Sprains, Strains, and Broken Bones in Kids

Podcast Transcript

Dr. Richard So:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time. In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Anthony Egger:

Do you worry every time your child takes a hard tumble or feel stressed trying to figure out if a swollen ankle is a simple bruise or something more serious? I'm Dr. Ace Egger, an orthopedic surgeon who specializes in pediatric and adolescent sports medicine. Today we're talking about everything from the big question of "is it broken?" to "why aren't kids just small adults when it comes to their bone and joint health?" We'll also touch on the best ways to help with their recovery. Joining me to discuss this is Dr. Kevin Sirdahely. He's a pediatric orthopedic surgeon at Cleveland Clinic. Children's, welcome to Little Health, Dr. Sirdahely.

Dr. Kevin Serdahely:

Hey, thanks for having me. Happy to be here.

Dr. Anthony Egger:

And so why don't you tell us a little bit about yourself?

Dr. Kevin Serdahely:

I am, uh, from the Midwest. I did some training, uh, in Toledo, Ohio, and, and, uh, I did my pediatric orthopedic fellowship down at Vanderbilt University. And I've been up here at Cleveland Clinic now, uh, for a year or two.

Dr. Anthony Egger:

Fantastic. Well, yeah, the Cleveland Clinic Children's is obviously very lucky to have you. Um, and your knowledge and expertise, um, will go a long way going over some of these topics. So, you know, just jumping right into it, I guess the, you know, the main question always is what is a sprain versus a strain and versus a fracture?

Dr. Kevin Serdahely:

Yeah, so I, I think ultimately it really comes down to, uh, what tissue is involved. Um, this is kind of the easiest way to think about it. Um, when you're thinking about a sprain, it's usually a ligament that's injured in some capacity, whether it's stretched or partially torn or, or torn all the way through. A strain is more of a muscle issue, typically, where it's the injury to the muscle belly or the connection to the tendon where you see some muscle fibers separate, uh, or some tearing in the muscle belly itself. Uh, and then a fracture is a bone. Um, and you also, uh, will hear, uh, people refer to that as a broken bone as well. Um, sometimes there's some confusion between fractures and breaks. Uh, but those are one in the same, but those happen to the bones.

Dr. Anthony Egger:

Yes. That's always a question I get, is it, is it broken or fractured? And so for, for us in our, our nomenclature, it's a, it's, it's the same thing. [Yeah.] So obviously different severities of breaks and fractures. You know, is it okay if your child has one of these injuries to, you know, wait until the morning? Or do we need to go, you know, wait in the ER and what, what do you notice there?

Dr. Kevin Serdahely:

Right. You know, I think it, it comes down to the severity of the injury. If something happens and you're pretty sure the arm's broken 'cause it's pointing off to the side, I'd say, go ahead and, and go on into the ER for something like that. You know, if it's a rolled ankle and, and maybe it felt a pop and it swelled up real bad, but, you know, still able to put some weight down on it and, and, uh, nothing's pointing funny, you're still feeling everything. Usually in those instances, it's okay to get some ice on it and come in the next morning to get in, be seen. So, you know, I, I think if you're ever overly concerned, it's never the wrong answer to go to the ER. But certainly, you know, for something that is maybe a little bit more minor, uh, I think us and families, uh, included, would all prefer to stay out of the ER overnight, waiting however long that can take.

Dr. Anthony Egger:

Right. And that's one of the benefits of, you know, Cleveland Clinic Children's is a lot of the next day, same day acute appointments, um, that we have built into our schedule. So, [Absolutely.] um, yeah, I agree with you. If it's, you know, if it's not looking totally crooked, [Yeah.] um, it's probably okay, um, to monitor it overnight.

Dr. Kevin Serdahely:

We, we also have, uh, a lot of urgent cares around the city, uh, in Cleveland too. Um, even some orthopedic specific urgent cares that are a really good option for that kind of stuff, if it's during the daytime, usually, uh, able to pop into one of those, get the X-rays done, those sorts of things. If you needed to go to the ER, they can send you there from there. But that spares you, you know, that wait time in the emergency department waiting room and all that jazz.

Dr. Anthony Egger:

Absolutely. So what would you recommend overnight, you know, dealing with some of these injuries? Is it heat, is it ice?

