Management of Musculoskeletal Injury in Children and Adolescents

Introduction

Sports injuries in children and adolescents are becoming more common in recent days. Traumatic injury due to sports events often leads to fractures, sprains, strains, and dislocations. Hence, special attention is required for children and adolescents due to skeletal immaturity (bone not yet developed completely). The initial treatment aims at stabilizing the injury, followed by recognizing appropriate treatment for fractures in skeletally immature individuals.

What Are the Most Common Musculoskeletal Injuries in Children and Adolescents?

The most common musculoskeletal injuries are:

• Tendon Attachment Site Injury or Growth Plate Traction Injuries: The growth plates are located at the terminal end of bones, wherein tendons are placed in close proximity to the growth plate. The attachment site of the tendon is relatively weak among children and more prone to injury (tendinitis - inflammation of tendon) due to overuse of muscles. Symptoms include pain during and after physical activity, swelling, tenderness, and bone thickening at the attachment site. Alteration of exercise is an integral part of managing this condition.

• Patella Dislocations and Subluxations: The knee cap displacement due to traumatic injury (hard hit to the knee or changing the direction of one leg while sprinting). Symptoms include unbearable pain, joint deformity, instability, swelling, and difficulty in weight bearing. They are managed appropriately by plenty of rest and a rehabilitation program to strengthen the specific muscles. Unfortunately, the chance of recurrence is high; therefore, surgery is indicated in particular conditions, such as in the case of spontaneous dislocations.

• Fractures: The types of fractures differ from adult to adolescent due to skeletal immaturity. The common types of fractures are:

1. Greenstick Fracture: During development in children, the bones are more flexible and rubbery than in adults and more prone to bend or crack due to falls. Common sites of injury are forearms and lower legs.

2. Growth Plate Fracture: The growth plates are located at the terminal end of bones (epiphysis). The bones are actively growing around the growth plate. Fractures involving the growth plates lead to typical changes in growth patterns. Common sites of injury include the wrist, elbow, ankle, and hip.

3. Avulsion Fracture: It is most commonly seen in teenagers due to kicking, jumping, and sprinting, and it often results in a partial or complete displacement of a tendon followed by a tear of muscle or tendon. The condition recovers through physical therapy and requires surgery in rare situations.

• Slipped Capital Femoral Epiphysis: The condition is characterized by instability due to a growth plate fracture of the hip joint. The symptoms include hip, knee, and groin pain, restricted movement, difficulty with weight bearing, and shortening of the affected leg (duck foot). The treatment protocol includes surgical intervention.

• Radial Head Subluxation: This condition is characterized by partial dislocation of the elbow. It is commonly seen in children between one to four years of age as a result of picking or swinging up a child by one arm. Predominant symptoms are pain, restricted movement, and difficulty in bending the elbow.

What Are the Common Causes of Musculoskeletal Injury?

The primary causes are distinguished based on the age of the children:

1. Toddlers or Preschool:

• Infection (leads to septic arthritis, osteomyelitis of the hip, and spin).

• Trauma.

• Congenital or developmental disorder (like hip dysplasia).

• Neurological disease (like cerebral palsy and hereditary syndromes).

• Inflammatory arthritis.

• Cancerous disease (like leukemia, neuroblastoma).

• 5–10 Years of Age:

• Trauma (due to overuse or sports injuries).

• Reactive arthritis (hip irritation).

• Perthes’ disease.

• Inflammatory arthritis.

• Idiopathic pain syndromes (cause is unknown).

• Cancerous disease.

• 10–17 Years of Age:

• Trauma (due to overuse or sports injuries).

• Slipped capital femoral epiphysis.

• Inflammatory arthritis.

• Idiopathic pain syndromes.

• Tarsal coalition (two bones grow together and are connected by a bridge of bone, cartilage, or fibrous tissue).

• Cancerous disease (leukemia, lymphoma, primary bone tumor).

What Are the Risk Factors?

The common risk factors are:

• Sports Injury- During growth spurt or development, the muscle and tendon can create tightness and inflexibility around joints due to trauma, resulting in imbalance (tendons are relatively weak among children and more prone to injury).

• Amenorrhoeic Athletes- It is characterized by decreased bone density, skeletal maturity, and muscle strength in female athletes who have not attained puberty.

• Inappropriate Training- Improper sports equipment and exercise leads to a major risk of injury.

• Psychological Factors- Participation in high-risk events can increase the probability of severe sports injuries.

How to Diagnose Musculoskeletal Injury?

The diagnosis is based on past medical conditions, physical examination with the correlation of X-rays, MRI (magnetic resonance imaging), CT (computed tomography), and ultrasound required for the confirmative diagnosis of the condition.

What Is the General Protocol of Management?

The general principles in managing musculoskeletal injury include:

• Early diagnosis.

• Evaluation of causative agents like biomechanical problems, non-fitted sports equipment, and frequent training load increase.

• Adequate rest followed by injury.

• Maintenance of cardiac health.

• Avoid straining the non-affected muscles.

• Maintenance of muscle strength and endurance on unaffected sites.

• Avoid aggressive physical activity.

• Gradual increase in sports activity without causing strain to the muscle and tendon.

What Is Physical Therapy and How Does It Heal Musculoskeletal Injury?

Physical therapy is also known as physiotherapy, which heals the tissue with the help of exercise based on injury and physiological demands of the human body. Physical therapists use various techniques in the rehabilitation phase, along with physical modalities of therapeutic exercise and cold or heat therapy.

• Therapeutic Exercise: Exercise is employed to stretch the muscles to improve joint mobility, maintain cardiac health, and increase strength, power, endurance, speed, agility, and sport-specific skills.

• Cold Therapy: Cold therapy (ice) helps reduce swelling, pain, and inflammation. It eventually limits secondary injury, ischemia (restricted blood flow), and damage to other structures. The ice pack is applied to target muscles without compression (compression increases contact between ice and skin and may limit rewarming) for 25 minutes to promote healing.

• Heat Therapy: Heat therapy reduces pain and muscle spasms. Simultaneously, it increases blood flow. The standard form is warm-up exercises or passive heating modalities like hot packs, hydrotherapy, and ultrasound. It is mostly used in chronic conditions and restricted muscle or joint motion.

• Other Modalities: Ultrasound and electrical stimulation also promote healing in the rehabilitation phase.

Conclusion

Commonly seen in young athletes, musculoskeletal injuries can be managed by primary care providers with appropriate training, followed by a rehabilitation program to protect the affected site and maintain muscle strength and endurance in unaffected muscles, followed by gradual reintroduction of sport-specific activities.