FAQ Category: Child

It’s very difficult to know how to approach problems like this one that involves a child suffering pain and disability. There isn’t a great deal known or understood about this condition. We know that women are affected more often than men. Likewise, girls seem more susceptible to this problem than boys.

There is usually a precipitating event that brings it on — it could occur as a result of 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, or in adults, as a result of a stroke.

Experts who treat this problem in children agree that as part of a total program, a nerve block can be very helpful. In fact, when nerve blocks are done early (first few months of symptoms), it only takes one injection to completely cure the problem.

But there’s a recommended algorithm (steps to take) in the treatment of complex regional pain syndrome (CRPS). Medications are the first line of care. Antiinflammatories, analgesics (pain relievers), muscle relaxants, and anticonvulsants have all been shown to help. The physician starts with the least invasive drug and works to find the right drug, dosage, or combination of drugs that work best.

Medications go hand-in-hand with an aggressive physical therapy program. Only if these two treatment methods fail to resolve the problem do they take the next step of a nerve block. But because a single nerve block injection can put a complete stop to the painful symptoms, this treatment approach is recommended under these circumstances by those who treat this problem.

Tyleonol 3 is a by-prescription-only drug in the United States, which means it is a regulated or controlled substance. In Canada, Tylenol 3 is sold as an over-the-counter medication. The pharmacies there do have limits on how many bottles you can purchase at one time. But there is nothing to stop someone from going to various pharmacies or going more than once to stock up. In fact, like you, many Americans do just that on trips across the border.

But there’s a reason why this drug is regulated more closely in the United States — the formulation contains codeine. Codeine is an opiate and as such, a powerful pain reliever. The down side of codeine is the potential for side effects: anything from itching, nausea, vomiting, drowsiness, dry mouth, and low blood pressure to depression and constipation. Some people may also have an allergic reaction to codeine, such as swelling and skin rashes.

In babies and young children, there have been reports of unexpected death making this a drug that is potentially very dangerous in this age group. Some experts recommend taking codeine off the market completely for use with infants and young children. Some hospitals in Canada have already done this. This action may seem drastic but with babies and pre-verbal children who can’t communicate their symptoms, it’s the safest way to ensure no one dies as a result of codeine use. And since there are acceptable, safe, and effective alternatives, children don’t have to suffer pain unnecessarily.

Always consult with your pediatrician and/or pharmacist before giving any over-the-counter (or other prescribed medications) to your children. The use of Tylenol 3 is under close scrutiny and study. Until clear guidelines have been published, children should not be given this drug without physician approval.

More and more physicians across Canada and America are raising concerns about the use of codeine as a pain reliever for babies and children. There is evidence now that codeine isn’t really effective as a pain reliever in this age group. And with all the potential for serious side effects with codeine, it might be best to stick with Tylenol with hydrocodone or ibuprofen. When used properly, these over-the-counter medications are safe and effective for pain control.

In a recent report, deaths have been linked with codeine in infants who have an unusual gene that turns codeine into morphine. Other genetic variations among the young also make it possible to break down codeine quickly and dump a larger amount into the bloodstream than intended or tolerated. Unpredictable serious side effects including death can be the result.

What you have heard is partially correct. Some experts have recommended taking codeine off the market completely for use with infants and young children. Some hospitals in Canada have already done this. This action may seem drastic but with babies and pre-verbal children who can’t communicate their symptoms, it’s the safest way to ensure no one dies as a result of codeine use. And since there are acceptable, safe, and effective alternatives, children don’t have to suffer pain unnecessarily.

The use of Tylenol with hydrocodone (also known as Vicodin, Vicodin ES, Anexsia, Lorcet, Lorcet Plus, or Norco) has been shown effective as an alternative. Hydrocodone is a similar drug to codeine but has a slightly different chemical formulation. Even so, there are potential adverse side effects with this medication as well. It will remain by prescription only under the supervision of a medical doctor.

If and when codeine is removed from the market for use with children, your pediatrician or primary care physician will assist you in finding effective alternative products.