Dr. Kevin Serdahely:

You know, the best first steps are always gonna be ice at the beginning. Uh, it helps a lot with the swelling, the inflammation, um, you know, regardless of the extremity, but especially your lower extremities, like an ankle injury, you want to get that thing nice and elevated too. Um, I think many people have heard of the RICE acronym, rest, ice, compress, elevate. And I think probably the most important part of that is, is rest and elevate, but also get some ice on there. And I find that's more helpful than heat at the beginning. Heat can actually sometimes, uh, make the swelling a little bit worse right at the beginning. Once you get a little further on, sometimes heat's... heat's as good or better than ice, but at the beginning, ice and elevate.

Dr. Anthony Egger:

Yeah, that's great advice. And then what about, you know, anti-inflammatories? Can you give them immediately right after to help with pain or is that not a good idea in your mind?

Dr. Kevin Serdahely:

Typically, okay to do. Anti-inflammatory medications are gonna help with the pain, but they're not gonna mask it so much that you would miss something more serious going on. And so, uh, depending on the age, ibuprofen or Aleve or things like that, or even children's Motrin, uh, for younger kids, it's usually a pretty safe thing to, to give your kids at home right after an injury.

Dr. Anthony Egger:

Fantastic. So a lot of times, you know, the kids will say, oh, something I heard a pop. Um, you know, does that always mean worst case scenario that a ligament or his torn or a bone is broken?

Dr. Kevin Serdahely:

Not always. Many times you'll actually hear a pop and, uh, it may be nothing. You know, you kind of think of it as like cracking your knuckles. Same concept. You crack your knuckles, you feel a pop, but you didn't break anything or tear anything. Maybe a little vacuum that forms inside of the joint. So you know, that's not a, a definitive, uh, reason that you to decide, hey, this is, you know, torn ligament or a broken bone or those things. Although it might make it a little bit more likely, that might be the case. And so all the more reason in those instances, you might want to think about getting an X-ray done, especially if you're not able to walk on your ankle or something like that.

Dr. Anthony Egger:

Is there anything parents can do to help sort of prevent or strengthen bones? You know, is there a link between low vitamin D and, you know, an increased risk of injury or fracture?

Dr. Kevin Serdahely:

I think the two main things that we can do for bone health for kids is to stay really active, uh, as much as possible. Exercise, weight bearing, all those things are good for the bones, you know, doing a lot of sitting around all day or, and we see this in, in people who, we keep them off of an extremity, you know, in a cast for a broken ankle or something when you're getting x-rays a month or two down the road, you see some of that bone demineralization happening from the lack of weightbearing. We call that disuse osteopenia. So that's not gonna happen by just being sedentary. But certainly active weightbearing activities are gonna be helpful for bone health and, and being regular with that. And then particularly for those of us that live in the north, uh, I do think that vitamin D supplementation and calcium supplementation is a real thing. Uh, and particularly for anybody that's had a, a broken bone, uh, any kids, even just the first time for a broken bone, but especially for kids who have had, you know, multiple fractures in their lifetime, living in the north, a a pretty good chance that we have some vitamin D deficiency that might be contributing to that. So, uh, I think it's a, it's a pretty good thing for everybody to be doing, really. You and me included [Yeah.] As well.

Dr. Anthony Egger:

Absolutely. No, I take it, I take it every day.

Dr. Kevin Serdahely:

I do too.

Dr. Anthony Egger:

Helps with immune health, bone health, it's, uh, it's a, it's a good, it's a good thing.

Dr. Kevin Serdahely:

Yeah. And, and I think it's important for kids too. Uh, you know, it, that's, uh, I think that's been shown pretty well through some studies that it is a, it is a beneficial thing to be doing.

Dr. Anthony Egger:

Absolutely. So, you know, you get to patients come to your clinic and a lot of times parents, um, you know, rightfully so, can be worried about radiation coming with X-rays. [Mm-hmm <affirmative>.] How do you as a physician balance the, you know, the need to get a picture versus, you know, also limiting radiation exposure to make your diagnosis?

Dr. Kevin Serdahely:

Sure. It's constantly on the forefront of our mind of, hey, you know, we're, we wanna limit radiation as much as we can. In some instances, you won't have the answer without an x-ray. And so, uh, I think at the beginning, after any, you know, concerning injury, it's worthwhile getting a, an initial x-ray. So for kids then we kind of decide, hey, does this need another x-ray down the road? Certainly, you know, in instances where things are broken and we need to make sure that heal correctly, we're gonna be following that along with some x-rays. And then, you know, if you're pretty sure it's more of a sprain type of injury and, and nothing is broken, then that may be the only x-ray that first go around.

