 from: v. Laer
Frakturen u.
Luxationen im
Wachstumsalter
Thieme 2001
 Therapy
conservative: sugery:
• undisloc. troch. • dislocated troch. maj.
maj. tears tears (compr.
• (pelvic ring cast osteosynthesis, x-ray
4-6 weeks) before loading)

Sport rehabilitation training after 6 weeks and

consolidation of the fracture
 Apophyseal tears of the
tuberosis os ischii
• hip flex. in knee ext.

• abd. and hyperext.

➩m.adductor magnus
semitendinosus &
semimembranosus,
caput longum M.
biceps
• gymnastics, long spagat,
hurdle-running
Age of the injuries between 18-22 y. (due to
late ossification of the apophyseal core)
 Forms of development of apophyseal
fractures at ossis ischii
(after
(after Steinbrück
Steinbrück and
and Krahl
Krahl 1985)
1985)

lesions before appearance of apophys. core:

x-ray is regular in the beginning. After weeks
type I ossification and osteolysis in the injury. In the
end: uniforme pseudotumor and corresponding
deformation of os ischii.

lesions after appearance of the apophyseal core:

x-ray: osteoapophyseal fracture. After months
type II and years the dislocated fragment may readapt
as a multi shape pseudotumor.

Re- adaptation of the bony fragment is missing.

type III The dislocated fragment may grow and leads to
an extensive deformation of os ischii.
Pat. male 15y
Pat. male 15y
Avulsion injuries of the pelvic region in
abdolescents
Wirth Stuttgart Orthopäde 2016

"Sometimes the boney part is very small ..."

Therapy: conservative
exceptions - dislocations >2cm
(Cohen et al. 2012, Nowak u. Schiekewei 2013)
- tuber ischiaticum (os ischii)
Complications: heterotopic ossifications
pseudotumors
pseudarthrosis
nerve injuries / tear
Avulsion fractures of the pelvis
pain/local SIAI n=112 pain 25 (22,3%) pseudarthrosis 1 (0,9%)

SIAS n=68 „ 2 (2,9%) „ 0

tub. isch. n=25 „ 4 (16%) „ 4,6

pelvic ring n=23 „ 1 (4,3%) „ 0

all n=228 „ 32 (14%) „ 5 (2,2%)

disloc. >20mm (7%) 26x risk of pseudotumor

n=15 pain after 3 months re- fracture Ø1,37y later

OP: n=7 (3%) n=2 disloc. >20mm

n=4 steroid. inj.

from: Schuett et al. 2015, retrospect. study, n=228

 Conservative and surgical therapy of apophyseal
fractures of the superior (SIAS) and lower (SIAI)
spina iliaca
Staucak et al. Karlsbad, Tschechien Acta chir. orthop. Traumatol. 2016

methods:

n=38 (31♂, 7♀) 15,1 years (4-17)

conservative n=14 OP (>1cm) n=24
course x-ray: 6 weeks, 3 months, 1 year

results:

ALL: complete return to sports (RTS)

OP - faster and better (SIAS)*
- partial loading: 7,2 days (2-10) > 24,1 days (18-27)*
- minim. heterotop. ossifications
 tear of the apophysis of tuber ischiaticum
Spencer-Gardner et al. Rochester, USA Knee Surg. Sports Traumatol. Arthrosc.2015

methods:

n=10 (Ø18 years (14-28) n. ischiat. irritation / dysfunct. hamstrings

OP: neurolysis n. ischiat, resection of fragments,
refixation of the hamstrings

Harris Hip Score (mHHS), hip outcome score (HOS)

follow up 2,2 years (1,7-3,5)

results:

mHHS / HOS> 90, 5x normal, 5x nearly normal

 Apophyseal / fractures of the
epicondylus ulnaris

course:
direct fall, over extension, sub- or
luxation (2/3) 25% intraarticular
blocking

gymnastics, ball sports, cycling, skiing,

rollerblade, skate- and snowboard

no / minor dislocation: cast

major dislocation / n. uln. irrit.: OP
fractures
fractures
 Discussion
apophyseal lesions
year authors Pat.side treatment

1978-2016 16 16 SIAS 11 conservative, 5 OP

1978-2016 13 13 SIAS 12 conservative, 1 OP
1971-2016 8 7 troch.m. 4 conservative, 3 OP
1971-2016 5 3 troch.m. conservative
1972-2016 10 65 tub.isch. 40-68% pseudarthrosis
OP:II°, III° acc. Rang
(Barnes et Hinds 1972,
Kjahl et al. 1997)
1994-2003 Haxihija 25 epicondyl. 19 OP, 6 conservative
et al. ulnaris
1991-2014 2 3 proc. spin. 1 resection
Conclusion - take home
message
therapy mostly conservative
 Surgical therapy
apophyseal lesions
• always for extensive dislocations /
absolute indication for surgery

trochanter major
tuber ossis ischii
tibiaapophysis (Type I, III)
epicondyl. uln. et rad.
olecranon

relative indication:
large fagments / extensive
dislocation
spina iliaca inf. et al.
 Conclusion for clinic & practice
avulsion
avulsion fractures
fractures at
at the
the pelvis
pelvis and
and tub.
tub. tibiae
tibiae
- diagnostics: sonography, x-ray (MRI, CT)

