FAQ Category: Child

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!

The first thing that comes to mind is a condition called juvenile idiopathic arthritis or JIA (previously known as juvenile rheumatoid arthritis (JRA). Usually only one or two joints are affected (knee and ankle). Girls are affected five times more often than boys.

Symptoms of joint swelling and loss of motion show up between ages one and three. The child doesn’t avoid putting weight on the leg and doesn’t usually complain of fever, fatigue, pain, or much more than a bit of tenderness.

Besides ruling out Lyme disease, your physician will look for evidence that this could be some other type of infection, lupus, tuberculosis, or inflammatory bowel disease. Each of those conditions has its own set of symptom pattern (the actual signs and symptoms and what makes them better or worse).

For example, pain that is worse after activity is more likely to be mechanical — meaning a tendon or muscle problem like patellofemoral syndrome. Pain that is worse at night after going to sleep for several hours is a red flag for tumor or growing pains.

As mentioned, pain with weight-bearing is not a typical pattern with juvenile idiopathic arthritis (JIA). Pain that moves around from joint to joint is another tip-off that the problem isn’t JIA. A hot, tender, swollen joint is more common with infection or trauma. And the presence of extra-articular symptoms points to other conditions.

Extra-articular means “outside the joint” and includes such things as fever, nausea, vomiting, weight loss, elevated blood pressure, skin rash, sores in the mouth, redness of the eye(s), or sudden muscle weakness. When these kinds of signs and symptoms are present, blood tests and urinalysis may be more valuable in identifying the underlying cause.

Diagnosing either Lyme disease or juvenile idiopathic arthritis (JIA) in children is a challenging task. The physician spends more time making sure it isn’t something else before being certain just what it is.

After reviewing the history, examining the child, and taking all the tests, the diagnosis is tested out by treating the problem and waiting to see what happens. For JIA, symptoms that do not respond to nonsteroidal antiinflammatory drugs (NSAIDs) signal a need to re-evaluate and test further.

There is no screening test that shows the presence of juvenile idiopathic arthritis or JIA as it is now called. This condition used to be referred to as juvenile rheumatoid arthritis. Idiopathic is a term that suggests “no known cause.”

In fact the lack of a screening test has made this condition difficult to diagnose. Even tests that are used reliably with adults to look for rheumatoid arthritis (e.g., rheumatoid factor, antinuclear antibody or ANA) are usually negative in children or are a false-positive.

False positive means the test is positive when there is no rheumatologic disease present at all. X-rays and other imaging studies have equally limited value. The diagnosis really depends on the child’s history and clinical presentation.

So there’s no way to predict ahead of time who might develop this condition. But knowing there is a positive family history on the paternal (father’s) side will alert you to watch for any signs and symptoms that might require further evaluation.

For example, persistent joint swelling and loss of motion in at least one and up to four joints for six weeks or more is a red flag. Morning stiffness and limping are more common than actual pain. The child feels well and does not complain of fatigue.

There are several subtypes of juvenile idiopathic arthritis (JIA) but the majority of children with this condition are girls. For every one male with JIA, there are five girls affected. The first symptoms start to show up early (ages one to three). The knee and ankle are involved most often.

Alert your pediatrician to your concerns and let him or her watch for any indications that there is a problem developing. Juvenile idiopathic arthritis is not an emergency situation. Early identification treatment are helpful and you are ready for that.

Children born with developmental dysplasia of the hip (DDH) are often treated with a special device called the Pavlik harness. This canvas sling holds the child’s hips and knees bent with the legs spread apart. But there can be complications with this treatment. One of those complications is a nerve palsy.

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

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

The idea of the Pavlik harness is to get the round head of the femur in close contact with the hip socket. This position helps the hip form a deeper socket that is less likely to dislocate. Many studies have been done now to show that this nonoperative approach to the problem is quite successful.

A recent study from the Texas Scottish Rite Hospital for Children might help answer your question. They looked back over records of the 1218 children treated at their clinic. All were treated with a Pavlik harness for developmental dysplasia of the hip. Less than three per cent developed a femoral nerve palsy.

