Children’s Orthopedics

A Patient’s Guide to Bipartite Patella in Children

Introduction

Bipartite patella is a congenital condition (present at birth) that occurs when the patella (kneecap) is made of two bones instead of a single bone. Normally, the two bones would fuse together as the child grows. But in bipartite patella, they remain as two separate bones. About one per cent of the population has this condition. Boys are affected much more often than girls.

This guide will help you understand

• what parts of the knee are involved
• how this condition develops
• how doctors diagnose this condition
• what treatment options are available

Anatomy

What is the patella and what does it do?

The knee is the meeting place of two important bones in the leg, the femur (the thighbone) and the tibia (the shinbone). The patella (kneecap) is the moveable bone that sits in front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

What causes this condition?

The patella starts out as a piece of fibrous cartilage. It turns into bone or ossifies as part of the growth process. Each bone has an ossification center. This is the first area of the structure to start changing into bone.

Most bones (including the patella) only have one primary ossification center. But in some cases, a second ossification center is present. Normally, these two centers of bone will fuse together during late childhood or early adolescence. If they don’t ossify together, then the two pieces of bone remain connected by fibrous or cartilage tissue. This connective tissue is called a synchondrosis.

The most common location of the second bone is the supero-lateral (upper outer) corner of the patella. But the problem can occur at the bottom of the patella or along the side of the kneecap.

Injury or direct trauma to the synchondrosis can cause a separation of this weak union leading to inflammation. Repetitive microtrauma can have the same effect. The cartilage has a limited ability to repair itself. The increased mobility between the main bone and the second ossification center further weakens the synchondrosis resulting in painful symptoms.

Symptoms

What does bipartite patella feel like?

Most of the time, there are no symptoms. Sometimes there is a bony bump or place where the bone sticks out more on one side than the other. If inflammation of the fibrous tissue between the two bones occurs, then painful symptoms develop directly over the kneecap. The pain is usually described as dull aching.There may be some swelling.

Movement of the knee can be painful, especially when bending the joint. Atrophy of the quadriceps and malalignment of the patella can lead to patellar tracking problems. Squatting, stair climbing, weight training, and strenuous activity aggravate the knee causing increased symptoms. For the runner, running down hill causes increased pain, tenderness, and swelling.

Diagnosis

How will my doctor diagnose this condition?

Most of the time, this condition is seen on X-rays of the knee that are taken for some other reason. This is referred to as an “incidental finding”. A radiolucent line is observed across the superior-lateral corner of the patella. This represents the extra ossification center and is seen most often in children between the ages of eight and 12. Sometimes, it is mistaken for a fracture of the patella. But since the problem usually affects both knees, an X-ray of the other knee showing the same condition can confirm the diagnosis.

MRIs or bone scans are useful when a fracture is suspected but doesn’t show up on the X-rays. The presence of fibrocartilaginous material between the two bones helps confirm a diagnosis of bipartite patella. An MRI can show the condition of articular cartilage at the patellar-fragment interface. The lack of bone marrow edema helps rule out a bone fracture. CT scans will show the bipartite fragment but are not as helpful as MRIs because bone marrow or soft tissue edema does not show up, so it’s still not clear from CT findings whether the symptoms are from the fragment or fracture.

Treatment

What treatment options are available?

Most of the time, no treatment is necessary. Most people who have a bipartite patella, probably don’t even know it. But if an injury occurs and/or painful symptoms develop, then treatment may be needed.

Nonsurgical Treatment

Conservative care involves rest, over-the-counter nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen, and activity modification. Avoiding deep flexion such as squatting, excess use of the stairs, and resisted weight training are advised.

Separation of the synchondrosis can be treated with immobilization for four to six weeks. The knee is placed in full extension using a cylinder cast, knee immobilizer, or dynamic patellar brace. An immobilizer is a removable splint. It’s usually only taken off to wash the leg and remains in place the rest of the time. The dynamic brace immobilizes the knee in an extended (straight-leg) position with limited flexion (up to 30 degrees). The brace reduces pain by decreasing the pull on the patella from the quadriceps muscle. Once healing occurs and the cast or brace is no longer needed, then stretching exercises of the quadriceps muscle are prescribed.

Surgery

If conservative care with immobilization is not successful in alleviating swelling and pain, then surgery may be suggested. When the bipartite fragment is small, then the surgeon can simply remove the smaller fragment of bone. When the bipartite fragment is larger and also contains part of the joint surface, the surgeon may decide to try and force the two fragments to heal together or fuse. The connective tissue between the two fragments is removed first and the two bony fragments are then held together or stabilized with a metal screw or pin. This is called internal fixation. The two fragments of bone heal together or fuse, creating a solid connection between the two fragments. Although successful in reuniting the patella, the procedure may require several weeks of immobilization. As a result, knee stiffness may occur. This usually requires physical therapy once the bones have healed to regain strength and motion.

Another potential treatment option is a procedure called a lateral retinacular release. It may be beneficial to remove the constant pull of the vastus lateralis tendon (a part of the large quadriceps muscle of the thigh) where it attaches to the bone of the bipartite fragment of the upper, outer patella. Simply cutting this attachment reduces the constant pull on the bony fragment. Healing of the two fragments may occur as a result.

Rehabilitation

What should I expect after Treatment?

Nonsurgical Rehabilitation

Most patients respond well to activity modification and immobilization. When the X-ray shows complete ossification of the two bone fragments, then you’ll be able to return to your regular activities. If there is no improvement after three months of conservative care, then surgery is considered.

After Surgery

Usually, the removal of a bipartite patella is a simple surgery with prompt relief of pain and quick recovery. Athletes can expect full range of motion, a stable knee, and a fairly rapid return to normal activity (one to two months). But runners and other athletes who have had an extended time of immobility, muscle weakness and atrophy, loss of normal joint motion, and patellar tracking problems may require a special rehab program. A physical therapist will prescribe and monitor a rehabilitation program starting with range of motion and quadriceps strengthening exercises.

Athletes will be progressed quickly to restore full motion and strength. An aerobic program to improve cardiovascular endurance is often needed after so many months of inactivity. Proprioception and functional activities are added in order to prepare the individual to return to full sports participation. Proprioceptive exercises help restore the joint’s sense of position. Proprioceptive activities are needed to restore normal movement and prevent further injury.

A Patient’s Guide to Transient Synovitis of the Hip in Children

Introduction

Transient synovitis of the hip is an acute inflammatory condition of the inner lining of the hip. Transient means it is temporary and doesn’t last long. Transient synovitis is also known as toxic synovitis or irritable hip.

This condition affects young children (boys more than girls) most often. In fact, it’s the most common cause of acute hip pain in young children between the ages of three and 10. However, there are reports of transient synovitis in children less than one year old and in adults.

This guide will help you understand

• how the condition develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the hip are affected?

The hip joint is a true ball-and-socket joint. The bones of the hip are the femur (the thighbone) and the pelvis. The top end of the femur is shaped like a ball. This ball is called the femoral head. The femoral head fits into a round socket on the side of the pelvis. This socket is called the acetabulum.

Transient synovitis affects the inner lining of the hip joint including the synovium and joint capsule. The synovium is a membrane that seals the synovial fluid in the joint to lubricate the joint surface. It is between the articular cartilage and the joint capsule. The joint capsule is a watertight sac that surrounds a joint. In the hip, the joint capsule is formed by a group of three strong ligaments that connect the femoral head to the acetabulum. These ligaments are the main source of stability for the hip. They help hold the hip in place.

Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage is about one-quarter of an inch thick in the large, weight-bearing joints like the hip. In the hip, articular cartilage covers the end of the femur and the socket portion of the acetabulum in the pelvis. The cartilage is especially thick in the back part of the socket, as this is where most of the force occurs during walking and running.

Articular cartilage is white and shiny and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.

Causes

What causes this condition?

The exact cause of this problem is unknown. In some cases, it may develop after a recent viral infection (such as a cold or upper respiratory infection). In a smaller number of children, trauma to the hip is followed by transient synovitis.

There is much debate about a possible link between transient synovitis and another condition called Legg-Calve-Perthes disease. In Perthes disease, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals.

Only a small number of children with transient synovitis develop Legg-Calvé-Perthes disease. It’s possible the prolonged increase in pressure inside the joint causes loss of blood supply to the hip. Some experts suspect children who develop Perthes disease may have undetected transient synovitis before collapse of the femoral head occurs.

Related Document: A Patient’s Guide to Perthe’s Disease

Symptoms

What are the symptoms?

Inflammation and effusion (swelling) can cause sudden hip pain. Usually only one hip is involved. The child may refuse to walk or may limp when walking as the first sign of a problem. Younger children who aren’t walking yet stop crawling or change the way they get around. They may cry at night or when having the diaper changed.

Your child may have a slight fever. A high fever is usually a sign of something more serious such as septic arthritis (bacterial infection of the hip) or osteomyelitis (bone infection).

In all age groups, there is usually a loss of hip motion. The child doesn’t want to put weight on that leg. The painful symptoms may travel to the thigh, groin, or knee on the same side. Sometimes there isn’t hip pain but just groin, thigh, or knee pain.

Your child may want to keep the hip and leg in a resting position of flexion (bent), external rotation (turned outward), and abduction (away from the other leg). This position opens up the joint capsule helps reduce the pain by taking pressure off the soft tissue structures.

Diagnosis

How do doctors diagnose this condition?

The history and physical examination are probably the most important tools the physician uses to diagnose transient synovitis of the hip. Motion is usually limited and painful. The hip is tender to palpation.

X-rays are usually taken. Though radiographs don’t show synovitis, they do help the physician rule out a fracture, tumor, or slipped capital femoral epiphysis (slippage of the growth plate). More advanced imaging such as MRI or bone scan may be needed if there is a need to rule out other more serious problems.

A blood test will show mild inflammation. If needed, the physician may order an ultrasound of the hip. This test will show any effusion (fluid collection) in the hip joint. Drawing the fluid out with a needle called needle aspiration will show if there is pus in the joint from septic (bacterial) arthritis. The fluid is clear in transient synovitis.

Related Document: A Patient’s Guide to Slipped Capital Femoral Epiphysis

Treatment

What treatment options are available?

Nonsurgical Treatment

Home treatment with rest and antiinflammatory drugs are the main treatment techniques. It is okay if your child keeps the leg turned out. Any position that is comfortable will help the healing process. The child is usually already limiting how much weight is put on that leg. If not, every effort should be made to avoid weight-bearing.

Vigorous physical activities such as running, jumping, and participating in sports activities should be avoided during the acute phase. Your doctor will let you know if crutches are needed to help limit weight-bearing through that leg. If crutches are advised, they will only be needed for a few weeks.

Surgery

Surgery is not usually necessary. In severe cases of transient synovitis children may be hospitalized for observation and leg traction. Applying pull on the hip through the leg can reduce the pressure inside the joint capsule. If the child is cooperative, home traction may be possible.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

A rehab program isn’t usually needed. Most of the time, this condition resolves (goes away) within a week or two. The child will naturally start to increase activity as he or she starts to feel better. The condition can come back. If this happens, it will most often occur during the first six months after it first appears.

Follow-up with your doctor is important. If the symptoms aren’t improved or improving after seven to 10 days, then contact your child’s doctor. There could be something else wrong with your child’s hip. Further diagnostic testing may be required. Even if your child has recovered fully, a repeat X-ray is advised. This should be done about six months after the first episode occurs. It will help identify any early signs of Legg-Calve-Perthes disease.

A Patient’s Guide to Congenital Flatfoot (Pes Planus) in Children

Introduction

Flatfeet (also known as pes planus) describes a condition in which the longitudinal (lengthwise) and/or medial (crosswise) arches of the foot are dropped down or flat. The entire bottom of the bare foot is in contact with the floor or ground surface during standing, walking, and other weight bearing activities.

The condition is often present at birth (congenital) in one or both feet. When only one foot is affected, the problem is referred to as unilateral pes planus or flatfoot. When both feet are involved, the condition is bilateral flatfeet.

This guide will help you understand

• what parts of the foot are affected
• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the foot are involved?

The anatomy of the foot is very complex. When everything works together, the foot functions correctly. When one part becomes damaged, it can affect every other part of the foot and lead to problems. With a flatfoot deformity, bones, ligaments, and muscles are all affected. A combination of malalignments results in the flatfoot appearance.

Bones

The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint.

The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heel bone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down.

The subtalar joint allows the foot to rock from side to side. People with flatfeet usually have more motion at the subtalar joint than people who do not have flatfeet. The increased flexibility of the subtalar joint results in many compensatory actions of the foot and ankle in order to keep proper foot alignment during standing and walking.

Just down the foot from the ankle is a set of five bones called tarsal bones. The tarsal bones work together as a group. They are unique in the way they fit together. There are multiple joints between the tarsal bones. When the foot is twisted in one direction by the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted in the opposite direction, they become unlocked and allow the foot to conform to whatever surface the foot is contacting.

The tarsal bones are connected to the five long bones of the foot called the metatarsals. The two groups of bones are fairly rigidly connected, without much movement at the joints. Finally, there are the bones of the toes, the phalanges.

Ligaments and Tendons

Ligament are the soft tissues that attach bones to bones. Ligaments are very similar to tendons. The difference is that tendons attach muscles to bones. Both of these structures are made up of small fibers of a material called collagen. The collagen fibers are bundled together to form a rope-like structure.

The large Achilles’ tendon is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the heel bone to allow us to rise up on our toes. The posterior tibial tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. Failure of the posterior tibial tendon is a major problem in many cases of pes planus.

Many small ligaments hold the bones of the foot together. Most of these ligaments form part of the joint capsule around each of the joints of the foot. A joint capsule is a watertight sac that forms around all joints. It is made up of the ligaments around the joint and the soft tissues between the ligaments that fill in the gaps and form the sac.

The spring ligament complex is often involved in the flatfoot condition. This group of ligaments supports the talonavicular joint. The spring ligament complex works with the posterior tibial tendon and the plantar fascia to support and stabilize the longitudinal arch of the foot.

Failure of the ligaments that support this arch can contribute to flatfoot deformity. Injury, laxity (looseness), or other dysfunction of the ligament and tendon structures can result in deformity of the foot and/or ankle resulting in pes planus.

Muscles

Most of the motion of the foot is caused by the stronger muscles and tendons in the lower leg that connect to the foot. Contraction of the muscles in the leg is the main way that we move our feet to stand, walk, run, and jump.

There are numerous small muscles in the foot. While these muscles are not nearly as important as the small muscles in the hand, they do affect the way that the toes work. Damage to some of these muscles can cause problems.

Most of the muscles of the foot are arranged in layers on the sole of the foot (the plantar surface). There they connect to and move the toes as well as provide padding underneath the sole of the foot.

Related Document: A Patient’s Guide to Foot Anatomy

Causes

What causes this problem?

Flexible flatfoot refers to a foot that looks flat when standing but appears to have an arch when the foot isn’t resting on the floor or against a flat surface. Sometimes the term fallen arches is used, but doctors prefer not to use this term in favor of the more accurate medical term pes planus.

Most babies and young children have what looks like flat feet. This is normal. Before the bones are formed, much of the foot and ankle are still made up of soft tissue, fat, and cartilage. The arch has not formed fully yet. The joints are still hypermobile when the child starts to get up on feet to walk. This is when the flatfoot deformity becomes obvious and parents may become concerned that something is wrong with their child’s foot. The vast majority of children will grow out of their flat foot deformity. Even if the deformity does not fully correct with age, it is unlikely to cause the child any difficulty in the future.

Stress and activities during early childhood requiring strength in the feet are actually the training needed to develop normal muscle, tendon, ligaments, and bone in the foot and ankle. But in some cases, the arch doesn’t form and the foot remains flat into adulthood. Flatfeet do tend to occur in families as an inherited condition.

There are many possible causes for the flatfoot condition. Biomechanically, many soft tissue structures must connect and support one another to prevent a flatfoot deformity. Tibial (lower leg bone) rotation, hindfoot alignment, and position of the joints of the foot, midfoot, hindfoot, and ankle are all important factors. There is no one cause of flatfoot deformity that can be identified.

In the flexible flatfoot, the bones are usually normal – but the supporting ligaments are lax or loose. The joints are hypermobile. As the soft tissues and joints of the foot and ankle try to maintain a normal foot position, increased stress is placed on them. This can lead to fatigue and loss of strength resulting in a sagging of the arch. This can affect the chain of anatomical structures all the way up the leg.

There are some uncommon causes of flatfoot that do affect the bones. A tarsal coalition refers to a condition where two or more bones in the midfoot or hindfoot fail to form separately during development. They remain connected together, altering the bone structure of the foot and limiting flexibility of the foot. This is a different type of flatfoot deformity altogether and is commonly referred to as a spastic flatfoot. This type of flatfoot deformity is not flexible. In fact, the foot is quite rigid due to the abnormal connection between the bones of the foot. This condition can be painful.

Related Document: A Patient’s Guide to Tarsal Coalition

Symptoms

What does the condition feel like?

For most children, the flexible flatfoot deformity causes no symptoms. They do not suffer from pain, swelling, or sore feet. Children with flexible flatfoot deformity may wear out shoes a bit different from a normal person, but there usually is not any reason to be concerned.

In moderate to severe cases, the patient may report fatigue and tired, sore feet after standing on them all day. During those times, they may limit their own activities.

In the uncommon severe cases, calluses may appear where pressure occurs as the bones make contact with the floor or hard surface. The loss of joint stability may alter the foot’s ability to absorb the load and conform to uneven ground or surfaces.

Rarely, the flatfoot deformity may get worse with age. Excess pressure on the surrounding soft tissues (ligaments, capsules, tendons, muscles) can lead to other problems such as malalignment of the patella (kneecap), hallux valgus (bunions), and rotation of the knee and hip.

When the flatfoot deformity is the result of a tarsal coalition, the situation is different. The foot may become painful. The child may begin to complain of foot and ankle pain after a minor twisting injury and the pain not resolve after a normal healing period. The symptom of pain combined with decreased motion and flatfoot deformity should suggest a more serious problem in the foot.

Diagnosis

How do doctors diagnose the problem?

The history and physical examination are probably the most important tools the physician uses to diagnose this condition. Clinical tests can be done to differentiate flexible flatfoot from rigid flatfoot. The examiner will check mobility in the forefoot, hindfoot, and ankle. Muscle weakness and/or muscle tightness will be assessed. The wear pattern on the shoes can offer some helpful clues.

X-rays or other more advanced imaging such as CT scans or MRIs may be ordered but these are rarely needed. The examiner may be able to see and feel a prominent bump with tenderness around the area when an accessory navicular bone is present. X-rays will show if there is an accessory navicular or tarsal coalition as part of the problem.

A very simple test called the wet footprint can be done at home or in the doctor’s office. The patient places the foot in water and then places the foot down on a piece of paper or thin cardboard. After making a footprint, the foot is lifted off the paper. Someone with a flat foot will leave a complete footprint where the sole makes contact with the paper.

The physician may have you perform a single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward).

Treatment

What treatment options are available?

Nonsurgical Treatment

There may be no treatment needed for mild cases of flatfeet, especially flexible flatfeet. This condition often corrects itself in time as the child grows and develops. Young children should be encouraged to walk barefoot whenever it is safe to do so. This will increase sensory input into the foot. At the same time, navigating various floor and ground surfaces helps build strength and stability.

For older children and adults, a simple modification to the shoe may reduce the fatigue and discomfort in the foot. Sometimes purchasing shoes with a good arch support is sufficient. Try to find a comfortable shoe with an arch support, firm heel counter (back of the heel), and a flexible sole (bottom). Supporting the arch helps decrease the tension in the posterior tibialis tendon. Stretching the Achilles’ tendon helps maintain normal motion of the hindfoot, which in turn, helps maintain alignment of the midfoot.

For other patients, an off-the-shelf (prefabricated) shoe insert works well. The goal is to support the foot and prevent further stretching of lax ligaments and tendons. These supports will not reverse the structural deformity and they will not build and arch by wearing them over time. These inserts simply help the shoe better fit the foot and support the structures of the foot. Improving alignment can take tension off the soft tissue structures, reduce fatigue, and improve the biomechanics of standing and gait (walking).

Further treatment is usually not needed for the flexible flatfoot deformity. Surgery is rarely needed for this condition. Patients with severe symptoms that do not respond to conservative care may benefit from further orthopedic evaluation and treatment. In rare cases, surgical intervention to correct the problem and realign the foot may be suggested.

Surgery

For children with a shortened Achilles’ tendon, a program of stretching exercises or serial casting may help reduce pressure on the talus bone and offer significant pain relief. Severe cases of flatfoot (pes planus) may require surgery to reconstruct the arch or fuse the bones. This is very rare as conservative (nonoperative) care is usually sufficient.

Children with tarsal coalition or an accessory navicular bone require orthopedic evaluation and management. Surgery is done to correct the problem by the early teen years (before skeletal maturity).

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Flatfeet seen in very young children just starting to walk often resolve with time. The very act of gripping with the toes to maintain support and balance along with the development of the bones forms the arches.

For older children who still have flatfeet, stretching and strengthening exercises won’t cause an arch to form where there isn’t one anatomically. But these activities can help ease any pain or discomfort caused by the condition. The same is true for any supports or shoe inserts that are used.

After Surgery

Corrective surgery is only done in cases of severe, painful and disabling flatfoot position. This is very rare. Reconstructive surgery for tarsal coalition or an accessory navicular bone requires a period of immobilization in a cast followed by rehabilitation to restore strength in the foot and ankle. In some cases, more than one operation is needed as the child grows and develops. Pain relief and joint stability are the goals.

A Patient’s Guide to Rotational Deformities in Children

Introduction

Rotational deformities of the legs and feet in children are often a cause of concern for parents. Most people think of the deformities as either toeing in or toeing out. The deformity actually comes from rotation of the femur and the tibia. Rotation of the legs at birth is normal. Most of the time, the deformities correct themselves by age seven or eight.

Rotational deformities are usually due to position and pressure in the uterus during pregnancy. It is important to determine if the deformity is from this, or from something more serious – like a neurological problem.

This guide will help you understand

• what parts of the body are affected
• how the condition develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the body are affected?

The two main long bones of the leg are the femur and the tibia. The femur is the bone of the upper leg or thigh. The tibia is the larger bone in the lower leg. The front part of the tibia forms the shinbone. The smaller lower leg bone is called the fibula. Excessive rotation (also called torsion) of the femur and/or tibia will cause the foot to appear to either toe in or toe out.

