Imaging Pediatric Sports Injuries: Upper Extremity

Pediatric Wrist

Pediatric wrist injuries pose unique diagnostic challenges due to distinct bone characteristics in children and their diverse injury patterns. The dynamic development of the wrist, marked by changes in bone age and emerging ossification centers, is crucial to evaluate growth and identify potential pathologies. The skeletal composition, rich in cartilage, renders bones relatively weaker yet more elastic, impacting their susceptibility to fracture. Forearm fractures display diverse patterns influenced by torsional forces. Scaphoid fractures, less common in children, differ from those in adults. Conditions like Madelung's deformity and ulnar variance are more common wrist disorders in the pediatric population. In addition, the scarcity and nonspecificity of symptoms in those with tendon injuries and triangular fibrocartilage complex lesions can be diagnostically challenging. This article reviews pediatric wrist injuries, emphasizing ossification patterns, common fracture types, and developmental variants. Grasping these complexities in pediatric wrist development and associated pathologies is essential for precise diagnosis and treatment.

Imaging of sports injuries in adolescents

Musculoskeletal injuries in adolescents tend to occur in particular locations and have distinct characteristics, as they affect an immature skeleton. Increased engagement in sports, extended training and competition periods, and early specialization in specific sports, among other factors, have contributed significantly to the rise in musculoskeletal sports injuries in adolescents. Furthermore, females show a particularly pronounced increase in sports participation, where anatomical and hormonal factors play crucial roles in the development and increased frequency of sports-related injuries. Consequently, there is a growing demand for diagnostic imaging techniques. Musculoskeletal and pediatric radiologists require a comprehensive understanding of intrinsic and extrinsic risk factors and the successive stages of skeletal development that can influence the specific characteristics of sports injuries in adolescents. These aspects are crucial for the diagnostic, prognostic, and therapeutic management of these injuries and for mitigating chronic conditions that could compromise future sports participation. This review analyzes the primary musculoskeletal injuries in adolescent athletes and highlights the pivotal role of different imaging methods in their diagnosis and management.

A narrative review of little league shoulder: proximal humeral physis widening is only one piece of the puzzle, it is time to consider posterior glenoid dysplasia

Baseball athletes across all levels of play are at an increased risk for upper extremity injury due to the supraphysiologic demands on the shoulder and elbow during overhead throwing. Little league baseball players present with a unique subset of injuries that can affect the growth plate, commonly at the shoulder or the elbow. Ascertaining a diagnosis and plan of care for little league shoulder (LLS) historically focuses on the proximal humeral physis in skeletally immature throwing athletes presenting with shoulder pain. However, while not a current standard of care, posterior glenoid dysplasia is often present in youth baseball athletes presenting with LLS, warranting a shift in the way clinicians evaluate for and treat the youth baseball athlete's pathologic shoulder. Therefore, purpose of this narrative review is 2-fold: first, to describe the current standard of care as it relates to a diagnosis of LLS, and second, to critically describe a comprehensive evaluation process for youth throwing athletes with shoulder pain that includes screening for evidence of posterior glenoid dysplasia. This paper summarizes the current state of the available evidence for anatomic considerations of LLS in the baseball athletes throwing shoulder. Additionally, we provide a framework for clinical evaluation using a multidisciplinary approach to evaluate the entire kinetic chain of the youth baseball athlete presenting with LLS and posterior glenoid dysplasia. A case study is presented to describe common presentations, clinical and objective examinations, and a plan of care from time of evaluation to return to throwing.

Rotator cuff injury in the pediatric population: a systematic review of patient characteristics, treatment, and outcomes