- at the pelvis: mainly conservative

- extensive dislocations (tub. ischiat., spin. iliaca ant. inf.) OP

- tuberosity tibiae: type , , V, V acc. Watson-Jones & Ogden

(Pest u. Havranek, 2008)
mini-invasive / ORIF
caution: meniscus and compartmentsyndrome after surgery:
bursitis, prominence, re-fracture
 Caution

back into exercise & sports

„too much too soon"

Lyle Micheli, 1979

sports related training

and special rehabilitation
programs
B
R
E
A
K
 Incidence of injuries in soccer
training: 1-4 h / week - 18-32 games / year
n = 854 competitions / injuries = 1275

lower extr. 58% contusion 54%

upper extr. 31% joint injuries 10-19%

head 7% open wounds 18%

trunc 4% fractures 4-12%

acc. Dauner u. Gaulrapp 1993

osteochondral fracture of the
intracondyle eminentia

from: Eichler Weber

 Knee injuries in girls soccer

Injury rate in girls and women soccer

> 2-3 x higher than in boys / men
- often ACL lesions (non contact)
- often meniscal tears
- often patella-femur (ant.knee) syndrom
- seldom groin injuries („soccer groin“)
acc. to Shea et al.2004, Prodomos et al.2007
 State of the Art
ACL lesions in children and abdolecents

0,5% of all ACL lesions before 12years of age

(USA: 3,5 mill. children ≥14 years, treatment for sports injuries)
haemarthros: 30% -60% ACL lesions with / without meniscal tear
transepiphys. tunnel for ACL plasty = risk of growing disturbance
amount of disturbance / growing capicity
growing zones dist. femur / prox. tibia, 70% / 55% of length
 Apophyseal overuse impairments
tub. tibiae: M. Osgood-Schlatter
patella dist .: M. Sinding-Larsen-Johansson

causes: traction overload & hormonal conditioned loosening of the

growing cartilage capacity of the apophysis (intensity 2 time) leads to
hypertrophy / degeneration and calzification / bone formation (ossicle)

clinic: pressure pain and in extension swelling - bump formation

diagnostics: sonography (x-ray / MRT)

therapy: stress red. / local NSAR / tape dressings surgery: only after
conclusion of growth ( resect. of ossicle & bursa)
 Anterior knee pain

femuro peripatellar (ant.knee)pain syndrom

chondropathia patellae

causes: muscul.-tend. dysbalance (m. rectus.fem. / hamstrings)

in growing, dysplasia of the patella and gliding zone,
instability

clinic: post- and peripat. pain at load / movement crepitation

Zohlen‘s sign

therapy: conservative: muscul. stabilisation

red. load but more movement
(sports break / temporary change)
 Patellar instability

- bone (trochlea) patella

- ligaments (MPFL) retinaculae

- muscles (m. vastus med., ect.)

Fig. from Niethard

 classification of patellar instability

subluxation luxation permanent luxation

mild - moderate- heavy short time / permanent new - articul. lat.
lat. lat. (med.) lat.> med.
0-30 ° 50-80 ° permanent
Patella instability / -luxation
diagnostics: x-ray: patella 3 planes + defileé
MRI

therapy: conserv.: PT (strengthening m. vastus med.)

orthesis

surgery: stepwise concept :

- reconstruction (sutures)

- MPFL semitend. plastic

(Schöttle et al. 2005)

- Roux / Elmsli / Goldthwait

- lat. splitting (retinaculum)

(Bieder & Netzer 2005)

- trochlear plastic
(Dejour & Locatelli 2005)
Patella instability / -luxation
chronic Patellaluxation
Discoid meniscus (planus)
clinic: block in motion, pain, effusion

diagnistic: MRI

therapy: partial resection (arthroscopy)

Discoid meniscus (planus)

while trimming

post trimming
Dancer‘s injuries at a school for
ballet
(technical and acrobatic sports)
 State of the Art
dancer‘s
dancer‘s injuries
injuries at
at aa school
school for
for ballet
ballet (technical
(technical and
and acrobatic
acrobatic sports)
sports)

• training and performance start in early childhood

• professional training after 15 years of age (180 min/daily)
• every 3rd dancer injured/year

0,53 injuries / 1000 hrs training

71% mild
21,5% moderate accidents
7,5% severe

after: Wanke et al. Sports Verl. Sportschäd. 2013

Dancer‘s injuries at a school for
ballet
(technical and acrobatic sports)
Ekegren et al. Queensland, Australia / London, UK J Med Sci. Sports 2013

methods: prospective longitudinal study over 1 year

n=266 (122♂, 144♀) Ø 17,2 years (15-23)
English National Ballet School (3 years of education, 16-19 years)

questionaire / accident report:

- sort (new accident / recurrence)
- cause (accident / overuse)
- "Orchard Sports Injury Class.
Syst. Diagn.“ (OSICS-10)
- days off
- treatments
- end of education
 Dancer‘s injuries at a school for
ballet
(technical and acrobatic sports)

results: incidence: 1,42 injuries / dancer (SD 1,24 , 0-7)

