Ask Us Anything About… Bone and Joint Injuries in Children

Scott Gilbert – From Penn State Health, this is ask us anything about bone and joint injuries in children. I’m Scott Gilbert. Whether it’s playing around the neighborhood or playing their favorite sport, there are plenty of opportunities for kids to get injured just by being kids. Today, we’re going to get your questions answered about bone and joint injuries in children by Doctor Joseph Petfield. He’s a pediatric orthopedic surgeon at Penn State Health Children’s Hospital. So, Doctor Petfield, great to have you with us today. You know, I’m curious as we age, it seems many bone and joint injuries are cause for at least aided by the aging process. Speaking somewhat from experience here and degenerative conditions, that kind of thing but what are the most common types and causes of orthopedic injuries in children? In people we e think of as young and healthy.

Dr. Joseph Petfield – So I — you know, that’s a complicated question. I think you can kind of divide it based on the child’s age. So I would say in school-aged children or children who are more typically doing things like playing on the playground is typically broken elbows, broken wrist. Something like a fall. Fall from a trampoline, some type of upper extremity injury, or sometimes a broken shin bone. I would say in children who are a little bit older, adolescents, it’s more sports related type injuries. So some type of knee injury if they play soccer or football, upper extremity, shoulder injury, and then typically shoulder and elbow injuries for baseball players.

Scott Gilbert – Yeh and because they’re still developing, are certain body parts and children that are especially susceptible to Injury?

Dr. Joseph Petfield – Yes, of course. So, I would say in younger children, typically the elbow and the wrist and the growth plates that they have to allow their bones to grow serve as a point of weakness where the bones can break more easily. And then I would say in older children kind of a similar thing fractures around the growth plates.

Scott Gilbert – Now you know, we hear that term growth plate injury with young athletes sometimes. I mean my son’s a pitcher. He had one back in the Little League. What are growth plates and where are they in the body and how susceptible are they to injury?

Dr. Joseph Petfield – Well, well, can I grab a model bone and show you?

Scott Gilbert – Oh, that’ll be great. Yeah. Yeah, if you have a model. You brought props, folks. This is always helpful. I love it.

Dr. Joseph Petfield – So, this is an adult bone. This is a femur which you can see here. And so when children at the top and the bottom of the bone there is typically a small stripe of cartilage. So, in the femur, it would be about right here and what that does is it allows the bone to continue to grow down and up. And that’s what allows bones to have their growth over time and that cartilage as it continues to grow slowly turns into bone and increases the length of the bone. And that’s important in injuries for children because if you have a damaged growth plate, that can potentially lead to long-term consequences and that’s why I think seeing somebody like a pediatric specialist is important when a child has growth plate injury because not everyone would be as cognizant or paying attention to the potential for growth — you know, growth issues in the future.

Scott Gilbert – Sure. You’re watching ask us anything about bone and joint injuries in children. I’m Scott Gilbert alongside Doctor Joseph Petfield who welcomes your questions, your comments. Just add those to the comment field below this Facebook post and we’ll get to as many questions as we can here in the time that we have for this interview. And even if you’re watching this on playback, feel free to add your questions and we’ll get you a written response. You know, you mentioned a couple of the more commonly broken bones on the shoulder. I think the upper arm. I think I heard is that the femur is another one. I’m curious what makes some of these more commonly injured in children versus others? Is it just the nature of the kind of stuff that they do?

Dr. Joseph Petfield – I think the those injuries being common are one because of specific activities that children do like playing on the monkey bars and falling out with their arms stretched out like this or falling on their wrist and trying to fall from their bike and protect themselves. And those type of typical injuries occur at known locations in the bone where the growth plate is thick or there’s some type of specific weakness of the bone. So, for example, a very common injury in elbows like a fall from the monkey bars is a supracondylar fracture of the humerus which is right here in your arm because that’s a spot of significant growth where there’s a weak growth plate.

Scott Gilbert – How often do bone injuries, bone fractures require just simple casting versus something more serious like surgery? And kind of what are the factors that determine the course of treatment there?

Dr. Joseph Petfield – I would say if you look at all broken bones in children in general, most of them can be treated without surgery particularly if they do not involve a joint like the elbow or the shoulder. And one of the reasons why they’re treated less frequently with surgery than adults is because children have a lot of growth remaining. Their ability to heal is exceptional and so that allows us to be able to treat a lot of injuries that we would treat with surgery in an adult just with a cast. If you look at all commons, we’d probably treat 80 to 90% of the injuries that come to us with casts.