The anatomy of the hip also affects the rotation of the entire leg. The femoral shaft, or thigh bone, attaches to the femoral neck near the hip joint. The femoral neck in turn attaches to the femoral head, the round ball that actually fits into the hip socket. How the femoral neck attaches to the femoral shaft affects how the entire leg lines up with the body.

There are two angles between the femoral shaft and the femoral neck that are important. Looking at the front of the body, there is an angle formed where the femoral neck joins the femoral shaft. Looking at the shaft of the femur from the top (along the axis of the femoral shaft), there is also an angle formed between the knee joint and the femoral neck. Doctors call this angle the version of the femoral neck. If the angle is more to the front (anterior) it is called anteversion and if it is more to the back (posterior) it is called retroversion. Normally the version of the hip in the adult is about 15 degrees anteversion.

Version can be difficult to understand – even for physicians. But remember, the end result is that too much or too little anteversion will make the entire leg look like it is twisted – either the toes turn in or they turn out. Too much femoral anteversion and the toes turn in; too little and they turn out.

Causes

How does this problem develop?

The vast majority of rotational deformities that are seen in children – and worry their parents and grandparents – are normal variations that will improve with time. The infant skeleton is made up of mostly cartilage. It is immature bone. It has not been calcified. This makes it fairly flexible. Babies are packed inside the uterus tightly. This affects the how our legs look when we are born. Immediately at birth, changes begin to take place. Throughout childhood, the femur and tibia (and the version of the hip) will continue to change and move towards what is normal for the adult.

Rotation of the legs at birth is not abnormal. The infant skeleton is made up of mostly cartilage. It is immature bone. It has not been calcified. This makes the infant skeleton fairly flexible. Position and compression in the uterus can shape the cartilage. Most fetuses are in a crossed-leg position in the uterus.

There are usually contractures (tightness of certain soft tissues and ligaments) in the hip and knee joints at birth. This also comes from positioning in the uterus. This can be a part of the cause of these various deformities. Positions for sleeping and play may also help shape the various deformities.

Sometimes the rotation at birth is excessive. Five in 10,000 children born will have rotational deformities of the legs. The most common cause is position and pressure in the uterus. An unstretched uterus in a first pregnancy causes greater pressure. This makes the first-born child more prone to rotational deformities. The unborn child grows a lot during the last 10 weeks. The compression or pressure in the uterus increases.

Premature infants have less rotational deformities than full-term infants. This is possibly due to decreased pressure in the uterus. Twins tend to be crowded in the uterus. They are more likely to have rotational deformities.

Sometimes, what is thought to be a rotational deformity is something different. Bowed legs are not necessarily considered a rotational deformity. When rotation is not involved the deformity is called an angular deformity. What looks like bowing of the lower leg can actually be caused by internal rotation of the tibia (lower leg). Because of this, the calf muscles lie on the outside of the leg instead of in the back of the leg. This gives the leg a bowed appearance.

Symptoms

What are the symptoms?

Rotational deformities are most often painless. The exception is with exaggerated femoral internal torsion (or femoral anteversion). Some teenagers with exaggerated femoral internal torsion may develop pain in the front of the knee. Climbing stairs usually aggravates this. Rotational deformities normally do not cause problems in adulthood.

Children with internal femoral torsion may have a habit of sitting in a “W” position, or on their feet, rather than crossed legged. Some children will trip over their feet if they toe in excessively. There is not a delay in the normal development of sitting, crawling, and walking.

Diagnosis

How do doctors diagnose this condition?

Your doctor will want to take a medical history. He/she may ask about the pregnancy, labor, and delivery of your child. Your doctor will need to know when the deformity was first noticed. Some are noticed right after birth. Some are noticed when the child starts to stand or walk. Some are not noticed until after age three. Your doctor will also want to know if it has gotten worse or better over time.

Your doctor will want to examine your child’s legs while your child is in different positions. If your child walks, he will want to watch him/her walk. Your child’s doctor will likely want to feel range of motion of the joints, to see if deformities can be corrected. The legs of the parents may also be examined to see if there is a similar deformity in adulthood.

Your child’s doctor may want to perform a neurological examination as well. This is to make sure there are no symptoms of cerebral palsy, or muscle disease that could be causing the deformity.

The diagnosis of rotational deformity is usually made by the findings of the physical examination. X-rays or other imaging is rarely needed.

There are four rotational deformities that affect the leg:

• Internal tibial torsion (ITT) – causes toeing in
• External tibial torsion (ETT) – causes toeing out
• Internal femoral torsion (IFT) – causes toeing in
• External femoral torsion (EFT) – causes toeing out

Internal tibial torsion (ITT) is the most common of the rotational deformities. It causes toeing in. It is usually noticed at birth or early infancy. Your child being cross-legged during growth in the uterus causes it. It often goes unnoticed until your child begins walking. The deformity is more obvious when standing. It usually goes away by age two or three. If internal tibial torsion is significant, and lasts past the age of five, surgery to derotate the tibia may be necessary, although this is very rare.

External tibial torsion (ETT) causes toeing out. While the child is in the uterus, the foot is held in extreme dorsiflexion. This means that the top of the foot lies against the shin of the same leg. This causes the foot to be in an externally (outward) rotated position. When your child stands, the foot will appear to toe out.

Internal femoral torsion (IFT) is the most common cause of toeing in after age three. If the tibia and femur are both internally rotated, toeing in may be even worse. This occurs more often in girls than boys. IFT can be diagnosed by comparing internal and external rotation range of motion of the hip. Your child will be placed on their stomach with knees bent. Normal children have equal amounts of internal and external rotation. In children with IFT there is an increase in the amount of internal hip rotation (torsion). Children with internal femoral torsion will want to sit in a “W” position, or on their feet, rather than crossed legged.

External femoral torsion (EFT) is much less common. This is because the usual position in the uterus makes the femur rotate internally, not externally. External femoral torsion can also be a cause of toeing out.

A significant difference between the left and right leg may mean that a deformity is caused by something else. Tumors, abnormal bone formation, fracture, and infection of the bone are possible causes. Excessive toeing out of one foot can be a sign of hip disease. Further evaluation is necessary. A child with progressive bowed legs after 20 months may have a pathological deformity known as Blount’s disease. Rickets can also cause bowed or knocked knees. Rickets is a vitamin D deficiency. It is also seen in kidney problems. Neurological and muscular disorders can also cause deformities of the legs.

Related Document: A Patient’s Guide to Blount’s Disease

Treatment

What treatment options are available?

Nonsurgical Treatment

The vast majority of children with rotational deformities need no specific treatment. The rotational deformity will change towards normal with time. Letting Mother Nature work things out is usually the best course of action. Sculpting of the body is a natural process. It includes the muscles, ligaments, and bones. Genetics also play a part. Muscle pull, lifting against gravity, and learning new postures all help with the normal development of the skeleton.

If your child’s foot looks normal when not weight bearing, then most likely no treatment is needed. Bracing or orthotics is not needed. External femoral torsion is much less common. Usually no specific treatment is necessary. Splints, orthotics, and corrective shoes are not usually beneficial.

Braces, casts, twister cables, exercises, and orthopedic shoes have been used to treat rotational deformities. Some studies show they may not be all that helpful. Their results are similar to no treatment at all. Stretching exercises, and encouraging certain positions for sleep and play cause no harm. But understand that these interventions may just make parents feel good that they are doing something for their child. Parents should consider the psychological effects of any type of rigid, disciplined program that restricts the child’s ability to interact normally with their surroundings.

Rotational deformities generally do not cause problems in adulthood. Many parents worry that these problems may cause arthritis in the joints when the child is grown. This is highly unlikely.

Surgery

Surgery is rarely needed to correct the majority of rotational deformities in either the femur or tibia. If external tibial torsion (rotation) is very severe and lasts longer than age four, surgery may be recommended to better align the tibia. Similarly, if surgery on the femur is recommended, it is usually done after the age of eight.

Surgery to correct the deformity is done only when the deformity is severe and affects the child’s function. In general, the type of surgery performed to improve the rotational deformity is called a derotational osteotomy. Derotation means to remove the rotation and osteotomy means to cut the bone.

A derotational osteotomy requires the surgeon to cut the bone, rotate it to improve the alignment and hold the bones in that positon while they heal. Some type of metal hardware is generally used to hold the bones in place until they heal.

The younger the child, the faster they heal. When the tibia is involved an osteotomy just below the knee or just above the ankle can be done and held in place with one or two metal pins through the skin. These pins can be easily removed in four to six weeks once the bone has healed. In the older child, a metal plate and screws attached on the outside of the bone or metal rod placed inside the marrow cavity of the tibia may be necessary to provide support for the longer period of time necessary for healing.

When surgery is recommended to derotate the femur, the intramedullary rod is commonly used to hold the bone in place. Children who require this surgery are generally older. A stronger type of fixation is required for a longer period of time. The intramedullary rod is placed through a small incision in the over the hip and the patient can be up and walking nearly immediately. The rod does not necessarily need to be removed in the older adolescent child. If the child is younger and the growth plates of the femur are still open, other fixation may need to be considered so there is no damage to the growth plates.

Another option is an external fixator. This device uses metal pins that are placed through the skin and into the bone. They are placed above and below the cut in the bone. The pins are then connected to bars on the outside of the leg that hold the bones in place while they heal. The pins are removed at a later date (usually four to eight weeks) when the surgeon feels the bone is strong enough. Pin removal can easily be done in day surgery. This can be safer when the growth plates are still open.

Rehabilitation

What can be expected after treatment?

Nonsurgical Rehabilitation

Most children require no active treatment whatsoever. There are no restrictions generally placed on children. Being a child IS the treatment. Allowing the child to pursue normal activity will result in a completely acceptable outcome.

If internal tibial torsion (ITT) lasts 18 months after the start of walking, some doctors will suggest the use of a Denis-Browne splint. A bar is attached to the sole of high-top shoes. The splint is worn at bedtime. The feet are forced into a toeing out position.

Some teenagers with exaggerated femoral internal torsion may develop pain in the front of the knee. Physical therapy may be beneficial for the knee pain. Use of ice, heat, taping, strengthening, and gait training may be helpful.

Your child’s doctor may want you to follow up periodically. This is to make sure the skeleton is developing as expected. Most rotational deformities correct themselves by age eight.

After Surgery

Your child will likely be hospitalized for several days after a derotational osteotomy. Because the bone is cut, it may take at least eight to 12 weeks to heal. Your child’s surgeon will want to see your child frequently following surgery. X-rays will need to be repeated. This allows the doctor to evaluate bone healing. If the bone does not heal, further surgery may be necessary.

When pins are used to hold the bone in place, cleaning them daily is important. This is to decrease the risk of infection. You will be taught how to do this before leaving the hospital. It is important that you contact your child’s surgeon immediately if you suspect an infection.

Your child will most likely need to be in a wheelchair to protect the bone. Physical therapy may be helpful for range of motion of other joints and to maintain strengthening.

Unless your child has had a surgical procedure that would allow immediate weight bearing, your child will not be allowed to stand on the leg until after the bone starts to heal. Weight bearing will be increased gradually. Usually by three months, your child will be allowed to walk alone. Walking should eventually appear normal.

An occupational therapist may also be helpful during recovery. They will assist with equipment to make dressing, transferring, and bathing easier. They can also help with wheelchair fitting.

When the bone has healed, your child may benefit from physical therapy if there is stiffness or weakness that does not get better on its own.

A Patient’s Guide to Limping in Children

Introduction

Limping in a child is a concern. Limping in a child is never normal. It can be caused by many things, sometimes by something minor, like a blister or cut. The most common cause of a limp in young children is a fracture. Sometimes it is caused by a serious infection. Although rare, it can be caused by a tumor.

This guide will help you understand

• what can cause this condition
• what the symptoms are
• how your doctor will diagnose the condition
• what treatment options are available

Anatomy

What parts of the body can be involved?

Sources of limping can involve many parts of the body. The hip, knee, shin bone, ankle, and foot are common parts that can cause limping. Limping can also be caused by problems in the back or pelvis.

The hip is a ball-and-socket joint. It is covered by a tough lining called the synovium. The ball of the joint is the end of the thigh bone, called the femur. Like other ends of bones in children, the ball has an area called a growth plate. A growth plate has cells that produce new bone. The growth plate is weaker than other parts of the bone. This makes this area more likely to fracture.

The socket part of the hip joint is called the acetabulum. It is actually part of the pelvis. The acetabulum forms a cup where the ball of the femur sits. It is covered with articular cartilage. Articular cartilage is the material that covers the ends of the bone of any joint. It’s a rubbery, slippery substance that allows the surfaces to slide against one another without damage to either surface.

The knee joint is made up of the other end of the femur and the end of the shin bone. The knee cap, or patella, also is part of the knee joint. In children, pain in the knee can actually be caused by a problem in the hip.

The lower leg is made up of two main bones. The larger bone is the shin bone, called the tibia. The smaller bone runs along the outside of the tibia it’s called the fibula. These bones, along with a saddle shaped bone at the top of the foot called the talus form the ankle.

The foot has many bones. There are short bones below the ankle towards the back of the foot called the cuboids. The long bones of the foot from the arch to the joints of the toes are called the metatarsals.

Causes

How can this condition develop?

The most common cause of a limp in small children is a fracture. Toddler’s fractures involve buckling or bowing of the tibia (shin bone). This usually happens when a child trips or falls up stairs.

Bunk-bed fractures are caused by jumping. The cuboid bone and first metatarsal in the foot are the bones that are usually broken in this type of injury.

In children from two to ten years old, the most common cause of hip pain is transient synovitis (TS). This involves swelling or inflammation of the synovium of the hip. The synovium is a tough covering of the joint. Often, the child will have had a cold or viral infection just before the hip pain started. Transient synovitis usually lasts ten days. It generally gets better on its own.

Related Document: A Patient’s Guide to Transient Synovitis of the Hip in Children

Joint infection of the hip causes a more sudden onset of pain. Children will usually not walk at all when the joint is infected.

Osteomyelitis is an infection of the bone. It usually happens near the ends of the bones, close to the growth plate.

Overuse syndromes are common in active adolescents. Stress fractures of the foot, patellofemoral joint problems, and Osgood-Schlatter’s disease are examples of overuse syndromes.

Related Document: A Patient’s Guide to Osgood-Schlatter Lesion of the Knee

Legg-Calvé-Perthes disease typically affects boys between the ages of five and ten. It is also called osteonecrosis and avascular necrosis of the hip. It literally means death of bone. The ball of the hip dies because the blood supply has been cut off. When this happens, the femoral head and acetabulum will change their shapes over one to three years. The ball of the femur will flatten out. This problem with the hip is often missed at first. It is frequently misdiagnosed as synovitis of the hip.

Related Document: A Patient’s Guide to Perthe’s Disease

Slipped Capital Femoral Epiphysis is the slipping of the growth plate of the ball of the hip joint. It usually happens in obese, older children.

Related Document: A Patient’s Guide to Slipped Capital Femoral Epiphysis

Tumors in bone are rare in children. Ewing’s sarcoma is a cancerous tumor that starts in the bone. More often, a tumor found in the bone is from cancer somewhere else in the body. Neuroblastoma and leukemia are both known to cause destruction of bones.

Rheumatoid arthritis is an auto-immune disease. It can affect children. When it does it is called juvenile onset rheumatoid arthritis. When left untreated it can destroy the synovium of joints, causing deformity, pain, and loss of mobility.

Neuromuscular disease such as muscular dystrophy or other genetic problems may also cause limping.

Back problems, appendicitis, or other problems in the abdomen or pelvis can cause limping, usually in older children.

Symptoms

What does the condition feel like?

In addition to limping, or not walking at all, other symptoms may occur.

Swelling or redness near a joint often means infection or inflammation. Fever or chills can also mean infection. Tenderness of a specific area could be suspicious for a fracture.

Transient synovitis often happens after having a cold or viral infection.

Diagnosis

How will your doctor diagnose the condition?

Making a diagnosis can be difficult. It is not surprising that it can require more than one evaluation by more than one doctor. In many cases, laboratory testing and imaging tests (x-rays) are needed to make the right diagnosis.

Your child’s doctor will want to do a thorough history and physical examination.
It is important to know whether or not the limping started suddenly. It is important to determine if there has been an accident or fall. Repetitive or strenuous activity may also be the cause of limping. Your doctor will want to know if your child has had any recent illness, such as a cold, or strep throat.

Your child’s doctor will want to look at your child’s skin and joints. He/She is looking for things such as cuts, blisters, rash, insect bites, joint swelling and deformity of bones. Range of motion of the joints may also be evaluated.

Since fractures are the most common cause of limping in children, x-rays are done in most cases. In young children, x-rays of the pelvis, hips, and lower legs are recommended.

Magnetic resonance imaging (MRI) allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not x-rays, to show the soft tissues of the body. It is best at evaluating soft-tissue injury and tumors. The test may require the use of dye in an IV. Children may need to have sedation or anesthesia in order to lie still for the test.

Computed tomography (CT) scan may be ordered. It is best for evaluating problems with bones. It is usually tolerated by children, however, it exposes them to radiation.

Bone scans, also called nuclear scans can be used to detect fractures, osteomyelitis, and Legg-Calvé-Perthes disease. A radioactive tracer, Technetium, is injected into your child’s vein. Where there is an increase in metabolic activity, such as in the case with inflammation, fracture, infection, or tumor, the Technetium will be more concentrated.

Ultrasound is another form of imaging that may be used. It uses sound waves to create a picture. Ultrasound of the hip can show osteomyelitis, septic arthritis, transient synovitis, and Legg-Calvé-Perthes disease.

Laboratory studies may help your child’s doctor make a diagnosis. Most common is a complete blood count (CBC). This checks the white blood cell count which can increase during an infection. When inflammation and infection are present, your erythrocyte sedimentation rate (ESR) and C-reactive protein increase, these lab tests may also be done. Other lab tests may be done, such as rheumatoid factor, sickle cell tests, and lyme disease tests.

If joint or bone infection is suspected, blood cultures can be helpful. Your child’s doctor will likely want the joint aspirated. The bone may need to have a biopsy. A needle is placed in the joint or bone, and some of the fluid is removed and tested. In the case of infection, the bacteria causing the infection can be determined and an appropriate antibiotic treatment can then be chosen.

Treatment

What treatment options are available?

Nonsurgical Treatment

Most of the causes of limping can be treated without surgery. Most children respond well to therapy and resume walking normally without any long-term problems.

In toddler’s fractures and bunk-bed fractures, sometimes casts must be used. Limiting weight bearing when walking may mean your child will have to use crutches, or be in a wheelchair for awhile.

Overuse syndromes require rest from activity. Stress fractures and Osgood-Schlatter’s usually respond well to a discontinuation of the activity that caused them. Exercises like swimming and exercise biking are usually encouraged to maintain conditioning. Patellofemoral joint problems usually respond to physical therapy, taping, and bracing.

Transient synovitis usually responds to anti-inflammatory medication and rest. Symptoms generally improve after 10 days, with an eventual return to activity.

In the case of infection, six weeks of intravenous (IV) antibiotics is usually required. Sometimes antibiotics taken by mouth can be effective instead of such a long period of IV antibiotics. Your child may need to be in the hospital for a few days at first. Sometimes surgery is necessary to drain the area that is infected.

Referral to a doctor who specializes in arthritis will be necessary if your child is diagnosed with rheumatoid arthritis.

Although tumors are rare in children, they do occur. Some tumors may respond to chemotherapy or radiation. Sometimes the tumor has to be surgically removed.

Surgery

Surgical treatment is specific to the cause of the problem.

In the case of slipped capital femoral epiphysis, surgery is often required. The femur can be pinned through the skin (percutaneous pinning). The surgeon may need to open the joint to place pins in it. Sometimes the hip that is not affected is also pinned because it is also likely to slip.

Legg-Calve-Perthes often requires surgery to shape the hip joint.

Tumors are rare in children but they do occur. Your child will probably be referred to a specialist to determine the best method of treatment for the type of tumor discovered. Some tumors respond to chemotherapy or radiation. Surgical excision (removal) may be necessary.

Osteomyelitis sometimes requires a surgeon to open the area. This allows drainage of the infectious fluid and removal of damaged tissue and bone if needed.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Depending on the cause of limping, physical therapy may be recommended. Range of motion exercises may be given to you by a physical therapist to do with your child in the home. Conditioning programs for older children can allow activity without making the problem worse. Taping, bracing, the use of modalities such as heat or cold, and anti-inflammatories can also benefit some causes of limping.

Your child’s doctor will want to follow up periodically. Sometimes this requires repeat blood work and/or imaging studies.

After Surgery

The particular type of surgical procedure required will have rehabilitation guidelines specific to that surgery. Your healthcare providers will talk with you and your child about what to expect during the rehabilitation process.

After a period of immobility, your child’s surgeon will likely prescribe physical therapy. The physical therapist will work on walking, range of motion, and strengthening.

Periodic follow-up will be necessary. This will probably include the need for repeat imaging and lab tests.

A Patient’s Guide to Nursemaid’s Elbow

Introduction

Nursemaid’s elbow is a common injury in young children. It occurs most often around age two and rarely seen after age eight. Lifting the child up a step by the hand, giving the hand a sudden jerk, or pulling the child away from a dangerous situation can result in a subluxation or complete dislocation. This condition is also known as pulled elbow or radial head dislocation.

This guide will help you understand

• how this problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What part of the elbow does this problem affect?

The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).

The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. The knob on the end of the humerus is called the capitellum. The capitellum fits into the cup-shaped end of the radius, also called the head of the radius, or radial head. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down. At the same time, it has to slide against the end of the humerus as the elbow bends and straightens. The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well.

In the elbow, two of the most important ligaments are the medial collateral ligament and the lateral collateral ligament. The medial collateral is on the inside edge of the elbow, and the lateral collateral is on the outside edge. Together these two ligaments connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is a severe injury or dislocation of the elbow. These ligaments are not generally injured in the condition referred to as nursemaid’s elbow.

There is also an important ligament called the annular ligament that wraps around the radial head and holds it tight against the ulna. The word annular means ring-shaped. The annular ligament forms a ring around the radial head as it holds it in place. This ligament can be torn when the entire elbow or just the radial head is dislocated.

