Pediatric Trauma: Spine and Sports

From Pediatric Emergency Medicine, sponsored by Nemours

John Loiselle, MD, Associate Professor of Pediatrics, Jefferson Medical College, and Chief,
Department of Emergency Medicine, Alfred I. DuPont Hospital for Children, Philadelphia, PA

Educational Objectives

The goal of this program is to improve the management of cervical spine injuries (CSIs) and sports injuries in children. Af­ter hearing and assimilating this program, the clinician will be better able to:

1.   Discuss differences between anatomy and mechanisms of injury of the CS in children, compared to adults.

2.   Determine which patients do not require imaging, based on the National Emergency X-Radiography Utilization Study (NEXUS) criteria.

3.   Avoid pitfalls in interpretation of x-rays of the CS in children.

4.   Practice general principles of treatment of sports injuries in children.

5.   Explain the pathophysiology and treatment of common sports injuries in children.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Loiselle and the planning committee re­ported nothing to disclose.

Acknowledgments

Dr. Loiselle was recorded at Pediatric Emergency Medicine, held April 15-18, 2009, in Lake Buena Vista, FL, and sponsored by Nemours. The Audio-Digest Foundation thanks Dr. Loiselle and Nemours for their cooperation in the production of this program.

Clearing the Cervical Spine

Cervical spine injury (CSI) in children: extremely rare, but consider with any traumatic injury

Clearance of CS: difficult in acute care setting; determine  —which patients at risk; which patients require imaging;  which imaging modality appropriate; which adjunctive studies useful; which patients require referral; which pa­tients can be cleared clinically without radiographic studies; which patients cleared after simple radiographic stud­ies; which patients cannot be cleared

Considerations: although rare, tolerance low for missed injury; cost; pediatric spine different from that of adult; pe­diatric films difficult to interpret; limitations on time and resources; risks of irradiation; risks of sedation; re­quirements for algorithm  —  simple; practical; evidence-based; high sensitivity; minimizes unnecessary irradiation; not resource-intensive; pediatric issues  —  mechanisms causing CSI different from those in adults; anatomic differences; developmental issues

Mechanisms of CSI in children: motor vehicle accidents (MVAs) leading cause; sports; bicycle injuries; falls (one study reported >50% due to fall from second-story window)

Pediatric anatomy: relatively larger head size (higher center of balance, with more injuries occurring at C1 and C2); underdeveloped neck muscles (less protective); horizontal facet orientation (potential for greater movement); odon­toid synchondrosis (relatively weak area); wedge-shaped vertebrae (allows more movement between vertebral bod­ies with force); ligamentous laxity; protecting CS main priority (not clearing CS)

Ruling out need for imaging: National Emergency X-Radiography Utilization Study (NEXUS)  —  looked prospec­tively at cases considered at risk for CSI; determined which patients at low risk and did not require imaging of spine; low-risk criteria  —  level of alertness sufficient for evaluation; no midline cervical tenderness on palpation; no focal neurologic deficit (at time of injury or at time of evaluation); no painful distracting injuries; no evidence of intoxication (toxicology screen or alcohol level not required); looked at >3000 patients <18 yr of age and found 30 with CSI; of those who fit low-risk criteria, none had CSI (reduced need for imaging by 20%); limitations  —  included only patients with x-rays; only 88 patients <2 yr of age; only 4 patients with CSI <9 yr of age; evaluated only stable injured patients

