ABSTRACT: Sports activities are becoming increasingly popularamong children in the United States. The number of pediatric injuriescontinues to grow with the number of participants; up to25% of the injuries are fractures. The authors used a broad searchof databases and analyzed the current literature to help define theepidemiology and identify possible prevention strategies. Commonfracture locations include the distal radius, hand, elbow, and clavicle;90% of fractures involve the upper limb. Males sustain fracturestwice as often as females. The highest numbers of injuries occur inbicycle riding, basketball, football, and roller sports. Prospectivestudies of preventive strategies for pediatric sport fractures areurgently needed. (J Musculoskel Med. 2008;25:230-234, 254)
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One-third of growth plate fractures occur in competitive sports, such as football, basketball, and gymnastics. Only about 20% of these fractures occur in recreational activities, such as bicycling, skiing, and skateboarding. Fractures may result from a single traumatic event, such as a fall or an automobile accident, or from chronic stress and overuse.
The most common pediatric fractures include those of the distal radius, hand, elbow, clavicle, radius/ tibial shaft, foot, ankle, and proximal humerus.17,18Landin19 categorized these fractures according to adolescent stage patterns. For example, late-peak fractures of the distal forearm, phalanges, and proximal humerus were correlated with sports and equipment issues. Fractures that demonstrated a bimodal pattern included those of the clavicle, femur, radioulnar joint, and diaphysis; there was an early peak at age 5 to 6 years that involved low energy trauma and a late peak at age 12 to 15 years with moderateor high-energy trauma, as seen in adolescent sports. Early-peak fractures, such as supracondylar fractures, were primarily the result of high-level falls. The "rising" category includes ankle fractures, the incidence of which increases throughout childhood, and an "irregular" pattern, as seen with tibial fractures.
This information may help in the design of prevention strategies for various fractures. For example, a strategy for distal radius fractures, which typically occur in adolescence (late-peak category) and correlate with sports and equipment issues, would focus on improving protective equipment for high-risk sports.
The components of injury prevention may be described with the "3 E's": (1) education, or behavioral modifications; (2) environmental changes; and (3) enforcement (eg, legislative interventions). Adirim, using concepts from Hergenroeder, discussed an outline for injury prevention that applies to youth sports.6,20 It included the following:
A model for injury prevention has been under investigation for youth ice hockey, which is played by about 400,000 children in the United States and a similar number in Canada.There has been an increase in serious head and neck injuries in youth ice hockey in recent years; studies have shown that these injuries account for 20% to 25% of injuries in hockey and that 38% to 86% of them result from body checking.21 In a Canadian study of peewee players (age 12 and 13 years) that compared a league that allowed checking with one that did not, players in the checking league had a 12-fold increased risk of fracture.22 In response to the serious levels of injuries, the Canadian Academy of Sports Medicine recommended banning checking at the peewee level and under.23
In 2000, the American Academy of Pediatrics (AAP) released a policy statement that recommended eliminating body checking for children 15 years or younger.The AAP cited studies showing that a high proportion of youth hockey injuries result from checking and that limiting checking can reduce injuries. Disparities in size and strength, especially in older age groups where the variations are most pronounced, also increased the risk of serious injury caused by checking. Therefore, the AAP recommended minimizing checking and other high-impact collisions in the bantam age group (age 14 and 15 years).
In addition, the AAP commended a fair-play concept of scoring ice hockey games, seasons, or tournaments, introduced in 1998, that rewards teams and players that incur few penalties and punishes those with numerous penalties.22 The system's authors suggested that it decreases penalties, intimidation, and violence during hockey games and creates a climate that promotes fun and player development. Although the idea is not universally accepted, a 1996 study of high school ice hockey that compared fair-play and regular rules in portions of a tournament showed an injury rate 4 times higher during the regular rules portion; during the championship round, a doubling of the penalties and injury rate occurred when the fair-play rules were suspended.24
A more recent study of about 2700 Canadian youth ice hockey players found that although injuries increased during the year body checking was introduced, most were somewhat minor and occurred as a result of inadvertent collisions rather than legal body checking.25 In the following year, the players adjusted and there was a decline to prechecking injury levels. The authors suggested that teaching "heads up" skating and enforcing the rules more strictly is a better way to prevent youth ice hockey injuries than banning body checking.
Because children are becoming more involved in sports activities, they are at greater risk for fractures. However, the data on pediatric sports fractures are deficient. NEISS does not provide data on injury severity, recurrence rate, or injuries evaluated outside the ED (those in patients who visit their primary care physician or an urgent care center or who do not seek medical attention).
There also is a lack of large-scale epidemiological data on incidence rates based on the number of participants in various sports, as in injury rates per 100 athlete exposures. These data would be useful in determining the relative risk of serious injury or fracture per sport, based on the number of participants. For example, cycling and football involve similar numbers of fractures, but assuming that there are many more bicyclists than football players, the relative risk of fracture during sports activity is much higher in football.
There also is little prospective evidence of the effectiveness of preventive strategies for pediatric sport fractures. Data from a 1995 study that analyzed 162,100 children treated in EDs for baseball injuries suggested 3 changes in the use of safety equipment that could reduce the number of injuries: face guards on helmets, softer balls, and breakaway bases (to reduce base-sliding injuries).26 The CDC, using data from a previous study, concluded that about 1.7 million injuries could be prevented with the universal use of breakaway bases for all age groups. A prospective follow-up study has not yet been performed.
A large proportion of pediatric fractures involve some part of the upper limb, often the wrist. Because childhood upper limb fractures often occur in bicycling and roller sports, a stricter policy of using wrist guards in these sports may reduce the incidence of wrist fractures.
Schieber and associates15 demonstrated a 10.4-fold risk reduction in wrist injury during inline skating with the use of wrist guards, which could reduce the number of wrist fractures by 87%. The AAP recommended in a 1997-1998 Committee on Injury Prevention report that full protective gear, including a helmet, wrist guards, knee pads, and elbow pads, be worn at all times during inline skating.21 A large-scale prospective study of wrist guard use in sports, particularly in bicycling and roller sports, is needed to determine whether these devices will reduce the incidence of pediatric upper limb fractures.
As children's involvement in sports activities increases, prospective research is needed to identify effective injury prevention strategies. Safety guidelines need to be re-evaluated in most major sports with the use of evidence-based models from prospective studies of preventive strategies for pediatric sport fractures. Regulations should be guided by data analysis of current trends in sports-related injuries, identification of possible modifiable factors, and evidence of the effectiveness of interventions, along with equipment modifications, rule alterations, and legislative policies. The establishment of preventive policies would require cooperation at multiple local, state, and national levels, including patient education, parental control, physician counseling, and policy changes.
The physician's role
Physicians also may help prevent pediatric fractures in the course of daily practice. A thorough understanding of a preparticipation physical examination is critical for each primary care physician and can easily be assessed via a joint monograph by the American College of Sports Medicine, American Academy of Family Physicians, AAP, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine, most recently updated in 2005. This examination can help screen for medical diseases and potentially life-threatening conditions and provides a great opportunity to counsel athletes on proper hydration, preseason conditioning, inseason training, proper warm-up, and proper equipment. The latest literature also may be useful in offering sport-specific recommendations to patients.