The hypertrophic zone continues to widen because of constant growth in the germinal and proliferative zones, the widening of the growth plate within the hypertrophic zone is usually temporary, as the resting and dividing cellular layers of the growth plate, and the attendant epiphyseal and. However, in some situations, this ischaemic condition may lead to osseous necrosis and deformity within the developing ossification centre and to growth irregularities in the physis. These changes may be localized and cause asymmetric growth, or they may involve the entire physis and result in an overall slowdown of the rate of growth or even complete cessation of growth. In either case, premature closure of some or all of the physis may occur (7). The most commonly reported physeal stress injuries have been those affecting the distal radial physes of young gymnasts. Almost all patients with stress related injury affecting the distal radius recover with rest, and do not experience premature physeal closure or abnormal growth.
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In type iv injuries, surgery is needed to restore the joint surface to normal and to perfectly align the growth plate. Type iv injuries have a poor prognosis unless the growth plate is completely and accurately realigned (8). The physis is involved in approximately 15 of all fractures in children (7). Many childhood misadventures, such as those incurred by falling off bicycles, skateboards, playground equipment, out of trees result in acute growth plate injuries. Hockey, football, baseball) accounted for.5 and recreational activities (e.g. Biking, skateboarding, skiing) for.7 of physeal injuries. Several studies reported that organized sports accounted for more physeal injuries than recreational activities (12, 26-29). Although American football is predominantly associated with acute physeal fractures, most other sports are also represented (12, 13, 30). Chronic physeal injury few can also appear as a result of sport training of sufficient duration and intensity and these pathological changes of the growth plate in extreme cases produce growth disturbance. This injury appears to occur through repetitive loading, which alters metaphyseal perfusion and in so doing interferes with the mineralization of the hypertrophied chondrocytes, which typically occurs in the zone of provisional calcification (7).
In type ii, the most common physeal injuries, the line of separation extends along the growth plate, then out through a portion of the metaphysis, producing a triangular shaped metaphyseal fragment sometimes referred to as the Thurston Holland sign. Type iii, which is intra-articular, extends from the joint surface to the weak zone of the growth plate and then extends along the plate to its periphery. In type iv, often involving the distal humerus, a fracture extends from the joint surface through the epiphysis, across the full thickness of the growth plate and through a portion of the metaphysis, thereby producing a complete split. In type v, a relatively uncommon injury, there is a compression of the growth plate, thereby extinguishing further growth (8). Prognosis for types essay i and ii fractures is good if the germinal cells remain with the epiphysis, and circulation is unchanged. However, these injury types are not as innocuous as originally believed, and can be associated with risk of growth impairment (7, 25). Type iii injuries have a good prognosis if the blood supply in the separated portion of the epiphysis is still intact and if the fracture is not displaced. Surgery is sometimes necessary to restore the joint surface to normal.
The fusion of end plates begins at the proposal age of 14 to 15 years and may be confused with fractures until it finishes at 21 to 25 years of age. If the end plate is damaged or changed, or partially apple fused, an increase in deformity may occur, especially during the rapid adolescent growth spurt. Aufdermaur's studies reported that fractures of the immature spine traverse the growth zone of the physis similar to long bone physeal fractures (23). Physeal closure and cessation of spinal growth result in decline of weak zone existence in the spine, therefore the failure occurs then through the bony vertebral body or the annulus fibrosus and the disc space. The immature intervertebral disc as more hydrophilic than the mature disc presents as more effective shock absorber between the vertebral bodies, which implies its marked resistance to injury (21). Sport related physeal and spinal injuries. Acute and chronic physeal injury, acute physeal injuries were classified by salter and Harris, whose classification system distinguishes 5 types of growth plate injury (24). Type i injuries show a complete separation of the epiphysis from the metaphysis without any bone fracture. The germinal cells of the growth plate remain with the epiphysis, and the calcified layer remains with the metaphysis.
