FAQ Category: Child

You are facing a dilemma that doesn’t have a perfect answer but we may be able to offer some useful information. For your current situation, you can take photos and present them to the judge to show why your child was not in a safety seat. You may be able to appeal one traffic fine this way.

As to whether or not the method you are using is unsafe, studies haven’t been done to prove or disprove the safety of various restraint methods for children in spica casts. And those casts come in several different arrangements.

There is the two-legged (goes down both legs) version. There is also a one-legged spica cast and a one and a half-legged (covers one leg down to the toes but only goes down to just above the knee on the other side) spica cast. Some children are placed in a semi-flexed position (for hip fractures) while others are straight-legged.

There is a commercially available special car seat for smaller children in a flexec spica cast and a chest restraint system for larger children. The children in the middle sizes fall through the cracks. Some parents arrange for ambulance transport. The child is strapped on a flat bed, which is tied down inside the ambulance. It’s a very safe way to travel but unless your insurance company covers the cost ($500 to 600 per trip), it can be an expensive way to travel.

Some hospitals keep some of the special car seats on hand and have a loaner program. Others will refer you to a rental company. If neither of these exists in your area, then travel becomes prohibitive.

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.

Osteochondritis dissecans of the knee is a fairly rare condition so conclusive evidence to guide treatment and follow-up are sketchy at best. Here’s what we can tell you from a recent set of guidelines put out by the American Academy of Orthopaedic Surgeons (AAOS).

A group of pediatric surgeons from all around the United States worked on this document. It’s called clinical practice guidelines (CPGs) for the treatment of osteochondritis of the knee in children. Sixteen (16) recommendations [that’s what they called clinical practice guidelines (CPGs)] were published.

For those who don’t know, osteochondritis dissecans (OCD) is a problem in the cartilage of the knee that affects the end of the femur (big bone of the thigh). The problem occurs where the cartilage of the knee attaches to the bone underneath.

The area of bone just under the cartilage surface is injured, leading to damage of the blood vessels to the bone. Without blood flow, the area of damaged bone actually dies. A joint surface damaged by OCD doesn’t heal naturally.

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.

And in your son’s case, follow-up remains important. Seeing his surgeon for periodic check-ups and reporting any new knee symptoms are important. The surgeon will complete a history, physical examination, and order imaging studies (X-rays, MRIs) to see what kind of healing response is present (and watch for signs of osteoarthritis).

Specific treatment recommendations based on identifiable patient characteristics (e.g., age, weight, activity level, bone maturity) may change over time. As new studies are done and more conclusive evidence is found, clinical practice guidelines may change. This is true even for those whose treatment was completed years ago.

For now, there’s probably nothing to be done. Patients who have no symptoms can engage in activities as they feel comfortable. Keeping up on strength and flexibility may prove useful as well.

There is no way to tell what is going on without a medical evaluation. The best thing to do is make an immediate appointment with your pediatrician or the surgeon who treated your son. The joint pain may be related to the previous injury or it could be something else.

Pain, skin or joint swelling, fever (even low-grade and intermittent) are all signs and symptoms of possible infection. Although very rare, children can develop a condition called septic arthritis of a joint. The condition can develop days, weeks, even months after an injury like this elbow fracture.

It may be necessary to X-ray the arm and a blood sample sent to the lab for analysis. Elevated white blood cells, sed rate, and/or C-reactive protein are tip offs that there may be an infectious process going on.

The X-ray will show if the fracture has been disrupted in any way. An MRI may be needed to look for abscess formation, unresolved hematoma (pocket of blood), or other changes in the bone, joint, or surrounding soft tissues.

Early diagnosis and treatment are important in order to preserve the joint and joint function. When caught early, treatment may be as simple as an antibiotic. If there is infection and pus within the joint, then cleaning that joint with a saline solution and removing any infection or dead tissue may be necessary.

But again, the first step is to get back into the physician’s office for an evaluation. Don’t jump to any conclusions until proper testing has been done to identify the problem and the underlying cause.

Septic arthritis is destruction of a joint from an infection such as staphyloccocus, streptococcus, or salmonella inside the joint. Septic arthritis in children after a closed bone fracture is rare.

With a closed fracture, there is no disruption of skin or other soft tissues. In other words, there was no obvious or known way for the bacteria that caused the infection to enter the body.

