Brian Kelly, MD, presents on being able to recognize conditions that are appropriate for care by the primary care provider.
Um, but hopefully for the next 45 minutes or so, we can talk about some, um, some common injuries that are, uh, likely to, to show up in the primary care office, uh, and hopefully injuries that we can gain a little bit more comfort, um, dealing with in the primary care setting. Uh, I think it's an appropriately, uh, appropriately timed talk given the, the unseasonably warm weather we've been having. Um, so hopefully it can be useful in the, in the weeks ahead. Uh, don't have any disclosures relevant to this conversation. Or to this uh topic. So, uh, trauma is obviously something that is common, uh, something that we, uh, see frequently, but it's not something that, uh, we're really taught in medical school. So learning about injury and trauma is something that often will happen on the job or stuff that you, you pick up along the way in residency, uh, but isn't always taught in a, in an actual kind of didactic way. Uh, I've been through multiple iterations of the, the WasU curriculum at this point. This was the, the new curriculum from a few years ago, uh, that, uh, didn't really include musculoskeletal pathology in any sort of, uh, you know, extended way. We're now moved on to the, the gateway curriculum, uh, and, uh, still kind of figuring out exactly how this works, but the, the phase one, the pre-clinical years, there's Ah, ah, talk or ah uh. Defense and in response to injury, but that's really cellular injury that they're referring to. And then there's a scaffolding and movement, uh, section, which is, I think, a little bit more metaphorical and talking about the, the scaffolds within our society and movement among those and how that impacts, uh, in health. So really not seeing much in terms of teaching, uh, in the pre-clinical years around injury. But we know kids are gonna be kids, and they will find new and interesting ways of of hurting themselves. Monkey bars probably our number one offender, uh, but there's no, no shortage of of trampoline parks around. Uh, we know as the weather gets warmer, they are gonna find these ways of hurting themselves, uh, and it's, it's really uh amazing that any of us survived childhood with all of the, the ways that we can, uh, Fine to, to, to injure ourselves. So today we're really just gonna be going through some cases, uh, different, uh, injuries that you might come across in the primary care setting, uh, maybe how we can uh start or or definitively treat these injuries and then some pitfalls when we're thinking about the, the management of these orthopedic injuries. Hopefully, by the end, uh, we'll have reviewed uh some relatively straightforward and simple orthopedic trauma that might come your way, and be able to recognize those conditions that are, are appropriate for care in the primary care setting, uh, gain comfort in the evaluation and treatment of these common injuries, and then avoid those pitfalls and understand when referral is, is appropriate. So, right into cases. Uh, We, I think, are gonna have a 70 degree day tomorrow, but we've already had a couple, uh, but this is the, uh, this is what the playground looked like when I took my kids. And it was a zoo, uh, and I know those warm weekend, uh, days, particularly early in the year in the spring, are going to, uh, Lead to a little bit of this. Uh, so this patient, 8 year old boy, uh, trying to get a little too fancy on the monkey bars, hang from his feet, that sort of thing, ended up with a fall from height onto his right hand. Comes right to your office, holding his wrist. Really is able to tell you that the pain is localized really to the wrist area and just really with movement of the wrist, that looking relatively comfortable otherwise, uh, you look at the wrist, maybe swollen. Mom always seems to think that the wrist is swollen. On your exam, you see that the skin is intact. There may be some minimal swelling, but no real bruising, no significant deformity at the wrist, and really has isolated over the distal radius. No tenderness in the anatomic snuff box, which is really the area, uh, overlying the scaphoid, so really just at the distal radius, uh, has some pain when trying to move the wrist, uh, and is neurovascularly intact in the hand. So, what do we do next? Uh, we know that injuries and skeletal injuries, fractures around the wrist and kids are the, the most common, uh, fractures that we're gonna see. Uh, and this fall from height is a perfect mechanism for seeing that. So, usually we're gonna start with some basic imaging, uh, as with all orthopedic imaging, we want to get imaging in two planes to try and understand the fracture three dimensionally or to understand the anatomy 3 dimensionally. And I think with a very localized exam, we can be thinking about