The problem was handled by either adjusting the harness so the hips weren’t flexed as much or the harness was removed until the nerve palsy went away and then reapplied with adjustments.

They found that children who responded quickly to the harness removal or adjustment were more likely to be treated successfully when the harness was reapplied. The longer it took for the nerve to recover, the less chance there was that the harness could be used. In fact, for children who still had some nerve loss after 29 days, there was no chance the harness would work. Fortunately, everyone did recover from the palsy.

You’ll have a better idea what to expect after you see how long it takes for your child to recover fully from the nerve palsy. Once the necessary adjustments are made and the harness is refitted, there may be no further problems. Your orthopedic surgeon will guide you through this process step-by-step.

Children born with developmental dysplasia of the hip (DDH) are often treated with a special device called the Pavlik harness. This canvas sling holds the child’s hips and knees bent with the legs spread apart.

The idea of the Pavlik harness is to get the round head of the femur in close contact with the hip socket. This position helps the hip form a deeper socket that is less likely to dislocate. Many studies have been done now to show that this nonoperative approach to the problem is quite successful.

Physicians have known for a long time that femoral nerve palsy is a potential complication from the use of a Pavlik harness for developmental dysplasia of the hips. The extreme flexed position of the hip can put pressure on the femoral nerve that supplies the muscles along the front of the thigh.

Orthopedic surgeons treating this problem at the Texas Scottish Rite Hospital for Children in Dallas, Texas did a study on this problem. They found that there was a 2.5 per cent incidence of femoral nerve palsy (that’s the 30 children out of the total 1218 in their study).

Most of those (87 per cent) developed in the first week after starting use of the harness. The palsy group were older, larger (taller and heavier), and had more severe dysplasia. Being a preemie, your son may not fall into the older, larger category. But if his dysplasia is more severe (requiring a more extreme harness position of hip flexion), that may account for the nerve palsy.

The study helped show why femoral nerve palsy develops with use of the Pavlik harness for developmental dysplasia of the hip. Future studies may be able to show ways to avoid this problem and improve the outcomes with harness use.

Parental concerns are always important. Be sure and ask any physician treating you or your family members for evidence to support their counsel and decisions. In some cases (like imaging studies that expose the body to radiation), the physician must weigh the advantages against the disadvantages.

With osteochondritis of the knee, there is agreement or consensus among surgeons and experts that current evidence supports the use of physical exam, X-rays, and/or MRIs to assess healing. If there is still knee pain, swelling, popping,locking, or giving way after treatment, further treatment may be needed.

Although arthroscopic exam would tell the surgeon much more about what’s going on inside the joint, it is an invasive procedure and much more expensive than a simple X-ray. X-rays show the lesion and its location.

MRIs give much more detail about depth and extent of the defect as well as show any other pathology in the knee that might have gone unnoticed otherwise. And there’s no radiation exposure with MRIs. This type of imaging uses magnetic and radio waves to create images.

Your surgeon may be able to get all the information needed using MRIs. They are more expensive than X-rays but they do offer more detail and with no exposure to radiation. Be sure and express your concerns and ask questions about this at your son’s next appointment.

You are definitely not alone. According to a recent study, athletes who have stabilization surgery for repeated dislocations of the patella (knee cap) have a 93 per cent success rate following the procedure. “Success” was measured by the surgeon as less pain and improved function.

They came to these conclusions by using patient surveys like the International Knee Documentation Committee (IKDC) or the Lysholm score. These tools are used to measure and compare before and after pain, function, and activity.

Yet when surveyed, these same patients reported a much lower subjective (opinion) level of satisfaction.

The study presented here confirms findings from other studies: patients do not always view their surgical results as successful. But at the same time, they do not return to the surgeon and report ongoing symptoms or problems. When knee assessment tools like the International Knee Documentation Committee (IKDC) or the Lysholm score are used to measure outcomes, the results look good on paper but do not always provide an accurate view of the patient’s response.

