Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine), 4th Ed.

CHAPTER 29. Orthopedic Injuries

Greg Canty

HIGH-YIELD FACTS

• Fractures account for 10% to 15% of all childhood injuries.

• Fractures may be more common than sprains, ligamentous injuries, due to the relative weakness of the physis, or growth plate.

• Injuries to the physis may lead to long-term growth abnormalities or growth arrest.

• Radiographs are more difficult to interpret in children than in adults, as the physis is radiolucent and there are secondary ossification centers.

• The majority (75%) of physis fractures are Salter II fractures.

• Up to 50% of fractures in children younger than 1 year may be due to nonaccidental trauma.

Orthopedic and sports-related injuries are one of the most common reasons for pediatric visits to the emergency department (ED). Approximately half of all children will fracture at least one bone during childhood, and it is estimated that up to 25% of children sustain an injury every year.1 Youth sports participation at earlier ages has been accompanied by a growing number of sports injuries. Studies suggest most of these injuries are related to falls, recreation, sports, or motor vehicle accidents, but the emergency physician should never forget to consider nonaccidental trauma. The diagnosis of pediatric orthopedic injuries is challenging because of growth plates and the difficulty of interpreting pediatric x-rays. The fractures most often missed during an ED visit are those involving the phalanges and metatarsals.2 With a better understanding of the growing skeleton, clinicians can improve the accuracy of their diagnoses leading to more optimal management, fewer complications, and better outcomes.3

THE IMMATURE AND GROWING SKELETON

The immature skeleton has many special characteristics to appreciate when comparing it to mature, adult bone. First, the growing bone is more porous and flexible which can lead to unique fracture patterns such as greenstick, torus (buckle), and bowing (plastic deformation). This allows the young skeleton to bend much further and absorb more force before a fracture occurs. The porous character of growing bone is why there is less comminution and propagation of fractures as seen in adult fractures.4

The growing bone is surrounded by a thick, active periosteum. It is not easily torn or stripped away when bones are fractured, so less displacement usually occurs. The periosteum can aid as a hinge during fracture reduction. This active periosteum is the primary reason fractures remodel so well and heal so rapidly in children making nonunion a rarity.

The most noticeable characteristic on radiographs of children is the presence of the radiolucent physis, or growth plate. It is radiolucent cartilage which gradually ossifies throughout childhood and adolescence. Clinicians must understand and recognize each bony region in addition to the physis when assessing orthopedic injuries (Fig. 29-1).

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FIGURE 29-1. Illustrations of the humerus and femur demonstrating specific features of the immature skeleton.

The growing bone begins at the joint surface with the epiphysis and is completely cartilaginous at birth (except for the distal femur) and begins to ossify at various stages during bone development making it visible on radiographs. Portions of the cartilaginous epiphysis can fracture with very little, or no, radiographic evidence of fracture if ossification has not begun. When radiographs do reveal a fracture involving the epiphysis, it is important to remember that a much larger, radiolucent piece of cartilage may be attached. The most common sites for cartilaginous injuries are the distal femur, the patella, the distal humerus, and the radial head.

Next to the epiphysis sits the actual growth plate, or “physis.” The physis is a thin layer of radiolucent, growing cartilage that leads to longitudinal growth of the bone. The physis is situated just between the epiphysis and the metaphysis and is considered the weakest part of the growing bone, weaker than the surrounding ligamentous attachments. Because of this weakness, the same injury mechanism leading to adult sprains will often cause a physeal fracture in children. In adolescents, the physis may be closing which also leads to altered forces across the joint. Always consider the stage of physeal closure when assessing injuries near a growth plate!

The metaphysis is the flare lying just between the growing physis and the long shaft of the bone known as the diaphysis. The metaphysis is frequently the site of fractures including the torus, or buckle fracture. The diaphysis is less commonly injured, but may be associated with transverse and oblique fracture patterns.

