Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole, and today we're highlighting treating patient's at the AHN Pediatric Orthopedic Institute.

Joining me is Dr. Anthony Silverio. He's an Orthopedist and the Director of the AHN Pediatric Orthopedic Institute. Dr. Silverio, thank you so much for joining us today. So I'd like to start with telling us a little bit about the institute and what are the most common injuries that you see there?

Anthony Silverio, DO: Well thank you Melanie, and thank you for giving me the opportunity to speak with you today. You know, the Pediatric Orthopedic Institute, is located in Wexford, just north of Pittsburgh. And what we do is we really specialize on children with open growth plates, and that's anywhere from an infant or newborn to 18 years of age. And we really specialize in injuries that can occur in that patient population. And we specialize in taking care and making sure that we are cognizant of those growth plates in children with growing bones. And you have to take special care of those children because those growth plates, some more than other's, can be very fragile. And if are injured, can really have some downstream effects that can affect those children into adulthood.

Host: Okay, so how common are growth plate injuries themselves? And we think of our little athletes, but it's not only athletes, right? And we used to say no weight training for our little kiddos because of those growth plates are still in ossification, they're still growing. But how common are these things and what are some of the most common reasons that they happen?

Anthony Silverio, DO: Before I answer that question, just a little background on a growth plate. A growth plate is cartilage. It's made up of a bunch of cells, but for all intents and purposes, it's cartilage. And cartilage is inherently weaker than bone. It eventually comes bone, but as kids are growing, that cartilage needs to become bone to make those bones longer and bigger.

And so the reason why we are so cognizant and respect those growth plates is because, like you said, not all kids are athletes. Not all kids have the same activity level. Those growth plates can be injured in a playground setting. Those growth plates could be injured on an athletic field. But these are common type injuries.

Kids unfortunately fall. They fall for multiple reasons, whether they're playing, whether they're in a sport, whether they just have an accident. And these growth plate injuries can be fairly common and can be treated in multiple different ways. Sometimes it needs a brace, sometimes it needs a cast, if severe enough, sometimes requires surgery, but that's where we come in to kind of wade those waters and have those discussions with family and try to give them decisions or opportunities to make the best choice for their child.

Host: Well, a lot of people think of children as being much more flexible and when they do have those falls and spills, you know, they kind of bounce back. But when they do, wrists and ankles are specifically predisposed to these kinds of injuries. Speak a little bit about those growth plate fractures and how they happen from some of these reasons.

Anthony Silverio, DO: Yeah, probably the two most common injuries that come into our practice, wrist and ankles, like you said. And at the wrist, the growth plates that are typically involved, occur at the lower end of the radius and ulnar bone. And luckily these growth plates are a little bit more robust.

And what I mean by that is, can respond to more significant trauma better than other growth plates. At the end of the radius bone, a growth plate injury, even a severe one, really only has about a seven to 10% chance of causing so much damage to the growth plate that it can cause downstream issues, whether that's a full growth plate arrest or a partial growth plate arrest, which potentially could cause an issue with the length of the bone or causing deformity.

Now that's a little bit different story at the ankle, the distal tibia growth plate is a little bit more sensitive to those types of injuries. And if significant enough of an injury, that growth plate can shut down either partially or completely, and can cause a leg length discrepancy and or deformity.

So in our practice, whether it's the wrist or the ankle, but more so the ankle, we may follow those injuries a little bit longer, and with x-rays to make sure that those certain downstream effects are not occurring, or if they are occurring, intervening at the appropriate time to make a corrective action.

Host: So another area that's particularly positioned to have these kinds of injuries are pediatric patellar instability injuries. So tell us a little bit about what's going on because right around that area and Dr. Silverio, you know, we can always throw in the ACL injuries that we see in our female athletes and just general area of the leg, median leg, knee, you know, what are you seeing happen there and what are we doing about that?

Anthony Silverio, DO: Yeah. Right. Kneecap instability is probably the most common sports related injury appointment that comes through my clinic, and it's becoming more and more common, and I think there's a couple reasons for that. The first reason is kids are getting active and into more competitive type sports at an earlier age.

So we're seeing more and more of these injuries. But I also think that we are understanding patella or kneecap instability more and more as time goes on. And, there can be a couple different reasons for kneecap instability in the growing child. Yes, they can have an injury, but sometimes, the injury isn't the full story.

Do they have a congenital deformity about the knee? Do they have some knock knees or what we call genu valgum at the knee that is predisposing them to this kneecap instability? Are they having some rotational deformity even in their femur bone or tibia bone that's predisposing them to this?

So these are things that kind of go through my mind as I'm evaluating a child for the first-time with kneecap instability and we're trying to work through all of these things to figure out, okay, we understand that they had this injury, but do they have an underlying reason that predisposes them number one to that injury, but to future kneecap instability injuries?

So that's some of the things that we work through as we're evaluating a child with that diagnosis.

Host: Along those lines, and we're sticking to the knee here for a minute, is Osgood-Schlatters. Do you see a lot of that, Dr. Silverio? And, and then we're going to get into what you're doing for some of these kids.

Anthony Silverio, DO: Yes. That is also a very common appointment that comes through my clinic. Now, unlike patellar instability, Osgood-Schlatters is really in that overuse category, and it's really no fault of the child. An active child that is pulling on the growth plate or stressing the growth plate of the tibial tubercle, which is an area of the tibia bone just below the knee joint. And what connects there is the patella tendon and kids that are runners, jumpers, kids that are cutting, pivoting, even just playing on the playground or playing out a recess or gym class, they can pull on that tendon and then that causes stress to go across the growth plate and it causes pain.

