Top 10 Things to Know about Pediatric Fractures

Top 10 Things to Know about Pediatric Fractures

by | Oct 31, 2022 | Fractures

These are key messages from a lecture provided as part of a free, monthly education series offered for Medical Professionals. Gerad Montgomery, M.S.N., FNP-C, is a certified family nurse practitioner and director of the Scottish Rite for Children Orthopedics Fracture Clinic in Frisco, Texas.

Download the PDF.

Watch Top 10 Things to Know about Pediatric Fractures on-demand.

Alternatively, you can access the full pediatric fracture care lecture on our Medical Professionals playlist where he also addresses questions from the audience including these:

  • What are your thoughts on the use of X-rays or advanced imaging in an urgent care or outpatient setting before sending to a pediatric musculoskeletal expert?
  • Would you recommend putting in a hematoma block for pain control before referring to a specialist?
  • Do you have guidelines for return-to-sport or load management after fracture?
  • What do you tell parents that wonder if their child needs an X-ray?

#10 A Methodical Exam Is Your Best Tool 

Perform a methodical exam every time, the same way. It may not be easiest, but it is the best tool.

  • X-rays and history should augment a good step-by-step physical exam.
  • Age-appropriate exam may include the parent assisting to help maintain comfort.
  • Encourage pointing to the injured area with “one finger at one spot.”
  • Then, examine the contralateral side first.
  • Always examine the joint above and below.

#9 Don’t Miss Signs of a Non-accidental Trauma  

More than half of children who die from non-accidental trauma have a history of prior maltreatment. Know your resources and obligations. Listen closely to the story and vigilantly observe for signs and red flags such as:

  • Inconsistent history
  • Unwitnessed trauma
  • Fracture doesn’t match story (i.e., femur fracture in non-ambulatory child)
  • Multiple fractures in various stages of healing – skeletal survey
  • Skin stigmata – bruises, burns

#8 X-Ray Views Matter

Poor alignment during X-rays can cause you to miss a fracture. Despite the patient’s discomfort, it is important to insist on good alignment and at least two views.

Learning how to describe a fracture over the phone when you are discussing a referral. Terms to use include:

  • Open vs. closed
  • Proximal vs. distal
  • Angulated – apex volar vs. apex dorsal
  • Shortening
  • Displaced vs. non-displaced

# 7 Not All Fractures Require a Cast   

Don’t let the treatment be worse than the injury. In some cases, immobilization may not be necessary. Depending on the condition, an alternative to a cast, such as a boot or a splint, may provide appropriate immobilization and allow early motion and an easier option for treatment.

#6 Splints and Casts Are NOT Benign  

When a cast or splint is indicated, here are key messages for patient education to prevent complications like skin breakdown:

  • Elevate the extremity for the first three days after the splint/cast is applied.
  • Never place anything inside of the splint.
  • DO NOT attempt to remove and re-apply a splint without help from a health care provider.
  • Monitor for signs and symptoms of neurovascular compromise.
  • Teach them how to check this and what to do should an issue occur (cap refill, sensation changes, increasing pain, proper elevation)
  • DO NOT get your splint or cast wet. Call your health care provider immediately if it does.

#5 Pediatric Fracture Patterns

Know the pediatric bony anatomy and fracture patterns. Though complete fractures are possible with higher mechanism injuries, incomplete fractures are more common on the pediatric population.

An open physis may look to some like a fracture. Additionally, an open physis may also hide a fracture that you don’t want to miss. Any injury near the physis may benefit from an earlier referral to ensure no growth disturbance.

#4 Most Pediatric Fractures Can Be Managed Without Surgery   

The Pediatric Orthopaedic Society of North America (POSNA) states on its website, “The standard of care for the treatment of pediatric forearm fractures remains nonoperative treatment with closed reduction and casting. An acceptable functional outcome with closed treatment is the rule in a majority of fractures.”

Our pediatric fracture clinic sees hundreds of children with fractures each week. Very few of these children require operative care for their fractures. Staffed with pediatric-focused nurses, medical assistants and orthopedic cast technicians, our clinic also has full-time, certified child life specialists. They are experts at providing developmentally appropriate education and support before, during and after diagnosis, care and complex in-clinic procedures.

