And lastly this is all of us Maria is actually on maternity leave but you can reach out to myself Amy and Lauren and we will be able to help you with whatever you need and if you've missed any of our lectures you can watch them at our med connection site. Um And that's the address. You can also find the cmi lectures that you've missed in the last few months. They are actually available for credit. So if you need to get more credit or if you wanted to watch those you can actually do that on our website. So I'm going to introduce our speaker. Dr Kristen Livingston is a pediatric um orthopedic surgeon who cares for our Children with muscular musculoskeletal abnormalities or injuries ranging from club foot and other lower limb problems to hip dysplasia and elbow fractures. Her actual primary interests lie and correcting lower limb deformities and treating orthopedic interest injuries. And she's going to talk to us today about fractures. So I'm going to stop sharing my screen and hand it over to Dr Livingston. 01 more thing before I forget. Um at the end of the lecture there will be a link in your zoom to reach your evaluation. Please fill those out or else you cannot get credit if you miss it or you have to leave before the end of the lecture you will get a a link in an email tomorrow and it will have the link for you. So please be on the lookout for those and that's the way you're gonna get your credits okay now? Off to you. Thanks dr Livingston. Alright thank you Tabitha. Um Hi everyone nice to talk to you today um And can everybody hopefully hear me and see my screen? Tabitha let me know if there's any technical challenges. Um Okay thanks. So today I'm going to talk to you about a few examples of pediatric musculoskeletal trauma specifically when not to refer. Um I love seeing your patients but at the same time there's a whole lot that I'm sure you guys are perfectly capable of managing and so I want to give you the um the skills to do that and the confidence to do that today. So um just a no financial disclosures but just by way of introduction to me, I probably don't know a lot of you. I'm Kristen Livingston again I am from massachusetts and uh went to school on the East Coast at Dartmouth but then came out here to UCSF for medical school. So I've been in the Bay Area um for a long time now but I went back to Harvard to do my orthopedic residents and then I also wanted to introduce you to my amazing teammates who aren't here today but they this is the big group of people that cares for our kids with orthopedic problems and we're growing still. We've got another musculoskeletal pediatrician and other sports medicine doc on the way. Um So these are the faces of the people who care for kids at UCSF and orthopedics. Um But just some objectives for the day for the afternoon. Um I want to make sure that you guys understand the epidemiology of childhood fractures. We're going to discuss some unique features of pediatric fractures, learn to identify common pediatric fracture patterns, and then I want to empower you to manage some common, uncomplicated pediatric fractures. Spa's specifically clavicle fractures. Deslauriers, buckle fractures and diesel fibula Salter Harris one fractures and will identify the characteristics and patterns which necessitate a referral to the orthopedic surgeon. Um and then happy to answer any questions about these or any topics. Um so, first of all, how come our pediatric fractures? I'm sure you guys know these are very common. Um so this is a very common reason for kids to seek care and when kids are seen for an injury, about 10-20% of them will actually have a fracture. So it's something that's always got to be on your mind when you see a kid coming in for an injury, approximately 1.2 million pediatric fractures occur every year, and that's about 1-2 fractures per 100 kids yearly. So you're gonna see it a lot. Um 1/5 of all kids will sustain at least one fracture during childhood and parents and kids will see this as a significant event in their life. And so it's really an opportunity for you to make a big impact and it's getting more common. So the graph here is granted about a decade old, but it does show that there has been a steady increase in fracture incidents over the last couple of decades. Um That that regardless of whether it's girls or boys injury frequency sort of peaks in the 10 to 14 age group. Um but and boys are always a little bit more prone to fractures than girls and we think that's mostly due to risk behavior. Um But factors you know that are associated with this increasing incidents are a few. So first of all, increased athletic participation, right, gone are the days of every kid being on the playground after school. It's they're they're playing soccer five days a week. Um We also have bigger kids now. So B. M. I. S. Are increasing. Um And that means a greater load to bone mass ratio. So when kids are bigger, their balance may not be quite as good and bigger kids fall harder and have higher energy injuries. So this is maybe why we're seeing more fractures than we ever have before and it's keeping us busy. Um So 32% of pediatric orthopedic office related RV usr fracture related. So you ask my family where I am on friday night and it's always fixing elbows in the O. R. Um So why are they so common in kids? Well, um there are a lot of differences. It's both, it's both behavioral and also structural. So the pediatric skeleton is structurally different than that of an adult. Um The cortex is more porous and less dense than an adult, and that's why we see these different fracture patterns and kids, namely that kids kids bones break or start to bend before they break. So these create green stick patterns and Children only, right? They have ductal bones as opposed to the brittle bones of older people. Um And they have some very specific weak points. So the growth plate or the crisis is a weak point. Um It's a layer of cartilage which is a lot less strong than the surrounding cortical bone. And also the metamorphosis is particularly weakened kids. Um But so these weak points are what explained the salt Harris