FAQ Category: Child

Bacterial arthritis (also called septic or infectious arthritis) causes a local response with joint destruction and infection. Bacteria, viruses, and fungi are all capable of infecting a joint, by invading and inflaming the synovial membrane.

Staphylococcus aureus and Kingella Kingae, and streptococcus pneumoniae are the most common organisms responsible for infectious arthritis in children.

Damage to the joint with possible permanent results is a concern with this diagnosis. The longer the wait from onset to treatment, the greater the risk for a poor outcome. Early treatment with IV (intravenous) antibiotics is the standard line of care.

Sometimes a broad spectrum antibiotic is used until blood tests (or tests of the joint fluid) come back from the lab with the exact microorganism (bacteria) that’s causing the problem. Then an antibiotic more specific to target that bacteria can be used if necessary.

Studies are being done to see if adding a steroid medication to the antibiotics might speed up the healing process without adding any negative side effects. The first experiments were done in mice. Recently, pilot studies with a small number of live patients have been done with promising results.

Hemivertebra is a congenital (present at birth) deformity. It means that only half of the vertebra (spinal bone) has formed. The other side is missing, which causes the bones above and below the half-vertebra to tip or collapse to one side. The result is a curved spine.

If this problem is diagnosed early (before age six), the deformed half of a vertebra can be removed surgically. Studies show that these children have excellent results with this procedure.

But this approach doesn’t work when the problem isn’t recognized until the child is older or as in your case, other methods of treatment are tried first without success. Treatment is especially challenging if the spine has matured (bone growth is complete or nearly complete).

Your surgeon may be referring to a procedure called a subtraction osteotomy. Instead of cutting out the deformed vertebra, a wedge- or pie-shaped piece is removed. The surgeon then 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).

Doing the procedure this way saves the bone and the discs between the deformed hemivertebra and the spinal bones above and below it. Having those discs in place helps stabilize the spine.

The procedure has the advantage of being simpler than removing the deformed hemivertebra with less time in the operating room. The risk of bleeding is less and there are fewer other complications compared with removing the entire half-vertebral body.

Scoliosis (curvature of the spine) can occur for no apparent reason. But it can also develop when there are deformities of the bone such as you describe. Congenital deformities such as a hemivertebra leave the spine unstable and curving to one side because only half of the spinal bone formed. The other side is missing, which causes the bones on either side to tip or collapse to one side.

If this problem is diagnosed early (before age six), the deformed half of a vertebra can be removed surgically. Studies show that these children have excellent results with this procedure.

But this approach doesn’t work when the problem isn’t recognized until the child is older or (as in your case), treatment wasn’t possible for some reason. Treatment is especially challenging if the spine has matured (bone growth is complete or nearly complete).

Usually by age 16, most girls have reached skeletal maturity. Boys may still continue growing for a few more years but their skeletal maturity is nearly complete by age 16 to 18, too.

Surgeons at the University School of Medicine in Shanghai, China recently reported on a new technique to correct the problem of untreated congenital spinal deformity in older children and teens. It’s called a posterior unilateral pedicle subtraction osteotomy of hemivertebra.

The surgeons entered the spine from the back rather than the front of the body. That’s what posterior means. Unilateral tells us only one side is operated on. And an osteotomy is removing a wedge-shaped piece of bone.

In this procedure, the surgeon removed this pie-shaped piece from the deformed hemivertebra. Along with the piece of vertebral bone, they also removed 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 guided 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).

Then screws and rods are placed above and below the level operated on to hold them in place until healing occurs. This part of the procedure is called corrective fixation or instrumented fusion.

Whether or not you are a good candidate for this (or some other procedure) must be determined by an orthopedic surgeon who specializes in spinal surgeries. Your first step is to find someone who treats children and teens with scoliosis and have an examination. Once you have been examined and imaging studies have been analyzed, the surgeon will be able to tell you what your treatment options may be.

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.

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.

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.

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.

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.

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!

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.

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.