Sports Injuries in Children and Adolescents (Medical Radiology)


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Directions to KKH. Moving around KKH. Visitor Registration. Contact Us. Home to skip to the main content on a page to skip to the main content on a page. Sports Medicine. Contact Information. Fitness Centre, Level 2, Children's Tower. Page Content. Our Multidisciplinary Approach to Treatment To ensure that you receive holistic specialized care, our Sports Medicine Programme is supported by a multi-disciplinary team comprising Physicians Sports orthopaedic surgeons Musculoskeletal radiologists Physiotherapists Exercise specialists and trainers Dieticians Psychologists Medical specialists in paediatrics, adolescent medicine, gynaecology and obstetrics Our Range of Services Our Sports Medicine Programme offers a comprehensive range of services for children, adolescents and women of all ages and fitness levels: Diagnosis and treatment of sport injuries Our team of physicians, physiotherapists and fitness specialists help women and junior athletes who have acute or chronic overuse injuries modify their training regime, correct biomechanical errors, and use physical therapies and reconditioning to resume sports participation as soon as possible.

If surgery is found necessary, our sports orthopaedic surgeons apply the most current technology to aid the recovery process. Diagnosis and treatment of medical problems affecting sports and exercise performance Those who exercise regularly sometimes encounter common medical problems that may affect their sports performance — exercise induced asthma, concerns relating to overweight or underweight, or menstrual irregularity, to name a few.

Our team work collaboratively with respective medical specialists to provide seamless and sports focused medical care. Management of sports and physical performance issues Our physicians and dieticians can help you address other performance-related issues such as strength, conditioning, dietary and hydration strategies in sports, the use of supplements to enhance performance etc.

Research View all. Education View all. News View all. Subscribe to our mailing list to get the updates to your email inbox The provocative squeeze test can be performed to aid in diagnosis. The squeeze test is performed by compressing the tibia and fibula together midway up the leg causing shear strain to the distal syndesmosis ligaments. A positive test is pain at the distal tibiofibular joint. Ankle ligament sprains classically are graded on a scale of I to III based on the degree of disability, swelling, and ligamentous injury determined by the amount of ligamentous laxity.

Grade I is the mildest, and involves stretching of the ligaments without rupture or joint instability. Grade II is moderate in severity and involves a partial rupture of the ligament resulting in moderate pain and swelling as well as mild to moderate instability, resulting in difficulty with weight-bearing. Grade III injuries are the most severe and involve a complete ligament rupture, leading to significant pain, swelling, and hematoma formation.

Grade III injuries cause severe functional impairment and instability.

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Ultimately, if the patient has significant swelling and loss of function ability to bear weight , this represents a higher ankle sprain that may require more aggressive immobilization with appropriate physical therapy and primary care follow-up. The first step in diagnosis of ankle sprains is classification of which type of ankle sprain occurred based on clinical history and a focused physical exam of the ligaments discussed above.

To confidently diagnose an ankle injury as a sprain rather than a more significant injury, the pain and swelling documented on exam must coincide with the injury pattern expected. See Table 1. The Ottawa Ankle Rules were developed by Stiell et al as a clinical decision tool to help determine when radiologic evaluation is necessary in acute ankle and midfoot injuries. In terms of midfoot imaging, the rules recommend imaging only with pain in the midfoot region plus one of the following: bony tenderness at the navicular bone or the base of the fifth metatarsal or inability to bear weight for four steps immediately after the injury and in the emergency department.

Navicular and fifth metatarsal injuries will be discussed later in this article. The Low Risk Ankle Rule is a tool that was developed specifically for children to help determine when X-rays are needed. Pediatric patients are considered low risk if the injury is acute defined as less than 3 days old , if they are not at risk for pathologic fracture for example, children with a focal bone lesion or osteogenesis imperfecta , if they do not have a congenital anomaly of the feet or ankles, if they are able to express pain or tenderness, if pain and swelling are limited to the distal fibular or surrounding lateral ligaments distal to the anterior tibial joint line, and if no gross deformity, neurovascular compromise, or other distracting injury is present.

These six spots are: 1 the proximal fibula to rule out Maisonneuve fracture; 2 talus to rule out a talar neck, dome, or lateral process fracture; 3 navicular bone to rule out navicular fracture; 4 base of the fifth metatarsal to rule out a Jones or pseudo-Jones fracture; 5 base of the first and second metatarsal to rule out a Lisfranc injury; 6 and the tibial and fibular physes to assess for Salter-Harris fracture.

The mechanics and management of these injuries will be discussed later in the article. To avoid missing high-morbidity injuries in the ankle, a simple ankle sprain can be diagnosed only if three criteria are met: 1 there is no pain over these six locations, 2 the exam is consistent with ligamentous injury, and 3 there is no indication for imaging per Ottawa Ankle Rules.

Although management of ankle sprains depends on the type of sprain as well as the severity, the overall goals of management for ankle sprains in the emergency department are to control pain, reduce post-injury edema, and functionally support the ankle to allow early mobilization. Minor ankle sprains caused from inversion strain can be managed conservatively with rest, ice, elevation, and immobilization. Recent studies suggest bracing, Aircast, and Ace bandage allow more rapid return to function by allowing early mobilization.