fractures through the growth plates, right? Those happen a lot. Um And also buckle fractures in the metaphor because it's this weak spot of the metaphysics, it's just not as strong as the shaft of the bone. Um And then the other factors that can make fractures so common in kids are risk taking behaviors. Um And lack of awareness, right? Kids are not afraid on the monkey bars. Maybe they should be a little bit at least. Um And then so we know fractures are all over the place and where do they occur? Um We've probably seen lots of them and the ones that we see are the most common ones, so that's gonna be pretty much the forearm, the wrist and the fingers. So these are the things that kids break all the time. Um Other common ones are um ankle fractures. Uh And um there are few other ones that are particularly common, but the ones that you're really going to see um the most are finger, wrist and forearm. So those are the ones you got to be prepared for. And then what what to do about these fractures. So there have been a number of studies that have looked first, you know, sort of what is getting referred out versus what staying in the primary care office. And um there are ap guidelines right for referral to pediatric specialists that were devised to help the primary care physician decided which conditions should be seen by a pediatric orthopedic specialist and a couple of stuff. We have looked at these in terms of the referral patterns to a pediatric orthopedic clinic. This study by reader at all. Um They found that nearly two of five referrals in their study were determined to be conditioned conditions that should be adequately managed by primary care pediatrician. So there are a lot of things that are getting referred that should probably be staying in the pediatrics office. Um and then another study was similar one, this one found that 47% of cases were considered to be primary care conditions and they noted that application of a simple splint short arm cast um buddy taping of non displaced finger injuries are examples of problems that are manageable by primary care clinicians and that the most common primary care condition was in a non displaced finger fracture that could have been managed without the need for a specialist referral. So simple stable fractures that were non displaced and did not require a long cast were considered manageable by a primary care physician, saving both time and resources. Um So that's important is that a lot of this management can be done with a lot less resource, both in terms of healthcare, resources and also time and money expenditure by the family. So these are the um those american Academy of Pediatrics recommendations um which are guidelines for referrals to pediatric surgical specialists. And they go through a number of conditions here. But the bottom um they suggest that infants, Children and adolescents with complex fractures and dislocations should be sent to a surgical specialist. Um but that it's not entirely clear, right? So what is complex versus simple? Um And I think that that you know, leaves a lot to interpretation and sort of up to the comfort level of the physician. But I wanted to go through a couple of very concrete examples that are simple fracture patterns um that you guys should be completely uh set to take care of um without us. And uh those would be clavicle fractures, distal radius buckle fractures and ankle sprains slash Salter hurst one distal fibula fractures. So with these injuries you really can't go wrong. Um Alright, so we're gonna go through a couple of specific examples. So this is a four year old boy who fell on on to his left shoulder and he comes in with shoulder pain. Um you appropriately order an X ray of the clavicle because he's tender right here, and this is what you see. So he's got this little um non displaced crack through the mid shaft of the clavicle here. So clavicles are pretty common. They represent about 5-15% of childhood fractures and most occur from a simple fall or sports injury fall into the shoulder. By far the most of them happen in the middle third of the clavicle, and most of these are non displaced or minimally displaced due to a thick curiosity, um especially in the younger kids. So, um complications from a simple, isolated clavicle fractures in Children are very, very rare. Um you can, you know, if, if you pay attention to any of the orthopedic controversies out there, one of the most controversial and sort of hotly debated areas is the surgical management of an adolescent displaced clavicle fracture. So, In an older teenager, if the fracture is totally displaced and shortened, we will debate that all day long and some people may end up fixing it. So there is some controversy if you've got a teenager or you know, at least a second decade kid with a clavicle fracture, but in little kids under 10, there is no controversy that is never going to get fixed. Uh and it will heal all on its own. And so kids with from 0 to 10 with an uncomplicated clavicle fracture almost never need surgery or complex management. So these are injuries that you guys can definitely manage. Um so what does an uncomplicated clavicle fracture mean? So we discussed that it's the first decade, right? So, again, teenagers are a little bit of a different story. Um but in the first decade kid, uh that is uncomplicated. Um the fracture needs to be in the middle of the bone, right? So right in the mid shaft and we're not talking or medial or lateral fractures, but mid shaft clavicle fractures, and then non or minimally displaced, but certainly a little bit of bend. A little bit of displacement is okay, and we'll go through examples of that and then it needs to be an isolated injury. So if these, if these things are met and then that is an uncomplicated clavicle fracture. So, just a couple of examples here. This is the one I showed you before, this is completely non displaced, you can barely see the fracture, right? Um then there's this one which you can see is a little bit displaced, right? Not completely displaced. We would say complete displacement would be where the two edges are completely