Size Matters

This week I attended the quarterly Seattle Children's Hospital Sports Medicine Symposium on Upper Extremity Sports-Related Trauma.  I wrote about the inaugural symposium here which was about Mental Health.  I always enjoy these types of gatherings - a chance to network with providers I haven't had the chance to meet in the past and catch up with my colleagues who work at the other Seattle Children's locations, continuing education with my coworkers that gives us more things to discuss and new knowledge.  My clinic is not one of the surgical centers so it is a rare opportunity that I get to interact with the orthopedic surgeons whose patients I spend so much time with and there are other providers I just never get to see, so that was another positive of the day.

While there were many interesting things I learned at this week's presentations, one of the discussions closely overlapped with a current patient I'm seeing and a recent injury to a family member.  Dr. Thomas Jinguji and Physician's Assistant Leslie Rodriguez presented an entertaining and informative discussion on "Forearm, Wrist, and Hand Fractures" with considerations for returning athletes with these injuries back to their sports.  The forearm includes two bones: the radius and the ulna.  These bones are both commonly injured in "FOOSH" injuries - "Fall On OutStretched Hand."  I had a classmate in PT School who once answered an exam question that FOOSH meant "Fall on opposite shoulder."  I still find that hilarious.

XRAY of a wrist

The presenters discussed the differences in healing, treatment, and returning to sports between when the injury to the arm occurs close to the wrist (distal radius fracture) versus in the middle of the bone (radial mid-shaft fracture). In this XRAY, the top is where the radius and ulna join at the wrist.  Not shown is the rest of the radius and ulna where they would come to meet the humerus at the elbow.  There is a growth plate, called a physis at both ends of these long bones, which you can see.  These are open in children and close with aging.  The physes near the wrist, according to this publication, tend to close around age 17-19 with girls a bit earlier than boys.  At the elbow, the growth plates closer near puberty with girls around 14 and boys around 16, per this publication.  Injury directly to the physis can impact the growth of the bone.

Just beneath the growth plates you can see the metaphysis, where the bone is wider, and the diaphysis, where the bone is more narrow.  Bones are like long, thick pipes with a hole in the middle.  When a fracture occurs in the metaphysis, because this bone region is larger, the injuries tend to be more stable and the bone doesn't usually move as much.  These can often be treated using a cast for a few weeks.  Did you know that in many sports, you can play wearing a cast as long as it is covered with sufficient padding that stops it from acting like a weapon?  (Rules vary state by state, we learned about those for Washington at the symposium, too!) So these patients tend to have a period of immobilization, may or may not really need any rehabilitation at all, and tend to recover quickly - unless their initial injury was so bad that they needed to be put to sleep for a doctor to re-align broken bones.  The few of these I've seen in the clinic have really just been for a few visits where a kid was afraid to start using their arm, so it was a little stiff, but once they learn they're OK to get moving, they take a few visits to get back on track, work on squeezing some theraputty to get their grip strength back, and are often good to go.

The situation differs if the injury occurs in the diaphysis, the long shaft of a bone.  Because this is a narrower area, these injuries tend to be more unstable and displace more often.  This is where you might see a more gruesome XRAY and the arm looks wrong right away at the time of injury.  I guess in this case, size really does matter.  Injuries of the diaphysis frequently require surgery because these are unstable and need to be re-positioned and secured with hardware.  The surgeries may require plates and screws to align the broken bone, and then once healing has progressed sufficiently, they will have another surgery to remove the hardware.  Two surgeries!  As you can imagine, this means slower recovery, longer period of immobilization, and greater need for rehab.  I've seen more of these in the clinic than the other type, though mostly I see elbow and upper arm injuries much more than at the forearm and wrist.

After learning about the differences between these two locations and the bone diameter/size and why that matters, I sent the presenters an email asking if this same concept applies in other long bones of the body.  I'm currently treating a patient recovering from a broken humerus and my nephew broke his in February, both from skiing accidents.  While the principles of the bone diameter are similar and the metaphysis is larger than the diaphysis, Dr. Jinguji was kind enough to educate me that it turns out that you can't just apply this same principle of recovery across the board. At the elbow, you need to have more consideration for the joint as well as the bones and so the metaphysis at the elbow is often as unstable and challenging to deal with as the diaphysis.  The proximal humerus (near the shoulder) behaves a lot like the distal radius (metaphysis injury described above), where it's proximity to the body and its size are probably helping those fractures to be more stable.

My nephew, Jeremy, broke his distal humerus in February.  With his permission to share, here's what it looked like when he injured it and a picture of the pins the surgeon put in to hold it together after everything was re-aligned.  They put those pins in, and actually left the ends of the pins out of his skin so he didn't need as much of an intense procedure for them to remove them after the bone had healed.  The pins were covered up by the cast and he was immobilized and in a sling for four weeks and then the pins came out and he was immobilized a little longer without the hardware before being cleared from everything.  He didn't need any physical therapy, despite my begging to get him some rehab to restore his motion.  Three months out he tells me he's pretty much back to his usual teenage boy things.  That cast certainly didn't get in the way of his video gaming skills.

Overall the presentations were really great and I enjoyed learning some new things and can't wait to hear what the topic of the next symposium will be.  The only negative of these events is the super early start time getting into Seattle... definitely interferes with my sleep!