Okay, thanks very much. I really appreciate this opportunity, invitation. No disclosures relevant to this discussion. So here's a nice study from the NEISS database looking at a 10-year period and showing that the epidemiology of youth in high school, American football-related injuries, you know, has really actually gone down. So this has been decreasing both at the high school and youth football level, but that high school risk is higher than the youth risk. Notable to their findings was that, you know, in the younger age, fractures were really much more common, whereas the older you get, you see more of the strains and sprains. We'll talk a little bit more about that. This single-site study from the Campbell Clinic showed a similar finding. Basically, they concluded fractures are more common in the younger participants, and this rate falls off as the rate of soft tissue extremity trauma increases with increasing age. This is shown there with that data based on a variety of age groups. And then the other takeaway from this study is that in the really young youth football players, the rates of injuries requiring hospitalization are very low, so rare to have severe injuries from a very young playing football. And then the sort of middle school and young adolescent, all under 10 percent, so not a high rate of severe injuries presenting to the ER. The knee is the most common site when we think about anatomic sites affected. Similar to data you've heard in the adult athletes there, the ankle was the second most in this nice review by Mike Stewart from Mayo, who cited one of his own prior studies most frequently. And then the others are all sort of under 10 percent with equal distribution. Their other takeaway was that with increasing age, there's increasing risk, and this was sort of steady and predictable with each increasing age group. There seemed to be a spike, though, around the age of puberty when they looked at the different grades from four through eight. Their other takeaway, offensive players have around two times the risk of defensive players. Linemen and linebackers had relatively low risk, so the positions at greatest risk were the quarterback and running back in youth football. Here's another study from George Mason University also corroborating this notion, the knee being the most common anatomic site. They also looked at time lost and saw that the head injuries and concussions probably had the highest time lost, which is probably appropriate as we start to understand youth concussions more and more and the developing brain and the need for rest. Most of the injuries seen in youth American football, though, were not severe. Severe injuries requiring more than three weeks of time lost was relatively rare, 5 percent. Here's a nice contribution. When they looked at flag football versus tackle football in almost 3,800 players in three leagues and they had 46,000 exposures and 128 injuries, the mean age of 10 and a half, when they looked at the hazard ratios of sort of tackle to flag in terms of injuries, it was actually lower with tackle football than with flag football, including that rate of severe injuries being about the same, but the rate of concussions was actually less in tackle than flag football. Their other takeaway was that older players within their age range had more risk. Our institution, Bill Meehan, Dai Tsujimoto, Luke Riddell, looked at just quarterbacks who had presented to our outpatient pediatric and adolescent sports clinic over a 15-year period, so 374 quarterbacks, 423 injuries. So two-thirds were acute injuries, 55 percent had occurred in games. The shoulder was actually the most common site involved amongst quarterbacks, but of the almost quarter that required surgery, the knee was the most common site, then shoulder and elbow. When they looked at the types of shoulder injuries affecting the quarterbacks, many were more chronic and non-acute, but the shoulder dislocations and subluxations, so instability, clavicle fractures, SC joint injuries, AC joint injuries were amongst the most common. So just a few illustrative case examples of how our youth football players may present differently. Tomorrow, I'll be talking about PEDS ACL and really the skeletally immature ACL and the approach to that issue. We know that's increasing, but of course the classic pediatric ACL injury is the tibial spine fracture. So this 11-year-old whose uncle, actually Ronnie knows a former Pro Bowl fullback for the Giants, who now lives in my area, had this non-contact twisting injury. We see this type 3 displaced tibial spine fracture here on this AP view, and then the lateral view allows us to characterize it. The fracture is all the way out the back. So this is not a hinged or type 2, not a non-displaced type 1, but a type 3. So about 100% of the time that should be a surgical injury. You can see the fracture fragment elevated there and exiting out the back. But here's a key finding, which is this intermeniscal ligament interposed. So if this was a type 2, one could consider non-operative treatment. But with the interposition of this IML, you don't have a great chance of reducing that to an anatomic degree. So here's an arthroscopic view of that tibial spine elevated. So we use a provisional kind of fixation with a little K-wire there to get an anatomic reduction, and then we see that our ACL is intact. So there may be some energy transmitted through the ACL, but usually it's pretty much intact. And then one can do suture or a screw fixation. If you use a screw it needs to be all epiphyseal, it doesn't cross the physis. And here's the technique most of us have come to favor for almost all the cases, which is suture-based. So you see the two guide wires up on either side of that tibial spine, which is where we'll pass our suture passers and then feed two transverse sutures. One can crisscross these, or I like one in the front third and then the back two-thirds of the ACL footprint right above the spine, and then pull those sutures down using the suture passers in the transphysial tunnels that you've put up from kind of your tibial ACL site there just above the PES. So once those are pulled down and tied over the anterior tibial metaphysis, one has anatomically reduced and nice tensioned ACL, and that fracture should heal. So here's the patient at three months, really robust healing in two planes, and had begun to run and then returned to sport. We can usually get these players back at this younger age much faster than the ACLs, don't have to wait the full nine months. When we've tested them in our ACL return-to-sport testing metrics, they're usually ready to go sometimes by five months, and he came back without an issue. Then with the collateral ligaments, a study from our institution, we looked at 51 knees in the pediatric group, and over half of them had open physes, but all