Causes

How does this problem develop?

In young children, the annular ligament to the radial head is thin and weak. A sudden pull on the forearm can tear this soft tissue structure. The radial head is pulled down through the tear. The annular ligament slips into the radiohumeral joint and becomes trapped between the two joint surfaces when the arm is let go. This is a radial head subluxation. When the annular ligament is pinched it causes pain.

A sudden jerk on the arm is the main cause of nursemaid’s elbow dislocation in children. As mentioned, lifting the child up a step by the hand, giving the hand a sudden jerk, or pulling the child by the hand or forearm can result in an elbow injury of this type. Many times the child will simply present crying with pain and inability to move the elbow.

This is a common injury in children. It occurs most often around age two and is rarely seen after age eight. Lifting the child up a step by the hand, giving the hand a sudden jerk, or pulling the child away from a dangerous situation can result in the injury. If the child is not old enough to talk, it may be difficult to determine what happened. Playing with other children where one child swings the other around by the arms can result in the injury.

As a child gets older, a true elbow dislocation is often the result of trauma leading to fracture and dislocation. Elbow dislocation with bone fracture is common in children between the ages of three and 10. This is a much different and much more serious injury. The most common site of the fracture associated with dislocation in this age group is a supracondylar fracture. The fracture is located below the humeral shaft (upper arm bone) where the olecranon (tip of the ulnar bone of the forearm) fits into the humerus. The bone is thin here in children. The olecranon is the part of the elbow we feel as the tip of the elbow).

Symptoms

What does nursemaid’s elbow feel like?

These injuries commonly occur in children too young to actually tell a parent or health care provider what happened. In young children, crying and refusing to use the arm while holding it against the body are common behaviors associated with nursemaid’s elbow. Pediatricians, family physicians and orthopedic surgeons usually recognize the pattern quickly because the injury is so common. Once you have seen a child with this condition, it is relatively easy to spot.

Pain and an inability to straighten the elbow or supinate the forearm by turning the palm up is typical. There is often tenderness along the lateral aspect of the elbow (side of the elbow away from the body). Bruising around the elbow several days after the injury is common.

In contrast, if the elbow is fully dislocated, it will look out of joint. There may be dimples or indentations of the skin over the dislocation where the bones have shifted position. Swelling on either side of the elbow may be a sign that there is a bone fracture. Pain can be intense until the arm is relocated.

Diagnosis

How do doctors diagnose the problem?

The history and physical examination are probably the most important tools your physician uses to guide his or her diagnosis. Moving the elbow passively is painful, especially extension and supination. The doctor will check for any signs of injury to the nerves or blood vessels.

X-rays are consistently negative in children with elbow subluxation or dislocation due to the large amount of fibrous cartilage present around the elbow before the bones are fully formed. It is easy to misinterpret the irregular or fragmented growth lines as fractures. Additional views may be needed to help the radiologist make an accurate diagnosis. Before age five (when the bones start to ossify or become bony) a separation of the growth plate at the end of the bone may go undetected. Many health care providers will not order X-rays if they suspect nursemaid’s elbow and will simply try to reduce the subluxation with a gentle manipulation.

Treatment

What treatment options are available?

Nonsurgical Treatment

It is possible for the nursemaid’s elbow to relocate by itself.

Manual (closed) reduction can be done on site by a trained medical professional (e.g., at an athletic event or car accident) in an emergency. Closed reduction refers to the fact that the subluxation of the annular ligament and radial head are put back in place without surgery. Generally this procedure is done in a clinic or hospital setting.

The technique of reduction is relatively simple. Once the health care provider has decided that the situation is most likely a nursemaid’s elbow, the next step is to calm the child and establish trust. The elbow is gently taken through a complete range of motion from completely extended to fully flexed. While flexed the forearm is maximally supinated. In some cases, a small pop is felt or heard. This can indicate that the annular ligament has popped from the joint and back into the normal position. If there is no pop, the child is encouraged to use the arm. In many cases, within minutes the child is using the arm normally.

If the child continues to exhibit pain, X-rays may be ordered to make sure that no other injuries are present in the elbow such as a fracture. If the X-rays are normal, then the child will be placed in a sling and observed for several days and probably schedule to return to the office for re-evaluation in a week or 10 days. Over time, the vast majority of cases of nursemaid’s elbow resolve spontaneously and only in rare circumstances require any additional treatment.

Rehabilitation

What can be expected from treatment?

Nonsurgical Rehabilitation

Nursemaid’s elbow generally doesn’t require rehabilitation after the subluxation is reduced. The child may favor the arm for several days and may feel more secure with a light splint for a day or two. The child should be encouraged to use the arm as tolerated. If there continues to be problems using the arm after several days or weeks, then it should probably be re-evaluated by an orthopedic surgeon.

It’s best to avoid any further traction on the elbow until healing has occurred. Pulling a heavy door open or lifting a heavy backpack are examples of activities and movements that put a traction force through the elbow. These kinds of movements should be avoided until healing occurs.

Parents of small children are cautioned to avoid pulling or lifting by the hand to prevent injuries of this type. Young children should always be picked up under the arms. They should never be forcibly pulled, lifted or swung through the air by the hand or wrist.

A Patient’s Guide to Back Pain in Children

Introduction

Until recently, a complaint of back pain in a child or adolescent was considered uncommon. It was usually associated with a certain condition such as tumor, curvature of the spine, a broken spinal bone, inflammation, or infection.

However, more recently, reports of back pain is much more common among children. By the age of 15, 20 to 70 percent of children will report back pain. It is seldom associated with a serious condition, particularly as age increases. Even though the majority of children will not have a serious condition, there is still a small portion that do.

This guide will give you a general overview of back pain in children. It will help you understand:

• What parts make up the spine
• What causes back pain in children
• How the diagnosis is made
• What treatment options are available

Anatomy

What parts make up the spine?

The spine is made up of a column of bones. Each bone, or vertebrae, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body, forming a canal for the spinal cord.

Facet joints are small joints on either side of the spine that allow motion. As the bones of the spine interlock, a facet joint is formed. Each vertebra will form two facet joints on either side. There is a pair at the top and a pair at the bottom of each vertebra. The area of the vertebrae bones that is between the upper and lower facet joints is called the pars articularis or pedicle.

Intervertebral discs form a cushion between the round blocks of bone making up the vertebral body. The area of the bone where the disc attaches to the vertebra is called an end plate. Discs are a collection of tough tissue similar to a ligament. They are filled with fluid when healthy.

There are three general portions of the spinal column. The cervical or neck portion, the thoracic portion making up the mid-back, and the lumbar or lower portion. The lumbar portion connects with the pelvis at the sacrum.

There are specific curves associated with each region of the spine. When looking from the side, the cervical spine has an inward curve called a lordosis. The thoracic spine curves outward and is called a kyphosis. The lumbar spine usually has a lordosis. These three curves maintain balance of the spine in a forward and backward plane.

When these curves are exaggerated or absent, the condition is called scoliosis.

Causes

What can cause back pain in children?

There are several red flag warning signs that may suggest a specific cause for back pain. Night pain, constant pain, or pain that spreads into the buttocks or legs are some of them. Leg weakness or bowel and bladder problems can indicate nerve or spinal cord problems.

Conditions that can cause back pain are grouped into nonspecific, meaning the cause is unknown; and specific back pain, meaning there is an identified cause for the back pain.

Nonspecific back pain means that there is no specific structural reason or cause for back pain. Approximately 60 to 75 percent of children reporting back pain will have non-specific back pain. Their physical exam and X-rays will be normal. It is usually considered a muscle strain or from poor posture.

In some cases, non-specific back pain may be related to mood problems such as depression or anxiety. It sometimes is related to problems at school or with peers. Visits with a school counselor or psychologist may be recommended.

Approximately 25 to 40 percent of children will have changes in imaging studies (such as X-ray or MRI) that indicate a pathological (specific) cause for their back pain. These include the following:

Spondylolysis is a fracture of the pars interarticularis or pedicle(s), usually of the L5 or last lumbar vertebrae. This is most likely caused by an injury. It may also be caused by repetitive activity. The activities that most likely cause spondylolysis include extension (bending backwards) and rotation. Sports that put athletes at higher risk include ballet, gymnastics, football, high jumping, diving, rowing, and weight lifting.

Spondylolysis is a common cause for back pain in children, especially those that are active in sports. It may happen in four to five percent of children by the age of six, and up to six percent of adults. Spondylolyis is three times more common in boys than girls. Growth spurts and involvement in contact sports may explain the difference between boys and girls.

Early on, X-rays may not show a fracture. Special imaging such as MRI, CT, or SPECT bone scan may show signs of a stress fracture. Spondylolysis may cause pain in a particular spot in the low back and spasm of the muscles along the spine. Often it will cause pain into the buttocks or thighs. Spondylolysis will likely heal with a change in activity, rest, and avoiding hyperextension and rotation. Bracing may be helpful if symptoms do not get better.

Related Document: A Patient’s Guide to Lumbar Spondylolysis

Spondylolisthesis occurs when spondylolysis worsens or does not heal. It can cause slippage of one vertebra on the other. This slippage is called spondylolisthesis. The slippage is graded from I through IV, one being mild, IV often causing neurological symptoms.

Related Document: A Patient’s Guide to Lumbar Spondylolisthesis

Scoliosis or curvature of the spine may be a source of back pain in children. Most cases of scoliosis only require watching for worsening. However, some may need bracing and even surgery. Sometimes a scoliosis is caused by tumor or infection of the spine.

Related Document: A Patient’s Guide to Scoliosis

Scheuermann’s kyphosis is a deformity where there is wedging of three or more vertebrae in a row in the thoracic region. Wedging means that the vertebra is wider towards the back, and narrower towards the front. The vertebra has lost its usual rectangular shape. This causes increased curvature or forward bending of the spine. This curvature is called kyphosis. The curve from a sideways view can be 50 degrees or more. If the curvature is greater than 75 degrees, surgery to straighten the spine may be necessary.

Related Document: A Patient’s Guide to Scheuermann’s Disease

There may also be narrowing of the disc spaces between the vertebrae. Most of the time there are also Schmorl’s nodes seen in the endplate of a vertebral body or several vertebrae. On imaging studies these look like small hollowed areas.

Discitis and vertebral osteomyelitis are rare in children. When a disc becomes inflamed and possibly infected, the condition is called discitis. If the vertebral bone becomes infected, the condition is called vertebral osteomyelitis.

Common symptoms of these conditions include refusal to crawl, sit, or walk and back pain. A limp and forward bending while placing the hands on thighs for support are also common signs. Fever of 102 degrees Fahrenheit or greater is common in vertebral osteomyelitis.

With discitis, the disc will appear narrowed on an X-ray or an MRI. Discitis usually happens in children less than five years old.

In vertebral osteomyelitis, the vertebral bone and surrounding tissue including the disc can become infected. On X-ray or MRI the bone and/or tissue can show destruction. Vertebral osteomyelitis tends to affect older children and adolescents.

Both conditions are treated with rest, antibiotics by IV and by mouth. A brace to support the spine may be suggested. Surgery may be necessary in osteomyelitis, to clean out the infection and/or to stabilize the spine.

Tumors are a rare cause of back pain in children. A tumor of the spine is an abnormal growth of tissue in or around the spinal column. There are many different types of spinal tumors. They can be benign or malignant. Benign means that the tumor does not spread to other parts of the body. It can still cause destruction of vertebral bone or spinal tissue. Some benign tumors can come back after they have been removed. Benign tumors include osteoid osteoma, osteoblastoma, and aneurysmal bone cysts. Malignant tumors are tumors that can spread to other parts of the body. These include sarcoma, leukemia, and lymphoma.

Related Document: A Patient’s Guide to Spinal Tumors

Symptoms

Depending on the age of the child, they may or may not be able to tell you about their symptoms.

In a younger child, refusal to crawl, sit, or walk may indicate back pain.

In older children, symptoms may include:

• Pain involving the spine
• Spasm of the nearby muscles
• Decreased range of motion or stiffness in the back
• Stiffness and pain after prolonged sitting or standing
• Pain with loading the spine as when lifting and carrying
• Pain may refer to areas away from the spine itself. It may cause pain in the buttocks or legs
• Leg weakness or bowel and bladder problems can indicate nerve or spinal cord problems
• Difficulty walking
• Fever

• Diagnosis

  How will my doctor diagnose this condition?

  Your doctor will perform an examination that will include your history. It will include questions about activity, spinal injuries, urination, bowel movements, weakness, what makes the pain better and worse, when does the pain occur, etc. Your doctor may also ask questions about school, home, and your moods.

  A physical examination will be done as well. This will include looking at the back to evaluate the curves of the spine, spasm of the muscles, and for unusual markings of the skin or soft tissue along the spine. Your doctor will also want to watch you move or walk, and evaluate the range of motion of the spine. Neurological examination may include checking reflexes, sensation, and muscle strength.

  Imaging studies

  X-rays are recommended for all children complaining of back pain. Views of the spine from the front, the side, and part way in between (oblique) should be taken. X-rays will show bone as well as the disc spaces.

  

  

  Magnetic resonance imaging (MRI) allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not X-rays to show the soft tissues of the body. This includes the spinal cord, nerves, and discs. It can also evaluate spinal bones. The test may require the use of dye in an IV. Sedation or anesthesia may be needed to help you lie still for this test.

  A computed tomography (CT) scan may be ordered. It is best for evaluating problems with the vertebral bones. It is usually tolerated by children, however, exposes them to radiation. Sometimes, it may require dye in the spinal canal fluid for easier identification of the spinal cord and nerve root anatomy. When dye is injected for this purpose, the technique is called a myelogram.

  Bone Scans, also called nuclear scans can be used to detect fracture, bone infection, or tumor. A radioactive tracer, Technetium, is injected into your vein. Where there is increase in metabolic activity the Technetium will be more concentrated. This occurs when there is inflammation, fracture, infection, or tumor. Some tumors in the spine can spread to other parts of the body, or come from cancer somewhere else in the body. A scan can be helpful to see if there are other areas in the body where the cancer may be.

  SPECT stands for Single Photon Emission Computed Tomography. SPECT imaging is often added to provide information that is not available on routine bone scan images. It provides three-dimensional (3-D) views of the area examined. Following a bone scan you will remain on the exam table and the camera will rotate around the table while it takes pictures. SPECT imaging adds 30 to 60 minutes to the time of the nuclear scan. Sedation may be needed.

  A biopsy of the spine may be required if an infection or tumor is found. In some cases tissue samples can be taken with a needle. Sometimes tissue for a biopsy is taken during a minor surgery. This allows the doctor a better view of the area he neeeds to biopsy. The tissue is then looked at under a microscope.

  Laboratory Studies

  Blood tests may be requested to evaluate the blood for specific bacteria causing the infection. A complete blood count (CBC), especially in children under the age of 10 is important. There is a greater chance that back pain is from leukemia in children younger than 10. If there is an infection, the CBC may show an increase in the infection-fighting white blood cells. A C-reactive protein (C-RP) and erythrocyte sedimentation rate (ESR) may also show an increase when an infection is present. A blood culture may be necessary to help determine what bacteria are causing the infection in discitis or vertebral osteomyelitis.

  A biopsy may be required to determine what bacteria are causing an infection. This will help your doctor choose the right antibiotic to treat the infection.

  Treatment

  What treatments are available?

  Non-surgical treatment

  Most treatment for back pain in children is non-surgical. Treatment of children with non-specific back pain includes change in activity and rest. Trunk strengthening and postural exercises with the help of a physical therapist may be useful. Short-term use of over-the-counter medications such as Ibuprofen (Advil, Motrin) may be beneficial. Weight loss may be recommended.

  

  Carrying backpacks may sometimes be to blame for non-specific back pain. It is suggested that children wear their backpack using both shoulder straps. Making more frequent trips to the locker can decrease the weight of the backpack. Some children choose to use wheeled backpacks.

  Treatment of non-specific back pain may include involving the school counselor or a psychologist. Children may complain of back pain when they are depressed or anxious. It may also indicate problems at home, in school, or with peers.

  Bracing may also be required for proper treatment of some conditions.

  Antibiotics either by IV and/or by mouth are necessary for the treatment of discitis and vertebral osteomyelitis.

  Surgical treatment

  Surgical treatment for back pain in children is rare.

  If a tumor has been discovered as the source of your back pain, the treatment options will vary depending on the type of tumor found.

  Some tumors are evaluated periodically on a watch and see basis. Surgery to remove the tumor is often recommended. If radiation or chemotherapy is required, you will be referred to an oncologist (cancer specialist). In the case of a tumor, radiation may begin as early as one to two weeks following surgery. Radiation usually lasts only 15 to 20 minutes per day for two to six weeks. Treatment options and the prognosis for many tumors have improved greatly in the past few years.

  The spine may need to be stabilized due to scoliosis or kyphosis, or from the removal of a tumor or infection. Metal hardware such as screws, rods, plates, or cages may need to be used. The bone may also be supported by bone graft or bone cement.

  Rehabilitation

  What should I expect after treatment?

  Non-surgical Rehabilitation

  Periodic follow-up with your physician is required. Repeated or different imaging studies may be necessary, particularly if symptoms do not improve. Laboratory tests may need to be repeated.

  Specific treatment by a physical therapist may be suggested. This treatment usually involves avoiding movements that could make the condition worse, posture training, as well as back and abdominal (core) strengthening. A physical therapist will also instruct you in safe lifting and proper body mechanics in other daily activities.

  Surgical rehabilitation

  If surgical intervention is required, your surgeon will require periodic follow-up visits. This could be on a long-term basis to watch for spinal deformity or recurrence of a tumor. Repeated or different imaging studies may be necessary. Laboratory tests may need to be repeated.

  The amount of time you are hospitalized depends on the type of surgery required. After surgery, activity such as sitting, crawling, or walking are usually allowed as well as activities that do not require stretching of the spine or straining. Lifting is limited during the initial recovery period. You will likely be required to use a brace or corset after surgery to help with stability.

  You may benefit from physical therapy and occupational therapy. Therapists can help with regaining strength, movement, coordination, and activities of daily living.

A Patient’s Guide to Blount’s Disease in Children and Adolescents

Introduction

Bowlegs also known as tibia varum (singular) or tibia vara (plural) are common in toddlers and young children. The condition is called physiologic tibia varum when it’s a normal variation and the child will grow out of it. Most toddlers have bowlegs from positioning in utero (in the uterus). This curvature remains until the muscles of the lower back and legs are strong enough to support them in the upright position.

In some cases abnormal growth of the bone causes the bowing to get worse instead of better over time. This condition is called Blount’s disease or pathologic tibia varum.

Blount’s disease becomes obvious between the ages of two and four as the bowing gets worse. Overweight adolescents or teenagers can also develop Blount’s disease.

This guide will help you understand

• what part of the leg is involved
• what causes the condition
• what treatment options are available

Anatomy

What part of the leg is involved?

The tibia (lower leg bone) or more commonly called the shin is affected by Blount’s disease. Infantile (less than three years old) Blount’s is usually bilateral (both legs are affected at the same time). The bones start to form an angle and rotate inwardly. Adolescent (11 years of age and older) Blount’s is more likely to be unilateral affecting just one leg.

In the growing child, there are special structures at the end of most bones called growth plates. The growth plate is sandwiched between two special areas of the bone called the epiphysis and the metaphysis. The growth plate is made of a special type of cartilage that builds bone on top of the end of the metaphysis and lengthens the bone as we grow.

In Blount’s disease the epiphysis and metaphysis both are involved. Only the medial or inside edge of the bone is affected. The metaphysis is the wider part of the tibial bone shaft. In the early stages of Blount’s disease, the medial metaphysis breaks down and growth stops. In the child who is still growing, the metaphysis containing the growth zone consists of spongy bone that has not yet hardened.

Causes

What causes this condition?

There are three types of tibia varum based on the age it begins: 1) infantile (less than three years old), 2) juvenile (occurs between four and 10 years), and 3) adolescent (11 years of age and older).

Physiologic tibia varum occurs between the ages of 15 months to three years. There’s no need for treatment for this normal stage of development. But it’s not always clear at this age if the tibia varum is physiologic (normal variation) or pathologic (Blount’s disease).

Blount’s disease is caused by a growth disorder of the upper part of the tibial bone. Toddlers or children who are large or overweight for their age and who walk early are most often affected. As the child walks, the repeated stress and compression of extra weight suppresses (slows) or stops growth of the developing bone. When only one side of the tibia stops growing, there are abnormal changes in bone alignment resulting in this curvature or bowing of the bone.

There can be other causes of bowed legs in toddlers or young children. Metabolic disorders such as a deficiency of vitamin D causing rickets is more common in other countries. In the United States many of our foods are fortified with vitamin D to prevent this problem. In a small number of children, vitamin D deficiency occurs as a result of a genetic abnormality. The child cannot absorb or metabolize vitamin D.

Juvenile or adolescent Blount’s disease is usually caused by obesity (being overweight) but can be the result of infection or trauma that disrupted the medial growth plate.

Symptoms

What does this condition feel like?

The young child may not feel any symptoms. However patients with adolescent tibia varum usually complain of pain along the medial side of the knee. The bowed appearance of the lower legs may be the first obvious sign. The child may have trouble walking without tripping. The way the child walks may not look normal. He or she thrusts the leg out away from the other leg when walking on the affected leg.

Diagnosis

How do doctors identify this condition?

Visual observation is the first method of diagnosis. The family or doctor sees the problem when looking at the child or watching him or her walk. The distance between the knees is measured with the child standing with the feet together. If the space between the knees is more than five centimeters (1 1/4 inches) further testing is needed.

Bowing of the bones can be seen more clearly on X-rays. There are six stages of tibia varum seen on X-ray and named after the physician (Dr. Langenskiold) who first described them. The radiologist will see a sharp varus angle and other changes in the metaphysis. Often there is widening of the growth plate. The top of the tibia looks like it has grown a beak just on the medial side.

Treatment

What treatment options are available?

Treatment depends on the age of the child and the stage of the disease. Between ages birth and two, careful observation or a trial of bracing (also called orthotics may be done. If the child doesn’t receive treatment, Blount’s disease will gradually get worse with more and more bowlegged deformity. Surgery may be needed to correct the problem. For the obese child, weight loss is helpful but often difficult.

Nonsurgical Treatment

Most of the time bowlegs or genu varum resolves on its own with time and growth. No specific treatment is needed unless the problem persists after age two.