In some cases (usually adults), septic arthritis develops after the person has had an infection somewhere else in the body. For example, pneumonia, urinary tract infection, or an infected IV in a hospitalized patient is the source of the bacteria. In children, strep throat, measles, tonsillitis, or upper respiratory infections are more likely to cause bacteria that can move through the blood system to a joint.

When there is no history of any of those potential problems or causes surgeons look for a different mechanism causing the infection. Some theories put forth include bacteria from a hematoma (pocket of blood caused by the fracture) might have entered the joint. Or perhaps there was an unknown lung, kidney, or bladder infection.

Like your daughter, the infection typically develops days to months after the original injury. Symptoms of persistent pain, fever, and erythema (redness of the skin) bring the children back to the surgeon for further follow-up.

Without knowing exactly what brought the infection on, the important thing is to identify the bacteria and take an antibiotic specific to that organism. Many bacteria have become resistant to antibiotics so it’s important to find the right one and avoid taking too many antibiotics.

It sounds like your daughter received the proper care needed and is well on her way to recovery. If there are any other suspicious symptoms that crop up, don’t hesitate to call the physician treating her. Early intervention is the key to a successful outcome in cases like this.

Vitamin D has been in the news a lot lately. Are we getting enough? Should we take supplements? What about people who can’t get enough sunshine to make vitamin D needed for bone health? And what about children? What are “normal” levels of vitamin D for them? These and many other questions are being answered and studied around the world.

Vitamin D helps regulate calcium absorption from the gut (gastrointestinal tract). The skin makes vitamin D but relies on sun exposure to do so. Calcium is an essential ingredient in strong bones.

It’s clear that there are some risk factors for low vitamin D. For example with so much time spent indoors and lower sunlight levels year round in the northern hemispheres, many children around the world have reduced levels of vitamin D.

Other risk factors for decreased vitamin D include obesity, increased skin pigmentation (dark skin), older age, and not enough vitamin D in the diet. Children with metabolic bone disorders such as osteogenesis imperfecta (weak and brittle bones) and rickets are at a much greater risk for poor bone healing, which can be compounded by low vitamin D levels.

Normal levels of vitamin D for children have not been clearly established. There are some general guidelines but scientists aren’t sure whether the same range should be used for all children (all ages, all geographical locations, all ethnicities). For now, vitamin D status is measured based on blood levels of a chemical compound needed to produce the active form of vitamin D: 25-hydroxyvitamin D or 25 OHD.

Next time you take your child or children in to see the pediatrician or your primary care physician, be sure and ask him or her this question. There may be some concerns based on risk factors to take a baseline measurement of the children’s vitamin D levels. Otherwise, general counsel is usually to get some sunshine everyday when possible, use sun protection for excessive sun exposure, take a multivitamin, and eat a balanced diet.

When it comes to traumatic injuries, children have amazing recuperative powers. In many situations, they heal faster with fewer problems than adults with the same injuries. But you should be prepared for some potential problems

Avulsion (traumatic amputation) of the digit (finger) in children can be a very complex and challenging injury to repair and reconstruct. The term for reattching a finger is replantation. Using a high-powered microscope is necessary in order to match up and reconnect tiny blood vessels and nerves.

The procedure becomes more difficult when the amputation is complete and the skin and bone must be restored. Replantation may not even be possible if the injury involves crushing of the soft tissues.

Once the surgeon is able to assess the condition of the tissues, it will be easier to plan what can be done. The chances of successful replantation are far less if only one blood vessel is left to supply the finger with an adequate blood supply. Having two working arteries gives a much better chance for healing and recovery.

Other factors that can have a negative effect on the results are the presence of pain, which in turn, increases anxiety. When pain and anxiety occur together, spasming of the blood vessels develops. The net result is reduced blood supply to the replantation (i.e., reattached finger). This development can also affect the replanted finger that is trying to recover.

Not too surprising is the fact that a long delay between the traumatic injury resulting in amputation and the reconstructive surgery needed to reattach the digit lowers the success rate.

The good news is that these days it is possible to perform replantation surgery for amputated digits (fingers). That wasn’t possible in years past. With the development of microsurgical techniques (using a very high-powered microscope) and special surgical tools, this type of surgery is both possible and successful now.

