Post on 27-Sep-2020
Things People Report that the
School Nurse Said to Them
J. Jay Crawford, M.D.
Knoxville Orthopaedic Clinic
Knoxville Orthopaedic Clinic
www.kocortho.com
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• Text “kocnow” to 61234.
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our appointment request.
Here’s what people say the School
Nurse didn’t say to them
• 1) “Your child is hurt. Please come
to the school to pick him up and
take him to the doctor.”
Topic #1: “Your child is hurt. Come
pick him up and take him to the
doctor.”
Are we worried about bumps and
bruises? Not really.
What we are worried about are
fractures. And, many fractures do not
seem like fractures on initial
presentation.
1. Upper extremity fractures
• Forearm/wrist
• Elbow
• 2. Lower extremity fractures
• Ankle
• Foot
Fractures seen by school nurses
Forearm/wrist
• Conventional teaching: forearm in little kids,
wrist in older kids may not be true anymore
• Most common fracture in school age children
• Most common mechanism: trip and fall from
ground level
• Frequently missed at initial presentation
Forearm/wrist
Forearm/wrist
Elbow fractures
• Classic ages: 5-11 years old
• Most common mechanism: FFMB
• Warning! Big trouble! Surgery
highly likely.
• Send to doctor/ER everytime.
Supracondylar fracture
• These frequently look pretty scary
• They are very scary
• High rent district: lot of important
nerves and blood vessels
• Only Pediatric Orthopaedic
Surgeons will take care of this.
Supracondylar fracture
Lateral condyle fracture
• Less impressive visually
• Much harder to fix
• Worse outcomes
• Almost always needs open surgery
Lateral condyle fracture
Radial neck fracture
• Frequently missed
• No big deal
• Heal quickly
• Almost never require surgery
Radial neck fracture
Ankle fractures
• Ages 4-15
• Younger patients get lateral malleolus fractures
• Older patients get bimalleolarfractures
• 13-15 year olds get transitional fractures
Lateral malleolus fractures
• Ages 4-10
• Very common
• Very frequently missed
• Often dismissed as a “sprain”
Lateral malleolus fractures
Bimalleolar fractures
• Less common and much worse
• Often require surgery
• Typically older kids—10-15
Bimalleolar fractures
Transitional fractures
• 11-13 year old girls and 12-14 year
old boys
• Complex fractures frequently
missed
• Virtually always require surgery
Transitional fractures
Foot fractures
• First and fifth metatarsal fractures
• First metatarsal fracture in 2-5 year
olds
• Fifth metatarsal fracture in 8-16 year
olds
• Rarely require surgery
Fifth metatarsal fractures
Topic #2: “Your child has a spinal
deformity.”
• Children often develop scoliosis between
ages 9-14.
• Scoliosis is often suspected based on
asymmetry of the shoulders, scapula, or
waist.
• Scoliosis almost never causes pain.
Scope and Incidence
• Scoliosis is spinal asymmetry in the coronal plane—not a specific disease, rather a family of similar diseases.
• 4-14% of all kids have some degree of measurable spinal asymmetry.
• 2% of children have “scoliosis” (>10 degrees of spinal asymmetry).
• 14-40% of those children need some form of treatment (Orthopaedic literature).
• Other disciplines (eg: Chiropractic) present wildly varying estimates.
• Scoliosis is not one thing—it is many, many things.
Goals
• Understand the family of diseases
that cause scoliosis.
• Develop an algorithmic approach.
• Minimize expense and radiation
exposure.
• Identify what needs referral vs.
reassurance/observation.
Types of scoliosis
• Non-pathologic spinal asymmetry
• Adolescent idiopathic scoliosis
• Juvenile idiopathic scoliosis
• Infantile idiopathic scoliosis
• Congenital scoliosis
• Neuromuscular disease (Cerebral Palsy)
• Myelodysplasia
• Tumor (typically benign)
• Neurofibromatosis
• Spondylolisthesis (Olisthetic)
• Diskitis/Infection
• Fracture
• Congenital defect
• Dwarfism
• Connective tissue disorders
• Muscular dystrophy
• Others…..
