Soccer Mom’s Guide to Sports Injuries and the Growth Plate

Podcast Transcript

Music (Intro).

Speaker 2: 0:08

Hello and welcome to the Bone and Joint Playbook with Dr. John Urse. Tips for pain-free aging. Dr. John Urse is a board-certified orthopedic surgeon with over 35 year’s experience in the Dayton, Ohio area. He’s also a clinical fellowship trained surgeon in total joint replacement from Harvard. Today we are joined by Dr. Charles Melman, professor of Clinical Affiliate Orthopedic Surgery at the College of Medicine for the University of Cincinnati. This episode is brought to you by

Speaker 3: 0:37

Ted’s authentic Greek salad dressing and marinade. It’s healthy, gluten-free, and delicious. You can find Ted’s in Dayton, Ohio at Dorothy Lane Market, Health Foods Unlimited and DOT’s markets. That’s Ted’s authentic Greek dressing and marinade. Thanks Ted.

Speaker 4: 0:54

Alright, folks, we are back here again. It’s the middle of July and we’re here with Dr. John Urse for another episode of the Bone and Joint Playbook with Dr. John Urse. Hello, Dr. Urse.

Speaker 5: 1:05

Hi Terry

Speaker 4: 1:06

How are you doing?

Speaker 5: 1:07

Doing great.

Speaker 4: 1:08

All right. You’re still in your scrubs, you just came outta surgery, is that correct?

Speaker 5: 1:12

Uh, well, I can’t tell a lie. That is correct.

Speaker 4: 1:14

I just didn’t know whether you walk around all day long in those things.

Speaker 5: 1:17

Not if I can help it.

Speaker 4: 1:18

Well, hey, we do have a special guest with us here today. You know, when he pulled up in his pickup truck and got out with a hat, I didn’t know exactly what to expect, but I’m gonna let you introduce your friend Dr Urse. Go ahead and tell us about him.

Speaker 5: 1:31

Well, I’m privileged to have a full professor of children’s orthopedics from the University of Cincinnati, who was just named by the way, their hospital as the number one pediatric hospital in the United States. Kudos to them. Dr. Chuck Melman, he’s a orthopedic specialist who has close to 30 years of training and care in the community. I was privileged to train Chuck some 28 to 30 years ago in our residency and he has gone out and planted a stake in Cincinnati and I’m really proud and happy to have him today.

Speaker 5:

Proud to be here with you, John, as well as Terry. Thank you.

Speaker 4: 2:17

Alright , so let me ask a real quick question. What the heck are we talking about today since he’s this doctor who focuses on children? What’s the topic for today, Dr. Urse

Speaker 5: 2:28

Well, we’re gonna crouch down here and we’re gonna talk about it, it’s called the playbook to prevent sports injuries in children.

Speaker 4: 2:37

Ah, so there , I guess in your world there, Dr . Melman, you see a lot of sports injuries in children.

Speaker 5: 2:43

It is the core of what we do is take care of injured children, that’s for sure.

Speaker 4: 2:47

Just curious, what’s the most common sports injury that comes into your practice?

Speaker 5: 2:52

Without a doubt, it’s fractures at the distal radius and ulna out there close to the wrist. Uh, it is number one on virtually every single epidemiological study looking at such injuries.

Speaker 4: 3:01

So, you’re telling me that basically sprained wrist, fractured wrists.

Speaker 6: 3:05

Very much a fracture, sprains can happen, but they are the minority of the time. Fractures are the majority of what we see

Speaker 4: 3:12

What causes those?

Speaker 6: 3:14

Wild kids who have, in some cases, incredible talent, sometimes limited talent, they take a hard fall, and their bones cannot take the full stress of what they just did, whether it’s skateboards or tackle football or soccer, gymnastics. I mean, take your pick.

Speaker 4: 3:31

Alright, well Dr. Urse I’m go pass a baton to you and you can kind of handle this for a while .

Speaker 5: 3:36

Alright , well thanks Terry. Well, I think, I think what’s gonna interest the listeners is why do certain fractures occur frequently in children and that make them a little different than what an adult would be? And we really wanna focus a lot of what we talk about on what’s called a growth plate. And the growth plates have to do with how bones grow. And that area where they grow is a little bit weaker than the regular bone itself. Isn’t that right, Chuck ?

