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Dr. Mike Smith (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Mike. And with me is Dr. Kevin Latz, a pediatric orthopedic surgeon from Children's Mercy. Together, we'll be discussing the critical topic of acute musculoskeletal injuries in kids—assessment, imaging, and return-to-play. Dr. Latz, thanks for joining me today. What are the most common acute musculoskeletal injuries that you see in pediatric patients?

Dr. Kevin Latz: Well, most of our injuries are fortunately not fractures. They are muscles strains and sprains as you get in adults as well, but we do see a fair number of fractures as well.

Host: And any body part, especially in kids, that seems to always be the area of injury?

Dr. Kevin Latz: Well, certainly most kiddos are falling on an outstretched arm, so we see a tremendous number of wrist injuries. We see also quite a bit of knee injuries as well, less fractures and more kind of sprain, strains, and other kind of ligamentous injuries in the knee.

Host: Yeah. I bet it probably depends on the age group too. I'm sure as you move into the pre-teens, teenagers getting into athletics, maybe you start seeing more lower limb, ankle sprain, stuff like that.

Dr. Kevin Latz: That's exactly right. Most adolescents and periadolescents are not falling on an outstretched arm like the fours and fives and six year olds are. And so, the injuries go, honestly, from fractures to more, you know, the ligamentous and muscle injuries as you get in adolescence.

Host: How do the patients typically present to you? You know, at this point, the parents have seen it, maybe a pediatrician has seen it. But when they come to you, what are they presenting with?

Dr. Kevin Latz: If it's from a pediatrician, it's often they just haven't recovered in the timeframe that was anticipated. You know, they're still limping. A couple weeks later, they're still having that knee pain and swelling. It's been a week, it's been 10 days. If it comes from the parent, it's typically they witness the fall on the playground or during the sports activity and just want to make sure that they're not missing a fracture.

Host: That's interesting. So, time, let's talk about timing here. At what point should a parent seek care? Should a pediatrician reach out to somebody like you? Is it the five, six, seven-day period and there's still issues or is it a little longer? What do you think?

Dr. Kevin Latz: No, I think that's actually quite a reasonable timeframe, I guess with the caveat that swelling's never normal. So, a big swollen ankle after an ankle sprain that, you know, is still there three or four days later. If that patient isn't now able to weight bear, that probably mandates a referral and maybe even an x-ray.

Similar in the knee. If you have a knee injury and it's tender but not terribly swollen, that's one that can probably wait frankly a week or so, and just make sure that it doesn't recover on its own. But any significant swelling in a knee or even an ankle probably should be referred pretty quickly in the next day or so.

Host: Let's talk about the pediatrician for a moment, because obviously this is your gatekeeper for a lot of this stuff. What steps should they take during the initial assessment of an acute injury before they reach out to you?

Dr. Kevin Latz: So, the acutely injured child exam is very much an art form. It's a lot of observation. It's a lot of asking them to move and seeing if they can. And then, the last thing is typically palpation. So, the growth plates in the wrist and the ankle are at the end of the bone. So, in the forearm, it'd be right above the wrist, right above the carpal bones, if you will. In the ankle, it would be just above the ankle joint itself; and in the knee, similarly just above the knee. So, palpation right where you think that growth plate is probably mandates a referral at that point in time, but it's really just not recovering or more swelling than you'd expect mandates a referral on down the road, I think.

Host: I like how you said that the art of examining a child, especially one after an injury. That would make a good title of a book, Dr. Latz, right? Because that's how I feel with pediatrics. No matter what's wrong, it's the art of exam with them, much more than science, right?

Dr. Kevin Latz: Agreed. Once you lose their trust, that exam is done.

Host: Oh, yeah. Yeah, for sure. What about red flags or warning signs that a pediatrician should definitely be looking for and sending—if they see them—going right to you?

Dr. Kevin Latz: Well, certainly, in the knee, the inability to extend the knee, there is a unique fracture that happens where the patella tendon attaches to the front of the leg called the tibial tubercle. And we see a large number of these on basketball season. You get a bunch of young men typically that have been lifting weights and running over the summer. They go up to dunk a basketball, and you and I might rupture our patellar tendon, and they will in fact break the piece of bone that the patellar tendon attaches to. So, the inability to straighten out the knee is a send that patient right then.

