FAQ Category: Child

Growing pains in children are nothing new. Physicians back in the 1800s made note of them. But are they real? And if so, what are they really? If you ask the children affected by this condition, you’ll know the pain is very real.

The more accurate question might be: what is causing these pains? Is it fatigue? Psychological? Or something in the joint, bone, or surrounding soft tissues? Believe it or not, even with all our current technology, we still don’t really know much about the underlying pathologic or biologic cause of what we refer to as “growing pains.”

Children under the age of eight aren’t as likely to be having leg pain as a result of rapid growth. So what else could these pains be caused by? The physician must sort through several different possible diagnoses including rheumatoid arthritis, muscle cramping, bone tumors, or some other bone disease.

Blood tests are often used to look for inflammatory or infectious causes of leg pain. Imbalances of body chemistry such as calcium, vitamin D, or magnesium are possibilities though not likely in a child this age. X-rays may reveal any bone abnormalities, tumors, or cysts.

Most leg pain in children is considered benign. In other words, it hurts at the moment but over time, the painful symptoms will go away as mysteriously as they arrived. There may never be a known cause of the problem.

Many studies in adults have proven now the importance of the meniscus (cartilage)in the knee. It used to be common to have a torn meniscus just removed surgically. But years of investigation have shown that the end result of that treatment approach is early knee joint arthritis. So now, the damaged meniscus (menisci – plural) is carefully repaired whenever possible.

Your question is a good one — what about young athletes with the same type of (meniscal) injury? What kind of results do they get with arthroscopic meniscal repair? Several studies have been done in this area. A recent one from the University of Michigan in Ann Arbor helps answer your question.

They followed 49 cases of knee arthroscopic surgery used to repair knees with either an isolated meniscal tear or a combined meniscal and anterior cruciate ligament (ACL) tear.

They measured the results using level of knee pain, knee range-of-motion, and physical activity. The surgeons noted any physical limitations. Scores from a specific survey (Tegner and International Knee Documentation Committee or IKDC) designed to measure function were also included.

The authors also paid attention to results based on patient age at the time of injury and time between injury and surgery. MRIs were used to determine type of injury (isolated meniscus, meniscus plus ACL tear, type and extent of meniscus injury). X-rays showed if the physes (growth plates at the ends of bones) were still open or not as this could be an important factor in the outcomes of treatment.

With the exception of two athletes who reinjured their knees, healing was 100% after two years. Even tears in menisci that wouldn’t normally heal in an adult were restored. Good results were obtained even for cartilage located in areas of little blood supply. The ability to heal in this age group can’t be underestimated.

The status of growth plates (open versus closed) did not seem to make a difference in results. The surgeons performing this study did think that the arthroscopic technique they used (called inside-out) was a significant factor in the healing response so that’s something else to consider.

The scaphoid is the bone fractured most often in the wrist. It is kidney shaped with three distinct fracture patterns involving the middle of the bone called the waist and the two ends on either side called poles.

The distal pole (thumb side) and the proximal pole (wrist side) make up the two other segments. The bone isn’t really divided anatomically into three parts — it is just shaped in such a way that makes it easy to categorize fractures based on their location in any of these three locations.

Some of the factors that affect healing of this bone include displacement (separation) of the fracture, location (waist or proximal pole fractures take longer to heal), longer time between injury and treatment, and the presence of osteonecrosis (bone death). Healing times vary from six to 15 weeks, depending on these factors.

Scaphoid wrist fractures in children can be a complex problem. The open physes (growth plates), presence of scaphoid cartilage that hasn’t turned to bone yet, and poor blood supply to this area can make treatment challenging.

Late-presenting (chronic) fractures have the worst record for healing and recovery. Body-mass index (BMI or size) may make a difference but the specific effects of size on the recovery time from scaphoid wrist fractures has not been reported.

