Be safe! It’s summer time!

Musculoskeletal Injuries in children:

It is finally summer! That means we are outside, exploring our community and moving!! So, in light of our increased activity levels and inspired by a recent incident my little one had, I thought I’d talk about musculoskeletal injuries in infants and toddlers; how to identify them and how to be apart of the rehabilitation process.

A few weeks ago, our little guy took a tumble down the stairs of our deck. Unfortunately, we didn’t witness the full fall or the landing, so after checking for major bumps, cuts, obvious breaks and paying attention to a change in cognitive function (of which he had none) we had to piece together what might have happened with his help.

Hmmm, here in lies the challenge…

How do you know when to go to the doctor or hospital and when to care for and calm your child at home? Firstly, I think we all know the best answer is to err on the side of caution. If you have any thoughts that your little one may need more assessment and care than you can provide, trust your gut and head to a medical professional.

We decided to take our boy to his doctor to rule out anything sinister. Even though I was able to complete a fairly decent assessment and a fracture, concussion and dislocation seemed unlikely, I am not a paediatric doctor. I was uncertain if it is routine to send for imaging in falls with young ones as forces on a little growing body are absorbed differently than in an adult.

In general, the musculoskeletal system of a child is more flexible than of an adult and will therefore react slightly differently to bumps and falls (1).

BONES

There are a number of differences in our skeletons (click here (1) if you would like a little more detail in an easy to read form) but for our purposes we will talk about the difference in elasticity. A child’s bones allow for a greater amount of deformation before they break and for this reason there are a couple of unique types of fractures that can occur in children.

Torus Fracture:
Also known as a buckling of the bone and is a common fracture seen in little ones where one side of a long bone buckles and produces a bulging of the bone’s cortex which can be seen on an x-ray image. A torus fracture occurs when an axial force is applied down the long axis of a bone. This is an incomplete fracture and heals quite well (2).

Greenstick Fracture:
A greenstick fracture is a fracture that occurs on only one side of the bone, like when you bend a young branch and it breaks or splinters on the convex side of the arch. You can see how this is a fracture unique to bendy bones! It can happen with an axial load along the long axis of the bone (as with a torus fracture) or from a force that is perpendicular to the bone like one that may occur from a direct hit (3).

Bowing Fractures:
There are two types of “fractures” in this category (although one really isn’t a fracture), elastic and plastic bowing fractures.

Elastic bowing can occur during lower force trauma. It cannot be seen radiographically; the bone returns to it’s normal shape as an elastic would after been moderately stretched and released. As you would imagine, the prognosis for recovery is great! This is the one that isn’t really a fracture.

Plastic bowing happens when larger forces are placed on the bone to an extent where the bone cannot return to it’s normal shape but does not break or fracture in the traditional sense. This type of injury can been seen on an x-ray (examples here(4) and here(5)) and upon very close examination (microscopic) there will be some evidence of tiny fractures. Again, to compare this to an elastic band, it is like stretching one just shy of it snapping; here you might see some tearing or fraying of the elastic fibres or it could be a little elongated and deformed, but not broken.

SOFT TISSUE

As with bone, muscles, tendons, ligaments and joint capsules are generally more elastic in the paediatric population and although sprains and strains are common, the prognosis for a full recovery is good. Our little ones heal so well and quickly! It is just up to us to read the signs and help them with appropriate rehabilitation.

So how do you know if, or how badly your infant or toddler is injured especially if you did not witness the incident?

Other than obvious deformities, cuts or abrasions you can see, identifying the type and severity of the injury can be difficult. Your little one may not be speaking yet or if they are, they may not have the depth of language to articulate the finer details of what happened and what they are feeling (the type of pain, the intensity of pain, the landing/falling position etc.). That said, they can still give us a significant amount of information with the communication skills they do possess; verbal and non-verbal.

