Pediatrics

Treating Pediatric Injuries

What happens in the ice and snow

BY ALLYCE FISK, PA-C, MMS, REBECCA ROUSE, PT, DPT

Some of these injuries will result in quick trip to the ER, where the pathway to a pediatric orthopedist is clear. However, few parents have a pediatric orthopedist in their speed dial or even know what one does. When the symptoms of an injury persist, the most likely remedy will be a trip to their regular medical home, and this is when it is important to remember that, regardless of the severity of injury, we are here to help. While many common injuries may be safely diagnosed and treated absent the advanced training and diagnostic skills we offer, there are important matters to keep in mind. For example, if a patient has suspected growth plate injuries, missing the growth plate injury diagnosis or mistreating it can cause malformation of the bone or complete arrest of the growth plate, causing a difference in limb length which can lead to lifelong diminished capacity.

The most common injuries in the winter range from mild sprains to significant fractures that require surgery. It is important to remember that pediatric orthopedic specialists are best equipped to evaluate, diagnose and treat pediatric injuries, as there are special considerations when evaluating and treating pediatric patients. Children are not small adults, and the developing skeletal system responds to trauma differently than that of the adult. The same mechanism of injury that may cause a sprain or strain in an adult, or even a teenager who is skeletally mature, may cause a growth plate injury in a child who has not reached skeletal maturity. This is because of actively growing bone at the epiphysis, metaphysis and apophysis, collectively referred to as the growth plates. This area of developing bone creates an area of instability that can be more easily injured in children, and providers who do not commonly treat pediatrics may not be able to recognize these injuries or treat them appropriately

Missing the growth plate injury diagnosis or mistreating it can cause malformation of the bone.

Common injuries

Common injuries resulting from walking in slippery conditions caused by Minnesota ice and snow include wrist injuries. These often occur due to a fall on an outstretched hand (also known as a FOOSH). This type of fall can result in buckle fractures of the ulna or radius at the wrist or throughout the forearm. Nondisplaced fractures may be treated with casting. More severe fractures to the wrist, forearm or elbow may also occur secondary to a slip on the ice and may require operative treatment. Clavicle fractures are often caused from activities such as sledding or falls directly on the shoulder. The majority of clavicle fractures are treated with immobilization in a sling.

Shoveling heavy snow is another common cause of injury during Minnesota winters. Adolescent patients may occasionally come in for care due to muscle strains in their back. Other common spine diagnoses in adolescent athletes include spondylolysis or spondylolisthesis; these are diagnosed most often in gymnasts and figure skaters, but may be exacerbated by activities requiring twisting while carrying a load just like shoveling.

Spondylolysis vs. spondylolisthesis

Spondylolysis is a stress fracture in the lower back. Children and teens who participate in sports that put repetitive stress on the lower back, such as gymnastics, basketball, skiing, figure skating and weightlifting, are at highest risk. As the athlete’s muscles become overly fatigued, the stress of the workload is transferred to their bones. Over time, the continued pressure can cause stress fractures in the lower back. Some children are born with a genetic tendency to develop spondylolysis even if they do not participate in sports; the risk of spondylolysis is higher during growth spurts. If left untreated, spondylolysis can progress to spondylolisthesis, a condition in which a vertebra, weakened by fracture, slips out of alignment with the rest of the spine.

Athletes with either condition can usually return to sports after several months of rest and physical therapy. Patients may need to wear a back brace as part of their recovery, which will be custom-made for them in our orthotics department. In rare situations, if a vertebra is severely out of alignment or if a child remains in pain after other forms of treatment, spinal fusion surgery may be needed from one of our skilled, experienced physicians.

Knee and ankle injuries

From a sports medicine perspective, the most common winter sports injuries generally involve the knee and ankle joints. Ankle sprains and fractures occur commonly in basketball players or from a fall on the ice, and ligamentous knee injuries are common in both basketball and hockey players.

Anterior cruciate ligament (ACL) tears are always a hot topic of conversation when it comes to pediatric injuries, and our team is well-trained to accurately diagnose and treat this injury. Treatment for a child’s ACL injury will depend on the severity of the injury, and all options will be discussed at a child’s first appointment.

ACL injuries generally occur in teenage athletes and are less common in younger children. Depending on the mechanism of injury, there may be concomitant injuries to the knee, such as a meniscus tear or collateral ligament injury. The possibility of these injuries is why we perform specialized examination tests to further evaluate the patient for multiple injuries and determine the most appropriate diagnostic tests to ensure no injury is missed. If an ACL tear or meniscal pathology is suspected, we will send the patient for an MRI of their knee to evaluate for these injuries. Should an ACL tear be noted, the patient will require surgical intervention in the form of an arthroscopy with ACL reconstruction. The specific surgical method of ACL reconstruction will depend on the patient’s age and activity level.

