Transcription:
Acute Evaluation of Sports injuries and What to Do in the Office

Dr. Michael Smith (Host): Sports injuries, what to do in the initial office visit. This is Pediatrics in Practice, the podcast from Children’s Mercy. I’m Dr. Mike. Let’s talk with Dr. Donna Pacicca, a Pediatric Orthopedic Surgeon at Children’s Mercy. So, sports injuries, as a general practitioner, these are tough for us. And so, having you on to really help us walk through that initial visit, I think this is going to be a fantastic conversation. So, let’s start off, what information is really needed for a good history for sports related injuries? Like what questions should providers ask?

Donna Pacicca, MD (Guest): Well the first thing I do is I ask the patient what they were doing when it happened. Were they in a game, were they at practice, was it a contact injury versus a noncontact injury, was it just a bunch of kids getting together in the back yard versus an organized injury? That gives me an idea of what the level of play was, what the mechanism may be and how much trauma happened.

It’s one thing when you have a kiddo on a trampoline, gymnastics practice versus somebody getting tacked on a football field versus somebody just dancing in their backyard and having a misstep and falling down some stairs. So, that can be really helpful to give us some information.

Host: Now often obviously in the pediatric population, usually the parents are in the room as well and they like to answer for the child. Tell us a little bit about like how do we work around that? I mean do you have any advice on how we can really listen to the story from the child’s point of view?

Dr. Pacicca: Yes. So, that’s always tricky because parents are super enthusiastic, and I respect that being a parent and enthusiastic. But I usually ask them to let me get the information from their child first because I want to hear from the primary perspective and then I will turn to them and say, tell me what you saw. Ask them if they were there at the time and then what they saw and what did they see if they weren’t there. I will ask the child like if a child comes in with an acute knee injury; did it swell up right away, were they able to walk on it. Ask the parents if the kid looks blankly at their parent, I will ask the parent did you see swelling right away or things like that.

And I will also ask if anybody saw an obvious deformity at the time of the injury. Sometimes it’s really hard or sometimes they have video tape. Parents carry their smart phones around and are constantly recording their children. So, sometimes that can be super helpful, horrifying but helpful to look and see the injury as it happens.

Host: Let’s move the conversation into the physical exam because this is another tough one for the general pediatrician, general practitioner. You see that it’s obviously bruised and swollen, let’s say it’s a knee or an ankle and that’s pretty much what we write down in the chart, right? We don’t feel always that comfortable examining something that’s bruised and swollen. So, what really constitutes a good exam for sports related injuries?

Dr. Pacicca: Well the nice thing about what I do is there’s always the other side to compare it to. So, I always like to look at the uninjured side. That also helps the patient be a little more comfortable with what they are going experience and so, like for example an elbow injury. I will ask them to go through a full range of motion and not whether they are able to hyperextend on their side as a lot of kids can do and whether or not they have any pre-existing abnormalities. Because every so often I get a kid that doesn’t have full extension. They can’t straighten out their arm all the way and they might have some pre-existing condition like a congenital radial head dislocation. I put them through forearm rotation as well because that can be important there.

And then when I go to the injured side, I try to not go directly for the area that’s bruised and swollen but try to palpate around and think about applied anatomy. So, anatomy for orthopedic surgeons is really the key to what we do. So, it’s about putting together where does it hurt, what’s there and knowing where your muscle tendon units are, where your ligaments are and how they work and so that’s super important.

So, what I usually get them to do a range of motion first and if they can go through a full passive range of motion, but they can’t do it actively; that may imply that you’ve got pain limiting movement or muscle weakness. But if you have a blocked passive motion; then that may indicate some derangement of that joint or a joint contracture if it’s longstanding and that can be helpful to delineate that.

Host: What about when the patient doesn’t want you to touch them? Like sometimes it’s painful, right, and they are automatically you start approaching them and they are crying, whatever that is. So, any advice on how to work around that?

Dr. Pacicca: Yeah, sometimes that tends to be more for the much younger kids. Usually the older kids can do that. Sometimes I have that, because I’ll get kids who are special needs that may be active. So, sometimes I will enlist the parent to help out with that. I tend to try to work proximal – from proximal and distal to the area. So, if they are really nervous, I’ll put my hand like on their flank or their thigh to say heh, this doesn’t hurt right. Or down on their ankle if I’m going towards the knee and then we try to mark out where’s the spot that’s really tender.

