Things People Report that the School Nurse Said to Them. J. Jay Crawford, M.D. Knoxville Orthopaedic Clinic

Transcription

1 Things People Report that the School Nurse Said to Them J. Jay Crawford, M.D. Knoxville Orthopaedic Clinic

2 Knoxville Orthopaedic Clinic

3 Use our App Text kocnow to You will immediately get a link to our appointment request.

4 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.

5 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.

6 Fractures seen by school nurses 1. Upper extremity fractures Forearm/wrist Elbow 2. Lower extremity fractures Ankle Foot

7 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

8 Forearm/wrist

9 Forearm/wrist

10 Elbow fractures Classic ages: 5-11 years old Most common mechanism: FFMB Warning! Big trouble! Surgery highly likely. Send to doctor/er everytime.

11 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.

12 Supracondylar fracture

13 Lateral condyle fracture Less impressive visually Much harder to fix Worse outcomes Almost always needs open surgery

14 Lateral condyle fracture

15 Radial neck fracture Frequently missed No big deal Heal quickly Almost never require surgery

16 Radial neck fracture

17 Ankle fractures Ages 4-15 Younger patients get lateral malleolus fractures Older patients get bimalleolar fractures year olds get transitional fractures

18 Lateral malleolus fractures Ages 4-10 Very common Very frequently missed Often dismissed as a sprain

19 Lateral malleolus fractures

20 Bimalleolar fractures Less common and much worse Often require surgery Typically older kids 10-15

21 Bimalleolar fractures

22 Transitional fractures year old girls and year old boys Complex fractures frequently missed Virtually always require surgery

23 Transitional fractures

24 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

25 Fifth metatarsal fractures

26 Topic #2: Your child has a spinal deformity. Children often develop scoliosis between ages Scoliosis is often suspected based on asymmetry of the shoulders, scapula, or waist. Scoliosis almost never causes pain.

27 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) % 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.

28 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.

29 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..

30 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?

31 Adolescent Idiopathic Scoliosis Age: 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?

32 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

33 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%.

34 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.

35 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.

36 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.

37 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.

38 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.

39 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..

40 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.

41 Do backpacks cause back pain?

42 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.

43 Algorithmic approach

44 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