Speaker 6: 4:02

No , that’s a great point, Dr. Urse. The growth plate is what distinguishes pediatric orthopedics from the rest of the specialty. I say my adult to pick on my adult colleagues. I say they have it easy, all they have to do is get the bone to heal. I go, we have to get it to heal and then make sure that it grows right. And if and when it doesn’t grow right, we have to do stuff to straighten it out by various techniques. So, the growth plates are classically in the long bones. Your leg bone, the femur bone, your shin bone, the tibia bone, there’s growth plates at either end of those long bones. That’s what lets your kid grow tall and reach their eventual height that God has basically determined for ’em. And as Dr Urse points out appropriately, the growth plate can also be a weak spot when the kids twist it just right, hit it just right, the fracture can easily propagate right through that growth plate near the end of the bone.

Speaker 5: 4:51

Well, that segues onto what you said earlier about sprains. And sprains are usually injuries to the ropey structures called ligaments that hold our bones together and hold our knee straight and our wrist straight. And when an injury or force goes through there the ligaments, or the ropey structures are actually stronger than the growth plates. So, when someone says to Dr. Melman, Hey, there’s a, there’s an ankle sprain in the ER, his alarm goes up and says, Hey, I’m pretty sure that’s a growth plate injury. And am I right or am I wrong?

Speaker 6: 5:24

Dr. Urse is basically always right. He has spoken bio-mechanical truth, bio-mechanical truth has been spoken. So, I grant the point in somewhat rare cases, as I like to say, there’s no law that says you can’t have two things, or somebody taught me years ago. If you only know how to diagnose one or two things, you probably diagnose those things a lot. But in this particular case, the fracture can be there and there might also be some associated ligament injury, but the fracture is the most important part.

Speaker 5: 5:52

Yeah, and we’re not gonna discount the fact that children and adolescents get ACL injuries. We talked about the anterior cruciate ligament that’s in the middle of the knee, that’s like a ropey structure. And that can occur from a lot of other reasons. We talked about that in a different podcast. So, we’re not gonna discount ligament injuries. Certainly, we know those occur. But today we’re gonna talk about the growth plate injuries. So, we talked about the most common growth plate fracture in children, which is the wrist. And actually, it’s one of the most common injuries in adults. And the acronym of the day is called FOOASH. So FOOASH stands for a fall on an outstretched hand. And when you go to stumble, your natural reaction is to put your hand out to break the fall. Otherwise, you break your brand-new Ray Bans, and you don’t look like Tom Cruise anymore. <laugh> . So, what we try to do is get our hand out there to protect it. But unfortunately, in an adult in grandma’s wrist or in little Billy’s wrist, the growth plate sometimes fails. The force goes through there and we get a fracture. So, what makes a growth plate fracture different, it’s not just getting it to heal, but getting it to heal straight. And you have the watchful eyes of mom and dad looking at little Cindy’s elbow or wrist making sure it doesn’t heal crooked. Is that correct?

Speaker 6: 7:11

Exactly, and there’s different growth plates have different degrees of risk, so to speak, a different percentage risk. There is a classic growth plate classification system where they’re split into basically four main types. And people tried to act at times, like there’s a similar prognosis. You know, prognosis is predicting the future, right? What’s gonna happen with that injury? And we act like the ones and twos are good and the threes are bad. And if you get to the fours or others, it’s somehow the ugly. And that’s a wild oversimplification. And growth plate fractures in reality are very regionally important. What people say, all politics is local. You can make a case that all growth plate risk is somewhat local. The risk that you started with is important. Distal radius, the big arm bone at the wrist and the skinnier bone, the distal ulna has a different risk. If you have a bad growth plate fracture of your distal radius, the risk may be in the 7-10% range. If you break the same sort of growth plate fracture on the ulna, it’s a 50% growth arrest risk.

Speaker 4: 8:14

So, can I jump in really quick?

Speaker 5: 8:15

Yeah. Terry , did you pick up on growth arrest? Are we getting into law here? What does that mean in regular parlance if the growth arrest occurs, it’s a what?

Speaker 6: 8:24

What that means the bone quits growing properly. Maybe either completely or sometimes partially, where now it grows crooked.

