Kids are pretty resilient. I’m often surprised watching my kids roll and fall off the couch/swings/slides/beds with nearly never skipping a beat. On the instances when they do cry, it usually is over by the time I have picked them up to ask if they are OK. This can be deceiving then. I must admit at times I am starting to expect that if they fall they are probably fine. So how do we know when to worry and when not to? It really is hard!
Kids are not just “little adults” though we sometimes like to think of them that way. Their anatomy is different and because of this, injuries need to be evaluated and treated with this in mind . Children tend to be more flexible than adults. They also have growth plates which do not close until in their teens. So, if they fall or twist their ankle, we worry about bones and ligaments (as we do with adults), but we also worry about those growth plates.
Generally speaking when someone twists or sprains their ankle, we are concerned about an overstretching of the ligaments that connect the bones together in the ankle. If they are overstretched or partially tear, this can lead to instability down the line. We treat sprains very cautiously at our office to minimize this risk. In an adult, when we look at x-rays after an ankle sprain, we can usually get a clear picture as to whether any bones were fractured. In children, the growth plates are a weaker part of the anatomy than bones or ligaments, so injuries are typically associated with damage to the growth plates.
So what is a growth plate? It is a section of cartilage that eventually ossifies (or turns into bone) as we get older. These growth plates are open until the skeleton has completely matured. If damaged or injured, growth plates can close prematurely which can result in a shorter bone (ie. Shorter toe or portion of foot or leg in some cases). A growth plate on x-ray looks like simply the absence of bone between two parts of bone. Compared to an adult and to the untrained eye they actually look like fractures in the bones. Therefore, injury to a growth plate in some cases cannot be visualized.
There is a staging system for growth plate fractures (as with most injuries in medicine) which describes the various ways in which a growth plate injury can occur. The first type of growth plate injury causes a separation of the growth plate. This is not usually identified well on x-ray, as the growth plate is an open space on x-ray. It would show on MRI but imaging like this is not traditionally done immediately following an injury.
The second type of growth plate injury involves a disruption in the growth plate as well as through what is called the metaphyseal bone on one side of the growth plate. These fractures can present on x-rays and look like a triangular shaped piece of bone. Depending on the severity of this injury, surgery to pin and immobilize the bone may be needed.
The third type of growth plate fracture extends into the epiphysis or end of the bone in which injury has occurred. This type of growth plate fracture has the added concern of disruption of the joint at the end of the bone. This can cause the start of degenerative arthritis. This type of injury is also usually visible on x-rays. In some cases this type of growth plate injury requires surgical fixation.
The fourth type of growth plate fracture is what we refer to as a ‘complete’ fracture. The reason for calling it this is that the fracture starts in the bone above the growth plate then through the growth plate itself and then through the end of the bone and into the joint. These are more serious as they are less stable and again they will need very strong fixation and immobilization.
The final type of growth plate injury is a crush injury to the growth plate. This fracture is not visible on plain x-rays. It is due to excessive compression of the growth plate. Just like the other four types of fractures, these can often result in a premature closure of a growth plate.
If your child experience an injury such as a fall or sprained ankle, it is essential to have a specialist perform an evaluation. If there is suspicion of a growth plate injury – even in the absence of x-ray changes – early treatment is so important. While your physician cannot undo the damage from the initial injury, we can help guide you to protecting the area, giving it the optimal chance of recovering and healing without further issue.
Some children experience instability in ankles and whether an ankle sprain is associated with a growth plate injury, failing to seek treatment results in further instability. The sooner an ankle sprain is protected and braced, the less likely it is that the structures (ligaments etc) will heal in an elongated attitude. Even in cases of mild ankle sprains, our office recommends either at-home or formal physical therapy in order to retrain the muscles/tendons in the feet and ankles and strengthen them. This is another vital component of care that helps reduce future injuries.
Please don’t wait! Call today if your little guy or gal is having trouble from a foot injury.