As participation of children and adolescents in organized sports continues to rise, so do concerns about the risk and severity of injury to a child’s growing body. Sudden and gradual onset physical injury is unique to the pediatric population and, if not treated properly, can lead to permanent problems with the bone and with growth.
Charles Goldfarb, MD, shares how growth plate fractures are diagnosed, treated, and when to refer to a specialist.
Selected Podcast
Understanding and Diagnosing Growth Plate Fractures in Young Athletes
Featured Speaker:
Learn more about Charles Goldfarb, MD
Charles Goldfarb, MD
Charles Goldfarb, MD, is a Washington University pediatric orthopedic surgeon at St. Louis Children's Hospital.Learn more about Charles Goldfarb, MD
Transcription:
Understanding and Diagnosing Growth Plate Fractures in Young Athletes
Melanie Cole (Host): As participation of children and adolescents in organized sports continues to rise, so do concerns about the risk and severity of injury to child's growing body. My guest is Dr. Charles Goldfarb, he's a Washington University pediatric orthopedic surgeon and hand surgeon at St. Louis Children's Hospital. Dr. Goldfarb, have you seen a rise in participation, and as a result an associated increase in both traumatic and overuse injuries in the youth athlete?
Dr. Charles Goldfarb, MD (Guest): Absolutely. As our youth participates more and more in sports and more involved with an active lifestyle, we've seen a rising rate of injuries, and many of these injuries involve the bones and the immature skeleton and they're somewhat characteristic in the way they appear.
Melanie: So as exposure rates - I mean obviously if there's more a rise in participation - as exposure rates alone don't account for all this increase in injuries, do you think that some of the sport-specific training, societal pressures to perform at high levels, coaches, athletes, can lead to more of these chronic injuries and even some of the fractures? Training intensity, frequency, do you think that this is part of the problem as these physiologic stresses are applied to the immature skeleton?
Dr. Goldfarb: I think when I was a child it was a little more simple in that kids went and played, and even if they were on a team or two, it didn't reach the level that it is at today for many children. And it's been called the professionalization of youth sports in that there's an expectation that the intensity of training, and the individual training outside of team practices, and simply the overall seriousness with which sports are taken has just dramatically changed. What that means for the kids is there's not an appropriate length of time between sessions to rest, let the body heal, and get ready for the next session. So it is a really concerning pattern, and it's shown no signs of letting up despite increase in conversation about this problem.
Melanie: So as adults, you know, you see a lot of soft tissue injuries, tendons, ligaments, but with kids those tendons and ligaments can be even stronger than those bones that are still in ossification. So as far as growth plate fractures, why are you seeing an increase in those? Why do they happen in the first place?
Dr. Goldfarb: Right, so whether it's a child playing sports or a child playing on the playground, the risk to the child as you so very well discuss is really to the bone more than it is to the tendon or the ligament. So the weakest part of the bone is often - not always - but it's often the growth plate. And so the growing growth plate, which every bone has, is the weakest point in the area, and so it's often the site of a fracture.
Melanie: Where do you see them most commonly? I mean you're a hand surgeon, are you seeing wrists and hands? Are you seeing- where are you seeing upper extremity with baseball players? What are you seeing?
Dr. Goldfarb: So certainly everywhere in the body, and it depends on the nature of the trauma. If it's a fall or a twisting injury, it could be in the lower extremity; the femur, the tibia. In the upper extremity, it depends on the sport, and so it can be elbow, wrist, hand. It really depends on what is being exposed and what the nature of the trauma is. A lot of sports injuries to kids are not overuse, they're simply kids playing sports, and a twisting injury happens, or a fall happens, and the growth plate is traumatized. But as we're alluding to, the other part of this process is overuse and repetitive use, and that really depends on the sport.
So for example, in baseball the elbow growth plate and the proximal humerus or shoulder growth plate can be traumatized more than other sites because of the repetitive throwing, and that gives rise to problems as well.