In the case of Blount’s disease aggressive treatment is needed. Severe bowing before the age of three is braced with a hip-knee-ankle-foot orthosis (HKAFO) or knee-ankle-foot orthosis (KAFO). Bracing is used 23 hours a day. As the bone straightens out with bracing, the orthotic is changed every two months or so to correct the bowlegged position.

Surgery

Surgical correction may be needed especially for the younger child with advanced stages of tibia varum or the older child who has not improved with orthotics. Surgery isn’t usually done on children under the age of two because at this young age, it’s still difficult to tell if the child has Blount’s or just excessive tibial bowing. A tibial osteotomy is done before permanent damage occurs. Brace treatment for adolescent Blount’s is not effective and requires surgery to correct the problem.

In an osteotomy, a wedge-shaped piece of bone is removed from the medial side of the femur (thigh bone). It’s then inserted into the tibia to replace the broken down inner edge of the bone. Hardware such as pins and screws may be used to hold everything in place. If the fixation is used inside the leg, it’s called internal fixation osteotomy. External fixation osteotomy describes a special circular wire frame on the outside of the leg with pins to hold the device in place.

Unfortunately, in some patients with adolescent Blount’s disease, the bowed leg is shorter than the normal or unaffected side. A simple surgery to correct the angle of the deformity isn’t always possible. In such cases an external fixation device is used to provide traction to lengthen the leg while gradually correcting the deformity. This operation is called a distraction osteogenesis. The frame gives the patient stability and allows for weight bearing right away.

Rehabilitation

What should I expect from treatment?

Nonsurgical Rehabilitation

A physical therapist will work with the family to teach them how to put on and take off the orthosis. Inspection and care of the skin is very important and will be included in the instruction. The child may need some help with gait training (learning how to walk properly). The therapist will help the child learn how to use any assistive devices (e.g., walker, crutches) that may be needed.

Failure to correct the tibia vara deformity early often results in permanent damage to the growth plate and growing bone. Later, joint degeneration may occur.

After Surgery

Osteotomy with internal fixation usually heals in six to eight weeks. The cast is removed five to six weeks after the operation if there’s enough bone build-up to prevent change or loss of position. A second cast is applied that keeps the knee straight but the foot and ankle free to put weight through the leg.

When the child has surgery with external fixators and distraction osteogenesis, gradual correction of the deformity takes place over the next three weeks. After the tibia is straightened, extra rods are used to stabilize the external frame. The frame is taken off about 12 weeks postoperatively.

Parents or guardians should be advised that Blount’s disease might not be cured with surgery. Results are usually good with infantile tibia vara. When treated at a young age and at an early stage, the problem usually doesn’t come back. Older patients with advanced deformity have a much higher risk of recurrence of the deformity. Patients must be followed carefully throughout their growth and development. Unilateral bowing can result in that leg being shorter than the other leg. This is called a leg length discrepancy and may need additional treatment.

A Patient’s Guide to Tarsal Coalition

Introduction

A Tarsal Coalition is a congenital condition that affects the bones of the foot in children and adolescents. Congenital means that the condition is present at birth and occurred during fetal development. A tarsal coalition occurs when the bones of the feet fail to separate during fetal development. This leads to a problem in the foot that can be painful. It also may cause a stiff, flat foot. The condition is not common, but it is not rare. About one in a hundred people, 1% of the population, have a tarsal coalition.

This guide will help you understand

• what part of the foot is involved
• what causes the condition
• what treatment options are available

Anatomy

What part of the foot is affected?

The tarsal bones are the seven bones that make up the heel and the midfoot. The metatarsals and the phalanges are connected to the tarsals and form the forefoot. A tarsal coalition can affect any of the tarsal bones; all but two types of tarsal coalitions are extremely rare.

The two most common types are the calcaneonavicular coalition and the talocalcaneal coalition. The calcaneonavicular coalition describes a failure of separation between the calcaneus and the navicular, while the talocalcaneal coalition describes a failure of separation between the calcaneus and the talus.

Sometimes the conditions are also called calcaneonavicular bar and talocalcaneal bar. The term “bar” refers to the abnormal “bar of bone” between the two bones. There is not a fully formed bar of bone between the two bones of the coalition in every case. The coalition or “bar” between the two bones can be made of bone, cartilage, or fibrous tissue. Each of these types represents a different degree of attachment between the two bones, with the stiffest being bone and the most flexible being fibrous tissue.

Related Document: A Patient’s Guide to Foot Anatomy

Causes

<What causes this condition?

During the nine months of pregnancy, the fetus undergoes remarkable changes. In the skeleton, these changes include the separation of each individual bone in the body from one mass of bone material. In some cases, this process is flawed. A tarsal coalition occurs when this type of failure to separate occurs in the tarsal bones of the foot.

Tarsal coalition is genetic, meaning that it runs in families. In addition it is an autosomal dominant genetic condition. This means that if you have one parent with the disorder, it is highly likely that you will inherit the disorder.

Tarsal coalition becomes a problem because it affects the way the bones of the foot move as we walk. The foot is an incredibly complex structure. To function correctly, all of the bones of the foot must move in relationship to each other. If the movement between two bones is abnormal or non-existent, the motion in other joints is disrupted. The abnormal motion increases the stress on other joints. Over time, this leads to wear and tear on those joints. Finally, it leads to pain.

Symptoms

What does this problem feel like?

In the past, this condition was called peroneal spastic flatfoot because doctors thought that the flattening of the foot was associated with spasms of the peroneal muscles that run along the outside of the calf. This is probably not a big part of the problem. A tarsal coalition does cause the foot to be flat and stiffer than normal.

The primary symptom caused by a tarsal coalition, no matter whether it is a calcaneonavicular coalition or a talocalcaneal coalition, is pain. Pain is usually located on the outside of the foot just below the fibula. The fibula is the large bump on the outside of the ankle. This painful area is called the sinus tarsi. Most problems that affect the joint between the talus and the calcaneus, the subtalar joint, seem to be felt in this area.

When the condition becomes more advanced, other joints can be affected. The two most common joints are the talonavicular joint and the calcaneocuboid joint. If these joints are affected, pain may be felt on the top of the foot and on the outside of the foot.

Diagnosis

How do doctors identify the problem?

The history and physical examination help to make the diagnosis of tarsal coalition. The doctor will need information about the age and activity level of the child. The doctor will watch the child walk and pay particular attention to the way the feet move during gait. Finally, examination of the feet is necessary to locate areas of tenderness and look for restriction of motion in each of the joints in the foot.

X-rays are helpful in diagnosing tarsal coalition. Special views have been developed to look specifically at the different areas where the coalitions occur. X-rays also show the other joints of the foot. This allows the doctor to determine how much wear and tear has occurred in other joints. This information may become important later in trying to decide what treatment is best to recommend.

The Computed Tomography (CT) Scan is the gold standard for making the diagnosis of tarsal coalition. The CT scan is a special type of x-ray test where a computer is used to create slices of the skeleton. In some cases, where the coalition is made of cartilage or fibrous tissue, a Magnetic Resonance Imaging (MRI) scan may be necessary. The MRI scan also makes slices of the foot but it shows soft tissue much better than the CT scan. The MRI scan uses magnetic waves rather than x-rays.

Treatment

What treatment options are available?

Nonsurgical Treatment

After making the diagnosis, your doctor may recommend placing the foot in a walking cast or a brace from the knee to the toes for two to four weeks. The purpose of the cast is to place the joints at rest and allow the inflammation and irritation to decrease. This reduces pain. Once the pain has stopped, the cast is removed and special orthotics are custom made for everyday use. This orthotic can be worn inside a normal shoe. The orthotic supports the foot, reduces the abnormal motion and reduces the pain with walking. If this is successful, this may all the treatment that is needed.

Surgery

When the condition continues to be painful despite non-surgical treatment, your doctor may recommend surgery. Surgery for tarsal coalition falls into two categories: 1) surgery to remove or excise the bar and attempt to restore normal motion between the two bones or 2) surgery to fuse the affected joints together solidly.

As a general rule, excision is more likely to be successful in the younger child. In the older child or adolescent, a fusion may be required. Once the surrounding joints have become excessively worn, or degenerative, restoring motion may not be enough to stop the pain. The older the patient, the more likely this has occurred.

Excision of Calcaneonavicular Bar

When the coalition occurs between the calcaneus and the navicular, excision can be highly successful. To perform this procedure, an incision is made in the lateral side of the foot immediately over the sinus tarsi. A muscle called the extensor digitorum brevis is detached from the bone and moved out of the way. The surgeon will then cut out the bridge of bone between the calcaneus and the navicular. Once all of the bone connecting the calcaneus and the navicular is removed, the empty space is filled with the extensor digitorum brevis muscle. The muscle is held in place with sutures. Placing the muscle between the two bones prevents the bone from growing back and recreating the bar or coalition. The skin is sutured together and the leg is placed in a cast or brace.

Excision of Talocalcaneal Bar

When the coalition occurs between the talus and the calcaneus, excision is less predictable. To perform this procedure, an incision is made in the medial side of the foot under the medial malleolus. The surgeon will then cut out the bridge of bone between the talus and calcaneus. Once all of the bone connecting the talus and calcaneus is removed, the empty space is filled with a piece of fat tissue taken from the lower leg. The fatty tissue is held in place with sutures. Similar to placing muscle between the two bones, the fatty tissue prevents the bone from growing back and recreating the bar. The skin is sutured together and the leg is placed in a cast or brace.

Fusion

A fusion, also called an arthrodesis is a surgical procedure that is usually done when a joint becomes worn out and painful. The purpose of a fusion is to stop the motion between two or more bones. The procedure is done by removing the cartilage that covers the joint surfaces and allowing the bone surfaces to heal together or fuse as one bone.

Two types of fusions are commonly used to treat tarsal coalitions. A subtalar arthrodesis fuses the talus to the calcaneus. This type of arthrodesis is commonly used to treat the talocalcaneal coalition that is too advanced to consider an excision. This type of arthrodesis is used when the joints in the rest of the foot are still in good shape and do not seem to be causing pain.

A triple arthrodesis fuses three bones together: the calcaneus, the navicular and the cuboid. This type of arthrodesis is commonly used to treat any tarsal coalition that is too advanced to consider an excision and the condition has affected other joints in the foot. This type of arthrodesis is commonly recommended in the older patient. It may also be recommended if an excision has been tried and failed to relieve pain.

Rehabilitation

What should I expect from treatment?

Nonsurgical Rehabilitation

When a cast is used to rest the foot, most children learn to walk in the cast fairly rapidly. No special training is needed. Once the cast is removed, you may need to see an orthotist to have a pair of orthotics made. Orthotics are special inserts for the shoes to support the foot. These fit inside the shoe and do not require any special training to use.

Surgical Rehabilitation

After surgery for excision of the tarsal coalition, a large bandage is applied to the foot. Some type of cast or brace may also be used. Weight bearing can usually be started in a few days, as soon as the pain and swelling subside. Since there is no bone to heal together, activity can usually advance as tolerated.

A fusion is somewhat more involved. When a fusion has been performed, the bones will need to heal together and fuse. Screws or metal pins may be used to hold the bones together as they heal. A non-weight bearing cast or brace is usually applied. Weight bearing may be delayed up to six or eight weeks to make sure that the fusion is healing and the bones are showing satisfactory healing on x-ray.

A Patient’s Guide to Clubfoot

Introduction

Clubfoot is a congenital condition that affects newborn infants. The medical term for clubfoot is Congenital Talipes Equinovarus. This condition has been described in medical literature since the ancient Egyptians. Congenital means that the condition is present at birth and occurred during fetal development. The condition is not rare and the incidence varies widely among different races. In the caucasian population, about one in a thousand infants are born with a clubfoot. In Japan, the numbers are one in two thousand and in some races in the South Pacific it can be as high as seven infants in one thousand who are born with a clubfoot. The condition affects both feet in about half of the infants born with clubfoot. Clubfoot affects twice as many males as females.

This guide will help you understand

• what part of the foot is involved
• what causes the condition
• what treatment options are available

Anatomy

What part of the foot is affected?

The tarsal bones are the seven bones that make up the heel and the midfoot. The metatarsals and the phalanges are connected to the tarsals and form the forefoot. Clubfoot primarily affects three bones: the calcaneus, talus and navicular. Other bones can be involved as the deformity can affect the growth of the entire foot to some degree.

The clubfoot is unmistakable. The foot is turned under and towards the other foot. The medical terminology for this position is equinus and varus. Equinus means that the toes are pointed down and the ankle flexed forward (sort of like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

This twisted position of the foot causes other problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight stiff foot that cannot be placed flat on the ground for walking. To walk, the child must walk on the outside edge of the foot rather than on the sole of the foot.

One interesting finding is that the calf muscles on the leg with the clubfoot are smaller than normal. If the clubfoot only affects one foot, the calf muscles on this leg will always remain smaller than the opposite side.

Related Document: A Patient’s Guide to Foot Anatomy

Causes

How does this problem develop?

During the nine months of pregnancy, the fetus undergoes remarkable changes. In the skeleton, these changes include the separation of each individual bone in the body from one mass of bone material. In some cases, this process is flawed. A clubfoot occurs when this type of failure of separation occurs in the tarsal bones of the foot.

Until recently, most experts believed that the deformity was due to the foot being stuck in the wrong position in the womb. As development progressed, the foot could not grow normally because it was turned under and held in that position. Today, most information suggests that clubfoot is hereditary, meaning that it runs in families. It is not clear what genetic defect causes the problem. It is not known yet whether the defect affects the development of the muscles, blood vessels, or bones of the foot.

The foot is an incredibly complex structure. To grow and develop correctly, all of the bones of the foot must move normally in relationship to each other. If the movement between two bones is abnormal, or non-existent, that changes how the bones grow after birth. If untreated, over time this leads to more deformity in the foot.

Symptoms

What does this problem feel like?

The primary problem of a clubfoot is that the foot can not be placed flat on the ground so that the child can walk on the sole of the foot. The condition is not painful to the child. In developing countries where there is sometimes no treatment for conditions such as this, adults with clubfoot walk on the side of their foot. They do not walk normally. The foot is extremely deformed with calluses where the foot contacts the ground. Shoe wear is very difficult to fit and usually must be custom made. Normal shoes will not fit.

Eventually the abnormality can lead to wear and tear arthritis in the abnormal joints, pain, and decreased ability to walk.

Diagnosis

How do doctors identify the problem?

The history and physical examination make the diagnosis of clubfoot. The appearance alone is usually enough to make the diagnosis. A complete examination of the newborn is critical, since there are other genetic conditions that are associated with clubfeet. Your pediatrician will perform a complete evaluation to make sure there are no other congenital conditions to be concerned with.

A clubfoot can be diagnosed before birth using ultrasound. Many women have routine ultrasound test to assess the status of the pregnancy. When a clubfoot is found, there is no treatment currently available before birth. Because clubfoot is associated with other serious congenital and genetic abnormalities, the obstetrician may recommend amniocentesis to look for genetic problems in the fetus. An amniocentesis is a test where a needle is inserted into the uterus and a small amount of fluid removed. This
fluid is sent to the lab for analysis. If evidence for serious genetic or congenital anomalies are found, then the option of terminating the pregnancy exists.

X-rays are helpful in determining the severity of the condition. This information may become important later in trying to decide what treatment is best to recommend. Usually, no other imaging studies are needed.

Treatment

What treatment options are available?

Treatment for clubfoot usually starts at birth. Treatment in the majority of infants will require both non-surgical treatment and surgery.

Nonsurgical Treatment

The most commonly used treatment in the newborn and infant is manipulation and casting. This is started as soon as possible. The foot is manipulated to stretch and loosen the tight structures. The foot is then placed in a cast to hold it in a corrected position. This is repeated every one or two weeks until the deformity is corrected or surgery is performed.

As any parent knows, the newborn grows rapidly after birth. The technique of manipulation and casting the foot is used to guide the growth of the foot towards the normal alignment. Without this guidance, the foot will remain deformed and may actually get worse. The greatest chance for correction of deformity occurs early in life when there is so much growth occurring.

There have been many different techniques proposed for the way the foot is manipulated and the way the casts are applied. Treatment of the infant with clubfoot is definitely one of the arts of medicine. Successful treatment requires patience and attention to detail.

The success of treatment of clubfoot by manipulation and casting alone varies greatly. The majority of infants will eventually require surgery. But, the manipulation and casting begins the process of guiding the foot towards a more normal form. In the infant that eventually needs surgery, the manipulation and casting are still required to obtain as much correction as possible prior to the surgery.

Surgery

When it is clear that manipulation and casting alone will not result in success, surgery will be recommended by your surgeon. The main question is when to perform the surgery. The earlier the surgery is performed, the more growth remains in the foot. The more growth remaining, the more the deformity can be corrected. But, a smaller foot is much harder to operate on effectively. The surgery is much harder and the risk of damage to the nerves, blood vessels, and bones is much higher.

Most surgeons recommend waiting until the foot is about eight cm (three inches) long. This usually occurs when the infant is about nine months old. Most surgeons agree that it is ideal to have the surgery over and healed before the infant starts to try and walk. Surgery performed at nine months usually will accomplish this as well.

The surgical procedure is tedious and complex, but the goals are always the same. Your surgeon will find and cut all the ligaments that are too tight. Ligaments are the connective tissues that connect bones to bones. When they are cut, they eventually heal back with scar tissue. In the growing infant, this scar tissue will grow back to form new ligaments that are not so tight.

Once the ligaments have been loosened, your surgeon can align the bones of the foot as normal as possible. Metals pins are commonly used to hold the bones in the proper alignment. These metals pins stick out through the skin and are removed three to six weeks after the surgery is completed.

Rehabilitation

What should be expected from treatment?

Nonsurgical Treatment

All treatment, both surgical or non-surgical, is designed to give the child a foot that can be placed flat on the floor. The foot will never be normal, but treatment can provide a very functional foot that can be used for walking without pain. If surgery is required, the goal is to have the foot healed by the time the child is starting to walk.

After Surgery

After surgery for clubfoot, a large bandage is applied to the foot. Some type of cast or brace may also be used. The child will probably need to wear some type of brace for several months – and maybe even years after the surgery – but ideally, the treatment should not interfere with the normal developmental milestones. Once the surgery is over, mother nature takes over. Weightbearing will help guide the growth in the foot towards a more functional orientation where the sole of the foot can be placed flat on the floor.

Complications

What can go wrong?

As with any treatment, complications can result from both conservative and surgical treatment of clubfoot. Failure of manipulation and casting to result in a successful outcome is not a complication. The majority of patients will not be treated successfully with non-surgical treatment alone.

Several complications are possible both during and after surgery. Wound problems may occur after surgery due to abnormal swelling or pressure from the cast. When the foot is markedly deformed, correction of the deformity may stretch the skin so tight that the blood supply is compromised. This may result in a small section of the skin actually dying. This normally heals with time and only rarely does this require a skin graft.

Infection can occur following any type of surgery. A wound infection can occur after clubfoot surgery. This may require additional surgery to drain the infection and antibiotics to treat the infection.

The infant foot is very small. The structures are very difficult to see even using magnifying glasses. Blood vessels and nerves may be damaged or cut during the operation. The bones of the infant foot are mostly made of cartilage. This material can be damaged, resulting in deformities of these bones. This damage usually corrects itself with growth.

Up to half of all patients undergoing clubfoot surgery will require at least one additional surgical procedure later in life.

A Patient’s Guide to Scoliosis

Introduction

Scoliosis is a deformity in the spine that causes an abnormal C-shaped (one curve) or S-shaped curvature (two curves). The spine is not straight but curves to one or both sides. There are three types of scoliosis depending on when it develops. Infantile occurs from birth to three years of age. Juvenile scoliosis develops between four and nine years of age. Adolescent presents between 10 years and when growth is complete. Adults can have residuals of childhood scoliosis.

This guide will help you understand

• what parts of the spine are involved
• what causes the condition
• what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column is the body’s main upright support.

When viewed from the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The thoracic spine curves outward. The low back, also called the lumbar spine, curves slightly inward. When viewed from the back, the vertebrae form a straight column keeping the head centered over the body.

Each vertebra is made of the same parts. The main section of each vertebra is formed by a round block of bone, called the vertebral body. Each vertebra increases slightly in size from the neck down. The increased size helps balance and support the larger muscles that connect to the lower parts of the spine.

Causes

How does this problem develop?

A specific cause of scoliosis is unknown or idiopathic. Idiopathic scoliosis is the most common type and affects about two to three per cent of the population. It tends to run in families and is more common in girls than in boys. Most often it develops in middle or late childhood during a rapid growth spurt.

The condition can also be congenital (present at birth) or it may develop as a result of another neurological condition such as cerebral palsy, spina bifida, or spinal muscular atrophy.

Any part of the spine can be affected by scoliosis including the cervical, thoracic, or lumbar vertebrae. Most often the thoracic and lumbar spine are affected. The vertebrae curve to one side and may rotate, which makes the waist, hips, or shoulders appear uneven.

At first, a C-shaped curve may develop causing the shoulders and hips to tilt down on one side. In an effort to keep the head in the middle, the spine may compensate by curving the lower part of the spine in the other direction, forming an S-curve.

The most common curve in infantile idiopathic scoliosis is in the low thoracic region. Single curves are almost always in the thoracic region with variable amounts of vertebral rotation. As the vertebrae rotate, the attached ribs shift causing a noticeable rib bump or hump on one side of the spine. Most of the curves (85 per cent) are to the right when they occur after the age of two years. The curve doesn’t always attempt to correct but when it does, a double (S-shaped) curve develops.

Infantile idiopathic scoliosis with the thoracic curve to the left occurs most often in boys observed before one year of age. This type of scoliosis tends to resolve on its own without treatment. It does not get worse with puberty during growth spurts.

Juvenile idiopathic scoliosis develops in boys at an earlier age than in girls. Boys also mature skeletally at a later age. This means there is a greater risk of curve progression in boys with this type of scoliosis compared to girls.

The typical curve patterns of juvenile and adolescent idiopathic scoliosis are similar with right thoracic and double major curves present most often.

Symptoms

What does this condition feel like?

Scoliosis is a painless condition. You may not feel any change in the spine but instead notice that your clothes don’t fit quite right. As the spine starts to curve, the body adjusts to keep the head in the middle over the pelvis.