Rotator cuff injuries (RCIs), traditionally thought to be an adult-type pathology, have been reported in the pediatric population, but there remains limited evidence regarding this injury pattern in pediatric patients. The purpose of this study was to systematically review the literature to characterize the epidemiology, injury patterns, treatment modalities, and outcomes for pediatric patients with RCIs. A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, reviewing Pubmed, Embase, Cochrane, and CINAHL databases. Studies reporting imaging confirmed RCIs, and treatment outcomes in patients less than 18 years of age were included. Patient demographics, mechanism, injury type, and injury location were recorded. Treatment type and patient outcomes were abstracted when available and summarized with descriptive statistics. Our search identified 28 studies published from 1994 to 2020, which included 215 total tendons injured in 185 patients. Twenty-six studies were classified as level IV evidence, whereas only two were level III. When described, the most injured tendon ( n = 184) was the supraspinatus, whereas the most described injury type ( n = 215) was a partial tear. Surgical intervention was pursued in 75.8% of injuries, with arthroscopy being more common than open repair (79.4% vs. 20.6%). Nonoperative treatment was primarily utilized for partial tears. Among the 24 studies reporting on return to sports, nonoperatively managed patients returned later than those treated operatively (mean: 10.7 vs. 7 months). Only eight studies included patient reported outcome measures (PROMs), and just five had pre- and posttreatment scores. Three complications were noted, all in operative patients. RCIs in pediatric patients have been reported in the literature with increasing frequency over the last decade, but the quality of evidence remains poor with inconsistent injury descriptions and outcome reporting. Excellent results were seen for all injury types and locations with both operative and nonoperative treatments. The literature for pediatric RCIs remains limited in guiding management decisions indicating a need for more high-quality studies to compare outcomes across injury and treatment type. Level of evidence: level III.

Osteochondrosis of Humeral Capitellum, Diagnosis and Treatment - A Case Report

Introduction:

Osteochondrosis of humeral capitellum (Panner’s disease) is a rare condition. Very few cases are reported in the literature and may be overlooked or misdiagnosed. Most cases are unilateral in distribution and occur in young boys during the first decade of life. It is often difficult to distinguish osteochondrosis from osteochondritis dissecans of the humeral capitellum that occurs in older children and adolescents in the second decade of life.

Case Report:

We describe a case of a 6-year-old boy who presented with pain, subtle swelling and limited extension in his right elbow following a fall. Diagnosis of Panner’s disease was made 2 weeks later on follow-up based on classical features on plain radiograph of joint effusion, irregular delineation of the articular contour, and faint sclerosis of the capitellum with a radiolucent line in the subchondral bone. The patient had uneventful full functional recovery with conservative treatment: Rest, temporary immobilization, and subsequent remobilization.

Conclusion:

Osteochondrosis of humeral capitellum though rare is a known condition. It may be overlooked or misdiagnosed. High degree of awareness is required and diagnosis can be made with utmost care based on the age of presentation, clinical signs and clearly recognizable plain radiographic features of joint effusion, irregular articular outline with radiolucent line in subchondral bone and faint sclerosis of capitellum.

Triangular Fibrocartilage Complex Injuries in Children and Adolescents

Triangular fibrocartilage complex (TFCC) tears can cause ulnar-sided wrist pain in children and adolescents following acute rotational injury or prior distal radius fracture. Surgical treatment, guided by the Palmer classification, is considered after activity modification and occupational therapy. All concomitant wrist pathologies, such as distal radioulnar joint instability, ulnocarpal impaction, and distal radius malunion, must be recognized and addressed at the time of TFCC debridement or repair. This article reviews recent literature guiding clinical evaluation and surgical treatment of children and adolescents with TFCC injuries. The authors' techniques for arthroscopic-assisted outside-in repair of Palmer 1B and 1D tears are described.

Physeal Injuries of the Coracoid Process Are Closely Associated With Sports Activities: A Systematic Review

Background:

Physeal injuries of the coracoid process are rare but may be increasing because of increased participation of youth in year-round sports.

Purpose:

To analyze reported physeal and apophyseal injuries of the coracoid process.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

PubMed and Scopus were searched using the terms scapula fracture and coracoid fracture. The inclusion criteria were English full-text articles describing coracoid fracture as well as articles that described patient characteristics and presented appropriate images. The exclusion criteria were descriptive cases without images as well as those lacking appropriate images. Citation tracking was conducted to find additional articles and full-text articles written in other languages. Articles were included if they reported physeal injury or judged to involve physeal injury based on the provided images.