Speaker 4: 8:31

Ok, so when does my growth plate stop? When do I quit having a growth plate? ’cause it sounds like at some point in time I don’t have to worry about a growth plate anymore.

Speaker 6: 8:39

That’s an excellent question, Dr. Urse. This guy’s good.

Speaker 5: 8:42

He is good. And he’s also not gonna get any taller <laugh> Tell him why his growth plates are closed

Speaker 6: 8:48

So, there’s a bit of a regionality also to such growth by and large, important growth plates that give you your height come from around your knees. And that growth is done in a boy by about 16 or 17 if you’re a late bloomer. There’s some other growth plates, like if your collarbone that may not truly be totally done grow until you’re in your early twenties or thereabouts. The end of the bone of the radius, like we’re talking about by the wrist, it may be about 16 or 17 for significant growth, maybe a little bit more beyond that. And so, in girls, as I like to point out to my residents all the time is that throughout the entire lifespan, girls are ahead of boys in their maturation and their psychological maturity, et cetera, et cetera. So, I like to praise the female side of the species, but girls on average are about two years ahead of boys in terms of their bone maturation.

Speaker 5: 9:40

Which means they actually stop growing a little earlier. Correct. And is also, I always heard that perhaps after they start the menstrual periods, it’s a couple years of growth after that, as a good guideline doesn’t mean, or if their shoe sizes quit changing. That’s the other Kmart method. <laugh> . I love a plugin for them.

Speaker 6: 9:59

I love the practicality. Again, Dr. Urse speaks the truth.

Speaker 5: 10:05

So, problems occur when the word growth arrest comes up or growth stoppage because you have two bones and think of two track runners going to the finish line, and one of ’em just stops. Well, the other one, if it continues, if the other bone next to it continues, it doesn’t have that other bone next to it. And it may turn a little bit to the side now. Kinda like a flower that has more room to grow, it stretches out, but all of a sudden that makes a wrist look crooked or an elbow not perfectly straight. So, there are times sometimes you actually slow down the bone next to the one where a growth arrest occurred. And the orthopedic specialists in the pediatric fields will calculate how much growth is left in that bone. What can we do to slow Mary’s end of her thigh bone down, so it doesn’t end up crooked at the knee. There are different techniques for that that are rather specialized. Is that right?

Speaker 6: 11:05

Yep. You are painting a very clear picture of two of the most important situations when there are paired bones. So, at the wrist you’ve got your radius and the ulna there by your wrist bones and at your ankle you’ve got your tibia and your fibula close to your ankle bones. And this produces parents who start nodding and understanding when I say it’s a bad thing, when one bone stops growing and the other one keeps going. So, in some cases, if that growth arrest area of the growth plate is a small area where it has stopped doing its job, there are operations to go in and take out that funky area to try to let the growth plate recover. But if it’s too big of an area, usually around somewhere between 33% to 50% or bigger, then we stop the growth. As Dr. Urse alluded to a few moments ago, to try to maintain the balance. And the important thing is finding that trouble early. It’s one of the most important speeches that I give to parents as we take care of their injured child, is I make it clear this is a growth plate injury. And we treat such growth plate injuries in two phases. Phase one is to get the bone to heal. And that’s the good part of a growth plate fracture. It heals faster, usually about three weeks instead of the usually longer period. And phase two is tougher. That’s the monitor growth and look for growth trouble. And I said, that’s when you’ll feel silly coming back because your child will be so normal, but you have to come back, please come back, so we can check. And we often check both the good side and the previously injured side to compare. They say God was good to the orthopedic surgeon because she gave us a normal side to compare to.

Speaker 4: 12:42

So let me make sure I got this right, just as a general guy sitting here. If I have a child who gets injured in a soccer game and falls, they can damage their growth plate, that growth plate can actually then just make it a factor of how they grow in the future.

Speaker 6: 13:01

Exactly.

Speaker 4: 13:02

I never knew that

Speaker 6: 13:02

Some are worse than others. Say the very end of your femur bone, the thigh bone. That growth plate produces about 10 millimeters of growth a year. And so, if you injure that at a young age and you’ve still got six or seven years to grow, you suddenly have a dramatic difference in the length of your legs. If you were lucky, there were ways to set the bone and to decrease the risk , shall we say, of growth arrest. But once a growth arrest occurs your main option is to lengthen that leg through a big surgery, a very complicated surgery that is doable, but not the easiest route.