As a result, the shoulders and hips may be uneven, causing one shirtsleeve or pant leg to seem shorter than the other. Often there is rotation of the vertebrae causing an uneven waist so that a pair of pants or skirt twists to one side.

The most common signs of scoliosis are:

• uneven shoulders
• uneven hips
• uneven breasts (girls) or nipples (boys)
• prominent or winging shoulder blades
• leaning to one side
• bump or rib hump on one side of the spine, most noticeable when bending forward at
  the waist

The presence of one or more of these signs suggests a need for a medical exam by your pediatrician, primary care physician, or orthopedic surgeon. Severe scoliosis can cause pressure on the heart, lungs, liver, and other internal organs. Early diagnosis and treatment are important to prevent problems with breathing and cardiovascular function.

Diagnosis

How do doctors identify the problem?

Many children are examined during a school screening program by the school nurse or physical therapist. The Adams forward bend test is used to look for prominence of the ribs or changes in the spine. From a standing position, the child slowly bends forward at the waist as if diving into a pool. Anyone with signs of scoliosis is referred to his or her family doctor.

Your doctor will examine the spine and look for any possible causes of scoliosis.

X-rays may be taken to look for any tilt or rotation of the vertebrae causing a curvature. X-rays are not immediately ordered for everyone in order to avoid needless exposure of growing children to radiation. Signs of asymmetry (unevenness) and other changes observed with scoliosis during the exam usually result in x-rays being taken. An MRI may be ordered if the physician suspects an infection, tumor, or problems in the nervous system.

When an x-ray is warranted, your doctor will use a technique called the Cobb method to measure the location and degree of each curve. Curves must be more than 10-degrees to be considered scoliotic.

X-rays are also used to identify skeletal maturation or bone growth. The Risser sign is applied to the x-rays of the pelvic bone to judge whether or not the child has stopped growing. The amount of spinal curvature is compared with the stage of growth activity to help guide treatment.

Treatment

What treatment options are available?

There are several ways to treat scoliosis in children: do nothing (observation), exercise, bracing, and surgery. Studies show that 90 per cent of infantile scoliosis resolve or go away on their own. In such cases, we say the child will “grow out of it.”

The optimal treatment depends on the degree or severity of the scoliosis. Examination and x-rays taken over a period of time will help show if the scoliosis is staying the same or progressing (getting worse). Curves 45 degrees or less are more likely to be treated conservatively with exercises or bracing. Curves that are changing rapidly or greater than 45 degrees may require surgery.

Nonsurgical Treatment

Selecting treatment options for the child with scoliosis involves several factors; the age of the child, the degree of the spinal curve, the skeletal maturity of the spine, and the preferences of the patient and family.

Treatment may be nothing more than observation especially if the curve is 30-degrees or less in a child who is no longer growing. If the curve is progressing and the child is growing rapidly, or if the curve is 30-degrees or more, the child is referred to an orthopedic surgeon for exercise and/or bracing.

Exercise

For many years,exercise was not considered effective in stopping or changing spinal curvatures from scoliosis. But recently, researchers have taken a closer look at exercise. They found that in previous studies, most of the children didn’t do the exercises. Or if they did, they only did them occasionally. Unless the exercise program was designed to prepare for a sports activity, compliance was very low.

Improved technology and the ability to assess muscle function have changed the picture. We now know that there is asymmetry in muscle function for everyone with scoliosis. More specifically, there is an uneven strength in trunk rotation.

The former exercise programs of stretching and general strengthening may have been the wrong approach. Studies using exercise equipment that can measure muscle function show that progressive resistive exercises (PREs) are effective for curves less than 45 degrees.

Bracing

The best bracing results occur in children with slowly progressing curvatures that are detected and treated early. A major thoracic curve before the age of five is more likely to result in other complications. Bracing is less likely to stop curves larger than 40-degrees. Bracing is more effective for single curves in the thoracic spine than for double curves. Most braces are worn over a tightly fitting cotton T-shirt but under the clothes. While you wear the brace, physical activity is restricted.

Two braces used most often for this condition are the Milwaukee brace and the Boston brace. The Boston brace is also called a thoracolumbosacral-orthosis or TLSO. Studies show that bracing controls the curve and prevents progression. In most cases, bracing does not correct the curve; it just keeps it from getting worse.

The Milwaukee Brace is a corrective brace used with children and adolescents who have scoliosis. It has a pelvic girdle, two posterior uprights, one anterior upright, and a ring around the base of the skull that also supports the lower jaw. Originally made of leather and metal, it has been revised now and is constructed out of rigid plastic with metal uprights. Pads with straps attached to the frame are used to apply corrective forces.

The Boston Brace used for the treatment of scoliosis is very similar to the Milwaukee orthosis. The Boston brace does not extend up as high into the thoracic spine. It does not have the vertical bar in front of the chest or the cervical ring. The Boston brace works best for children who have immature spines or moderate scoliotic curves in the lower thoracic and upper lumbar spines.

Surgery

If bracing doesn’t stop the progression of scoliosis, then surgery may be needed. Metal rods or screws are used to help straighten and hold the spine in a corrected position. The vertebra are fused (joined together) to help correct the curvature. Only a small number of people with scoliosis require surgical intervention. New surgical techniques are designed to give maximum correction with a minimum of incisions and scarring.

Surgery for idiopathic scoliosis is generally suggested when the curve is 50 degrees or more and bracing fails. Surgery is recommended with two goals in mind; 1) prevent progression of the spine deformity, and 2) to lessen the existing spine deformity. The surgical procedure most often used to correct idiopathic adolescent scoliosis is a posterior (through the back) fusion with instrumentation (rods, hooks, screws and wires) and bone grafting. Sometimes if the curve is severe, additional surgery may be required through the front of the body.

Scoliosis surgery is one of the most complicated orthopedic surgical procedures performed on children. The operation will take several hours.

Rehabilitation

What should I expect during and after treatment?

Nonsurgical Rehabilitation

Exercise

Exercises to improve trunk rotation strength must be done on the correct equipment. It is important to use equipment that can isolate and strengthen torso rotation. The exercise will equalize strength from one side to the other. You will probably start at one-fourth your body weight. Resistance can be increased five per cent when you can do 20 repetitions in each direction. A physical therapist will help you set up this program. It should be done twice a week until the curve stabilizes. Some adults find this exercise program helpful in controlling pain.

Bracing

While in your brace, you won’t be able to participate in sports that require flexibility such as gymnastics or tumbling. Physical contact sports such as football, hockey, or soccer are also prohibited while wearing the brace. Some children are allowed to remove the brace for two to three hours each day and participate in sports with their physician’s approval during that time.

Bracing is generally used for at least two years or until there is no sign of further change. Your surgeon will follow you at regular intervals. Follow-up visits and repeated x-rays are needed more often for the child who has a rapidly progressing curve or who is in a growth spurt.

After Surgery

Post-operative patients are usually discharged from hospital within five to seven days. They are able to progress quickly, returning to routine daily activities, including returning to school. Your surgeon will discuss your activity restrictions.

A Patient’s Guide to Panner’s Disease of the Elbow

Introduction

Panner’s disease affects the dominant elbow of children, mainly boys, between the ages of five and 10. For unknown reasons, normal growth in the outer edge of the elbow is disrupted, which causes the small area of bone to flatten out. The child begins to complain of pain during activity. The pain eases with rest. Over a period of one to two years, the bone slowly rebuilds itself. During this time, symptoms gradually disappear, although the elbow may never fully straighten out.

Panner’s disease is similar to osteochondritis dissecans, a condition that occurs after the skeleton is done growing. Both conditions are most common among certain young athletes, especially baseball pitchers and gymnasts.

This guide will help you understand

• what part of the elbow is involved
• how this problem develops
• what treatment options are available

Anatomy

What part of the elbow is affected?

The elbow is the connection of the humerus (upper arm bone) and the two bones of the forearm (the ulna and the radius). The radius starts on the outer edge of the elbow and runs down the forearm to the thumb-side of the wrist.

The joint where the humerus meets the radius is called the humeroradial joint. This joint is formed by a knob and a shallow cup. The knob on the end of the humerus is called the capitellum. The capitellum fits into the cup-shaped end of the radius, also called the head of the radius.

When the head of the radius spins on the capitellum, the forearm rotates so that the palm faces up toward the ceiling (supination) or down toward the floor (pronation). The joint also hinges as the elbow bends and straightens.

Panner’s disease affects the developing bone within the capitellum of the humerus.

Related Document: A Patient’s Guide to Elbow Anatomy

Related Document: A Patient’s Guide to Adolescent Osteochondritis Dissecans of the Elbow

Causes

How does this problem develop?

This unique condition is part of a category of bone development disorders known as the osteochondroses. (Osteo means bone, and chondro means cartilage.) In normal development, specialized bone growth centers (called growth plates) change over time from cartilage to bone. The cartilage cells within the growth plates actually change into bone cells. As this occurs, the growth centers expand and unite. This is how bones grow in length and width. Bone growth centers are located throughout the body. Panner’s disease involves disruption of the growth plate of the capitellum.

Scientists are not exactly sure how the growth plate within the capitellum is disrupted. Some think the problem is hereditary (handed down in the genes). Others believe that small strains add up over time, such as from repeatedly throwing a ball.

Another possible cause is that the tiny blood supply to the humeroradial joint is somehow blocked. During development, only the ends of a few small blood vessels enter the back of the humeroradial joint. If this scarce blood supply is damaged, there is no back-up. The cells within the growth plate of the capitellum die, causing the knob of bone to collapse.

Regardless of how the problem starts, the next stage in Panner’s disease is cell death within the growth plate of the capitellum. The death of these cells comes from avascular necrosis. Avascular means without blood, and necrosis means death.) When necrosis occurs, the bony knob of the capitellum begins to flatten out. It flattens out because the newly formed bone begins to be absorbed by the body.

Then, over a period of one to two years, new blood vessels enter the area, and new cells begin to form within the growth plate. These cells help gradually rebuild the original shape of the capitellum.

Panner’s disease affects the growth plate of the capitellum in children under the age of 11. As mentioned earlier, a separate but similar condition that affects the capitellum of older children and adolescents. This separate condition is called osteochondritis dissecans (OCD). In older children, OCD of the capitellum doesn’t involve the growth plate. Instead, the problem affects the smooth covering of the capitellum called the articular cartilage. OCD also affects the bone just below the articular cartilage, called the subchondral bone.

Symptoms

What does this problem feel like?

Symptoms usually come on without notice. The child rarely remembers a specific event or injury to explain the symptoms.

The child may report tenderness on the outside edge of the elbow, near the capitellum. Pain generally worsens with activity and eases with rest. The elbow often feels stiff, and the child is unable to completely straighten out the elbow.

Symptoms from Panner’s disease generally go away gradually as the bones mature, usually over a period of one to two years. However, the condition may leave the child unable to fully straighten the elbow.

Diagnosis

How do doctors identify the problem?

The doctor will want to know the child’s age, activity level, and which arm is dominant. In the physical exam, the sore elbow and healthy elbow will be compared. The doctor checks for tenderness by pressing on and around the elbow. The amount of movement in each elbow is measured. The doctor checks for pain when the forearm is rotated and when the elbow is bent and straightened.

X-rays are needed to confirm the diagnosis. X-rays let doctors see the shape of the capitellum. An elbow X-ray may show an irregular surface on the capitellum. The entire growth plate may appear fragmented and transparent. Transparent areas mean that the bone that makes up the capitellum has been absorbed. The capitellum may appear flattened out, which means that the bone has collapsed. Within a period of one to two years, an X-ray comparison will usually show that the capitellum has completely grown back to its normal shape in patients with Panner’s disease.

Occasionally, a magnetic resonance imaging (MRI) scan may show more detail. The MRI can give a better view of bone irregularities. The MRI can also detect swelling.

Treatment

What treatment options are available?

Nonsurgical Treatment

In some cases of Panner’s disease, children may need to stop sports activities for a short time. This gets the pain and inflammation under control. Usually children don’t need to avoid sports for long.

Sometimes, the passing of time may be all that is needed. It takes one to two years for the growth plate that makes up the capitellum to grow into solid bone. At this point, pain and symptoms usually go away completely.

The doctor may prescribe anti-inflammatory medicine to help reduce pain and swelling. Physical therapy treatment may also be recommended.

In severe cases, when regular treatment is not effective, doctors may recommend that the child wear a long-arm splint or cast for three to four weeks. The goal is to stop the elbow from moving so that inflammation and pain go away.

Surgery

The symptoms of Panner’s disease usually disappear when the growth plate in the capitellum finishes growing. Surgery is not generally an option for Panner’s disease.

Rehabilitation

What should I expect from treatment?

Nonsurgical Rehabilitation

In nonsurgical rehabilitation, the goal is to reduce pain and inflammation. Nonsurgical treatment can help ease symptoms of Panner’s disease. Some doctors have their patients work with a physical therapist. Treatments such as heat, ice, and ultrasound may be used to ease pain and swelling.

Therapists also work with young athletes to help them improve their form and reduce strain on the elbow during sports. When symptoms are especially bad, patients may need to avoid activities that make their pain worse, including sports.

Symptoms from Panner’s disease tend to go away slowly over time. This means that nonsurgical rehabilitation doesn’t really cure the problem. Treatments can only help by giving short-term relief from symptoms.

A Patient’s Guide to Adolescent Osteochondritis Dissecans of the Elbow

Introduction

Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to an odd and troubling elbow condition. The forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. This condition is called osteochondritis dissecans (OCD).

In the past, this condition was called Little Leaguer’s elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, primarily gymnastics and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes.

This guide will help you understand

• how this problem develops
• how doctors identify the problem
• what treatment options are available

Anatomy

What part of the elbow does this problem affect?

The elbow is the connection of the upper arm bone (the humerus) and the two bones of the forearm (the ulna and the radius). The radius runs from the outer edge of the elbow down the forearm to the thumb-side of the wrist.

The joint where the humerus meets the radius is called the humeroradial joint. This joint is formed by a knob and a shallow cup. The knob on the end of the humerus is called the capitellum. The capitellum fits into the cup-shaped end of the radius. This cup is called the head of the radius.

When the head of the radius spins on the capitellum, the forearm rotates so that the palm faces up toward the ceiling (supination) or down toward the floor (pronation). The joint also hinges as the elbow bends and straightens.

In the elbow joint, the ends of the bones are covered with articular cartilage. Articular cartilage is a slick, smooth material. It protects the bone ends from friction when they rub together as the elbow moves. Articular cartilage is soft enough to act as a shock absorber. It is also tough enough to last a lifetime, if it is not injured.

Elbow OCD affects the articular cartilage in the capitellum. It also affects the layer of bone just below the cartilage, which is called the subchondral bone. In advanced stages of OCD, the upper end of the radius, particularly the head of the radius, is also involved.

Related Document: A Patient’s Guide to Elbow Anatomy

Causes

How does this problem develop?

The cause of elbow OCD in adolescents is unknown. Scientists think that genetics is one possibility. This means that certain families are more likely to develop OCD. The condition often occurs among relatives, and it is sometimes seen in several generations of the same family.

Another possible cause is that the tiny blood supply to the humeroradial joint is somehow blocked. Only the ends of a few small blood vessels enter the back of the humeroradial joint. If this scarce blood supply is damaged, there is no back-up.

Although the exact cause of elbow OCD in adolescents is not known, most experts agree that overuse of the elbow plays a major role in its development.

Pitching can lead to overuse strain and, in turn, elbow OCD. Throwing puts a lot of force on the elbow joint. When the throwing action is repeated over and over again, it can damage the immature joint surface of an adolescent’s elbow. After winding up and cocking the arm back, the pitcher must quickly accelerate the arm to gain ball speed. Then, almost immediately, the pitcher has to slow the arm down and follow through. The pitcher may angle the elbow outward slightly during the acceleration phase to get more ball speed. This action jams the head of the radius against the capitellum. During the slowing and follow-through after a pitch, the forearm is fully pronated. This action puts extra pressure on the humeroradial joint.

Hitting a ball with a racket can strain the elbow just like pitching a baseball. The player may angle the racket and elbow out slightly to gain ball speed. Hitting the ball with the arm and racket in this position jams the radial head against the capitellum, similar to what can happen during pitching motions. Gymnasts are also at risk for high forces on the capitellum when they repeatedly do maneuvers on their hands with their elbows locked out straight.

These actions done over and over again can eventually cause an overuse injury to the humeroradial joint of adolescent athletes. Adolescents’ articular cartilage is newly formed and so can’t handle these types of forces. The subchondral bone (under the articular cartilage) in the capitellum takes the brunt of the stress. A portion of the bone may eventually weaken, and possibly even crack. When the bone is damaged, the tiny blood supply going to the area is somehow blocked. Without blood supply, the small area of bone dies. This type of cell death is called avascular necrosis. (Avascular means without blood, and necrosis means death.)

The crack may begin to separate. Eventually, the small piece of dead bone may break loose. This produces a separation between the articular cartilage and the subchondral bone, which is the condition called OCD. If the dead piece of bone comes completely detached, it becomes a loose body. The loose body is free to float around inside the joint.

Another condition, called Panner’s disease, also affects the capitellum in children. It is not the same as elbow OCD in adolescents. Panner’s disease affects the bone growth center (the growth plate) of the capitellum. Panner’s disease generally occurs in kids (mainly boys) between five and 10. Panner’s disease is a childhood condition that involves the entire capitellum and usually heals completely when bone growth is complete.

Elbow OCD in adolescents is different. It occurs after growth in the capitellum has stopped, which is usually between the ages of 12 and 15. Elbow OCD in adolescents affects only a portion of the capitellum, generally along the inside and lower edges of the bony knob. Unless elbow OCD is diagnosed and treated early, the results are not as good as the results for Panner’s disease. The adolescent with elbow OCD sometimes ends up with elbow arthritis by early adulthood.

Related Document: A Patient’s Guide to Panner’s Disease of the Elbow

Symptoms

What does this problem feel like?

Only about 20 percent of kids with elbow OCD remember hurting their elbow. The remainder usually develop symptoms over time, which is typical with overuse problems.

In the absence of a specific injury, the athlete may at first feel bothersome elbow discomfort only while playing sports. The soreness generally goes away quickly when the elbow is rested. Over time, however, the elbow pain worsens, is hard to pinpoint, and may linger after using the arm. The elbow feel may feel stiff, and it may not completely straighten out.

In advanced cases of elbow OCD, the patient may notice that the joint grinds (called crepitus). The elbow may catch, or even lock up occasionally. These sensations may mean that a loose body is floating around inside the elbow joint. The joint may also feel warm and swollen, and the muscles around the elbow may appear to have shrunk (atrophied).

Bad cases of elbow OCD, and those that are not caught and treated early, tend to create bigger problems later in life. The joint may become arthritic early in adulthood. As a result, the patient may always have greater difficulty using the problem elbow.

Related Document: A Patient’s Guide to Osteoarthritis of the Elbow

Diagnosis

How do doctors identify the problem?

The doctor begins by asking questions about the patient’s age and sports participation. In the physical exam, the sore elbow and healthy elbow will be compared. The doctor checks for tenderness by pressing on and around the elbow. The amount of movement in each elbow is measured. The doctor checks for pain and crepitus when the forearm is rotated and when the elbow is bent and straightened.

X-rays are needed to confirm the diagnosis. A front and a side view of the elbow are generally the most helpful. Early in the course of the problem, the X-rays may appear normal.

As the condition worsens, the X-ray image may show changes in the capitellum. The normal shape of the bony knob may appear irregular. In bad cases of elbow OCD, the capitellum might even look like it has flattened out, suggesting that the bone has collapsed. The X-ray could show a crack in the capitellum or even a loose body. In the late stages of elbow OCD, the radial head may appear enlarged, and the humeroradial joint not be aligned as it normally should. These findings suggest early arthritis.

A magnetic resonance imaging (MRI) scan may show more detail. The MRI can give an idea of the size of the affected area. It can show bone irregularities and also help detect swelling. Doctors may repeat the MRI test at various times to see if the area is healing.

The doctor might order a computed tomography (CT) scan. The CT scan helps confirm the diagnosis. A CT scan clearly shows bone tissue. The doctor can compare CT scans over a period of time to monitor changes in the bones of the elbow.

Treatment

What treatment options are available?

Nonsurgical Treatment

At first, athletes may need to stop their usual sport activities. This gives the elbow a rest so that healing can begin.

The doctor may prescribe anti-inflammatory medicine to help reduce pain and swelling. Patients are shown how to apply ice to the area. When sport activities are resumed, ice treatments should be used after activity. Ice treatments are simple to do. Place a wet towel on the elbow. Then lay an ice pack or bag of ice over the elbow for 10 to 15 minutes.

The doctor may also suggest working with a physical therapist. Physical therapists might use ice, heat, or ultrasound to control inflammation and pain. As symptoms ease, the physical therapist works on flexibility, strength, and muscle balance in the elbow.

Therapists also work with athletes to help them improve their form in ways that reduce strain on the elbow during sports. Pitchers and racket-sport players might benefit from keeping the elbow aligned correctly, instead of angled outward, during the acceleration phase of the pitch or swing.

When symptoms are especially bad, athletes may need to make changes that require less overhand activity. For example, pitchers could shift to playing first base. Gymnasts could focus on maneuvers that don’t stress the sore elbow. However, if the piece of bone is loose but still attached, all sports activities must be stopped. Sports can begin again when the patient has no pain and shows full elbow movement.

In severe cases, patients may need to wear a sling or a long-arm splint for several weeks before starting elbow motion exercises. As symptoms ease and elbow movement improves, a guided program of strengthening and sport training begins.

Surgery

Patients may need surgery if the elbow locks up, if it won’t straighten out, or if pain continues even after a period of rest and physical therapy. Unfortunately, surgery isn’t 100 percent successful. The various procedures don’t necessarily improve athletes’ chances for returning to high-level competition. Patients often lose the ability to fully straighten the elbow. And even after surgery, they are prone to elbow arthritis in early adulthood.

Surgical procedures to treat elbow OCD are done from the outside edge of the elbow. The joint may be opened up to allow the surgeon to see and work on the joint. Opening up the joint is called arthrotomy. Many surgeons prefer instead to use an arthroscope. An arthroscope is a slender instrument with a TV camera on the end. The arthroscope can be inserted into a very small incision. It lets the surgeon see the area where he or she is working on a TV screen.