just X-rays of the wrist. We obviously want to be aware that uh kids not can uh Maybe not always localized quite as well uh as adults can, and elbow injuries are also very common, so we really need to um use our exam to help guide that imaging and if there is any question about the location to expand the imaging you obtain. Um, so really trying to focus on the wrist, and typically for kids, I'm just gonna get to use an AP and a lateral. Uh, and here are some images of the wrist, um, on the left, obviously the lateral, on the right, the AP image. And Uh, try and bring up my, uh, laser pointer here. Relatively subtle findings here, uh, but if you follow the contour of the radial cortex, we see that there is a little bit of a bulge here. We see an irregularity here, um, proximal to the fiss, and similarly on the lateral we see the anterior or volar cortex intact. We see a little bit of irregularity, some buckling of the posterior cortex. So this is a this is a buckle fracture, uh, very, very common injury, um, in this age group. And it's a uniquely pediatric fracture. Uh, we like to think about, uh, the material science behind these things, and we're using a lot of, uh, different implants that we think about this stuff a lot. But in general, the, the point is that adult bones are more brittle. They do not bend very far before they crack, whereas kids' bones are more ductile, they're plastic, they can bend before they break. And that's really what's what's uh what's happening here is that in with an axial mechanism, you're landing on the wrist, instead of seeing the bone crack, the bone just buckles. And that compression mechanism actually makes the bone more dense and creates a very stable injury, uh, that it doesn't want to move. So, Treatment is usually pretty straightforward in these injuries. That we have tried to move away from uh more uh uh. And I don't wanna say invasive, uh, more rigid mobilization and move towards things that are a little bit easier, uh, for the patient and family. Uh, so for these true buckle fractures, we really tried to move towards this removable off the shelf splint, something that's easy to put on, it's easier for the patient and caregiver, uh, and these tend to heal very quickly, uh, and very reliably, um, without any major sequelae. So typically going to immobilize in this splint, pretty much at all times except for hygiene, for a period of 3 weeks. At 3 to 4 weeks, I see patients back. I take this splint off, I push on their wrist. If there's no tenderness at that point, they are done. They can discontinue the splint, they can return to full activities. Um This is a um an initiative that that spans uh disciplines, this choosing Wisely, uh, project, uh, but it's it's been in an effort to try and limit, uh, the, uh, testing and treatment that is provided, uh, and the American Academy of Pediatrics and the Pediatric Orthopedic Society in North America. I found 5 areas where maybe we have traditionally overtreated, uh, buckle fractures being one of those things that Sorry? We're not moving around enough in here? Um, that, or buckle fractures, uh, we really don't need to repeat imaging for these, uh, we, we don't need to prove that they've healed, they heal reliably, so, uh, we don't even need to obtain uh follow-up imaging for these if they are, are truly not, uh, tender or painful. Uh, couple of studies, uh, again, the, the move has been towards trying to do less for these, uh, and there's good evidence that for these buckle fractures of the distal radius, we really do not need to be immobilizing these in a cast. Uh, both from our institution and other institutions that they are, uh, easier for the provider. They are, there's a higher degree of satisfaction for the patients and families, uh, so lots of reasons to try and, uh, avoid doing too much for these. Couple of pitfalls here, uh, needs to be a buckle fracture, I think is the, the, the point, uh, and you really should not be able to see a crack in the cortex that the The cortex opposite that buckle really should look intact, um, and definitely have seen some that were true bicortical fractures that were thought to be buckle fractures placed in a splint, and they will displace. So I think the point here is if you can really be sure that it's a buckle fracture, that it is appropriate to treat this in a splint. If there is any question about whether or not this is a buckle fracture, uh, immobilizing and referring is is always gonna be appropriate. I don't know if any questions have come in, feel free to to throw those in the chat or or unmute yourself, um, if just as long as someone will, will let me know if there's anything in the in the chat, um, otherwise I go on to our next case. Yes, we did get one question in the chat. Yes, fire away. It says, do you limit activity for buckle fracture? Can they swim? And where