It's a little more tough in the ankle. I would typically say if you just can't weight bear at all after an ankle sprain, that probably also is a referral. But you've also got to read the child. Some periadolescents and adolescents are a little more stoic than others. Some are not so much. And so, you know, once the original apprehension from the injury is resolved, you've got some ice on there. If that patient can't put any weight at all on the ankle, I think that probably is a referral also.

Host: Okay. I would, imagine that when an injury happens, especially maybe in an older child, maybe in your preteen, teens, that a lot of times the patient themselves might be like, "No, I don't want to go see a doctor. Let's just go home and take care of it at home." You know, for those kind of situations, are there any home remedy things you would say to the parents or ask the parents to do?

Dr. Kevin Latz: My passion is keeping people out of the emergency room when possible. And so, I do think the natural reflex as a parent is to go right to the ED. And while that's certainly not inappropriate, it's often expensive and time-consuming. And so, I want to be a little careful. You don't want to miss a big injury. But generally speaking, going home, taking a safe dose of an anti-inflammatory, icing, elevating. Not returning back to play that game. That's the other thing we'll see, is somebody will sprain their ankle or hurt their knee, but all that adrenaline is going and they go back in the game for the second half. That's where you see injuries that are just really significant. So, coming out of the game, going home, ice elevation, anti-inflammatory. You know, kind of the usual RICE protocol, I think, is in most cases the right thing to do.

Host: Let's talk a little bit about imaging. What are the types of images that you normally take when you see a patient with these acute injuries, say, in kids and then in the teenage years?

Dr. Kevin Latz: Yeah. So, we always start with a plain film. I can't tell you how many referrals I see where the only imaging that's been done is an MRI, which while it's an incredibly powerful tool, it is incredibly expensive as well. And you can often get the information you need from a plain x-ray. And so, in the ankle, it's typically three views or at least two views of you from the front and a view from the side. In the knee, we will often want more than just a front and side view. But plain x-rays, 99.9% of the time are the way to go. And then, only advanced imaging, frankly, you know, once that referral's been made, I would argue that it's probably always the purview of the specialist to order the MRI.

Host: Yeah. Okay. So, that's some good advice, right? So, plain film have that in hand. But anything beyond that really should be up to you, maybe up to the radiologist who may want a little more detail. Is that kind of how you approach it?

Dr. Kevin Latz: No, I think it's a great summary. And I think, honestly, again, goes back to you want to do what's right for your child, your natural response is to frankly not think about money, and the cost of things. But frankly, that's a huge stress on families. And so, we just want to be thoughtful about when we get advanced imaging.

Dr. Mike Smith (Host): So now, we're talking about kids here, right? We're talking about young kids, preteens, teens. And, you know, they want to get back to playtime, they want to get back to the sports to get back out there. And it's tough to keep them from jumping right back in. So, how do you handle that? Like, what do you say to families to help them manage that expectation of when it is safe to go back?

Dr. Kevin Latz: Great question. Often long conversations in clinic. First of all, let's go back to the knee joint or the ankle. Full range of motion, no swelling whatsoever. And those are rigid rules, no swelling whatsoever. When you have any swelling in your knee, it makes your quadriceps muscle weak, and it makes your knee more likely to give out. And so, it's literally not safe to play with a swollen knee. Beyond that, when they can walk without a limp, they can jog. When they can jog without a limp, they can run. When they can run without a limp, they can start doing some agility work. If they can do that that pain-free and fluidly, Then they can return to. play.

Host: Yeah. Those are very good instructions there for family members too, right? Look at that swelling, look at that range of motion, look at that limp. Because your teenager's going to try their best to hide that limp. So, you got to watch closely, Dr. Latz, right?

Dr. Kevin Latz: For sure. And I will tell you, it's not hard to hide a limp when you're walking, but it's very difficult to hide a limp when you're running. And so, in the clinic, I'll have them walk up and down the hall. I'm stunned often how good they look walking and how poor they look running.

Host: Oh, that's really good. A lot of parents are writing that down. That's great advice. What about physical therapy in all of this? Do you use that a lot?

Dr. Kevin Latz: I've used a ton of physical therapy. I've also got an athletic trainer in most of my clinics. And while there's a separation of skills, there is some overlap there. I've got an athletic trainer who can usually start some exercises and instruct that patient until they get into physical therapy.