Imaging of CS: x-rays  — study of choice; 3-view series most useful when possible; 2-view series (anteroposterior [AP] and lateral) when patient unable to cooperate with odontoid or open-mouth view; sensitivity »90% in most studies; 98% sensitivity for ruling out unstable CSI; if negative, 99.9% certain that no CSI present; pitfalls of pedi­atric x-ray interpretation  —  widened spaces; possible pseudosubluxation; odontoid synchondrosis difficult to eval­uate and resembles fracture; ring epiphyses; high risk for spinal cord injury without radiographic abnormalities (SCIWORA); pediatric variants  —  predental space larger (4-5 mm considered normal; >3 mm in »20% of children <8 yr of age [would be abnormal in adult]); prevertebral space also larger; greater degree of C2-C3 override; poste­rior cervical line  —  drawn through anterior cortex of spinous process of C1 through anterior cortex of spinous pro­cess of C3; considered normal if it falls along or within 2 mm of anterior cortex of C2; if fracture present, anterior displacement of vertebral body of C2 and posterior displacement of spinous process; SCIWORA  —  diagnosed based on symptoms, ie, transient (sometimes persistent) neurologic symptoms that may remit and recur; theoreti­cally, due to excessive movement of spine without causing injury to ligaments or bone; children <8 yr of age at greater risk due to ligamentous laxity and hypermobility; reported incidence varies from 0% to 50% of children with spinal cord injury; ruled out through magnetic resonance imaging (MRI)

Adjunctive studies: computed tomography (CT)  —  use increasing for CSI; no routine case in which CT of entire CS in child indicated; indications include inadequate x-rays (eg, to rule out CSI in infant or toddler [odontoid or open-mouth x-ray view not possible] for whom CT of head already ordered; limited to C1-C2 region), abnormal or sus­picious plain film, and in presence of focal pain or neurologic change despite normal x-ray; flexion-extension views  —  dynamic study to look for ligamentous injury; rarely useful in acute setting; likelihood of isolated liga­mentous injury without bone injury extremely small (yield low); difficult to perform in child already in pain; possi­bly useful 2 to 3 wk after injury; MRI  —  ideal for visualizing soft tissues and spinal cord itself; not as good for bony areas; generally not necessary in emergency department (ED); indicated in presence of transient neurologic symp­toms and in obtunded or comatose child

Missed CSIs: study divided cases resulting in litigation into 3 categories (inadequate or improper tests; misread tests; tests not sensitive enough to detect injury); first 2 categories indefensible; concluded that more liberal use of CT ap­propriate

Indications for referral: unconscious trauma patient; abnormal x-ray; neurologic symptoms; other concerning clini­cal symptoms

Case 1: child, 4 yr of age, awakened with neck pain; may have struck head after tripping on previous day (question­able trauma); at low risk for CSI, per NEXUS criteria; lateral tenderness probably muscular pain; soft collar and ibuprofen appropriate

Case 2: child, 10 yr of age, unrestrained back seat passenger in MVA; presented with forehead laceration and facial contusions; placed on board and collared by emergency medical services (EMS); anxious and crying; unable to evaluate and clear patient; 3-view x-rays of CS indicated; if x-rays negative and patient asymptomatic, reevaluate and clear

Case 3: child, 7 yr of age, struck by car; Glasgow Coma Scale score 7; facial and abdominal injuries; x-rays indi­cated; if negative, apply collar, consider MRI, and refer; patient fails NEXUS criteria (unable to clear)

Case 4: child, 10 mo of age, fell down flight of stairs; brought in by EMS on board and in collar; low-risk mechanism; calm patient and perform neurologic and physical examination (PE); imaging indicated only if concerning findings present

Case 5: football player, 16 yr of age, ran head-first into opposing player; fell to ground and unable to move arms or legs for several minutes; normal neurologic examination and 3-view x-rays of CS negative; high-risk mechanism with con­cerning neurologic symptoms; concern for SCIWORA (cannot clear patient); keep immobilized and admit; obtain neurosurgery consult and consider MRI

Case 6: child, 8 yr of age, fell from bicycle without helmet; angulated right forearm fracture and abrasions to scalp; received dose of morphine before evaluation; apply NEXUS criteria; provide pain relief to arm with splint; con­sider whether distracting injury present and effect of morphine; x-rays probably indicated

Pediatric Sports Injuries

Risk factors: unwillingness of child to stop when injured; insufficient recovery time; increasing intensity of exercise too rapidly; growth spurts; improper technique