can we get a splint? Should we treat them without referral to ortho? So I think if you have access to a splint, uh, then it is appropriate to treat in the primary care setting, kind of given your, you know, based on your level of comfort, your, uh, especially with whether or not it's a buckle fracture or not, um, if the, if splints like this are not available in your clinic. Uh, there are splints, uh, available over the counter. It can be difficult to size those things for our pediatric patients. Um, you know, they, uh, I don't, I don't know would be finding them if you don't have access to those things, um, certainly referral is totally fine. I tend to not allow for any activity. So trying to avoid things that put them at risk for falling. Now, that doesn't mean they can't get into a pool. They should not do that with the splint on, but they also should uh not be swimming around, chicken fights, flip turns, what what have you, um. That we are trying to avoid taking a stable, very stable injury and and making that unstable. Uh, so there is a, there is an issue with the bone. We don't want to fall on it again, we want to limit activity for those 3 weeks. And there are just 2 more comments in the chat. One says, I'm guessing that the radiologist would be able to confirm if a buckle or not, and then another person says DME order or call and call to ensure sizing. So, fortunately someone else has more experience obtaining these things. We know I we we have them in clinic, it's um Uh You know, it's gonna be particular to your setting. Uh, I think you can use the radiologist's uh interpretation, but these are probably ones you should look at yourself, um, and really make sure that you're not seeing any disruption, um. And if you're feeling, uh, feel like there's any question or the radiologist read isn't entirely clear, uh, call us and ask, send them our way, nothing wrong with that. All right, case 2. Still warm out, everyone's still playing outside. We know there's gonna be more business for us. This is a 3 year old girl. wants her dad to swing her around. Suddenly she screams, stops using the arm. She comes right to your office. She actually doesn't look too uncomfortable there eating her cracker with her doll, uh, just doesn't want to move the arm. Uh, when you ask her where it hurts or why she won't move the arm, she kind of just vaguely points to the forearm. On your exam, uh, she's holding her, her arm kind of like is uh demonstrated in this picture with the shoulder abducted, so the arm against the side of the body, the elbow slightly flexed and the forearm pronated. Her skin is intact, there's no swelling, no ecchymosis, no erythema, nothing that is really localizing where this injury is. Can't really find any obvious areas of tenderness. And actually she's gonna let you start moving her shoulder around. She lets you flex and extend on her wrist, but when you try to supinate that arm, she lets out a shriek. So, what's next here? Well, we don't have an exam that localizes exactly where this pain is coming from. It's a little bit more vague, but we have a very classic story with a patient whose arm was pulled. has pain and has a very classic exam. So the next step here is to fix it. This is a very classic presentation, uh, and story for a nursemaid's elbow, uh. Kids being led around by the hand and pulled uh by by nursemaids in the old days, gave uh gave this this name. Uh, and it's a result of attraction force the elbow. That ligaments in kids, a little bit more relaxed than in adults, and that traction injury can allow for separation of the elbow joint and unfolding of the annular ligament around the radial head and allows that to become entrapped in the joint. So, when they're not moving, since there's no skeletal injury, it doesn't really bother them, but with rotation, it's gonna pull on that ligament and cause pain. If you have this classic presentation, uh, you don't need an X-ray. Um, there are a number of reduction techniques or really two reduction techniques that are described. Um, the one that I prefer, uh, is the hyperproation technique. So with the elbow flexed to 90 degrees, You place one hand over the elbow. I usually try to put my thumb on the lateral side of the elbow, more to than to actually push or try to reduce, but if you can kind of have, uh, have your thumb over the area of the radial head, you can sometimes, uh, feel that, um. Annular ligament clicking back into place, which can be a very uh reassuring thing that you achieved reduction. And then you're gonna grab the wrist and the forearm, uh, distally, and you're gonna pronate. And generally I think about pronating fully and then going a little bit further. So it's really hyper pronation, and hopefully at that point you feel that little click at the elbow. Sometimes if I don't feel that click, and I'm pretty confident that