TERMINOLOGY

The best way to communicate meaningfully with orthopedic consultants is to know the “language of orthopedics” (Table 29-1). When describing an injury, it is important to use the precise anatomic location and morphology of a given fracture. A good rule of thumb when describing any injury is to start with the age, gender, mechanism, location, and degree of soft-tissue damage and finish with an excellent radiographic description of the injury. If the physis is involved, use the Salter–Harris or Ogden classification systems described in Figure 29-2.5

TABLE 29-1

Fracture Terminology

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FIGURE 29-2. Examples of physis injuries classified by Salter–Harris (I–V) and Ogden (VI and VII).

FRACTURES INVOLVING THE PHYSIS

Just over 20% of all fractures in children involve a physis, or growth plate. When recognized and treated properly, most of these heal well. Be aware of the increased risk for complications including growth arrest, overgrowth, and malunion. Salter and Harris developed a practical classification system in 1963 that continues to be widely used today (Table 29-2 and Fig. 29-2). The Salter–Harris (SH) classifications depend upon the amount of radiographic involvement seen in the physis, epiphysis, and metaphysis. The SH classifications carry both therapeutic and prognostic implications. Other classification systems such as the Ogden (Table 29-2 and Fig. 29-2) have been developed, but none are as widely used.

TABLE 29-2

Classification and Overview of Physis Injuries

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Most fractures involving a physis are either SH I or II, and managed with closed reduction. SH III and IV fractures involve both the physis and the articular surface, which usually require surgical fixation for optimal outcomes. SH III and IV fractures also result in more growth disturbances, but any fracture of the physis can result in growth deformities. The SH V classification involves a crush injury to the physis and is difficult to appreciate on initial radiographs. The SH V fracture often goes unrecognized until growth arrest occurs. Any suspected fracture of the physis warrants close follow-up due to the increased risk of complications.

CLINICAL EVALUATION

The initial evaluation begins with ensuring that the patient is stable from other life-threatening injuries, so life-threatening injuries must be addressed first. The evaluation in the pediatric patient can be complicated by pain, fear, and the developmental stage of the child. These issues are best overcome with proper pain control, reassurance, gaining the child’s confidence.

The history should be obtained from the patient with assistance from the family and any other witnesses. Any information about the timing of the event, surrounding circumstances, mechanism of injury, direction of force, and previous injuries is helpful. Any incompatibility between the history and the injury should raise concern for possible child abuse.

The physical examination begins with exposing the injured extremity and grossly assessing for any deformity or discoloration. Most experts then recommend examining the uninjured extremity closely to establish a baseline before moving to the injured extremity. The injured extremity should be examined closely for any swelling, deformity, or breaks in the skin suggestive of an open fracture. Joints above and below the injury are palpated for tenderness and taken through a range of motion. Any abnormalities should be noted and appropriate radiographs ordered. Distal neurologic and vascular assessments should be thorough and reassessed throughout the visit. Any suggestion of compartment syndrome, like pain out of proportion to examination, or signs of neurovascular compromise warrant emergent orthopedic consultation.

Appropriate radiographs begin with at least two views (AP and lateral) of the injury that are perpendicular to one another. Views of the joints proximal and distal to the injury may also be helpful. Oblique radiographs of the injury are helpful in many situations, and always when suspicions persist despite initially negative radiographs. Comparison views of the uninjured extremity are another option to consider in young patients with a radiolucent physis and questions about injury versus normal variants. More liberal use of radiographs is common in pediatrics because of the subtle x-ray findings and challenging examinations. Inadequate views should never be accepted.