And if that stress occurs over a long period of time, it can cause fragmentation of that area. It can cause enlargement of that area. But with an open growth plate, there really is no surgery for that diagnosis. With Osgood-Schlatters what we're doing is management of symptoms, backing off the activity that is causing the increase in pain, physical therapy, over-the-counter medication like Ibuprofen or Tylenol, ice, heat and sometimes even over-the-counter bracing or taping can be beneficial. But really kids with open growth plates, there is no surgical option for Osgood-Schlatters. And the good news is that once kids are done growing, about 95% of those kids will have complete resolution of pain. On the opposite side of that coin, unfortunately this can start bothering kids or affecting kids in early adolescence, 10, 11, 12 years of age.

And for girls and boys, even at that age, they can have 3, 4, 5 years left of growth, which can be sometimes a very debilitating thing.

Host: Well, it certainly can. And you know what a field that you're in now, really just such an important field as we think of our little athletes, and there's rules set in place, Dr. Silverio for certain athletes, and as you and I have mentioned; you know they're starting to get into this very sport specific training, which we could go on about for a long time, about overuse injuries.

We're not talking so much about that today, but that is a part of some of these injuries that I imagine you see. But in baseball specifically, Little League shoulder. There's pitch counts, there's issues with training. Speak a little bit about the kids that come in with that sort of thing and why we have to have some of those rules in place.

Anthony Silverio, DO: So, you mentioned it, Little League shoulder and Little League Elbow, and again, you're talking about overuse type injuries because there are open growth plates involved, and I think having a pitch count, days of rest between pitching, these are things that have been put in place to kind of keep the athlete safe.

These kids, all they want to do is go out and play and they don't want to have to think about injuries. Oh, am I affecting my growth plate? These aren't things that kids need to worry about. These are responsibilities of parents, coaches, physicians, athletic trainers. We need to be the custodians for these children and make sure that these things are in place to protect children from injury. And pitch count and days of rest between pitching are two ways that we can do that. The kids nowadays are throwing so much harder and have so much more volume of throws than even when I grew up in the late eighties and nineties. And because of that, we are seeing these overuse type injuries, even with these kind of precautions in place.

So we just need to keep that in mind and, and really reminding parents, reminding coaches, and obviously reminding the kids, but really the ones that are responsible for overseeing these kids and keeping them safe so they can keep playing at a level that they're accustomed to doing with minimal to no pain.

Host: So then along those lines, Doctor, how do you work with coaches, athletic trainers, the parents, to develop that safe return to play plan for injured athletes? Because we know, and I'm the mother of a gymnast, I know they don't want to miss, even with an injury, they want to get right back out there.

And whether we're talking about concussion or any sorts of injuries, but there is a return to play protocol with orthopedists where you're going to discuss this with the coaches. Tell us a little bit how that works.

Anthony Silverio, DO: Well, we are affiliated at AHN with a lot of high schools. So we have a direct line of communication with the athletic trainers, probably more so than the coaches, but the athletic trainers have a direct line of communication with the coaches. You know, our conversations obviously start in the clinic between the patient and the family, and I think that's probably the most important time to communicate expectations. And everybody has a role there, but including the child in that conversation is very important because if you're just talking to the parent and not including the child in the decision-making progress; it's difficult for them to get on board with, okay, we maybe need to take a little time off.

We need to rest. We need to back off a little bit. So the first-time that I'm meeting a child and the family, I am making sure that I am incorporating all parties and including all parties in the discussion. Because when you do that, at least in my experience, keeping them in that conversation, actively involved, makes that return to play, makes that timeline easier to digest.

Because a lot of times we're not able to say, Hey, you can go back tomorrow. Unfortunately you have an injury that is going to require some time, but if you include them in that timeline and spell it out for them in ways that they can understand, it usually is easier for them to digest and easier for them to get on board with that plan.

Host: Yeah, that's really important and great information. Now, Dr. Silverio, what makes the AHN Pediatric Orthopedic Institute so unique?

Anthony Silverio, DO: You know, I think we're unique because we pride ourselves on getting patient's in quickly. And what I mean by that is if a child has an injury and family calls at eight o'clock in the morning, we are going to do everything we can to get that patient in that day. If for whatever reason we can't get the patient in that day, then it's the next day.

And whatever's convenient for families. We understand. You know, I have three kids of my own. Everybody has lives. Everybody's lives are busy. We want to get that kid in, get them evaluated, put the family's mind at ease, the best we can, and get them on the road to recovery. That is what we really pride ourselves here on the Pediatric Orthopedic Institute.

We're here to serve the people of Pittsburgh and the surrounding region. And we want to do our best to do that as efficiently and as completely as possible.

Host: Well, thank you so much Dr. Silverio. That is really great information and reassuring for parents to know and coaches and the little athletes to know that you are there and that you can, you know, do your best to try and get them in as quickly as possible and be seen, because we just know kids just really want to get back to play.

So, thank you again for joining us and giving us such great information. And to learn more or to refer your patient to Dr. Silverio, please call 844-MD REFER, or you can visit findcare.ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network.

I'm Melanie Cole.