We tried asking our little one what step he fell from and how he landed. Unfortunately, we didn’t receive very clear answers so we relied on other things to tell us what structures were injured and what movements were painful.

He could point quite easily to where he felt the pain or the “ouch”. He indicated a couple of places, depending on what movement he performed or what position he was in. In the initial days he pointed to his neck and shoulder. As the acute pain decreased, he began showing us that his clavicle (collar bone) was the source of his pain. Fairly recent research has showed us that at very young age (weeks old) our little ones experience pain similarly to adults (9), therefore, when you ask of pain or search for the pain source (by palpation) your munchkin will be able to let you know there is something wrong and even identify the location as our little guy did.

Another way to uncover the injury is to watch your young one move. Our guy could easily and painlessly move his head around so I knew that his neck was fine, but he wouldn’t use his left arm at all in the early stages. Not to eat, not to reach for things and certainly not to help himself get up or down. As he moved around he would hold his left arm close to his body as a way to brace his injury and keep it in a position of comfort. I knew then that even though he sometimes pointed to his neck as the painful spot, that his injury was likely his clavicle or his shoulder. Little people feel and do things so purely, all you need to do it watch them and their bodies will tell you the answer or at least give you a really good hint!

Ok, so how can you help?

Knowing how tissues heal will give you a good guideline of how to progress your little one’s movements as he or she navigates through their recovery. We often either protect our injuries too long, which can be just as detrimental as the other habit we have of overusing a newly injured body part.

Right after an injury we enter the acute stage or protective/inflammatory phase which usually lasts 4 -6 days. This phase is important! Inflammation is good and although it is a painful part of the healing process it is the body’s way of cleaning up of the dead tissue and laying the groundwork for later stages of healing.
In this phase your will one will want to protect his or her injury by supporting it or not using it much. This is OK, this is the time to limit provocative movements and control the pain and spasm. Once you have cleared the first 48 hours or so, you can help by performing some passive movement in a pain free range with your little munchkin. If you would like to read more about what ranges of motion occur at each joint, click here(10). By about the fourth day your little one should be feeling a bit better or at least showing some improvement (8).

It was taking my little guy more time to clear this phase than I thought reasonable. At about day four his range of motion was not improving, his pain level was not decreasing and he was continuing to brace his arm during movements. I also noticed a new bruise forming along his clavicle. At this point I wanted an x-ray to see if his clavicle was fractured, so, we went back to our doctor’s office and received a script to get an x-ray. It came back clear, which was great, but the new bruising got me thinking…why would a bruise appear in such a superficial area after a relatively long time? If he had landed on or contused his clavicle, there most likely would have been a bruise or scrape seen in the first day or so. Bruises that take a while to appear are typically due to injury of deeper tissues. This got me thinking about the elasticity of his skeleton…perhaps he experienced an elastic bowing of his clavicle from the fall (6). This would explain the delayed bruising, the significant and lingering pain and the clear x-ray. Without seeing what happened there is no way I can confirm my suspicion, but perhaps a decent deduction? Paediatric experts what do you think!?

At around day 5 or 6 things started to improve and we entered the subacute stage or repair and healing phase, right on time. Depending on the tissue type and it’s vascularity, this phase can last up to 6 weeks but most commonly it last about 2 to 3 weeks post injury. In this stage, your little one will start feeling better and the inflammation and swelling is often significantly decreased. However, the injury is still vulnerable because new and fragile tissue is forming in the area. That said, this is the optimal time to start moving in a controlled and pain free manner in order to create mobility in the freshly laid scar tissue (8).

We started playing some easy games with our little one like Simon Says or getting him to copy our movements for some healthy treats. We even involved our dog and made him do tricks for treats too. We treated it like a game and made it fun. We were careful to not ask our little guy to explore ranges at his shoulder that were obviously painful; noting the pain by a grimace on his face or compensatory movement that looked different from the other limb. This became our nightly routine and every night we were able to do a little bit more. Our movements became bigger, we incorporated high fives and some dexterity games like touching fingers. We played gentle pushing and pulling games and asked him to roll a ball to us. Again, we made everything light-hearted and didn’t focus too much on the fact that he was injured. He knew he had pain and he played within his comfort zone, he listened to his body and it was up to us to respect that and not emphasize the pain and injury.