Sometimes, uh, if it's a little bit questionable because you are unclear if maybe there's a growth plate fracture that you can't necessarily see on the x-ray, that's another reason that sometimes we'll get some repeat x-rays, even if the first x-ray is negative. Uh, but certainly always on, uh, always on the forefront of our minds to make sure that we are being, uh, responsible with, uh, the amount of radiation that we're dosing kids with.

Dr. Anthony Egger:

So in a pediatric patient, the initial x-ray can be negative, but they still could have a fracture that you could see at a later date?

Dr. Kevin Serdahely:

Absolutely. That actually happens a lot. Uh, particularly for younger kids who have big open growth plates and lots of growing left to do, uh, something that looks like a sprain injury right from the get go. And, and an x-ray that's initially normal, uh, might not always tell the whole story. Um, in many instances, the ligaments for kids are actually stronger than the growth plate itself, which can kind of be a relative weak point. And so if it's, if it's an injury where there's a lot of swelling, a lot of bruising, we don't see anything on that original x-ray, but the mechanism and the physical exam is still pretty concerning, that can be a time where it bone is actually broken.

It's just that it's broken through that area of the growth plate that looks like a little line where nothing's there and you can't see it on the x-ray because the fracture line didn't kick out into the bone on either side.

Dr. Anthony Egger:

Yeah. And while not all growth plate fractures are created equal, why do some of them give you some concern more than sort of a break in the middle of the bone?

Dr. Kevin Serdahely:

For sure. So like you said, we're always worried about growth plate fractures. The, the main concern would be for a growth plate to stop growing as part of the fracture healing process. Uh, what can sometimes happen is that the body tries to heal the fracture, but in doing so, it actually kind of heals the growth plate like it would be healing the fracture. And, and that can cause some issues because it can lead to things like leg length discrepancies in the leg or angular deformities, you know, the, the bone or the, uh, the extremities where there's two bones like your forearm or your lower leg. If it happens to one of the growth plates and not the other, we worry that one keeps growing and the other doesn't. And so we're just keeping a really close eye out for those things. Some spots are, uh, more notorious for having that problem, whereas some spots we rarely, if ever see that happen.

Certainly if it doesn't involve the growth plate, uh, <laugh>, it's greater when that happens that way because we don't have as much concern there with the growth plates. Ironically, the closer it is to the growth plates, uh, usually the quicker it heals. And, uh, relative to growth plates, while we're on the topic, uh, if you break something kind of near a growth plate, but you still have a lot of growing left to do when you're a kid, it's actually sometimes okay if it's a little bit angled or a little bit outta place because once the body's healed it, the body can straighten it back out. Uh, whereas for adults, if you break it and then heal it, it's gonna heal exactly where it broke and healed and it isn't gonna change anymore from there. So in some ways, you know, if it's close to the growth plate, uh, there's, there's, uh, and sometimes it can be a little bit more beneficial there.

Dr. Anthony Egger:

Yeah, there definitely is some magic around those, uh, around those growth plates. So, and so there's times that you'll follow patients even after their fracture has healed further on six months, a year out just to try and alleviate those concerns [Definitely.] so that doesn't happen.

Dr. Kevin Serdahely:

Definitely, especially for those really high risk ones. You know, older kids that are getting a little closer to their teenage years but still have growth left, broken ankles in that scenario or, or a kind of a higher risk for that one. And so that's, that's when we always follow pretty closely. But, but really any concerning injury, I'm usually getting x-rays at about six months and sometimes even a year, if anything looks a little suspicious at six months.

Dr. Anthony Egger:

Fantastic. And so obviously, you know, we wanna get these kids back and doing what they want to do again. And as a general timeline, you know, what is sort of the average recovery time for, you know, a sprain versus a a fracture?

Dr. Kevin Serdahely:

Yeah, great question. You know, fractures in general take about six to eight weeks to heal up all the way. And so if we're pretty sure something's broken, you know, or we see something's broken on the x-ray, um, it's usually gonna be somewhere around that timeline. Anywhere from six to 12 weeks, depending on the location and the fracture and, and how long it takes to heal. And then sort of rehab and rebuild strength after that. Sprains can be quicker, you know, depending on the degree, anywhere from one week to three weeks. But you know, sometimes the more severe sprains can even take a month or two, almost more like a fracture to heal up depending on how significant that is. You know, you, you probably hear people talk about grades of ankle sprains and how quickly you can return from those types of things. And that is largely dependent on, hey, is that just stretched a little bit at the ligament or is it partially torn or did it really completely tear all the way through? And that can change that timeline quite a bit as well.