Success rates reported in the published literature for replantation of fingers in children remain low (53 per cent). Despite some reports of low survival rates, there are others who have published studies with an 80 per cent success rate. In those cases, the reattached finger continues to grow as well.

In a recent study from a children’s hospital in France, hand surgeons who performed microsurgery in children with traumatic digital avulsion report their results for 23 patients. In one-third of the cases, they were unable to save the finger and the child was left with an amputated stump.

There may be some specific reasons why one child will have a successful result and another doesn’t. Looking back at the results and comparing them to the records of patients helped these hand surgeons identify key factors that predicted problems ahead.

These items are referred to as prognostic factors for survival. They included the number of arteries that can be recovered (two is essential), repairing torn blood vessels without a graft, and large sized blood vessels.

Only having one working artery to supply blood to the finger is linked with poor finger survival. Smaller damaged blood vessel have the worst prognosis for survival. Pain and anxiety reduce blood supply to the reattached finger because they cause spasming of the blood vessels. The net result is reduced blood supply to the replantation that is trying to heal.

Not too surprising is the fact that a long delay between the traumatic injury resulting in amputation and the reconstructive surgery needed to reattach the digit lowers the success rate. When both skin and bone must be reconnected, the risk of failure is greater.

Surgical management of such injuries is not always easy to plan out. Because of the many and varied factors just mentioned, making accurate statistical predictions about success versus failure is difficult. There may be times when an amputated finger in a child just cannot be replanted.

In some cases, the reattached finger takes beautifully. In those children who do not have a successful outcome, a second surgery to remove the dead tissue is required. Parents and children who are old enough to understand should be informed of the risks, factors predicting success or failure, and possible prognosis.

Most adults do think about hip arthroscopy exams as being for hip pain from age-related degenerative osteoarthritis. Many are thinking they might need a hip replacement. But, in fact, inserting a surgical scope into the hip of a child or adolescent can be a very useful diagnostic tool.

Children can have many different hip disorders that would be better treated if the surgeon could look inside the hip and see exactly what’s going on. That’s what arthroscopy offers over a simple X-ray or even the more detailed CT scan or MRI.

Hip problems in patients 18 and under range from juvenile rheumatoid arthritis and fractures to labral (cartilage) tears and tendinitis. Treatment of specific hip diseases such as Legg-Perthes and slipped capital femoral epiphysis (SCFE) is also aided by arthroscopic exam.

More and more children are participating in sports and activities that affect the hip such as gymnastics, ballet, track and field, and horseback riding. The recognition of a hip problem called femoroacetabular impingement (FAI) in children has really put hip arthroscopy into use for this age group.

It is expected that the need for arthroscopic exam to diagnose and treat a variety of hip disorders will continue to expand its use in the near future.

You have described a procedure called a hip arthroscopy. Using a special type of real-time X-ray called fluoroscopy, a highly trained surgeon does indeed insert a scope into the joint. With the ability to broadcast a picture, this tool shows the inside of a joint such as the hip on a computer screen.

It is a procedure that is used everyday in adults. Arthroscopy is becoming more widely used in children and adolescents as well. Complications can arise but the reported complication rate is low (1.8 per cent). And most of the problems that develop are mild and/or temporary (e.g., nerve palsy, abscess around a stitch).

Rarely, there can be broken hardware when a surgical tool is damaged while inside the joint. The surgeon has to stop the main procedure and take care of the new problem but no permanent harm is done.

Studies in this area show that concerns about damaging the growth plate, altering bone growth, or injuring developing cartilage are unfounded. These events are possible complications but don’t seem to occur.

Hip arthroscopy in children and adolescents is a valuable diagnostic tool. It is safe and effective in the hands of a skilled and highly trained orthopedic surgeon.

Your child may have a condition referred to as early onset scoliosis (EOS). EOS can be a challenging problem and studies to provide evidence-based treatment just aren’t available.

According to a recent on-line survey completed by pediatric orthopedic surgeons, treatment varies depending on two major factors: the age of the child and the type of clinic or hospital where treatment is delivered. For example, children under the age of two are more likely to be treated conservatively (nonoperative care). This is true even if there is a severe curve. But by age five, surgeons choose surgery more often to treat severe curves.