This isn’t the first study to show a “disconnect” between surgical success and patient’s perception of the results. More research is needed to understand all the reasons for less than optimal outcomes reported following patellar realignment surgery.

In the meantime, it might be helpful for your surgeon if you put your thoughts and observations about your own outcomes down on paper. Sometimes seeing it in black and white helps bring home the message you are trying to get across.

Adolescent idiopathic scoliosis (AIS) refers to a condition of spinal curvature and deformity in children and teens that has no apparent cause.

The word “idiopathic” means “cause unknown”. Another word for the underlying cause of a disease or condition is etiology. There are many theories about the etiology of adolescent idiopathic scoliosis (AIS) but no clear single cause. Most experts consider AIS to have multiple linked causes including genetics, environment and lifestyle, and nervous system dysfunction with biologic and hormonal influences.

Treatment specific to the cause is usually the most effective approach. Without that, the symptoms become the focus and that’s where bracing comes in. The idea is that by placing the spine in an upright position, the forces causing the curvature can be stopped — or at least slowed.

You are aware that the results are variable. No one has been very successful predicting who will do well and by how much. When surgeons are asked why they use bracing without convincing evidence that it always works, there is agreement that the chance to reduce the risk of needing surgery is worth the effort. And in young children with adolescent idiopathic scoliosis, studies show 25 per cent of the patients do avoid surgery because of the bracing.

Once the decision has been made to use bracing, the next natural question is: which one or what kind? The brace maker (called an orthotist because orthosis is the more modern name for brace) helps guide the decision. This is done in communication with the parent, surgeon, and physical therapist. A team approach is best when looking at the whole child and taking into consideration spine, surrounding soft tissues, general health, and activity level.

Some of the more commonly used braces for adolescent idiopathic scoliosis include the Boston brace, the Wilmington brace, the SpineCor brace, the Milwaukee brace, the Triac brace, the Sforzesco brace, the Charleston brace, the Providence brace, and the Cheneau brace.

Some of these braces are intended to derotate the vertebrae. Others force the spine to bend in the opposite direction of the developing curve. The Charleston bending orthosis provides this type of overcorrection and is worn only at night.

Most of today’s braces are made of plastic with either metal uprights or velcro or canvas straps to hold them in place. With the exception of the braces intended only for night-use, most braces used for adolescent idiopathic scoliosis are designed for use 23 of each 24 hours. The brace is removed only for bathing, swimming, and dressing.

If the surgeon who gave you the prescription didn’t tell you where to go, call the office and ask for a recommendation. The orthotist will guide you through the process from there. Sometimes clinics are held on a specific day each week or month so that the team can all be assembled together to evaluate, discuss, and plan the best approach for each child. In some cases, the orthotist will begin the process and then team evaluations take place later.

Thank you for such a positive report. There has, indeed, been quite a controversy over bracing. In today’s health care climate of demanding evidence to support treatment, bracing has had some mixed reviews. Some of the problems stem from the fact that there are different types of scoliosis (curvature of the spine). Bracing seems to be helpful with some, but not all types.

In the case of adolescent idiopathic scoliosis (AIS), it does look like bracing can keep the curve from getting worse if it is caught early enough (before the growth spurt). Adolescent idiopathic scoliosis refers to a condition of spinal curvature and deformity in children and teens that has no apparent cause. Children (especially girls) with AIS and curves between 25 and 35 degrees seem to respond better than others.

There is also some evidence that bracing seems to work the best when the brace is worn 16 or more hours a day. Your daughter’s dedication to the brace may very well be the reason (or at least one reason) why she had such good results.

Comparing children who are braced with children who do not wear a brace seems to offer some consistent evidence that observation alone (no bracing) isn’t as effective as bracing. Long-term results (what happens five-to-10 years later) in both groups are unknown.

