What is developmental dysplasia of the hip?

In a normal hip the ball at the upper end of the thigh bone fits firmly into the socket. In babies with DDH the hip joint is not formed normally and the ball is loose in the socket so it’s easy to dislocate. The degree of hip instability will vary in children.

My 12 year old recently was bitten by our cat and now has a red track running up into his forearm.  Should I be concerned about this?  If I took him to the doctors, what could they do for him?

You should seek immediate medical attention for your son.  Cat bites typically carry a higher risk of infection rate and it sounds like your son has a well-developed infection that is quickly spreading.  The physician will begin him immediately on antibiotics and be able to determine how deep the infection is and if surgery is needed to better clean the wound.

My toddler bit me yesterday on my upper arm and broke the skin. Should I seek treatment? I am embarrassed about this however I am wondering if there is a chance of infection.

There is always a high risk of infection associated with bites as mouths of mammals tend to carry a high number of bacteria.  Human bites are no exception. The major concern with human bites is also the chance of infectious diseases transmitted through the bite, but if your son is a toddler this risk would be low.  That being said, however, you should follow up with your physician for a thorough assessment and cleaning of your wound.

What is idiopathic congenital clubfoot?

Congenital means that the patient is born with it and idiopathic means it is of unknown cause. Clubfoot is known as Talipes Equinovarus – where the ankle and foot are in an atypical position (talipes) in that the foot points downward at the ankle (equinus) and the heel of the foot is turned inwards (varus).

My son is 7 and has very flat feet.  I am concerned that this will cause him problems in the future.  Is there anything that we should be doing now for him?

If your son has a flexible flatfoot then there is typically nothing to worry about.  A kid with flexible flatfoot will have an arch in sitting that will disappear with weight bearing whereas a rigid flat foot will not present with an arch at all.  A rigid flatfoot is more likely to cause problems in the future, however not necessarily.  It is currently recommended that he stay strong with his foot muscles (go barefoot!).

How many surgeries are common when someone is diagnosed with childhood hip dislocation?

According to this study it appears that it is quite common for these patients to have a surgery within three years of the conservative treatment, and in fact more than one half had such a surgery, including eight percent that completely failed the skin traction treatment. In this study this early surgery was a derotational femoral osteotomy. In addition to this early surgery, about one third of the hips had a later, after five years, open reduction surgery to further address unresolved hip dysplasia. Only a handful of patients in this study needed a second or third procedure, however later in lift total hip replacement becomes increasingly more common. In this particular study at the age of thirty only one percent of hips had been replaced, and at the age of fifty-two twenty-six percent of hips had been replaced. This study also indicates that current treatment is slightly more likely to include an open reduction at the time of diagnosis. So it does seem that with such a diagnosis, one surgery is common in childhood, followed by and increasing likelihood of having a total hip replacement after the age of thirty.

My child was just diagnosed with hip dysplasia, and he his sixteen months old, what are the changes in lifestyle that might be expected based on this information?

A recent study out of the Journal of Bone and Joint Surgery looked at the long-term outcomes of infants with late-detected hip dislocation. For your child the outcome is better since he is younger than eighteen months that he will have a good result from the initial treatments. You can expect treatment to include a period of time in skin traction and a spica cast, and possibly an open surgery within about three years if the alignment doesn’t remain stable. This may alter his immediate abilities for activity, but working with a physical therapist may be advisable to minimize this effect.

This study did not completely address activity level of these patients through their lives. There was one functional questionnaire used called the Harris hip score, which asks very basic questions such as range of motion, ability to walk, use stairs, and sitting tolerance. And the mean sore on this test was in the excellent category. There is a likely hood of the need for a total hip replacement, however at the mean age of fifty-two only twenty six percent of hips in this study had been replaced.

My 9 year old son recently fell off our coffee table and dislocated his shoulder. I took him to the emergency room and it was put back in place and he was put into a sling.  What can I expect from here on out?

