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By U. Wenzel. Medical College of Ohio.

Typical injury in adolescents: Apophyseal avulsion (here (rhythmic and standard gymnastics 100mg topamax fast delivery, figure skating and in the anterior inferior iliac spine buy topamax 200 mg, attachment of the rectus femoris also ballet dancing) order 200mg topamax overnight delivery. Murray PM topamax 200mg sale, Weinstein SL, Spratt KF (1993) The natural history and The musculoskeletal system consists of tissues with wide- long-term follow-up of Scheuermann kyphosis. Murray RO, Duncan C (1971) Athletic activity in adolescence as an occur at the weakest point. The mechanical properties of etiological factor in degenerative hip disease J Bone Joint Surg 2 the various structures change during growth. The critical structure in small children under 10 dylolysis in the female athlete. Clin Orthop 372: years of age is bone tissue, while this role is as- 74–84 sumed by growth cartilage in adolescents. Pouliquen JC, Kassis B, Glorion C, Langlais J (1997) Vertebral adults, the ligaments can ultimately be described growth after thoracic or lumbar fracture of the spine in children. J as the weakest point in the tissue system of the Pediatr Orthop 17: 115–20 14. Segesser B, Morscher E (1978) Die Coxarthrose bei ehemaligen musculoskeletal apparatus. Segesser B, Morscher E, Goesele A (1995) Störungen der Wachs- the lowest loading tolerance. Stokes I, Mente P, Iatridis J, Farnum C, Aronsson D (2002) Enlarge- So what advice should we give to young athletes? When ment of growth plate chondrocytes modulated by sustained should they start performance training? J Bone Joint Surg Am 84-A: 1842–8 cents wait until growth is completed and run the risk of 17. Tanchev P, Dzherov A, Parushev A, Dikov D, Todorov M (2000) no longer being competitive? Spine 25: 1367–72 questions we need to know more about the long-term ef- 18. Williamson A, Chen A, Masuda K, Thonar E, Sah R (2003) Tensile mechanical properties of bovine articular cartilage: variations fects of the aforementioned illnesses. Legitimate doubts exist as to whether a thoracic Orthop Res 21: 872–80 19. Clin Scheuermann disease or spondylolysis actually rep- Sports Med 21: 77–92 resents a major problem in later life. Wren T, Beaupré G, Carter D (1998) A model for loading-depen- apply, however, to a tilt deformity, which leads to dent growth, development, and adaptation of tendons and liga- impingement in the hip and constitutes a distinct ments. J Biomech 31: 107–14 form of pre-arthrosis – and coxarthrosis does actu- ally appear to be more common in former athletes than in the general population. Consequently, ex- cessive loading should be avoided particularly dur- ing early puberty. Beunen GP, Malina RM, Renson R (1992) Physical activity and growth, maturation and performance: A longitudinal study. Dorizas J, Stanitski C (2003) Anterior cruciate ligament injury in the skeletally immature. Herman M, Pizzutillo P, Cavalier R (2003) Spondylolysis and spon- dylolisthesis in the child and adolescent athlete. Hasler C, Dick W (2002) Spondylolyse und Spondylolisthesis im Wachstumsalter. Hatton J, Pooran M, Li C, Luzzio C, Hughes-Fulford M (2003) A short pulse of mechanical force induces gene expression and growth in MC3T3-E1 osteoblasts via an ERK 1/2 pathway. Hefti F, Morscher E (1985) Die Belastbarkeit des wachsenden Be- wegungsapparates. Hefti FL, Kress A, Fasel J, Morscher EW (1991) Healing of the tran- sected anterior cruciate ligament in the rabbit. Mankin K, Zaleske D (1998) Response of physeal cartilage to low- level compression and tension in organ culture. Morscher E (1968) Strength and morphology of growth cartilage under hormonal influence of puberty Reconstr.