separate, but they're still sort of touching. Um and overlapping and said we would call that minimally displaced. Um and then this one just has a tiny bit of a bend to it, but it's still non displaced. So all of these are examples of an uncomplicated clavicle fracture. Even this one I'm gonna I wanna I wanna give you confidence to say this is totally fine, the bones are touching um and it's gonna be completely okay and nobody's going to operate on that. So there are certainly some clavicle fractures that are different, right? So there are a couple that, you know, every once in a while they need to go to the emergency department. So obviously an open fracture um or somebody who has an injury with multiple fractures that person needs to go to the emergency department. We always talk about skin tenting in a clavicle fracture. So this is where the bone is so displaced and point that the bone is literally palpable, right underneath the skin and it's like tenting or blanching the skin, that's more of an emergency. And then certainly nerve vascular injuries can happen with these. They're exceedingly rare. We always have to do a good nerve vascular exam to make sure that there's not any kind of nerve injury underlying there. Um And and again, also extremely rare but possible as a pneumothorax associated with this. Um or of course if there's non accidental trauma, those are the kids that we want to see in the emergency department. Um And then not all clavicle fractures need to go to the emergency department, so lots of them can be managed in an orthopedic clinic because this is almost never an emergency except for the things that I mentioned previously. So the reasons why we want to talk about management and orthopedic clinic there'd be a couple. So number one if there's combination meaning multiple pieces, especially if there's this Z fragment. So this is one of the ways that a clavicle tends to break in a higher energy adolescent injury is if it isn't a Z pattern, so you've got this little combination segment. Um And those are ones theoretically maybe could get fixed, but even probably not, I'm gonna be fixed. Um And then a repeat fracture, Those are also ones that we should probably have a conversation with them about. And then if there you guys probably manage lots of perinatal clavicle fractures that do find in the heel and you know, a couple of days. Um But if there's any if there's any concern for an abnormal motor exam suggesting a break of plexus injury, then those are kids that we should see as well um underlying bone disease. Um And then as we talked about a second decade child with with significant fracture displacement. So if that is broken and shortened and displaced, we want to see those kids and then if it's medial or lateral because those can be a little bit different and a little bit more complicated. Um And then also if you see a child and then 4 to 6 weeks later get another X ray and there's no signs of healing. Those are also good ones for us to evaluate. So I just wanted to um to make you comfortable with like what's okay and what's not okay. So when we talk about non displaced this is this this example up top is non displaced. So the bone edges, even if you can see a fracture, the bone edges haven't really shifted at all. But the middle one here is like 50% displacement. So the the ends are still touching right? It's not it's not shortened at all. The ends are still in contact. That's completely fine. We're not going to touch that even when it's 100% displaced. So on the bottom there 100% displacement is that it's completely shifted. Um And even that is totally fine. Especially if the bone edges are touching then on the bottom. I've I've put these other beautiful drawings here which show complete displacement and shortening. Right? So these are the ones where we should probably see them in our clinic just to discuss options again, still unlikely that we're going to fix it. But at least we have the conversation. Um And so again if it's displaced and shortened then we want to see those kids or if it's the Z fragment or think the the Canadians were involved in naming these. So we call it a zed fragment. Um But those are ones where we want to see them in orthopedic clinic but up on the top half of that screen those are all completely fine. We're not gonna touch them, they're gonna heal beautifully. You guys can manage those. So in terms of the work up um we get a two view X ray of the clavicle right? And then if we do see a fracture, the treatment recommendations would be that if it's a middle third fracture with less than 100% displacement they can and should be treated by PCP. The way that I would manage them would be to immediately let them start doing pendulum exercises. So that's where they lean over and sort of let their arms just dangle just to keep the shoulder moving into let the arms stretch out and they can start doing those pendulum exercises right away. And then you would want to start a range of motion of the shoulder after a couple of weeks to get them start getting their range of motion back. Probably gonna have them in a sling for about four weeks. Especially at school where they can get bumped around. Um And then check a check a follow back straight between four and six weeks. Um And as long as they're healing on the X ray and there's some bone callus. It's for me who can let them go back to their activities in about six weeks. So um and then usually for a follow up again, you see them and examine them between six and eight weeks to make sure that they have the range of motion back and if they're back to full range of motion and pain free then they're okay to go back to their sports. The outcomes are excellent. Um Even in the cases of you know of where the fracture is displaced and shortened, they're not gonna have any meaningful loss of motion or strength. Um You will they will notice that sometimes there's a bump there for a while um Usually can tell parents that that's going to smooth out over time. They may still have always have a little bit of a bump there. But overall complications are exceedingly rare for a simple