#3 Pediatric Bone Remodeling Is Remarkable   

Pediatric bone is structurally different than adult bone in the following ways:

  • Less dense/more porous
  • Increased elasticity
  • Tend to break in “patterns” (greenstick, torus/buckle, plastic deformation, complete, etc.)
  • Thick periosteum
  • Potential to remodel

These characteristics make remodeling “easy” in young patients. Fractures in these conditions have greater remodeling potential with:

  • Patient is younger in age
  • Fracture is closer to the physis
  • More growth remaining in the adjacent physis

Learn more about how Scottish Rite for Children is helping to define evidence-based care for treating clavicle fractures and how the outcomes in operative and nonoperative care are similar.

# 2 Not All Fractures Are an Emergency

Every fracture does not need to be treated in the emergency setting. This can save stress and use of expensive resources. A study of more than 200 cases has shown this can cause unnecessary anxiety and increased pain due to increased number of assessments before definitive care with pediatric orthopedic specialist.

Be familiar with your resources to manage and refer accordingly.

  • Safely immobilize with sling, boot or splint.
  • Provide crutches, when indicated

Educate the patient and family:

  • Pain control
  • Warning signs
  • Elevation
  • Immobilization and proper education
  • Appropriately timed referral to pediatric orthopedics

Examples of orthopedic emergencies that can’t wait include, but are not limited to:

  • Open fractures
  • Neurovascular concerns
  • Severe swelling
  • Severe clinical deformity
  • Slipped capital femoral epiphysis (SCFE)
  • Femur fractures
  • Pain uncontrolled with over-the-counter medications

#1 You Are Treating the Patient AND the Parents!

Majority of second opinions are requested to provide clarity, not necessarily a different treatment. Here are suggestions to optimize the conversations at the first visit:

  • Spend extra time with the family. This may reduce frustration and duration of subsequent visits.
  • Discuss expectations and timelines for both treatment and healing.
  • Map out what to expect at subsequent visits.
  • Identify and address questions or complications right away. Pediatric injuries are not always straightforward, and you must be able to explain things in ways that parents will understand and trust your diagnosis and treatment.

Montgomery emphasized the important role that patient and family education plays in pediatric fracture care. “If that family leaves your office and the family does not feel comfortable with your plan, you’ve lost,” he says. “We spend a lot of time with families to make them comfortable.”

Top 10 Things to Know about Pediatric Fractures

Top 10 Things to Know about Pediatric Fractures

by | Oct 31, 2022 | Fractures

These are key messages from a lecture provided as part of a free, monthly education series offered for Medical Professionals. Gerad Montgomery, M.S.N., FNP-C, is a certified family nurse practitioner and director of the Scottish Rite for Children Orthopedics Fracture Clinic in Frisco, Texas.

Download the PDF.
 
Watch Top 10 Things to Know about Pediatric Fractures on-demand.
 
Alternatively, you can access the full pediatric fracture care lecture on our Medical Professionals playlist where he also addresses questions from the audience including these:

  • What are your thoughts on the use of X-rays or advanced imaging in an urgent care or outpatient setting before sending to a pediatric musculoskeletal expert?
  • Would you recommend putting in a hematoma block for pain control before referring to a specialist?
  • Do you have guidelines for return-to-sport or load management after fracture?
  • What do you tell parents that wonder if their child needs an X-ray?

#10 A Methodical Exam Is Your Best Tool 

Perform a methodical exam every time, the same way. It may not be easiest, but it is the best tool.

  • X-rays and history should augment a good step-by-step physical exam.
  • Age-appropriate exam may include the parent assisting to help maintain comfort.
  • Encourage pointing to the injured area with “one finger at one spot.”
  • Then, examine the contralateral side first.
  • Always examine the joint above and below.

#9 Don’t Miss Signs of a Non-accidental Trauma  

More than half of children who die from non-accidental trauma have a history of prior maltreatment. Know your resources and obligations. Listen closely to the story and vigilantly observe for signs and red flags such as:

  • Inconsistent history
  • Unwitnessed trauma
  • Fracture doesn’t match story (i.e., femur fracture in non-ambulatory child)
  • Multiple fractures in various stages of healing – skeletal survey
  • Skin stigmata – bruises, burns

#8 X-Ray Views Matter

Poor alignment during X-rays can cause you to miss a fracture. Despite the patient’s discomfort, it is important to insist on good alignment and at least two views.
 