Speaker 4: 13:42

Is that a common thing? I mean this is kind of new to me. I’ve never heard of this.

Speaker 6: 13:47

If you’re asking is leg lengthening common? I would say yeah, there’s been methods in use for lengthening legs for the better part of close to a hundred years. There were some crude methods at the beginning. By the eighties, there was a wild doctor out of Russia named Azarov that created some elaborate ways to lengthen it. And now there’s fancy intra-medullary, you know, inside the bone ways of lengthening. It’s a pretty routine procedure at nearly every children’s hospital in the country. Now with very proper indications. We found that the rate that you slowly pull on the bone about one millimeter a day is what it takes for the rest of the tissues to sort of wake up and tag along as the bone is lengthened.

Speaker 5: 14:36

We’ll jump out of the metric system into the imperial system for a minute, <laugh> only because there are a few staunch Americans still using the imperial system of measurement. But we talk about 10 millimeters, that’s about half an inch. Chuck just talked about one millimeter. That’s 25th of an inch. So, you don’t need to think that’s very much. But in terms of when you look at how growth occurs in the knee or where the majority of somebody’s entire leg growth occurs, when say 70% of the growth of the whole leg occurs in those growth plates above and below the knee, we pay pretty close attention to how we think that that outcome is gonna be. And that’s why the skilled pediatric orthopedist says this thing is a marathon, not a sprint. We follow the child till maturity. And there are probably a few lawyers following it till then, too <laugh>.

Speaker 6: 15:34

But that’s one of the most important things they worked out in the deeper historic roots of limb lengthening is lengthen too slow and it just doesn’t work lengthen too fast and there’s some horrible complications for the nerves in particular as well as some of the other tissues. And it also just doesn’t work, right? So, it has to be, it’s Goldilocks not too hot, not too cold, just right.

Speaker 4: 15:54

So, if this is a guide for soccer moms to kind of know what’s going on with their kids in sports. Are there certain sports they should avoid at a certain age?

Speaker 6: 16:03

That is, as they say, the $64,000 question. The facts as I understand them are of course mainly from our experience in the United States, but I can’t imagine there’s a lot of difference in similar countries. And that is for kids with talent, by about age 10, they have become very focused on their sport. Before that age, they’re dipping in and out and trying different things, and they’re figuring out their aptitude for X, Y, or Z. Around age 10, it’s one sport and one sport only. And then that leads to some of these issues. You know, if the kid has talent, they’re playing more games, sometimes they’re bouncing around between a couple different leagues, and maybe each coach doesn’t even know. And so, I like the question a lot, and there has to be moderation. You can’t burn out a kid too early ’cause you can very, very much cause some pain, cause some trouble. Okay.

Speaker 5: 16:58

Well, we alluded to that a little bit in our Tommy John elbow injury podcast where we said little kids throwing curve balls in baseball, stress that inside elbow ligament. And to Dr. Melman’s adage he doesn’t like seeing curve balls out of little leaguers until they can shave. So that keeps that problem away. But you also have to understand the body is not used to 12 months a year of baseball. The best athletes in the world, you watch Steph Curry, a great basketball player, make an eagle on the last hole to win a golf tournament. That kid can play a lot of different sports. And when your body has a chance to recover from baseball, when you play basketball or when you play golf, or when you do something else, you’re not only developing other muscles and other skill sets, but you’re also resting the part of the body you need for your favorite sport. And I always tell people that you might wanna look at a couple things. Multiple sports are always a good idea, and year-round sports in one area is a bad idea. The second thing is we also talked about sports injuries and injuries to the head and concussions. And so, to quote Jerry Seinfeld, we don’t stop our skull cracking activities, we just put a helmet on and keep doing it <laugh> . So, we tell people, you don’t really wanna take your most valuable asset, which is your head, and repetitively bang it against something. Nothing against football, but again, it’s that and soccer and many other sports have a lot of repetitive blows to the head, which you could be putting to better use with other activities.