Melanie: Dr. Goldfarb, we hear about ACL injuries in soccer playing girls, but that's again a rupture, a tear that's ligamentous and soft tissue. So what about knees? How subject are young athletes to knee injuries that would involve fractures? Is there something different about the knee that it would be more subject to soft tissue than fractures?
Dr. Goldfarb: So I think it goes both ways. So on the one hand, you can have bony fractures instead of ligamentous injuries about the knee, which emphasizes the importance in the skeletally immature or young adolescent to see a pediatric orthopedic surgeon who has expertise in sports. But the other issue in children is that they become fatigued, whether they realize it or not. So part of the protective mechanism against knee injuries is the strength of the quadriceps muscles and the hamstring muscles. And if your child is playing four soccer games and two basketball games in a weekend, whether they know it or not, the muscles get tired and they can no longer be protected, which is fascinating and unfortunate because it really does happen. But what we've also learned is that we can really dramatically cut down on ACLs, for example, by teaching kids and coaches and teams an ACL prevention program. And what that prevention program does is it does build specific muscle strength, it does teach proprioception, and it's something we're trialing now and we've had good results with it and it's an important way to move forward.
Melanie: What are some of the consequences of mistreating or misdiagnosing a growth plate fracture, and at what point would you want a referring pediatrician to refer a patient with a suspected fracture?
Dr. Goldfarb: I think the time to refer is based on the comfort level of the individual pediatrician. So some will feel very comfortable, others may be less comfortable, and certainly in the community we see some doctors who at the first inclination that this may be a growth plate fracture, they are sent over to us. Others may wait until it's obviously a growth plate fracture, even if there's problems developing.
So for me, it's about the comfort level of those in the community, but I think the growth plate can be tricky, and if a growth plate fracture is displaced or out of position and they require a reduction or putting it back into correct position, that's certainly the time to refer.
Melanie: Are there some long-term effects associated with these types of fractures, even the ones that heal properly? I mean is it like now are they more at risk for arthritis in that joint?
Dr. Goldfarb: So it's not arthritis thankfully, but what can happen is if the growth plate is traumatized, so let's say there's a fracture that goes through the growth plate, and there's different types of growth plate fractures, but basically one of two things happens. Either the growth plate does fine and continues to grow and there's no problem, or sometimes when the growth plate is traumatized with the fracture, the growth plate shuts down, and therefore it does not grow anymore, and so that bone will not reach its maximum length, and that can cause problems. If it's for example the femur, one leg can end up shorter than the other, especially if it's in a younger child. If it's the forearm where the radius and ulna need to be roughly the same length, if one of them shuts down, the discrepancy in length between the two bones can cause problems.
And so it's really a matter of will the growth plate grow? Will it grow appropriately? Or will it not? And so as orthopedic surgeons, if we encounter a child who has a growth plate injury and we need to put it back in place, we do so in a very careful fashion to minimize additional trauma through the treatment process.
Melanie: Because these kids' bones are still growing, do they heal better than those of us that are adults?
Dr. Goldfarb: Absolutely, and so one of the main differences- there's many reasons for it, but one of the main reasons is that there's a protective covering of the bone called the periosteum, and kids have a very thick and robust periosteum. And so what happens is when they break the bone, the periosteum kicks into the healing process, and then typically kids heal more reliably and more quickly than we do.
Melanie: It's really great information and what can a referring physician expect from your team of pediatric orthopedic physicians at St. Louis Children's hospital in so far as communication? What would you like them to know?
Dr. Goldfarb: First I think they can expect our comfort level with these injuries to be high, and I think that will help put the family at ease and give the family the comfort and the knowledge that their child is going to be treated appropriately. Now we can't necessarily control what the growth plate is going to do, meaning we can treat the child perfectly and the growth plate may respond exactly as we want it, or sometimes the growth plate will close down, but we will do the appropriate thing for the growth plate, and then I hope and expect we're going to communicate back to the referring physician both at the time of initial referral, but just as importantly down the road as we follow a child, as we make sure the growth plate grows, and hopefully avoid problems down the road.