Learning how to describe a fracture over the phone when you are discussing a referral. Terms to use include:

  • Open vs. closed
  • Proximal vs. distal
  • Angulated – apex volar vs. apex dorsal
  • Shortening
  • Displaced vs. non-displaced

# 7 Not All Fractures Require a Cast   

Don’t let the treatment be worse than the injury. In some cases, immobilization may not be necessary. Depending on the condition, an alternative to a cast, such as a boot or a splint, may provide appropriate immobilization and allow early motion and an easier option for treatment.

#6 Splints and Casts Are NOT Benign  

When a cast or splint is indicated, here are key messages for patient education to prevent complications like skin breakdown:

  • Elevate the extremity for the first three days after the splint/cast is applied.
  • Never place anything inside of the splint.
  • DO NOT attempt to remove and re-apply a splint without help from a health care provider.
  • Monitor for signs and symptoms of neurovascular compromise.
  • Teach them how to check this and what to do should an issue occur (cap refill, sensation changes, increasing pain, proper elevation)
  • DO NOT get your splint or cast wet. Call your health care provider immediately if it does.

#5 Pediatric Fracture Patterns

Know the pediatric bony anatomy and fracture patterns. Though complete fractures are possible with higher mechanism injuries, incomplete fractures are more common on the pediatric population.
 
An open physis may look to some like a fracture. Additionally, an open physis may also hide a fracture that you don’t want to miss. Any injury near the physis may benefit from an earlier referral to ensure no growth disturbance.

#4 Most Pediatric Fractures Can Be Managed Without Surgery   

The Pediatric Orthopaedic Society of North America (POSNA) states on its website, “The standard of care for the treatment of pediatric forearm fractures remains nonoperative treatment with closed reduction and casting. An acceptable functional outcome with closed treatment is the rule in a majority of fractures.”
 
Our pediatric fracture clinic sees hundreds of children with fractures each week. Very few of these children require operative care for their fractures. Staffed with pediatric-focused nurses, medical assistants and orthopedic cast technicians, our clinic also has full-time, certified child life specialists. They are experts at providing developmentally appropriate education and support before, during and after diagnosis, care and complex in-clinic procedures.

#3 Pediatric Bone Remodeling Is Remarkable    

Pediatric bone is structurally different than adult bone in the following ways:

  • Less dense/more porous
  • Increased elasticity
  • Tend to break in “patterns” (greenstick, torus/buckle, plastic deformation, complete, etc.)
  • Thick periosteum
  • Potential to remodel

These characteristics make remodeling “easy” in young patients. Fractures in these conditions have greater remodeling potential with:

  • Patient is younger in age
  • Fracture is closer to the physis
  • More growth remaining in the adjacent physis

Learn more about how Scottish Rite for Children is helping to define evidence-based care for treating clavicle fractures and how the outcomes in operative and nonoperative care are similar.

# 2 Not All Fractures Are an Emergency

Every fracture does not need to be treated in the emergency setting. This can save stress and use of expensive resources. A study of more than 200 cases has shown this can cause unnecessary anxiety and increased pain due to increased number of assessments before definitive care with pediatric orthopedic specialist.
 
Be familiar with your resources to manage and refer accordingly.

  • Safely immobilize with sling, boot or splint.
  • Provide crutches, when indicated

Educate the patient and family:

  • Pain control
  • Warning signs
  • Elevation
  • Immobilization and proper education
  • Appropriately timed referral to pediatric orthopedics

Examples of orthopedic emergencies that can’t wait include, but are not limited to:

  • Open fractures
  • Neurovascular concerns
  • Severe swelling
  • Severe clinical deformity
  • Slipped capital femoral epiphysis (SCFE)
  • Femur fractures
  • Pain uncontrolled with over-the-counter medications

#1 You Are Treating the Patient AND the Parents!

Majority of second opinions are requested to provide clarity, not necessarily a different treatment. Here are suggestions to optimize the conversations at the first visit:

  • Spend extra time with the family. This may reduce frustration and duration of subsequent visits.
  • Discuss expectations and timelines for both treatment and healing.
  • Map out what to expect at subsequent visits.
  • Identify and address questions or complications right away. Pediatric injuries are not always straightforward, and you must be able to explain things in ways that parents will understand and trust your diagnosis and treatment. 