Speaker 6: 18:38

Now, without a doubt I mean, to touch on sports related concussion is an appropriate thing at almost any time for my own kids through their high school years, the worst concussions on my kids’ high school experience were girls’ volleyball and girls’ basketball. For reasons that we still don’t understand, there’s gender differences in sports concussion where girls have a worse go of it than boys. The proverbial football boy can effectively be knocked out for like 5 seconds, 10 seconds, and sort of wake up and get off the field a little punch drunk. And a girl can take repetitive minor hits, never really have ever lost consciousness, and she has a worse problem to bounce back from on average.

Speaker 4: 19:20

I know during these podcasts, Dr. Urse we like to kind of have a message, an overall message about what they can take away from this. So, if a soccer mom’s out there listening, what is the overall message they should take away about growth plates and injuries to their child?

Speaker 5: 19:37

Well, I would tell them that they are in charge of their children’s wellbeing and that they should moderate what their children do and not put them in every travel team, every season of the year in that single sport. I think that that’s up to them. As Dr. Melman said the coaches don’t even know sometimes how many other teams a players on. And let’s face it, everybody wants their kid to get a scholarship to go to college in that sport. But honestly, if they throw out their elbow or if they injure their knee or do something because they’ve overtrained or overused that body part, they’re not gonna get that scholarship. I think a good parent would moderate what’s going on. I think they should look at nutritional status. I think they should look at the balance of the child. We know that there are eating disorders, there are hormonal changes that affect young boys and girls differently. We know there’s external pressures from coaches, from other parents, and from the kids themselves who want it. Just because the kid wants it doesn’t mean the parents should condone it. So, I think we try to moderate not just their social, but their athletic endeavors as their guardians.

Speaker 6: 20:54

What I would add, Terry, is there’s a strong case for musculoskeletal rest. Sometimes that’s cross training, like Dr. Urse was alluding to earlier. I have this conversation with my share of parents through various sports and various situations. And they’ll, they’re really focused on the next thing, the next they’re gonna get on a plane and go to Colorado for the next gymnastics competition. They’re going to Florida for the football competition with their future Hall of Famer. I believe very strongly in tailoring the treatment to the patient and the family’s needs. And so, I said, are we talking about a truly unique opportunity? Is this the championship game that your kid and his team, you know, blah, blah, blah. And so there are some , some injuries where we can come up with a safe plan for how that kid could still be part of that. And there’s other times where it’s not even close to a significant thing like that. And it’s like, I’m thinking about next season. I’m thinking about all the other games, not this thing a week from now.

Speaker 4: 21:54

One of the things let me ask as you walk out of the door of this studio, this house. You’re gonna see probably 10 kids on electric scooters, right? Whizzing up and down the street. These things remind me of just some accident waiting to happen. What do you tell parents when their kids are riding these scooters like mad men and you know, they’re gonna fall, they’re gonna reach out, they’re gonna hit their wrists. What should we be telling these folks?

Speaker 5: 22:20

My vote is for a helmet, because number one, you can have Dr. Melman set that wrist and it’s looks pretty darn good, and it’ll be okay whether they wear a little wrist splint, and he can ask you how preventative and helpful those are. But I think the main thing would be a helmet. We know skiing and ice skating and hockey players wear ’em, and there are things you just don’t want to hit your head. They can be really serious injuries to something you really want to use the rest of your life,

Speaker 6: 22:48

Life changing. Head injuries are brutally, brutally horrible for kids. But as Terry asked the question, he talked about motorized scooters. And so, this is a place where I cite the American Academy of Pediatrics, which has had it very simple for a lot of years, <laugh> . And that is, if you ain’t got a driver’s license, you got no business driving anything that has a motor <laugh> . And that’s whether that’s a riding lawnmower, right? The scooter or what have you. And so, I think that’s the simplest rule. But as an old farm boy who went over his share of handlebars on minibikes in the pasture here, I understand the realities also. And this thing that saved me for the times I hit hard was the helmet I was wearing.

Speaker 4: 23:24

That may be the best message yet, because they’re out there and there’s nothing you can do. They’re just gonna have fun and there’s nothing we can say to stop ’em.

