HJAR Jul/Aug 2023

HEALTHCARE JOURNAL OF ARKANSAS  I  JUL / AUG 2023 47 Brant Sachleben, MD Chief of Pediatric Orthopedic Surgery and Co-Director of Sports Medicine Arkansas Children’s Hospital Pain Pain could represent a lack of healing but can also be a normal response to re- turn to activity. While the risk of new or repeat injury is relatively low, the young athlete could still experience pain. Deter- mining if this is an expected response to return to play requires further delineation. • Does the pain limit activity? • Does the level of discomfort return to baseline at the cessation of the activ- ity? • Is there an increase in pain from the day before with each successive day or session of activity? While these are questions medical pro- viders should ask, ultimately, the answers will come from the young athlete. Function If the risk of injury is low and the pain level is nonexistent or within a reasonably expected level, then the next consider- ations involve function. • Can the athlete function at the level they need to help the team or them- selves? The answers to this question are shared among the athlete, their caregivers, and their coaches. Shared decision-making may determine it is physically safe for the athlete to return but may not yet be in the team or individual’s best interest. A fractured forearm in the context of safety, pain, and function Fractures of the forearm are prevalent in children. Typically, they result from a fall on an outstretched hand, which can happen in nearly any sport. Fractures in- volving the growth plates at the wrist or el- bow are of particular concern in pediatric patients because they can have long-term impacts on bone development. When fractures in children are seen in the ER, they are splinted and sent to the or- thopedic clinic if not displaced. If they are displaced, they generally require a reduc- tionmaneuver. Resetting broken bones is a painful procedure, so medical providers in the ER must take measures to protect the child from undue pain. There are several options. The simplest is a hematoma block in which lidocaine is injected directly into the fracture site. Unfortunately, this often does not provide adequate pain relief. An axillary nerve block is very effective, but few children can tolerate needle placement in the axil- la. Conscious sedation is very effective but requires an empty stomach for the patient and the availability of ER staff to adminis- ter the sedation. As a result, there may be prolonged delays for the patient, family, and orthopedic physician. In the Bier Block method, an IV is start- ed in the hand distal to the fracture site, and a tourniquet is placed on the upper arm. After the inflation of the tourniquet, dilute lidocaine is injected, rendering the forearm insensate within a few minutes, allowing for reduction, fluoroscopic visu- alization, and splinting. Once the proce- dure is complete, the tourniquet is deflated in stages to prevent a large bolus of lido- caine from suddenly entering the circula- tion. The sensation returns to normal in a few minutes. This procedure has been in place at Arkansas Children’s Hospital for many years and is safely administered by residents. The advantages are that the Bier Block is simple, safe, and does not require an empty stomach. This procedure em- phasizes safety while minimizing pain and expediting the healing process. Ongoing monitoring during the recovery and re- habilitation process sets the stage for ad- dressing the questions of safety, pain, and function. Summary Recovery from a sports-related inju- ry often leaves scars on the body and the mind. While not always possible, the goal of treatment is for children and adoles- cents to get back to and stay at their previ- ous level of sport. Determining the optimal timetable for returning to sports is crucial to reaching that goal. Making that deci- sion and providing families and athletes a framework to understand that decision is paramount to the successful return to sport. n Robert Blasier,MD, is a pediatric orthopedic surgeon atArkansas Children’s Hospital and a professor in the Department of Orthopedic Surgery in the College of Medicine at UAMS. His specialty interests include the treatment of pediatric trauma and adolescent idiopathic scoliosis. Brant Sachleben, MD, chief of pediatric orthopedics at Arkansas Children’s Hospital (ACH), is a sports medicine and pediatric orthopedic surgeon at ACH and an associate professor in the Department of Or- thopedic Surgery in the College of Medicine at the University ofArkansas for Medical Sciences (UAMS).