Children receiving care at a pediatric orthopedic specialty hospital are more likely to be placed in a series of casts designed to gradually straighten the spine as much as possible. Care received at a university-based or private pediatric hospital is more likely to be with bracing.

Some of the treatment choices do depend on the equipment present in various settings. Casting tables, halo traction, and customized devices that help regulate the amount of traction force applied aren’t always available. Most of the surgeons who responded to this survey had the necessary equipment and made use of it.

The intent of treatment for early onset scoliosis (EOS) is to keep the spine as straight as possible using nonoperative approaches until fusion can be done. Serial casting works better for younger children.

A child the age of yours (less than two) will almost always receive conservative (nonoperative) care. Delaying tactics like using serial casting are advised for as long as possible without compromising final results. Close (regular) monitoring will be needed to determine if and when a change in treatment is needed.

Scoliosis is an abnormal curvature of the spine. Idiopathic scoliosis means the cause of the curvature is unknown. Sometimes scoliosis is the result of a neuromuscular disorder such as cerebral palsy or muscular dystrophy.

Idiopathic early-onset scoliosis (EOS) is a curvature that occurs in young children (under age five) for no apparent reason. The curve can progress rapidly causing rotation of the ribs and chest. This twisting squashes the organs (e.g., heart, liver, lung) and compromises their function.

In young children, surgeons try to avoid spinal fusion because the child is growing. Many favor the use of serial casting to realign and hold the spine as the child grows. Sometimes halo-traction is used first to pull the vertebral (spinal) bones apart and lengthen the spine as much as possible before putting a cast on to hold the spine in place.

Reversing the spinal deformity using these nonoperative techniques is more likely to work in younger children (under age three). Older children with severe curves may be treated using something referred to as “growing rods”. These metal rods placed alongside the spine to hold it in place are telescoped and can be lengthened to “grow” as the child grows.

The intent of treatment for early onset scoliosis (EOS) is to keep the spine as straight as possible using nonoperative approaches until fusion can be done. Each child is evaluated individually and decisions made in the best way possible with the information currently available.

Clubfoot deformity present at birth is usually treated right away following a protocol developed by an orthopedic surgeon (Ignacio Ponseti, MD). Dr. Ponseti died in 2009 but was Professor Emeritus in the Department of Orthopaedic Surgery at University of Iowa Hospitals and Clinics.

The Ponseti Method or Technique is a non-surgical treatment that uses a series of casts, followed by a brace, to correct congenital clubfoot. Each week, the surgeon manipulates the bones of the foot into as close to neutral alignment as possible.

The bones are then held in place by a cast. Once a week the cast is removed, the bones are moved again as close to normal as possible and another cast wrapped around the leg to hold everything in place. This weekly treatment continues for about five to six weeks (or until maximum correction possible is achieved).

Some surgeons have experimented with doing the procedure twice a week to speed up the process. Five weeks can be whittled down to three weeks if performed every three-to-five days. This modified approach has not been adopted by everyone because there have been some reports of swelling in the feet and toes.

But a recent comparison of the standard (once a week) Ponseti method against a modified (twice weekly) approach showed that faster results are possible without problems. The treatment must be followed by a splint worn on the feet to hold the legs in proper position.

After surgery, feet are maintained in the corrected position using a special brace or splint called Dennis Browne abduction boots. High-top shoes attached to a bar between the shoes hold the child’s feet and ankles apart.

The splint is worn 24 hours/day everyday for three months. After three months, the brace is only applied at night while the child is sleeping. Bracing must be continued for two more years.

Encouragement and support of the baby’s parents in following the surgeons directions is probably the best way to help. Studies show that noncompliance with the home program leads to recurrence of the problem.

Clubfoot is an unmistakable deformity present at birth. The foot is twisted (turned under and towards the other foot). The medical terminology for this position is equinus and varus.

Equinus means that the toes are pointed down and the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

The medical term for clubfoot is Congenital Talipes Equinovarus. Congenital means that the condition is present at birth and occurred during fetal development. Clubfoot mainly affects three bones of the foot: the calcaneus (heel bone), talus (just above the heel bone), and navicular (bone next to the talus).