Non-surgical treatment for ACL sprains or less severe knee injuries include avoiding activity and potentially using a knee brace. We rely heavily on our rehabilitation team to help these patients get back to play or sport. Physical therapy is an important treatment for all sports injuries, especially ACL tears. Our on-site physical therapists work with patients and families to create custom rehabilitation plans and goals. Physical therapy and occupational therapy can be utilized for both surgical and non-surgical patients.

Many high impact injuries that we see can occur with activities like skiing and snowboarding. Such injuries may include tibial shaft fractures due to ski boots, metaphyseal fractures due to falls, or intense axial loads during snowboarding. Again, the treatment for these injuries depends on the severity of injury. If an ankle sprain is suspected, we may use an ankle brace and physical therapy to help a patient return to their activities. For a nondisplaced tibial shaft fracture, we may treat the patient with a cast, using crutches to remain non-weightbearing to the affected extremity. Unfortunately, if the fracture is significantly displaced, these injuries may require surgical intervention. For all pediatric patients, the growth plate is a special consideration. Therefore, in the event of concern that the patient’s growth plate has been affected during an injury, we will typically follow the most conservative treatment plan to ensure we are protecting the growth plate.

EOS is a medical imaging system that provides 360-degree images.

Radiology

Our new state-of-the-art facility offers in-house radiology for X-ray imaging prior to the patient’s appointment with an orthopedic provider, which means no time is lost scheduling another appointment or driving somewhere else.

X-rays expose children to radiation in low doses, and we take additional steps to reduce this exposure. When performing X-rays on children, we make sure we use the lowest possible radiation dose, described as ALARA (As Low As Reasonably Achievable).

EOS imaging

We use EOS imaging for many of the X-rays we take. EOS is a medical imaging system that provides 360-degree images while limiting the X-ray dose absorbed by the patient, who is either sitting or standing.

EOS offers a number of advantages over more traditional X-ray units, including fast, stress-free, low-dose radiation exams for children with hip, knee and spine conditions. It is ideal for children with conditions that require multiple X-rays. Studies have shown that using low-dose EOS imaging can reduce the radiation dose by 55% compared with digital and computed radiography (standard X-ray technologies) without compromising image quality.

EOS scans are also easier for children that may have a fear of X-rays. These scans, which take six seconds or less with a total exam time of 3-4 minutes, capture both front and side views of a child’s body and can be taken with the child sitting or standing in a natural, weight-bearing position. There is no need for them to lie down or turn over, as they often do for traditional X-ray.

Rehabilitation

Our team of physical and occupational therapists are highly trained in addressing a multitude of different diagnoses. With regard to non-operative and post-operative management of injuries, we are able to tailor our treatment strategies to the patient and their needs–whether it be using crutches to get around at school or progressing back to playing a high-level sport.

We use the most current evidenced-based practice when utilizing modalities and strengthening techniques following injury or surgery and work closely with the medical providers to make sure the patient is making progress and meeting their goals as expected.

Specializing in treating pediatrics also gives us a clear lens of how treating a young athlete differs from treating a high school athlete and the importance of using high-level training when appropriate. Our therapists have additional experience treating athletes who may use a wheelchair to play basketball, a sled to play hockey or a prosthesis to go snowboarding. It is crucial to consider all aspects of an athlete’s life and not just their performance on the court or the ice, but how their rehab will affect their ability to engage in their everyday activities

In conclusion

Unfortunately, it is impossible to eradicate all risks our Minnesota winters or winter sports pose. However, ensuring proper protection during sports is one way to reduce the risk of injury to athletes. Wearing a helmet to ski or snowboard or full pads to play a hockey game is important to provide the maximum protection to our athletes. Wearing good winter attire and using a broad-based stance to walk on the ice and snow can help to reduce the risks of falls when out and about on slippery sidewalks and driveways.

Shriners Children’s is one of the world’s greatest philanthropies and has evolved into an international health care system for children, able to treat many health care issues including orthopedic conditions, spinal cord injuries, burns and cleft lip and palate. All children receive care regardless of the families’ ability to pay. Our centers vary regionally in terms of the range of conditions they treat.

Shriners Children’s Twin Cities is a specialty clinic focused on the diagnosis and treatment of pediatric orthopedic impairments and injuries. Initially we served a six-state region providing care for some of the most difficult congenital deformity cases, such as children born with their feet facing the wrong way. Some of our patients required over a dozen major surgeries before they were 18. As time went on, we have expanded the range of services we offer to include common injuries. We recently relocated to a new facility in Woodbury where, under one roof, we have a skilled and knowledgeable medical team consisting of orthopedic surgeons and physician assistants, physical and occupational therapists, prosthetic and orthotic providers, radiology technicians, child life specialists and licensed social workers. This collaborative approach allows us to treat a wide spectrum of patients with diagnoses ranging from cerebral palsy to ankle sprains. Please think of us as a resource and partner when you have patients who may benefit from these services and skills.

Allyce Fisk, PA-C, MMS, is an orthopedic physician assistant at Shriners Children’s in Woodbury.

Rebecca Rouse, PT, DPT, is a physical therapist at Shriners Children’s in Woodbury.