The standard treatment for a shoulder dislocation from a trauma like falling on an outstretched arm is a period of immobilization (4-6wks) followed by physical therapy for gradual strengthening and return to function.  Surgery is only considered if the dislocation should happen again or if there was a tear of the capsule or rotator cuff in the shoulder as result of the fall.

My 14 year old son is keeps subluxing his shoulder.  He says this does not bother him and I’ve found him doing it for his friends’ amusement.  Should I be concerned about this?  Does he need surgery?

Children and teenagers tend to be more elastic than adults. Over time, our tissues stiffen and the hypermobility, like your son has, becomes more of a hypomobility as wear and tear sets in.  It is in your son’s best interest that he stop subluxing his shoulder on demand and begin some physical therapy for rotator cuff strengthening.  While it does not hurt him now, in the future a stretched capsule could possibly fully dislocate after which he would need to wear a shoulder brace for 4-6 weeks and follow with physical therapy. At worst, he could possibly face surgery to avoid future dislocations.

I am a sports enthusiast — not just watching on TV but playing every sport that comes along. The problem is I’ve developed a hole in my right knee cartilage that is going to require surgery. The surgeon is going to plug the hole with a new collage treatment they are using in other countries. I’m going to ask at my next appointment about how soon I can be active again. But I thought I’d check on-line and see what I could find out. What do you people advise?

You might find the results of a recent study of interest. In this study, orthopedic surgeons from Italy explored the use of a minimally invasive, one-step osteochondral scaffold to repair damage to the surface of the knee joint. The level of evidence is low (rated four on a scale from one-to-four) because it was a case series. But the information about results is still valuable for the type of treatment you are considering.

The condition you described (a hole in the cartilage) is known as osteochondritis dissecans or OCD. As you have experienced from your activities, this is an acquired injury from repetitive microtrauma. A lack of blood supply to the damaged area causes separation of the first two layers of the knee joint: the cartilage that lines the joint (articular cartilage) and the subchondral bone (bone just under the cartilage).

The end-result is a hole (referred to as a “lesion” or “defect”) in the knee joint cartilage that goes down to the bone. The defect is on the bottom of the femur (thigh bone) where the femur comes in contact with the tibia (lower leg bone). Instability of the articular cartilage causes pain, swelling, and loss of knee motion and knee function. Left untreated, uneven contact of the joint eventually causes further degeneration of the joint and arthritis.

The most effective treatment (especially for large lesions) is surgical with a wide variety of procedures currently in use. The goal of surgery is to restore the joint surface to as normal as possible (anatomically). Placing collagen tissue (the basic building block of cartilage and bone) into the defect is one of the techniques under investigation.

In this study, a three-layer scaffold made of type I collagen fibers was placed in the defect. The idea was to stimulate the body to fill in the scaffold as part of the natural healing process. All measures of function improved for each patient over the two-year period. In fact, continued improvements were observed between year one and year two. And the more active patients had a faster recovery.

Your surgeon will outline a post-operative plan of recovery for you. This usually starts on the second (or even the first) day after surgery. A physical therapist will guide you through a series of movements and beginning exercises. Compression of the joint is carefully controlled through these supervised activities. You will likely be on crutches for several weeks and perhaps involved in a pool therapy program (again under the careful eye of the physical therapist).

When there is no sign of swelling and the knee can extend (straighten) fully, your program will be advanced to include full weight-bearing and strengthening exercises. Your return-to-sports should not be premature and only after completing sports-specific skills as part of the rehabilitation program. Your release date will be determined by the physician in coordination with the physical therapist based on your clinical progress. Your cooperation and compliance with all aspects of the program will be an important key to the most successful results.

I just found out that my knee cartilage has separated from the bone underneath. So now I have something called osteochondritis dissecans or OCD. I’ve been told this problem won’t go away without surgery. Why not?

The condition known as osteochondritis dissecans or OCD is an acquired injury from repetitive microtrauma. A lack of blood supply to the damaged area causes separation of the first two layers of the knee joint: the cartilage that lines the joint (articular cartilage) and the subchondral bone (bone just under the cartilage).

