FAQ Category: Child

Your question is a good one. There are likely many pros and cons around the use of a spinal brace for a child like this with a spinal cord injury. The brace does restrict breathing, activity, and motion. It certainly reduces independence.

The brace may be a temporary treatment when the spine is healing and movement must be eliminated. If the spinal bones are broken and/or dislocated, once they are put back in alignment, the brace will keep them there until healing has occurred. Movement could disrupt the healing bones and even cause further damage to the spinal cord and worse paralysis.

In cases of pediatric spinal cord injuries, the advantages of bracing outweigh the disadvantages. Temporary restriction of movement and activity that might result in a stable spine is worth the wait. There are times when the brace prevents (or delays) the need for spinal surgery. That is a very important advantage of bracing.

After the spine has been stabilized, bracing might be needed for spinal deformities such as scoliosis (curvature of the spine) that might start to develop. Bracing is used at the first sign that the spine is starting to lose its anatomic alignment and curve or collapse.

Again, the advantages gained from this type of treatment often make it worth the inconvenience, discomfort, and decreased function for the child in the long run.

Spinal cord injuries in children are rare but when they do happen, there is understandably grave concern for them. Most of the children affected are in their teens (15 and older). Only 10 per cent of all pediatric spinal cord injuries affect children younger than 15.

All of that is to say there isn’t a lot of evidence to guide treatment. Much of what is done is based on how adults are treated. Fortunately, children seem to respond well (often better than adults).

The first goal of treatment is to stabilize the spine. There is a concern that fractures and broken pieces of the spinal bone could cut into the spinal cord. Dislocated vertebrae can alter the size and shape of the spinal canal (opening for the spinal cord).

Anything that changes the dimensions of the spinal canal can put pressure on the spinal cord. Treatment is designed to realign the spine and prevent compression of the nerve tissue. Sometimes this can be accomplished without surgery. But much more often, surgery is done to realign the bones and hold them in place until healing occurs.

Taking pressure off the spinal cord is referred to as a decompression procedure. Using wires, screws, metal plates, or rods to hold the spine in place is referred to as internal fixation or instrumentation.

After the spine is stabilized, everyone on the team (parents or family, physicians, physical therapists, nurses) monitors the child closely for the first sign of scoliosis (spinal curvature) or other spinal deformity.

Bracing right away is strongly encouraged to keep the curve from getting worse and perhaps prevent the need for spinal fusion. When bracing doesn’t prevent worsening of the deformity, then surgery may be needed to fuse the spine and hold it in place.

The health care and rehabilitation team caring for your granddaughter will walk the family through each step and each decision required. Your steady support will be a tremendous help to all who are involved.

Osteochondritis dissecans (OCD) is a condition in which a piece of cartilage and the underlying bone have been damaged. In some cases, the damaged fragment separates from the bone and floats freely within the joint.

The problem can develop in the elbow as a result of trauma (injury) but more often, it occurs when there is repetitive compression of the radiocapitellar joint. Athletes affected most often include baseball pitchers, weight lifters, tennis players, cheerleaders, and female gymnasts.

The radiocapitellar joint is located where the radius (bone in the forearm) joins the bottom of the humerus (upper arm bone) to form part of the elbow joint. Osteochondritis dissecans (OCD) of the elbow doesn’t occur in immature throwing athletes very often so there isn’t a lot of information about it to help guide treatment.

The first step is to rest for three to six weeks. Athletes must learn how to change the way they do things or the problem will come right back. This process is called activity modification.

A physical therapist will prescribe exercises to stretch and strengthen appropriate muscles. The physician may prescribe medications such as nonsteroidal antiinflammatories (NSAIDs). There aren’t enough studies to show that this is really needed or beneficial. Specific guidelines regarding dosage (how much) and duration (how long) these medications should be used are not available.

Athletes most likely to recover nicely with conservative (nonoperative) care are younger and have early (mild) disease. Patients who have completed six months of conservative care but who still have symptoms are considered candidates for surgery.

Surgery is also considered when there are fragments of cartilage and/or bone inside the joint. These are called loose bodies. Patients who have loose bodies are most likely to develop the catching and locking symptoms of the elbow reported.