Montgomery emphasized the important role that patient and family education plays in pediatric fracture care. “If that family leaves your office and the family does not feel comfortable with your plan, you’ve lost,” he says. “We spend a lot of time with families to make them comfortable.”

Get to Know our Staff: Stephanie Forbis, Dyslexia

Get to Know our Staff: Stephanie Forbis, Dyslexia

by | Oct 28, 2022 | Spotlight

What is your job title/your role at Scottish Rite for Children? 
I am currently the center coordinator for the Luke Waites Center for Dyslexia and Learning Disorders. I started with Scottish Rite in 2006 as an assessment specialist, became the diagnostic services coordinator in 2013 and shifted to my current role in 2021. Each step has provided a whole new world of experiences!

What do you do on a daily basis or what sort of duties do you have at work?
My role is an interesting combination of clinical and administrative. I have some form of direct patient care each day, either providing patient learning assessments or conducting clinical consultations with patient families. I support the LWCDLD team with any problems that might need solving. In the context of my role, I have the opportunity to support many projects and presentations, which allows me to build relationships with folks in IT/Empower, Media, Communications, Engineering, Environmental Services, and HR. It’s exciting to meet people in other departments and have the ability to work alongside of them to meet a common goal. And, as with most administrative roles, I attend a lot of meetings!

What was your first job? What path did you take to get here or what led you to Scottish Rite? How long have you worked here?
My father is a Methodist minister. My very first “real” job was working on the daycare center at one of his churches. I knew from a very early age that I would form my career around children!
While in graduate school, I managed a 7-Eleven not far from my university campus. There was a very kind woman, Jeri McClendon, who would stop in almost every day for a Diet Coke and drop off cookies on all major holidays. One day, while visiting, she asked about my background, studies and hopes for the future. I told her I wanted to work with children and my dream job would be evaluating them for learning disorders and associated mental health challenges. Jeri, who was an assessment specialist in the Center for more than 20 years, insisted I apply for an opening. She supported me through the rigorous interview and hiring process and provided my initial training once hired. I firmly believe people are put into our lives to help shape our futures. Mrs. Jeri was definitely one of those for me!

What do you enjoy most about Scottish Rite?
I have been part of the Scottish Rite family for 16 years. While here, there have been many changes. One of the aspects that has remained the same is our mission. We support patients and their families with warmth and kindness. We strive to make challenges understandable and encourage hope while explaining next steps. Working alongside parents to change the trajectory of their child’s life is the most rewarding part of each day.

Tell us something about your job that others might not already know?
I quite literally learn something new every day. Between my interactions with colleagues, patients and families, I pick up a new skill, strategy, fact, concept, leadership technique, stress management tool, diagnosis or best way to write a challenging report at least once daily. Some days provide even more opportunity for growth and really get the neural connectivity flowing!

Where is the most interesting place you’ve been?
My husband and I spent our honeymoon in Rome. It was fascinating to take the subway, exit and be standing directly in front of the Colosseum or to walk through a rather modern neighborhood, turn a corner and spot the Pantheon. The architecture, history, culture (and rather reckless moped drivers!) were truly special.

What is your favorite game or sport to watch and play?
My daughter is a competitive artistic roller skater — think ice skating on wheels. I love to watch her passion for the sport and her teammates, as well as her drive to consistently improve. The athletes show off their gifts in a multitude of events that include both individual and group participation. During meets, they wear fabulous costumes and way too much makeup, which is my daughter’s favorite part. While she has not yet talked me into strapping on skates, I feel like part of the team!

If you could only eat one meal for the rest of your life, what would it be?
I’m a Tex-Mex girl! I could easily live off of chips and queso, fajitas and chalupas for breakfast, lunch and dinner.

What’s one fun fact about yourself?
I love to read! I have two books (one text, one audio) in progress at any given time. I am a fan of a variety of genres and love recommendations.

Osteochondritis Dissecans (OCD) in the Elbow

Osteochondritis Dissecans (OCD) in the Elbow

by | Oct 19, 2022 | Sports Medicine

Our Center for Excellence in Sports Medicine treats a wide array of sport-related injuries and conditions in young athletes. One common condition treated is osteochondritis dissecans (OCD) of the elbow. This condition can happen to anyone but is especially common in sports such as gymnastics, tumbling, and baseball.