It can be difficult to advise parents or caretakers of children with traumatic fractures of the talus because this type of fracture is rare. We know how these fractures develop (the mechanism of injury). But other information on talus fractures in children is limited.

A recent study from Children’s Hospital in Boston might help shed some light on the subject. Although they only had 29 cases to review, it was the largest group of patients with this type of injury to learn from. Here’s what they found.

There were no cases of infection or problems with wound healing and only one fracture that failed to heal. A couple of children/teens needed another surgery to help stabilize the joint. A closer look at those who developed joint problems later showed that these patients had high-energy injuries and a displaced fracture. Likewise the one nonunion and all cases requiring additional surgery were displaced fractures.

Post-traumatic arthritis was the most common complication affecting 17 per cent of the group. Second to arthritis were nerve injuries and avascular necrosis (loss of blood to the bone causing death of bone tissue). Most of the nerve injuries were temporary and healed. Only one patient had residual loss of sensation.

Surgeons think that perhaps younger children have fewer complications and better recovery rates because they have thicker periosteum (outer layer of bone). This feature may offer some protection. And, of course, supportive cartilage in and around the joint in children is more flexible allowing for more give and bend during trauma.

If your grandson has a nondisplaced fracture (two fracture ends of the bone have not separated or shifted apart), then treatment will likely be with a cast. Holding the bone in place for four to six weeks may be all that’s needed. If all goes well, there is every reason to believe he will be back in action within eight or nine weeks.

Displaced (separated) fractures that require surgery take longer to heal. Expect about a 12-week recovery period.

Evidently not according to a recent study from UCLA Orthopaedic Hospital in California. They compared this exact type of fracture in two groups of children — those whose treatment was delivered within eight hours against those who had the necessary surgery at least 21 hours later.

They used a variety of ways to compare results: elbow motion, rate and type of complications, and carrying angle of the elbow (a sign of deformity from poor bone healing). Patient and family satisfaction were also measured. In all ways, the results were the same between the two groups. Only when loss of blood or nerve damage were present at the time of injury (before surgery) was there an alarm sounded and the time of surgery pushed up immediately.

But as with your situation, there are times when delays are unavoidable. Sometimes there just isn’t an orthopedic surgeon available to evaluate and treat that child. The family may have to travel to another hospital or clinic where a physician is on-site. In other situations, the hospital’s operating rooms are full. That means another delay in getting proper care for the fracture.

As the results of this one study show, delay in pinning displaced fractures of the supracondylar humerus (at the bottom of the upper arm bone above the elbow) can be done safely and without adverse outcomes. Of course, delays are always to be avoided whenever possible and each child should have treatment based on his or her individual needs. Any child with displaced supracondylar humeral fractures having extreme pain, loss of blood flow, and/or loss of sensation must be treated absolutely as soon as possible. Delayed treatment is not acceptable in this group.

A supracondylar humeral fracture refers to a break just above the elbow at the bottom end of the humerus (upper arm bone). As many as 60 per cent of all elbow fractures in children occur at this location. This can be a serious fracture if the break has separated (displaced fracture) and the jagged edges of bone have cut a blood vessel or nerve.

If that’s the case, then surgery is performed immediately. But most of the time, the bones can be reduced using traction to pull the bones apart and reset them. Using X-rays to show the bones are in proper alignment, the surgeon will then use pins to hold them in place until healing takes place.

This procedure is called closed reduction and internal fixation. The pins are inserted percutaneously (through the skin) and can be removed easily after bone healing has occurred. If an open incision is needed to repair the damage, then the operation is referred to as an open reduction and internal fixation (ORIF).

The results of this kind of surgical management are usually quite good. There can be complications with any surgery — from the anesthesia, from infections, poor wound healing, or delayed fracture healing. But studies show that even when treatment (pinning) is delayed, final outcomes are good to excellent without problems or complications in the majority of children.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition three names to honor the three physicians who each separately described the disease.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die.
The blood supply eventually returns, and the bone heals. In the process, the joint cartilage softens, the round head of the femur flattens, and subluxation (head of the femur shifts out from inside the hip socket) occurs.