First, let’s start with the type of wrist fracture you are asking about. The scaphoid bone is on the thumb side of the hand. It is located at the end of the forearm with just one small bone (the trapezium) between the scaphoid and the base of the thumb.

The scaphoid is the bone fractured most often in the wrist. It is kidney shaped with three distinct fracture patterns involving the middle of the bone called the waist and the two ends on either side called poles.

The distal pole (thumb side) and the proximal pole (wrist side) make up the two other segments. The bone isn’t really divided anatomically into three parts — it is just shaped in such a way that makes it easy to categorize fractures based on their location in any of these three locations.

An acute fracture is one that has occurred (and was treated) in the last six weeks. A chronic (sometimes called late-presenting) fracture is one that is not diagnosed and/or treated until more than six weeks after the injury.

Most scaphoid wrist fractures in children are high-energy injuries. In other words, the event that caused the fracture involved trauma that occurred quickly and often with a lot of weight behind it. Speeding along on a skateboard or snowboard and taking a sudden fall, for example. Or having someone three times your size tackle you while playing football or extreme soccer.

Low-energy fractures are more likely to occur when a person falls from a stationary or standing position (e.g., losing your balance and falling off a stool or ladder or tripping over a crack in the sidewalk and falling on the outstretched hand/wrist).

Other terms you might come across as you read about fractures include displaced (two ends of the fracture separate) and reduction (surgeon puts the bone back together and holds it in place with wires, screws, and/or a cast).

Fractures in children can also involve the physes (growth plates) so you might see that word in your reading. With younger children involved in these sports, there is always a concern about the effect of the fracture on the physes. A fracture through the growth plate could alter the bone growth and result in a shorter wrist/hand on that side.

Cysts are cavities or spaces that form and usually fill up with some type of material — either fluid, blood, or fibrous tissue. In the case of unicameral bone cysts, the cavities are fluid-filled. As the cavity gets larger and larger, the area of affected bone becomes thin and weak. That’s why the bone fractures near the cyst.

In the case of children, the two bones affected most often are the humerus (upper arm) and the femur (thigh). Boys are affected by fractures associated with unicameral bone cysts twice as often as girls. Although these lesions can occur earlier, the usual age-group affected are between 10 and 20 years old.

No one really knows why unicameral bone cysts form. There are a couple of theories involving certain molecules and chemicals found in the cysts but no real answers. Treatment is also highly debated.

Without any treatment, the cyst often just gets bigger and bigger, compromising the bone. Removing the cyst isn’t always the end of the problem, either because they often come back even after treatment.

It even appears that some cysts do better without treatment. But predicting which cyst is going to expand, which cyst will disappear on its own, and when to do surgery to remove it is all under investigation.

In cases like your granddaughter, the fracture must be treated. Most likely the cyst will be removed at the same time. If the cyst is not surgically removed, the child will be watched very carefully to make sure the cyst doesn’t continue to increase in size. A stable cyst (one that is not changing in size or at least not getting larger) may just be observed using periodic imaging studies.

The surgeon may also choose to inject a steroid medication into the cyst. This treatment has been shown to help reduce the size of the cyst. It is minimally invasive but doesn’t always do the trick the first time. Several more injections may be needed before the cyst is completely gone.

Every now and then, when you rub your hand along a bone, you may feel some odd dents and bumps. That’s normal. But some people have many bony bumps or protuberances called exostoses or osteochondromas. This could be part of an inherited condition called multiple hereditary exostoses.

When something goes wrong in the gene that controls bone growth, the cells don’t line up in well-ordered stacks like they are supposed to. Instead, they form uneven, irregular outgrowths of bone. These bony outgrowths are usually covered with a cap made of cartilage.

Most of what we know about the biochemistry, cellular biology, and molecular biology of this condition comes from studies of fruit flies, zebrafish, and mice. Don’t laugh! The genetic structure and miscoding of the involved cells are remarkably similar

The result of the altered bone growth can be one bone growing longer than another or deformity as one bone curves too much. Some children have growth disturbances that give them an odd appearance (e.g., arms or legs too short compared with the spine).