The standard treatment for a clubfoot deformity in infants and young children is the procedure you are becoming familiar with: the Ponseti Method. Developed by an Italian physician, the Ponseti Method involves manipulating (moving) the bones of the foot and ankle toward a neutral position of alignment. The bones are then held in place by a cast.

Each week the cast is removed, the bones are moved again as close to normal as possible and another cast wrapped around the leg to hold everything in place. This weekly treatment continues for about five to six weeks (or until maximum correction possible is achieved).

The reason this approach works is that manipulation stretches the still very flexible joint capsule ligaments, tendons, and muscles in infants and young children. The Ponseti method also corrects the abnormal relationships of the bones in the foot. By aligning the bones where they belong, this treatment even has the potential to reshape the bones so that they fit together as they should.

A corrective brace is worn after the Ponseti treatment is completed. Many studies over the years have shown that just wearing the brace is not enough to correct the abnormal ankle and foot alignment. Combining manipulation with immobilization followed by corrective bracing has the best results overall.

You may be referring to Dr. X-F Li at the University School of Shanghai in China who recently reported on the use of pedicle subtraction osteotomy to correct congenital spinal deformity in children. The results of that study were published in The Spine Journal (February 2011).

In that same journal Dr. M. N. Imrie from Children’s Hospital at Stanford University wrote a commentary on the study and the procedure. She also offers a nice review of congenital scoliosis including what it is and how it is treated.

Anything “congenital” means it is present at birth. In the case of congenital scoliosis, there is a curvature of the spine caused by a defect in the vertebral (spinal) bone. There are several different types of spinal defects that can cause this type of congenital scoliosis.

The pedicle subtraction osteotomy for the treatment of mild to moderate congenital scoliosis was reported to be safe and “simple.” It’s that word “simple” that Dr. Imrie takes some exception to.

In this procedure, the surgeon removes a pie-shaped piece from the deformed hemivertebra. Along with the piece of vertebral bone, they also remove the transverse process — that’s the bony bump you feel along the back of your spine. The effect is to allow the remaining edges of bone to collapse toward each other.

The surgeon guides either side of the remaining bone fragments to move together — enough to close the gap formed by removing the piece of bone. The end result is correction of the curve. It’s called a subtraction osteotomy because only a portion of the deformed vertebra is removed or taken away (subtracted).

But there are several limitations to this procedure. First, the hemivertebra has to be large enough to allow a chunk of it to be removed. Some are too small for that. Second, since only part of the bone is removed, the curve correction is less than if it were removed completely. And third, this method won’t work if there is a rigid bar of bone present because of a segmentation deformity.

Dr. Imrie agrees that the reduced operative time and smaller blood loss are important advantages of the subtraction osteotomy. But the surgical technique described with this approach is not simple. Highly skilled spine surgeons with the right kind of experience and expertise are needed to perform such procedures.

In addition, the patient must be monitored carefully for any damage to the spinal cord or spinal nerve roots. This type of neural injury could result in sensory and/or motor loss that could even be serious enough to cause permanent paralysis.

Only 12 patients were included in the study. And only those with a defect at the T12 vertebra were operated on with this new technique. Despite the positive outcomes, Dr. Imrie urges caution before adding this procedure as a confirmed, safe treatment option.

Further comparative studies are needed with children of different ages, with different types of deformities, and comparing results to other more tried and true surgical approaches. The first report of pedicle subtraction osteotomy is important but not the final word.

Anything “congenital” means it is present at birth. In the case of congenital scoliosis, there is a curvature of the spine caused by a defect in the vertebral (spinal) bone. There are several different types of spinal defects that can cause this type of congenital scoliosis.

The first is the failure of the vertebrae to form normally. For example, there may be only one half (one side or the other) of the vertebra. This type of defect or anomaly is called a hemivertebra (hemi means half). Or there may be a wedge shape to the normally block-shaped vertebra.

Either of these problems changes the way the vertebrae above and below the hemivertebra stack up. Without a squarish-shaped bone to rest on, the other bones tilt to one side. The effect is like dominoes: each bone shifts in position until the entire spine is listing or curved to one side.

That sounds fairly simple but it does tend to get a bit complicated when other structures are examined. The discs between the hemi- or block vertebra may be fairly normal but sometimes they are only partially there or completely missing.