MANAGEMENT

Management of orthopedic injuries in the ED starts with pain control for patient comfort and optimal evaluation. Once pain control is established and the clinical evaluation is complete, management decisions center around whether operative or nonoperative care is necessary to stabilize the fracture (Fig. 29-3). Traditionally, most pediatric fractures have been managed by conservative, nonoperative means due to their tremendous ability to remodel and heal. Most are managed by closed reduction, if necessary, and then sent home with appropriate immobilization. Operative repair is necessary in some situations, and consultation with an orthopedist is always recommended for Salter–Harris III and IV fractures, most tibia fractures, all femur fractures, supracondylar fractures, and any fracture with significant displacement. Emergent orthopedic consultation is required if there are any signs of neurovascular compromise, compartment syndrome, or the possibility of an open fracture. When present, compartment syndrome is limb-threatening and most often occurs in the forearm and lower leg. Early symptoms include pain out of proportion to the injury or extreme pain with passive range of motion. Do not wait for late signs such as pallor, pulselessness, and paresthesias before consulting orthopedics. Open fractures need irrigation, antibiotics, and appropriate tetanus prophylaxis in the ED while awaiting orthopedic consultation.

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FIGURE 29-3. Algorithm for the management of physis injuries in children.

The hallmarks of nonsurgical fracture care are closed reduction and immobilization. Closed reduction is necessary for significantly displaced or angulated fractures. Reduction is often performed by orthopedists, but can also be performed by appropriately trained emergency physicians in many hospitals. The use of procedural sedation is strongly recommended for any attempts at fracture reduction.

Once a fracture has been reduced, or if it was initially nondisplaced, the fracture is immobilized. Immobilization offers protection, decreases the risk for any further displacement, and improves patient comfort. The most common types of immobilization involve plaster, fiberglass or commercial splints. Casts are avoided by many in the ED because of the risks associated with progressive swelling in acute injuries. The types of splints differ in the degree of molding allowed, the ease of application, and the ability to properly immobilize the injury. A sling and swathe provide immobilization for injuries of the clavicle, shoulder, and humerus. For supracondylar, elbow, forearm, and wrist injuries, a posterior long-arm splint with the elbow at 90 degrees and the hand in neutral works well. An ulnar gutter splint best immobilizes fractures of the fourth and fifth metacarpals. The scaphoid and thumb are immobilized with a thumb spica splint. Fractures to the distal femur, knee, and majority of the tibia require a long-leg posterior splint. Ankle and foot injuries can usually be immobilized in a posterior short-leg splint. When in doubt, always immobilize the joint proximal and distal to the injury.

The final step in caring for orthopedic injuries is to remember proper discharge instructions, and their importance cannot be overemphasized. Discharge instructions need to include information on splint/cast care, indications for returning to the ED, specific follow-up plans, and outpatient pain management. Elevation and ice are important to control pain and decrease swelling. Returning to the ED is emphasized for specific findings such as changes in extremity color, severe swelling, or a marked increase in pain. Follow-up plans should be clear and within 1 week due to the rapid rate of healing in children. Outpatient pain control is also very important and should not be overlooked in children. Fractures and significant injuries need pain control to last until their orthopedic follow-up. Proper discharge instructions result in optimal patient care and fewer unnecessary returns to the ED.6

image NONACCIDENTAL FRACTURES

Nonaccidental trauma is a major concern in pediatrics, and one that often presents with an orthopedic injury. About 25% to 50% of abused children will have some type of fracture. Before 1 year of age, one out of every three fractures is nonaccidental, and before 18 months of age, it is one out of every nine fractures.7 The younger the patient with a fracture, the higher the suspicion should be for possible abuse (Table 29-3). Recent evidence shows the most common fracture with abuse is the routine transverse fracture (Fig. 29-4).10 The biggest clue is not the fracture type, but the inconsistent history. Any history that appears inconsistent with the type or degree of injury or the child’s developmental stage should raise concerns about possible abuse. The law in all 50 states requires physicians to report any concerns about nonaccidental trauma to the proper authorities for further investigation. Any suspicion of nonaccidental trauma in young children requires a skeletal survey and hospital admission for further evaluation. The skeletal survey should include the long bones of the skeleton along with the hands, feet, spine, and pelvis. Significant numbers of occult fractures can be missed if all views are not included.8

TABLE 29-3

Radiographic Findings Suggestive of Nonaccidental Trauma

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FIGURE 29-4. These are rare fractures which are often referred to as classics in nonaccidental trauma. A. Illustrates a “bucket-handle” fracture of the distal tibia. B. Illustrates a “corner” fracture of the distal femur. C. Illustrates a lumbar fracture of L-2.