Every so often, we get kids who also have amplified pain and so that can be really tricky and so, being able to see whether it’s a pressure that hurts them or if it’s just light touch then I know they have some allodynia and we may have to work around that, and I might not be able to get a good exam. And that’s okay. I mean sometimes I think people think that you have to have a complete exam and sometimes you can’t get a good exam because the kid’s too swollen and so in that situation; I try to make sure that there’s nothing that’s problematic like a fracture that’s going to interfere and try to get them maybe into a little bit of therapy first and then see them back in a week or two and reevaluate.

Host: Right. And I think this is a good lead in then into when is it appropriate to do some imaging studies? Right and I know again, thinking about the general pediatrician. We might want to that right away because that kind of takes the place of the exam for us in a sense. But I know it’s not always appropriate. It is radiation. We do have to think about that kind of stuff. So, what are some of the guidelines there?

Dr. Pacicca: Yes. So, there’s some variability. Like MRI is really tricky. Everybody loves to go to MRI. I start with plain films because I want to make sure. Fractures are fairly obvious and that can help guide you and sometimes there’s some bony findings that you can see that help to guide you towards whether or not you need to have some advanced imaging. But I don’t generally jump straight to advanced imaging unless it’s a patient of mine that has an ACL reconstruction that had a reinjury and we are concerned that they might have re-torn and that would be something that I’d probably go straight to MRI.

So, I think if you start off with plain films, I think that can give you an idea at least tell you that there’s nothing terrible going on. Not everything needs an MRI right off the bat. So, I think being able to get them started in some therapy and being able to reevaluate can be very helpful. The hard part is the pushback you get from families who think that everybody needs an MRI in the emergency room. So, it can be a little tricky.

But the MRI isn’t really an image in the same way that an x-ray is. So, it’s really interpreting the response of hydrogen atoms in the body to the magnetic field that’s being passed through them. And so, it’s really more like I explain to my parents, more like an impressionist painting in some ways. You have an idea of what might be going on, but it doesn’t necessarily help you. You have to correlate it with that physical exam.

Host: Yes, of course. So, here’s I think the big question for a lot of the generalists out there. At what point, or do you have some guidelines for us when we should definitely refer the patient to a specialist like yourself?

Dr. Pacicca: Yeah so, I think if you have a situation where you have a kid that comes – I mean obviously fracture, like a displaced fracture, there is definitely something that probably needs to be referred on to one of us. I think if you have a situation where you had a kid that had an injury to their knee, they had an acute effusion; usually what causes that is patellar dislocation, fracture, ACL tear or big meniscus tear. And so with an immediate effusion especially if they are not able to walk on it; those are kind of worrisome things and so those probably need to see somebody like a sports medicine provider sooner rather than later.

Same thing like when we think about ankle injuries, ankle sprains; if you have somebody that comes in and has an ankle injury but they are really swollen and they are really hesitant to put any weight on it compared to the kid that can kind of muddle along; those are kids that I worry about who may have more severe ankle sprains that could go on to some chronic instability or potentially a fracture that may not be very readily apparent.

And then elbow is another one that’s always tricky. Kids that may have had – especially throwers that may have had a prodrome of pain who have a sudden onset, loss of velocity, probably to have some evaluations soon. Gymnasts who are complaining of not being able to straighten their arm or having an acute pain; I worry about loose bodies and issues there that may need further evaluation quickly.

Host: So, Dr. Pacicca, in summary, what would you like the general practitioner, the nurse practitioner, the general pediatrician, what would you like for them to know about sports injuries?

Dr. Pacicca: Well, I think the most important thing is the kids really want to get back to doing what they do best because it’s their big coping mechanism. So, anything we can do to get them moving quickly are going to be important. I think being able to get them to a provider who can help them out or even get them started with some therapy and get them along to back to where they are from, I think is going to be a good thing for them. And I think don’t hesitate to refer them on when you are concerned because most of these kids don’t tend to complain about a lot of things because it keeps them out of their sport.

So, if they are complaining about something, take it seriously.

Host: That’s Dr. Pacicca. She’s a Pediatric Orthopedic Surgeon at Children’s Mercy. Thanks for checking out this episode of Pediatrics in Practice and please visit www.childrensmercy.org to get connected with Dr. Pacicca or another provider. If you found this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you and be sure to check back soon for the next podcast. I’m Dr. Mike. Thanks for listening.