How the bone heals determines how much problem the condition will cause in later life. This condition can lead to premature hip arthritis. That’s why every effort is made to contain (hold) the hip in the socket during the necrosis and revascularization phases. Necrosis refers to the period when loss of blood to the bone results in the death of bone cells. Revascularization is the restoration of normal blood supply.

There are different ways to contain the femoral head. Two of the better known (and most often used) methods are called femoral varus osteotomy and Salter innominate osteotomy. A triple pelvic osteotomy uses the bones on three sides of the femoral head (pubic bone, iliac bone, ischium) to hold the head of the humerus firmly in place. The surgeon uses tools and instruments to cut the bone in the pelvis, shift the pieces of bone, and reshape the bones to form a holding container around the femoral head.

This “container” approach is used with severe cases of Perthes disease. In such cases, holding the femoral head in place is required for a longer period of time than is possible with cast immobilization. Using one of the other two more traditional osteotomy procedures isn’t enough either.

The surgeon uses X-rays and other more advanced imaging studies to examine the anatomy of the hip when planning the most appropriate (and hopefully most effective) procedure. Studies show that even in older children whose bones are less likely to reshape easily do respond well to the triple pelvic osteotomy.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip most often in teenagers between the ages of 12 and 16. Cases have been reported as early as age nine years old. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone).

Left untreated, this can lead to serious problems in the hip joint later in life. Severity of slipped capital femoral epiphysis (SCFE) can be rated as mild, moderate, or severe. This grading is determined by looking on X-rays at the angle of the epiphysis compared to the other side (if the other hip is normal and not also affected by SCFE).

Another way to classify severity of the condition is by assessing joint stability. Children who can put weight on the hip and walk (sometimes despite pain and/or with or without crutches) are considered to have a stable SCFE. Children with pain so severe that weight bearing and walking are impossible (even with crutches) are considered to have unstable SCFE.

It sounds like your child’s condition is mild and stable but with symptoms painful enough to require the support of cructhes. Studies have shown that the more severe the slip, the worse the long-term outcomes. The earlier the diagnosis is made, the more effective the treatment. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip most often in teenagers between the ages of 12 and 16. Cases have been reported as early as age nine years old. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). Left untreated, this can lead to serious problems in the hip joint later in life.

The very same institution your son has been receiving his care (Mayo Clinic) recently published a study on hip replacement after slipped capital femoral epiphysis (SCFE). They conducted a review of their medical records from 1954 up to 2007. There were 33,000 patients who had hip replacements during that time period. Only 38 were done in hips with degenerative changes or impingement linked with slipped capital femoral epiphysis (SCFE).

A closer look at these patients showed that a severe slip with avascular necrosis was linked most often with the need for joint replacement. There were some patients with SCFE who needed a joint replacement because of impingement rather than degeneration, but the majority were for damage done by the necrosis.

Hip replacement for necrosis occurred early on (mean time was 7.6 years) compared with a delay of over 20 years for patients with joint degeneration or impingement. And the rate of implant failure requiring revision (a second) surgery was fairly high in the necrosis group as well. The reason for implant failure was usually cup loosening or femoral neck fractures. Success of implant revision was good though — 95 per cent of the implants were still in good shape five years later.

The authors say this was the first study of its kind — to show the actual rate of hip replacements in patients who had slipped capital femoral epiphysis (SCFE) as a child. What they uncovered with the study was the understanding that hip replacement following a diagnosis of SCFE occurred most often because of hip necrosis not degenerative hip arthritis.

Many of these patients received all of their care over the years at this Mayo Clinic.

Your son may benefit from the knowledge gained from this study. Future treatment should be focused on preventing avascular necrosis in severely slipped, unstable hips.

Cast immobilization was the standard treatment for Perthes disease until surgical methods were developed to hold the hip in place without the severe movement restriction required by casting. Bracing has also been tried but studies show that brace treatment isn’t very helpful either.

It’s difficult to design a brace that is comfortable but still does its job of holding the legs apart and the head of the femur (thigh bone) in the hip socket. The child can’t walk with a brace or cast. The effect this has on attending school and participating in social events is negative enough to find some other way to treat the problem.