image FRACTURES FROM BIRTH TRAUMA

Fractures seen within the first few weeks of life may be due to birth trauma. Many of these fractures are found accidentally on chest x-rays, in evaluations for not moving an extremity, or due to parental concerns about a “bump.” The most common fracture from birth trauma involves the clavicle, but fractures of the femur and humerus are not uncommon. Healing from birth injuries is rapid, and callus should be seen within 2 weeks of delivery. A lack of callus formation within this time line or an absent history of traumatic delivery requires closer investigation for possible nonaccidental trauma.

image PEDIATRIC SPORTS INJURIES

Over half of all children and adolescents participate in organized sports and many more participate in less-organized individual sports such as skateboarding, bicycling, and “extreme sports.” Previous data indicate more than 20% of all pediatric injury–related visits are sports-related. These injuries include fractures, dislocations, contusions, sprains, strains, lacerations, and other injuries quite familiar to the ED physician.1113 A number of sports-related musculoskeletal injuries are discussed below, but also remember many sports-related injuries may involve multi-system injuries (abdominal trauma, concussion, dental injury, etc.) and are discussed elsewhere in this textbook.

Fractures are extremely common in youth sports. A recent study shows 10% of high school sports injuries involve a fracture and is even greater in the younger athlete.14As the growth plate begins to close during adolescence, both fractures and sprains may occur depending upon the forces involved. Adolescents are more prone to unique fracture patterns like the SH III and IV which often involve a partially closed physis. Keep in mind the stage of the growing skeleton when evaluating sports injuries, and remember “the younger the athlete, the more likely it’s a fracture!”15

image AVULSIONS

Avulsion fractures are fairly unique to adolescents and most commonly occur in sporting activities. These injuries occur when a stronger tendon from a large muscle group adheres to a weaker area of bone called a secondary ossification centers or apophysis. When a strong muscular contraction occurs, this tendon actually “pulls” the apophysis off from the larger piece of bone. The most common site for avulsion fractures is the pelvis at either the iliac crest, anterior inferior iliac spine (AIIS), anterior superior iliac spine (ASIS), or the ischium (Fig. 29-5). Avulsions are occasionally seen at the tibial tubercle, greater and lesser trochanters, and phalanges. A unique avulsion of the knee is the tibial spine (eminence) avulsion which occurs following hyperextension. Management of avulsion fractures is usually nonoperative, but surgical repair may be necessary if there is a significant avulsion or intra-articular displacement. Most pelvic avulsion fractures are managed with crutches and non–weight-bearing for 4 to 6 weeks.16

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FIGURE 29-5. A 13-year-old girl who presented to the ED because of inability to bear weight after feeling a “pop” while doing the splits during gymnastics. Radiographs revealed an avulsion of her ischium.

DISLOCATIONS

Dislocations are rare before adolescence, but the combination of sporting activities and increasing physical maturity leads to the increased risk of joint dislocations in the adolescent age group. The most commonly dislocated joints are the proximal interphalangeal joint (PIP) of the hand, the patellofemoral joint of the knee, and the glenohumeral joint of the shoulder. Other dislocations such as the hip are rare, but interestingly, the mechanism is frequently sports or low-energy mechanisms when they occur.17

Evaluation of suspected dislocations starts with pain control using narcotics or regional anesthesia. If time allows, prereduction radiographs can be taken in a timely manner. Reductions of larger joints, such as the glenohumeral or patellofemoral, may be better achieved using some form of procedural sedation or a regional anesthesia block. Recent studies in adult shoulder dislocations show no significant difference between intra-articular lidocaine and intravenous analgesia when comparing success rates, pain, or reduction failures, and intra-articular may be less expensive, have fewer side effects, and a shorter recovery time.18