Eventually we entered the chronic stage or remodelling phase and this is where we are now. This final stage is a long one and may last 6 months to a year, but likely to be much less than that if your little one experienced a minor injury. There is no inflammation or swelling left and pain is minimal. Maturation of the newly laid scar tissue predominantly occurs during this time. Your goal here is to safely and progressively stress the area so that the scar tissue can align itself in the direction of stress and be as strong as possible once the healing process is complete. The tissue that is laid down is primed and ready for remodelling for up to 10 weeks due to its malleable molecular bonds. If you wait much longer to begin progressively loading the tissue your job will be a tough one as the bonds become thicker, stronger and more challenging to remodel (8).

Depending on the physicality of your child, this could be a stage where you let your kid be a kid and a relatively easy part of the rehabilitation process. That said, it is important to observe a couple of things before you abandon your rehab sessions, as this is a very important stage of healing to ensure proper development. David Laurin, CAT(C), DOMP and owner of Find Your Health [ LINK http://www.findyourhealth.ca/index.html], works with the paediatric population very regularly and says that “soft tissue injuries falls between bone development and motor development in toddlers. In that sense, unresolved soft tissue injuries may affect their motor development and influence forces that shape their bones.” Long story short, we want to help our little ones move through their full ranges of motion and acquire full strength without pain in this phase. So, what do we want to see?
that the affect side moves through the same range of motion as the unaffected side
that the affect side is equally as strong as the unaffected side
that your child is using the affected side to play and do activities of their daily living as much as they were before the injury if it was an upper body injury is your child:

pulling themselves up with that side?
grabbling and pulling objects with that side?
hanging easily?
supporting themselves in a push-up position or crawling position?
if it was a lower body injury is your child:
squatting down to play with equal weight on both sides?
walking or crawling smoothly and evenly?
running with equal gait?
lunging or stepping up with both sides (there may be a natural bias here, but as long as your little one can do it on the affected side smoothly and pain free)?
hopping?
walking on toes?
galloping?

If you suspect that your little one is still favouring the injured limb or body part at this stage, continue working on the rehab process in a progressive manner but remember, make sure it is less like work and more like fun! Also, as I mentioned at the start, if you have any thoughts that your little one may need more assessment and care than you can provide at this stage or at any of the stages, head to a professional such as one of us at The Athlete Centre!

Do you have a story? Or any questions about what your little person is going through right now related to injury? Let us know!

1. General review of the skeletal system of children and toddlers
https://emedicine.medscape.com/article/1899256-overview#a2

2. Torus Fractures
https://radiopaedia.org/articles/torus-fracture-1

3. Greenstick Fracture
https://radiopaedia.org/articles/greenstick-fracture

4. Bowing fractures in children/toddlers
https://radiopaedia.org/articles/bowing-fracture

5. Acute bowing fractures of the forearm in children: a frequently missed injury
https://www.ajronline.org/doi/pdf/10.2214/ajr.128.6.981

6. Background information on the clavicle – info on – states that plastic bowing fracture can occur in children
https://pubs.rsna.org/doi/pdf/10.1148/radiographics.9.4.2756192

7. Sports injuries in Children – soft tissue references
https://academic.oup.com/bmb/article/86/1/33/378284

8. Kisner, C., & Colby, L.A.. (2007). Therapeutic Exercise: foundations and techniques (5 ed.). Philadelphia: F.A. Davis Company

9. Pain in infants – “Babies feel pain like adults”
http://www.ox.ac.uk/news/2015-04-21-babies-feel-pain-adults

10. Ranges of motion
https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=965&sectionid=53599866