How is this condition treated? Sometimes no treatment is required. The bony outgrowths aren’t painful and don’t cause any problems. In some cases, the bone growths are removed.

The major area of concern is the deformities — not just because they can limit function, but also because of the cosmetic effect on children. Surgery is often needed to correct bone alignment, put a dislocated joint back in place, and manage differences in leg- or arm-length.

It may be possible to prevent some dislocations by surgically cutting a ligament before the uneven pull has a chance to have its full effect. Exostoses of the spine can put pressure on the spinal cord or spinal nerve roots causing neurologic problems. Once again, by removing these bony overgrowths, the problem is prevented.

In the future, it may be possible to design medications that could interrupt the extra bone growth. A better understanding of the hereditary links and cellular biology is required before pharmacologic prevention can be developed.

Although what we refer to as growing pains mostly occurs in the legs (thighs, knees, shins, calves), this type of symptom is reported in the arms by a small number of children.

In either location, the pain begins most often during the night either keeping the child awake or awakening the child after falling asleep. Afternoon is another common time period when the pains are reported.

Most children experience pain lasting anywhere from 10 to 30 minutes. The frequency (how often pain occurred) seems to be much more variable. Some children report pain every day while others either have pain once a week or less often (e.g., once a month, once every three months).

The pain is often severe enough to wake the child up and cause crying. Massage and over-the-counter pain medications are enough to relieve symptoms. Some children have to rest and limit their activities before the pain will go away.

If none of these home remedies work for your daughter, make an appointment to see her pediatrician for further testing and follow-up.

Communication is always the key in situations like this. Everyone is concerned about the safety of children so approaching the topic with that point-of-view may be helpful. If you will have availability by telephone, text, or email, ask the grandparents to contact you before giving any medication.

If you are unavailable, provide them with the name and contact information for your pharmacist and/or physician. Gently, but firmly insist that they discuss any decision about medications before giving your daughter even the smallest dose of anything.

It may be helpful to include some specifics about medications in the list of information you leave with them with day-to-day details. For example, the Food and Drug Administration has guidelines for dispensing over-the-counter (OTC) liquid medications to children. It may be appropriate to give them a copy of this:

Any medication (even over-the-counter drugs) can become deadly when taken in large amounts or in combination with other chemicals. Liquid medications taken by mouth (called oral dosing) are formulated for ease of swallowing. This is helpful for the elderly, anyone with difficulty swallowing, and children.

With liquid drug products, there is a grave concern that children will be given too much of a good thing. That’s why the Food and Drug Administration (FDA) has provided guidance for dispensing over-the-counter drugs. Drug companies that make liquid medications follow these guidelines by providing a cup, dropper, syringe, or spoon to measure out the right dose.

The idea in throwing away the cups is to avoid any misunderstanding on the part of the child as to their intended use. Children who are given a tasty liquid in the cup by a parent or guardian may decide to help themselves to more at a later time without adult supervision. Discarding the cups by throwing them away permanently may help in preventing unfortunate and potentially deadly drug overdoses.

Scoliosis is a deformity in the spine that causes an abnormal C-shaped (one curve) or S-shaped curvature (two curves). The spine is not straight but curves to one or both sides.

There are three main types of scoliosis depending on when it develops. Infantile occurs from birth to three years of age. Juvenile scoliosis develops between four and nine years of age. Adolescent presents between 10 years and when growth is complete. Idiopathic means the cause of the curve is unknown.

There are many spinal curve types: fixed curves, flexible curves, structural curves, major curves, minor curves, thoracic curves, thoracolumbar curves, double curves, triple curves, and so on. Finding a way to accurately evaluate and successfully treat this condition is a challenge.

One way to approach the problem is through the use of a classification system. Such a system helps define the location, type, and severity of the spinal curve. The goal is to direct treatment so that children with the same problem get the same treatment. A secondary goal is to guide surgical treatment (when fusion is needed).