Without these important supporting structures, the spine (and attached trunk) cannot grow normally. The surgeon must take all of these structural changes into consideration when forming a plan of care. But before we look at treatment options, let’s finish the discussion of types of spinal defects a child can be born with that cause scoliosis.

Besides the formation problems already discussed, there can also be what’s referred to as failures of segmentation. This means instead of each vertebral body being formed separately with discs and endplates in between each adjoining vertebra, two (or sometimes more than two) vertebra are fused together and form one unit.

Segmentation problems are divided further into two groups: block and bar. Block segmentation means both sides of the bone are solid. Bar segmentation refers to just one side (either right or left but not both) being fused. It is possible to have both types if more than two segments are involved.

Now, what about treatment? Any parent, family member, or caretaker of a child with this condition wants to know what can be done? Bracing, casting or doing nothing have not been shown helpful. The curve gets worse.

And bracing has even been shown to keep the chest wall from moving so the trunk cavity doesn’t grow properly. Rib and trunk expansion are essential for proper breathing and growth of all the internal organs. The next likely solution is surgery.

But there’s nothing simple or easy about this problem. There are many different types of surgery that can be done. Fusion-based approaches have been used for a long time with differing results. The deformed vertebra is removed and the remaining vertebrae above and below are fused together with bone graft and hardware fixation (metal plates, rods, screws).

Fusionless surgery has also been developed. The surgeon inserts “growing” rods that can be lengthened as the spine grows. This keeps the child from having stunted growth and makes room for all the organs.

Each of these approaches (fusion versus fusionless) has its own advantages and disadvantages based on “indications” (i.e., when to use it). The child’s age and the severity of the deformity are key factors in the decision.

How cartilage and bones grow and develop is a complex series of steps. There are feedback loops that involve hormones, signalling pathways, and as yet unsolved mysterious mechanisms.

So when something goes wrong and a child develops too much inward or outward angling of the bones, it’s not always clear what happened or what to do about it. There may be inherited or genetic factors we don’t know about that can affect the final outcome.

If the problem is mild, the orthopedic surgeon may advise a “watch-and-see” approach. Bone growth, bone alignement, and closing of the growth plates is different from one child to the next.

There is some evidence that individual factors such as activity levels may make a difference. For example, weight-bearing through the joint causes load and pressure that stimulates bone growth. But the bone seems to grow the most when the child is non-weight-bearing during rest or sleep.

At age four, there is still quite a few years left for the bones to develop and the child to reach full skeletal maturity. But if the problem looks to be getting worse instead of better, intervention is advised.

The optimal timing for correction of the problem remains unknown. Common sense tells us earlier is better but there may actually be an optimal time — and that “optimal” moment may be different from child-to-child.

There is also a guided growth system now available to treat this problem. A flexible band placed across the knee joint and held in place with two screws makes it possible to slowly but safely correct the problem as the child grows. This management tool is quickly replacing the old method of surgical osteotomy (removing bone to change the tilt or angle).

Your surgeon will guide you through this time of watching, waiting, and intervening as needed. Knowing about the different treatment options will help you ask questions and get the best treatment available for your child. This is especially true if it starts to look like the problem isn’t going to self-correct early on.

Tension banding or guided growth is a new surgical technique for the treatment of angular deformities. Angular deformities include too much outward bowing of the bones that make up the knee joint or an excess inward angle we refer to as being “knock-kneed.” Guided growth is replacing the previous “gold standard” treatment of surgical osteotomy.

Instead of cutting a piece of bone out and realigning the affected bones and joints (that’s what an osteotomy does), a special device called a flexible tension band is used instead.

The band spans each side of the knee joint and is held in place with two screws. The band doesn’t prevent bone growth but it slows growth down. This treatment makes it possible to slowly but safely correct the alignment problem. This can be done without surgery and without halting growth altogether.

The flexible band and screws can be taken out when the child has reached neutral alignment and/or full skeletal maturity. Skeletal maturity means the growth plates at the ends of the bones have closed, and the child is no longer growing.

Sometimes the guided growth system is removed when the bones are in neutral alignment but the child is still growing. If X-rays show the problem (angular deviation) is coming back, the procedure can be repeated.