Parents both working outside the home also makes casting or brace immobilization a poor practical choice for everyday living. That’s why surgeons have found alternative ways to treat this problem — namely with surgery. Today every effort is made to contain (hold) the hip in the socket during the necrosis and revascularization phases of this condition. Necrosis refers to the period when loss of blood to the bone results in the death of bone cells. Revascularization is the restoration of normal blood supply.

There are different ways to contain the femoral head. Two of the better known (and most often used) methods are called femoral varus osteotomy and Salter innominate osteotomy. A third approach is the triple pelvic osteotomy — using the bones on three sides of the femoral head (pubic bone, iliac bone, ischium) to hold the head of the humerus firmly in place.

The surgeon uses tools and instruments to cut the bone in the pelvis, shift the pieces of bone, and reshape the bones to form a holding container around the femoral head. This type of surgical containment of the femoral head in the hip socket is safe and effective in the treatment of severe Legg-Calvé-Perthes disease. Using the triple pelvic osteotomy surgery can reshape the head of the femur into a round sphere that stays in the hip socket.

The final result is a pain free, functional hip that can eliminate differences in leg length, and restore a normal walking pattern without a limp.

Bone growth and skeletal maturity follow a path determined by hormonal changes managed by an internal clock. Growth spurts are common during puberty (those teenage years) when hormones rise, peak, and then slowly fall back down.

Girls peak sooner than boys. This is usually around age 12 but the range is from 10 to 14. Boys seem to peak closer to age 14 (range from 12 to 16). By the time most girls are 14, they are skeletally mature and not likely to grow any more. Skeletal maturity for boys is around age 16.

These ranges are only estimates. X-rays are needed to determine actual skeletal growth and maturity (end of growth). For example, when children and teens break a bone, the surgeon decides whether to do surgery and what kind of surgical procedure is required based on the type, location, and severity of fracture. But bone age (skeletal maturity) is also a deciding factor.

Even so, adolescents (teens) who have completed bone growth (or nearly completed it) fall into a gray zone when it comes to fracture management. There is still a difference in the quality of bone for that adolescent who isn’t quite an adult yet. There is less mineralization and more blood to the bones compared with an adult. The bones of an adolescent are still a bit more elastic than a fully skeletally mature adult.

Teens with bone fractures (and children, of course) heal faster than adults. Bones in children and adolescents seem to absorb stress, load, and force better than adults. This means they are less likely to break a bone into tiny little parts (as occurs more often in older adults).

For children and teens who are still growing, the physis (growth plate) is at greater risk for fracture than the shaft of the bone. In adults, ligaments are more likely to be ruptured and joints dislocated before the bone breaks. In fact, with some severe soft tissue injuries, it would have been better if the bone had broken because healing is often faster and more straight forward for bone than for soft tissues.

The talus is located just above the calcaneus (heel bone). The talus has a bit of an odd shape with a main square-shaped body and a small extension of bone coming off the body called the talar neck. It is sandwiched between the calcaneus and the bones you feel on the top of your foot where the end of the tibia (lower leg) meets the foot. The talus is an important bone in ankle motion because it helps create the rocking motion needed for front-to-back and side-to-side movement of the ankle/foot complex. It is the link between the other major joints in the ankle.

Fractures of the talus are more common in adults but rare in children. However, children and teens of all ages (from one up to 18) can fracture this area as well. Talar fractures in patients under the age of 18 are more common in teens who are involved in sports or driving cars. Younger children are less likely to fracture this bone.

The most common place for a talar fracture is the talar neck. There can be fractures of the talus body as well. Fractures in more than one area of the talus (neck and body) are also possible. High-energy injuries are more likely to result in damage to other areas of the foot and ankle.

Most motor vehicle accidents resulting in talus fractures are high-energy injuries. Displacement (separation) of the fracture is the key here. More severe injuries are displaced fractures with accompanying damage of the surrounding soft tissues (e.g., ligament, cartilage, tendons).

