Faculty Bibliography

Background: Female hockey players have rates of sports-related concussion that are similar to male hockey players at various levels of play, despite differences in the rules that do not allow for body checking in the women's game. One proposed hypothesis is that females are more likely than their male counterparts to report concussion symptoms to a coach or medical professional. At the elite level, there are limited data regarding concussion rates and concussion symptom reporting.
Purpose(s): The purpose of this study was to determine the incidence of concussion and concussion symptom reporting in professional women's ice hockey players.
Method(s): An anonymous survey was given to players of two National Women's Hockey League (NWHL) teams at the time of their 2018-2019 end-of-season physicals. Players reported on the number of concussions in their career diagnosed by a physician, the number of times they have had concussion symptoms, how many times they continued playing after experiencing concussion symptoms, how many times they never told a medical professional or coach after having symptoms, and how many times they eventually disclosed their symptoms.
Result(s): Fifty-four players anonymously completed the survey. Thirty-one(57%) of respondents reported at least one concussion diagnosed during their playing career, with 16(30%) reporting 2 or more diagnosed concussions. Thirty-six(67%) players reported experiencing concussion symptoms at least once, with 26(48%) reporting 2 or more occurrences of such symptoms. Of these players, 68% reported that they continued playing at least once after experiencing concussion symptoms. 36% of those players reported that they never told anyone about these symptoms on at least one occasion. Forty-four(81%) players either agreed or strongly agreed with the statement "I'm more likely to report concussion symptoms knowing what I know now."
Conclusion(s): There is a high incidence of sport related concussions in women's professional ice hockey players as well as an alarming rate of symptom non-reporting. More than half of players experience at least one concussion during their career, with more than two-thirds of these continuing to play despite having concussion-relatedsymptoms and more than one-third of these never reporting the concussion symptoms at all. Additional research is needed to determine the reasons for the high rates of concussion in women's ice hockey players despite the no-checking policy; the motivation for not disclosing concussion symptoms when they occur; and the effects that concussion education has had on changing symptom reporting behaviors for ice hockey players at the elite level

Background Recent studies have demonstrated a high prevalence of femoroacetabular impingement (FAI) in elite men's ice hockey players, yet little is known about the hips of elite women's ice hockey players. Purpose The primary purpose of this study was to determine the prevalence of radiographic cam-type FAI in professional women's ice hockey players in the National Women's Hockey League (NWHL). The secondary purpose was to analyze the relationship between the presence of cam deformity and both hip range-of-motion (ROM) and age of menarche. Methods Clinical, radiographic and demographic data were collected during player preparticipation physicals. ROM measurements were performed with a goniometer. Alpha angles were measured on 45degree Dunn radiographs, with alpha angles >55degree defined as campositive (Figure 1). Measurements were performed 3 separate times by 4 investigators. One-way ANOVA, independent means t-test and Pearson correlation coefficients were calculated, with statistical significance set at p<0.05. Results Twenty-six female athletes were included. Average menarchal age was 13.8 +/-1.5 years. 24 (92%) had alpha angles >55degree; 20 (77%) had bilateral cam deformity. Inter-rater reliability was excellent at 0.86. Intra-rater reliability was also excellent, with mean ICC=0.87 (range= 0.82-0.90 for each rater). There was a significant positive association between age of menarche and alpha angle (p<0.02, Figure 2). There was no association between alpha angle and hip ROM. Conclusion Elite female ice hockey players have a higher prevalence of cam morphology than the general population. The positive association between alpha angle and age of menarche supports the etiological hypothesis of the cam lesion resulting from activityrelated stress at the proximal femoral physis during a period of physiologic vulnerability. Professional women's ice hockey players have a high risk of developing cam morphology of the proximal femur, although each player's age of menarche may mediate her individual risk for cam lesion development.(Table Presented)

CASE/METHODS:Case 1 is a 6-month-old female who presented for evaluation of asymptomatic vertebral anomalies in the setting of jaundice and cardiac murmur; she was diagnosed with Alagille syndrome (AGS). Her spine has been monitored clinically. Case 2 is a 10-year-old female who sustained a pathologic femur fracture in the setting of known AGS, requiring operative stabilization and optimization of her bone mineral density. CONCLUSIONS:Pediatric orthopaedists care for children with AGS both in management of congenital musculoskeletal anomalies and in treatment of pathologic fractures. Familiarity with the current AGS literature is necessary for provision of optimal multidisciplinary care.

Peripheral neuropathies of the shoulder and upper extremity are uncommon injuries that may affect the young athletic population. When present, they can result in significant pain and functional impairment. The cause of peripheral neuropathy in young athletes may be an acute, traumatic injury such as a shoulder dislocation or a direct blow to the shoulder girdle. Alternatively, repetitive overuse with resultant compression or traction of a nerve over time may also result in neuropathy; overhead athletes and throwers may be particularly susceptible to this mechanism of nerve injury. Regardless of etiology, young athletes typically present with activity-related pain, paresthesias, and dysfunction of the affected upper extremity. In addition to physical examination, diagnostic studies such as radiographs and magnetic resonance imaging (MRI) are commonly performed as part of an initial evaluation and electrodiagnostic studies may be used to confirm the diagnosis of peripheral neuropathy. Electrodiagnostic studies may consist of electromyography (EMG), which evaluates the electrical activity produced by skeletal muscles, and/or a nerve conduction study (NCS), which evaluates a nerve's ability to transmit an electrical signal. Although data are not robust, clinical outcomes for young patients with activity-related peripheral neuropathies of the shoulder are generally good, with most young athletes reporting both symptomatic and functional improvement after treatment.