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On the lateral view buy generic topamax 100mg on-line, the tibial plateau normally slopes in the posterior direction at an angle of approx buy discount topamax 200mg on-line. This is primarily attributable to the finding on the bone scan is local hyperactivity buy generic topamax 200 mg on line, while fact that this region is mechanically well protected: later- the CT scan shows perifocal edema in the soft tissue ally by the fibula cheap topamax 100 mg without prescription, ventrally by the tuberosity and patellar ligament, medially by the growth plate-bridging medial collateral ligament and posteromedially by the attachment of the semimembranosus muscle. The growth plate of the proximal tibia projects anteri- orly like a tongue into that below the tibial tuberosity. This plate section is exposed to traction forces produced by the patellar ligament, which is inserted at this point, and can thus be considered as an apophysis from the functional standpoint. In physiological respects, these anterior sec- tions are the last to undergo physeal closure towards the end of growth. Diagnosis Clinical features The tibial head (and thus the proximal epiphysis and metaphysis) is readily inspected and palpated, at least in its anterior sections, thanks to the thin soft tissue cover- ing. Epiphyseal fractures usually lead to hemarthrosis, while metaphyseal fractures, in contrast with the cor- ⊡ Fig. The size is Fractures of the intercondylar eminence correspond to frequently underestimated on the x-ray because of the bony avulsions of the distal anterior cruciate ligament cartilaginous section. Epiphyseal fractures (Salter-Harris types III and IV – The accident mechanism in such cases corresponds to chapter 4. They hemarthrosis and increased anterior tibial translation in occur predominantly during adolescence. The latter is the most sensitive test for ligament lesions or menisci trapped in the fracture gap anterior cruciate ligament lesions: The anterior transla- are often identified only secondarily or during surgical tion of the tibia is tested in the supine patient at approx. The ligaments should not be tested, Compression fractures are stable, are not associated however, after recent trauma, partly because this is a pain- with any misalignment and heal without complications. The following Epiphyseal separations (Salter-Harris types I and II) degrees of displacement are differentiated: are the result of indirect valgus forces or hyperextension ▬ type I: No displacement. The latter produce anterior displacement of the ▬ type II: The fragment is elevated anteriorly like a like a epiphysis, including the tuberosity. As a consequence, the tongue the posterior hinged part is still in contact with now prominent metaphysis may compromise the popli- the tibial plateau. Epiphyseal fractures of the proximal tibia: Avulsion ity (b), epiphyseal fracture without (Salter III; c) and with (Salter IV; d) of the intercondylar eminence (a), avulsion of the tibial tuberos- metaphyseal wedge a b c d e ⊡ Fig. The tibial tuberosity is part of the epiphysis and is also separation without (Salter I; a – lateral view in b) and with (Salter II; detached during epiphyseal separations c) metaphyseal wedge. Usually there is no 3 Metaphyseal bowing fractures of the proximal tibia: genuine correction, rather the proximal and distal epiphy- sis realign themselves horizontally, while the deformity in The initial valgus deformity is usually so slight that it is the shaft grows, resulting overall in an S-shaped defor- easily overlooked if there is no consistent check for split mity. Top priority is accorded therefore to the elimination fractured sections on the medial side and the axial relation- of all primary valgus and varus deviations. If the initial deformity younger than 10 years old, any (rare) deformities of up is left untreated there is a high risk of a progressive valgus to around 20° in the sagittal plane can be left to correct deformity (see below for complications; ⊡ Fig. Avulsions of the tibial tuberosity typically affect ado- lescent athletes after a sudden, strong quadriceps con- Conservative treatment traction or forced knee flexion while the quadriceps is Non-displaced fractures: Initial immobilization in a plaster activated, e. Extra-articular avulsions slab, replaced by an encircling cast after the swelling has are considered to be displaced if there is more than 5 mm subsided, usually after a few days. In all cases a cylinder be differentiated from malignant tumors even on the basis cast is applied for 4 weeks. Young female endurance athletes should be ques- Eminence fractures: tioned specifically about a possible female athlete triad: Type II: The fragment can usually be reduced by anorexia, osteoporosis and amenorrhea are the key ele- closed manipulation with knee extension under im- age intensifier control. Failure to produce a complete reduction may be due to interposition of the anterior horn of the lateral meniscus or, more commonly, the transverse genicular ligament, which can be freed by arthroscopy (⊡ Fig. For multifragment avulsions, sutures may be inserted in the distal part of the cruciate ligament, which are then passed distally through 2 small holes drilled in the tibia and knotted over the proximal tibia. A slight lowering of the avulsed fragment below the a b c level of the surrounding cartilage compensates for the ⊡ Fig. Growth disorder after metaphyseal bowing fracture of plastic elongation of the ligment. The already existing valgus deformity will be exacerbated, the result fixed percutaneously with crossed Kirschner resulting in a unilateral genu valgum wires (⊡ Fig. For epiphyseal fractures, the guidelines for the man- agement of joint fractures apply (⊡ Fig.