Waiting too long before using bracing may be a factor. Studies that show a 50 to 60 per cent success rate still leave 40 to 50 per cent of patients turning to surgery for correction. That leads researchers looking for reasons why some patients have a successful outcome in hopes of selecting patients in the future who would be good candidates for bracing.

Symptoms of Lyme arthritis are similar to septic (infectious) arthritis but the treatment for these two conditions is different.

Efforts are being made to collect data that will help physicians make an early and accurate diagnosis. This is important because septic or infectious arthritis is often a surgical emergency to prevent joint destruction. Lyme arthritis requires treatment but it is not an emergency. In both cases, an accurate diagnosis is needed to direct treatment and prevent long-term complications.

The diagnosis of Lyme arthritis is a bit tricky for several reasons. One, the arthritic symptoms don’t always develop until late in the disease — sometimes months and even years after the tick bite that caused it.

Two, special highly sensitive blood tests that are used to identify Lyme disease aren’t always available in small towns or local hospitals. An enzyme immunoassay or immunofluorescent assay followed by a Western immunoblot are required. The turn around time on results can be a week or more. By the time the diagnosis is made, days to weeks may have passed.

And three, if the physician suspects septic arthritis and treats it with an antibiotic rather than the antimicrobial medication needed for Lyme disease, appropriate treatment is further delayed.

Efforts are being made to collect data that will help physicians make an early and accurate diagnosis based on clinical presentation. If the most common signs and symptoms of each condition could be categorized, a clinical diagnosis (without accurate blood tests) might be possible.

Studies show that the rates of Lyme disease is actually increasing in places where the condition is most common. This includes the Northeast, Upper Midwest, and Pacific Northwest portions of the United States.

Physicians and especially pediatricians in states like Connecticut, Delaware, Maryland, Massachusetts, Minnesota, New Jersey, New York, Pennsylvania, Rhode Island, and Wisconsin are aware of this problem and know when to look for it. If you live in any of these areas, an immediate evaluation may be advised.

Blood tests can be done but these aren’t always reliable or helpful. There are other conditions such as septic (infectious) arthritis that must be identified and treated quickly.

Children with septic arthritis are more likely to have a significant fever (higher than 101.5 degrees Fahrenheit) and refuse to put weight on the affected leg. Neither one of these symptoms is typical of the clinical presentation of Lyme disease.

Children with septic arthritis are more likely to have high levels of synovial fluid cell count and elevated white blood cells compared with children who have Lyme arthritis. But these tests are not used to make a definitive diagnosis because some children with Lyme disease also have high levels as well.

A quick phone call to your physician’s office and answering a few of their questions will probably give you the answer you need.

It sounds like your grandson may have had a fracture of the femur(thigh bone) since he was in a hip spica cast. Hip spica cast refers to a cast that goes from waist-to-toe. This type of cast is required when the upper leg is broken and must be held still until healing takes place.

A loose cast does make it possible for objects to get under the cast. This accounts for a fair number of skin problems. The specific types of foreign objects reported over the years by surgeons removing casts includes anything and everything from small toys or crayons to rocks, money, paper clips, and food. Pretty much anything children can stuff down inside the cast can end up surprising the surgeon (and parents/grandparents) when the cast is removed.

The best warning we can give any caregiver of children wearing casts is to take your child back to the physician when a cast becomes too loose. Sometimes tissue wasting occurs (especially muscle wasting or atrophy) after the cast has been on for several weeks. In other cases, swelling present at first goes down or goes away. In either case, the cast is looser and problems with skin abrasion or skin breakdown can occur (not to mention odd things finding their way down inside the cast).

Fractures of the femur (thigh bone) in young children often require a special hip-to-toe cast called a hip spica cast. A special cut-out is made so the child can eliminate body wastes (urine, feces). But because the child cannot bend at the waist, using a potty chair or toilet usually isn’t possible. Most parents continue to use diapers during this time of immobilization.

The nurses at the hospital will give your daughter (and any other caretakers such as yourself) an inservice on care of the cast and child. Usually some written materials and reminders are sent home. Some hospitals provide a video with instructions, ideas, and tips for the care of a child in a hip spica cast.