Results:

Overall, 22 studies including 32 patients (29 males, 3 females) were identified. All but 2 patients were younger than 18 years of age, and 66% (21/32) had sustained injuries during or as a result of participation in sporting activities. The affected site was the physis at the base in 18 patients, an intra-articular fracture in the primary coracoid ossification center combined with the subcoracoid ossification center to form an intra-articular fracture in 5, the apophysis of the tip in 3, the apophysis of the angle in 5, and uncertain in 1. Eleven patients had concurrent acromioclavicular injuries. The injury was acute in 23 patients, chronic in 6, and traumatic nonunion in 3. Among 21 cases in which treatment methods and outcomes were described, 21% of the acute cases (4/19), and 2 of the 3 nonunions were surgically treated. Only 1 study used a widely accepted evaluation method. Follow-up periods ranged from 6 weeks to 2 years. Outcomes were generally excellent for nonoperative and operative treatment and without any serious complications.

Conclusion:

Coracoid physeal injuries occurred most commonly in patients aged 13 to 15 years of age (71%) and were usually sustained during or as a result of sports activities (66%). The most common injury site was the physis at its base. The cause of these injuries is probably severe or repeated traction of the attached muscles and ligaments. The majority of these injuries can be successfully treated nonoperatively.

Magnetic resonance imaging of elbow injuries in children

Evaluating elbow injuries is challenging because of the complex anatomy of the joint. In children, injury patterns depend on the sports-specific mechanism as well as the stage of skeletal maturity. This article reviews the anatomy of the elbow and common injury patterns seen in children, with an emphasis on MRI and the throwing athlete. Imaging pitfalls specific to children are described.

Frequently Missed Fractures in Pediatric Trauma: A Pictorial Review of Plain Film Radiography

Missed fractures are common in pediatric trauma patients. Pediatric bone differs from adult bone in its composition and response to injury, leading to fracture patterns that may be subtle, radiographically unfamiliar, and challenging to distinguish from normal variation. Familiarity with the unique fracture types of the pediatric skeleton and site-specific injury patterns is critical, because prompt diagnosis can significantly alter clinical management and outcome. This article examines the unique features of pediatric bone contributing to missed fractures, the incidence of missed fractures, common injury types of the pediatric skeleton, and frequently missed site-specific fracture patterns, highlighting problem-solving techniques for challenging cases.

Injuries of the adolescent girl athlete: a review of imaging findings

With the rising participation of girls in sports at both the recreational and elite levels, there has also been increased awareness of injuries common in this athlete population. Anatomic differences between boys and girls cause girl athletes to be predisposed to certain injuries. Certain behavioral patterns, such as eating disorders, also cause problems specific to girl athletes that may result in injury. Imaging plays a large role in diagnosis and ongoing management, but there has been only scant literature dedicated to the specific topic of imaging in girl athletes. The purpose of this article is to review the imaging findings and recommendations for injuries and other conditions affecting the adolescent girl athlete. This article first provides an overview of the key anatomic differences between boys and girls, including both static and dynamic factors, as well as non-anatomic differences, such as hormonal factors, and discusses how these differences contribute to the injury patterns that are seen more typically in girls. The article then reviews the imaging findings in injuries that are commonly seen in girl athletes. There is also a discussion of the "female athlete triad," which consists of osteoporosis, disordered eating, and amenorrhea, and the role of imaging in this condition.

Anatomy and injuries of the pediatric wrist: beyond the basics

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.

Systematic assessment of the growth plates of the wrist in young gymnasts: development and validation of the Amsterdam MRI assessment of the Physis (AMPHYS) protocol

Objectives

To develop and validate a protocol for MRI assessment of the distal radial and ulnar periphyseal area in gymnasts and non-gymnasts.

Methods

Twenty-four gymnasts with wrist pain, 18 asymptomatic gymnasts and 24 non-gymnastic controls (33 girls) underwent MRI of the wrist on a 3T scanner. Sequences included coronal proton density-weighted images with and without fat saturation, and three-dimensional water-selective cartilage scan and T2 Dixon series. Skeletal age was determined using hand radiographs. Three experienced musculoskeletal radiologists established a checklist of possible (peri)physeal abnormalities based on literature and clinical experience. Five other musculoskeletal radiologists and residents evaluated 30 MRI scans (10 from each group) using this checklist and reliability was determined using the intraclass correlation coefficient (ICC) and Fleiss' kappa. A final evaluation protocol was established containing only items with fair to excellent reliability.