Dr. Anthony Egger:

And for these kids with these injuries, is there ways for them to still try and stay active?

Dr. Kevin Serdahely:

Yeah, you know, if it's an upper extremity injury a lot of the time, you know, it depends on the, the fracture, I suppose. Uh, I, I usually will tell people, Hey, let's try to keep feet on the floor activities if it's, you know, a pretty significant broken bone. But if it's something more like a buckle fracture, we'll get in a brace or cast and can still be, you know, active doing stuff with your feet, moving around, still using the other arm, things like that, I think it can be a little bit more challenging, uh, if it's a lower extremity fracture that you're having to stay off of in a cast or something. And so, you know, still trying to find ways to be active mentally and or, you know, get around as much as you can is still a reasonably good idea

Dr. Anthony Egger:

For certain. Casts, you know, they have the waterproof technology now. Um, do you feel that that's worth the potentially extra cost, um, that may go into it?

Dr. Kevin Serdahely:

I think it largely depends on a few things. First of all, what, uh, is it an arm or a leg and, and is it a long arm or, or a long leg? You know, I, I think there's actually some variety in what people will use waterproof casts for. But for something like a short arm cast in the summertime, if you want to keep swimming, uh, I think it's a great option. And, and for some people it's probably worth the, the slight extra cost to keep the kids happy and, and you know, getting in the pool and doing the stuff they want to do. In the wintertime if we're not in the pool anyways, or if it's, uh, an extremity where you gotta take a 90 degree turn or multiple 90 degree turns like a long leg cast, you know, I worry a little bit about getting water in there down and around those, those 90 degree turns if it pools a little too much. So in some instances, I actually don't recommend waterproof casts, whereas in some other instances I do.

Dr. Anthony Egger:

Yeah. And same for me, you know, if I'm having to sort of mold the fracture or do anything to manipulate the cast, you don't wanna move that, um, that, that waterproof material.

Dr. Kevin Serdahely:

Absolutely. That's another great reason to, and, and, and same thing for me. If we're mold, then I'm usually going non waterproof.

Dr. Anthony Egger:

Yeah. Do you have any tips to keep the cast fresh and clean or prevent inching?

Dr. Kevin Serdahely:

So I don't know what families have told you, but for me, uh, I usually kind of recommend at this point using the cast covers for like showers. I, I know, you know, everybody's always heard of tape, a plastic bag on, you know, uh, those types of things. But I find that inevitably that just gets watered down it and the cast gets wet. The cast covers, they're pretty cheap nowadays and they sell 'em almost everywhere. It's really, it's just a fancy plastic bag with a rubber sleeve on the top. But, uh, you know, most families that when they come back, if they tried that versus the the plastic bag, they tell me, Hey, uh, way better <laugh>, the cast cover was way easier, uh, than a plastic bag. And then, you know, beyond that, trying to keep it as comfortable as possible. I think the number one most important thing is if it does get itchy to not stick anything down there that could get stuck in there.

Um, I've seen, uh, unfortunately some bad problems from things getting stuck in casts. And so trying to find ways to limit that itchiness can be helpful. Things like baby powder, uh, kind of lightly sprinkled down in there can help if things are getting too sweaty. Uh, hair dryer on cool as opposed to hot can help dry things out if it's getting a little sweaty in there as well. Uh, but really doing everything we can to, to minimize that itching too 'cause uh, that's, that's where we can sometimes run into some problems if something gets stuck down there and we don't know about it.

Dr. Anthony Egger:

Yeah, it can create a lot of skin issues that we don't know about. [Mm-hmm <affirmative>.] create some problems. Yeah, I've also anecdotally heard that tapping it with a wooden spoon can help. I have no idea why, but I have patients tell me that.

Dr. Kevin Serdahely:

There you go.

Dr. Anthony Egger:

So obviously kids that have these injuries and have fractures are going to have some level of pain. How do parents, what are your recommendations for them managing the pain at home and what are some things that they should potentially look out for as warning signs?