this is a nursemaid's elbow, I'll try the second reduction maneuver, which is flexion and supination. Uh, but hopefully you feel that little click. Um, after your reduction maneuver, you leave. That kid's gonna shriek when you do this. You gotta give them a little bit of time, uh, so remove yourself, uh. Uh, um, after that reduction, I usually give him 15 minutes and come back. Uh, hopefully what you find is that they're feeling a lot better. They're using that arm more normally. After a successful reduction, if you find that the kid is now using the arm, you do not need any X-ray, uh, post reduction, you do not need immobilization, you do not need any activity restriction. Now, these kids, once they've had a, uh, uh, a nursemaid's elbow, are more likely to have uh a recurrence. Uh, as the child ages and those ligaments get a little bit tighter, uh, the incidence of uh recurrence is gonna go down, and these are essentially not seen after about 5 to 7 years of age. Um In terms of evaluating these, uh, these reduction maneuvers, the hyper pronation maneuver, uh, while I think is not taught quite as frequently, uh, it has been shown to have a higher success rate with less discomfort for patients, so that's why it's my, my, uh, first go to in terms of reduction maneuver. Um, mentioned this already, that recurrence is common. Um, there have been a couple of cases where I've actually taught the parents, uh, after multiple, um, Recurrence is how to perform the reduction maneuver themselves. Um, this is really uncommon. Typically, if it recurs, uh, probably should seek medical attention. It's those multiple recurrences with the very typical mechanism in a reliable family. Um, best way to prevent it is to try and avoid those traction injuries. So not swinging kids around, not picking them up by the arms, uh, but even with those precautions, uh, that traction mechanism still can occur. Um, pitfalls here. Uh, is that it's not a nursemaid's elbow. Uh, so you're for that classic story, uh, and there really should never be any localizing, uh, signs, so no swelling, no bruising, no deformity. Um, one of my mentors who is a very well known, um, pediatric upper extremity surgeon. Uh, tried to reduce his own kid's nursemaid's elbow, uh, and turns out he was manipulating her supracondylar fracture like is uh demonstrated in these pictures, um, so it can be something that can fool even, um, Uh, very experienced people. Uh, it is, you really should be looking for that classic story and exam. Um, and if there is question about, uh, your exam, the mechanism, uh, you know, is, is a fall or something like that, uh, obtaining imaging or referral is appropriate. Uh, nursemaid's elbows. I would say that rarely do these actually make it to my office. Uh, it is one of the most satisfying things to have a kid who is not using their arm, uh, and is in pain to do a quick maneuver and almost immediately have them feeling 100% better. Uh, so, uh, if you, if you come across and have not, uh, ever reduced an inpa's elbow, it's a very, very satisfying thing. All right, case number 3. Right, now those kids on our 70 degree day have their bikes out. Uh, at least they're wearing their helmets. We got a 5 year old now on his pedal bike, really excited, first time without training wheels. Sorry about the lights. I'm in one of our clinics. Not moving around very much. Uh, don't let go, Dad, and of course, as we're learning, uh, how to, how to go on those pedal bikes, we have a fall. Um, Comes to your office complaining about shoulder pain. He's cradling his arm uh against his body with the shoulder abducted against the side. On your exam, the skin is intact and he has some tenderness, swelling uh over the mid shaft of the clavicle. Uh, doesn't have any discomfort or pain with movement of the elbow form and wrist, but doesn't really want that shoulder moved and is neurovascular and tact distally. Fall from a bike very classic way, you can get an injury to this area, um, Very common area in general to have uh skeletal injuries and our pediatric patients. Um, so with that tenderness over the clavicle, we're gonna image that area. Now, it's hard to get true 90 degree, uh, Uh, X-rays of the clavicle, but typically they're gonna take pictures at two different angles, two views of the clavicle, uh, and this is what they demonstrate that, uh, fracture in the mid shaft of the clavicle. Um, clavicle hole is kind of a funny bone, has a unique shape and anatomy. Uh, it's S-shaped, uh, connecting the, uh, sternum to the, uh, scapula, uh, holding the scapula out away from the, uh, body, so the muscles of the shoulder can work at their optimum length. But due to that anatomy and how round and thin it is at the mid shaft, uh, a compression mechanism such as falling on the shoulder, uh, it's a relatively weak space, very common, um, for that to, to fail