Algorithmic approach
• School screening: worthwhile or not? No firm
answer.
• Primary care provider: inspection, test flexibility,
ubiquitous forward bend test, consider
scoliometer.
• When to refer?
• Four main variables are severity, maturity,
progression, associated symptoms.
• Xrays? MRI?
Adolescent Idiopathic Scoliosis
• Age: 10-16
• Sex: 90% female
• Ethnic: Most common in Caucasian, then
Asian, then African-American
populations.
• Familial incidence is an important
consideration.
• The big questions:
– Is it bad?
– Is it getting worse?
Adolescent Idiopathic Scoliosis
• What is the goal?
– Less than 40 degrees at skeletal
maturity
• What are the treatments?
– Observation, bracing, surgery
• Who gets what treatment?
– Old and mild: observation
– Young and stable: observation
– Young and progressive: bracing
– Over 40 degrees at any point:
surgery
Juvenile Idiopathic Scoliosis
• Onset less than age 10.
• Highly associated with intra-spinal
pathology?
• Deserves MRI at first visit.
• Very high rate of progression and
needing surgery.
• Brace almost 100% of these kids.
• Surgery on over 50%.
Infantile Idiopathic Scoliosis
• Scoliosis at birth or in first
year.
• Can be very problematic.
• Sometimes spontaneously
remits.
• Surgical options are not
good.
• Bracing is very difficult.
Congenital Scoliosis
• Scoliosis at birth due to structural
defects.
• Usually does not require surgery.
• Bracing is not an option.
• Surgical options frequently require
excision of a hemivertebra.
Neuromuscular scoliosis and others
• Bracing generally not an option.
• Treatment is either observation or surgery.
• Surgery can be more difficult/complicated,
but is associated with major improvements
in quality of life.
• Scoliosis is very frequently associated with
other musculoskeletal problems that
require Orthopaedic treatment.
• Early referral is highly recommended.
Treatments
• Test or treat?
• Observation
• Brace
• Surgery
– Surgical options have gotten much
more effective and risks have become
much lower over the past 20 years.
Topic #3: “Your child is complaining of
back pain.”
• Back pain is a symptom, not a disease.
• Many conditions can cause back pain
(spondylolysis, diskitis, kyphosis, etc.)
• This talk specifically discusses the work-up of
back pain and treatment of mechanical back
pain.
• Incidence of back pain in pediatric and
adolescent populations is estimated to be
between 8-18% per year (no recent studies).
• Infrequently a cause of significant pathology that
requires treatment.
Comorbidities/Differential diagnosis
• Obesity
• Deconditioning
• Backpack wear
• Posture
• Overuse/Misuse/Abuse
• Kyphosis
• Spondylolysis/Spondylolisthesis
• Scoliosis
• Diskitis/Infection
• Leukemia
• Fracture
• Congenital defect
• Dwarfism
• Referred pain
• Rheumatologic
• Others…..
Do backpacks cause back pain?
• Yes. But, who cares?
• Numerous studies in last ten years.
• Consensus that increasing weight (30% of child
weight) is positively associated with back pain,
but not with treatable pathology.
• Treatments are to reduce weight, to use both
straps, and to wear the back pack in a “high
carrying” position.
Do backpacks cause back pain?
Mechanical back pain
• This is where the money is.
• >80% of all back pain that leads to healthcare
encounter.
• Associated with overuse/misuse, obesity,
deconditioning, poor posture.
• Key is an algorithmic approach and minimization
of expenditures and medical testing.
Algorithmic approach
Treatments
• This is where we start. Think backwards—what
tools do I have and which one(s) should I use?
• Test or treat?
• Observation
• Medication
• Brace/Cast/Rest
• Physical Therapy/Fitness
• Surgery