“This condition often presents to us in very late stages because it develops without symptoms,” says pediatric orthopedic surgeon Philip L. Wilson, M.D. He advises athletes, particularly baseball players and those in weightbearing sports like gymnastics, not to ignore nagging elbow pain. “Painless loss of extension is another sign that should not be ignored,” he says. “Proper diagnosis and early treatment can make a real difference in the course of care and outcomes.”

Our pediatric sports medicine team is a national leader in caring for and studying elbow OCD in young athletes. “The more we learn about the condition and the athletes, the better we can be at treating elbow OCD and teaching others the best way to prevent and manage it,” Wilson says. Here are two examples of Scottish Rite’s work:

  • An ongoing study called SAFE is open to young athletes, including gymnasts and baseball players. This study is looking at movement mechanics and the causes of injuries in these populations. Check out this video about SAFE testing.

  • A study published in 2021, “Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes: Comparative Findings and Outcomes in Radial Head Stress Fractures and Capitellar Osteochondritis Dissecans,” specifically addressed findings in 58 elbows in gymnasts (average 11 years of age) treated at Scottish Rite for Children throughout a course of five years. This study was the first to describe the differences between OCD and radial head stress fractures.

Learn more about OCD of the elbow, its causes, symptoms, treatment, and prevention below.

What is osteochondritis dissecans of the elbow?
The surfaces of the bones inside joints are covered with a smooth, gliding surface called cartilage. Osteochondritis dissecans (OCD) is a condition in which an area of cartilage and the underlying bone begin to soften, crack, or even separate. If left untreated, OCD can cause further damage to the cartilage in the joint and early arthritis.
This is a rare condition that most often affects the knee, but it can also affect the elbow, hip or ankle. In the elbow, the surface on the end of the humerus, the capitellum, is the most affected. This is typically seen in active individuals ages 8 to 19, more often boys than girls.

How does elbow OCD occur?
There are likely several factors, and the exact cause is still unclear. A common cause is a temporary loss in blood supply to an area of bone in a growing child, often combined with repetitive joint impact (overuse). There may be a genetic cause as well. Athletes at risk also often have a history of early sport specialization and year-round training. Some may report a history of a minor injury, but this is likely not the cause of the OCD lesion.

What are the signs and symptoms of OCD in the elbow?
OCD may be present even if there are not symptoms. An asymptomatic OCD lesion, one that does not cause any symptoms, may be identified when evaluating another concern. Signs and symptoms vary and may include:

  • Pain that worsens with activity
  • Popping or clicking
  • Swelling
  • Fluid inside the joint
  • Catching or locking with movement
  • Limited motion

How is elbow OCD diagnosed?
Physical examination, history, and X-rays are used to diagnose OCD in the elbow. Advanced imaging, such as an MRI, is often necessary to fully assess the condition and determine treatment options.

How is elbow OCD treated?
Properly treating and managing osteochondritis dissecans in the elbow lowers the risk of long-term damage to the joint. With diagnosis and treatment in the early stages, tissues may heal with rest and limiting activities that cause pressure on the OCD lesion.

Athletes benefit from continued training while resting their elbows. It is important for our team to help them understand what activities are safe and will not cause further problems on the elbow. Examples of activities to continue while receiving treatment for elbow OCD include:

  • Jogging
  • Stationary bike
  • Core strengthening
  • Lower body weightlifting of resistance training
  • Swimming
  • Golf putting only

These “weightbearing” activities are not allowed because they put pressure directly on the area of the OCD lesion:

  1. Sports of any kind
  2. Handstands
  3. Tumbling
  4. Push-ups, planks
  5. Upper body weightlifting or resistance training

When may surgery for elbow OCD be needed?
Many elbow OCD lesions can improve with conservative, nonoperative treatment. However, surgery may be necessary if the:

  • The OCD lesion appears loose, unstable, or large.
  • Cartilage becomes loose in the joint.
  • Imaging shows an advanced or worsening condition.
  • Symptoms are worsening despite nonsurgical treatment.