in that area. Uh, treatment, uh, again, tends to be pretty limited, uh, that typically I'm gonna put these kids in a sling really just for comfort. Uh, that they can start motion usually pretty early. I tell them that I actually want them to start getting rid of the sling after a couple of weeks. Uh, they can take it off for hygiene, they can take it off for moving, uh, immediately moving the elbow, wrist, forearm, uh, and as these kids start healing, uh, they're gonna start moving their shoulders on their own as they, um, uh, start feeling better and those bones start healing. Um, we wanna try to avoid refracture, uh, so typically The challenge here is actually limiting the kid as they feel better. Uh, We don't need anything fancy with the sling, typically, uh, you don't necessarily need the swath to keep the arm against the body. A figure of 8 braces, so the ones that went around both sides of the shoulders and connected in the back to try and pull those clavicles back, uh, haven't been shown to do anything other than hurt patients. Uh, so those have kind of gone by the wayside, and it's really just trying to keep the patient comfortable while their body does what their body is gonna do, which is heal this. Um, does the displacement or the type of fracture matter? Um, this has been, uh, uh, a question that is kind of swung back and forth in terms of how we view these things. Um, almost 15 years ago now, there was a big, uh, randomized trial of Clavicle fractures in adults. And what that study generally showed us is those fractures that were completely displaced and then shortened. So those fragments were overriding, those patients tended to have more problems uh after treatment, uh, if allowed, uh, non-operative treatment, that they had maybe some more uh fatigueability with overhead activities that they tended to have more pain. Uh, and we started applying all of those concepts and principles to our pediatric patients. So for a while after the study, we saw a big spike in the number of these clavicle fractures that uh that were actually getting fixed surgically. Um, but as we all know, kids are not little adults. And there has actually been a large multicenter study that has been conducted over about the past 7 years, uh looking at uh treatment non-operative versus operative for clavicle fractures in our pediatric or adolescent patients. Uh, this is a study that was, um, published just about a year and a half ago, looking at the, the results of uh this multicenter study. Basically, any way that they examine these fractures, displacement, uh, fracture pattern, age, uh, there were no benefits to surgery over non-operative treatment. So this was looking at patient reported outcomes and functional results, uh, as long as these were mid-shaft fractures, they All went on to heal, and there were no differences in either patient reported or uh functional outcomes. Pitfalls here, um, maybe our our older patients, those ones who are kind of getting out of the adolescent, uh, sort of age group towards, uh, more young adults, uh. who may behave a little bit more like adults, um, I think unacceptable prominence that cosmetically sometimes these can be uh um Problematic for uh for patients, uh, but also can be functional. So, uh, this patient, uh, for instance, uh, relatively thin, uh boy who couldn't wear a backpack with this amount of displacement, uh, that it was very uncomfortable for him. Uh, and while it wasn't an immediate threat to the skin, you can imagine putting weight on that over time could potentially cause skin issues. Uh, and then, uh, as with a lot of, uh, orthopedic injuries, open injuries or neurovascular injuries tend to be indications for treating these operatively. It's about clavicle fractures. We do have one question in the chat. Mhm. It says, do you have any data regarding successful nurse meds reduction after 24 to 48 hours? Sometimes parents don't come in initially, and I have a much higher reduction failure rate in those cases. Is it still reasonable to attempt to reduce after 48 hours, and then if it fails, refer to ortho? Seems like those kids usually end up getting splinted. I, I totally agree with you that uh the best we have in the literature is suggesting that uh those cases are a little bit more difficult and not quite as straightforward in terms of that immediate response to a reduction maneuver. That those kids who have the classic story, have the classic exam, but present a day or two later, uh, I think it is still appropriate to try a reduction. Hopefully you can still get that little click, but I think the the best that the literature is gonna tell us is those kids may not return to normal activity right away. That it may take a few hours or even a couple of days for that to happen. Um, there is nothing wrong if the story doesn't quite line up. You don't feel like you