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Weight in girls: Average with mean and percentiles accord- Skeletal age ing to age generic 100 mg topamax amex. Not all 50% 60 children mature at the same rate generic topamax 100 mg fast delivery, and the physiological 25% 50 5% range incorporates differences of ± 2 years order 100 mg topamax with visa. In boys discount topamax 200 mg mastercard, the 30 voice can break between the ages of 12 and 16 years of age. Weight in boys: Average with mean and percentiles at about aged 10 compared to around 12 years in boys according to age. At the outwardly visible changes with the secretion of go- fairly high concentrations, the sex hormones inhibit the nadotropins by the anterior lobe of the pituitary gland secretion of growth hormone and maturation is promoted at around age 8 in boys and 7 in girls. Evaluation of the maturation status in boys and girls Stage Characteristics Duration Development stages of the genitalia in boys Stage 1 Prepuberty: Scrotum and penis remain the same size as during childhood Stage 2 Enlargement of scrotum and testes 1 year Stage 3 Lengthening of penis 1 year Stage 4 Penis becomes larger and thicker, the glans develops, the scrotal skin turns a darker color 2 years Stage 5 Genitalia assume their adult form Maturation stages of pubic hair in boys and girls Stage 1 Prepuberty: Still without pubic hair Stage 2 Sparse growth of fine, light-colored, downy hair, which is straight or only slightly curly, primarily on the 1 year root of the penis and the labia Stage 3 Hair becomes darker, coarser and more curly. Downy facial hair in boys 1 year Stage 4 Hair growth resembles the adult pattern, but the area covered by the hair is smaller, hair growth also in 2 years the armpits. Facial growth more pronounced in boys Stage 5 Pubic hair assumes its adult form Development stages of the breast in girls Stage 1 Prepuberty: Still without breasts, but nipples project Stage 2 Budding breast: Projection of the breast and nipple as a small protuberance 1 year Stage 3 Further enlargement and swelling of the breast without demarcation of contours, the areola also grows 1 year Stage 4 Separate swelling of the areola and nipple across the actual surface of the breast 2 years Stage 5 Breast assumes its adult form. The areola recedes into the general contour of the breast, and only the nipple projects 48 2. The rate of regeneration of the and always in adolescents, between athletic, leptosomic chondrocytes on the one hand and their hypertrophy and pyknic physiques. The intercellular substance with its collagen References fibers maintains the internal cohesion of the growth 1. Thieme, cartilage and is almost exclusively responsible for its me- Stuttgart New York, S 54–55 chanical strength. J Pediatr Orthop 21: 549–55 Within the epiphyseal plate we can distinguish be- 3. Prader A, Largo RH, Molinarik L, Issler C (1989) Physical growth of tween various zones that differ in terms of their organi- Swiss children from birth to 20 years of age. Helv Paediatr Acta zation, the shape and size of the chondrocytes and the Suppl 52 quantitative relationship between cells and intercellular 4. Since the intercellular sub- Stuttgart stance is primarily responsible for the mechanical loading capacity, the weakest zone is in the area of the hypertro- phic cells close to the metaphysis, where the volumetric 2. The growth rate in all mammals is at its greatest im- W e have become accustomed to seeing teenagers win- mediately after birth, and an acceleration of growth also ning Olympic medals in certain sports, for example in occurs during puberty. But perfor- properties of the growth plates occur during this phase, as mance training frequently begins before the completion has been shown by animal experiments employing tensile of growth in other disciplines as well. Sporting activity almost invariably involves peri- in a reactive enlargement of the chondrocytes in the zone ods of acceleration and thus forces and torques. Potential energy is constantly being converted into A reduction in the ability of the epiphyseal plate to kinetic energy and vice versa. If the forces exceed a withstand tensile forces is observed at the start of puberty, certain level, the structure subjected to the greatest particularly in male rats (⊡ Fig. Various hormones stress will fail at the point of weakest mechanical specifically affect the growth plate. If this hormone is lacking, growth tures undergo major changes in terms of their mechani- stops, the epiphyseal plate narrows and its mechanical cal strength between birth and adulthood. By contrast, the administration of important difference between children and adults is the growth hormone above a certain optimal level prolongs presence of growth cartilage. During sexual maturation, the anabolic effect The growth plate normally adopts a position at right an- of the androgens predominates, while estrogens acceler- gles to the force resultants. The anabolic effect of jected to compressive and shear forces and, more rarely, the testosterones is responsible both for the faster growth to tensile forces. Typical growth cartilage plates subjected of male animals (and boys) and for the decline in the to tension are those of the lesser trochanter and humeral mechanical strength of the epiphyseal plate at the onset epicondyle. Unlike androgens, estrogens do not have any plays an important role in the strength of the connec- obvious effect on protein synthesis. At low doses, they tend tion between the epiphyseal plate and the metaphysis. During puberty estrogens slow down the activity of the epiphyseal plate possesses indentations and notches the epiphyseal plate, resulting in an acceleration of the mat- of varying depth. This probably explains why shear forces, but do not play a major role in resisting the phase of epiphyseal plate weakening lasts longer, and is tensile forces.

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