Speaker 5: 23:32

I would probably leave the last note in the playbook as kids rarely fake injuries or malinger. And if they’re hurting or something isn’t right, I think you need to get ’em checked. Their x-rays may not look abnormal to the cavalier observer, but the experts will know that, or they’ll find the special views they need to find the problem. And so, we’re pretty good checking out when our animals aren’t right, but you also know when your kids aren’t right. And if their performance is diminishing on the athletic field, it’s usually a reason something hurts and they’re not wanting to tell you about it. You may find it, it’s not much, but something as simple as rest and a couple weeks off of that , uh, sport will get ’em right back in their game.

Speaker 6: 24:23

Parents know their kid and they can tell when something’s wrong. Coaches who are appropriately attentive also know when something’s wrong. So, they and the honesty of kids is pretty much legendary. There’s the occasional kid that’s trying to be too much of a psycho tough kid and minimize their symptoms, but it can be really problematic to fight through it.

Speaker 4: 24:42

Okay. Well, as we land this podcast, is there anything we should have talked about about growth plates? Because I found it fascinating. I never knew about this. So, anything we should leave the listeners with about growth plates?

Speaker 6: 24:54

I think that growth plates are cool. Growth plates are normal. Growth plates are what distinguished pediatric orthopedics from the rest of this wonderful specialty that we know and love. The key thing is that by and large, a growth plate fracture heals faster. That’s the good part. Phase one of treating a growth plate fracture and phase two, with very few exceptions, is to monitor the growth of that growth plate fracture. Growth plates don’t grow as fast as fingernails or hair. They grow at their own rate. And it takes up to four to six months or so to really get the first hint as to whether there’s gonna be trouble. So, it’s not four or six weeks, it’s more like four to six months.

Speaker 5: 25:33

And just to throw in one thing, because I treat adults and Dr . Melman treats kids, most of the things we treat in the adult fracture department are fixed. We do surgery, we put little plates and screws like a little broken pencil, they fit right back a certain way, and we all pat ourselves in the back. But in the children’s world we rarely have to do surgery. They can set the bone by a manipulation effort, put it in a fiberglass cast, it’s waterproof. Little Billy goes to the pool for a few weeks and that thing comes out with a lot of ability to look pretty darn good without surgery. And I’d say in the pediatric world, we see a lot more casting and a lot more watch and look and observe than a more aggressive treatment of fractures in the adult world.

Speaker 4: 26:20

So, I got two things I want to ask before we sign off. First off, if a kid breaks his arm, is that arm always gonna be delicate? Or is that arm as good as new once he comes outta that cast

Speaker 6: 26:32

Good as new. Once it’s fully healed.

Speaker 4: 26:34

Okay. And then the last question I have for you, and this is really for you Dr. Melman about Dr. Urse. I understand he was your professor, your teacher when you were a resident at Ohio State, is that right?

Speaker 6: 26:47

Ohio University. Ohio’s first university <laugh> Founded in 1804. For reasons that are still somewhat mysterious, Dr. Urse considered me trainable.

Speaker 4: 26:57

That’s good. So, how was he as a teacher?

Speaker 6: 27:01

He was as delightful as you and I have seen him here today in the studio.

Speaker 4: 27:04

Well, that’s always good to know. I’m glad to hear that. So, at this point in time, we’re gonna leave you, I’m sure we’ll have Dr. Melman come back for future episodes. We want to thank you for joining us here on the Bone and Joint Playbook. Dr. Urse, tell us about Ted’s Salad dressing before we go though, that’s a very important thing.

Speaker 5: 27:20

Well, we always wanna thank our sponsors. Teds has always stepped up to the plate to help the Bone and Joint Playbook. You know, it’s a sugar-free, dairy-free, gluten-free, great dressing. It’s a great marinade for your chicken. It is put on your salads and it’s available at all the local areas here in southwest Ohio. They’re looking to get global one of these days and get a website and let you mail order someday. That isn’t there right now, but we do appreciate the sponsorship.

Speaker 4: 27:49

Alright, well at this point we’re gonna sign off for the Bone and Joint Playbook with Dr. John Urse. This is Terry O’Brien at Tri-Level Records. We will see you again very soon

Speaker 7: 28:04

Thank you for joining us today on this episode of The Bone and Joint Playbook with Dr. John Urse, Tips for Pain for Aging. Please join us again for another episode produced by Terry O’Brien.