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.

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 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 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 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 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 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 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 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.