Objectives: Participation rates in women's ice hockey is increasing in North America. Recent studies have demonstrated an increased prevalence of femoroacetabular impingement (FAI) in elite male ice hockey players, yet little is known about hip pathology of players in the National Women's Hockey League (NWHL). The primary purpose of this study was to determine the prevalence of radiographic FAI in women's professional ice hockey players. The secondary purpose was to analyze the relationship between the presence of radiographic cam deformity and hip ROM, clinical impingement signs and age of menarche.
Method(s): In this IRB-approved study, physical examination and demographic data were prospectively collected for 27 NWHL players. Alpha angles were measured on 45-degree Dunn views with an alpha angle >55degree defined as cam-positive. Pearson correlations were performed to analyze the relationship between alpha angle and ROM measurements, clinical impingement signs and self-reported age of menarche. Players were grouped into those with and without cam impingement and group differences were assessed using the student's t-test. Statistical significance was set at p<0.05.
Result(s): Twenty-seven athletes were included in the study. Nineteen of the 27 players (70%) had radiologic evidence of cam-type impingement with alpha angle >55 degrees; 14 players (52%) had bilateral cam deformity. The average age of menarche was 13.9+/-1.5 years. There was a significant association between age of menarche and right alpha angle (R=0.57, CI [0.16, 0.81], p=0.011), as well as age of menarche and left alpha angle (R=0.48, CI [0.03, 0.77], p=0.039). There was no statistically significant association between alpha angle and any ROM measurement. Additionally, there was no difference in the incidence of clinical impingement for players with or without an alpha angle >55degree.
Conclusion(s): This study suggests that elite female ice hockey players have a significantly higher prevalence of cam-type morphology than the general population. The clinical significance of this radiographic finding is uncertain as the majority of these deformities seem to be asymptomatic. Interestingly, the positive association between alpha angle and age of menarche lends support to the etiological hypothesis that cam lesions are a result of activityrelated stress at the proximal femoral physis. This data suggests that players with earlier menarche (and therefore earlier physeal closure) seem to be less vulnerable to the development of cam deformity of the proximal femur

The Pediatric Orthopaedic Society of North America took actions to address the well-being of its members. The epidemic of physician burnout interferes with the delivery of high-quality care that our patients and families need and deserve, and at the same time places the care-providers at an increased risk of depression and suicide. The actions taken by Pediatric Orthopaedic Society of North America serve as a model for other professional medical societies to emulate.

Discoid meniscus is a rare anatomical variant with altered morphology and structure that can sometimes present symptomatically, typically in the pediatric population. The discoid meniscus is usually in the lateral compartment of the knee and is characterized by a partial or complete filling-in of central meniscal tissue, increased meniscal thickness, disorganization of longitudinal collagen fibers, and sometimes lack of peripheral attachments. These changes to both the macro- and micro-structure of the meniscus predispose affected patients to increased rates of both meniscal tears and mechanical symptoms. Surgical management of symptomatic discoid meniscus is directed toward symptom resolution while preserving sufficient functional meniscal tissue to delay or prevent the development of osteoarthritis. Modern surgical techniques consist of arthroscopic saucerization of the discoid meniscus with repair of associated meniscal tears and stabilization of peripheral attachments. Although long-term outcome data are lacking, short- and mid-term outcomes for patients treated with arthroscopic partial meniscectomy and meniscal repair and/or stabilization as needed are generally good.

Multiligamentous knee injuries occur rarely in the pediatric population. Few reports are available in the existing literature; furthermore, no longitudinal studies regarding the choice of treatment and long-term outcomes for this unique population have been published. To fill this knowledge gap, the literature on multiligamentous injuries of the knee in the adult population is commonly used as a guideline in clinical decision making for children and adolescents. However, the developing bone and physis are often weaker than the ligamentous structures of the knee-particularly during periods of rapid growth-and may be the first to fail in the event of injury or trauma. Bony avulsion fractures and peri-physeal fractures, rather than mid-substance ligamentous ruptures, may result. Patients with skeletal immaturity may therefore present with different patterns of multiligamentous injury after acute trauma to the knee. This article describes the clinical presentation, our treatment approach, and short-term outcomes for three pediatric patients with multiligamentous injuries of the knee and reviews the current literature relating to these uncommon injuries.

The patient's sex plays an important role in mediating the risk for, and experience of, disease. Injuries of the musculoskeletal system are no exception to this phenomenon. Increasing evidence shows that the incidence, clinical presentation, and treatment outcomes for male and female patients with common sports injuries may vary widely. Stress fracture, which is associated with the female athlete triad, is a sports injury with known sex-based differences. Other common sports-related injuries may also have distinct sex-based differences. Understanding these differences is important to optimize each patient's musculoskeletal care.