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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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