of the bony avulsion variants of our MCL and LCL injuries were in the skeletally immature. Over a third of these were football injuries, more common MCL than LCL. But you can see these variants. You know this is an avulsion right off the lateral epicondyle or on the right side off of the fibular head, rather than the mid-substance ligamentous tears. Here's another patient, similar. He had an opened varus stress test, so we saw this little cortical fragment that we felt needed to get fixed acutely. It might have healed on its own, but with some concern for laxity, we were able to affix that right back in the bony bed with an anchor above just below the physis to really grab the ligament, and then the bony fragment fit right there. So by three months, he was healed, sort of back to sports, similar timeline, four to five months. With the shoulder, there's also adolescent or pediatric variants. So in the similar ABER mechanism that we'll see anterior dislocations, one needs to be aware of the subscap avulsion fracture or lesser tuberosity avulsion phenomenon. When I was a resident, happened to see two of these on my rotation with Dave Olchek, so we wrote up his series of three, all fixed arthroscopically. Two of the three had delays in diagnosis. They were all diagnosed in the office before advanced imaging with a positive liftoff signs. The MRI revealed this little chondrocortical fragment. Sometimes one can't see it on x-ray, so don't bank on that with suspicion of this just from an x-ray and arthroscopic repair with suture anchors. At our institution, a JBGS study looking at eight of these, four of these were really understood to be as common as we now know. With a mean age of 13, these were all treated open, 100% were sports injuries. The range of timing from injury to surgery was two weeks to six months, speaking to how common this is a missed diagnosis. They often get chalked up as strains or sprains, maybe a subluxation. But here's a complete avulsion that you can see on the left picture attached to the subscap. So we reattached the lesser tuberosity either with screws or suture anchors with good results. And then SC joint dislocations or the sternoclavicular injuries are really the most common in the adolescent age group. Most of the series are from our pediatric sports colleagues and from our institution. Here's a 16-year-old quarterback. It's usually a direct blow. Instead of breaking in the midshaft, one can sublux or dislocate posteriorly. Remember, these are often fracture dislocations rather than pure dislocations in this age group because the epiphysis is that medial physis is still open. He was actually discharged from the ER in Connecticut and called us. And he was at home with shortness of breath and pain with deep breathing and had had two syncopal episodes. So this is an acute fracture or fracture dislocation that does not get discharged. We admit these and fix them the next day. Though not everybody in our group of over 20 pediatric orthosurgeons has a comfort level with these. So identifying people who have seen this and are comfortable. We always alert the CT surgeons on site on the off chance that reducing this causes an issue to any of the metastinal structures. We have to be ready for an acute emergency. However, we don't, you can see the trachea being displaced there on the CT. So we usually start sort of from lateral to medial, find normal, and then pull it out from its dislocated position, sometimes a dramatic clunk, and then use a suture repair. So the nice thing, we don't need plates or screws here and decrease risk so can suture this closed. And we're a little bit more strict about the sling and swath for the full six weeks. But bony healing is really quite predictable with these. One is making little drill holes in the manubrium or in the fragment of the epiphysis. A final sort of variant of an adult injury would be a hamstring tendinous avulsion. Well because of the age group that this tends to happen in adolescence, they have an open apophysis on their ischial tuberosity. And so it's a bony injury. The tendon stays intact. You can see this fracture fragment there, about two to three centimeters displaced. And the standard of care would be non-operative treatment for these, but we really don't have great literature. And we certainly see some people who show up with symptomatic non-unions, and that's a much harder surgery. So it's an evolving discussion. We have some prospective research we're trying to do on this, as well as a retrospective study. Those less than a centimeter displaced really should be left alone. But the more displaced I would say probably depends on the athlete and the family's kind of risk tolerance. Because while the majority treated non-op that are completely displaced or significantly displaced probably do well, it's not been studied well enough to know what that rate is of the people that are going to need to come back and have a surgery for their non-union. So this family, this is the normal side. So we kind of wanted to understand the anatomy before placing these two screws and treat it like a proximal hamstring repair in terms of rehab. So he healed in about six weeks and got back to sports. So here's an example on the left side of this x-ray. So his right ischial tuberosity also evolves, but you can barely see it. So it got missed. And then three months later, this is what he had. Obviously this is a bone-forming apophysis. So HO develops in that spot. So that's a harder problem to treat. He was quite symptomatic with pain and weakness three months out. Trying to get back to sports and unable. So we actually shelled out this fragment and just repaired his tendon with the high-strength suture anchors. So that's a good option with the larger fragments that may be more difficult to anatomically fix or reduce. So in summary, the safety of youth football appears to be improving, which is the best news of the day. Flag football may not be any safer, including concussion risks. In the younger athlete, those younger youth athletes is really much lower. And the rate of severe injuries is quite low. But concussion is associated with more time lost. Overall, the knees, the most affected joint with injury in youth football. For quarterbacks, it's the shoulder. But running backs and quarterbacks are more common to have injuries than linemen in other positions. Fractures are more common in the younger children. So we see these unique variants of the growing skeleton and so quite different than their skeletally mature counterparts. So understanding those idiosyncratic injuries is important for avoiding delays in diagnosis and then potentially intervening with people familiar with working around the feces and apophases. So thanks very much. Thank you.

youth American football injuries

NEISS database

fractures

concussion risks

timely diagnosis