The end-result is a hole (referred to as a “lesion” or “defect”) in the knee joint cartilage that goes down to the bone. The defect is on the bottom of the femur (thigh bone) where the femur comes in contact with the tibia (lower leg bone). Instability of the articular cartilage causes pain, swelling, and loss of knee motion and knee function. Left untreated, uneven contact of the joint eventually causes further degeneration of the joint and arthritis.

Many studies have shown that the prognosis for OCD is poor without surgery. Young patients with very small, stable lesions have the best chance for healing with conservative (nonoperative) treatment. But usually, because the area affected is the weight-bearing surface of the knee, compressive forces from standing and walking just further erode the damage already present.

The joint no longer lines up evenly on both sides. An uneven wear pattern develops and significant osteoarthritis is the final outcome. Studies have also shown that patients with untreated OCD can expect degenerative osteoarthritis a full 10 years before someone who doesn’t have an OCD defect.

The bone has some potential for regeneration but self-healing is limited. That’s why surgery to aid the process seems to have the best results. The goal of surgery is to restore the joint surface to as normal as possible (anatomically). There are a variety of surgical techniques available to treat this problem. Our publication A Patient’s Guide to Osteochondritis Dissecans of the Knee provides more information on the various types of treatment. You may find this document informative and helpful in understanding your condition.

Before agreeing to spinal fusion surgery for our eight-year-old son, I want full disclosure of all possible problems during and after the procedure. I have a list of things that can happen (provided by the surgeon’s office). Some of them are pretty scary like stroke and death. They said they would use the kind of screws (pedicle) that have lower risks and “superior” results. This does not make me feel any better. How often do these kinds of things really happen?

It might help you to know a little bit about the history of pedicle screws, how they are used, when they are used, and the results of some recent research related to the complication rates of these devices.

Back in the 1960s, surgeons started to use this type of fixation device to help hold the spine together during a fusion procedure. The pedicle is a column of the vertebra between the main body and the back half of the spinal bones. Placement of a screw through this portion of the vertebra has some risks but many advantages over other types of fixation (e.g., wires, hooks). For example, there is less movement in screws compared with wires or hooks. This increased stability of the fixation device reduces the risk that the hardware will poke into the spinal canal damaging the spinal cord. Likewise, there is less risk of injury to blood vessels in the area.

Pedicle screws are also able to give better correction of the spinal deformity by providing multiplanar correction. Vertebral bones are able to rotate, flex, and extend as well as slide and glide slightly forward, back, and sideways. Multiplanar stabilization stops motion in all directions. Superior correction of spinal deformity with fewer problems make pedicle screws (as a fixation device) the preferred choice of many surgeons.

At first, this screw through the bone was only used in the lumbar spine (low back). But over time, the use of pedicle screws expanded — first to the thoracic spine in adults and then to the spine of adolescents and now younger children.

Studies show that pedicle screws used in the lumbar and thoracic spines of adolescents and adults are less likely to pull out or fail compared with hooks and wires. Complication rate and types of complications have recently been reported for children up to age 12 (compared with children between the ages of 13 and 18) having spinal fusion for scoliosis or other spinal deformities. Rates of infection, hardware failure, and neurovascular (nerve tissue or blood vessel) problems were reported after at least one full year of follow-up.

Overall complication rates were 13.6 per cent for the younger group and 16.9 per cent in the adolescent group. Broken down by category, there was a 0.5 per cent rate for neurovascular complications in the younger group compared with 1.92 per cent among the adolescents. Hardware-related problems were 13.4 per cent (younger group) versus 15.4 per cent (older group). And the infection rate was 9.2 per cent (younger group) compared with 11 per cent among the older patients.

Other areas examined in this study were 1) number of screws used and risk of complication (no link between these two factors), 2) timing of neurovascular complications (all occurred within the first 24 hours), and most common late complications (screw prominence sometimes requiring screw removal).