The underlying desire of treatment is to save as much motion and flexibility as possible. The surgeon gives consideration to the need for good alignment, posture, function, and cosmetics (appearance). Sometimes there’s a fine line between correcting the spinal deformity while preserving flexibility.

The Lenke classification system for adolescent idiopathic scoliosis (AIS) was first developed in 2001. There are six curve types described by this system. They are based on location (thoracic, lumbar, thoracolumbar), type (main, double, triple), and whether or not the curve is structural (cannot be corrected) or flexible (can be corrected).

Using this classification system as a guide, surgeons fuse major curves and minor curves that are structural (fixed). But there are times when individual patient factors lead the surgeon to make a different decision. These are the “rule-breakers”. For example, a structural (fixed or permanent) curve that doesn’t get fused or a nonstructural (flexible) curve that does get fused are “rule-breakers.”

The system is being evaluated and studied by different groups around the U.S. A study like this is important because what’s the point of having a classification system if the guidelines (“rules”) don’t apply to the majority of patients? When too many patients fall outside the established criteria, then treatment varies and the system breaks down.

After reviewing the records of over 1300 patients, the authors found that 15 per cent of the group did not follow the rules when carrying out surgical treatment. They took a closer look at the patients who were evaluated using the Lenke classification but treated differently than recommended by this system.

Analysis of the data showed that treatment was more consistent when using the Lenke system (compared with before the system was put into place). Treatment deviated most often when the less common curve types were the focus of treatment. But for the most part, the system did give surgeons a better handle on which curves were structural versus nonstructural and therefore when to fuse the spine.

Future studies are needed to measure the results of treatment when the Lenke classification system is followed and compare those results to cases where the rules are broken. Another area of research focus might be looking at reasons why surgeons choose to ignore the treatment recommendations based on this classification system and outcomes in those cases as well.

Adolescent idiopathic scoliosis (AIS) isn’t an easy problem to treat. Just ask any orthopedic surgeon involved in the treatment of children with this condition. The cause of this type of spinal curvature in teens is poorly understood. That’s why it’s called idiopathic (unknown).

There are many spinal curve types: fixed curves, flexible curves, structural curves, major curves, minor curves, thoracic curves, thoracolumbar curves, double curves, triple curves, and so on. Finding a way to accurately evaluate and successfully treat this condition is a challenge.

One way to approach the problem is through the use of a classification system. Such a system helps define the location, type, and severity of the spinal curve. The goal is to direct treatment so that children with the same problem get the same treatment. A secondary goal is to guide surgical treatment (when fusion is needed).

The underlying desire of treatment is to save as much motion and flexibility as possible. The surgeon gives consideration to the need for good alignment, posture, function, and cosmetics (appearance). Sometimes there’s a fine line between correcting the spinal deformity while preserving flexibility.

Recommendations may differ based on geographical location (east versus west), the way the surgeon was trained, and the tools used to evaluate the curve. For example, there are three different systems used to classify and guide treatment: the Cobb system, the King system, and the Lenke system. Each one takes a slightly different approach.

The oldest system in use is the Cobb method. The most recent one is the Lenke system (developed in 2001). The King classification system may be the least commonly used system as researchers have questioned its reliability. Depending on which method your two surgeons used, you might get two different treatment recommendations.

In a situation like this, you may want to get a third opinion. You can certainly ask the two surgeons involved to consult with one another in order to help you understand treatment recommendations — and of course, make the best treatment plan possible for your daughter.

You have the name correct; Sever disease. Sever disease is also known as Sever syndrome or by its medical term: calcaneal apophysitis. Sever disease is a painful heel condition that affects growing adolescents between the ages of nine and 14.

In this condition, the growing part of the heel bone 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.

Heel pain is the main symptom. 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 and foot may feel stiff, especially first thing in the morning. The heel tends to hurt during activity and feel better with rest. The calf muscles and Achilles tendon may also feel tight.

