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Sports injuries in children
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Patricia T. Castiglia, PhD, RN-C, PNP Dean, College of Nursing and Allied Health the University of Texas at El Paso El Paso, Texas
9 Sports Injuries in Children A m e r i c a is experiencing an on-going love affair with sports. We mark our seasons by sports: baseball, tennis, football, soccer, hockey, basketball. Then to sustain us, we have year-long sports including swimming, gymnastics, and weight-lifting. This intense interest in sports has filtered down to our children. We have Little League baseball, football, and hockey among other sports. In the not-too-distant past, interest in sports was primarily at the high school level. In more recent years, young children from approximately 8 years of age begin competing in a competitive mode. Frequently the school nurse, whose knowledge of anatomy, physiology, and sports medicine is often the only resource, especially in small communities, is consuited regarding safety precautions as well as injuries. Therefore the intent of this article is to emphasize the magnitude of sports injuries, to discuss sports injuries in general, and to promote continued education regarding sports injuries for school nurses and nurse practitioners. A significant number of children are injured in sports activities today despite improved coaching, equipment, officiating, and changes in rules designed to reduce injuries (Buckley, 1994). No sports are risk free. It has been estimated that approximately 20 million children, aged 6 to 16 years, compete in athletic activities outside of school; 25 million children participate in school activities (Ostrum, 1993). These figures translate to sports participation by approximately 25% of girls and 50% of boys aged 8 to 16 years (Metcalf & Roberts, 1993). Sports injuries in children can result in the permanent alteration of bone growth resulting in long-term morbidity and disability. An understanding of the growth and development of long bones forms a basis for prevention. Briefly, bone derives from cartilage. A gradual ossification of cartilage occurs during the first 10 years of a child's life at the proximal and distal ends of the J PEDIATRHEALTHCARE. (1995). 9, 32-33. Copyright 9 1995 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/95/$3.00
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+ 0
25/8/61063
9
long bones. Secondary ossification centers are separated by the epiphyseal plate or physis. The presence of open physis means that injuries can be permanent. Muscular strength plays a major role in athletic activity. Muscles exert force on skeletal levers. Most of the skeletal levers are class III levers meaning that there is a relatively short force arm and the muscular force needed is large (Metcalf & Roberts, 1993). All sports place demands on the musculoskeletal system. There are two mechanisms of sports injury: macrotrauma and microtrauma. Macrotrauma is a sudden acute injury from a major force. This includes fractures, sprains of joint ligaments, strains of muscle tendon units, and contusions of muscle tendon units and the overlying soft tissue. Microtrauma results from chronic repetitive injury over an extended period of time. These injuries include stress fractures, bursitis, and tendinitis, among others (National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc., 1993). Ted Quedenfeld, Director of the Temple University Sports Medicine Centers states that 40% of the injuries seen at their facilities would be considered acute although 60% or more of the injuries result from overuse (Ostrum, 1993). Physical conditioning is a process designed to prevent injuries. It is generally accepted that a properly designed resistance training program will develop muscles and be an adjunct in preventing injuries. This strategy uses a variety of progressive resistance exercises to increase the ability to exert muscular force against resistance (Metcalf & Roberts, 1993). Although, it was believed in the 1970s and 1980s that resistance training was harmful for children, Michli (1988) states that there is little if any evidence that resistance training for children causes harm. The design of athletic training programs must take a number of factors into consideration. For example, there is virtually no difference in strength between boys and girls until pubescence. After puberty boys have greater strength than girls. The increased strength of males is attributed to testosterone production. Strength is also directly related to age; that is, strength increases JOURNAL OF PEDIATRIC HEALTH CARE/January-February 1995
Journal of Pediatric Health Care January-February 1995