Very rarely, complications such as stroke during the surgery, aspiration pneumonia, failure of wound healing, and ileus (bowel blockage) are reported. Such complications are not directly caused by the use of pedicle screws but are usually associated with having major (spinal) surgery. Only one child in this study had a stroke (due to other serious health problems) and there was complete recovery for that individual. There were no deaths among the 726 children in the study.

Our three-year-old granddaughter is going to have spinal fusion for a severe, severe scoliosis. She is developmentally disabled with a rare chromosomal abnormality. The surgeon showed us the screws they will use to hold the spine in place. She called them peddle screws and mentioned they are considered “off-label” but still safe. When I looked on-line about what off-label means, I got a little nervous about this for our girl. Are these things really safe?

According to a recent study done at The Musculoskeletal Research Center (Children’s Hospital in Colorado), pedicle screws for spinal stabilization are considered safe, reliable, and effective. Compared with other types of fixation (hooks, wires, rods), pedicle screws have a lower rate of complications. Superior correction of spinal deformity with fewer problems make pedicle screws (as a fixation device) the preferred choice of many surgeons.

The pedicle is a column of the vertebra between the main body and the back half of the spinal bones. Placement of a screw through this portion of the vertebra has some risks but many advantages over other types of fixation (e.g., wires, hooks). For example, there is less movement in screws compared with wires or hooks. This increased stability of the fixation device reduces the risk that the hardware will poke into the spinal canal damaging the spinal cord. Likewise, there is less risk of injury to blood vessels in the area.

Pedicle screws are also able to give better correction of the spinal deformity by providing multiplanar correction. Vertebral bones are able to rotate, flex, and extend as well as slide and glide slightly forward, back, and sideways. Multiplanar stabilization stops motion in all directions. Studies show that pedicle screws used in the lumbar and thoracic spines of adolescents and adults are less likely to pull out or fail compared with hooks and wires.

The use of pedicle screws in the 13 to 18 year old patient for spinal stabilization has been approved by the Food and Drug Administration (FDA). Its use in younger children has not yet been approved because of a lack of evidence for the safety of this device in this age younger group. But when pedicle screws are used for younger children, it is referred to as off-label (because of the lack of FDA approval at this time).

With this study (and other similar reports), it looks like complications from the off-label use among younger children are no different than with the adolescent group. This data may help spur other studies with the eventual outcome of FDA approval of pedicle screws for spinal stabilization in young children.

I’m a little worried about the upcoming arthroscopic surgery our 11-year-old is going to have for a shoulder injury that causes his shoulder to pop in and out of joint. Any surgery would worry me but poking tubes into the shoulder of a growing child just gives me the willies. How safe is this procedure anyway?

Surgeons recognize that the use of shoulder arthroscopy in the pediatric population is a valuable tool that must be used carefully and judiciously. In all aspects of treatment (evaluation, preoperative and postoperative care, and the surgery itself), this age group is treated individually and not automatically regarded as adults in small bodies.

This is an important concept as more and more children are developing sports-related shoulder injuries previously only seen in the adult population. Children and adolescents are not “mini-adults” and must be treated with special consideration when performing arthroscopy on the shoulder.

As for surgical techniques, surgeons select the size of arthroscope they use based on the procedure, age of the child, and individual anatomy of each child. Placement is individualized for each pediatric patient since anatomy varies from child to child. Surgeons know that the basic arthroscopic skills learned during training may not always apply to this age group.

When scopes are placed through the anterior (front) of the shoulder, soft tissue structures must be released in a particular order in order in order to preserve and protect them. The surgeon will be careful to avoid damaging the physis (growth plate) or joint in any child or teen who has not completed skeletal growth yet.

There are many advantages of arthroscopic surgery. Arthroscopic examination gives the surgeon the opportunity to carefully and thoroughly examine the shoulder. As a result, damage or injury to the shoulder structures that might have gone undetected is identified and treated.