Scott Gilbert – And again, why are children so good at healing? What is it about the young body that makes like broken bones heal better than they do in folks of say my age?

Dr. Joseph Petfield – I think it’s just their exceptional growth potential. The bones have a really thick covering on the outside of them called periosteum. So it’s almost like a skin that covers the bone. And in children the periosteum is so much thicker than an adults and the blood supply is so great that it just stimulates a very robust healing response. And I think that’s one of the things that allows children heal so quickly.

Scott Gilbert – All right, A lot of good stuff there about bones and we can certainly take more questions if the audience has questions about those. I’d like to shift to sprains and strains because those are other really common injuries. What is the difference between a sprain and a strain? Those two words, they sound so similar. I feel like they’re easy to confuse.

Dr. Joseph Petfield – Sure. So, a sprain is an injury to a ligament that keeps the joints stable. So, for example, a common one is a sprained ankle whereas a strain is typically something that involves a muscle. So, say someone is doing a sprint and the muscle contracts very hard and quickly like your calf muscle, you can strain your calf muscle. You typically sprain your ankle. Now, I will add that strains are very uncommon in children under about 12 years old. And the reason why is because the ligaments are actually stronger than the bones. So, it’s much more common for a child to break their bone around the ankle than it would be for them to sprain their ankle. A sprained ankle in a children — in a child less than 11 years old is very uncommon.

Scott Gilbert – In terms of severity, I know all of them have varying degrees of severity but in general, are sprains or strains — is one worse than the other generally?

Dr. Joseph Petfield – So it really depends on how bad the sprain or strain is. So, there — I mean there could be mild sprains and there could be severe strains. It really — the treatment is really based dependent on how severe it is. But like I said, strains are very uncommon in children and because they’re more often — they more often break their bone than they do sprain an ankle or something like that, it actually allows them to heal better and return to function faster because bone heals much faster than an injured ligament.

Scott Gilbert – Very interesting. You’re watching ask us anything about bone and joint injuries in children. Doctor Joseph Petfield is a pediatric orthopedic surgeon. He knows his stuff about bones and ligaments and tendons and sprains and strains. And we welcome your questions. Just add them to the comment field below this Facebook post and we’ll get to as many questions as we can in the time that we have. What are the most common joint injuries in children?

Dr. Joseph Petfield – So, I would say joint injuries are more common in adolescence who are kind of closer to becoming adults and they place more stress on their joints like, for example, playing soccer, basketball, something like that. I would say the most common is probably an injury to the anterior cruciate ligament, the ACL, which is a common, you know, if you watch professional football or professional basketball, you probably heard about that. That’s a knee injury that happens during some type of pivoting motion and typically requires a surgery to reconstruct it. I would say the second most common in children is typically a dislocation of the kneecap and that occurs in children just because the ligaments are a little bit more stretchy than others. We often try to treat that without surgery at first but sometimes if we’re unsuccessful, we will require a surgery in the future.

Scott Gilbert – And because sometimes I know some people wear a knee brace, right to try to get that knee to kind of refix I guess on there.

Dr. Joseph Petfield – Exactly. Yeah, there’s different types of knee braces that we use for different purposes which is all the more reason have a knee injury to come in and see us and not just consider buying one off the shelf because different knee braces work for different reasons.

Scott Gilbert – I apologize. You might hear my dog barking. Who knows what’s hidden back there? I was just going to ask you about dislocation. You mentioned knees, I’m sure that’s very common. Anything else? Any other parts of the body where dislocations are common especially in as you mentioned adolescent athletes.

Dr. Joseph Petfield – So similar to like what I said before, dislocations in children under 12 are extremely uncommon. And the reason why is to dislocate something, you typically have to tear a ligament. And so in in children, that are not adolescence, it’s much more common to have a fracture and if it’s a really severe injury, a fracture and a dislocation at the same time. As children get older and they’re kind of transitioning to adults, then we start seeing adult pattern injuries. Like in football or rugby players, we see shoulder dislocations. In — I would say older adolescent baseball players or softball players, we start to see some ligament injuries on the inside of the elbow.

Scott Gilbert – And that was actually, I was, — that’s kind of where I was going next and that is overuse injuries because some of those ligaments, you know, can be damaged by overused by say again, I have a bias here but youth pitchers and other types of things. How prevalent are overuse injuries among children? And I mean, are they becoming more common as time goes on?