At a risser stage 1, the iliac apophysis has not yet formed and the spine is immature. At a risser stage 4 the entire apophysis has formed but has not united with the pelvis. This stage corresponds to the end of spinal growth. In the immature spine the facet joints are more horizontal and incompletely ossified, which results in more spinal mobility. They achieve a mature configuration by 8 years of age, but the full, more oblique adult pattern is not seen until 15 years of age (21). The epidural sac ascends to its normal level opposite L1 in the spinal canal by 1 year of age and the spinal canal attains adult volume by 6 years of age (22). The physes of immature growing spine appear radiographically between 8 and 12 years of age when the vertebral apophyseal ossification begins to develop in the periphery of the cartilaginous end plates. Early in their development they appear as rings because they are thicker at the periphery than at the centre. The ring apophysis contributes to vertebral body breadth and the physeal portion contributes to the vertical height.
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A temporary disparity between muscle-tendon and bone lengths appears as a result of initial longitudinal growth in the long bones of the extremities and subsequent muscle-tendon units elongation. Application of excessive muscular stress may produce muscle-tendon imbalance and increase in susceptibility to injuries (18). It is claimed that the joint, and in particular the growth cartilage, as the weak link in this assembly, may increase the risk of injury at this site during the growth spurt (16). The vertebral column consists of the seven cervical vertebrae, the twelve thoracic vertebrae, and the five lumbar vertebrae, perched upon the sacrum and pelvis. The structure and function of each segment of the spine is specific to demands placed upon it anatomically and physiologically. The vertebrae of the neck have demands for both range of motion and structural integrity.
The majority of the 'overuse injuries' of the cervical spine are the result of a combination of discogenic and facet deterioration and arthrosis with secondary bony overgrowth and impingement. Impingement, as noted, is generally that of the exiting nerve roots, but sometimes a frank myelopathy may occur. Sport related injuries of the thoracic spine are relatively rare, and this is undoubtedly related to the structure and function of the thoracic spine, characterized by normal posterior angulation, or kyphus, which varies normally between 20 and 40 (19). Despite the sparseness of direct injury of thoracic spine elements from repetitive sport overuse, its indirect contribution to overuse injuries in both cervical and lumbar spine may occur. Major components of lumbar motion, as well as the concentration of relative stresses in the lumbar spine, occur near the base from the L3-L4 juncture through L5-S1. This in turn is reflected in the pattern of degenerative changes seen from repetitive activity report in the lumbar spine, where the alterations are localized mainly at the level of L5-S1, followed sequentially by L4-L5 and L3-L4 (20). The spine in the adolescent differs from that of an adult in numerous respects.
Fractures most commonly occur at the junction of calcified and uncalcified hypertrophic cells because it is structurally the weakest portion of the growth plate (7, 8). In the zone of cartilage "transformation the cartilaginous matrix is penetrated by metaphyseal vessels, which break down the transverse cartilaginous septa, allowing invasion of mature cell columns. The cartilage and the bone are remodelled, removed and replaced by a more mature, secondary spongiosa, eventually containing no remnants of the cartilaginous precursor (7, 8). Irreversible damage to the growing cells may be produced by physeal injuries, resulting in growth disturbance. Growth plate cartilage is both less resistant to stress than adult articular cartilage and less resistant than adjacent bone to shear and tension forces (9, 10).
Therefore, when disruptive forces are applied to an extremity, failure may occur through the physis. Research shows that the physis may be 2-5 times weaker than the surrounding fibrous tissue (11). For these reasons, injury mechanisms that in an adult may result in a complete tear of a ligament or in a joint dislocation may produce a separation of the growth plate in a child (8). The growth plate appears to be especially susceptible to injury during periods of rapid growth (7, 9, 12, 13). An increase in the rate of growth is accompanied by structural changes that result in a thicker and more fragile plate (14). Furthermore, bone mineralization may lag behind bone linear growth during the pubescent growth spurt, rendering the bone temporarily more porous and more subject to injury (15). Increased incidence of fractures during pubescence has been reported in human physeal injuries studies, with the peak fracture rate probably occurring at the time of peak height velocity (12, 14, 15). Presumption that the growth spurt may also increase susceptibility to growth plate injury by causing an increase in muscle-tendon tightness about the joints and an accompanying loss of flexibility remains controversial (16, 17).