Results

Twenty-seven items were assessed for reliability. Intra-rater and inter-rater agreement was good to excellent (respective ICCs 0.60-0.91 and 0.60-0.78) for four epiphyseal bone marrow oedema-related items, physeal signal intensity, metaphyseal junction and depth of metaphyseal intrusions. For physeal thickness, thickness compared with proximal physis of first metacarpal, metaphyseal intrusions, physeal connection of intrusions and metaphyseal bone marrow signal intensity, intra-rater agreement was fair to excellent (ICC/kappa 0.55-0.85) and inter-rater agreement was fair (ICC/kappa 0.41-0.59). Twelve items were included in the final protocol.

Conclusion

The Amsterdam MRI assessment of the Physis protocol facilitates patient-friendly and reliable assessment of the (peri)physeal area in the radius and ulna.

Overuse wrist injuries in young athletes: What do sports physicians consider important signals and functional limitations?

This study's objective was to collect items from experienced sports physicians, relating to the presence and severity of overuse wrist injuries in young athletes, for developing a measurement instrument for signals of overuse wrist injury. Seven Dutch elite sports physicians involved in guidance and treatment of young athletes in wrist-loading sports (gymnastics, tennis, judo, field hockey, volleyball and rowing) participated in a focus group. They discussed signals and limitations related to overuse wrist injuries in young athletes. Data were coded and categorised into signals and limitations with subcategories, using an inductive approach. Of the resulting 61 signals and limitations in nineteen (sub)categories, 20 were considered important, forming a comprehensive item set for identifying overuse wrist injury in young athletes. Signals such as pain, "click", crepitations, swelling and limited range of motion were marked useful for early identification of overuse wrist injury. Limitations in movement and performance were considered indicative of severe overuse injury but less relevant for initial injury identification. The focus group provided 17 important signals and 3 important limitations indicative of overuse wrist injury. These provide the basis for a valid measurement instrument for identifying overuse wrist injury in young athletes, with equal emphasis on pain and on other symptoms.

Overuse injuries in children

There has been a substantial increase in the number of children participating in organized competitive sports, which has led to a surge in the number of both acute and overuse injuries. To prevent further complications such as limb deformity and disability, radiologists must be familiar with typical overuse injury patterns in children. Traction apophysitis, chronic physeal injury, and stress fractures are the principal overuse injuries. This article reviews overuse injuries in children with an emphasis on the role of magnetic resonance imaging in diagnosis, prognosis, and treatment.

A systematic, multimodality approach to emergency elbow imaging

The elbow is a complex synovial hinge joint that is frequently involved in both athletic and nonathletic injuries. A thorough understanding of the normal anatomy and various injury patterns is essential when utilizing diagnostic imaging to identify damaged structures and to assist in surgical planning. In this review, the elbow anatomy will be scrutinized in a systematic approach. This will be followed by a comprehensive presentation of elbow injuries that are commonly seen in the emergency department accompanied by multimodality imaging findings. A short discussion regarding pitfalls in elbow imaging is also included.

Imaging of physeal injury: overuse

Context:

As the intensity of youth participation in athletic activities continues to rise, the number of overuse injuries has also increased. A subset of overuse injuries involves the physis, which is extremely susceptible to injury. This paper aims to review the utility of the various imaging modalities in the diagnosis and management of physeal injuries in the skeletally immature population.

Evidence Acquisition:

A search for the keywords pediatric, physis, growth plate, x-ray, computed tomography, magnetic resonance imaging, and overuse injury was performed using the PubMed database. No limits were set for the years of publication. Articles were reviewed for relevance with an emphasis on the imaging of growth plate injuries.

Study Design:

Retrospective literature review.

Level of Evidence:

Level 4.

Results:

Three major imaging modalities (radiographs, computed tomography, and magnetic resonance imaging) complement each other in the evaluation of pediatric patients with overuse injuries. However, magnetic resonance imaging is the only modality that offers direct visualization of the physis, and it also offers the best soft tissue contrast for evaluating the other periarticular structures for concomitant injury.

Conclusion:

Imaging has an important role in the diagnosis of physeal injuries, and the information it provides has a tremendous impact on the subsequent management of these patients.