What can the surgeon do for this condition? Drilling is a popular technique for lesions that are stable. Stable means there are no loose fragments or unstable bits of cartilage that could get torn off and form a loose body.

Drilling refers to the practice of putting tiny holes in the surface of the cartilage down through the layer of bone underneath the cartilage and right through to the bone marrow. Tiny drops of blood seep up from the bone into the defect and stimulate a healing response. This type of bone marrow stimulation has good short- to medium-term results. Long-term data (especially about return-to-sports status) is still needed.

When there are loose bodies or an unstable cap, the authors prefer to use debridement first, then bone marrow stimulation. Debridement involves removing any fragments and smoothing down any remaining rough edges. If the lesions are large (more than half of the cartilage in the radiocapitellar joint is damaged), then osteochondral autograft transplantation (OAT) is advised.

The OAT technique is a two-step process. First, normal, healthy plugs of articular cartilage and bone are harvested. Because the radiocapitellar joint is so small, surgeons must rely on another joint as the donor site.

Usually the femoral condyle (end of the thigh bone forming the upper half of the knee joint) is the main source of graft plugs. The plugs are then transferred to the damaged area of the elbow joint and inserted.

More studies (especially long-term studies) are clearly needed to find out what works best for each type of athlete given the location and severity of the damage done to the radiocapitellar joint.

Your orthopedic surgeon will take all of this into consideration when making a plan of care for your son. But it’s always good for parents to have some information in hand when helping to guide treatment for a child with an unusual condition like this one.

Although these two conditions are considered separate problems, some experts view them as two stages of the same thing.

Both affect the capitellum bone of the elbow but Panner disease causes fragmentation of the entire capitellum. OCD is usually more of an isolated lesion that breaks away from the main bone causing a loose body to float inside the joint.

Here’s a quick review of elbow anatomy to help you picture the capitellum. The elbow is the connection of the humerus (upper arm bone) and the two bones of the forearm (the ulna and the radius).

The joint where the humerus meets the radius is called the humeroradial joint. This joint is formed by a knob and a shallow cup. The knob on the end of the humerus is called the capitellum. The capitellum fits into the cup-shaped end of the radius, also called the head of the radius.

Panner disease tends to develop in young boys between the ages of 5 and 10 who aren’t involved in repetitive motions that cause trauma to the joint. For unknown reasons, normal growth in the outer edge of the elbow is disrupted, which causes the small area of bone to flatten out.

Symptoms of diffuse elbow pain are common with both Panner disease and OCD. Diffuse means the pain feels like it is throughout the entire elbow. Pain can occur along the outside or lateral aspect of the elbow. The pain is present with activity and there’s a loss of extension. The child cannot straighten the elbow all the way. There may be stiffness, swelling, and when there is a loose body associated with OCD, clicking, catching, and/or locking of the elbow can occur.

How does the physician tell the difference between OCD and Panner disease? The child’s age and activity level help sort this out. X-rays, MRIs, and the most definitive method: arthroscopy shows the type, location, and severity of cartilage and subchondral damage. MRIs are especially good at showing early changes when X-rays appear otherwise normal.

Once the diagnosis has been made, then a plan of care is developed. One main difference between Panner disease and OCD is that Panner disease is self-limiting. That means it will go away with rest and doesn’t require additional treatment. Over a period of one to two years, the bone slowly rebuilds itself. During this time, symptoms gradually disappear, although the elbow may never fully straighten out.

OCD may respond to rest, which removes the compressive load and shear forces long enough to allow healing. The use of antiinflammatory medications and a physical therapy program of stretching and strengthening exercises are also recommended. OCD does not always improve with conservative care. With more advanced (more severe, unstable) lesions, surgery might be needed to help the cartilage heal.

Osteochondritis dissecans (OCD) is a problem encountered most often by male adolescents (teens) involved in repetitive overhead throwing activities. Young girls participating in gymnastics are the second group affected most often. Gymnasts can spend quite a bit of time engaged in activities that require repeated weight-bearing on the arms leading to OCD.