clavicle fracture. So this is just an example of the normal callus that forms after about a month or so. You'll feel a golf ball under the skin and that's normal. Um And reassure parents that it's just bony callus and it will remodel over time. So we're gonna move on to buckle fractures. Sorry? Okay, so just the radios buckle fractures. This is a six year old child who prevents presents with wrist pain and swelling after a fall on the soccer field and you you feel their risk their tender, you get an X ray and this is what you see. So I want you guys also get very familiar with this X ray, you're gonna see it a million times if you look. Um And this is one of the most common fractures in Children. It may be the most common fracture in Children. Um But you can see this little buckle of the cortex. Okay, so you see on this side, I hope you can see my arrow on this side of the screen um onto the side of the bone. The cortex is smooth and on the dorsal side there's a little ripple. Okay, so you might see that ripple on you know, one or two sides on the ap but only one side on the lateral. Um This is a very stable fracture pattern. It's extremely common. Be on the lookout for it, It's a distal radius buckle fracture. A lot of people call it a tourist fracture. We call it a buckle fracture, potato, potato. Um And this is common in between ages two and 12 and it occurs in one in 25 kids. So again, you're gonna see it all over the place. This is 50% of risk fractures and kids. And what it is is a compression fracture of the distal radius metamorphosis that involves cortical failure without cortical disruption or faisal injury. So, I mean failure in the sense that the that the cortex buckles, but it doesn't crack. So there's no actual complete fracture line. The bone is not cut into pieces, it's just a crunch or buckled. Okay? Um And so generally this is due to a fall on an outstretched arm. Wrist pain is the most common presenting symptoms. Sometimes you'll see some swelling. Maybe some bruising. They'll definitely be tender. You will not see any deformity. So the dinner fork deformity that's not what we're talking about here. The this is completely a normal looking risk. Maybe just a little bit swollen and tender and oftentimes these patients present days after a fall. I see a lot of these kids who are like yeah well they fell and then they were just still complaining of pain five days later So we finally had an X ray and sure enough there was a buckle fracture there. Um And then in terms of your physical exam just to make sure you guys are very confident having a you know knowing the neurovascular exam that we use to make sure all the nerves and everything is functioning in the hand. So when we when we do our motor exam um you know of course we have them. You can do rock papers sir scissors, right thumbs up. A okay and cross your fingers. Um When I'm when I really need to test very carefully I'm making sure that I see that the radial nerve work. So I want to see their E. P. L. Work. And I also want to see their E. I. P. Work. Okay so this and this to me tells me that there's a radial nerve working for their median nerve. I want to see that they can bend their thumb down. Okay so I hold their thumb at the base here and I and I have them bend down the thumb and I do the same thing to the index finger and you can see that the D. I. P. Joint fires. That's the F. P. L. Um I'm sorry the F. D. L. Of your index finger and that's a good media nerve exam and then for your ulnar nerve you can check the pinky finger. Okay so that's my pinky finger. And again I'm gonna hold gonna hold their middle failing so I'm gonna have them bend just at the D. I. P. And that tells me that they're all nervous working. And also I want to see them spread their fingers apart or cross their fingers and that's gonna show me that the that the owner nerve is fine. And then of course their sensory areas right to check the radial nerve function. I test them right over here over the thumb to check their media nerve. I feel on the bottom of their of their index finger here and for their owner nerve I feel them on the side of the owner of the pinkie finger. Um And so that's a good sensory exam. And then for this fracture in particular generally if you push right here over the wrist over the distal radius where they're gonna be tender. Exactly right here. They're not gonna be tender and their skateboard you always want to check that they're not gonna be tender. And the rest of their hand, they're probably not gonna be tender over the owner side. But they're gonna be tender right here over the distal radius. And kids are usually pretty ex explicit about where they're where they're tender. So if you really poke around you'll find exactly the spot that they're tender and that it's gonna be at the spot where the fracture is. And then of course you wanna feel for a good radio pulse as well. Um And so you'll get your ap and lateral wrist x ray that's all that you need. And again you see the compression and bulging of the cortex on the dorsal side. So you see on the lateral view here it's just the dorsal side of the wrist that's buckled. And you can also see it buckled on one side of the ap view as well. But the important thing to note about this is that the volar side, right opposite the dorsal cortex. The volar side of that wrist on the lateral view is completely intact and normal. There is no distinct fracture line. There is no displacement, there is no angular ation. So this is just a plastic deformity that occurs in pediatric bone. You're not going to see this happen in a 60 year old woman. Um so there again that that line right there that I just drew that's the intact bowl or cortex that is not disrupted in this injury. That's what makes it a stable fracture. And again, just another example. So you guys can feel completely comfortable seeing this on X ray. Um You see this tiny little buckle, right? Does everybody see that little ripple in the cortex? So there's a line you can see it okay? So that it's very subtle, so it's a very subtle injury. Um But that's what it is and you should be confident