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Longitudinal growth is accomplished by lined the proliferation of germinal cells in the "zone of 'growth". These cells are attached to the epiphysis and obtain their vascular supply from the epiphyseal artery. The zone of growth is the area of greatest concern with any fracture type involving the growth plate, as damage to cells in this zone may have long term consequences for normal growth patterns. The next functional area is the zone of cartilage maturation. Increased extracellular matrix is formed in this zone, primarily between columns. The extracellular matrix exhibits cell mediated biomechanical changes, then calcifies. The cells align in vertical columns as they hypertrophy and are eventually replaced by osteoblasts.
Two types of epiphyses are found in the extremities: traction and pressure. Traction epi-physes (or apophyses such as apophysis of the tibial tubercle, are located at the site disadvantages of attachment of major muscle tendons to bone and are subjected primarily to tensile forces. The apophyses contribute to bone shape but not to longitudinal growth (6 therefore, acute or chronic injuries affecting traction growth plates are not generally associated with disruption of longitudinal bone growth. Overuse apophyseal conditions, such as Osgood-Schlatter disease, sever's disease and medial epicondylopathy in the throwing arm are commonly found in young athletes. Whereas pressure epiphyses are situated at the end of long bones and are subjected to compressive forces. The epiphyses of the distal femur and proximal tibia provide examples. The growth plate or physis is located between the epiphysis and meta-physis and is the essential mechanism of endochondral ossification (7). In contrast with traction growth plates, injury to pressure epiphyses and their associated growth plates may result in growth disturbance.
for children, the safety and effectiveness of youth sport training are now well documented (1, 2). The significant concern is that the growing children's bones could be less resilient and less resistant to physical stresses than the adult ones (3). However low-back injury continues to be the greatest clinical concern, especially in weight lifters and power lifters. Individuals involved in strength training are at risk for both lumbar flexion- and torsion-related injuries (e.g., forward displacement of one vertebral body over another that leads to spondylolisthesis, herniated in-tervertebral disc, paraspinous muscle strain) and lumber extension-related injuries (e.g., facet syndrome, pars interarticularis stress fracture. However, there is no evidence that strength training is riskier than participation in youth sporting and recreational activities (4). Most of these injuries occur as the result of improper training, excessive loading, and lack of qualified adult supervision and could be avoided by proper sport training schedule (3, 5). To design and administer a sport training program appropriate for young children and adolescents, it is imperative to understand the unique anatomical and physiological nature of children spine and epiphyses. Anatomy and physiology of the bones and spine. The growing parts of the bone include the physis and the epiphysis.
An alarming finding is the growing number of reports of the stress related bones and spine injuries affecting young athletes that may result in significant growth disturbance and deformity. This article elucidates sport related osteoarticular alterations, possible risk injury factors and countermeasure recommendations for children and adolescents training. Key words: sport, children training, adolescents training, articular, vertebral column, bones. Introduction, the children's and youth participation in sports is widespread in modern culture. Many youngsters initiate year plan round training and specialization in particular sports at very early age. Increased involvement and difficulty of skills practiced at the early age and continuation throughout the period of growth with high level of intensity required to be competitive implies the concern about the risk and severity of injury for young athletes. Both the acute and chronic bones and spine injuries related to participation in sports have been reported but the information of their circumstances are limited. The growing number of stress related injuries concerns those affecting the extremities and spine. Although most injuries appeared to resolve with treatment and rest there is an evidence of growth disturbance and deformity.
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Physiology of back pain, approaching the essay patient with back pain 2 Normal spinal anatomy and physiology. The bony vertebrae, the intervertebral disc, the posterior facets. The spinal ligaments and muscles, the nerve roots and spinal cord 3 Spinal degeneration, the intervertebral disc, the facet joints, imaging of degenerative changes 4 Acute trauma, disc herniation. Compression fracture 5 Chronic pathological changes, spinal stenosis, muscle trauma, immobilization and atrophy 6 Spinal deformity. Spondylolysis, isthmic spondylolisthesis, degenerative spondylolisthesis, scoliosis, inflammatory diseases 7 Space-occupying and destructive lesions. Spinal tumors, spinal infections, arachnoiditis 8 Spinal surgery 9 Selected bibliography. Abstract, recent expansion of sport and strength training among children and adolescents inspire for special concern about possible risks associated with this phenomenon.