Debridement

Debridement is the most common procedure used for elbow OCD. It is especially helpful when the damaged part of the capitellum is loose but still attached. The surgeon uses a small shaver to clear away (debride) irritated tissue from the area. All the dead tissue is shaved away until the bone bleeds.

This allows the defect to fill with scar tissue. Often, surgeons use a small instrument to poke holes through the damaged area and into the healthy bone just below. Bleeding from the holes promotes healing. The surgeon looks for and removes any loose fragments of bone.

Pinning

If the section of bone has completely detached from the capitellum, the surgeon may surgically pin the bone back in place. The spot where the bone detached is prepared. As in debridement, the bone tissue is shaved until it bleeds. Then the surgeon attempts to replace the loose piece of bone exactly in its original position. Small lengths of surgical wire are inserted through the bone fragment and into the main bone. The wires hold the piece of bone in place so that it can heal. The wires are usually left in place and not removed at a later date.

Graft Method

Damage to a small area of the capitellum may be replaced with a graft (replacement tissue). The idea is to fill in the spot in order to reshape the knob of the capitellum. By using a piece of living tissue for the graft, it is hoped that the graft will restore the normal function of the original articular cartilage. The results of this procedure are not always optimal. The goal is that, by reshaping the capitellum, the alignment of the humeroradial joint will be improved. When it works, the joint has a better chance of lasting longer before becoming arthritic.

This procedure uses an autograft, a graft of tissue from the patient’s own body. The surgeon takes a small piece of bone and cartilage from a nearby area and puts it in the damaged area on the capitellum. The biggest challenge is getting the surface of the graft to match the original shape of the capitellum.

Rehabilitation

What can be expected from treatment?

Nonsurgical Rehabilitation

In nonsurgical rehabilitation, the goal is to calm pain and inflammation and to protect the elbow from further harm. The doctor may prescribe anti-inflammatory medicine to help reduce pain and swelling.

The elbow may need to be rested. When symptoms are especially bad, patients may need to avoid activities that make their pain worse, including sports. Even after symptoms ease up, activity may need to be restricted for another six to eight weeks.

Some doctors have their patients work with a physical therapist. Treatments such as heat, ice, and ultrasound may be used to ease pain and swelling. Therapists also work with young athletes to help them improve their form and reduce strain on the elbow during sports.

When the elbow starts to feel better, exercises are begun to get the elbow moving. At first, the movements are done passively, meaning that the therapist moves the arm. This is followed with active motion exercise, which means the patient’s muscles help do the work of moving the arm. As elbow motion and strength improve, patients progress in more advanced strengthening exercises.

After Surgery

A bandage or dressing is worn for a week following the procedure. The stitches are generally removed in 10 to 14 days. However, if the surgeon used sutures that dissolve, patients don’t need to have the stitches taken out.

Patients are shown ways to protect the elbow after surgery. Although elbow motions are avoided early on, patients are shown ways to keep motion in their shoulder, wrist, and hand.

The surgeon may have the patient take part in formal physical therapy a few weeks after surgery. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery.

Exercises are chosen to help improve elbow motion and to get the muscles toned and active again. At first, the elbow is exercised in positions and movements that don’t strain the healing cartilage. As the program evolves, more challenging exercises are chosen to safely advance the elbow’s strength and function.

Most patients will need to modify their activities after surgery. Most pitchers are unable to throw hard and without pain afterward. In general, most athletes with elbow OCD need to stop playing high-level sports due to lingering elbow pain and reduced elbow motion.

If symptoms come back again, patients must modify their activities until symptoms subside. They’ll need to avoid heavy sports activity until symptoms go away and they are able to safely begin exercising the elbow again.

A Patient’s Guide to Sever’s Syndrome

Introduction

Sever’s syndrome is a painful heel condition that affects growing adolescents between the ages of nine and 14. In this condition, the growing part of the heelbone grows faster than the tendon that connects on the back of the heel. This tightens up the tendon and creates tension where it attaches to the heel. Eventually, the tension causes the area to become inflamed and painful. Fortunately, the condition is not serious. It is usually only temporary.

Youth who play running and jumping sports are most prone to this problem. Sever’s syndrome used to happen mostly in boys. But with more girls playing sports, boys and girls are now affected equally. Both heels hurt in more than half the cases.

This guide will help you understand

• what part of the heel is involved
• what causes the condition
• what treatment options are available

Anatomy

What part of the heel is affected?

Sever’s syndrome affects the bone growth center in the back of the heelbone (the calcaneus). The Achilles tendon connects the calf muscles in the back of the lower leg to the back of the calcaneus. (Tendons attach muscles to bones.)

Related Document: A Patient’s Guide to Foot Anatomy

Causes

How does this problem develop?

This unique condition is part of a category of bone development disorders known as osteochondroses. (Osteo means bone, and chondro means cartilage.) In normal development, specialized bone growth centers (called growth plates) change over time from cartilage to bone. The growth plates expand and unite. This is how bones grow in length and width. Bone growth centers are located throughout the body.

As the bones of the leg begin to grow longer, they sometimes grow at a faster pace than the Achilles tendon. The Achilles tendon is then too short. It begins to put tension on the back of the heel. When this happens in kids who are active in running and jumping sports, pain occurs where the Achilles tendon attaches to the heel.

Other factors have a role in the development of Sever’s syndrome. Kids with tight hamstring and calf muscles seem to have a greater risk for the condition. The problem is compounded when they play sports on hard surfaces, such as playing soccer on hard outdoor fields. The constant impact can disrupt the bone growth centers in the back of the heel, causing inflammation and pain.

Symptoms

What does this problem feel like?

The back of the heel may appear red and swollen. It will probably be tender to the touch. Squeezing the heel is painful. The heel tends to hurt during activity and feel better with rest.

The heel and foot may feel stiff, especially first thing in the morning. The calf muscles and Achilles tendon may also feel tight.

Diagnosis

How do doctors identify the problem?

The history and physical examination are usually enough to make the diagnosis of Sever’s syndrome. The doctor will need information about the age and activity level of the child. The doctor will press on and around the back of the heel and may even squeeze both sides of the heel to see if there is any tenderness. The doctor will compare both heels.

The doctor may also ask the patient to rise up on the toes. This makes the calf muscles work, which puts tension on the Achilles tendon. Pain during this test can help the doctor make the diagnosis of Sever’s syndrome.

X-rays aren’t that helpful in diagnosing Sever’s syndrome. The X-ray may appear to show small cracks within the bone at the back of the heel. However, even kids who have no pain at all may seem to have these cracks on X-rays. The cracks are the bone growth center and are normal. Doctors may order an X-ray anyway to make sure there are no other problems, such as a fracture.

Treatment

What treatment options are available?

Nonsurgical Treatment

In some cases of Sever’s syndrome, the patient may need to stop sports activities for a short period. This gets the pain and inflammation under control. Usually patients don’t need to avoid sports for a long time.

Sometimes, the passing of time may be all that is needed. It takes one to two years for the bone growth plates that make up the back of the heel to grow together and form one solid bone. At this point, pain and symptoms usually go away completely.

The doctor may prescribe anti-inflammatory medicine to help reduce pain and swelling. A small lift or pad placed under the sore heel may help, too. The lift angles the foot down slightly. This angle relaxes the Achilles tendon and reduces stress where the tendon attaches on the back of the heel.

The doctor may also suggest working with a physical therapist. Physical therapists might use ice, heat, or ultrasound to control inflammation and pain. As symptoms ease, the physical therapist works on flexibility, strength, and muscle balance in the leg. The therapist may also design special shoe inserts, called orthotics, to support the arch and take tension off the Achilles attachment. Taping the arch is an option when orthotics won’t work, such as in footwear used by gymnasts and ballet dancers.

Children with Sever’s syndrome should avoid running on hard surfaces. Running barefoot should be avoided. The impact worsens the pain and inflammation.

Cortisone injections are commonly used to control pain and inflammation in other types of injuries. However, a cortisone injection is usually not appropriate for this condition. Cortisone injections haven’t shown consistently good results for Sever’s syndrome. There is also a high risk that the cortisone will cause the Achilles tendon to rupture.

In severe cases, when other forms of treatment don’t give relief, doctors may recommend a walking cast for six to 12 weeks. The goal is to stop the foot from moving so that inflammation and pain go away.

Surgery

The symptoms of Sever’s syndrome usually disappear when the growth plates in the heel grow together. Surgery is not generally an option for Sever’s syndrome.

Rehabilitation

What should I expect from treatment?

Nonsurgical Rehabilitation

In nonsurgical rehabilitation, the goal is to reduce pain and inflammation. Nonsurgical treatment can help ease symptoms of Sever’s syndrome. Some doctors have their patients work with a physical therapist. Therapists also work on the possible causes of the problem. The major treatment for Sever’s syndrome is stretching exercises for the Achilles tendon. Ice is often applied after the stretching program for up to 20 minutes. The stretches and ice treatments reduce tension and inflammation.

It is also important to stretch the hamstring and quadriceps muscles. This can help reduce tension in the Achilles tendon where it attaches to the heel. Orthotics are sometimes issued to put the leg and foot in good alignment.

Therapists work with young athletes to help them improve their form and reduce strain on the heel during their sports. When symptoms are especially bad, patients may need to avoid activities that make their pain worse, including sports.

Symptoms from Sever’s syndrome tend to go away slowly over time. This means nonsurgical rehabilitation doesn’t really cure the problem. Treatments only help by giving short-term relief.

A Patient’s Guide to Jumper’s Knee in Children and Adolescents

Introduction

When a child or adolescent complains of pain and tenderness near the bottom of the kneecap, the problem might be from jumper’s knee. Kids in sports that require a lot of kicking, jumping, or running are affected most. Doing these actions over and over can lead to pain in the tendon that stretches over the front of the kneecap.

Sometimes the bone growth center at the bottom tip of the kneecap is affected. This condition is known as Sinding-Larsen-Johansson disorder. It is mostly likely to occur during growth spurts. Disruption within the developing bone in the bottom tip of the kneecap may produce pain and tenderness in the front of the knee. Fortunately, this condition is not serious. It is usually only temporary and will improve with age.

This guide will help you understand

• what part of the knee is involved
• what causes the condition
• what treatment options are available

Anatomy

What part of the knee is involved?

Jumper’s knee affects the patellar tendon. The patellar tendon connects the large and powerful quadriceps muscle in the front of the thigh to the tibia (shinbone). The patellar tendon wraps over the front of the patella (kneecap). The upper end of the patellar tendon connects to the bottom tip of the patella. This area is called the inferior pole of the patella. The lower end of the patellar tendon connects to a small bump of bone on the front surface of the tibia. This bump is called the tibial tuberosity.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

How does this problem develop?

Jumper’s knee is usually caused by overuse of the patellar tendon. Kids who play sports with lots of squatting and jumping seem to be most at risk. In order to squat and to land softly from a jump, the quadriceps muscle must work extra hard to slow the body down and protect the knee. It does this by lengthening as it works, which is called an eccentric contraction. This muscle action places unusually high tension on the patellar tendon. When squatting and jumping are done over and over, the repetitive stress on the tendon causes injury to the individual fibers of the tendon. The tendon becomes inflamed and painful. This is the condition called jumper’s knee.

Another possible cause of jumper’s knee is from abnormal alignment of the lower limbs. Kids who are knock-kneed or flat-footed seem to be most prone to the condition. These altered postures put a sharper angle between the quadriceps muscle and the patellar tendon. This angle is called the Q-angle. A large Q-angle means there is already more tension on the patellar tendon. The risk of developing jumper’s knee is thus higher. A large Q-angle also places abnormal tension on the bone growth plate of the inferior pole of the patella, increasing the risk for Sinding-Larsen-Johansson disorder. A high-riding patella, called patella alta, is also thought to contribute to development of jumper’s knee in children and adolescents.

Patellar tendon pain has a slightly different cause in an active child whose bones are not done growing. Increased tension in the tendon starts during growth spurts. The patellar tendon is unable to keep up with the growth of the lower leg. As a result, the tendon is too short. This causes the tendon to pull on the bottom tip of the kneecap. Heavy or repetitive sports activity stresses this area even more. Eventually the increased tension disrupts normal growth of the bottom tip of the patella. When this happens, the condition is known as Sinding-Larsen-Johansson disorder.

This unique condition is part of a category of bone development disorders known as the osteochondroses. (Osteo means bone, and chondro means cartilage.) In normal development, specialized (called growth plates) change over time from cartilage to bone. The growth plates expand and unite. This is how bones grow in length and width. Bone growth centers are located throughout the body.

Children with bone development disorders in one part of their body are likely to develop similar problems elsewhere. For example, children who have Sinding-Larsen-Johansson disorder also have a small chance of bone growth problems where the lower end of the patellar tendon attaches to the tibial tuberosity. This is known as an Osgood Schlatter lesion.

Related Document: A Patient’s Guide to Osgood Schlatter’s Lesion

Symptoms

What does this problem feel like?

Jumper’s knee commonly produces pain and tenderness directly over the patellar tendon, just below the kneecap. Sometimes there is a small amount of swelling. Kneeling on the sore knee usually hurts. Activities where the quadriceps muscle works eccentrically, such as squatting, jumping, and going down stairs, are often painful.

Kids with Sinding-Larsen-Johansson disorder may feel similar symptoms along the top of the kneecap, where the quadriceps muscle meets the patellar tendon. Sometimes they feel tightness in this area, especially when they try to fully bend the knee.

Diagnosis

How do doctors identify the problem?

The history and physical examination are usually enough to make the diagnosis of jumper’s knee. The doctor will need information about the child’s age and activity level. The doctor will press on and around the patella and patellar tendon to see if there is any tenderness. The doctor will compare the sore knee and the healthy knee. The doctor may also ask the patient to straighten the knee against resistance. This makes the quadriceps muscle work, putting tension on the patellar tendon. Pain during this test can help the doctor make the diagnosis of jumper’s knee.

If the doctor suspects problems with Sinding-Larsen-Johansson disorder, it is likely that an X-ray will be ordered. The X-ray is taken from the side of the knee. This view may show small fragments of bone where tension in the patellar tendon has disrupted the growth plate in the bottom tip of the patella. The X-ray may also show calcification or roughness around the bottom of the patella.

An X-ray will be needed if the kneecap is painful from trauma such as a fall. In this case, the X-ray will help the doctor see if a patellar fracture has occurred.

Occasionally, a magnetic resonance imaging (MRI) scan may show more detail. The MRI can give a better view of any calcification in the patellar tendon where it attaches on the bottom tip of the kneecap. The MRI can detect swelling. It can also show if injury or inflammation is present within the patellar tendon.

Treatment

What treatment options are available?

Nonsurgical Treatment

In some cases of jumper’s knee, the patient may need to stop sports activities for a short period. This gets the pain and inflammation under control. Usually patients don’t need to avoid sports for a long time.

When jumper’s knee is affecting a patient before the skeleton has stopped growing (Sinding-Larsen-Johansson disorder), the passing of time may be all that is needed. It takes one to two years for the bone growth plates that make up the inferior pole of the patella to grow together and form one solid bone. At this point, pain and symptoms usually go away completely.

To treat jumper’s knee, the doctor may prescribe anti-inflammatory medicine to help reduce swelling. A variety of knee straps and sleeves are available that may help keep pain to a minimum. The doctor may also suggest working with a physical therapist.

Physical therapy treatments might use ice, heat, or ultrasound to control inflammation and pain. As symptoms ease, the physical therapist works on flexibility, strength, and muscle balance in the knee. Posture exercises can help improve knee alignment. The therapist may also design special shoe inserts, called orthotics, to support flat feet or to correct knock-kneed posture.

Cortisone injections are commonly used to control pain and inflammation in other types of injuries. However, a cortisone injection is usually not appropriate for this condition. Cortisone injections haven’t shown consistently good results for jumper’s knee. There is also a high risk that the cortisone will cause the patellar tendon to rupture.

Surgery

Surgery is rarely needed for jumper’s knee. Surgery is really not even an option when symptoms are caused by Sinding-Larsen-Johansson disorder, unless bone growth is complete and symptoms have not gone away with nonsurgical treatment. Even then, surgery for Sinding-Larsen-Johansson disorder is unusual.

Surgery may be considered if the problem involves only the tendon (not the growth plate) and if symptoms have not gone away with other forms of treatment. In these cases, the surgeon may do an operation to strip away inflamed and damaged tissue on the surface of the patellar tendon.

In this procedure, a small incision is made down the front of the knee, below the patella. The skin is opened to expose the patellar tendon. Next, the surgeon carefully peels damaged tissue off the surface of the tendon. Three to five thin lengths of the tendon are removed. In some cases, small drill holes are made in the bottom tip of the patella. The drilling causes a small amount of bleeding, which signals the body to begin healing the area. Then the surgeon removes any damaged tissue nearby.

To complete the operation, the surgeon stitches up the skin and wraps the area with a bandage.

Rehabilitation

What can be expected from treatment?

Nonsurgical Rehabilitation

In nonsurgical rehabilitation, the goal is to reduce pain and inflammation. Nonsurgical treatment can help ease symptoms of jumper’s knee. Some doctors have their patients work with a physical therapist. Treatments such as heat, ice, and ultrasound may be used to ease pain and swelling.

Therapists also work on the possible causes of the problem. For example, flexibility exercises for the hamstring and quadriceps muscles can help reduce tension in the patellar tendon where it attaches to the patella. Orthotics are sometimes issued to put the leg and knee in good alignment. Strengthening exercises to improve muscle balance can help the kneecap to move correctly during activity. Therapists work with athletes to help them improve their form and reduce knee strain during their sports. When symptoms are especially bad, patients may need to avoid activities that make their pain worse, including sports.

When the problem involves the bone growth plate (Sinding-Larsen-Johannson disorder), the symptoms tend to go away slowly over time. This means nonsurgical rehabilitation probably won’t cure the problem. Treatments can only give short-term relief.

After Surgery

The surgeon may recommend wearing a hinged knee brace for a few weeks after surgery. The brace lets the knee bend, but it doesn’t let the quadriceps muscle fully straighten the knee. Crutches may be needed for a few days after the operation, until the patient can bear weight without pain or problems.

Patients need to check in with the surgeon 10 to 14 days after surgery. Stitches are taken out, and patients are encouraged to begin actively bending and straightening the knee.

The surgeon may recommend physical therapy after the operation. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. The physical therapist will choose exercises to help improve knee motion and to get the quadriceps muscles toned again.

Daily activities can be resumed gradually. Vigorous activities and exercise should be avoided for at least six weeks after surgery. Athletes should hold off high-level sports for six months. After that they should be safe to go back to their sports, as long as they have regained normal strength in the quadriceps muscle.

A Patient’s Guide to Osgood-Schlatter Lesion of the Knee

Introduction

An Osgood-Schlatter lesion involves pain and swelling in the small bump of bone on the front of the tibia (shinbone), right below the kneecap. It occurs in children and adolescents. The problem affects the area where bone growth occurs. Too much stress on the growing bone causes the pain and swelling. The pain often worsens with activity and eases with rest. Fortunately, the condition is not serious. It is usually only temporary.

The condition is the most frequent cause of knee pain in children between the ages of 10 and 15. The problem used to happen mostly in boys. But with more girls playing sports, boys and girls are now affected equally. Because girls’ skeletons begin to mature earlier than boys, girls tend to have this condition when they are one to two years younger than boys. Kids who play sports have this condition 20 percent more often than nonathletes. And the lesion seems to run in families; when one child is affected, there’s a 30 percent chance a sibling will have it, too.

This guide will help you understand

• why the condition develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What part of the knee is affected?

The Osgood-Schlatter lesion affects the tibial tuberosity. The tibial tuberosity is the bump on the top of the tibia (shinbone) where the patellar tendon connects. Tendons connect muscles to bones. The patellar tendon stretches over the top of the patella (kneecap). The patellar tendon connects the large quadriceps muscle on the front of the thigh to the tibial tuberosity. As the quadriceps muscle works, it pulls on the patellar tendon and extends (straightens) the knee joint.

A small bursa sometimes develops where the patellar tendon meets the tibial tuberosity. A bursa is a normal structure that often forms in areas where friction occurs, such as between muscles, tendons, and bones. A bursa is a thin sac of tissue filled with fluid. The fluid lubricates the area and reduces friction.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

How did this problem develop?

Osgood-Schlatter lesions fit in a category of bone development disorders known as osteochondroses. (Osteo means bone, and chondro means cartilage.) In normal development, specialized bone growth centers (called growth plates) change over time from cartilage to bone. The growth centers expand and finally unite. This is how bones grow in length and width. Bone growth centers are located throughout the body.

Children with bone development problems in one area are likely to develop similar problems elsewhere. For example, among young athletes with growth plate problems in the back of the heel (Sever’s syndrome), about two-thirds also develop an Osgood-Schlatter lesion. Children who have an Osgood-Schlatter lesion also have a small chance of problems at the top of the patellar tendon, where it attaches to the bottom tip of the kneecap. This condition is known as Sinding-Larsen-Johansson disorder.

Related Document: A Patient’s Guide to Sever’s Syndrome

Related Document: A Patient’s Guide to Jumper’s Knee in Children and Adolescents

The main cause of Osgood-Schlatter lesions is too much tension in the patellar tendon. The tension can come from overuse from sports activity and from growth spurts. Usually both happen together. Both put extra stress on the tibial tuberosity.

During growth spurts, the tendon may not be able to keep up with the growth of the lower leg. The tendon becomes too short. It constantly pulls at the tibial tuberosity. Tension from sports activity comes from overuse. When the quadriceps muscle on the front of the thigh works, it pulls on the patellar tendon. The tendon in turn pulls on the tibial tuberosity. If the tension is too great and occurs too often while the bone is developing, it can pull the growth area of the tibial tuberosity away from the growth area of the shinbone.

The bump forms because the separated growth plates keep growing and expanding. The area between the bone fragments fills in with new tissue, either cartilage or bone. The new tissue causes the tibial tuberosity to become enlarged and painful.

Another possible cause of Osgood-Schlatter lesions is abnormal alignment in the legs. Kids who are knock-kneed or flat-footed seem to be most prone to the condition. These postures put a sharper angle between the quadriceps muscle and the patellar tendon. This angle is called the Q-angle. A large Q-angle puts more tension on the bone growth plate of the tibial tuberosity, increasing the chances for an Osgood-Schlatter lesion to develop. A high-riding patella, called patella alta, is also thought to contribute to development of Osgood-Schlatter lesions.