In this condition, repetitive microtrauma from repeated motions of the elbow causes the articular cartilage that lines the elbow joint to separate and break into pieces. When the cartilage pulls away from the joint, it takes a layer of subchondral bone with it. Subchondral just means “under the cartilage,” which describes the first layer of bone next to the articular cartilage.

Most young athletes can expect to return to the sports activity of their choice (even if it’s just throwing the ball for the dogs). But there’s an extended period of time of physical therapy, rehab, and recovery.

When full, pain free elbow motion is possible, then strengthening begins and progresses to include sports-specific training (e.g., overhead throwing). Expected results are good when the problem is caught early and the damage done is minimal.

But beware that the prognosis for osteochondritis dissecans of the capitellum is not always good. Studies show that at least half of the children affected by this condition end up with arthritis and continued elbow pain, stiffness, and limitations.

The prognosis seems poorest for those patients with the most severe, unstable lesions. New treatment techniques are undergoing study with hope for more promising long-term results.

A little understanding of the anatomy of the child’s hip will help explain this phenomenon.

In the growing child, there are special structures at the end of most bones called growth plates. The growth plate is sandwiched between two areas of the bone called the epiphysis and the metaphysis. The growth plate is made of a special type of cartilage that builds bone on top of the end of the metaphysis and lengthens the bone as we grow. In the hip joint, the femoral head is one of the epiphyses of the femur.

The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. The joint capsule is the tissue that surrounds the joint.

Here’s the key to osteonecrosis developing: the blood vessels that go to the epiphysis run along the side of the femoral neck and are in danger of being torn or pinched off if something happens to the growth plate. This can result in a loss of the blood supply to the epiphysis and then death of the bone (osteonecrosis) that your surgeon told you about.

The question about what can be done to prevent osteonecrosis has received a great deal of attention and study. There are many proposed theories: length of time between diagnosis and surgery, amount of slippage and pressure inside the joint capsule, age at the time of diagnosis, body weight, and so on.

In a recent study (probably one of the largest studies done on this topic), pediatric orthopedic surgeons from The Children’s Hospital of Philadelphia (CHOP) report finding three factors that might be significant.

The first risk factor for osteonecrosis after surgery to stabilize SCFE was age. Younger children with very little warning symptoms before the problem was diagnosed had a higher incidence of osteonecrosis after surgery. The second was severity of slippage at the time of diagnosis. It’s likely that the more severe the problem and the greater the instability, the shorter the time before symptoms develop.

The third significant factor was based on the type of surgery that was done. The children in the study from Children’s Hospital of Philadelphia fell into one of three groups based on the type of surgical treatment. Group one consisted of children who had the slipped epiphysis held in place with a screw. This procedure is called in situ screw fixation.

Group two had a closed reduction. Reduction means the slipped epiphysis went back into place. Closed tells us this happened without open surgery with an incision. Sometimes just positioning the hip in a certain way will reduce or realign the hip. This can happen while moving the child or placing him or her on the operating table.

And group three had open surgery to put the slipped epiphysis back in place and hold it there with a long pin (screw) placed through the bone. This procedure is called an open reduction and internal fixation (ORIF).

Group two (closed reduction) had the largest number of cases of osteonecrosis (26 per cent). Group one (in-situ fixation) had the second highest incidence (19 per cent).

Group three (open reduction and fixation) had only one patient develop osteonecrosis. For all the children in the study, the more severe the slip was before surgery, the greater the risk of developing osteonecrosis after surgery. The overall incidence of osteonecrosis for the entire group (all 70 children) was around 20 per cent.

So, that’s a lot of information to say, we really don’t know all the reasons why children develop osteonecrosis after surgery to correct slipped capital femoral ephiphysis. The factors found to be significant so far (age, severity at diagnosis, and type of surgery) aren’t really under your control.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip in teenagers between the ages of 12 and 16 most often. 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).

Children and teens with a stable slip are still able to put weight on that leg and walk. It may be necessary to use crutches, walking sticks, or some other assistance but they can get around. There is pain but not to the point of being incapacitated as with an unstable hip.

Unstable means they are unable to put any weight on the affected leg. The pain is so severe that even with crutches or other supportive aids, they are unable to walk. Usually, the more severe the slippage, the greater the painful symptoms and the more likely it is that the hip is unstable.