Melanie: Dr. Goldfarb, speak about your orthopedic coverage in the ERs at Missouri Baptist and Progress West. Why is it important and how can it help to improve outcomes?
Dr. Goldfarb: Right so traditionally, and I guess it goes back as long as I can remember, we have provided care at St. Louis Children's Hospital. So any child that comes in to St. Louis Children's Hospital with a bony injury is likely to see an orthopedic surgeon. And I believe we've done a great job, but it's a busy emergency room, and I don't think it provides access for the region as well as we would have liked.
So recently we have begun to provide coverage at both Missouri Baptist and at Progress West with the idea that we can bring Washington University and St. Louis Children's Hospital expertise to those two locations. That makes it easier for families, especially families who would rather avoid traveling to Children's Hospital. It also makes it timelier because a lot of the time when we see a child at Missouri Baptist or we see a child at Progress West, we can complete their treatment at least initially in those two locations.
There will be times when the nature of the injury requires the child to come to Children's Hospital, but our goal is to treat the child in a convenient location; again Missouri Baptist or Progress West. The benefit to the child specifically regarding their injury is if there is a growth plate injury or a fracture which is out of position, we can get it back in better alignment sooner at one of those two hospitals.
Melanie: So wrap it up for us. Dr. Goldfarb, what else would you like the referring physician to know about understanding and diagnosing growth plate fractures, and when to refer?
Dr. Goldfarb: Growth plate fractures are a part of the care of the growing child. It's something that we at St. Louis Children's Hospital and Washington University take very seriously and have the expertise to treat appropriately. And we look forward to taking care of these kids because we can help maximize their outcomes.
Our goal is to provide the highest level of care in the best possible location for a kid's family, and I think we're doing that, and we will continue to grow our presence both in Children's Hospital and in the community. And I think that with the appropriate care, we can maximize every child's outcome and get them back to playing sports as soon as possible.
Melanie: Wow, what a great segment. What a fascinating topic, that really is. Thank you so much, Doctor, for being with us today. A physician can refer a patient by calling Children's Direct Physician Access Line at 1(800) 678-HELP. That's 1(800) 678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to www.StLouisChildrens.org. That's www.StLouisChildrens.org. This is Melanie Cole, thanks so much for tuning in.
Understanding and Diagnosing Growth Plate Fractures in Young Athletes
Melanie Cole (Host): As participation of children and adolescents in organized sports continues to rise, so do concerns about the risk and severity of injury to child's growing body. My guest is Dr. Charles Goldfarb, he's a Washington University pediatric orthopedic surgeon and hand surgeon at St. Louis Children's Hospital. Dr. Goldfarb, have you seen a rise in participation, and as a result an associated increase in both traumatic and overuse injuries in the youth athlete?
Dr. Charles Goldfarb, MD (Guest): Absolutely. As our youth participates more and more in sports and more involved with an active lifestyle, we've seen a rising rate of injuries, and many of these injuries involve the bones and the immature skeleton and they're somewhat characteristic in the way they appear.
Melanie: So as exposure rates - I mean obviously if there's more a rise in participation - as exposure rates alone don't account for all this increase in injuries, do you think that some of the sport-specific training, societal pressures to perform at high levels, coaches, athletes, can lead to more of these chronic injuries and even some of the fractures? Training intensity, frequency, do you think that this is part of the problem as these physiologic stresses are applied to the immature skeleton?
Dr. Goldfarb: I think when I was a child it was a little more simple in that kids went and played, and even if they were on a team or two, it didn't reach the level that it is at today for many children. And it's been called the professionalization of youth sports in that there's an expectation that the intensity of training, and the individual training outside of team practices, and simply the overall seriousness with which sports are taken has just dramatically changed. What that means for the kids is there's not an appropriate length of time between sessions to rest, let the body heal, and get ready for the next session. So it is a really concerning pattern, and it's shown no signs of letting up despite increase in conversation about this problem.