Dr. Joseph Petfield – They are most definitely becoming more common, and I think that that reflects the competitive nature of children and how year-round sports are becoming much more common these days. And so that typically just happens because if you do a single type of motion for a long amount of time, the bone and the ligaments in that area are going to fatigue. And so I would — some things you can do to minimize overuse injuries or make sure that your child or you if you’re an adolescent listening to this have some type of off season because your body needs a few months to recover if you’re continually stressing it. So, for pitchers for example, you need to have a period of time where you are not pitching to allow your body. In addition to that, if you have a child who plays baseball or gymnastics, a lot of the national academies like the — or the Little Leagues Association of America make sure that you are following their guidelines. So, if you go to the Little League website, there is a number for how many pitches can be thrown based on the age of your child and you are putting your child at risk If you do not obey those numbers and I’ve seen it in clinic. Another thing that you need to do is make sure that your child is getting enough vitamin D. And vitamin D is something that’s critical for the bone to heal and be resilient. And if you look at the data around 30 to 40% of Americans are deficient or have low level deficiency in vitamin D. So, I take vitamin D. I give my kids vitamin D and I think it’s a useful thing for people to know.

Scott Gilbert – Yeah. So, is that something that they can usually get a sufficient dose of in a multivitamin? Or are you recommending a supplement possibly even beyond that?

Dr. Joseph Petfield – You know, it really depends on which multivitamin you’re taking and if you Google the website, Ortho Kids and vitamin D. That’s from Pediatric Orthopedic Society of North America. There’s about a two page article that you can read about vitamin D and how much your child should be taking based on their age. It also explains how vitamin D works and why it’s important.

Scott Gilbert – You’re asking — you’re watching ask us anything about bone and joint injuries in children. I’m Scott Gilbert joined today by Dr. Joseph Petfield. He’s pediatric orthopedic surgeon at Penn State Health Children’s Hospital and we welcome your questions for him. And also, if you find this as we hope you do, we hope you’ll share this Facebook post. So, others on your page can take part in the great information that we’re sharing today. You know I imagine there are sometimes — there are some injuries where people are wondering, can this be treated at home, or do we need to get medical attention? And I’m sure there’s some where it’s pretty obvious one way or the other something rather minor versus something like an obvious compound fracture but then there are those injuries in the middle. Any advice for people in terms of you know when to possibly seek medical treatment and when that treatment should take the form of just say the next day at the doctor’s office versus maybe an urgent care or an ED right now?

Dr. Joseph Petfield – So, I would say reasons to go to the emergency department. If there’s gross deformity, if your child fell off from the playground or something like that, arm is bent really crooked, some type of problem, then, I think that that is probably where you should go to the emergency department right away or an urgent care. Another thing where it really depends on your judgement whether to go to the emergency department at night or wait till the next morning is someone who’s refusing to bear weight. So, children typically, you know, especially younger children, they don’t really fake things and so if your child is persistently refusing to put weight on their leg after some type of injury, that’s a reason to go get it checked out. Now, whether that be in our orthopedic clinic where we have acute appointments every day or whether that be an urgent care, your pediatrician or an emergency department, it really depends on your level of concern but it’s something that needs to be looked into because children will typically not fake limping around for a prolonged period of time.

Scott Gilbert – That’s a great point. What about use of ice or heat on an injury? It seems like some injuries are good for one whereas others require the other right?

Dr. Joseph Petfield – So, that’s a complicated topic but I would say in general, if you have some type of injury where there is swelling, we typically recommend ice because the ice allows — it constrict the blood vessels in that area and it allows the swelling to go down. If there’s some type of chronic muscular strain, I would say this is less common in children, more common in adults. Heat is more effective in those areas.

Scott Gilbert – Right. When we talk about injuries that damage a bone, a muscle ligament, or a tendon, how important is it to ensure that the injury won’t reaggravate or you know, happen again especially if you know in the near future?

Dr. Joseph Petfield – So, I would say the biggest thing especially if you have a teenager who plays sports is if your child has some type of overuse injury, make sure that they have an adequate amount of rest where they can appropriately heal the injury and I — in these days of competitive sports where people have traveled tournaments and everything like that, there’s a lot of pressure to get people back to playing right away. And typically when people come to talk to me in the office, I tell them that they almost need to treat their child as if they were some type of professional athlete. If you have professional athlete who’s looking to prolong their career for the next, you know, 10 to 15 years, they’re not going to really worry about getting unless it’s like some type of championship — national championship game where they’ll never play it again in their life, they’re not going to worry about getting back to that next game right away because they’re concerned more about the longevity of their career. A I think that that, you know, also can be applied to children who want to get back to sports as soon as possible is that they really need to take that time and invest it because if they go before they’re fully healed, they’re just setting themself up for a reinjury in the future.