One key issue is keeping the cast dry and free of urine or stool. Skin breakdown associated with spica cast application can occur as a result of urine or feces getting under the cast or soiling the edges. Moisture and chemicals from urine and stool irritate the protective outer layer of skin. Additional complications can occur if bacteria entering open cracks or sores and cause infection.

Special diapering techniques are usually demonstrated to the parents and caregivers. Proper positioning is also important to prevent skin problems. Again, the information should all be provided in written (if not video) form. Don’t hesitate to contact the nursing staff if you need help.

Any visible sign of skin irritation (rash, redness, bleeding) should be checked right away. This is usually done by the nursing staff or physician. Since skin problems can develop under the cast in places where it can’t be seen, a fussy baby or as in this case, young child may be an indication of a problem. It may be necessary to remove the cast, take care of the skin problem, and recast the child. Again, early recognition of the problem and immediate intervention is the key to preventing more serious complications.

Another 10 years has gone by and scientists still haven’t unraveled all the mysteries surrounding the diagnosis of adolescent idiopathic scoliosis (AIS). AIS describes a condition of spinal curvature (scoliosis) among teens (adolescent) of unknown cause (idiopathic). Girls are affected more often boys, especially beginning during the pre-adolescent stage of life.

Efforts have been made to find a leading factor such as hormonal, genetic, environmental, lifestyle, biomechanical, or nervous system dysfunction. With all the new information available now on motor control, some scientists are taking a second look at that area as a possible avenue of understanding.

Is there a link between diet and exercise? Too much sugar? Not enough calcium? At best, experts agree it might just be multifactorial with more than one cause linked together. Right now, treatment is still based on symptoms instead of cause, so the search for etiology (cause) is still on.

Like you, pediatricians and orthopedic surgeons have asked: What causes the curves to start in the first place? Is the same mechanism responsible for worsening of the curve? Which part of the spinal anatomy is affected first: is it the bone itself or the muscles pulling on the bone? Or are all segments (disc, bone, muscle, cartilage) affected equally and at the same time?

What do we know to be true about this condition? Twin studies do support a genetic link but gene studies show many different genes are involved. It may be possible to identify subgroups based on specific genes involved but that’s only a theory at this point.

Problems in the nervous system also seem to play a part in this condition. More advanced MRIs have helped scientists pinpoint specific areas of the brain (vestibular system, pontine and hindbrain regions) where the pathology may begin.

The role of vision, balance, neuron-motor timing, and failure of postural mechanisms in spinal deformity is also under investigation. Another big area of study is skeletal and spinal cord growth — speed of growth, coordination between soft tissue and bone, and symmetry of growth have been observed and discussed.

The body of the vertebrae (spinal bones) grows faster than the bony parts along the back of the spinal segment. That process of uneven growth is referred to as relative anterior spinal overgrowth or RASO. The RASO growth pattern results in tension and tightening of the spinal cord and spinal nerve roots (called tethering).

And that’s not the end of the research list. Studies have also been done looking at the effect of hormones such as growth hormone, melatonin (sleep wake cycles linked with growth and bone density), leptin (helps with energy), and calmodulin (regulates muscles).

Clearly, there is a pattern of abnormal skeletal growth with possible genetic links and biologic as well as biomechanical factors. Research is needed to continue finding successful ways to treat this condition based on an accurate understanding of the underlying cause.

Although the name adolescent idiopathic scoliosis (AIS) includes the word adolescent and implies a condition limited to teenagers, the age of onset can be pre-pubertal (before puberty or adolescence). This is especially true among girls who develop AIS. And of all the different kinds of scoliosis (subgroups are based on cause), AIS is more likely to affect girls than boys.

The average age of girls entering the biologic phase of puberty and adolescence may be dropping. There are reports of puberty beginning as early as age seven in some girls. The whole idea of earlier development in females remains under investigation. Results have been mixed and all studies have not reached the same conclusions.