treating that um on your own. You do not need us. And uh so for distal radius buckle fracture, we talked about ap and lateral of the wrist and you only need one, you do not need to repeat this X ray it's gonna be fine. Um There's not really much help of doing a repeat X ray And then really limited or no follow up is sufficient. Again, this is a stable injury pattern, the displacement risk is about 0%. Um and the treatment is just demobilization and activity restriction. So we say no playground in sports and that's really because you know, even even though this is a stable injury, it is it is a weakened area of the bone and it needs time to heal. So if they were to take a fall on it, there's a potential that it could worsen or become a complete fracture and then in terms of their re mobilization. So this is traditionally treated um in a cast or splint for 3 to 4 weeks. Um there have been randomized control trials that show that applying a removable braces equivalent to a cast or splint. So um the cast is no better than a brace in terms of outcome and pain relief. And the brace has higher patient and caregiver satisfaction. Probably a lot of that has to do with the fact that you can give a kid a bath um without worrying about getting a wet cast and uh doing a single x ray and a brace is more cost and resource efficient. Um So you do not need to send them to our office for a cast. You can send them to CVS or amazon, you know send them to dr amazon and have them get themselves a wrist brace and they're gonna be perfectly fine. So recommendation for this um for distal radius buckle fracture it's okay. In fact preferred to treat in a PCP office. You can reply you can apply a removable brace for 3 to 4 weeks full time but removing it for bathing and as they get more comfortable, I think you can also remove it for sleeping. I probably have them wear it for a total of six weeks at school because that's where they're more active And they can certainly return to activity activities as tolerated in four weeks or sorry in 4-6 weeks really if they're going to go back to activities after four weeks, I would suggest that they do so with a brace. Um they do not need repeat x rays and if they're not completely back to normal after about six weeks, you know, we can always check them out, but I've never seen it happen. And this was just a study looking at primary care physician follow up of distal radius buckle fractures and they analyzed 100 80 patients with distal radius buckle fractures um and 88% of them received exclusively PCP follow up. Um And they I think 75% of them required one visit at 2 to 3 weeks. Um Most of them used a splint or brace for less than three weeks and there was high status, high satisfaction with primary care management without the need for orthopedic consultation. So this is literature backed. Um You guys can do it. And the caveat though is that only stable buckle fracture should be treated this way? So what is the stable buckle fracture? Well, most importantly it's no lucent line extending through the bone. Okay, so again this is that classic x ray of the buckle fracture, there is no cortical disruption, right? There's no crack, there's a crunch, but there's no crack or line through it and it's over a centimeter from the Fyssas and there's no angular deformity or displacement. Now the only thing would be if a really little kid gets this like if you've got a three or four year old old with this injury. Sometimes their little arms just don't work so well in a brace. Um Or they are troublemakers and they take it off and you might need a cast in order to really protect a kid that age. So um if it's a very little kid who needs a cast, then you know, we can certainly do that because the braces aren't always perfect for every age group and then a couple other things to just be wary of. So be wary of the imitators, right? This is a distal radius green stick fracture. You can see in this one it's it's not just a buckle, it's bent as well and this one is mild and if you just treat it in a brace, that would be fine. But there are some that are actually bent significantly. Um And then we, you know, want to have the conversation at least lay eyes on it to make sure it's not too much angular ation. Um And then this is a complete fracture. So you can see the difference in this one. This one has a line, a fracture line that goes all the way through the bone. And what happens with this one if you ignore it is it becomes this and then that's a bigger problem. Um And then this is a feisty old track, right? So this is a distal radius salter Harris to fracture, you can see the fracture line that I've drawn there. Um And that is also one that we need to be on the that we need to have eyes on. And pretty quickly to any fight still fractures that are displaced. We need to deal with urgently because we don't want to be reducing a growth plate after a you know sooner is better for sure. Um And then next we're gonna go on to ankle fractures and then we'll be wrapping it up in a few minutes. Um Time for questions. So I want to talk about that cannot rule out Salter Harris one distal fibula fracture, right? This is everywhere on x rays. So Um ankles are not quite as common in terms of fractures but they're sure common injuries. Um and ankles represent about 5% of childhood fractures, but about 20% of faisal injuries, these are usually sporting injuries from basketball, soccer, football, scooters, etc. Um And they have a higher incidence with increased B. M. I. Just because kids are have bigger force and maybe maybe less balanced. Um And these are often low energy injuries. Um But just wanted to make sure you guys are comfortable with the anatomy of the ankle. So you've got your tibia, your fibula and your tail list underneath here, this is your tibia growth plate. And this right here. The other arrow is your fibula growth plate. Um And then this is also this is the Salter Harris classification, right? So you guys are all probably familiar with this but the Salter Harris one fracture is the one that goes straight through the growth plate. The Salter Harris to is through the