1st year 0,72 2nd year 0,76 3rd year 0,81
risk: 76% / year
injury rate: training 1,38 / 1000 hours (1,24 -1,52 = 95%)
performance 1,87 / 1000 hrs (1,68- 2,06 = 95%)
overuse n = 272 (72%) - 7 days break.
trauma n = 106 (28%) - 28,2 days break

joints / ligaments: 46% (ancle / knee jt.)

muscles / tendons: 30%
bones: 19% (stress fractures)
others: 5%

lower extrem. 77% (ancle / knee)

trunc 16% (90% lumbar spine)
head and neck 3% (cervical spine)
upper extrem. 3% (64% shoulder)
 Conclusion for the practise
Dancer‘s
Dancer‘s injuries
injuries at
at aa school
school for
for ballet
ballet
(technical
(technical and
and acrobatic
acrobatic sports)
sports)

school of ballet: high risk for injuries and overuse

preventions:
• warm up
• endurance training
• adjustment of the training of cycles
• alternative movements and exercise
• sport med. (selection ? qualification ?)
and yearly examination
Facit for the practise
Dancer‘s
Dancer‘s injuries
injuries at
at aa school
school for
for ballet
ballet
(technical
(technical and
and acrobatic
acrobatic sports)
sports)

Discussion
Helmets for prevention of head
injuries
 State of the Art
Helmets
Helmets for
for prevention
prevention of
of head
head injuries
injuries

traumatic head injuries: 1,6-3,8 mill./year in sports and leisure time (USA)
fall 28%
motor vehicles: 20%
collisions: 19%
attacks: 11%
acceleration → brain injury without skull fracture
helmets reduce skull fractures and linear acceleration
 Helmets for prevention of head
injuries
Kumar, S. et al. Atlanta, USA Biomech. Sci.Instrum. 2013

methods: experimental study with standard Hybrid III / dummy on a swinging platform

stop of the platform -> fall + impact of the skull at the parietal and temporal
region of the brain

triaxial acceleration measurements

clin. biomech. tests: accel. of the head and head‘s angle
head injury factor

with and without a skateboard helmet

 Head
Head injuries
injuries after
after fall
fall with
with side
side impact
impact on
on aa
scateboard
scateboard helmets
helmets

Results: head impact 24 km / h (6,7 m/sec.)

lin. acc. (g) head injuries angle acceleration (rad/sec2)
no helmet 827 13444 41429
Helm III 93 124 17621
Helm IV 223 1710 13849
limitations: 4,500-8,000 rad / sec2 contusion
12,500 rad / sec2 subdur. hematoma
15,000 rad / sec2 diffuse inj. to the axons
Facit for the practise
Helmets reduce the danger of head injuries,
but only few at side impact.
 Discussion
helmets
helmets for
for the
the protection
protection of
of brain
brain injuries
injuries
later I will become a goverment offical
 prevention
- prospective proprioceptive training
(Knobloch et al. 2005)
 Sports
Sports encouraging
encouraging instructions
instructions
(Jüngst 2002)

"orthopedic gymnastics"
1928

posture-, organ- and

coordination weakness

daily exercise (sports) lessons 1882: Med. Fac. Univ. Strasbourg

1902: Schulthess, Zurich

special indicated: girls, foreign & refugee children,

children of lower sozio-econom. status (Graf 2010)
Voluntary sport couragement for fat and weak children
10 min exercise a day makes puples slim again.
 Medical certicate for exemption
from exercise (sports) in school
n. Jüngst et al., 1995

• possible exemption
(partial, full, prohibited
load and intensity)
• remaining
activities,alternatives
• restriction in period
of time
• schools notes
• diagnosis
• special exercises/ sports
encouragement
 Consensus statment IOC 2011
Montjoy, M. et al., Br. J. Sports Med. 2011;45:835-848

health & fitness in

young people
by physical
activity and sports
 Health and fitness in young people

increase activities:

• sports in social/local settings

• family (example function)
• school
• 60 min./daily mod. intensity
• minimum 3h exercises/sports
in school/week + sport offers
in the afternoon
• information about necessity → sport activities
• coop. external sport offers (clubs)

• IOC Consensus statment 2011

 daily school
sports/exercises
+ 18% of daily activity

- 25% physical activity by sitting in school

Siegmund et al.2009, Uhlenbrock et al.2011

Exercise - Sport - Playing

• joy, pleasure

• self extimation

• fairness

• health

• improvement of functions
(physical and mental)

• performance
 Sports medical examination
in children & abdolescents

children and youth : health prevention check up

school health examinations
sports med.exam.for evaluation of suitability
(mech.capicity) and follow up tests

certfication for sports ability

 take home message

in order to reduce the negative effects

of movement deficiency syndrome
extensive incentives are urgent necessary
offering possibilities and encourgement
for movements, exercises, playing and sports
Discussion
29. Berlin internat. sportsmed.
weekly seminar
Ruhpolding 2017

29.Jan. – 5. Febr. 2017