Emergency providers should be familiar with multiple techniques for reduction and should emphasize the gentlest methods possible to prevent further injury.19 Following reduction, all dislocations require careful neurovascular examination and postreduction radiographs to look for osteochondral injuries. Common sites for osteochondral injuries include the glenoid rim (Bankart), proximal humerus (Hill–Sachs), patella, and femoral condyle. Once radiographs confirm adequate reduction, all dislocations need immobilization with follow-up arranged for 3 to 5 days. Patients should be cautioned about the risk for recurrent dislocations.20,21

SPRAINS AND LIGAMENTOUS INJURIES

The incidence of sprains (ligamentous injuries) increases as athletes mature during adolescence. Beware of the preadolescent with a “sprain” due to the higher risk of a fracture. The sprained ankle is the most common sporting injury of adolescents, and 90% involve the ligaments of the lateral ankle, specifically the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). It is important to palpate and stress each ligament during the ankle examination to determine whether the injury is bony or ligamentous. The “high ankle sprain” or syndesmosis sprain also occurs but produces more anterior pain in the tibiofibular space. A number of clinical decision rules have been developed for determining which ankle injuries need radiographs, and studies suggest these rules are very effective for the school-age child and older.22

Anterior cruciate ligament (ACL) injuries are increasing due to the increased number of young athletes in competitive sports, the increased number of female athletes, and better recognition of the injury. ACL injuries usually present to the ED as an acute traumatic knee effusion following a hyperextension or valgus mechanism which frequently does not involve contact. There is no indication for emergent MRI of these injuries in the ED, but close follow-up of any acute traumatic knee effusion is necessary. Initial management is temporary protection with a knee extension immobilizer, compression bandage, gentle range of motion, crutches, and follow-up with a sports medicine physician.

Ligamentous injuries, or sprains, are graded from I to III (Table 29-4). Most grade I and II sprains can be managed with protection and weight-bearing as tolerated. Grade III sprains require more stringent immobilization and non–weight-bearing. Follow-up, rehabilitation, and range-of-motion exercises should always be emphasized with ligamentous injuries during discharge.23

TABLE 29-4

Grading of Ligamentous Injuries

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OVERUSE SYNDROMES

Overuse syndromes in the young athlete are becoming epidemic due to year-round training, repetitive activities, overtraining, and improper conditioning. ED physicians must be familiar with these syndromes because 2.6 million ED visits occur each year for sports-related injuries, and many of these patients will have acute worsening of a more chronic condition.24 One of the keys to diagnosing overuse syndromes is inquiring about any previous history of pain in the injured extremity, the type of sport(s) played, and the amount of practice and number of events. Stress fractures are an example of an overuse syndrome. The most common stress fracture involves point tenderness along the proximal to middle third of the anterior tibia, but stress fractures also appear in the metatarsals, femur, and humerus. ED physicians should also be aware of spondylolysis, which is a stress fracture of the pars interarticularis in the lumbar spine, as it is a common cause of lumbar back pain in young athletes. Back pain from spondylolysis usually worsens with back extension. Repetitive motions can also lead to epiphysiolysis injuries like “Little League” shoulder. Epiphysiolysis occurs with repetitive overhead-throwing motions causing irritation of the growth plate and shoulder pain in baseball pitchers or overhead throwers. “Little League” elbow is a similar constellation of elbow pain and medial epicondyle tenderness from the repetitive stress of throwing. Other common overuse syndromes of the lower extremity include Osgood–Schlatter disease (tenderness over tibial tubercle), Sinding–Larsen–Johansson syndrome (″jumper’s knee” with tenderness at the distal pole of the patella), patellofemoral pain syndrome, and medial tibial stress syndrome (″shin splints” with diffuse tenderness over the middle to distal third of the medial tibia). Overuse syndromes are best managed by discontinuing the offending sports/activities and encouraging proper rehabilitation before resuming activities.