Dr. Kevin Serdahely:

Yeah, absolutely. So, you know, uh, we kind of touched on it a little bit earlier, but first line pain management at home for me is gonna be children's Motrin, ibuprofen, Tylenol, some of those over the counter available options. Um, I would say most kids aren't going to need a narcotic level pain medication for a broken bone typically, unless there's a surgery involved in the treatment. And so usually those are along with ice, uh, sufficient at managing the pain from the initial injury. As we're getting over into a cast, we need to be a little bit careful transitioning into a cast because especially at the beginning with lots of swelling, we don't want too much swelling inside of the cast. And so may even start somebody with a splint or a split cast and then transition over to a solid cast when it's time and the swelling has gotten better.

That's because we don't want that blood supply to get cut off to the extremity. But beyond that, once you're in a cast, you know, should be pretty comfortable. If your kid is feeling good for a few days and all of a sudden things are different, they're complaining of a lot more pain, something has changed, that's usually a good time to say, Hey, we should probably get back in and, and see the provider again. Um, whether it's the cast fit, sometimes the swelling has come down and the cast is a little bit loose and that's all that it is, but, uh, we wanna make sure the bone still lined up well and that the cast still fits well.

Dr. Anthony Egger:

Yeah, absolutely. And, you know, after they finish their, you know, sort of treatment, how do you know when they're strong enough to get back out on play again?

Dr. Kevin Serdahely:

So I usually kind of give people my three rules for return to sports. The first is that if anything's broken on the x-ray, uh, usually we're gonna be waiting for that to be healed on the x-ray. There's a few, you know, exclusions to that if it's an avulsion fracture or something from that nature. But if it's a, a true broken bone, you know, we're gonna be waiting for that to be healed on x-ray. So that's number one. Number two is that I want to have people have most of their strength and their range of motion back so that they could do that sport safely and not be in a position for re-injury. And then the third is that they can get back and do that sport with minimal or no pain. So if you're a basketball player, you know, that means being able to jump, stop and do it confidently and not have a whole lot of pain when you're doing it.

Dr. Anthony Egger:

Yeah, absolutely. And there's obviously the physical component, but there's also a mental component, um, you know, after injury. Um, how do you counsel your patients or recommend parents can help their kids, you know, sort of get over that mental hurdle of potentially not wanting to play again due to fear of injury?

Dr. Kevin Serdahely:

For sure. Sometimes that's the most challenging part of injuries like this is, is getting back into it. There's a couple different things that can be helpful for that. Uh, in some instances if we still have some weakness around a, a joint that is leading to some of that sensation, sometimes some physical therapy can be helpful as part of the rehab process. If everything feels strong and, and we're confident that it's well healed, but we're still kind of struggle and to cross that mental hurdle, sometimes they can even be helpful with that. But sometimes something like a brace can be helpful, uh, especially after a bad ankle sprain where we're trying to get back and, and things are looking good, but we don't quite have that confidence yet. A brace temporarily can be helpful in that setting. Same thing, you know, after an arm fracture, sometimes we're confident the bone healed up, but maybe not, won't quite have that mental confidence in something like a brace can be a little helpful there.

I do caution people if we're using a brace to help bridge that barrier, that our goal is to get out of the brace. We don't want to be in that long term because, uh, if it's not needed long term, then it can actually lead to some weakness around like an ankle, uh, in a brace for too long. So I do want people to rehab and get out of the brace, uh, as soon as we can, but sometimes it's a helpful tool to cross that mental barrier, so to speak.

Dr. Anthony Egger:

Yeah, that makes a lot of sense. And, you know, we just wanna say thank you to, uh, to Dr. Serdahely, um, for being here today. He's provided us with a lot of, uh, wonderful pearls and, um, knowledge and so thank you again Dr. Serdahely for, for being here.

Dr. Kevin Serdahely:

Yeah, thanks for having me. This was a lot of fun. Um, hopefully we're helpful for you and, and, and can give some information to families of how to manage these. Um, but, uh, we're always here for you guys. All of us here are, are kind of spread around the city too, so lots of options and we're, we're happy to see your kids anytime.

Dr. Anthony Egger:

Yes. And so we hope you feel more confident, you know, managing your children's bump, bruises and breaks, and especially recognizing when they need specialized care. Being prepared and staying calm in those first few minutes after an injury is the most powerful support that you can give them. If you would like to schedule an appointment with a pediatric orthopedic specialist at Cleveland Clinic Children's, please call 216.444.2606. That's 216.444.2606.

Dr. Richard So:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.