Melanie: So as adults, you know, you see a lot of soft tissue injuries, tendons, ligaments, but with kids those tendons and ligaments can be even stronger than those bones that are still in ossification. So as far as growth plate fractures, why are you seeing an increase in those? Why do they happen in the first place?
Dr. Goldfarb: Right, so whether it's a child playing sports or a child playing on the playground, the risk to the child as you so very well discuss is really to the bone more than it is to the tendon or the ligament. So the weakest part of the bone is often - not always - but it's often the growth plate. And so the growing growth plate, which every bone has, is the weakest point in the area, and so it's often the site of a fracture.
Melanie: Where do you see them most commonly? I mean you're a hand surgeon, are you seeing wrists and hands? Are you seeing- where are you seeing upper extremity with baseball players? What are you seeing?
Dr. Goldfarb: So certainly everywhere in the body, and it depends on the nature of the trauma. If it's a fall or a twisting injury, it could be in the lower extremity; the femur, the tibia. In the upper extremity, it depends on the sport, and so it can be elbow, wrist, hand. It really depends on what is being exposed and what the nature of the trauma is. A lot of sports injuries to kids are not overuse, they're simply kids playing sports, and a twisting injury happens, or a fall happens, and the growth plate is traumatized. But as we're alluding to, the other part of this process is overuse and repetitive use, and that really depends on the sport.
So for example, in baseball the elbow growth plate and the proximal humerus or shoulder growth plate can be traumatized more than other sites because of the repetitive throwing, and that gives rise to problems as well.
Melanie: Dr. Goldfarb, we hear about ACL injuries in soccer playing girls, but that's again a rupture, a tear that's ligamentous and soft tissue. So what about knees? How subject are young athletes to knee injuries that would involve fractures? Is there something different about the knee that it would be more subject to soft tissue than fractures?
Dr. Goldfarb: So I think it goes both ways. So on the one hand, you can have bony fractures instead of ligamentous injuries about the knee, which emphasizes the importance in the skeletally immature or young adolescent to see a pediatric orthopedic surgeon who has expertise in sports. But the other issue in children is that they become fatigued, whether they realize it or not. So part of the protective mechanism against knee injuries is the strength of the quadriceps muscles and the hamstring muscles. And if your child is playing four soccer games and two basketball games in a weekend, whether they know it or not, the muscles get tired and they can no longer be protected, which is fascinating and unfortunate because it really does happen. But what we've also learned is that we can really dramatically cut down on ACLs, for example, by teaching kids and coaches and teams an ACL prevention program. And what that prevention program does is it does build specific muscle strength, it does teach proprioception, and it's something we're trialing now and we've had good results with it and it's an important way to move forward.
Melanie: What are some of the consequences of mistreating or misdiagnosing a growth plate fracture, and at what point would you want a referring pediatrician to refer a patient with a suspected fracture?
Dr. Goldfarb: I think the time to refer is based on the comfort level of the individual pediatrician. So some will feel very comfortable, others may be less comfortable, and certainly in the community we see some doctors who at the first inclination that this may be a growth plate fracture, they are sent over to us. Others may wait until it's obviously a growth plate fracture, even if there's problems developing.
So for me, it's about the comfort level of those in the community, but I think the growth plate can be tricky, and if a growth plate fracture is displaced or out of position and they require a reduction or putting it back into correct position, that's certainly the time to refer.
Melanie: Are there some long-term effects associated with these types of fractures, even the ones that heal properly? I mean is it like now are they more at risk for arthritis in that joint?
Dr. Goldfarb: So it's not arthritis thankfully, but what can happen is if the growth plate is traumatized, so let's say there's a fracture that goes through the growth plate, and there's different types of growth plate fractures, but basically one of two things happens. Either the growth plate does fine and continues to grow and there's no problem, or sometimes when the growth plate is traumatized with the fracture, the growth plate shuts down, and therefore it does not grow anymore, and so that bone will not reach its maximum length, and that can cause problems. If it's for example the femur, one leg can end up shorter than the other, especially if it's in a younger child. If it's the forearm where the radius and ulna need to be roughly the same length, if one of them shuts down, the discrepancy in length between the two bones can cause problems.
