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Over 30 million, or half of all children and adolescents, now participate in organized sports, and the number of children participating in nonorganized sports such as skateboarding, bicycling, and “extreme sports” is even harder to quantify. This boom in sporting activities has resulted in large numbers of patients presenting to the ED following sports-related injuries. Recent data indicate more than 20% of all pediatric injury-related visits involved a sports-related injury, and up to 10% of pediatric ED visits involve a sporting injury. The injuries include fractures, dislocations, contusions, sprains, strains, lacerations, and other injuries quite familiar to the ED physician. There are also a number of unique injuries and issues involving the pediatric athlete.13 Injuries are not just musculoskeletal but also include neurologic injuries such as the challenging pediatric concussion and the “stinger” or brachioplexus injury. The challenge is recognizing the complexities of the growing skeleton and the developing nervous system. This chapter covers some of the unique injuries seen in the ED following sports injuries, and includes avulsion fractures, physeal fractures, overuse syndromes, pediatric concussions, and brachioplexus injuries. We also briefly discuss return-to-play recommendations because many of these patients are seeking definitive care for their injuries in the ED, and it is important to understand why the ED provider is not in a good position to answer all of these questions.


Fractures are very common in youth sports due to the weakness of the physis and the strength of the attached ligaments. Mechanisms that result in adult sprains frequently result in physeal fractures of the skeletally immature athlete due to the stronger ligaments pulling on the weaker bone. During adolescence, the skeleton starts to mature and both fractures and sprains become common. The most common injuries to the physis in athletes are the Salter–Harris (SH) I and II fractures. Once the physis begins to close during adolescence, unique fracture patterns like the SH III and IV also emerge. It is important to always keep in mind the stage of the growing skeleton when evaluating sports injuries, and remember “the younger the athlete, the more likely it's a fracture!”4 (see Chapter 35).


Avulsion injuries are usually fractures that occur when stronger tendons adhere to weaker areas of bone called secondary ossification centers or apophyses. These tendons attach to large muscle groups, and when a strong muscular contraction occurs, the tendon actually “pulls” the apophyses apart from the larger piece of bone. These injuries mostly appear in adolescent athletes as the muscle mass increases and the contraction forces become much greater. The most common site for avulsion fractures is the pelvis where the iliac crest, anterior inferior iliac spine (AIIS), anterior superior iliac spine (ASIS), or the ischium (Fig. 36–1) can have an avulsion injury. The tibial tubercle, greater and lesser trochanters, and phalanges are also frequent sites of avulsions. A unique avulsion of the knee is the tibial spine (eminence) avulsion which occurs following ...

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