The true cause of AIS remains a mystery. Despite 20 years of intense research and study, the best we can say is that it is a multifactorial condition. In other words, there are probably many causes linked together. Hormonal influences, growth factors, genetics, diet and nutrition, and many others could contribute to whatever mechanism turns on this problem.

A recent study from St. Luois Children’s Hospital has shed some new light on this topic. They found that the longer the condition went on before surgery, the more likely results would be less than optimal. They also reported that younger children had better outcomes.

Those particular outcomes have led the surgeon to recommend patellofemoral reconstruction after only 2 subluxation or dislocation episodes — rather than waiting until the child has had many more than that months to years after the first episode.

But before surgery, the usual first-line of treatment for this problem is conservative (nonoperative) care. Rehab under the supervision of a physical therapist is essential. Only when dislocations continue after attempts to realign the joint with manual therapy, postural alignment, and exercises to improve neuromuscular control is reconstructive surgery advised.

The stabilization procedure varies from patient-to-patient. Age, skeletal maturity, and etiology (cause) are important factors in the decision-making process. The surgeon also performs an arthroscopic exam before doing surgery in order to find out what the patellofemoral joint looks like inside. Any unknown or previously unseen problems with the soft tissue structures and joint surface are identified.

The surgeon may perform a lateral release (cuts the soft tissue along the outside edge of the patella) with or without retensioning the medial soft tissue (changing the tension on the other side of the patella closest to the other knee). Other options include an osteotomy (the surgeon removes a wedge of bone to change knee alignment), repair of any damaged patellar ligaments, or a patellar tendon transfer (changes the angle of pull on the patella).

The work may be done from above or below the knee to create the stability needed based on the cause of the problem. In some cases, the patella is reshaped by doing a patellar shaving procedure. Any loose pieces of bone or cartilage found in the joint are removed as well.

Many patients end up having more than one thing done during the same surgery — this is referred to as combined procedures. Would fewer operative steps be required if the surgery were done sooner? That’s unknown and would be the topic of another interesting research project!

Children with complex regional pain syndrome or CRPS often suffer intense pain and swelling of the affected arm and hand or leg and foot. They also experience skin changes (color, texture, hair growth, temperature). The net result is a loss of motion and function along with reduced quality of life.

Children develop CRPS most often after an injury as minor as having blood drawn, or a sprained ankle. Other times, it may be the result of a more significant injury such as surgery, a fracture, immobilization with casting or splinting.

Risk factors for developing CRPS include immobilization of the affected limb with a cast, splint or sling; genetics; and psychological factors. The problem is not understood very well. Doctors don’t really know what causes it or why it happens. That makes CRPS a difficult condition to treat effectively.

But the good news is that several large pediatric centers have developed a method of treatment that seems to be very effective. At one U.S. hospital, 100 per cent of the children were “cured” — all symptoms resolved. Physicians at a similar Canadian hospital agreed that the steps used worked for them, too.

Step one is a review of all the ways the child has already been treated so far. Most often, medications have been prescribed and the child has worked with a physical therapist. Step two: if previous medications (usually pain relievers and/or antiinflammatories) have not worked, a second line of drugs to try are muscle relaxants and anticonvulsants.

Step three: the child goes back to physical therapy for a more aggressive approach. Failure to achieve pain relief and return of function with these measures results in step four: a referral for a sympathetic (nerve) block.

If the nerve block works, then great! But if it only provides temporary relief from pain, at least it’s clear that the team is on the right track. Inpatient hospitalization is recommended. That’s when the multidisciplinary team gets to work.

The surgeon provides a continuous block to the nerve while the physical therapist works with the child in a total program of sensory modulation, postural alignment, desensitization, motion and movement training and strengthening (as appropriate). During this five-day intense in-patient treatment, a psychologist also offers psychological therapy and behavioral training.

This type of multidisciplinary treatment approach to complex regional pain syndrome (CRPS) is worth a try. Studies show that the earlier nerve blocks are used, the better the results. Waiting months to years results in a slower recovery time.