Common overuse injuries in the young athlete

Pediatric overuse injury is a common complaint presenting to pediatricians. Overuse injury can affect the soft tissues or bone, and results from an imbalance between training and load to the tissues and recovery time. In the skeletally immature athlete, physeal and apophyseal tissue is particularly vulnerable to overuse resulting in different patterns of injury compared to adults. Awareness of age-dependent patterns of overuse is necessary for proper recognition, treatment, and prevention of injury. This article reviews the most common pediatric overuse injuries with emphasis on risk factors, diagnosis, and treatment. Guidelines for prevention are included, as this is the key component for successful management of overuse injury in pediatric athletes.

Spectrum of operative childhood intra-articular shoulder pathology

PURPOSE

With increased sports participation and medical community awareness, there appears to be an increase in pediatric musculoskeletal injuries. Our purpose was to identify the intra-articular injury pattern seen within the pediatric shoulder.

METHODS

A retrospective review was performed at two tertiary-care children's hospitals between 2008 and 2011 on all patients who underwent magnetic resonance imaging (MRI) and subsequent shoulder arthroscopy. Exclusion criteria included: girls >14 years old and boys >16 years old. Demographics, MRI and arthroscopic findings were recorded. Labral pathology was grouped: Zone I (Bankart lesions, 3-6 o'clock for right shoulder), Zone II (posterior labral lesions, 6-11 o'clock), Zone III (SLAP lesions, 11-1 o'clock), and Zone IV (anatomic variants, 1-3 o'clock).

RESULTS

One hundred and fifteen children met criteria, mean age 14.4 years (range 8-16). There were 24 girls and 91 boys, with 70 right shoulders. Of 108 children, labral pathology involved: 72 Zone I (16 isolated anterior), 56 Zone II (15 isolated posterior), 38 Zone III (four isolated superior), and three had an isolated Buford complex. Seventy had more than one labral zone injured, and 31 (30 %) had more than two zones injured. Non-labral pathology included partial rotator cuff tears and humeral avulsions of the glenohumeral ligament.

CONCLUSION

With 94 % of intra-articular pathology being labral tears, the distribution of proportion in children differs from adults; moreover, 23 % involved only the posterior or posterosuperior labrum. Treating surgeons should be prepared to find anterior tears extending beyond the zone of a classic Bankart lesion and an association with C rotator cuff tears.

In vivo pediatric shoulder muscle volumes and their relationship to 3D strength

In the pediatric shoulder, injury and pathology can disrupt the muscle force balance, resulting in severe functional losses. As little data exists pertaining to in vivo pediatric shoulder muscle function, musculoskeletal data are crucially needed to advance the treatment of pediatric shoulder pathology/injury. Therefore, the purpose of this study was to develop a pediatric database of in vivo volumes for the major shoulder muscles and correlate these volumes with maximum isometric flexion/extension, internal/external rotation, and abduction/adduction joint moments. A methodology was developed to derive 3D shoulder muscle volumes and to divide the deltoid into sub-units with unique torque producing capabilities, based on segmentation of three-dimensional magnetic resonance images. Eleven typically developing children/adolescents (4F/7M, 12.0 ± 3.2 years, 150.8 ± 16.7 cm, 49.2 ± 16.4 kg) participated. Correlation and regression analyses were used to evaluate the relationship between volume and maximum, voluntary, isometric joint torques. The deltoid demonstrated the largest (30.4 ± 1.2%) and the supraspinatus the smallest (4.8 ± 0.5%) percent of the total summed volume of all six muscles evaluated. The anterior and posterior deltoid sections were 43.4 ± 3.9% and 56.6 ± 3.9% of the total deltoid volume. The percent volumes were highly consistent across subjects. Individual muscle volumes demonstrated moderate-high correlations with torque values (0.70-0.94, p<0.001). This study presents a comprehensive database documenting normative pediatric shoulder muscle volume. Using these data a clear relationship between shoulder volume and the torques they produce was established in all three rotational degrees-of-freedom. This study furthers the understanding of shoulder muscle function and serves as a foundation for evaluating shoulder injury/pathology in the pediatric/adolescent population.