Scott Gilbert – And I bet those discussions about return to play, I mean, can those be difficult especially because when you’re talking with parents and athletes about that, it might involve news that they don’t want to hear.

Dr. Joseph Petfield – You know, kind of like I said, it can be difficult. One of the things we’re aided by in medicine today is we use a lot of objective criteria for return to play. And so if somebody has an injured extremity like they injured their knee for example, we can now test the knee, the strength, how far you can jump, things like that and compare it to the knee that’s not injured. And so I usually use a cut off of 85%. That you’re injured knee needs to be performing at 85% of the capacity of the non-injured knee. And so that way it takes quite a bit of the discussion and debate out of it because there’s evidence that shows if you don’t return to that level that you’re setting yourself up for a problem. Now, that’s still is a difficult discussion to have but I think, you know, when people are able to look at the numbers and it gives them a goal to shoot for it, it kind of makes them a little bit more determined to get back to play in the future.

Scott Gilbert – This sounds like what you’re saying though too is that there are injuries that can happen even early in childhood that could create problems later in life if they don’t heal properly. Correct?

Dr. Joseph Petfield – Oh yeah, that’s completely true. So, if there’s an — for example, a fracture that involves the growth plate, very rarely you can have an injury to the growth plate where a part of that cartilage turns into bone and then the growth plate stops growing in a certain area. And so that can lead to issues with the way that the bones are formed in the future. And so I think for example, those children that we see where they have a growth plate injury of their wrist or a growth plate injury of their ankle, we will typically watch them intermittently in our office for up to a year to make sure that they are growing appropriately and that that injury has not happened.

Scott Gilbert – Are there ever cases where what seems at first to be maybe a routine bone or joint injury leads to the discovery of an underlying bone disease or disorder?

Dr. Joseph Petfield – That can be the case. Things like infections,, stress fractures. They — people typically think, oh I just, you know, I bumped into someone who I was playing soccer or something like that. But what I would tell patients and their parents is that it’s probably if you’re having persistent pain after a couple of days, you should probably have it checked out because playing through the pain if it is true pain, you’re either going to potentially make yourself worse or there could be some type of underlying issue that you’re missing.

Scott Gilbert – Yeah. And you know, playing through the pain, I think that’s a really important thing because sometimes whether you know, there are many different sports, you know, where children can feel pressured to do so because in the moment they might think, well, I’ll just soldier through because that’s the strong thing to do but that may not be the best idea for long-term health, right?

Dr. Joseph Petfield – Yeah, I mean, I completely agree and if you look at children who play gymnastics, basketball, baseball. All of these sports that are associated with overuse injuries. Cross country running. You’re looking at someone who has the entirety of the rest of their life when they’re 11, 12, 13, 14, 15 years old and so you really — you know, some type of injury while the bone or the joint is still developing can cause some significant problems in the future. So, I think it’s really important that we pay attention to those injuries now.

Scott Gilbert – As a surgeon, what are some of the most common procedures you find yourself in the OR for especially, you know, again with younger folks who — and their injuries.

Dr. Joseph Petfield – With younger folks and sport injuries, I would say most commonly pediatric elbow fractures. The reason why we operate on elbow fractures much more commonly than something like a wrist or a shoulder is because a lot of the growth of your upper extremities. Sorry, I put my arm in the picture here. A lot of your growth comes from this part of the bone down by your wrist and a lot of it comes from your shoulder. The growth plates up by the elbow grow much more slowly and so what that means is that there’s limited healing capability there where if the bone is not aligned right it won’t be able to correct itself over time. And so that’s why we have to correct those bones and their alignment with surgery which is much more common for those areas. So, typically, elbows, elbows, and elbows is the most common thing. Elbows and ankles.

Scott Gilbert – Great advice today, Doctor Petfield. We appreciate your time sharing both about how to keep kids safe and healthy and how to get them healthy again after an injury. And in fact, we’ll share a link in the comment section below this Facebook post to some more information should you want to contact Doctor Petfield or somebody else in his clinic. Doctor Joseph Petfield, thanks so much for your time today and we want to thank you for watching ask us anything about bone and joint injuries in children from Penn State Health.