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osteoarticular linked to sport in children and adolescents

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Osteoarticular linked to sport in children and adolescents
I. osteochondrosis


The term of osteochondrosis to replace all other terminologies that are confusing, as osteochondritis, osteonecrosis, apophysitis, epiphysitis. Originally sometimes poorly defined (mechanical, vascular ...), they are part of the broader framework of ostéochondrodystrophies, alongside genetic and metabolic ostéochondrodystrophies.


A - General


a - Classification Sifert
It takes into account data etiological, pathogenetic and anatomical separating:
? joint osteochondrosis, which includes:
• Primary damages articular cartilage, for example disease or Freiberg polyostéochondrose the femoral condyles,
•• secondary damage by necrosis of the bone core, for example in the tarsal scaphoid (Kohler-Mouchet disease) or at the hip (Legg-Calve-Perthes);
? non-articular osteochondrosis, receiving processes affecting a ligament or tendon insertion, as the tibial tuberosity where the patellar tendon inserts giving the disease Osgood-Schlatter. They should have the qualifier of "apophysoses";
? the osteochondroses by achievement of growth cartilage, such as the Blount disease or disease Sheuerman.
b - The basics of diagnosis
They should be well known, and the key is first not to succumb to the labeling too easy "sports overload".
We must first remove a tumor pathology, infectious or chronic inflammatory whose frequency remains high during growth.
• Clinically, it is a mechanical pain, revealed or exacerbated by sporting efforts, sometimes prolonging the evening in bed, but do not usually waking during the night. Clinical examination search a painful point on palpation of the ossification nucleus when it is available, the pain woke up being well recognized by the child as one that discomfort.
• Radiological examination is essential but its interpretation must take account not only of normal skeletal ossification and its variants (ossification nuclei accessories), but the correlation between clinical symptoms and radiographic images. Thus, some very similar images will be interpreted here as variants of normal without pain, and there, as images of osteochondrosis if there is a pain syndrome. These images, in general, comprise, alone or in combination, fragmentation, density unevenness and contour of ossification nucleus.
• Laboratory tests, done in principle, remains normal (count, CBC, ESR, CRP).
c - Treatment
It must be simple in this benign pathology. The sporty rest is based, and the rest is an adjuvant. While it is difficult to accept a child motivated a complete no treatment, objectivity and the real risk appraisal should avoid double trap: first condone carelessness by excess, on the other hand, provide abusively the child of any sport.
• The cast immobilization guard indications in hyperalgic forms or in the unruly child, especially when the pain interested knee or elbow.
• Steroid injections are obviously to formally ban.
• Surgery is only for some symptomatic complications or sequelae.
• The sports recovery after prolonged shutdown of the activity should be gradual highlighting here the necessary knowledge of sports technology and its anatomical and functional implications (role of management, prevention).
Finally, once the episode in question healed, it is essential to provide regular clinical and radiological assessments, especially in articular osteochondrosis.


B - osteochondrosis basin


Generally late onset, they concern the teenager. They occur either insidious and deceitful bastard way with so referred pain, or a bru-tal way during a violent effort (starting, pulse trigger, shoot) driving a tear apophysis.
a - osteochondrosis anterior iliac spines
They are sometimes insidiously revealed by pain in the abdominal wall or anterior thigh, but most often it is the occasion of a brutal attack (shoot countered football, for example) they are recognized with a sharp pain on palpation of the tearing area, within a context of significant functional impairment (table muscle tear).
The radiological diagnosis requires oblique views releasing the contours of the iliac wing: heterogeneous nucleus or torn, with true diastasis.
In uncomplicated forms (no tearing), the simple sports stand for 4 to 6 weeks is enough. If tear, it is necessary to advise bed rest for several days, hips flexed, then resumed walking under cover of a pair of crutches for a month, finally sporting rest for three to four months . The surgical repositioning is justified only in large displaced cut away the end of growth, particularly for cutaway displaced by the prior right of the anterior inferior iliac spine.
Figure 1

b - Osteochondrosis of the ischium (Mac Master's disease)
It proves mostly acutely in an array of muscle strain with sharp pain radiating buttock hamstring.
The X-ray shows either a speckled appearance of the bone matrix, a tearing of the mastoid can evolve into hypertrophic consolidation with tumor-image or to the appearance of a para-ischial ossification.
The treatment uses the same principles as the osteochondrosis of the iliac spines.