have success with that reduction maneuver, cause I've, I've definitely done it in kids who are over 24 hours and they still have that immediate return. Uh, I've had kids, you know, I call them the next day just to make sure that everything is OK and they're feeling better the next morning. Um, but putting them in a splint, referring to us if the story isn't quite, um, classic, or you don't feel like you have that, um, that immediate success with the reduction is, is appropriate. OK, we'll keep rolling. Case 4. Oh yeah, they're uh out playing sports now too in the spring. So, got a 9 year old boy who fell in soccer yesterday, uh, as is often the case with these sports injuries, he doesn't exactly remember what happened, uh, but he fell and now his ankle hurts. He has been able to walk on it, but it's uncomfortable. It's kind of up on his toe and hopping around a little bit. On exam, yep, he's kind of hopping into your office. He doesn't have crutches, he's able to put some weight on that leg, and we do see swelling, tenderness, and ecchymosis on the lateral side of the ankle. He's neurovasculally intact. So, what next, uh, again, very, very common to have injuries to the ankle, uh, sporting mechanism, a perfect way this can happen, but it can happen any number of ways. Uh, and, uh, we wanna evaluate that particularly with that sort of exam, with the swelling, with the tenderness over the lateral side of the ankle, uh, with the ecchymosis. Um, oftentimes we will get 3 views of the ankle, an AP, a lateral, and a mortis. A mortis is just more in line with the actual joint to, um, evaluate the joint space. Uh, but even getting two views is often going to be enough to, to evaluate the ankle. Here we have uh an attempted an AP and a mortis here, um. We demonstrating a pretty normal looking, uh, anatomy at the ankle joint. So, historically, Any child who had uh tenderness over the lateral side of the ankle was assumed to have a vial injury. Uh, and here's a good demonstration of a true Salter Harris I fracture of the distal fibula. Uh, but These kids were treated as a non-displaced. Fial fracture, non-displaced salter Harris one, that was the the the traditional teaching with these. But maybe not all of these injuries are true growth plate injuries. When you start looking at these kiddos who have no obvious displacement with advanced imaging and MRI, uh, we actually find that the rate of injury to the fiss is, uh, is extraordinarily low. That actually, what we're seeing are ankle sprains, that ankle sprains, uh, happen in kids just like they happen in adults, that the ligaments on the lateral side of the ankle supporting the ankle joint fail before the fis does. Uh, and as such, they can be treated as ankle sprains rather than a fyal fracture. So these were kids that were typically placed into a short legged cast, uh, for 4 to 6 weeks, uh, which is, uh, can be a huge burden for the family and tends to be overtreating these. So just like our buckle fractures, there's been a big trend towards moving, uh, to, to doing less for these kids, and using removable orthoses, uh, walking boots, uh, essentially for these injuries that do not have, um, obvious displacement on X-ray. So, I put these kids in a walking boot, uh, and they do come very small. Uh, I allow them to weight bear is tolerated. Uh, they do not need to start weight bearing immediately, uh, and, uh, ankle sprains can be a spectrum, uh, some can be, uh, pain can improve over the course of days. Some it's gonna take 6 to 8 weeks depending on the severity of the ligament stretch and tear. Uh, so, immediate walking isn't needed. You let the kid do that on their own. Um, typically, uh, I'm gonna reevaluate them in 3 to 4 weeks. Uh, again, this is a spectrum of injury. Some kids at 3 to 4 weeks, their swelling is gonna be, um, resolved, they're not gonna have tenderness, uh, and we can start weaning the boot and letting those muscles start working again. Typically, uh, return to activity is when there's full range of motion and strength, and that's gonna vary based on the injury. Uh, but when these kids can move their ankle like the other side, they're not hurting, the ankle is strong, uh, they can start getting back to activity. And that may take 1.5, up to 3 months in certain cases to the severity of the injury. Uh, physical therapy for our younger patients, I tend to avoid, they tend to bounce back pretty well. Um, those kids who are looking to get back to, uh, sporting activity, kids who maybe have had problems with their ankle before may benefit from physical therapy to provide some strength, particularly to the lateral compartment muscles, the ones that resist that inversion mechanism. Um, to help prevent injury and help them get back to the activities they want to get back to as fast as they can. Pitfall, very sim similar to some of our other uh uh