18 Pediatrics CASES
CASE 18
You are performing preparticipation physicals for the local youth sports team. An 11-year-old male presents with 6 weeks of medial elbow pain that is aggravated by throwing. He notes a vague history of a “pop” while playing 6 weeks ago in baseball game. He pitches multiple times a week utilizing a variety of pitches. He plays baseball year round and chose to specialize in this sport at age 9. The pain does not bother him while at rest. On physical examination, he is tender to palpation over the medial side of the elbow with slightly decreased range of motion. Radiographs of the affected and normal elbow are obtained (Figs. 10–34 and 10–35).
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Figure 10–34
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Figure 10–35
What is the next best course of action?
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MRI of the right elbow
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Open reduction internal fixation
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Ulnar collateral ligament reconstruction
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Cessation of all throwing activity and physical therapy
Discussion
The correct answer is (D). The patient has “Little league elbow” due to repetitive throwing which causes valgus stress on the medial elbow structures. On radiographs, there is widening of the medial epicondyle apophysis compared to the contralateral side. Poor throwing mechanics, overuse, and single sport specialization are risk factors for the development of this condition. As this is an overuse/mechanical problem, cessation of throwing activity and an examination of mechanics/physical therapy are key in treatment. The patient does not require an MRI given his history, physical examination, and radiographic findings; failure of conservative treatment should warrant an MRI. The patient is too young to have suffered a UCL injury. Furthermore, the patient’s widening of the medial
epicondylar apophysis is due to overuse not an acute fracture; therefore fixation is not necessary.
The next patient arrives in clinic complaining of increasing knee pain and a “bump” over his proximal tibia. This 10-year-old patient plays basketball and notes this “bump” has been increasing in size over the past several months. He has pain with repetitive running and jumping activities. On physical examination, he has exquisite tenderness over the proximal tibia and pain with resisted knee extension. He has very tight popliteal angles. There is no ligamentous instability about the knee. Radiographs of the affected knee are obtained (Fig. 10–36).
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Figure 10–36
What is the next best course of action?
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MRI of the knee to evaluate for malignancy
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Open reduction internal fixation
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Reassurance
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Arthroscopy
Discussion
The correct answer is (C). The patient has Osgood–Schlatter’s disease. This is a condition which occurs in children who are engaged in repetitive explosive
activities, which can cause a painful bump over the proximal tibia. This bump is due to the patellar tendon pulling on the tibial tubercle apophysis during explosive activities; particularly during periods of rapid growth. Symptoms typically abate once growth ceases, although the bump may persist into adulthood. The vast majority of cases can be treated with rest, ice, activity modification, and stretching. An MRI is not necessary as the “bump” is due to traction apophysitis; not a malignancy. The patient’s presentation is not consistent with a fracture, and fixation of the fragment in a child of this age could lead to a recurvatum deformity. Finally, as the patient’s pain is due to an extra-articular process, arthroscopy is not indicated. The younger brother of the patient above is the next patient that you see in clinic.
He is complaining of “heel pain.” He enjoys playing soccer. This pain has waxed and waned over the past several months and is worse with running and kicking. On physical examination, he is tender over the calcaneus with weakness in plantarflexion and limited dorsiflexion. There is some localized swelling over the calcaneus.
The patient is at greatest risk for the following if he continues to play:
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Achilles tendon rupture
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Calcaneal fracture
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Growth arrest
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Increased pain and duration of symptoms
Discussion
The correct answer is (D). The patient’s clinical presentation is consistent with Sever’s disease which is a traction apophysitis of the calcaneus. This occurs during periods of growth causing pain and swelling. There is no association of this condition with Achilles tendon rupture (which would be rare in this age group regardless), calcaneal fracture, or growth arrest. Continuing activity will increase the intensity and duration of symptoms. Patients can be treated for this condition with rest, ice, anti-inflammatory medications, gastroc-soleus stretching, and limited wear of unsupportive shoes such as cleats.
At the end of clinic, the parents of the previous three patients ask you advice as to how to best manage their children’s athletic career in regards to injury prevention; particularly overuse.
Which of the following is an appropriate recommendation?
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Single sport specialization before age 13 to prevent stress from playing multiple sports
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6 months of complete rest during the year in which no active sporting activity takes place
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A well-designed weight lifting and plyometric program to build muscle bulk and explosive strength
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Periods of active rest in which athletes are playing multiple different sports
Discussion
The correct answer is (D). The concept of active rest (taking a break from one sport by playing another sport) is essential in preventing overuse injuries in young athletes. Active rest not only provides physiologic benefits through the utilization of different movement patterns and muscle groups, but it also provides emotional and social benefits through different teammates and coaches. Although periods of complete rest should be incorporated, 6 months of complete rest is extreme. Although weight lifting and plyometrics are an important component of a well-designed athletic program, it is not indicated for prepubertal patients. Finally, the detrimental physical, social, and emotional effects of early single sport specialization have been well documented. Burnout, both emotional and physical, can be avoided by encouraging a breadth of activities.
Objectives: Did you learn...?
The history, physical examination, and radiographic findings of Little league elbow?
The initial treatment for throwing injuries in the young athlete (i.e., cessation)? The clinical presentation of Osgood–Schaltter’s disease?
The treatment modalities for Sever’s disease?
The risk factors for overuse injuries and the modalities to combat its occurrence?