X-rays are also used to estimate bone growth and plan the guided growth process. The goal is to find the most optimal time while there is still enough bone growth left to make a difference. At least one year of bone growth left is ideal. It may be best to use this approach earlier than later but the exact best timing is still unknown.

In order to avoid recurrence, orthopedic surgeons look for any other problems that might contribute to the angular deformity. They check both sides as well as the joints above (hips) and below (ankles and feet). The child’s gait (walking) pattern is examined and corrected.

Early results of the guided growth system are positive. The technique is much less invasive than surgical osteotomies. Unlike an osteotomy (which is permanent), guided growth is reversible (by removing the band). No bone is lost or destroyed with guided growth. In essence, bone growth is only “restrained” or slowed down.

We don’t have long-term studies yet to show what happens over time using this management technique. Children grow at different rates and that variability may affect the long-term results. Likewise, putting weight on the leg alters bone growth. More active children may have a different final outcome than less active children.

Predicting bone growth is not an exact science and can be inaccurate. The effect of the guided growth system on the patella (knee cap), ligaments, and other surrounding soft tissues has not been assessed either. These are all factors that will be investigated and studied in depth. The potential for correction of angular deformities without osteotomies makes this technique worth pursuing.

The growth plate (also known as the physis or physes (plural) is located at the ends of bones. It allows for normal joint function while leaving room for the bones to get longer.

The physis is a complex structure with many different types of cells (bone, cartilage, collagen) and multiple layers. There is a network of tiny blood vessels called capillaries to supply the area with nutrients and oxygen.

It is unique because it must be flexible enough to grow (i.e., it has not yet hardened into bone). But it must also be strong enough to withstand tension, compression, and shear loads placed on it during the many and varied activities of children.

One of the big dangers of physeal injury is the formation of a physeal bar. In the process of healing, bone is laid down across the break in the physis. A bar of bone is created that essentially stops any further growth of the physis on one side. The other side continues to grow causing angular deformities and uneven bone growth.

Scientists don’t know a lot about physeal bar formation. They have been able to show that if only a small part of the physis is damaged, then bar formation does not occur. Until it is known the exact mechanism by which this bar forms, we are powerless to stop it from happening. Research is actively seeking ways to unlock the mysteries of this problem.

Once they form, then what? The bar can be removed surgically. The surgeon must put a piece of graft tissue (often fat harvested from some other part of the body) in the space created by cutting the bar out.

Without this interposition tissue, the bone will just grow right back again. Animal studies are being done to find ways to stop physeal bar formation. Until that happens, research is also looking into finding better ways to support the physis after bar resection.

The growth plate (also known as the physis) is a complex structure with many different types of cells (bone, cartilage, collagen) and multiple layers. There is a network of tiny blood vessels called capillaries to supply the area with nutrients and oxygen.

The physis is unique because it must be flexible enough to grow (i.e., it has not yet hardened into bone). But it must also be strong enough to withstand tension, compression, and shear loads placed on it during the many and varied activities of children.

Growth is regulated by hormones, feedback loops, and factors that signal when to increase or decrease cell growth and when to stop growth altogether. Collagen is the basic building block of all soft tissues and bone. In order to turn collagen into bone, there has to be just the right amount of calcium, alkaline phosphatase, and matric metalloproteinase.

There are actually tiny packets called vesicles inside the chondrocytes (cartilage cells) that contain these chemicals. By some mechanism at the cellular level, these vesicles open up and release their contents at just the right moment for mineralization of the bone.

Anything that disrupts even one of these pathways can lead to abnormal physis. Lead poisoning, metabolic bone disease, tumors, infection, and trauma head the list of reasons why bone growth can get stunted or altered.

Disturbance of the growth plate resulting in stopping bone growth can lead to a limb length difference (arm or leg) from one side to the other. Studies show that up to one-third of all bone fractures in children that extend into the physis result in this type of growth disturbance.

The factors that determine growth problems after fracture include the location of the injury, whether or not the blood vessels to the physis were damaged, and how close the child was to skeletal maturity (end of bone growth) at the time of the fracture.

Understanding growth plate biology, anatomy, and physiology is an important tool. Today’s 6th graders who understand the basics of physeal growth and development may become tomorrow’s scientists finding ways to repair and restore damaged growth plates. Kudos to you for trying to gather a bit of knowledge and come alongside her in this project!