growth plate and up into the metamorphosis. The Salter Harris three is through the growth plate and down into the joint line. The Salter Harris four is from the metamorphosis through the crisis and down into the joint line. And the five is that crush injury of the crisis. So we're gonna be talking a little bit about these presumed salter Harris one fractures of the distal fibula. So um Children have unique physiology and biomechanical properties of the ankle. Um There ligaments structures are actually pretty robust, but again the faces that biomechanically vulnerable spot and twisting injury that can cause an ankle sprain and an adult, right? Where you where you've injured, your ligament may cause a fracture instead in kids, through that growth plate, through the distal fibula growth, like though we always everybody always says I was probably a non displaced Salter Harris one fibula distal fibula fracture, but we think it's probably a lot less common than than we used to believe. So, so distal fibula fractures have been looked at and they're probably vastly over diagnosed in Children with negative X rays. So every kid who enters their ankle and has pain and difficulty walking. You know, they get an X ray and it's normal and then the radiologist says cannot rule out non displaced Salter Harris one faisal fracture. And so every kid thinks they have a fracture and that's probably not true. Um And there was a 2 to 2016 M. R. I study that found only 4% of these were actually Salter Harris one fractures and 80% were sprains. So even though we used to think oh kids get Salter when fractures, not ankle sprains probably not true. Probably most of these kids are still just getting ankle sprains even though, yes some of them may be fractures. Um But that can be really difficult to sort out and it probably doesn't make that much of a functional difference. Um The kids who didn't have the fracture had bone contusions, small little avulsion fractures, like a little fleck of bone that gets pulled off from the ligament which is just the equivalent of having an ankle sprain. So for these low risk ankle injuries um you know in terms of how to examine them, well the kid may not be able to bear weight. Their ankle may look like this bruised and swollen ankle up top here. The bruising is very common laterally. Um But things like medial or plantar Eskimo sis are less common and more concerning or if they're tender immediately right, that's not as normal. So those are kids that we might want to evaluate. Um And then you really want to be specific about, you know, where are they tender. So I've I've I've tried to do, I've did a very terrible drawing right here but I'm gonna hopefully you guys can see these the structures that I've drawn here. So when you when you examine them you really want to be very specific like touching with one finger, not just sort of feeling the ankle as a whole, but really really being very specific about where your pal painting them to get a sense of what's injured. So if you tap on the on the towards the bottom of the fibula over the growth plate tapping on that bone and that causes if that causes a lot of pain that it may be a soldier Harris one fracture. Whereas if they're more tender, like at the tip of the fibula over the bottom or the front that's more of a ligament injury. Um Sometimes they're even tender along the back of the fibula where the peroneal tendons run. So that may be a perennial tendon strain um or in the front of the ankle joint which is more likely to be just a, you know, a joint center Vitus or something. So you want to be very um disciplined and sort of poking in very specific spots and that will give you a better sense of what you think the injury is. So if there's ankle swelling tenderness and difficulty weight bearing you should get an X ray. Um But if it's negative really let the physical exam guide you. So if they are tender over that distance I feel a growth plate right in the bottom area of the bone then maybe it's a fracture. Um But if they're tender moreover the A. T. F. L. Right? So at the at the tip of the fibula in the anterior edge of the tip of the fibula or along the back of the perennial tendons. Um Then those things may not be a fracture. If you really think if you think it's a fracture then you can put them in a cam boot. Have them be weight bearing is tolerated. They can remove the boot for sleeping, showering or resting. Um they might want to wear the boot for you know 3-4 weeks until they're pain free. And then probably should be activity restricted for 4-6 weeks. But if you think this is more likely an ankle sprain based on your exam then we would recommend you know a boot for comfort but um activity as tolerated and winning the boot as as tolerated. Um They may not even need a boot if they're okay to walk. Uh And then if they're not getting better as fast as they'd like. Or if it's a high level athlete they need to get back to their activities then you can send them to physical therapy right? I just wanted to get you guys comfortable with with a couple of ankle X rays here. Right? So I've I've list the first one I I have here is fracture. Question mark. So this is a normal X ray with no fracture that you can see. But this is the one where they're gonna say cannot exclude Salter Harris one disa fibula fracture because it's such a thought to be such a common injury. Um And we wouldn't see it even if it was there because the fracture through the growth plate. And then the middle picture is actually of a Salter Harris to fracture. So, that's that little you can see this little abnormality at the distal fibula metamorphosis and that's a fracture that goes through the growth plate. But then up into the metamorphosis. Um That is also a totally stable fracture treated with a boot. Um Keep them, you know, activity restricted for six weeks and then let them go back at it. Um And then the last X ray here on the right side is fracture and quotation marks because that'll get read by a radiologist as a as a fracture. But it's really what we call a little avulsion fleck injury. That's what that's what happens from