cases that we wanna make sure that these aren't true fractures. So we, we wanna make sure we're not seeing displacement of the epiphysis, uh, such as in this picture. Uh, the other one that can be tricky as we get towards, um, uh, closure of the, of the growth plates. These interesting patterns of injury that are actually inarticular fractures, they can be a little bit more subtle on X-ray, so we actually can see, uh, this is a Salter Harris 3 fracture of the lateral side of the distal tibial um epiphysis. This is a tallow fracture. Um, and in this case, on the AP radiograph, things look pretty good, but we can see a subtle fracture line through the posterior part of the distal tibias is a salter Harris 2 fracture of the distal tibia. Uh, so we do need to make sure that we, we aren't, um, dealing with a, a true fracture. The questions about ankle injuries. All right. Oh, it's finally starting to rain. It doesn't matter. Kids are still gonna find ways, they can still jump on the bed. All right, so 2 year old boy jumping on the bed with his siblings, uh, fell from the bed and landed funny according to his big brothers. Uh, seems to have pain in the foot, doesn't really want to walk on that foot. Um. Not really swollen. Not hurting so much when he's not walking, uh, but still doesn't really wanna walk the next morning. When he comes into your office, he's being carried by his parents. Uh, maybe the foot's a little swollen. Again, Mom certainly thinks so. Has some tenderness over the midfoot, dorsally, kind of, uh, around the, the first metatarsal, will wiggle his toes. That's the most you can get from this two year old. So, we have a kid with a mechanism, uh, an area that is tenderness, uh, that is tender, who doesn't want to bear weight. So our, uh, concern for an actual skeletal injury is there, um, doesn't have ankle tenderness, just tenderness in the foot, so we're gonna try and limit our imaging to just that area. Uh, so typically when we're getting foot X-rays, um, We are gonna be getting 3 views of the foot in AP, an oblique and a lateral. Uh, that oblique view can be really helpful, uh, because the lateral, when you have all of the metatarsals and toes overlapping one another, can sometimes be difficult to interpret. The the oblique view is uh trying to get a slightly different perspective on those bones, uh, where they're not overlapping. Um, so this is an example of an AP and an oblique. Uh, these X-rays can be pretty subtle. There's a lot going on on these X-rays. There's a lot of bones, and there's a lot that we can't see that we know that there's more here in the midfoot than uh we can see on X-ray right now that a lot of um the tarsal bones are still cartilaginous. Um, but you go based on your exam. Uh, that's gonna focus how you evaluate this X-ray. Uh, and if your pain is more medial and in the midfoot, you're looking in this area, and very subtly, we can see that the bone takes a turn here. Um, that we don't see the nice gentle curve of the metatarsal like we do on the other bones. Um So that is a metatarsal buckle fracture, essentially. Now, all metatarsal fractures, regardless of whether they're a buckle fracture in a 2 year old or a complete fracture in a bigger mechanism in a child or adolescent, tend to be pretty stable because they've got essentially four splints right there. But the transverse metatarsal ligament, the ligaments that are supporting these tend to keep these things uh relatively well aligned and keep them relatively stable. Um Foot fractures in general are very, very common. Uh, The more common injuries is gonna be just stubbing that small toe, um, and seeing these extra-articular distal phalanx fractures are very, very common. Uh, toes are obviously different than fingers in terms of their function and what they need to do. Uh, that the very fine motor skills that the, the fingers need to perform, don't need to be performed by the toes, and they don't have that level of dexterity. They need to essentially fit in a shoe and be not painful. So most of these injuries, most of these foot injuries, uh, in kids are gonna be treated non-operatively. They're typically going to heal reliably. We're going to try and provide essentially symptomatic relief while that occurs, um, but rarely are are foot injuries and kids going to need, uh, much in the way of treatment. So our ankle fractures were uh and our uh buckle fractures were trying to do a little bit less, that most of these are going to be appropriate for a hard-soled shoe or a boot with weight bearing as tolerated. Um, typically, these are in our, our pediatric population gonna heal relatively quickly. Um, again, boot for symptoms for 4 to 6 weeks perhaps. Uh, the return to sports again is, is gonna be partly based on your exam, uh, that the kid is non-tender, uh, that we're, uh, we have good range of motion and