The patient you were talking about earlier, trying to figure out if we're ready to return to play, we do what's called functional testing, which is jumping on one and two legs. It's a shuttle run. It's really provocative motions to prove to both the patient and the family and the therapist that they're ready to return to play. So, yes, our athletic trainer and the clinic and our physical therapists are vital tools for safely getting these athletes back to play.

Host: Let's talk a little bit about prevention. And let's start with younger kids. You know, as you said, most of them are just playing, they're in the playground. And a lot of that is, you know, they fall and they put their arms outstretched. What can you really do as a parent to prevent any major injury there?

Dr. Kevin Latz: I want to be careful. I want the patient, the young man, the young lady off the computer and on the playground. There's a risk involved with that, and I respect that. But, you know, most of those injuries, these kiddos will bounce back from. So, I think injuries are part of childhood. I want to be a little careful of overstating that. But I do think we want the kids outside. We want them challenging themselves physically and mentally.

With some specific apparatus, for trampolines, our experience here at Children's Mercy has been typically one child on a trampoline is safer than multiple children on a trampoline. When you get more than one child on a trampoline, that's when you see these catastrophic injuries. And so, I'm not going to be at the sporting goods store pushing trampolines this afternoon, but if you've got one in your backyard already, then I would just try to police that to one child at a time. I mean, the surface does make a difference at the playground. You probably want to make a walkthrough and make sure there's not a bunch of rocks out there. But you know, most of these community playgrounds are relatively safe, relatively well-maintained.

Host: For sure. Well, they are nowadays compared to when I was a child in the '70s growing up. It was a little different back then. So, that's true. And I like your advice. Trampolines scare me, right? I've seen so many injuries, so I think that's good advice there.

As you move up now into the preteen, teen, you know, now we're talking about athletics, you're talking about basketball players, baseball players, football, track. Those are, I think, probably the main ones. What are we doing there? What's our best strategies for prevention of injuries?

Dr. Kevin Latz: Yeah. So, the biggest one is at that level—so we kind of a saying our practice that, when you're doing recreational sports, we're big on sports sampling, which means trying many sports to figure out, A, what you're good at, B, what you enjoy. And so, I think sports sampling multiple recreational sports are great.

When you get to the high school level and playing on a high school team or an elite club team, I really think one sport a season is mandatory. That's not the culture we live in. You'll have a young man or a young lady on a competitive swim team and a baseball team simultaneously, and those are overuse injuries waiting to happen. So, my advice to families is "one real sport" at a time. And if they've got to overlap for a week or two, that's okay, but we want to really avoid two simultaneous club or high school sports seasons.

Host: That's really good advice. And you're right, so many teen athletes, they do all the sports like they never rest. So, I think that's really good advice. How important is stretching and staying limber?

Dr. Kevin Latz: I think we've learned that static stretching. So, you know, going out there cold, candidly, for an adolescent athlete, it's probably fine. For you and I, not a great idea. So, a little bit of jogging to get things warmed up and then doing the stretching, ideally led by a coach or an athletic trainer, rather than a teammate, so it's supervised and done correctly. But a little bit of dynamic stretching is great.

Host: But, you know, at the end of the day, Dr. Latz, we were talking about active kids, you're never going to fully prevent injuries. So, what's the last thing kind of in summary that you would like to say to parents to maybe community pediatricians about musculoskeletal injuries?

Dr. Kevin Latz: Well, the big thing is I want the kids out there. I want them on the trampoline if they love that by themselves. Ideally, I want them on the playground. I want them playing the sports. We're big in promoting activity, and we encourage sports, but I want the kids to be active. That's so important. And I want to kind of keep things in perspective. It's so important to be out there and be moving. Injuries will happen. You don't want to miss the injury, and then send your child back into play and injure them more. So, I do think that joint swelling part, range of motion part that we discussed is super important. It is difficult to know when it's safe to return your child to play. When they're moving fluidly and they have good range of motion and no swelling, then I think you can safely return that child back to play.

Host: Dr. Latz, this has been fantastic information. A lot of great advice. So, thank you so much for coming on the show today. For more information, you can go to cmkc.link/cme podcast. If you enjoyed this podcast, please share it and explore our podcast library for topics of interest to you. This is Pediatrics in practice, a CME podcast. I'm Dr. Mike. Thanks for listening.