an ankle sprain when a ligament pulls off the bone. And that's going to pull a tiny little fleck of bone with it. So, it's not really a fracture so much as a sprain, right? But these are all low risk. Um And uh they can be treated in a boot. So again, the first one is a soldier's one or maybe a sprain. The middle one is a non space Salter hairs, too. And the last one the right side is avulsion fracture which is basically a sprain. All right. And then the outcomes of these ankle injuries are great. So the distal fibula growth plate is extremely robust. There is no growth arrest with a non displaced salter Harris one fracture. Right? Unlike other growth plates. The distal femur, the distal tibia. They shut down if you look at it wrong. Um But the distal fibula is very robust and it's not gonna have any kind of growth plate problems over time. Um And then you know physical therapy can be helpful and we would when I prescribe it I just prescribe it with no ankle range of motion strengthening stabilization, pro perception. And you can do that if they're not recovered in six weeks. But most of the time kids are going to get better on their own. Um And then when to refer. So certainly any displacement. Um Or if the radiologists read it as you know joint joint, space widening or something like that. Those are those are injuries that we definitely want to see. Um If there's any tibia sided injury. Those are things that we want to see. Um And then sometimes kids will get recurrent ankle sprains. So even though they're simple sprains they're happening over and over again and those can be a problem because you're developing an incompetent ligament or sometimes your current ankle sprains can indicate a structural abnormality, like a parcel coalition and then if they're having persistent pain. Also sometimes they can have a tailor O. C. D. Or something that may warrant an M. R. I. And evaluation evaluation. And then just a random note as well. Since we're talking about kids fractures, just a plug for checking vitamin D. Vitamin D. Insufficiency is really common um And it is likely related to fracture risk in kids. So we recommend, you know if you see a A kid with either two fractures in childhood or fracture less than three years old, certainly any kid with a stiffy slowly or fractures requiring surgery then checking vitamin D. Is always helpful. We think that under 30 is insufficient and recommend supplementing and and rechecking. Um So I think that that's it for me. Um So just in summary, the pediatric primary care provider is the front line of the of evaluated musculoskeletal conditions and Children. You can treat these right just a radius buckle fracture and put a brace on it, clavicle fracture, put them in a sling for a couple of weeks ankle injury, put in a boot. Um And then when you do need us this is our number um for my clinic, my cell phones there and uh and then you can also get a hold of us that any of these locations were all over the place and um this is just the slide of how to refer the patients to UCSF So thank you guys and happy to take any questions. Yes thank you dr Livingston so if you have any questions please feel free to put them in our Q. And a function. Um dr johnston I saw that you had put a question earlier. Sorry we couldn't get to it. We're waiting till the end if you want to like um specify what those repeat images would before you can go ahead and put it in. Okay. Perfect thank you. Okay so we have one. It wasn't a question but it was something that was um alluded to. It says biggest problem. Parents don't want to pay for splint in the office and want referral to Ortho overcast since it's covered by their insurance. Do you have any? Yeah I mean so we certainly run into this problem um when we're trying to get like specialized orthotic devices that need to be delivered by our Ortho tous test but these things are all ordering all on amazon for extremely you know low cost or at least the wrist brace is under $20. A sling is certainly under $20 and um and then the cam boot is a little bit more, it's about $60. Um And many people will have insurance that pays for something like this from an orthodontist. So there are some people who are lucky enough when they show up we say yep your your boot is covered. It is $0 included with the price of your visit. That's great. But there are a lot of people who aren't so lucky and it's actually pretty common that insurance companies don't cover any DME. And then to get it through our orthotics ist is gonna be like $800 or something outrageous like that. And so what we do is we say here's the here's this listing on Amazon, go ahead and you'll have it by tomorrow and by yourself. So there are a lot of patients that even we end up recommending that they buy it on Amazon themselves and for you know for the wrist brace it's no different getting the amazon one versus the fancy exitos brace that you know some of our patients can get if they if they have the right insurance coverage but it's really no different. Um The brace, the braces that you can get on amazon are perfectly acceptable and there are eight 1000 options. Um So I don't have any particular brands of slings or braces that I would recommend because there are so many of them. Um But I often recommend to parents that they you know maybe order a couple and then return which one you know return the ones that don't fit as well. Um And then um and then also they always get injured right before going to hawaii and so have them by a pool brace and a dr grace. Um And you mentioned that there are a lot of brands. Are there any in particular that you would recommend? People are asking for if you could share a list and maybe you can send that to me and I can share that if you have any particular said clavicle, uh what brand of sling for clavicle fractures or finger splint? Any recommendations? Yeah. So for the, I mean, again, I, the brands I just put actually think I put like, you know this, this is just one, right? But I mean I literally just put this up as an example. I have no idea what brands um and there are some that are, you know, you just don't want