With smaller incisions possible, there is less pain and stiffness following arthroscopic procedures (compared with open incision surgeries). And studies show that with arthroscopic stabilization of a chronically dislocating shoulder, there are fewer recurrences of dislocation after arthroscopic surgery compared with nonsurgical treatment.

What do they mean when they tell us “less aggressive” care is best for an arm fracture in children? Our son ended up in the emergency department over the weekend for a broken arm that was treated less aggressively (according to the physician’s assistant we talked with). They put the forearm in a cast on the basis of a single X-ray. Then we started hearing our friends tell horror stories of other children who got a cast but really needed surgery. Did we miss something important here for our child?

Current trends in treatment and evidence-based recommendations for management of upper extremity fractures in children support a “less aggressive” approach. Less aggressive is defined as fewer diagnostic tests, less medicine, no surgery (or slower time to surgery) with less invasive surgical procedures. Splinting or casts for short periods of time under the care of a generalist (rather than a surgical specialist) may be all that’s needed in most cases.

These recommendations come from a study done at the Division of Orthopaedic Surgery in Cincinnati Children’s Hospital. Using information presented at annual meetings of two orthopedic groups, they summarized current trends in treatment and evidence-based recommendations for management of these injuries. Abstracts on the treatment of pediatric upper extremity fractures were reviewed from the Pediatric Orthopaedic Society of North America (POSNA) and the American Academy of Orthopaedic Surgeons (AAOS). The time period selected was from 1993 through 2012 (20 years).

Papers, posters, and abstracts were included with evidence from all Levels (I through IV). Level I and II were prospective, randomized controlled trials (RCT). Level III were case-control studies and retrospective comparative studies. Level IV was only case series.

Two pediatric orthopedic surgeons with special skill and training in the treatment of pediatric upper extremity fractures rated the treatment recommendations made in each publication as: 1) more aggressive, 2) less aggressive, or 3) neutral.

More aggressive meant there were more diagnostic studies performed, more medications prescribed, surgery more often than conservative (nonoperative care), and faster time to surgery. Other criteria for a classification of more aggressive included treatment by a specialist and more invasive surgery (open incision, use of pins and plates).

The majority of comparative studies and case series recommended conservative (less aggressive) care for upper extremity fractures in children.

We need some help as soon as possible. Our eight-year-old daughter has a broken arm (forearm to be exact). The on-call surgeon at the hospital recommended surgery but our pediatrician took a look at the X-rays and said a cast would be enough. If surgery is needed, it can be delayed without additional problems. We love and trust our pediatrician but the orthopedic specialist’s idea of surgery rings in our ears. Is the expert always right? Ack! I hate making decisions like this when it involves the kids!

There is a clinical trend toward more aggressive treatment for upper extremity (arm) fractures in children despite research evidence that less aggressive treatment is just as effective. Large studies that compared operative versus nonoperative treatments have concluded that less aggressive care is safe and effective.

More aggressive treatment is not to be recommended routinely. Case studies published describing individual patients with specific concerns are more likely to advise the use of aggressive treatment. Perhaps there are some reasons why the surgeon advised surgery for your daughter that must be considered.

Some surgeons may take the more aggressive approach because of improved techniques and advancing technology making it easier to perform these procedures. It’s also possible that surgeons are influenced by advertising of newer surgical techniques. Patients may even be the source of pressure to be surgically aggressive if they believe “more is better.”

In terms of research evidence, the majority of comparative studies and case series recommend conservative (less aggressive) care for upper extremity fractures in children. As your pediatrician suggested, fewer diagnostic tests, less medicine, no surgery (or slower time to surgery) with less invasive surgical procedures is advised.

The bottom line is that you want an evidence-based, least invasive treatment plan that is safe and effective for your daughter. With this in mind and the information presented here, talk with your pediatrician about your concerns. You always have the option of getting a third opinion with an orthopedic surgeon recommended by your pediatrician.