Symptoms

What does an Osgood-Schlatter lesion feel like?

In an Osgood-Schlatter lesion, the tibial tuberosity will probably be enlarged and painful. It hurts when bumped. It also hurts when pressure is put on it, such as when kneeling. Activities like running, jumping, climbing, and kicking may hurt because of the tension of the patellar tendon pulling on the tibial tuberosity.

Symptoms generally go away gradually over a period of one to two years. However, the condition may leave a permanent, painless bump below the knee. The area may always be tender. Many adults who had a lesion as a child still have pain when kneeling on that knee.

Complications can occur if the area between the bone fragments fills in with cartilage rather than bone. Normally, the bone growth plates join together with solid bone in between. If cartilage fills in the space, the condition is called a nonunion.

Diagnosis

How do doctors diagnose the condition?

A doctor can usually make the diagnosis from the history and physical examination. The doctor will want to know the child’s age and activity level, and whether there are any siblings who’ve had an Osgood-Schlatter lesion.

The doctor will press on and around the patella and patellar tendon to see if there is any tenderness. The doctor will compare the sore knee and the healthy knee. The doctor may also ask the patient to straighten the knee against resistance. This makes the quadriceps muscle work, putting tension on the patellar tendon. Pain during this test can help the doctor make the diagnosis of an Osgood-Schlatter lesion.

The history and physical examination are usually the only tests necessary, but sometimes an X-ray is ordered. A knee X-ray may show a raised area of irregular bone in the tibial tuberosity. Most often it will show swelling in the soft tissues in front of the tibial tuberosity. In more severe cases, the X-ray may show small bony fragments that are separated from the rest of the tibial tuberosity.

An X-ray is necessary if the tibial tuberosity hurts after an injury such as a fall. In this case, the X-ray will help the doctor see if the tibial tuberosity fractured as a result of the trauma.

Treatment

What can be done for the problem?

Nonsurgical Treatment

The passing of time may be all that is needed. It takes one to two years for the bone growth plates of the tibial tuberosity to grow together and form one solid bone. When this occurs, symptoms usually go away completely.

In some cases, the patient may need to stop sport activities for a short period. This gets the pain and inflammation under control. Usually patients don’t need to avoid sports for a long time. It is unlikely that the bone will completely separate, so not all athletes need to completely avoid sports.

The doctor may prescribe anti-inflammatory medicine to help reduce swelling. Physical therapists might use ice, heat, or ultrasound to control inflammation and pain. A variety of pads, straps, and sleeves are available that can help keep pain to a minimum. For example, wearing a knee pad cushions the sore area while kneeling.

As symptoms ease, the physical therapist works on flexibility, strength, and muscle balance in the knee. Posture exercises can help improve knee alignment. The therapist may also design special shoe inserts, called orthotics, to support flat feet or to correct knock-kneed posture.

Cortisone injections are commonly used to control pain and inflammation in other types of injuries. However, a cortisone injection is usually not appropriate for Osgood-Schlatter lesions. Cortisone injections haven’t shown consistently good results for this condition. There is also a high risk that the cortisone will cause the patellar tendon to rupture.

Severe pain and problems may require a knee brace or cast for up to six weeks. The goal is to stop the knee from moving so that inflammation and pain go away.

Surgery

Surgery is not considered unless bone growth is complete and symptoms are still bothersome despite nonsurgical treatments. Even then, surgery for an Osgood-Schlatter lesion is rarely recommended.

When surgery is needed, the usual operation involves removing the raised area of the tibial tuberosity, the bursa, and irritated tissue nearby. The surgeon makes a small incision down the front of the lower knee, just over the tibial tuberosity. The patellar tendon is split in half. Retractors are used to pull the skin and the patellar tendon apart. This makes it easy for the surgeon to see and work on the tibial tuberosity. The surgeon uses an osteotome to cut away the raised area of the tibial tuberosity. Care is taken while removing the bursa and nearby tissue.

The retractors are removed. The cut edges of the patellar tendon are brought together. Scar tissue eventually binds the edges back together. To complete the operation, the surgeon stitches up the skin.

Rehabilitation

What can be expected from treatment?

Nonsurgical Rehabilitation

With nonsurgical rehabilitation, the goal is to reduce pain and inflammation. These measures can help. However, most Osgood-Schlatter lesions still get better over time, as the bones mature.

Some doctors have their patients work with a physical therapist. Therapists work on the possible causes of the problem. For example, flexibility exercises for the hamstring and quadriceps muscles can help reduce tension in the patellar tendon where it attaches to the tibial tuberosity. Orthotics are sometimes issued to put the leg and knee in good alignment. Strengthening exercises to improve muscle balance can help the kneecap move correctly during activity. Therapists work with athletes to improve form and to reduce knee strain during sports.

When symptoms are especially bad, patients may be instructed to avoid any activity that makes their pain worse, including sports. In severe cases, bracing or casting may be needed for up to six weeks.

After Surgery

After surgery, daily activities can be resumed gradually. The knee should be propped up routinely during the day to help reduce swelling and throbbing. Medicines should be taken exactly as prescribed by the surgeon.

The surgeon may recommend using crutches or a cane for awhile. Vigorous activities and exercise should be avoided for six weeks after surgery. Athletes should not take part in high-level sports for two to three months. Some surgeons have their patients attend physical therapy after surgery.

A Patient’s Guide to Perthes Disease of the Hip

Introduction

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calve-Perthes disease in honor of the three physicians who each separately described the disease. In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals. How the bone heals determines what problems the condition will cause in later life. Perthes disease may affect both hips. In fact, 10 to 12 percent of the time the condition is bilateral (meaning that it affects both hips). This condition can lead to serious problems in the hip joint later in life.

This guide will help you understand

• what part of the hip is involved
• what causes the condition
• what treatment options are available

Anatomy

What part of the hip is affected?

The hip joint is where the thighbone (femur) connects to the pelvis. The joint is made up of two parts. The upper end of the femur is shaped like a ball. It is called the femoral head. The femoral head fits into a socket in the pelvis called the acetabulum. This ball and socket joint is what allows us to move our leg in many directions in relation to our body.

In the growing child, there are special structures at the end of most bones called growth plates. The growth plate is sandwiched between two special areas of the bone called the epiphysis and the metaphysis. The growth plate is made of a special type of cartilage that builds bone on top of the end of the metaphysis and lengthens the bone as we grow. In the hip joint, the femoral head is one of the epiphyses of the femur.

The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.) The blood vessels that go to the epiphysis run along the side of the femoral neck and are in danger of being torn or pinched off if something happens to the growth plate. This can result in a loss of the blood supply to the epiphysis. The dead bone cells are eventually replaced by new bone cells but this can take several years. In the meantime, pressure and load from weight on the bone causes the bone to flatten. The smooth, round head of the femur that sets inside the hip socket (acetabulum) becomes oval shaped (ovoid) or misshapen. Instead of fitting tightly inside the acetabulum, bone extrudes or expands outside the confines of the socket.

Causes

How does this problem develop?

Perthes disease results when the blood supply to the capital femoral epiphysis is blocked. There are many theories about what causes this problem with the blood supply, yet none have been proven. Many experts believe Perthes disease is the result of several or even many factors. Another way to say this is that Perthes is a multifactorial disease with both genetic and mechanical contributing factors.

On the genetic side, it’s possible some children are more susceptible (more likely) than others to develop this problem. But it takes one or more “triggers” (environmental or external factors) to start the process. For example, there appears to be some relationship to nutrition. Children who are malnourished are more likely to develop this condition.

Children who have abnormal blood clotting (a condition called thrombophilia) may have a higher risk of developing Perthes disease. These children have blood that clots easier and quicker than normal. This may lead to blood clotting that blocks the small arteries going to the femoral head. As a result of new evidence, the certainty of thrombophilia as a cause of Perthes is now under debate. This will remain an area of study until scientists clear up the significance of thrombophilia as a possible cause of Perthes.

There is some new evidence that Perthes disease is genetic as a result of a mutation (abnormal change) in the type II collagen (fibers that make up soft tissue structures). Previously there was no known increase in risk for children whose parent had Perthes disease as a child. But this belief may no longer be accurate.

Studies among Asian families who have many members with this disease have been found with this mutation in the type II collagen gene. Scientists think that the mutation results in weakening of the hip joint cartilage that also affects the blood vessels within the cartilage.

Other potential biologic factors that may be linked with Perthes disease include low levels of abnormal insulin-like growth factor (IGF-1), low birth weight, and short body length at birth. Exposure to nicotine and other chemicals from tobacco is an important factor recently discovered. Likewise LCP may be triggered by exposure to tobacco if the mother smokes during pregnancy or the child is exposed to second hand smoke during infancy and early childhood.

There is some evidence that Perthes disease can develop after a single episode of ischemia (lack of blood to the area) no matter what the cause. But the risk goes up with repeated (multiple) episodes of blood loss. Whatever the true cause of ischemia (lack of blood to the area), the result is bone death (called necrosis) of the femoral head. Without a normal blood supply, the bone loses its strength and shape. The loss of bone density and softening of the head result in a misshapen head. With the hip supporting the weight of the body, tiny microfractures in the soft, necrotic bone fail to heal.

The dead bone cells are eventually replaced by new bone cells but this can take several years. In the meantime, pressure and load from weight on the bone causes the bone to flatten. The smooth, round head of the femur that sets inside the hip socket (acetabulum) becomes oval-shaped (ovoid) or misshapen. Instead of fitting tightly inside the acetabulum, bone extrudes or expands outside the confines of the socket. This is another reason why normal wear and tear results in deformity.

Symptoms

What does this problem feel like?

Most children with Perthes disease develop discomfort in the hip and walk with a limp. Children will not usually complain of pain unless specifically asked. The most common way that the disease is discovered is when someone, usually a parent, notices the limp and consults a physician.

When the doctor examines the hip, the motion of the hip is abnormal and restricted. Turning the leg inward produces pain. This usually indicates that the hip is inflamed and may have inflammatory fluid (called an effusion) present in the hip joint.

Interestingly, problems in the hip sometimes do not cause pain in the hip itself. The knee is where the pain is felt. This can be confusing both to patients and physicians. In general, a child with knee pain (who has no clear-cut reason to have knee pain), or an abnormal gait, should be examined for possible Perthes disease. This usually includes X-rays of the hips to make sure that Perthes disease is not missed.

The main problem with Perthes disease is that it changes the structure of the hip joint. How much it affects the way the hip joint works depends on how much the hip joint is deformed. Muscle weakness and atrophy affecting the thigh and calf muscles may develop over time. The affected leg can shorten as a result of the changes in the hip. The result may be a significant leg length difference. Problems later in life are more likely the greater the deformity after the condition has healed.

In general, the most common problem later in life is the development of arthritis in the hip joint. The type of arthritis that develops in the hip is osteoarthritis (also known as wear and tear arthritis). Just like a machine that is out of balance, the hip joint wears out and becomes painful.

Diagnosis

How do doctors identify the problem?

The history and physical examination are usually enough to make the doctor highly suspicious about the diagnosis of Perthes disease. X-rays are usually necessary to make the diagnosis.

It is usually not necessary to get an MRI scan to make the diagnosis. However, this test may be useful to determine whether the other hip is involved in the disease. A special MRI using a dye called gadolinium may help show changes in blood supply before anything shows up on an X-ray.

In planning treatment another test, called an arthrogram, may be required. In this test, dye is injected into the hip joint to outline the cartilage surface of the joint. Much of the child’s hip joint is made up of cartilage. Cartilage does not usually show up on X-rays. The dye is necessary to see what the hip will actually look like when the cartilage turns to bone.

Treatment

What treatment options are available?

Age is the determining factor in this condition. Recovery is more likely in children under the age of eight. Development in teens is infrequent but with a poorer prognosis. But the good news is that many children have mild Perthes disease, and they are able to heal and recover fully even without treatment. The hip actually remodels itself and remains smooth moving. Early degenerative hip arthritis does not always occur and these children have no hip problems in adulthood related to their childhood history of Perthes disease.

The primary goal of treatment for Perthes disease is to help the femoral head recover and grow to a normal shape. The closer to normal the femoral head is when growth stops, the better the hip will function in later life. The way that surgeons achieve this goal is using a concept called containment.

Containment is a simple concept. The femoral head can be molded as it heals. This is very similar to molding plastic. Plastic is poured into a molded and held in the mold as it cools. It then holds the shape of the mold. The hip socket, or acetabulum, is not affected when the femoral head loses its blood supply. It can be used as a mold to shape the femoral head as it heals. The trick is that the femoral head must be held in the joint socket (acetabulum) as much as possible. It is better if the hip is allowed to move and is not held completely still in the joint socket. Joint motion is necessary for nutrition of the cartilage and for healthy growth of the joint.

All treatment options for Perthes disease try to position and hold the hip in the acetabulum as much as possible. Giving the hip every opportunity to heal itself by limiting load on the joint may prevent the flattening of the femoral head and deformity that can develop. The only problem is — it can take two to four years for the necrotic bone to get resorbed and replaced by new bone. And in some cases, new bone never forms. Instead, there is new granulation (healing) tissue, but that area doesn’t harden into bone, it just forms cartilage.

Many children who are diagnosed with Perthes disease do not require any treatment except careful watching. When the condition is mild, the results of not doing anything are often as good as aggressive treatment. Active treatment is advised when more than half the epiphysis is affected.

The majority of children who are treated for Perthes disease these days require only a program for maintaining a near-normal range of motion. This may include nighttime splinting, home traction, and physical therapy. Your doctor will determine treatment based on your child’s age and the classification of the severity of the disease. The classification is determined by the X-ray findings.

Bracing may be recommended if the child is six years old or younger. Surgery may be a best option for children who are seven or older and who have severe disease. Most of the studies support the idea that treatment of any kind just doesn’t seem to make a difference for mild to moderate disease in younger children.

Nonsurgical Treatment

Hip motion, as near to normal as possible, is critical to the successful treatment of Perthes disease. The disease causes inflammation in the joint. This leads to loss of motion and contracture (tightening) of the muscles surrounding the hip joint. Treating these problems to restore normal motion is common.

When lack of motion has become a problem, the child may be admitted to the hospital and placed in traction. Traction is used to quiet the inflammation.

Anti-inflammatory medications may be prescribed. Antiresorptive agents may also protect the bone and help decrease deformity. Studies are being done to fully test the effect of these medications in children with Perthes.

Physical therapy is used to restore the hip motion as the inflammation comes under control. This process usually takes about a week. Home traction may also be an option.

In the past, surgeons have tried to hold the hip in the best position where the femoral head was molded by the acetabulum using casts and braces. The most common way of doing this today is the Scottish Rite Orthosis. This brace fits around the waist and thighs and has hinges at the hip joints. The brace allows the child to walk and play while it holds the hip joint in the best position for containment.

Evidence from recent studies have changed our thinking about the usefulness of bracing. Bracing just doesn’t seem to change the anatomy or alignment of the hip. There are some children who might benefit but they must be evaluated carefully and selected individually for this type of treatment.

Children who are younger and have significant (more than 50 per cent) of the epiphysis affected may benefit the most from bracing. Children who have chronic synovitis (inflammation of the synovial fluid inside the hip joint) may also benefit from bracing. Holding the hip in place with less load or force helps quiet the inflammatory process.

When X-rays show involvement of the lateral pillar (outside portion of the femoral head), bracing is used to contain the flattened head in the hip socket. The role of bracing is to restore the natural round shape needed for normal hip motion. Results should be followed closely and discontinuation of bracing if no benefit is observed.

Surgery

In some cases, surgery will be required to obtain adequate containment. Sometimes, adequate motion cannot be regained with traction and physical therapy alone. If the condition is longstanding, the muscles may have contracted or shrunk and cannot be stretched back out. To help restore motion, the surgeon may recommend a tenotomy of the contracted muscles. When a tenotomy is performed, the tendon of the muscle that is overly tight is cut and lengthened. This is a simple procedure that requires only a small incision. The tendon eventually scars down in the lengthened position, and no functional loss is noticeable.

Surgical treatment for containment may be best in older children who are not compliant with brace treatment or where the psychological effects of wearing braces may outweigh the benefits. Surgical containment does not require long-term braces or casts. Once the procedure has been performed and the bones have healed, the child can pursue normal activities as tolerated.

Surgical treatment for containment usually consists of procedures that realign either the femur (thighbone), the acetabulum (hip socket), or both.

Realignment of the femur is called a femoral osteotomy. This procedure changes the angle of the femoral neck so that the femoral head points more towards the socket. To perform this procedure, an incision is made in the side of the thigh. The bone of the femur is cut and realigned in a new position. A large metal plate and screws are then inserted to hold the bones in the new position until the bone has healed. The plate and screws may need to be removed once the bone has healed.

Realignment of the acetabulum is called a pelvic osteotomy. This procedure changes the angle of the acetabulum (socket) so that it better covers, or contains, the femoral head. To perform this procedure, an incision is made in the side of the buttock. The bone of the pelvis is cut and realigned in a new position. Large metal pins or screws are then inserted to hold the bones in the new position until the bone has healed. The pins usually must be removed once the bone has healed.

If there is a serious structural change in the anatomy of the hip, there may need to be further surgery to restore the alignment closer to normal. This is usually not considered until growth stops. As a child grows, there will be some remodeling that occurs in the hip joint. This may improve the situation such that further surgery is unnecessary.

In severe cases, both femoral osteotomy and pelvic osteotomy may be combined to obtain even more containment.

Osteotomy Types

Rehabilitation

What should I expect from treatment?

Follow-up visits are used to monitor the symptoms, hip mobility, and to make sure that the condition is not deteriorating. The surgeon will take X-rays during the recheck visits to follow the healing of the femoral head. Patients with Perthes disease are always at higher risk of developing osteoarthritis of the hip. The more flattened the bone and the more misshapen the round femoral head becomes, the more likely degenerative arthritis will occur at an early age. The reason for this is that joint surfaces need to be evenly matched or congruent. Without this tight fit, the bones rub against each other unevenly. Over time with repeated movements, the joint degenerates where the greatest amount of pressure has been applied.

The end result is that most patients with Perthes disease will require an artificial hip at some point in the future. Most patients do not develop problems for 40 years or more. How soon patients have problems with their hip is directly related to how much deformity is present once the condition heals. In general, the more round the femoral hip is at that time, the longer the hip will stay free of pain.

A Patient’s Guide to Slipped Capital Femoral Epiphysis

Introduction

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip in teenagers between the ages of 12 and 16 most often. Cases have been reported as early as age nine years old. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). If untreated this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. Surgery is usually necessary to stabilize the hip and prevent the situation from getting worse.

This guide will help you understand

• what part of the hip is involved
• what causes the condition
• what treatment options are available

Anatomy

What part of the hip is affected?

The hip joint is where the thighbone (femur) connects to the pelvis. The joint is made up of two parts. The upper end of the femur is shaped like a ball. It is called the femoral head. The femoral head fits into a socket in the pelvis called the acetabulum. This ball-and-socket joint is what allows us to move our leg in many directions in relation to our body.

In the growing child, there are special structures at the end of most bones called growth plates. The growth plate is sandwiched between two special areas of the bone called the epiphysis and the metaphysis. The growth plate is made of a special type of cartilage that builds bone on top of the end of the metaphysis and lengthens the bone as we grow. In the hip joint, the femoral head is one of the epiphyses of the femur.

The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.)

The blood vessels that go to the epiphysis run along the side of the femoral neck and are in danger of being torn or pinched off if something happens to the growth plate. This can result in a loss of the blood supply to the epiphysis.

Causes

How does this problem develop?

SCFE develops at a specific age. The changes occurring in the growing skeleton during puberty play into the chances that a child will develop SCFE. The cartilage epiphyseal plate is weaker than the surrounding bone. Children who are overweight are more prone to developing SCFE. This suggests that the main cause of SCFE is from increased force on the hip at a time when the femoral head is not quite ready to support these forces. The femoral head fails at the weakest point, through the epiphyseal plate. As a result, a condition similar to a stress fracture develops.

SCFE may affect both hips. In fact, 20 to 40 percent of the time the condition is bilateral (meaning that it affects both hips). Only one hip may be painful, so it is common for doctors to carefully watch the other hip to recognize the disease as early as possible. The earlier the diagnosis is made, the more effective the treatment. Studies have shown that the more severe the slip, the worse the long-term outcomes. The earlier the diagnosis is made, the more effective the treatment.

Symptoms

What does the problem feel like?

Most teenagers with SCFE develop pain in the hip, and they begin to walk with a limp. When the doctor examines the hip, the motion of the hip is abnormal and restricted. Because the anatomy of the hip joint is altered, patients usually walk with the foot and leg turned out on the affected side.

Interestingly, problems in the hip sometimes do not cause pain in the hip itself. The knee is where the pain is felt. This can be confusing both to patients and physicians. In general, a teenager with knee pain and who has no clear-cut reason to have knee pain should be examined for possible SCFE. This usually includes X-rays of the hips to make sure that SCFE is not missed.

The main problem with SCFE is that it changes the structure of the hip joint. How much it affects the way the hip joint works depends on how much the epiphysis slips. The more the slip, the more likely there will be problems later in life.

In general, the most common problem later in life is the development of arthritis in the hip joint. The type of arthritis that develops in the hip is osteoarthritis (also known as wear-and-tear arthritis). Just like a machine that is out of balance, the hip joint wears out and becomes painful.

There are two complications of SCFE that may occur immediately after the condition develops. One complication is chondrolysis, a condition where the articular cartilage of the hip joint is destroyed. Articular cartilage is the smooth material that covers the joint surface. It is unclear why this develops. It may occur with or without surgery. This condition results in narrowing of the joint space and a painful, stiff hip.

The other possible complication is called avascular necrosis of the capital femoral epiphysis. This usually occurs when the blood vessels that provide blood to the epiphysis are damaged, torn, or pinched. This can happen when the SCFE develops very rapidly and presents like a true fracture. This can also occur when attempting to reduce, or align, the two parts of the femoral head before inserting a screw. The result is that the epiphysis dies and the bone collapses causing further deformity. This can lead to early arthritis in the hip joint.

Diagnosis

How do doctors identify the problem?