strength. Uh, is gonna help guide our return to play, but thinking 10 to 12 weeks for these foot fractures, I think is, is probably a reasonable estimate. Um, pitfalls here, um, multiple metatarsal fractures, uh, these tend to be less stable, uh, as you start, uh, disrupting more of these, uh, these splints. Uh, so multiple metatarsal fractures can be more problematic. Um 5th metatarsal fractures, particularly at the base, uh, is a watershed area in terms of the vascular supply. So, fractures, uh, at the base of the 5th metatarsal tend to be a little less reliable in terms of their healing, uh, so may be treated a little bit differently. And then Seymour fractures, which are hyal fractures of the distal phalanx. Um, so these are occurring essentially under the nail bed, and what occurs with these, as this displaces, it disrupts the nail bed and portion of the nail bed and matrix gets embedded in the fracture. So I, um, tissue interposed. It is an open fracture, uh, and these have a higher rate of infection if left untreated. So these distal phalanx fractures that are in uh uh intra or physeal injuries, uh, often will be treated surgically. To remove that tissue, clean it out, uh, realign and repair, repair the nail bed. So nail bed injuries and see more fractures, the other potential pitfall. I do have a couple more cases. I'm happy to kind of keep going for a full hour. Uh, I wanna make sure that the, the rest are, are, uh, less common injuries. Um, if there are questions or more questions, I'm happy to, to take some time now or, or keep, keep moving through. So there are 2 more questions in the chat. I'll read them to you real quick. Um, we do need to put the QR code up before 9 just so people have time to scan. All right, this question is, if there is pinpoint tenderness in the lateral malleolus, does this require a radiograph? I think so there's there's been lots of attempts to try to limit radiographs. Uh, I think that the Ottawa ankle rules are, are the, the most commonly used criteria to try and determine whether or not radiographs are necessary. Uh, one of the criteria in the, the Ottawa ankle rules is tender specific tenderness, um, over the posterior aspect of the lateral malleolus. So trying to stay away from those anterior supporting structures, the ones that are more commonly, um, Uh, injured in a I think if you have tenderness over the bone, um, with a, with an appropriate mechanism that X-rays are gonna be appropriate. And then the next question is, for a distal phalanx fracture in a toe, can you just buddy tape the toe or or would we do a boot or hard soled shoe, and then they comment they're less likely to wear the hard-soled shoe, I think. I totally agree with you as uh attractive uh as those, those shoes tend to be, uh, I, I find that kids aren't gonna wear those very frequently. Um, it, it is, it's symptomatic treatment, essentially, um, that buddy taping is totally appropriate. We want these kids to be comfortable and be able to mobilize safely. Um, if that requires something with a little bit more of a firm, um, sole, either a hard sole shoe or a boot, I that's totally fine. Um, they don't necessarily need it if they're comfortable and can get around, uh, I will often, um, you know, depending on what shoes the kid walks in on, uh, walks in with, uh, there are Some shoes that kids will have that will have a, a more firm sole, uh, and, you know, if they, excuse me, can get by with whatever shoe that they have that has the stiffest sole, sometimes that that can work as well. Um, but it's uh it's essentially symptomatic treatment. You want them to be able to mobilize safely and comfortably. I got about 8:55. Do you want me to do one more? Do you wanna move to QR QR codes? Um, Do you think you would be able to end at 8:55 or a little after? OK. Yeah, those are the, I I, the, the 1st 5 cases were the ones that I wanted to get through. Uh, if those went fast, I had a bunch bunch of others just to make sure we filled the time, but I think those are, those are all very, very common injuries. Uh, that often we're not gonna see those patients going directly to the emergency room, uh, that will very frequently, uh, present to your office or, or call into a primary care office, uh, for some advice. Um, Hopefully, uh, you know, as these roll around, uh, as the weather gets warmer, feel some more comfort with potentially managing some of these, we are always available to help, um, either by answering questions. We're happy to see any of these kids or anyone else in referral, um. But, uh, you know, some of these, uh, with, uh, in the right side uh can, can definitely be managed in the, in the, in the primary care office. So, thanks for letting me chat about things I love to talk about, uh, hopefully it's helpful. If other questions come up, um, uh, please feel free to reach out to me anytime.