Figure 2

radio 2

c - Osteochondrosis of the pubic symphysis
Common among the young footballer, the clinical expression mode is the groin. Palpation of the pubic symphysis awakens a well-known by the child pain.
The frontal radiograph of the pelvis, the interpretation must take into account variations of ossification at this age, shows the edges of the pubic nibbled, subchondral geodes, an appearance delay or fragmentation of secondary ossification centers or a widening of the pubic spaced.
The outcome was favorable with a simple sporting rest for two to three months; there should be no infiltration and learn to wait recovery, radiographic images that can persist for months or years, especially if the rest is not enough.


C - osteochondrosis knee


a - tibial osteochondrosis (disease Osgood-Schlatter)
Achieving the best known, it mainly affects the turbulent boy between 10 and 14 years.
It is revealed by pain in the front of the knee during or after exercise and clinical examination revealed painful swelling at the anterior tibial tuberoinfundibular sity while the knee joint itself is normal. Bilateral cases are not rare, either contemporary or delayed by a few months.
The X-ray shows a mastoid in "elephant trunk", inhomogeneous, sometimes fragmented with intra-tendon calcifications.
The treatment of this benign condition that develops over a period of six to twelve months and leaves no sequelae outside an enlarged tuberosity, should remain simple.
In the usual form, there is no indication against-sports, it simply should modulate avoiding jump and shoot during the painful phase. In some forms hyperalgic, the cast immobilization should be recommended for a period of 3 to 4 weeks. The resumption of sporting activity (jogging, swimming) will then be in a few months, against-stating formally that form in team sports, gymnastics and athletics for 4 to 6 months.
You should know, indeed, that these forms can announce hyperalgic avulsion of the anterior tibial tuberosity, which usually reveals the impulse to jump and to be treated surgically when the move is important.
Apart from this case, surgery has virtually no indication, at most, we can send them the forms trailing after age 15, especially when there is a detached fragment intra-tendon , painful and mobile, including surgical excision is curative.
It should be noted finally that a disease Osgood-Schlatter can simulate a revealing entésopathie a chronic inflammatory joint disease.

figures 3

radio 3

b - Osteochondrosis of advanced patella (Sinding-Larsen's disease)

It also affects mostly the boy 10 to 14 years and is revealed by the peri-patellar pain found by palpation of the tip ball. The X-ray can confirm the diagnosis.

radio 4

The outcome was favorable in a few months of relative sporting rest. There is also a risk of tearing litigant surgical reposition if movement is important.
c - Polyostéochondrose the femoral condyles
It is very different from osteochondritis dissecans of the knee.
It occurs between 7 and 12 years, after early and intense sports (gymnastics, soccer, tennis, judo, etc.) it results in unilateral or bilateral knee pain exacerbated by stress, operating on a chronic mode. The pain is caused by the pressure of the condyles of the knee flexed or during active against-leg extension. The X-ray shows, including the impact of the intercondylar notch or small irregular gaps, a large irregular gap partially filled with a congruent bone core (osteochondritis false) or incongruent.
Radiographic evolution is slow, for one to two years and allows to attend the bony core of the connection to the gap, and spontaneous healing is constant. Treatment is to plaster in poorly tolerated forms and sporting rest (except swimming) in chronic forms.

figures 5

radio 5

d - osteochondritis dissecans of the knee (König's disease)
Occurring in older children, it is characterized by the occurrence of sequestration of the subchondral area of the lower femoral epiphysis. Sometimes appearing in a context of genu-valgus or patellar dysplasia, it reaches above the internal condyle bilaterally in some cases. It translates clinically by pain occurring in walking or sporting effort, sitting either at the line spacing, or in the internal para-patellar region. This pain can be found on palpation of the medial condyle, knee bent, sometimes a passing pain when bending back toward the active upset extension.

Radiography (face, profile, intercondylar notch) shows juxtaarticular notch found on both impacts, which should be assessed the seat and extent (area bearing or not). This lesion (niche) can be the site of a receiver, from defect limited to a very wide amputation of the femoral condyle.