Case: girl, 11 yr of age, presents with left knee pain of 6-wk duration; plays basketball on 2 teams and participates in practices or games 6 days/wk; pain worse when playing and better with rest; slight swelling below kneecap; no his­tory of acute trauma or fever

Rapid examination of knee: inspection  —  look for swelling and obvious signs of injury; palpation  —  areas of point ten­derness; range of motion  —  should flex to <90° and extend to ³180°; rule out effusion  —  “milk” down superior bursas, ballot patella, and compare with normal knee; ligaments  —  to test anterior cruciate ligament, look for drawer sign (with leg at »90°, pull briskly on lower leg, feeling for tight end points); to test lateral collateral ligament, hold knee at »20° of flexion and push on medial aspect; pain on lateral side indicates injury of lateral collateral ligament; perform reverse for medial collateral ligament (pain on medial aspect)

PE of case patient: point tenderness over tibial tubercles, mild swelling, no effusion, intact ligaments, and full range of motion; Osgood-Schlatter disease diagnosed

Osgood-Schlatter disease: provocative tests include active extension against resistance (causes pain), climbing stairs, and kneeling; x-rays generally not recommended, but consider if unilateral pain present; form of apophysitis

Apophysitis: irritation or microfracture at musculotendinous insertion; risk factors  —  growth spurt (bones growing faster than muscle-tendon unit, resulting in more tension in area); organized sports activities (constant repetitive stress); poor biomechanics; sudden increase in training intensity

Treatment of sports injury: in general  —  for pain and swelling, nonsteroidal anti-inflammatory drugs (NSAIDs), ice, and rest; provide patient with plan for return to activity; strengthening and flexibility exercises; consider alter­native training; prevention (change in training, technique, and equipment); moderate to severe pain generally re­quires rest; avoid activities that aggravate; for case patient  —improve flexibility and strength of quadriceps and hamstring muscles specifically; start with low-intensity or isometric exercises, with gradual increase in intensity; if performing strengthening or weightlifting exercises, limit to low weights; refer if unresponsive to conservative treatment; condition resolves in majority of children; recommend dynamic stretching of hamstring and quadriceps muscles (ie, warm up muscles with, eg, brisk walk, then stretch) before physical activity; ice after activity benefi­cial; infrapatellar strap helpful (reduces tension or redistributes forces on tibial tubercle); use soft surfaces when performing exercises or sports activities

Case: boy, 12 yr of age, complains of gradually increasing pain and stiffness in right elbow; star pitcher on baseball team, but length and strength of pitches now diminished; pain greatest at end of each pitch; pain on medial aspect of elbow; denies numbness or tingling in hand; PE  —  no swelling or bruising; tenderness over medial epicon­dyle; no lateral elbow pain; normal range of motion; no locking; Little Leaguer’s elbow diagnosed; provocative testing (flexion of wrist against resistance) causes pain in medial epicondyle

Treatment: no throwing until symptoms resolve; strengthening exercises for forearm muscles; when resuming sport activities, “long toss” recommended; guidelines from American Academy of Pediatrics limit number of pitches to 6 innings per week, 200 pitches per week, and 90 pitches per outing; pitching mechanics important; avoid breaking pitches (eg, curve, slider)

Little Leaguer’s elbow: affects children 9 to 12 yr of age; caused by valgus stress on skeletally immature elbow; medial elbow pain and tenderness (epicondylitis); x-ray useful (due to possibility of avulsion fracture)

Case: dancer, 13 yr of age, complaints of anterior knee pain for past 3 mo; no history of acute trauma; denies locking of knee; pain greatest when sitting for long period and improves when ambulatory; pain exacerbated when run­ning down inclines or going down stairs; occasional sensation of knee giving way; PE  —  no point tenderness; no effusion; normal range of motion; provocative testing includes having patient squat (causes pain) and patellar compression with isometric tightening of quadriceps; patellofemoral pain syndrome diagnosed