RETURN TO PLAY

Many athletes and their families are immediately interested in the ED about when an athlete can return to play following sports injuries. This is a conversation that cannot be properly answered in the ED with an acute injury, and its implications should be understood by all. In order to return to play following a musculoskeletal injury, an athlete must be able to meet certain criteria for range of motion, functional ability, adequate strength, and minimal to no pain. Proper follow-up and rehabilitation should be emphasized to the family during their ED visit.25

REFERENCES

1. Vitale M. Epidemiology of fractures in children. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:3.

2. Mounts J, Clingenpeel J, McGuire E, et al. Most frequently missed fractures in the emergency department. Clin Pediatr. 2011;50(3):183.

3. Mathison DJ, Agrawal D. An update on the epidemiology of pediatric fractures. Ped Emerg Care. 2010;26(8):594.

4. Xian CJ, Foster BK. The biologic aspects of children’s fractures. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:18.

5. Wenger DR. Orthopedic literacy: fracture description and resource utilization. In: Wenger DR, Pring ME, eds. Rang’s Children’s Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:27–40.

6. Bachman D, Santora S. Musculoskeletal trauma. In: Fleisher GR, Ludwig S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1335.

7. Fassier A, Gaucherand P, Kohler R. Fractures in children younger than 18 months. Orthop Traumatol Surg Res. 2013;99(1 suppl):S160–S170.

8. Lindberg DM, Harper NS, Laskey AL, et al. Prevalence of abusive fractures of the hand, feet, spine, or pelvis on skeletal survey: perhaps “uncommon” is more common than suggested. Ped Emerg Care. 2013;29(1):26.

9. Coffey C, Haley K, Hayes J, et al. The risk of child abuse in infants and toddlers with lower extremity injuries. J Pediatr Surg. 2005;40:120–123.

10. King J, Dietendorf D, Apthorp J, et al. Analysis of 429 fractures in 189 battered children. J Pediatr Orthop. 1988;8:585–589.

11. Jenny C, American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluating infants and young children with multiple fractures. Pediatrics. 2006;118:1299–1303.

12. Centers for Disease Control and Prevention (CDC). Non-fatal sports and recreational injuries treated in emergency departments—United States, July 2000–2001. MMWR Morb Mortal Wkly Rep. 2002;51(33):736–740.

13. Simon TD, Bublitz C, Hambidge SJ. Emergency department visits among pediatric patients for sports-related injury. Pediatr Emerg Care. 2006;2(5):309–315.

14. Swenson DM, Henke NM, Collins CL, et al. Epidemiology of United states high school sports-related fractures, 2008-09 to 2010-11. Am J Sports Med. 2012;40(9):2078.

15. Wenger DR, Pring ME, eds. Rang’s Children’s Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:11–26.

16. Sanders TG, Zlatkin MB. Avulsion injuries of the pelvis. Semin Musculoskelet Radiol. 2008;12(1):42.

17. Kovacevic D, Mariscalco M, Goodwin RC. Injuries about the hip in the adolescent athlete. Sports Med Arthrosc Rev. 2011;19(1):64.

18. Wakai A, O’Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane Database Syst Rev. 2011, Issue 4.

19. Johnson FC, Okada PJ. Reduction of common joint dislocations and subluxations. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins. 2008:962.

20. LaBella CR. Common acute sports-related lower extremity injuries in children and adolescents. Clin Pediatr Emerg Med. 2007;8:31–42.

21. Benjamin HJ, Hang BT. Common acute upper extremity injuries in sports. Clin Pediatr Emerg Med. 2007;8:15–30.

22. Gravel J, Hedrei P, Grimard G, et al. Prospective validation and head-to-head comparison of 3 ankle rules in a pediatric population. Ann Emerg Med. 2009;54(4):534.

23. Chorley JN. Ankle sprain discharge instructions from the emergency department. Pediatr Emerg Care. 2005;21:498–501.

24. Soprano JV, Fuchs SM. Common overuse injuries in the pediatric and adolescent athlete. Clin Ped Emerg Med. 2007;8:7.

25. Gregory AJ. Return to Play Issues. Paper presented at: American Academy of Pediatrics Sports Medicine Course; June 22, 2008; Vancouver, Canada.