Youth who play running and jumping sports (especially on hard surfaces) are most prone to this problem. Sever disease or 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.

Once the diagnosis has been made, treatment consists of activity modification (the child may have to stop participating in sports activities for a short period. Children with Sever syndrome should avoid running on hard surfaces. Running barefoot should be avoided. The impact worsens the pain and inflammation. 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.

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 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. 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.

You can always decline any medical testing and/or treatment but it may not be in the best interest of the patient. In the case of Sever syndrome or disease, we mention in our Patient’s Guide to Sever’s Syndrome that physicians may order X-rays in order to make sure there isn’t something more serious going on.

The X-ray may appear to show small cracks within the bone at the back of the heel. The cracks are the bone growth center and are normal. However, even kids who have no pain at all may seem to have these cracks on X-rays.

The surgeon is looking for any lesions that require additional treatment. More serious problems such as true bone fractures, fibromas (or other tumors), or cysts could be present along with the Sever disease. Any abnormal radiographic findings will likely be followed up with MRIs in order to determine the best treatment approach possible for the problem(s) identified.

Let your surgeon or other physicians know of your desire to minimize the child’s exposure to radiation. They will be able to guide you through this process balancing the need to minimize costs, reduce radiation exposure, yet find out what’s wrong and plan treatment accordingly.

Over the past 50 years, orthopedic surgeons have changed and improved the way spinal deformities are corrected in children. Safer and more effective ways to correct and hold the spine straight have been developed.

It started with the use of the rods you mentioned. Placed alongside the spine to correct the curve, Harrington rods were used for a long time before newer, improved methods of fixation were developed.

Wires were used for awhile. But there was a concern about the wires poking into the spinal cord and causing problems, so hooks were tried next. Hooks provided three-dimensional correction that was better and safer than wires.

Most recently, screws placed through the pedicle (supporting column of the vertebral bones) have replaced rods, wires, and hooks. Pedicle screws are used in adults as well as children. But there is one safety concern with screws: putting them in the wrong place (misplacement).

Computer-assisted navigation is helping to put an end to that problem. Over time, with continued improvements in technology, we should see even better accuracy rates of screw placement than the currently reported 95 per cent.

It sounds like the surgeon has suggested using pedicle screws as a way to hold the spinal segments in place. Pedicle screws are placed through the supporting structure of the pedicle (a rigid column of bone on the backside of the vertebra).

Correcting a scoliosis (spinal curvature) and holding it in its new straighter location can be quite a challenge. In the past, long rods were placed on either side of the spine to hold it in place.

Over time, the rods have been replaced with wires, then hooks, and now screws. Each one of these fixation devices has its pros and cons. But the pedicle screws have a reportedly high success rate with good placement.

In fact, a recent study from the University of Minnesota reported an overall accuracy rate of 95 per cent in screw placement among children. That is even better than the 91 per cent accuracy rate for adults.

The question about using pedicle screws in children who have not completed their growth is a good one. Could this technique compromise the bone and slow (or even stop) bone growth? In theory, maybe — but in practice, no one has demonstrated or reported this yet. More studies are needed but for now, the use of pedicle screws in young children and teens is safe and effective.

Pills that taste bad or are too hard to swallow can be difficult to get down even for adults. But when it comes to giving meds with similar problems to children, the task can be impossible.

Scientists have started finding alternative ways to administer medications. One of those ways is called intranasal atomized medications. As the word intranasal suggests, the medication is delivered into the nose. Atomized tells us the drug is broken down into tiny particles that are sprayed into the nasal passages.

The drug still has to be sprayed twice (once on each side) but the amount of medication that is absorbed is much greater than with nose (nasal) drops. The child tolerates intranasal atomized medications well because a special device called a mucosal atomizer is used. This tool is inserted into the nasal opening and delivers the drug quickly and easily.