The biggest concern following displaced talus fractures is avascular necrosis. This is a loss of blood to the area because the blood vessels have been cut or damaged. Nerve injuries can also occur but most of the time, the nerve repairs itself so any sensory disturbances are temporary.

When younger children experience a talus fracture, it is often less severe and less involved than in older children and teens. A recent study from Boston Children’s Hospital on talus fractures in children did not find that avascular necrosis is a likely complication following treatment in this age group.

There were no cases of infection or problems with wound healing and only one fracture that failed to heal. A couple of children/teens needed another surgery to help stabilize the joint. A closer look at those who developed joint problems later showed that these patients had high-energy injuries and a displaced fracture. Likewise the one nonunion and all cases requiring additional surgery were displaced fractures.

Most of the children healed well and were able to return to full weight-bearing and activities on average of nine weeks.

Back pain after any type of spine surgery can be a symptom of late complications such as infection or problems with the hardware used to hold the spine in place. Sometimes the hardware (rods and screws) used to hold the spine in place break or get dislodged and must be repaired or removed and replaced.

The fusion might not be complete, in which case a pseudoarthrosis (a false joint) may have formed. Loss of correction or an uncorrected second spinal curve getting worse may cause back pain.

Until and unless an examination is performed, there may be no way to discern when pain is from a physical problem and what is an emotional or psychologic issue. There are many things that could cause late developing pain following spinal surgery. Don’t delay in having the surgeon take a look and figure out what’s going on.

Modern medicine can perform many “miracles” these days. Among them is the ability to surgically straighten a spine that is severely curved from a childhood condition called scoliosis. Pediatric spinal deformities requiring surgery may also occur associated with other developmental problems, neuromuscular diseases, or genetic conditions such as your daughter has.

But a one-time procedure is unlikely over the lifetime of those children as they grow and move into and through adulthood. Revision surgery is required in up to one-fourth (25 per cent) of all cases. The reasons for revision spinal deformity surgery vary.

It could be there wasn’t enough spinal correction the first time or there is a remaining imbalance in the spine that requires a two- or three-step series of operations. The fusion might not be complete and pseudoarthrosis (a false joint) develops. Loss of correction and an uncorrected second spinal curve getting worse may drive the decision to reoperate.

Sometimes the hardware (rods and screws) used to hold the spine in place break or get dislodged and must be repaired or removed and replaced. Revision surgery is needed then. If infection develops, the surgeon may have to go back in and perform additional procedures. And in some cases, the child or teenager develops pain at the operative site that must be investigated.

Whatever the reason, each case is unique and requires careful consideration and preplanning in order to gain a good result. Surgeons know this can be a very stressful time for the patient and the family. Many times the possibility of a revision surgery was discussed at the beginning (at the time of the first surgery). But there is so much information to take in that the family rarely hears that news.

When the decision is made to perform a revision procedure, the surgeon must plan carefully. Every effort is made to prevent further complications. Be prepared for some of the same decision-making steps that you went through the first time.

Preoperative imaging including X-rays and CT scans help the surgeon plan his or her correction strategy. CT scans are especially helpful in showing areas of infection or the presence of a pseudoarthrosis (false joint). Every angle and every level of the spine is taken into consideration during the pre-operative planning phase.

Everyone on the team (including you!) wants what’s best for the child. Don’t hesitate to express your frustration and ask any questions you may have. That is an important part of the process. And beware that on occasion, the revision surgery requires additional revisions (meaning possibly a third procedure).

Legg-Calvé-Perthes Disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Perthes disease. It was named in honor of the three physicians who each separately described the disease. Boys are affected five times more often than girls. In 10 to 15 per cent of children with this disease, both hips are affected.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. Hip pain, limited hip motion, and a limp bring the child into the physician’s office for diagnosis. The blood supply eventually returns, and the bone heals. But how the bone heals determines how much problem the condition will cause in later life. This condition can lead to serious problems and even permanent deformity in the hip joint later in life.

Perthes disease results when the blood supply to the capital femoral epiphysis is blocked. There are many theories about what causes this problem with the blood supply, yet none have been proven.