And so it's really a matter of will the growth plate grow? Will it grow appropriately? Or will it not? And so as orthopedic surgeons, if we encounter a child who has a growth plate injury and we need to put it back in place, we do so in a very careful fashion to minimize additional trauma through the treatment process.
Melanie: Because these kids' bones are still growing, do they heal better than those of us that are adults?
Dr. Goldfarb: Absolutely, and so one of the main differences- there's many reasons for it, but one of the main reasons is that there's a protective covering of the bone called the periosteum, and kids have a very thick and robust periosteum. And so what happens is when they break the bone, the periosteum kicks into the healing process, and then typically kids heal more reliably and more quickly than we do.
Melanie: It's really great information and what can a referring physician expect from your team of pediatric orthopedic physicians at St. Louis Children's hospital in so far as communication? What would you like them to know?
Dr. Goldfarb: First I think they can expect our comfort level with these injuries to be high, and I think that will help put the family at ease and give the family the comfort and the knowledge that their child is going to be treated appropriately. Now we can't necessarily control what the growth plate is going to do, meaning we can treat the child perfectly and the growth plate may respond exactly as we want it, or sometimes the growth plate will close down, but we will do the appropriate thing for the growth plate, and then I hope and expect we're going to communicate back to the referring physician both at the time of initial referral, but just as importantly down the road as we follow a child, as we make sure the growth plate grows, and hopefully avoid problems down the road.
Melanie: Dr. Goldfarb, speak about your orthopedic coverage in the ERs at Missouri Baptist and Progress West. Why is it important and how can it help to improve outcomes?
Dr. Goldfarb: Right so traditionally, and I guess it goes back as long as I can remember, we have provided care at St. Louis Children's Hospital. So any child that comes in to St. Louis Children's Hospital with a bony injury is likely to see an orthopedic surgeon. And I believe we've done a great job, but it's a busy emergency room, and I don't think it provides access for the region as well as we would have liked.
So recently we have begun to provide coverage at both Missouri Baptist and at Progress West with the idea that we can bring Washington University and St. Louis Children's Hospital expertise to those two locations. That makes it easier for families, especially families who would rather avoid traveling to Children's Hospital. It also makes it timelier because a lot of the time when we see a child at Missouri Baptist or we see a child at Progress West, we can complete their treatment at least initially in those two locations.
There will be times when the nature of the injury requires the child to come to Children's Hospital, but our goal is to treat the child in a convenient location; again Missouri Baptist or Progress West. The benefit to the child specifically regarding their injury is if there is a growth plate injury or a fracture which is out of position, we can get it back in better alignment sooner at one of those two hospitals.
Melanie: So wrap it up for us. Dr. Goldfarb, what else would you like the referring physician to know about understanding and diagnosing growth plate fractures, and when to refer?
Dr. Goldfarb: Growth plate fractures are a part of the care of the growing child. It's something that we at St. Louis Children's Hospital and Washington University take very seriously and have the expertise to treat appropriately. And we look forward to taking care of these kids because we can help maximize their outcomes.
Our goal is to provide the highest level of care in the best possible location for a kid's family, and I think we're doing that, and we will continue to grow our presence both in Children's Hospital and in the community. And I think that with the appropriate care, we can maximize every child's outcome and get them back to playing sports as soon as possible.
Melanie: Wow, what a great segment. What a fascinating topic, that really is. Thank you so much, Doctor, for being with us today. A physician can refer a patient by calling Children's Direct Physician Access Line at 1(800) 678-HELP. That's 1(800) 678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to www.StLouisChildrens.org. That's www.StLouisChildrens.org. This is Melanie Cole, thanks so much for tuning in.