radio 6

The evolution of such a lesion is highly variable: the lesion, once discovered, can regress in a few months and fill completely. Sometimes, on the contrary, it extends and can see his receivership be released to the joint as a foreign body that cause blockages repeatedly. Attitude practice before such injury depends on age of onset (before or after 13 years of bone age), place and whether or not a receiver.
Faced with a limited lesion without visible sequestration, only quarterly radiological monitoring is sufficient, advising only the removal of violent sports, leading to regression of symptoms and retrocession radiographic images (the more so that the child is young: a variant polyostéochondrose?). Before sequestration, measure the escrow release risks.
Before 13 years, the treatment remains resolutely medical, which may involve capital plastered in discharge position of the sequestered area (depending on the seat, knee immobilization more or less flexed). After 13 years, the indication can be put before a large area sequestered responsible for pain, effusion, and annoying sport (standard procedure Wagner excision of the bony area subchondral necrotic, with graft and respect for cartilage area in continuity).
In the case of release of intraarticular in receivership, removal of the foreign body and the realization of perforations in the stall for revascularization enough to ensure healing in forms not wearing seat.
The repositioning of the detached fragment with filling the niche subchondral bone graft should always be attempted in the forms bearing zone.
Similar lesions may be encountered in the patella or the trochlea, identical in age of onset, their evolution and treatment principles.


D - osteochondrosis foot


a - Osteochondrosis of the talus
Rare, it occurs in a child 12 to 15 years by pain in the ankle. It may be a little swollen and increased in size and limited in mobility.
Radiographs should be very attentive, looking for a nail shot image on the talar pulley. But sometimes the diagnosis is obvious, the image of a receiver being manifest, seat posteromedial in general (as opposed to osteochondral lesions anterolateral seat of origin rule traumatic sprain waning severe external ankle).
CT scans of or, better, a CT arthrography allow more precise images and condition of the cartilage lining of the talar pulley. We must of course remove any tumor or infectious cause, and bone scan may be indicated in the forms of beginning. As osteochondritis dissecans of the knee, radiographic progression is variable depending on the case: the disappearance of the images in a few months or persistence of a receiver image larger or smaller which may be released to the joint.
The therapeutic attitude remains similar to that of osteochondritis dissecans of the knee, depending on the age of onset, of the size and sequestration of the lesion.
Landfill or the cast immobilization, may be necessary in young children in painful thrust. The indication for arthroscopic resection seems logical if released from an escrow small area of necrosis without subchondral important underlying.
In extensive lesions with extensive necrosis subchondral, the indication can be surgically placed in the absence of radiographic regression of images, combining at that time, excision of necrotic subchondral bone, transplantation and repositioning of cartilage lining.
b - Apophysitis posterior calcaneal (Sever's disease)
Reaching the posterior calcaneal apophysis doubly assaulted by constraints impaction (receiving jumps) and traction (insertion of the triceps muscle through the Achilles tendon), it occurs in child athletes between 9 and 12 years, resulting in heel pain from the posterior lower edge of the heel, especially on exertion. The pain can be reproduced by the pressure of the posterior lower edge of the heel and increased to upset the contraction of the triceps. The comparative profile radiograph shows intensification images and fragmentation of the mastoid highly polymorphic. Evolution is always favorable in six to twelve months.
The treatment is adapted sports activities, eliminating the jumps and the extended run on hard ground, with furnishings by the boot heel protection by foam shell, sometimes with a short cast immobilization in hyperalgic forms.
c - Osteochondrosis of the metatarsal head (Freiberg's disease)
It mainly concerns the second metatarsal, but in some cases can reach the 3rd or 4th metatarsal. Favoured by a Greek or a round forefoot foot, it results in an effort metatarsalgia or support that is found in the elec-tive pressure. The X-ray confirmed the diagnosis after a silent period of weeks: the head becomes denser, has irregularities, then evolves towards a flattening deformation with or towards a full recovery. The radiographic monitoring is necessary to detect the forms evolving into sequestration, so as to propose a surgical reorientation of the metatarsal head before a possible extension of the necrotic area with escrow release, including surgical treatment remains uncertain. During this phase of monitoring, treatment is orthopedic: complete sports rest discharge sole under the metatarsal head for months, correction of static foot fault.
d - Osteochondrosis of the sesamoid of the first toe (Renander disease)
It affects the child from 8 to 12 years old, keen on gymnastics, dance, race or combat sport. The most often impairs the external sesamoid, reflected in an internal metatarsalgia, awakened to the pressure under the first toe. Radiography (incidence sesamoid) shows an irregular sesamoid more or less dense and chunky inhomogeneous. Treatment should remain resolutely orthopedic (discharge sole retracting support under the first toe).
e - Osteochondrosis of the tarsal navicular (Köhler-Mouchet disease)
Often bilateral, it affects young children between 4 and 9 years. The radiograph made ??on the occasion of pain from the inner edge of the foot shows a worrying picture at first of a tarsal scaphoid flat, dense, sometimes fragmented.
Therapeutic measures are simple: sports rest and wearing a sole supporting the arch and avoiding support under the scaphoid. The evolution is towards healing without sequelae within 12 to 18 months.