There appears to be some relationship to nutrition. Children who are malnourished are more likely to develop this condition. Depending on the birth mother’s prenatal care and nutrition and conditions at the orphanage, there may be a link here for your child.

There is some new evidence that Perthes disease is genetic as a result of a mutation (abnormal change) in the type II collagen (fibers that make up soft tissue structures). Previously there was no known increase in risk for children whose parent had Perthes disease as a child. But this belief may no longer be accurate.

Studies among Asian families who have many members with this disease have been found with this mutation in the type II collagen gene. Scientists think that the mutation results in weakening of the hip joint cartilage that also affects the blood vessels within the cartilage.

These are all theories that remain to be fully investigated and proven. The important thing is to make sure your child is followed closely by your pediatrician and orthopedic surgeon.

Early treatment can often be accomplished with conservative (nonoperative) care. If there are signs of disease progression and hip deformity, then surgery may be needed. Your surgeon will be able to advise you on this. Decisions are made based on the age of the child, condition of the bone, presence of bone fragmentation, and loss of blood supply at the time of diagnosis. The younger the child (under age six), the more likely conservative care can be effective.

Legg-Calvé-Perthes Disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Perthes disease. It was named in honor of the three physicians who each separately described the disease.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. Hip pain, limited hip motion, and a limp bring the child into the physician’s office for diagnosis. The blood supply eventually returns, and the bone heals. But how the bone heals determines how much problem the condition will cause in later life. This condition can lead to serious problems and even permanent deformity in the hip joint later in life.

Treatment centers around the main goal of preventing deformity of the femoral head. When prevention isn’t possible, then minimizing the damage to this area is the next best approach. Treatment varies depending on the age of the child at the time of diagnosis. Long-term management for adults affected by this condition during childhood is another aspect of treatment.

The surgeon’s challenge is being able to tell which child needs surgery and when. X-rays and MRIs are used to get a handle on where the bone is affected, how much damage is present, and what kind of blood supply is present.

Studies show that surgery is needed when there is a large area of the femoral head and epiphysis affected. Earlier treatment (in children up to eight years old) yields better results. Treatment is more difficult when the femoral head has already fragmented and/or collapsed.

Some surgeons try conservative (nonoperative) care using a cast or brace to hold the hip in place. Sometimes a removable brace is used for a long period of time (up to a full year). The brace is worn at night. During the day, the child is allowed to move the leg and get around with a walker or crutches. Weight-bearing on the leg is NOT allowed.

When surgery is indicated, there are several different ways to approach the problem. All of the surgical techniques are designed to provide a deep hip socket for the femoral head and restoration of the normal, round head that fits inside the socket. Sometimes surgery involves cutting some tendons to change the angle of pull on the joint while building a shelf over the femoral head to hold it in place.

There hasn’t been enough research yet to really pinpoint which procedure works best for each individual child. Decisions are made based on the age of the child, condition of the bone, presence of bone fragmentation, and loss of blood supply at the time of diagnosis. The younger the child (under age six), the more likely conservative care can be effective. Older children are almost certain to need surgery to prevent hip deformity.

Management of this conditionwith new treatment ideas may be developed in the near future. As more information about the cause and pathogenesis of Legg-Calvé-Perthes disease becomes available, studies can be done to find predictive factors to guide treatment. This will be a tremendous help to all who are trying to provide the best outcome possible for children with this disease.

You are quite right that the number of concussions among adolescent athletes is a problem. It is estimated that there are 136,000 concussions each year just among high school athletes. And that is probably a very conservative number because many athletes avoid reporting injuries of this type.

Football players seem to be at greatest risk for head-to-head collisions resulting in concussions. Soccer players have the next highest rate of concussions. But head-to-head collisions isn’t the only way sports athletes end up with a concussion.

Hitting the ground after a fall and running into sports equipment such as goal posts and sideline bleachers are other ways athletes can get a concussion. “Heading the ball” has not been reported as a source of concussions among soccer players.