The approach to elbow pain in the pediatric and adolescent throwing athlete

Elbow pain in pediatric throwing athletes can be very concerning and challenging to diagnose. Diagnosis involves determining whether the injury is chronic or acute in nature and the anatomical location of the pain. Physicians should be aware of the sport-specific forces that predispose athletes with immature skeletons to injury and should be familiar with the common presentations of these injuries. In order to narrow the diagnosis, physicians should gather a detailed history of how and when the pain occurred in addition to performing a thorough physical exam that includes tests, such as the modified milking maneuver and the moving valgus stress test. Appropriate imaging helps physicians to confirm the diagnosis and elucidates any associated pathology in patients. In most cases, the treatment given to patients is conservative and involves rest, ice, non-steroidal anti-inflammatory drugs for pain, and an appropriate physical therapy regimen with a progressive return to play when symptoms have resolved. When patients fail to respond to conservative treatment, surgical intervention may be needed. Knowing when to refer patients for orthopedic evaluation helps athletes return to play quickly and safely.

Diagnostic performance of magnetic resonance arthrography of the shoulder in children

BACKGROUND

No reported data demonstrate the usefulness of magnetic resonance arthrography of the shoulder in children.

OBJECTIVE

To evaluate the sensitivity, specificity and accuracy of MR arthrography in the assessment of superior labral anteroposterior (SLAP) tears of the shoulder, Bankart-type injuries and Hill-Sachs lesions in children as compared to arthroscopy.

MATERIALS AND METHODS

We retrospectively interpreted 66 MR arthrograms of the shoulder and compared them with surgical findings. Assessment included evaluation of the osseous structures, labral-ligamentous complex and determination of skeletal maturity. We calculated sensitivity, specificity and accuracy and compared sensitivity and specificity between skeletally mature and immature children.

RESULTS

MR arthrography demonstrated a sensitivity, specificity and accuracy of 88%, 98% and 94%, respectively, for depiction of SLAP tears; 94%, 92% and 94% for detection of Bankart-type injuries; and 100%, 94% and 97% for diagnosing Hill-Sachs lesions. There was no statistical difference between the skeletally immature and skeletally mature groups.

CONCLUSION

There is no significant difference in the diagnostic accuracy of MR arthrography in skeletally immature versus skeletally mature children. MR shoulder arthrography is an effective method for the detection of labral and bone pathology.

Acromial apophysitis in a 13-year-old adolescent boy: a common condition in an uncommon location

OBJECTIVE

Traction apophysitis is a common condition in physically active and skeletally immature adolescents. This case study describes the clinical presentation and plain film imaging of traction apophysitis of the acromion process of the scapula.

CLINICAL FEATURES

A physically active 13-year-old adolescent boy presented to a chiropractic physician with an acute onset of moderate shoulder pain. Plain film radiographs of the shoulder were performed that revealed fragmentation, sclerosis, and irregularity of the left acromial apophysis.

INTERVENTION AND OUTCOME

The patient was treated with conservative therapy for 10 weeks, with complete resolution of symptoms. Follow-up radiographs 9 weeks later revealed no radiographic change in the appearance of the apophysis; however, clinical symptoms were absent. The apophyseal growth cartilage is the most vulnerable site in the muscle-tendon unit in the skeletally immature patient and is more susceptible to very small avulsion fractures. Repetitive microtrauma following chronic overuse at a tendon insertion site in a skeletally immature patient may result in traction apophysitis.

CONCLUSIONS

Acromial apophysitis should be included in the differential diagnosis when presented with a young active patient with shoulder pain. Early treatment with restriction of activities is important in the prevention of permanent injury to the acromial cartilaginous growth plate. This case demonstrates that a prompt diagnosis can be made with a careful history, physical examination, and conventional imaging.

Osteochondritis dissecans of both knees, both elbows, and the first metatarsophalangeal joint in a female soccer player

A 19-year-old female soccer player presented for evaluation of pain at the base of the right hallux after a recent sports injury. She had a history of 4 operations, 1 each at both knees and both elbows, for the treatment of osteochondritis dissecans (OCD). Examination showed tenderness to palpation and limited range of motion of the first metatarsophalangeal (MP) joint, and radiographs showed stage 4 OCD of the first metatarsal head with a detached osseous fragment. Diagnostic arthroscopy confirmed the presence of OCD, and treatment included arthrotomy, excision of the loose body, and microfracture of the defect. Evaluation at 3 months after surgery showed that the first MP joint pain and limited motion had completely resolved, and the patient returned to soccer practice. Although OCD at 1 location is diagnosed frequently in athletes, involvement of 5 different joints in the same patient is uncommon.