Intranasal atomized medications can be used for drugs that must be given over a long period of time (e.g., daily seizure medication). They can be used for more immediate problems like nosebleeds or a narcotic drug overdose. Orthopedic surgeons like this method of drug delivery to manage pain and for sedation before and during surgery.

Intranasal medication for children has not received approval by the Food and Drug Administration (FDA) yet. That doesn’t mean physicians can’t use this method of drug delivery.

Proper equipment must be used by health care professionals who are trained and skilled in using this form of drug delivery. With continued studies enough evidence will eventually be gathered to support FDA approval. In the meantime, you will have to ask your pediatrician (or the prescribing physician) about the use of this application method for your grandson.

Separation anxiety between parent and child is a common problem. Nurses who prepare patients for surgery are usually already prepared when they know the patient is a child. But it can’t hurt to call the hospital or surgery department where the procedure will be done and give them a heads up as to what to expect.

If you can talk with your partner about the problem, it may possibly help ease her anxiety as well. Pre-sedation is one way to reduce the distress over parent-child separation. In this case, we are referring to sedating the child, though some parents request a mild sedative for themselves to help ease the transition.

One of the new tools surgical teams have available for use with children is called an mucosal atomizer device (MAD). It takes medications and turns them into tiny droplets that are sprayed into the nose.

Orthopedic surgeons like this method of drug delivery to manage pain and for sedation before and during surgery.

Surgeons say that atomized intranasal pain relievers are really appreciated when the child is in severe pain from bone fractures, joint dislocations, or other orthopedic emergencies.

Other physicians sing their praises when it comes to managing pain from burns or large surface injuries to the skin (called abrasions). And during an emergency, using a spray on a child rather than poking around to gain access to a vein for an intravenous delivery significantly reduces anxiety and trauma associated with the injury and its treatment. The intranasal spray is also helpful in first calming a child when an IV is unavoidable.

There’s one other big advantage in using intranasal atomized medications in children and that’s reducing parental distress. When the child is sedated before surgery, there is less distress in separating the parent and child in order to take the child into the operating room.

Studies show that intranasal drug delivery isn’t as effective as intravenous administration (with a needle into the vein). But that can be remedied by increasing the amount of drug (dosage) atomized into the nasal passageways. The sedating (calming) effects of drugs given intranasally are slower than the intravenous (IV) route but not by much.

Can idiopathic scoliosis (IS) be improved through bracing? That is a question that has been studied and debated for years. There are plenty of studies that conclude it is not possible, especially when the curve is more than 45 degrees in a growing child. But the results of this study may bring new information to that conclusion.

Idiopathic scoliosis refers to a curvature of the spine that has no known cause. The child does not have a neurologic or neuromuscular problem like muscular dystrophy or cerebral palsy that could account for this problem. Treatment in the past with bracing and exercises just hasn’t been effective in large curves.

But the results of this new study from Italy show that in some children, the curve can be stopped and even improved with bracing and exercises. They claim the difference is in patient compliance (willingness to follow a strict program) and the use of good bracing. Oh yes, and time — the program of bracing and exercise was followed for years (three to seven).

The study was small in number (28 children) and all were skeletally immature (still growing). At age 16, you may still have some growth left (if you are a boy). Most girls have completed their full growth potential by this time.

The children in the Italian study were told to wear the brace everyday, all day (at least 23 hours/day) for a full year. After six months, the child could reduce his or her brace wearing time by two hours. And every six months after that, the brace wearing time could be decreased by two more hours until the child was weaned from the brace altogether.

At the same time, physical therapists helped the children with postural and stabilization exercises. This type of rehab program helps retrain motor control of the muscles. The goal was to maintain the correction received with the brace during and after the weaning time.

The idea behind this bracing/exercise/weaning program is that the slow method allows the postural system to adapt. The intended results are improvement of the curve and maintenance of any spinal correction achieved.