Figure 8

radio 8

f - Osteochondrosis cores accessory ossification
This may be the scaphoid accessory (medial tibial bone) or bone Vesalius (5th metatarsal base) The accessory navicular is present in one in ten children. his achievement is revealed by pain from the inner edge of the foot, often bilateral, sometimes with swelling, pain awakened to upset contraction of tibialis posterior. The radiograph shows the accessory bones to more or less regular contours. Simple tips for buying shoes (soft with good arch support and foothills) are sufficient. It is quite exceptional that one is led adolescents to excision of this accessory bones.
Reaching the Vesalius bone is manifested by pain and swelling of the outer edge of the foot, at the base of the fifth metatarsal, without any traumatic situation. The X-ray shows bone formation accessory styling the extremity of the last metatarsal. Again, simple changes are sufffisantes boot to relieve the child.
All this pathology, so common in children, is favored by postural disorders of the foot to be taken into account in the therapeutic attitude. Before a banal flat valgus foot, well balanced sports can only encourage the progressive and spontaneous correction toning muscle stays. A dynamic insole or orthotic is often beneficial for prolonged periods of walking, running or sports. Front hollow foot that does not require surgical correction, an orthosis must be prescribed, particularly since there is a varus of the hindfoot or retraction of the Achilles tendon which are still a foot at risk .
Such brevity Achilles should always be sought in a child who complains of the hindfoot and at least be corrected by an appropriate footwear. In practice, any static disorder of the foot should be corrected or protected for sport, particularly since there are only painful events or intolerance.


E - osteochondrosis of the elbow


This is achieved mature kernels with low reconstruction capabilities, the evolutionary potential is highly variable and can be the source of important consequences when these violations are widespread as in the achievement of capitellum or disease Panner.
They occur mainly in the practice of three sports: gymnastics, tennis and throws. Clinical examination revealed a painful or more points on the epicondyle, the medial epicondyle, the radial head, etc. Flexion contracture of the elbow is frequent, the real blockade is rare to evoke an intra-articular involvement with or without foreign body. Comparative radiograph may show fragmentation of secondary cores, gaps or the lateral condyle of the radial head, intra-articular foreign bodies if evolution is unfavorable or osteochondrosis late for the receiver to release stage. The basic treatment is the sports rest with during the recovery, a technology study that may lead to a modification of equipment or training methods. Surgery remains an exceptional remedy being proposed only for extracting foreign bodies by arthroscopy or arthrotomy.


II. Ligament injuries


The ligament injury is rare in children, the mechanism of injury that most often cause trauma of marital cartilage rather than a ligament injury. As it is seen more often after 10 years. Clinical characters allow, in apparently normal standard radios, to distinguish between injury marital cartilage and ligament injury on the superficial joints accessible to palpation. Indeed exquisite pain on palpation awakened seat either at the conjugal cartilage or ligament at the trip.


A. At the level of the ankle


Orthopaedic treatment is still the rule, using more often to cast immobilization as knee bracing, given the greater frequency of non-displaced lesions of the growth plate. Only in very rare cases that surgical treatment is contemplated: big tibial-talar rocker higher than 20 ° compared to the healthy side, osteochondral fracture associated hollow foot or short Achilles in a sports competition. External instabilities are rare in children, and before a clinical picture of external sprained ankle in rehearsal, we must first think about a tarsal synostosis or synchondrosis calcaneofibular scaphoid (often integrated in a context of flat foot).


B. knee


The diagnostic approach should be the same as in adults before posttraumatic hemarthrosis, with clinical examination looking bruises, exquisitely tender points, abnormal movements in a comparative manner.
Radiographic examination (at least 4 implications: face, profile, patellofemoral 30 ° and inter- condylar notch) can often make the diagnosis: pull the anterior tibial spines, dislocated patella associated or not with an osteochondral fracture .
In the absence of bone lesions radiographically visible and conclusive clinical examination, an MRI, or an examination under general anesthesia with arthroscopy, allows for the assessment of the lesions and to evacuate hemarthrosis. Traumatic injury of a meniscus will be treated as economically as possible by pushing to the maximum indications of meniscal reintegration. A lesion of the central pivot and especially the anterior cruciate ligamentNot exceptional in child athletes must receive a careful analysis arthroscopic not miss an avulsion ceiling or floor to benefit from surgical rehabilitation. When the lesion shredded remains in the middle, it seems logical to do a repair on tendon guardian of the crow's feet (domestic law or semitendinosus), by adapting the size of the bone tunnels to residual growth potential and not releasing no periosteal areas near the growth plate at the risk of damaging the perichondrial ring growth.
The initiation of a simple functional treatment is considered as among the very young child, with an annual monitoring by prohibiting all sports activities.