The overall consensus is that if a patient has a mild or moderate ankle sprain, an Ace bandage 28 or Aircast should be used. If the patient has considerable swelling, loss of function, and instability, a walker boot will immobilize the injury more aggressively and will allow functional return to activities of daily living. With the exception of syndesmotic ankle sprains, numerous studies show that early weightbearing and mobilization more rapidly improve functional return after an ankle sprain.

All ankle sprain patients should be advised of the importance of physical therapy in follow-up. Therapy that emphasizes ankle strength and proprioception can be effective for the prevention of ankle sprains in athletes with previous sprains. For emergency medicine physicians, ankle sprains are ultimately a diagnosis of exclusion.

The emergency provider first must consider injuries that can mimic ankle sprains but are associated with a high morbidity. See Table 2. These include Maisonneuve fracture, talar fractures, navicular fractures, Jones or pseudo Jones fractures, Lisfranc injuries, and Salter-Harris fractures.

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Proximal fibular fractures, or Maisonneuve fractures, are caused by external rotation of the ankle joint with force transmitted through the tibiofibular syndesmosis. Although proximal fibula fractures alone do not require surgical intervention, they do suggest an injury from a high degree of force and may be associated with a medial malleolus fracture or a rupture of the deltoid ligament, anterior talofibular ligament, or interosseous ligament.


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The gravity view will help ascertain if there is considerable mortise instability that will require operative intervention. Maisonneuve fractures should be placed in a long-leg posterior splint with urgent orthopedic follow-up. Although less common than other ankle injuries, fractures to the talus see Figure 2 can occur with rotational injuries to the ankle and have a high rate of complications.

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If the talar neck, dome, or lateral process is painful to palpation on exam, the provider should obtain ankle X-rays, including an oblique view. Talar neck fractures are the most common talar fracture but are often overlooked in the setting of ankle injuries. On exam, patients will have focal tenderness over the talar neck associated with edema and pain with range of motion.

Talar neck fractures are best viewed on the lateral view of the ankle X-ray.

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The blood supply to the talus is distal and there is a retrograde supply to the talar body from branches of the posterior tibial artery. This leads to a risk of osteonecrosis if the talar neck is disrupted. Talar dome fractures see Figure 4 , or osteochondral dome fractures, occur with impaction in inversion and eversion ankle injuries. This results in trauma to the cartilage of the talus and its underlying subchondral bone.

Radiographically, talar dome fractures are best visualized on the mortise view. Missed injuries can lead to non-union and early-onset arthritis; thus, specialist follow-up is imperative. These are exceptionally difficult to diagnose, as they present identically to an inversion ankle sprain with pain in the location of the ATF ligament. The lateral talus is the insertion point of the ATF. On exam, pain is most prominent 1 cm distal to the lateral malleolus.

Pain with dorsiflexion and external rotation should raise concern since this maneuver causes impingement on the fracture site but does not stress the ATF ligament and, thus, inversion ankle sprains should not hurt with this maneuver.


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They are best seen on mortise and oblique views. If a provider has clinical suspicion for a talar fracture even if X-rays are negative , the patient should be placed in a walker boot or posterior splint with a non-weightbearing status and have follow-up imaging and reassessment by an orthopedic specialist in one week. CT scan is recommended in patients who present with a history of a snowboard injury or jump plus one or more positive Ottawa ankle criteria. The navicular bone see Figure 2 is critical for maintaining the medial longitudinal arch; thus, delayed diagnoses can lead to chronic gait disturbances and disabling foot pain.

Navicular fractures are classified as dorsal or tuberosity avulsion fractures or body fractures. Avulsion fractures are the most common fractures and are associated with a low-energy mechanism of injury, while body fractures require high-energy mechanisms like a motor vehicle collision.

Tuberosity avulsion fractures occur with forced eversion of the ankle and midfoot, causing traction to the posterior tibial tendon or deltoid ligament, which then results in the avulsion fracture. Tuberosity fractures see Figure 6 must be differentiated from an accessory navicular on X-ray. An accessory navicular is usually bilateral and appears as a smooth corticated bone medial to the navicular, while a tuberosity fracture has an irregular trabecular appearance.

Dorsal avulsion fractures are best seen on lateral view, and tuberosity avulsion fractures on AP and external oblique views. Because of the high morbidity associated with these fractures, the emergency provider should palpate the medial navicular and N spot for every rotational ankle and foot injury. The medial navicular is the bony prominence just distal to the talus at the mid-arch of the foot.

The N spot is the dorsal navicular between the anterior tibial tendon and the extensor hallucis longus tendon. Pain in these locations requires non-weightbearing and placement in either a walker boot or posterior splint, as well as specialist follow-up in one week.

Figure 7 depicts basic bony anatomy of the foot. Pain with palpation to the fifth metatarsal necessitates dedicated foot films to examine the zone-specific location of the injury. There are three zones of injury in which fifth metatarsal fractures can occur.

Sports Injuries in Children and Adolescents (Medical Radiology) Sports Injuries in Children and Adolescents (Medical Radiology)
Sports Injuries in Children and Adolescents (Medical Radiology) Sports Injuries in Children and Adolescents (Medical Radiology)
Sports Injuries in Children and Adolescents (Medical Radiology) Sports Injuries in Children and Adolescents (Medical Radiology)
Sports Injuries in Children and Adolescents (Medical Radiology) Sports Injuries in Children and Adolescents (Medical Radiology)
Sports Injuries in Children and Adolescents (Medical Radiology) Sports Injuries in Children and Adolescents (Medical Radiology)

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