What kinds of procedures are used to treat OCD in the elbow?
The choice of surgical procedure depends on the condition of the tissues at the time of surgery. Most procedures are performed using an arthroscope, a camera, and tools inserted through small incisions, but a large surgery may be needed in some cases. Our sports medicine pediatric orthopedic surgeons are experts at treating OCD and can walk you through what to expect.

Procedures that may be offered alone or in combination include:

  • Drilling – drilling holes into the bone to increase blood flow and healing.
  • Stabilizing – inserting a screw, suture, or other piece of hardware to keep loose tissue in place.
  • Grafting – placing biological tissue in the area.

What can be expected after surgery for elbow OCD?
Our sports medicine experts work with every patient to develop an individualized postoperative treatment plan. After surgery, closely following postoperative instructions will protect the joint while the tissue is healing. Exercise and activity recommendations will be different for every patient.

How long does OCD in the elbow last?
Each case is unique, and the timing of returning to normal activity or sports will be discussed with your sports medicine physician, surgeon, or advanced practice provider. Symptoms may last months or years. It’s very important to understand that symptoms may return if the area does not fully recover before returning to repetitive or weight-bearing activities.

How can elbow OCD be prevented?
Overuse injuries like OCD occur with a high volume of training, repetition of certain movements, and early specialization in a sport.

These suggestions can help to prevent elbow OCD and other similar conditions:

  • Learn how to moderate training loads and intensities.
  • Make time for free play and lifetime sports like tennis, golf, cycling, and hiking.
  • Take breaks weekly and between seasons.
  • Learn to properly warm up and perform conditioning for your sport.

Learn more about sport specialization and preventing overuse injuries in young athletes.

Common Youth Ice Hockey Injuries and How to Avoid Them

Common Youth Ice Hockey Injuries and How to Avoid Them

by | Oct 17, 2022 | Sports Medicine

Ice hockey is a contact sport that carries a higher risk of injury as the skill and competition level increase. Though ice hockey may not be as prevalent in North Texas as it is in other regions, Scottish Rite’s Sports Medicine team still takes care of injuries from this fast-paced and fast-growing sport.

Rules, such as delaying body checking, change an athlete’s risk of injury. We asked Jacob C. Jones, M.D., RMSK, and Madelyn White, P.T., D.P.T., to answer a few questions about pediatric sports medicine and physical therapy as it relates to ice hockey. Here’s what they had to say.

What do we know about ice hockey injuries?
Injuries occur quite frequently. Even though much of youth hockey prohibits checking and overt contact, that doesn’t entirely eliminate all contact in the sport. Both acute and chronic musculoskeletal injuries happen to hockey players. Concussions are also common in ice hockey players.

Are there different injuries in different age groups or skill levels?
Although many injuries are similar, younger hockey players may have more frequent injuries involving their growth plates since older adolescents may be near completion of growth. As a result, providers should be aware of how any injury may affect a growth plate. This can help provide the best treatment and avoid future complications.

Are there certain considerations when a player returns to the ice after an injury and rehabilitation?
It’s important to allow a gradual return to full participation in on-ice and off-ice training after injury. Be sure to warm up adequately prior to practice and games and avoid playing through pain.

Are ice hockey injuries preventable?
Yes, some of them may be preventable, especially the chronic injuries. Different youth leagues around the world have implemented rules changes regarding checking to help reduce the incidence of acute injuries.

What are tips for a skater to help prevent injuries?
Wearing proper gear, continuing to build flexibility and core strength. Some common injuries include ankle and shoulder injuries. Focusing regularly on exercises that help with the strength and mobility of these areas could help prevent injuries. Many overuse injuries and burnout can be prevented by trying to find at least three months out of the year to do a non-hockey sport or activity.

What should parents know about concussions in ice hockey?
Like other contact sports, these happen even with appropriate protective equipment and rules to avoid contact. Given the unique nature of the sport of hockey compared to other field sports, a treatment plan and return to play program should be tailored to hockey players. Seeing a medical provider familiar with sport-related concussions and hockey can help determine when it is safe to return to the ice, then safe to return to full hockey participation.

Are there exercises to help prevent back pain in ice hockey skaters?
Exercises to maintain hip mobility can help maintain good skating form and avoid back pain during hockey. It’s also important to build up abdominal and glutes strength. Exercises such as planks, banded side steps and crab walks can help prevent low back pain.