Many coaches and family members wonder how can you tell if an athlete has suffered a concussion. The first clue comes from symptoms such as headache, blurred vision, nausea and vomiting, sleepiness and dizziness. Other symptoms can include difficulty concentrating, feeling in a fog or feeling slowed down, ringing in the ears, irritability, and sensitivity to noise.

Loss of consciousness is a very important signal that something serious has happened. But being “knocked out” isn’t necessary to have a concussion. Headache is the most common symptom but some players aren’t aware of any symptoms.

Symptoms resolve within the first 24 to 36 hours for most athletes. Symptoms persisting beyond a week are not uncommon. These usually clear up within a month’s time. Only a small percentage of athletes (1.5 per cent) report symptoms lasting more than 30 days.

The immediate question after a collision is whether or not that player can return-to-play right away and if not, when can he or she get back into action? Symptoms offer some guidance but there are reports of deaths among athletes who failed to report symptoms and went back to play right away.

To avoid the deadly consequences of concussion, medical experts recommend computerized neuropsychologic (NP) testing. This type of test includes questions that evaluate the athlete’s brain function including memory, attention, language, and visual-spatial skills. The NP test provides a comparison to expected norms for each task and a baseline from which to measure changes or progress after injury.

The safety of the player has to be the number one priority. Athletes should not be allowed to return to play until it is safe to do so. Neuropsychologic (NP) testing is one way to assure that players get the protection and treatment they need after a significant head injury.

Scoliosis or curvature of the spine can develop at an early age. In fact children under the age of five can develop serious spinal scoliosis. Children with curves that are growing too fast to hold in place with bracing must have growing-rods placed along the spine.

The goal is to prevent deformities while still allowing for growth and development of the spine and trunk. Careful monitoring is essential to get the best results with the fewest problems.

In the database, there were 140 patients who had a total of 897 growing-rod procedures. More than half (58 per cent) of those 140 children had at least one complication. The rate of complications was higher in children with the single-rod support or subcutaneous placement. They also found that the more surgeries the child had, the greater the risk of problems developing.

There was a whole host of different complications. Infections, blood loss, rods breaking, painful scars, hook or screw pullout, and rods poking through the skin give you some idea of what was happening. There were also cases of lung, heart, and/or intestinal problems.

A recent study of this problem was done at the San Diego Center for Spinal Disorders in California. The information gathered on children came from The Growing Spine Study Group. This is a computer database with information downloaded from around the world. Various spine centers treating children with early-onset-scoliosis provided information about results of treatment using these growing rods.

Over the years, this group has been able to show that early spinal fusion (before age seven) is not a good idea. These are the kids who end up with cosmetic deformities and difficulty breathing. This same group was also able to show that growing rods have more complications than previously appreciated.

More recently, they found that the rate of complications is higher in children with the single-rod support or subcutaneous placement. They also found that the more surgeries the child had, the greater the risk of problems developing.

Anyone with a young child who has scoliosis that is getting rapidly worse must be prepared for sudden changes in treatment. Casting or bracing may be used at first and then replaced with surgery. Complications, problems, and additional (often unplanned) surgeries are to be expected.

Scoliosis refers to an abnormal curvature of the spine. When present in young children (five and under), the condition is referred to as early-onset scoliosis.

Early-onset scoliosis can be treated conservatively with bracing or casting. But if it progresses (gets worse), it can become a serious problem in young children. The spine can curve so much that the lungs and heart are compressed causing complications.

When scoliosis is present early like this, the chances of a fast growing curve are much higher than when the curvature develops in the teen years. Treatment may have to progress from bracing to surgery. The surgeon places one or two metal rods alongside the spine to help support it in an upright, neutral alignment.

As the child grows, the rod can be lengthened. This type of treatment prevents removing the rods and replacing them as growth occurs. Instead, with each growth spurt, another surgery is done to expand the rod(s). You can see the advantages of such treatment in cases of early-onset scoliosis. When the child stops growing, then spinal fusion can be done.

In the future, it may be possible to lengthen the rods without doing surgery. The internal rods could have an external remote. The remote could be used to allow for expansion without opening up the spine to adjust the rods by hand. This type of technology could reduce the number of procedures (and complications) until spinal fusion is possible.