with age. Additionally, large amounts of body fat decrease strength. Children involved in physical activities develop more lean body mass and have less fat (Roberts, 1993). Females present special problems in athletics. Late menarche and a high prevalence of abnormal or absent menstrual cycles are commonly seen. Although caused by multiple factors, nutritional intake and caloric balance seem to be very important factors. Anorexia and bulimia are frequently seen in these female athletes and in dancers. Other problems exhibited by girls include the failure to meet peak bone mass, reduced bone density, scoliosis, and stress fractures. Usually hypoestrogenism is a contributing cause. A study by Baxter-Jones, Maffulli, and Helms (1993) followed 453 athletes between 8 to 16 years of age for 2 years. There were 231 boys and 222 girls in the study. Four sports were studied: football (soccer), gynmastics, tennis, and swimming. Overall injury rates were found to be low. Over the 2-year period it was found that there was less than one injury per 1000 hours of training. Football presented the highest risk of injuries (67%), and swimming had the lowest risk (37%); 70% of the injuries that did occur were acute and minor. Only four athletes in the study retired from their sport because of injury. Boys are nearly one and one-half times more likely to sustain a school-rated injury than girls. Middle/junior high school students had the highest rate of injury. High school students were most frequently injured in the gym; middle/junior high school students, on the athletic field; and elementary students, on the playground (Lenaway, Ambler, & Blaudoin, 1992). Young athletes suffer a variety of accidents either from injury or overuse. Overuse injuries are frequently reported as pain in the legs (epophysitis and tendinitis) (Larkins, 1991). Other measures in addition to resistance training to prevent injuries include measures to prevent eye and head trauma. Eye protectors with polycarbonate lenses are recommended regardless of whether the athletes have normal vision or wear glasses or contact lenses (Farber, 1991). Helmets should be worn for bicycle riding, hockey, football, and skateboarding. Children under 5 years of age should be prohibited from using skateboards on streets and highways. Mouth guards are typically used for football, but other sports such as ice hockey or skating can also result in dental trauma. The use of mouth guards in many other sports should be considered. Finally, it is important to consider the effect of exercise and sports activities performed in hot climates. Reactions to heat may make the child more subject to falls and subsequent injury as well as the actual heat prostation and exhaustion. Children produce more heat
Growth & D e v e l o p m e n t
33
relative to body mass during physical activities; they have a low sweating capacity, and their body core temperature rises at a higher rate in dehydration (Bar-Or, 1994). Children usually do not drink enough when exercising in the heat. Bar-Or (1994) states that children 10 years of age and younger should drink until they no longer feel thirsty and should then drink an additional one-half glass of fluid. Older children should drink an additional full glass. Beverages should be palatable and stimulate thirst. It is estimated that up to one half of all injuries children sustain while participating in organized sports are preventable. Prevention can be accomplished by attending to the child's physical condition (ascertaining whether any physical problems exist), by using appropriate safety equipment, by ensuring that appropriate training is available for the activity, and by fostering psychologic health. Fitness programs and sometimes the modification of game rules for children may help to develop a positive approach to athletic activity. Children tend to select the sports activities they wish without consideration of possible injuries. Sometimes this decision is enhanced by body build or parental interest. Sometimes it is stimulated by exposure to the sport~ It is the responsibility of all concerned with sports training and medicine to help children enjoy sports activities with as few injuries as possible. REFERENCES Bar-Or, O. (1994). Children's responses to exercise in hot climates: Implications for performance and health. Sports ScienceExchange, 7, unnumbered pages 1-5. Baxter-Jones, A., Maffialli, N., & Helms, P. (1993). Low injury rates in elite athletics. Archives of Disease in Childhood, 68, 130-132. Buckley, S. L. (1994). Sports injuries in children. Current Opinion in Pediatrics, 6, 80-84. Farber, A. S. (1991). Preventing eye injuries. What to tell patients. Postgraduate Medicine, 89, 127-128. Larkins, P. A. (1991). The little athlete. Australian Family Physician, 20, 973-974, 976-978. Lenaway, D. D., Ambler, A. G., & Blaudoin, D. E. (1992). The epidemiology of school-related injuries: new perspectives. American Journal of Preventive Medicine, 8, 193-198. Metcalf, J. A., & Roberts, S. O. (1993). Strength training and the immature athlete: An overview. Pediatric Nursing, 19, 325-332. Michli, L. J. (1988). Strength training in the young athlete. In E. W. Brown, & C. F. Crystal, eds. Competitive sports for children and youth: An overview of research and issues. Champaign: Human Kinetics Publishers, 96-106. National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc. (1993). Draft fact sheet. In S. A. Ostrun, ed. Sportsrelated injuries in youths: Prevention is the key--and nurses can help. Pediatric Nursing, 19, 334-335. Ostrum, G. A. (1993). Sports-related injuries in youth: Prevention is the key--and nurses can help! Pediatric Nursing, 19, 333-342. Roberts, S. O. (1993). Exercise trainability of children: Current theories and training considerations. In M. Leppo, ed. Healthy from the start: New perspectives on childhood fitness. Washington, DC: ERIC Clearinghouse on Teacher Education.