Patellofemoral pain syndrome: common, especially in girls; formerly referred to as chondromalacia patellae (de­fined as injury to cartilage beneath patellar surface); onset of pain gradual; majority improve with conservative treatment; pathophysiology  —  abnormal tracking of patella due to either imbalance of quadriceps or anatomy of particular individual (sharper angle of knee [Q angle] seen in girls); overload of joint (eg, sports, dancing); poor biomechanics; unknown whether significant wearing of joint surface behind patella present; treatment  —reduce activity (no need to eliminate); NSAIDs and ice helpful; goal to reduce muscle imbalance by strengthening mus­cles on medial aspect and stretching on lateral aspect (especially vastus medialis oblique); increase flexibility of hamstring muscles and iliotibial band; avoid bent-knee exercises or squats

Case: hurdler, 15 yr of age, presents to ED with acute onset of pain in right hamstring; experienced sharp pain while clear­ing hurdle midway through race; heard “pop” and grabbed back of leg; difficulty ambulating due to pain; coach as­sumed athlete “pulled hamstring”; ice applied; PE  —  mild bruising at back of leg; tenderness near insertion of hamstring; significant pain on passive hip flexion with extended knee; active contraction of hamstring causes pain; x-ray appropriate and showed avulsion fracture

Avulsion fracture: consider location of fracture and age of child; apophysis weaker than muscle-tendon unit; pelvis most common location (anterior superior iliac spine and ischium); almost always related to athletic activity; usually oc­curs before child fully grown; due to sudden and forceful muscle contraction; treatment  —  ice and NSAIDs; avoid weight-bearing until pain-free (2-4 wk); heat, massage, and vigorous stretching not recommended; referral and possi­ble surgical fixation indicated if significant displacement present; once pain resolved, begin isometric stretching and strengthening exercises

Case: girl, 15 yr of age, developed right foot pain at end of cross-country camp; training included twice-daily prac­tices; mild swelling and localized tenderness of forefoot; no acute trauma recalled; pain worse when running and immediately after workout; patient not awakened by pain; PE  —  no fever; occasional swelling of mid forefoot; point tenderness over area of swelling; pain with pressure from above and below foot; differential diagnosis in­cludes plantar fasciitis and stress fracture; x-ray normal, but callus formation seen 2 wk later

Stress fracture: pathophysiology  —  repetitive stress on bone, especially over pressure points, without sufficient recovery time; most common in runners, especially with hard surfaces, poor shoes, and/or overtraining; common in metatarsals, distal tibia, and distal fibula; treatment  —  avoid painful activities until healing occurs; rest for »1 mo; walking boot better choice than cast; cross-training; gradual return to activity (increase by »10% per week); suggest running in pool

Suggested Reading

Brenner JS: American Academy of Pediatrics Council on Sport Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics 119:1242, 2007; Cassas KJ et al: A. Childhood and adolescent sports-related overuse injuries. Am Fam Physician 73:1014, 2006; d'Amato C: Pediatric spinal trauma: injuries in very young children. Clin Orthop Relat Res 432:34, 2005; Hutchings L et al: Cervical spine clearance in pediatric trauma: a review of current literature. J Trauma 67:687, 2009; Launay F et al: Pediatric spinal cord injury without radiographic abnormality: a meta-analysis. Clin Orthop Relat Res 433:166, 2005; Loud KJ et al: Correlates of stress fractures among preadolescent and adolescent girls. Pediatrics 115:e399, 2005; Pieretti-Vanmarcke R et al: Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma. J Trauma 67:543, 2009; Prince JS et al: MRI of anterior cruciate ligament injuries and associated findings in the pediatric knee: changes with skeletal maturation. Am J Roentgenol 185:756, 2005; Ribbans WJ et al: Pediatric foot fractures. Clin Orthop Relat Res 432:107, 2005; Sanchez B et al: Cervical spine clearance in blunt trauma: evaluation of a computed to­mography-based protocol. J Trauma 59:179, 2005.