The history and physical examination are usually enough to make the doctor highly suspicious about the diagnosis of SCFE.

X-rays are usually necessary to make the diagnosis in SCFE. Based on X-ray findings of the lateral head-to-shaft angle, the slip can be graded. Grades are defined as mild (less than 30 degrees), moderate (30 to 50 degrees), or severe (more than 50 degrees). In the past, SCFE was classified as acute or chronic. The terms stable or unstable are used now because this status is a better predictor of osteonecrosis.

Treatment

What treatment options are available?

Nonsurgical Treatment

Treatment of SCFE usually requires surgery. If surgery is absolutely not possible for other reasons, then placing the child in a type of body cast called a hip spica may be an option. This is not as successful as surgery and is not the preferred choice.

Surgery

The primary goal of the treatment of SCFE is to stop any further slippage of the capital femoral epiphysis. The less slip, the lower the risk of problems in the hip during the child’s life.

Once the epiphysis has closed, slippage will stop. Epiphysis closure occurs when the two areas of bone–the epiphysis and metaphysis–join, or fuse, into one single bone. At that point there is no cartilage growth plate remaining between the two parts of the femur. Surgery usually speeds up the process of epiphysis closure.

Once the diagnosis of SCFE is made, surgery is usually suggested immediately. The surgery is scheduled within a few days following the diagnosis. Until the surgery can be performed, it is highly advisable to use crutches and restrict activities to a minimum. The surgery can usually be done as an outpatient. General anesthesia (where the patient is put completely to sleep) is usually recommended, unless there are reasons not to use a general anesthetic. If so, a spinal block may be used instead.

The preferred method for stopping the epiphysis from slipping further is to place a large screw into the epiphysis to hold it in place. This screw is placed using a special X-ray machine called a fluoroscope. The fluoroscope allows the surgeon to see an X-ray image on a TV monitor while doing the surgery. In this way, the surgeon is able to accurately place a screw into the epiphysis using a small incision in the side of the thigh.

Other types of surgery have been used in the past. For many years surgeons thought it necessary to use two or three screws to hold the epiphysis. This has been shown to be unnecessary in most cases. Using additional screws may actually increase the risk of complications. Open operations using much larger incisions have also been used in the past. These procedures have been abandoned because using a single screw works better and is easier to do.

If there is a serious structural change in the anatomy of the hip, there may need to be further surgery to restore the alignment closer to normal. This procedure is usually not considered until the child is done growing. As a child grows, there will be some remodeling that occurs in the hip joint. This may improve the situation such that further surgery is unnecessary.

In the case of unilateral (one-sided) SCFE, experts also recommend pinning the normal hip. This is called prophylactic pinning. The child with moderate to severe unilateral SCFE is at risk for slippage to occur on the other side.

Prophylactic treatment is easy to do and can be done at the time of the operation on the involved side. Taking this step reduces the need for repeated X-rays to check the normal side for any sign of SCFE. The child can remain more active without constant worry that the hip will slip. The complications of chondrolysis, avascular necrosis, and/or degenerative arthritis can also be avoided.

Rehabilitation

What should I expect from treatment?

Crutches are required following surgery for SCFE. Within three to five days, most patients will be able to start putting some weight down while standing or walking. Over the next few weeks and as pain subsides, the crutches may be discarded. Physicians differ in their postoperative regimen, so make sure you are clear on what your surgeon recommends, especially how long crutches are needed.

The surgeon will take X-rays during the follow up visits to make sure that the screw remains in the right place. The X-rays are also required to determine when the epiphyseal plate fuses. At that point, there won’t be any chance that the slip will get worse. When this is known, the follow up visits will be focused on whether the abnormality is likely to need any additional surgery to realign the hip.

Opinions differ on the need to remove the screw once the epiphysis has fused. Removing the screw requires a second surgery that can be expensive and carries a slight risk due to the need for anesthesia. The hole left when the screw is removed also increases the risk of fracture after the screw is taken out. If the screw is removed, the surgeon may recommend crutches for three to six weeks afterward. Many surgeons feel that the screw should be left in place if it isn’t causing problems.

A Patient’s Guide to Septic Arthritis of the Hip in Children

Introduction

Septic arthritis of the hip in children is a painful joint condition caused by a bacterial infection. Septic arthritis of the hip can occur at any age from newborn to older child. The infection is caused by different bacteria at different ages, but the disease behaves the same. About half of all cases occur in children younger than three years old.

In most cases the condition is monoarticular, meaning it only affects one joint. The knee is most often involved, followed by the hip then ankle. If untreated, disastrous results can occur, especially in the hip.

This guide will help you understand

• what part of the hip is involved
• what causes the condition
• what treatment options are available
  

  Anatomy

  What part of the hip is affected?

  

  The hip joint is where the femur (thighbone) connects to the pelvis. The joint is made up of two parts. The upper end of the femur is shaped like a ball. It is called the femoral head. The femoral head fits into a socket in the pelvis called the acetabulum. This ball and socket joint is what allows us to move our leg in many directions in relation to the body.

  Causes

  What causes this condition?

  

  Infections are a part of growing up. Young children commonly get many different types of bacterial infections, such as sore throats, skin infections and wound infections from scrapes and cuts. As we are exposed to these infections, our immune system develops better protection from these infections. When a bacterial infection occurs anywhere in the body, bacteria from the infected area can enter the bloodstream. These bacteria are then transported all over the body. Usually our immune system kills these bacteria quickly, before they have an opportunity to begin to reproduce and cause another infected area. Because young children have not completely developed their immune system, their bodies are not quite as good at rapidly destroying the bacteria.

  

  Sometimes, these bacteria in the bloodstream move into the hip joint. If they are not destroyed quickly, they can set up an infection. Blood containing bacteria moves from the bone across the synovial membrane into the joint. The synovium is a protective layer of fluid around the joint. Bacteria can also move into the joint cavity indirectly by moving from the growth plate at the end of the femur (thighbone) into the joint.

  

  It’s not always clear what causes septic arthritis to get started. In some cases an injury seems to lead to a joint becoming infected. In other cases, the child may have other medical problems that create an altered immune system and reduce the ability of the body to fight off an infection. Either one of these problems can increase the risk of infection.

  Low-birth weight babies are at risk for infection from the commonly present bacteria Streptococcus also known as strep. Invasive procedures such as fetal monitoring through the scalp or drawing blood from the heel can also introduce the bacteria into the bloodstream. Once bacteria are in the bloodstream, they can settle in the hip joint and create an infection.

  Infection from Staphylococcus (staph infection) can occur just from being in the hospital setting. These bacteria are very common in the hospital, where many patients undergoing treatment have active infections. The chance of exposure is much greater while the child is in the hospital rather than at home. Both strep and staph infections affect children from birth to three months and children older than two or three years old most often.

  There are many other different bacteria and underlying infections besides the two named here. In each case the infection behaves a little differently and is more common in a slightly different age group.

  Bacteria that can cause meningitis can also cause septic arthritis of the hip. The bacteria enter through the nose and throat, then quickly enter the bloodstream and travel to distant joints.

  Symptoms

  What does this condition feel like?

  Some children with septic hip arthritis have no apparent symptoms at first. The most common symptoms are sudden fever, hip pain and a limp. The young child will commonly refuse to put weight on the affected leg. The child who can walk may limp. Infants may be irritable and refuse to eat.

  Pain or tenderness is usually in the front of the hip and may travel down to the knee. The skin may be warm and red over the area of tenderness. Both are signs of inflammation from the infection in the joint.

  Hip extension or straightening the hip back and rotating it inward increase the painful symptoms. The child prefers to lie on his or her back with the hip flexed (bent) and externally rotated (rotated outward). This position takes the pressure off the joint.

  Diagnosis

  How do doctors identify this condition?

  Early diagnosis is important. The infection in the hip joint can damage the joint and the sooner treatment is started the better. The history and physical examination are usually enough to make your doctor highly suspicious of septic hip arthritis. Blood tests help confirm the diagnosis. A high erythrocyte sedimentation rate (ESR) or “sed rate” and a white blood count greater than 12,000 are red flags to suggest inflammation or infection. Sudden onset of symptoms with fever and positive blood tests all point to septic arthritis.

  

  It may be necessary to remove a small amount of synovial fluid from the hip joint for laboratory analysis. Because the hip joint is deep in the pelvis, ultrasound or fluoroscope is sometimes used to help the physician locate the joint cavity and guide the needle into the joint. This procedure is called arthrocentesis. Some type of sedation is usually required for the procedure as well. Once the fluid is removed from the hip, it is sent to the laboratory where it will be analyzed for signs of infection. If the initial tests are suspicious for infection, the fluid will also be cultured to determine the type of organism that is causing the infection.

  Treatment

  What can be done to relieve the symptoms?

  Nonsurgical Treatment

  Antibiotic therapy is the first step in treatment. The type of antibiotic given depends on which bacteria are present. Results are best if antibiotics are started as soon as possible after the diagnosis of a joint infection. First, medication is given intravenously (directly into blood stream) for about seven days and then orally (pills taken by mouth) for another two or three weeks.

  Surgery

  Surgery is usually required to drain the joint of all infected material. The joint is thoroughly rinsed with a saline solution. The goal is to remove any products of inflammation and reduce the number of bacteria present. Both actions give the antibiotics a better chance of working quickly. A drain may be placed in the joint for 24 to 48 hours to clear any fluid that has leaked into the nearby tissues.

  The surgeon may have to drill into the bone if there is any sign of bone infection. This procedure helps bring increased blood flow to the area to clean away bacteria, infection, and dead tissue.

  Rehabilitation

  What should I expect after treatment?

  Nonsurgical Treatment

  The child should respond to the antibiotics with decreased fever and increased energy and appetite. Hip range-of-motion will return to normal and the child will be able to put weight on the hip (leg) again. Children who can walk will gradually resume normal activities. Infants and babies will also start holding the head up, eating, and moving freely on the floor again.

  After Surgery

  Bed rest is advised for the first 24 hours to allow time for inflammation of the synovial fluid to resolve. The physical therapist will perform and teach family members how to do passive range-of-motion (motion performed by others) for the entire leg. Movement is very important to prevent other joint problems from developing.

  More surgery may be needed later if the hip loses too much motion or develops deformity and/or dislocation. Release of tendons and muscles, bone grafts, or reconstruction surgery may be needed.

  Long-term follow-up is very important for any child who has had septic arthritis. This is true even for those children who have had early diagnosis, early treatment, and a good result. Changes can occur later in the hip with degeneration of the joint leading to treatment failure.

A Patient’s Guide to Developmental Dysplasia of the Hip in Children

Introduction

Developmental dysplasia of the hip (DDH), previously known as congenital hip dysplasia is a common disorder affecting infants and young children. The change in name reflects the fact that DDH is a developmental process that occurs over time. It develops either in utero (in the uterus) or during the first year of life. It may or may not be present at birth.

In this condition there is a disruption in the normal relationship between the head of the femur and the acetabulum (hip socket). DDH can affect one or both hips. It can be mild to severe. In mild cases called unstable hip dysplasia the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called subluxation.

This guide will help you understand

• what part of the hip is involved
• what causes the condition
• what treatment options are available

Anatomy

What part of the hip is affected?

The hip joint is where the femur (thighbone) connects to the pelvis. The joint is made up of two parts. The upper end of the femur is shaped like a ball. It is called the femoral head. The femoral head fits into a socket in the pelvis called the acetabulum. This ball and socket joint is what allows us to move our leg in many directions in relation to the body.

The right amount of pressure and contact between the surfaces of these two parts helps make sure the hip joint develops normally. Most of the acetabulum is cartilage at birth. The head of the femur inside the acetabulum helps shape the joint as it continues to form. In DDH the usual contact between the femoral head and the acetabulum is disrupted.

An abnormal position of the femoral head can result in a dysplastic hip. Sometimes the acetabulum is too shallow or sloping rather than a normal cup shape. It cannot hold the femoral head in place.

If the problem is not diagnosed and treated early, the soft tissues around the hip start to stretch out. There can be changes in the blood supply to the hip. Sometimes the hip joint tries to form another hip socket called a false acetabulum. Without the proper ligaments, soft tissues, and joint capsule to hold the femoral head in place, the false acetabulum creates even more problems.

Causes

How does this problem develop?

There isn’t one single known cause of DDH. In some cases there is laxity or looseness of the ligaments around the joint. This may be hereditary. In other cases the infant’s position may affect how the hip joint forms, either during growth inside the mother or after birth.

For example, a breech position (buttocks first position) in utero limits movement. It also puts the hips in a position with the hips bent, knees straight, and legs together. This position puts abnormal stresses on the joint that do not foster normal development.

Hip position and free hip movement remain important during the first months after birth. This is when the hip continues to develop and forms a deep socket and stable joint. An infant carried on a parent’s hip with the child’s hips bent and open wide is less likely to develop DDH. Infants in some cultures are swaddled or wrapped with the legs together and extended out straight. For example, in some Native American cultures infants are carried on a papoose board. The infant is wrapped on the papoose board with the legs straight down and bound together. An infant that spends a good deal of time in this position is at greater risk for DDH. DDH is more common in Chinese, Korean, and African American infants.

DDH is much more common in girls than boys. This may be linked with hormonal differences. Estrogens and a hormone called relaxin present during development in utero and still present at the time of birth may cause generalized laxity or looseness of the ligaments. The left hip is affected more than the right hip. Again, this is probably linked with position before birth. The most common position in utero places the child’s left hip next to the mother’s spine and limits hip motion.

Children with developmental disabilities who do not move normally or who can’t stand up and walk are also at risk for DDH.

Symptoms

What does this problem feel like?

The newborn, infant, or young child may not have any symptoms such as pain to signal a problem. There may be some differences in how the legs and buttocks look from side to side. Sometimes the problem isn’t noticed until the child starts to walk. If only one hip is affected, the child may walk with a limp. If DDH is present in both hips, the child may sway from side to side or waddle. When both hips are dislocated, it is sometimes very difficult to see an abnormality in the way the child walks.

Diagnosis

<How do doctors identify the problem?

Early diagnosis in the newborn and young infant is important to avoid major problems later. The physical examination performed by the pediatrician is the most important diagnostic tool. All newborns and infants should be screened as early as possible. Babies born breech or with a family history of DDH are of special concern.

Special tests are performed by the doctor while the infant is still in the nursery, The doctor is trying to look for signs of an unstable hip. The two most reliable physical exam tests are Ortolani’s maneuver and Barlow’s test. These tests are designed to detect if the hip is sliding in and out of the acetabulum. To perform these tests, the doctor places the infant on a table in a supine position (on his or her back). The doctor then abducts the hips by moving the bent hips and knees apart. If the hip feels like it can be pushed out the back of the socket, this is considered abnormal. This is called a positive Barlow’s Test and is a sign of instability in the hip. As the hip is abducted further, the doctor might feel the ball portion (the femoral head) slide forward as it slips back into the socket. This is called a positive Ortolani Maneuver and is also a sign of hip instability. If either one of these tests are positive, the child will be watched closely or immediate treatment with a brace may be considered.

For the infant three months or older, Galeazzi’s or Allis’ test can be performed. The child is placed in the supine position with the hips and knees bent and the feet flat. The examiner looks for any unevenness between the knees. If one knee is lower than the other, there may be a dislocated hip on the lower side.

Since DDH can develop over time, repeated exams are advised. Well-baby check-ups should include repeated hip examination. This is done until the child begins to walk normally with no sign of a limp or altered gait (walking) pattern. The doctor also looks for changes in hip range of motion, uneven skin folds around the thighs and buttocks, and a difference in leg length from side to side.

X-rays aren’t reliable in infants but may be of some diagnostic value in the older child. Ultrasound is more accurate in the first six months of life.

Treatment

What treatment options are available?

The goal of treatment is to keep the femoral head in good contact with the acetabulum. A stable hip encourages the development of a normally shaped socket and rounded head of the femur. The proper hip position must be maintained for enough time to stabilize the joint. The hip should be flexed to 95 degrees and abducted (apart) at least 90 degrees. This position keeps the ball (the femoral head) in the best position and allows the ligaments and joint capsule to tighten up.

Nonsurgical Treatment

There are several ways to treat DDH depending on the child’s age and the severity of the condition. Double and triple diapering may be all that is needed in the first six weeks. If the problem persists, a special harness called the Pavlik harness can be used for three to nine months. The harness keeps the hip in flexion and abduction. It may be worn until the doctor can no longer move the hip in and out of the socket. In the older child, x-rays may be used to confirm that the hip is stable.

For children with developmental disabilities, a standing program may be required. Special standing boxes or equipment to hold them upright are used to give the hip the mechanical force it needs to develop normally.

Surgery

In the infant older than 6 months, the Pavlik harness may not work. The child may be too large to wear the harness or may be too active to keep the harness on all day. In this age group, a closed reduction under general anesthesia may be the best option. If the hip cannot be easily reduced, the child may be placed in traction to loosen the soft tissues around the hip. When the surgeon thinks it may be time to reduce the hip, the child is taken to the operating room and placed under general anesthesia. There the surgeon gently moves the hip and feels to see if the hip can be placed in the socket. Fluoroscopy is used to watch the bones of the pelvis and hip as they line up. Fluoroscopy is a type of x-ray where the surgeon can watch the x-ray picture on a TV screen.

Once the hip can be put back in the socket easily, the child is put in a hip spica cast from waist to toe. This cast holds both legs so that the hip joint remains in one position – in the socket while the soft tissues around the hip tighten to hold the hip reduced. The cast may be needed for several months to hold the hip in place. The cast usually is replaced every two weeks to one month while it is needed. Each time the cast is changed, the child is taken to the operating room and placed under general anesthesia. This treatment is called a closed reduction.

Surgery may be needed when the hip cannot be stabilized and kept in the socket. Surgery is more likely required in the child older than 18 months. Before the surgery, the child may be placed in traction to loosen the soft tissues around the hip. Then the child is put in a full hip spica cast from waist to toe. The cast may be needed for several months to hold the hip in place. An open reduction is a surgical procedure used most often in children two years old or older when hip dysplasia has not been corrected. During this operation, the surgeon removes any abnormal tissues that are keeping the femoral head from fitting inside the acetabulum and cuts any tight ligaments in the joint capsule around the hip joint. The surgeon may perform a tenotomy during the surgery to cut the tightly contracted tendons or muscles in the hip area. This relaxes the tight structures around the hip joint and allows the hip to be placed in the socket. These tissues grow back with scar tissue as the child heals. The child is usually placed in a spica cast after this type of surgery and will need to wear this cast for several months.

An operation called derotational osteotomy may be needed. In this surgical procedure, the femur is cut and rotated to make it easier to keep the femoral head inside the acetabulum. When this procedure is done, the soft tissues loosen up and the forces of the muscles tend to keep the femoral head reduced. Once again, the child is put in a spica cast for several months while the bone heals. A CT scan may be used to confirm successful reduction before removing the cast. A CT scan is a special type of x-ray that takes slices of the body. This allows a much better picture of the hip and acetabulum than plain x-rays.

In children older than 18 months, the problem may require additional surgery to change the acetabulum (socket) in addition to the femur (thighbone). The problem has been present longer and the anatomy has grown more distorted over the longer period of time. Your doctor may recommend surgery to change the way that the acetablum is aligned in this situation. There are many different types of pelvic osteotomies that have been designed and are still used.

Several different types of osteotomies are used to tilt the acetabulum in a more horizontal angle to the floor. By doing this, the femoral head is less likely to slide up and out of the socket with weightbearing. These include the Steele, the Salter and the Pemberton osteotomies.

In the Chiari osteotomy, the bone of the pelvis just above the acetabulum is cut to allow the bone to slide out and form a new roof over the hip joint. This can stop the femoral head from sliding up and out of the socket. Over time this shelf of bone above the acetabulum remodels and forms a deeper acetabulum.

The Staheli osteotomy uses a bone graft placed just above the hip joint to create a new, wider roof, or shelf over the acetabulum. This keeps the femoral head from sliding up and out of the socket and, as it heals, makes a larger weightbearing surface to spread out the weight that needs to be transferred from the femoral head to the acetabulum and pelvis. The Dial osteotomy is not as common. In this procedure, the entire acetabulum is cut free of the pelvis and moved or dialed at the best angle and then allowed to heal in that position.

Young children have incredible powers of healing. Because the skeleton is still forming, many of the changes created at surgery will remodel dramatically and create a hip socket that will serve the child well into adulthood with minimal problems. All children that require surgery to address a dysplastic hip have a higher risk of developing wear and tear arthritis of the hip as they age into adulthood. Many will age well into their 40s and 50s before experiencing significant problems with the hip. Some may never have any additional problems.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

The child in a Pavlik harness benefits from as much motion in the hip as possible – while still keeping the hip reduced. Motion allows for nutrition of the developing bone and cartilage inside the hip joint. The therapist will review positions to avoid such as sidelying with the top leg down toward the other leg past the midline. The harness must be used continuously until the hip is stable. Use may be gradually decreased to just nighttime wear before finally stopping.

For the infant in a harness, care must be taken not to set the harness in too much abduction. Abduction is the motion when the thighs are pulled away from one another. The Pavlik harness is designed to hold the legs bent at 95 degrees at the hip and abducted, or pulled apart, about 45 degrees each. The harness can be tightened too much, pulling the legs apart too much. Too much force into abduction can block the blood supply to the femoral head causing a condition called avascular necrosis. This is a serious complication that can prolong the treatment of the hip and may lead to other problems. Your surgeon or physical therapist should instruct you on how to correctly adjust the Pavlik harness. Make sure you understand how to do this properly. Ask questions if you do not feel you understand.

After Surgery

The child who has surgery will not be able to walk afterwards because of the spica cast. A special hole is cut open to allow the older child to go to the bathroom. Younger children remain in diapers. Your physical therapist will help the family with any special equipment needed for daily tasks and transportation. Special tips for positioning and handling will be reviewed as well.

Special care must be taken not to get the cast wet with water or urine. The cast may be removed and replaced only if the child grows and there are signs that the cast is too small or if there is evidence of skin breakdown. The child should be checked several times each day for changes in skin color or sensation. Leg or foot pain, cool or numb toes, or loss of motion in the feet must be reported to the physician right away.

Physical and occupational therapy is important during the postoperative period in the cast. Opportunities to move and develop gross motor skills are limited. The therapist will closely monitor overall gross and fine motor skills normally occurring during this time.