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I
I[~
Patricia T. Castiglia, PhD, RN-C, PNP Dean, College of Nursing and Allied Health the University of Texas at El Paso El Paso, Texas
9 Sports Injuries in Children A m e r i c a is experiencing an on-going love affair with sports. We mark our seasons by sports: baseball, tennis, football, soccer, hockey, basketball. Then to sustain us, we have year-long sports including swimming, gymnastics, and weight-lifting. This intense interest in sports has filtered down to our children. We have Little League baseball, football, and hockey among other sports. In the not-too-distant past, interest in sports was primarily at the high school level. In more recent years, young children from approximately 8 years of age begin competing in a competitive mode. Frequently the school nurse, whose knowledge of anatomy, physiology, and sports medicine is often the only resource, especially in small communities, is consuited regarding safety precautions as well as injuries. Therefore the intent of this article is to emphasize the magnitude of sports injuries, to discuss sports injuries in general, and to promote continued education regarding sports injuries for school nurses and nurse practitioners. A significant number of children are injured in sports activities today despite improved coaching, equipment, officiating, and changes in rules designed to reduce injuries (Buckley, 1994). No sports are risk free. It has been estimated that approximately 20 million children, aged 6 to 16 years, compete in athletic activities outside of school; 25 million children participate in school activities (Ostrum, 1993). These figures translate to sports participation by approximately 25% of girls and 50% of boys aged 8 to 16 years (Metcalf & Roberts, 1993). Sports injuries in children can result in the permanent alteration of bone growth resulting in long-term morbidity and disability. An understanding of the growth and development of long bones forms a basis for prevention. Briefly, bone derives from cartilage. A gradual ossification of cartilage occurs during the first 10 years of a child's life at the proximal and distal ends of the J PEDIATRHEALTHCARE. (1995). 9, 32-33. Copyright 9 1995 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/95/$3.00
32
+ 0
25/8/61063
9
long bones. Secondary ossification centers are separated by the epiphyseal plate or physis. The presence of open physis means that injuries can be permanent. Muscular strength plays a major role in athletic activity. Muscles exert force on skeletal levers. Most of the skeletal levers are class III levers meaning that there is a relatively short force arm and the muscular force needed is large (Metcalf & Roberts, 1993). All sports place demands on the musculoskeletal system. There are two mechanisms of sports injury: macrotrauma and microtrauma. Macrotrauma is a sudden acute injury from a major force. This includes fractures, sprains of joint ligaments, strains of muscle tendon units, and contusions of muscle tendon units and the overlying soft tissue. Microtrauma results from chronic repetitive injury over an extended period of time. These injuries include stress fractures, bursitis, and tendinitis, among others (National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc., 1993). Ted Quedenfeld, Director of the Temple University Sports Medicine Centers states that 40% of the injuries seen at their facilities would be considered acute although 60% or more of the injuries result from overuse (Ostrum, 1993). Physical conditioning is a process designed to prevent injuries. It is generally accepted that a properly designed resistance training program will develop muscles and be an adjunct in preventing injuries. This strategy uses a variety of progressive resistance exercises to increase the ability to exert muscular force against resistance (Metcalf & Roberts, 1993). Although, it was believed in the 1970s and 1980s that resistance training was harmful for children, Michli (1988) states that there is little if any evidence that resistance training for children causes harm. The design of athletic training programs must take a number of factors into consideration. For example, there is virtually no difference in strength between boys and girls until pubescence. After puberty boys have greater strength than girls. The increased strength of males is attributed to testosterone production. Strength is also directly related to age; that is, strength increases JOURNAL OF PEDIATRIC HEALTH CARE/January-February 1995
Journal of Pediatric Health Care January-February 1995