the super short ones. That's what I tell parents is when they're ordering them. Don't don't, there's some that look like really short and that only, you know, go to like this distance and the risk, you're only one as long of a brace as you can. So ideally, you know, one that that is suited to go down at least like midway down the forum is best. Um And then I just, you know, this is an example of a of a cam boot. But I mean, I think honestly that the what ends up telling us like which one they should get is the one that's going to be available by tomorrow on amazon. So and then this is also like a a nice little sling that sort of keeps them at the side. There are some slings that you know have the the swath that keeps them um that keeps the arm down to the body. Those are helpful in the beginning but you don't you don't need um to be secured to the body the whole time. Um So again it's it's really just up to patient and parent preference. Um And then first you know, finger splints. Um I don't again I think in the beginning if they have a really tender swollen finger, the alumina foam splints can be helpful. But one thing that we don't want to see is if you have a stable finger injury, like if you get an X ray and there's no fracture, we don't want to see that finger mobilized for too long. Like if they just have a you know a damned P. I. P. Joint, a finger sprain a big swollen finger, we actually want that to start moving. Um And so if you get an X ray and the and the finger is a finger X ray is normal. Um Then I would just have them buddy taped until their pain is gone because you actually want them to get moving so that the thing doesn't get too stiff. So pretty much every time we see a kid in here with a finger injury who comes in a big splint, we throw it right away because we want to get them moving. Um And for pretty much every finger injury that's a non op treatment. Um We're gonna we're gonna go with buddy taping on that, but certainly for a couple of days, the loom a foam splint can be helpful while they're still very um still in a lot of pain. And then um I see a question here about how many times per day to do the pendulum exercises. There's no magic number, but certainly doing it a few times a day just to let the shoulder sort of hang out and um and let the elbows stretch out and relax. That's good. But I don't um you know, the kids tend to get their motion back regardless and um I don't think we need to prompt them too much, you know, as soon as they start feeling better that sling is gonna be coming off more and they're gonna be moving around more naturally. So, um I think that the pendulums are just good to to give them permission, you know, to come out of the sling a couple of times a day and just let that arm hang and and and uh and stretch out of it. So, what's the difference between an ankle sprain and a high ankle sprain? And are there treatment differences? Yeah. So there are the high ankle sprain refers to a cinder asthmatic injury. Um So there's the complex system of of ligaments between the tibia and the fibula that keep the ankle joint stable alright. They keep the keep the fibula sort of glued to the tibia and and keep that ankle nice and tight, so a high ankle sprain is going to be something that's higher up in the leg. Um It's not the it's not the ligament down at the tip of the fibula, so the one that I'm talking about is pain at the very bottom of the bottom of the fibula right like at the bottom of the ankle joint. Um And so that's a regular regular old ankle sprain, the A. T. F. L. But a high ankle ankle sprain where you have a child who's got pain more a little bit higher up above the ankle. Um That's something where we would worry about a high ankle sprain and the treatment difference, there are treatment differences. I mean, we're gonna we're gonna treat the high ankle sprain more aggressively because we need that ligament to heal. Um The treatment for like a low ankle sprain is just sort of functional rehab and uh ankle strengthening to get back to normal activity. And then question here when our ankle support braces needed. Um I assume you mean like the lace up ankle brace and that can be helpful for a kid who has an ankle sprain who maybe doesn't need a whole big cam boot if a kid is walking around comfortably, but just with a little bit of a limp um or even just a little bit of discomfort after an ankle sprain then one of those lace up ankle braces can be helpful. Um But uh I'm like for a kid who really like has difficulty ovulating or feels like they need crutches, the bigger cam boot is going to give them more support and is going to make it easier for them to um to start walking, get getting back on their foot again. So I would say, you know, if a kid comes in with crutches, it's actually probably better for them to be weight bearing on the foot in a boot as opposed to non weight bearing with crutches. So I would encourage them to get off the crutches walking in a boot and then take off the boot as you feel more comfortable walking. And then sometimes that ankle braces nice as a transition when they don't feel like they need the big boot anymore, but when they feel like they want to get back to a little bit more activity but don't feel quite as strong as normal yet. Great. So if there's any more questions, you can go ahead and put them in the Q. And A. Um And I just want to remind everybody again, um after the at the end of the webinar, um you will see a link to zoom zoom link that will pop up and that will be to the evaluation, please make sure you fill that out if you're unable to do that um today you can we will receive an email tomorrow that will come to your email box from the same email address as your invite, and so please make sure you fill those out so you can get CMI credits. And if there's no more questions then I'm just gonna thank Dr Livingston for a great hope. There's someone coming in. Oh no, they're just saying thank you. Um I just want to say thank you Dr Livingston and um thank you everyone for joining us and have a great day. Thanks everybody. Nice to talk to you. Have a good day. You too.