We can’t really generalize from this study and say that bracing for scoliosis is effective for large curves. If you are wearing a brace but still progressing, there are several things you can check on.

First, is the brace still fitting and is it the best possible brace for you? There are several types to choose from. Second, are you still growing (an X-ray will give your surgeon the answer to this question). Third, are you wearing the brace as prescribed? Are you doing your exercises correctly and consistently? Failure to follow the program as prescribed may be a key factor in the success or failure of a conservative approach to this problem.

The question of whether or not bracing can improve scoliosis has been studied and debated for years. There are plenty of studies that conclude it is not possible, especially when the curve is more than 45 degrees in a growing child. But the results of a new study from Italy may bring new information to that conclusion.

The group of 28 patients in question was older than 10 years. They were skeletally immature (i.e., still growing) and had at least one spinal curve that measured on X-ray as 45-degrees or more. Surgery (usually recommended for curves this large) was refused by the patient and family. That left the surgeon with no choice but to treat the curve conservatively as best as possible.

Each child was evaluated individually and prescribed one of three braces (Risser, Lyon, Sforzesco). Risser actually refers to a body cast used for scoliosis. The Sforzesco brace has since replaced casting. The two braces (Lyon and Sforzesco) are specifically designed for scoliosis.

The children were told to wear the brace everyday, all day (at least 23 hours/day) for a full year. After six months, the child could reduce his or her brace wearing time by two hours. And every six months after that, the brace wearing time could be decreased by two more hours until the child was weaned from the brace altogether.

At the same time, physical therapists helped the children with postural and stabilization exercises. This type of rehab program helps retrain motor control of the muscles. The goal was to maintain the correction received with the brace during and after the weaning time.

The idea behind this bracing/exercise/weaning program is that the slow method allows the postural system to adapt. The intended results are improvement of the curve and maintenance of any spinal correction achieved.

How well did it work? Three-fourths of the children improved by at least five degrees (and some by as much as 15 degrees). The curves that improved the most were in the lumbar spine (low back). Only one child got worse.

The authors concluded that it is possible to successfully treat scoliosis curves 45-degrees or larger without surgical fusion. It takes good patient cooperation over a long period of time. Motivation seems to be a central key to success with conservative care of this type. A team approach with involvement and communication among family, patient, surgeon, physical therapist, and orthotist (brace maker) is also essential.

You are correct that the American Academy of Orthopaedic Surgeons (AAOS) recently released Clinical Practice Guidelines for the diagnosis and treatment of osteochondritis dissecans (OCD). Althought OCD can affect other joints, the knee is involved most often, so the guidelines are specifically directed at that particular joint.

Osteochondritis dissecans (OCD) is a problem that can affect joints such as the elbow and knee. It is much more common in the knee than anywhere else. In this condition, a piece of cartilage and the underlying bone have been damaged. In some cases, the damaged fragment separates from the bone and floats freely within the joint.

Shear stresses from repeated motions probably start the problem. Poor mechanics and fatigue of the muscles and ligaments are added to the shear load. Combined together, these forces cause the cartilage to separate from the bone, taking a piece of the underlying layer of bone with it.

OCD is not self-limiting condition. In other words, it doesn’t get better on its own. In any joint, the joint surface damaged by OCD doesn’t heal naturally. But other than that bit of information, the natural history (what happens over time) and the best way to treat this condition isn’t known.

There are some studies that show over time, OCD lesions can lead to further degenerative changes in the elbow. Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis. That’s why proper treatment (based on evidence of what works and what doesn’t) is so important.

To read the full report and summary of clinical practice guidelines for the diagnosis and treatment of osteochondritis dissecans, you can go to: http://www.aaos.org/research/guidelines/OCD_guideline.pdf

Here’s a brief summary of their findings. Most of the recommendations made by this group were graded as inconclusive — meaning there’s not enough evidence to say for sure. Based on clinical experience combined with data from the studies collected, the panel was able to agree (consensus) on four recommendations.