with age. Additionally, large amounts of body fat decrease strength. Children involved in physical activities develop more lean body mass and have less fat (Roberts, 1993). Females present special problems in athletics. Late menarche and a high prevalence of abnormal or absent menstrual cycles are commonly seen. Although caused by multiple factors, nutritional intake and caloric balance seem to be very important factors. Anorexia and bulimia are frequently seen in these female athletes and in dancers. Other problems exhibited by girls include the failure to meet peak bone mass, reduced bone density, scoliosis, and stress fractures. Usually hypoestrogenism is a contributing cause. A study by Baxter-Jones, Maffulli, and Helms (1993) followed 453 athletes between 8 to 16 years of age for 2 years. There were 231 boys and 222 girls in the study. Four sports were studied: football (soccer), gynmastics, tennis, and swimming. Overall injury rates were found to be low. Over the 2-year period it was found that there was less than one injury per 1000 hours of training. Football presented the highest risk of injuries (67%), and swimming had the lowest risk (37%); 70% of the injuries that did occur were acute and minor. Only four athletes in the study retired from their sport because of injury. Boys are nearly one and one-half times more likely to sustain a school-rated injury than girls. Middle/junior high school students had the highest rate of injury. High school students were most frequently injured in the gym; middle/junior high school students, on the athletic field; and elementary students, on the playground (Lenaway, Ambler, & Blaudoin, 1992). Young athletes suffer a variety of accidents either from injury or overuse. Overuse injuries are frequently reported as pain in the legs (epophysitis and tendinitis) (Larkins, 1991). Other measures in addition to resistance training to prevent injuries include measures to prevent eye and head trauma. Eye protectors with polycarbonate lenses are recommended regardless of whether the athletes have normal vision or wear glasses or contact lenses (Farber, 1991). Helmets should be worn for bicycle riding, hockey, football, and skateboarding. Children under 5 years of age should be prohibited from using skateboards on streets and highways. Mouth guards are typically used for football, but other sports such as ice hockey or skating can also result in dental trauma. The use of mouth guards in many other sports should be considered. Finally, it is important to consider the effect of exercise and sports activities performed in hot climates. Reactions to heat may make the child more subject to falls and subsequent injury as well as the actual heat prostation and exhaustion. Children produce more heat
Growth & D e v e l o p m e n t
33
relative to body mass during physical activities; they have a low sweating capacity, and their body core temperature rises at a higher rate in dehydration (Bar-Or, 1994). Children usually do not drink enough when exercising in the heat. Bar-Or (1994) states that children 10 years of age and younger should drink until they no longer feel thirsty and should then drink an additional one-half glass of fluid. Older children should drink an additional full glass. Beverages should be palatable and stimulate thirst. It is estimated that up to one half of all injuries children sustain while participating in organized sports are preventable. Prevention can be accomplished by attending to the child's physical condition (ascertaining whether any physical problems exist), by using appropriate safety equipment, by ensuring that appropriate training is available for the activity, and by fostering psychologic health. Fitness programs and sometimes the modification of game rules for children may help to develop a positive approach to athletic activity. Children tend to select the sports activities they wish without consideration of possible injuries. Sometimes this decision is enhanced by body build or parental interest. Sometimes it is stimulated by exposure to the sport~ It is the responsibility of all concerned with sports training and medicine to help children enjoy sports activities with as few injuries as possible. REFERENCES Bar-Or, O. (1994). Children's responses to exercise in hot climates: Implications for performance and health. Sports ScienceExchange, 7, unnumbered pages 1-5. Baxter-Jones, A., Maffialli, N., & Helms, P. (1993). Low injury rates in elite athletics. Archives of Disease in Childhood, 68, 130-132. Buckley, S. L. (1994). Sports injuries in children. Current Opinion in Pediatrics, 6, 80-84. Farber, A. S. (1991). Preventing eye injuries. What to tell patients. Postgraduate Medicine, 89, 127-128. Larkins, P. A. (1991). The little athlete. Australian Family Physician, 20, 973-974, 976-978. Lenaway, D. D., Ambler, A. G., & Blaudoin, D. E. (1992). The epidemiology of school-related injuries: new perspectives. American Journal of Preventive Medicine, 8, 193-198. Metcalf, J. A., & Roberts, S. O. (1993). Strength training and the immature athlete: An overview. Pediatric Nursing, 19, 325-332. Michli, L. J. (1988). Strength training in the young athlete. In E. W. Brown, & C. F. Crystal, eds. Competitive sports for children and youth: An overview of research and issues. Champaign: Human Kinetics Publishers, 96-106. National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc. (1993). Draft fact sheet. In S. A. Ostrun, ed. Sportsrelated injuries in youths: Prevention is the key--and nurses can help. Pediatric Nursing, 19, 334-335. Ostrum, G. A. (1993). Sports-related injuries in youth: Prevention is the key--and nurses can help! Pediatric Nursing, 19, 333-342. Roberts, S. O. (1993). Exercise trainability of children: Current theories and training considerations. In M. Leppo, ed. Healthy from the start: New perspectives on childhood fitness. Washington, DC: ERIC Clearinghouse on Teacher Education.