A lesion of the central pivot, including ACL, should benefit from a careful analysis arthroscopic not miss an avulsion ceiling or floor to benefit from surgical rehabilitation.


III. Fatigue fracture


They see in the above child between 10 and 13 years, and especially since the sport was started earlier, the training is intensive and high (gymnastics, dance, skating). They result in a chronic pain syndrome, calmed by rest. Clinical examination may find swelling facing a painful area exacerbated by palpation. All signs remain discreet and diagnosis often difficult, especially as radiography may be silent at first (interest oblique shots). Later radiography may show: cracking, periosteal apposition, densification, before one can truly see hypertrophic callus.
It is in this particular context that we must strive to eliminate an infectious or tumor pathology. Bone scintigraphy often shows then localized uptake of little help to the etiological diagnosis. The main locations of these stress fractures in child athletes are, in descending order, tibia, fibula, the ischiopubic branches, metatarsals and head. The treatment, based on the age of onset, appealed mostly to the capital and the sports rest.



IV. spine problems


There are minor forms of spinal deformity (scoliosis, low-degree scoliosis, kyphosis attitude) found incidentally or occasionally mundane back pain,spine slightly deformed remaining flexible and reduced. In such children in pre-pubertal and pubertal period, monitoring should be seriously by clinical assessment and possibly biannual radiographic, the risk is always possible to go to a major deformation fixed.
• Before a flexible kyphosis with little signs of reach enchondral marked by irregularities of the vertebral plates, but without distortion corner of the vertebral bodies should be discouraged combat sports, jumping and riding, at least if this latter is done at a pace exceeding more than one hour per week.
However, swimming should be advised and may authorize asymmetrical sports such as tennis.
• When scoliosis is discovered, somewhat important, not evolutionary, it is unfair and abusive, as is too often done, remove the school gym, which usually represents a unique opportunity for a child to open up to physical activity. Recommended activities must be based on elongation, like swimming, basketball, volleyball, gymnastics floor. Remedial gymnastics has some interest to the extent that it creates new attitude automation and provides muscle building. Continued too long, it becomes tedious for a child and therefore ineffective; it is better to extend by a sport chosen by the subject to himself, by his own will, will make a much more profitable use. In some forms of severe scoliosis, requiring orthopedic brace treatment, the practice of some sports should be strongly recommended, such as swimming, cycling, running or tennis. After surgery, swimming can be resumed after three to six months and other sports adapted after a year.
• Before spondylolisthesis, must be booked on the practice of intensive sport (gymnastics). The laxity allowing significant hyperlordosis favors Iyses Isthmian and thus slipping. However, a moderate spondylolisthesis, without signs of severity, authorizes the normal practice of school sport or leisure without cons-indication. The occurrence of low back pain requires rest and sports rehabilitation based lumbosacral lock, stretching the hamstrings and the fight against pelvic kyphosis (interest of the property by Boston brace in algic phases). The resumption of sporting activities should focus on a possible modification of the technical gesture to reduce the lumbar lordosis. Finally, spondylolisthesis operated by lumbosacral fusion for over a year does not prevent the practice of leisure sports, whether it be jogging, tennis or horseback riding.


V - Conclusion


We did a quick review of this pathology micro- or macro-trauma (excluding fractures) which meets daily basis in child athletes. Simple rules of common sense, logic and knowledge of pediatric orthopedics allow the vast majority of cases simply solving a temporary mechanical problem and therapeutic measures to be considered should be the image of a benign pathology in most cases. Always keep in mind the possibility of an infectious intricate pathology, inflammatory or tumor, which does not spare more athletes than other children. In case of clinical suspicion or drawling evolution, do not hesitate to resort to the advice of a specialist, afraid to initiate therapy with a disproportionate impact in one way or another.




Doctor Serge HERMAN. - 3 janvier 2011.

Conflicts of interest: the author or authors have no conflicts of interest concerning the data published in this article.


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