If untreated this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. Surgery is usually necessary to stabilize the hip and prevent the situation from getting worse.

A peel-off injury refers to a tearing away of the posterior cruciate ligament (PCL) from the tibia (lower leg bone), one of the places where it attaches. The posterior cruciate ligament is one of two ligaments that criss-cross to form an X-shape inside the knee.

Together, these ligaments hold the knee stable and keep the bones from shifting too far apart. The posterior cruciate ligament is designed to prevent the tibia from sliding too far back underneath the femur (thigh bone).

The word “peel-off” refers to the fact that the ligament litreally pulls clean away from the bone where it normally attaches. Another term for this type of injury is tibial avulsion of the PCL. Trauma from sports injuries or falls is the main mechanism leading to a peel-off injury of the PCL. Although adults can have this injury, most cases occur in boys between the ages of 12 and 13.

A direct blow to the upper portion of the tibia (just below the knee) while the knee is bent can cause a peel-off injury. Most of these injuries occur during sports participation (e.g., soccer, basketball, dodge ball) or as a result of a fall.

A peel-off injury refers to tearing away of the posterior cruciate ligament (PCL) from the tibia (lower leg bone), one of the places where it attaches. Another term for this type of injury is tibial avulsion of the PCL.

As with your patient, the typical person affected is a boy between the ages of 12 and 13. These injuries occur most often during soccer, basketball, dodge ball, or as a result of a fall.

It’s a fairly uncommon injury so large studies comparing the results of treatment are not available. In fact, most studies are just case reports of a single patient or small number of cases presented together.

A recent report from orthopedic surgeons in Korea who treated six boys with this problem reported their postoperative physical therapy program. Their protocol starts right after surgery. The children are kept in a hinged, long-leg brace locked in a fully extended position for four weeks. This approach of immobility is designed to protect the healing ligament. Quadriceps strengthening exercises are allowed with the leg in the brace.

At the end of the four-week period of time, the brace is unlocked and passive movement is allowed. The child is allowed to put gradual, increasing amounts of weight on the leg until the brace is removed eight weeks after surgery. All activities are resumed as the child is able to perform them. Sports activity are allowed when motion and strength are within normal limits.

It might be a good idea to submit your plan of care to the surgeon for a quick review and approval. The child in question may have some specific needs that your evaluation will uncover. And the surgeon may have some directives once he or she sees the proposed plan in writing. Good luck!

Trigger finger (and trigger thumb) are conditions affecting the movement of the tendons as they bend the fingers or thumb toward the palm of the hand. This movement is called flexion.

The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects.

Triggering is usually the result of a thickening in the tendon that forms a nodule, or knob. The pulley ligament may thicken as well. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule.

What causes trigger finger? In children, triggering can be caused by a congenital defect that forms a nodule in the tendon. Type 1 diabetes has also been linked with trigger finger in children and teens. There are rare cases reported of trigger finger in children following a viral infection. In general, trigger finger tends to occur in younger children (most often under eight years old).

In adults, rheumatoid arthritis, partial tendon lacerations, repeated trauma from pistol-gripped power tools, or long hours grasping a steering wheel can cause triggering. Symptoms are similar in children and adults. Treatment is usually surgical release but there are some cases (especially viral-induced) when a wait-and-see approach can be adopted.

Triggering is usually the result of a thickening in the tendon that forms a nodule, or knob. The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys.

The pulley ligament may thicken as well. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule.

Treatment is usually surgical release. Normally, to keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects.

But when thickening and fibrosis (scarring) develop in the synovial lining, it doesn’t go away on its own or even with conservative (nonoperative) care. One exception to that is in the case of trigger finger caused by viral infection. In the rare cases reported, trigger finger in these children went away after a period of time (one to four months).

Your pediatrician and surgeon may agree to a wait-and-see approach for a few weeks up to several months. But an extended period of time (many months to years) is not advised. If there is evidence that the trigger finger was caused by a recent infection (e.g., elevated sed rate), a trial period of waiting is acceptable as well.

Loeys-Dietz syndrome is a disorder named after the two physicians who first identified and described it. The word syndrome tells us there is a cluster of signs and symptoms that are present in each child who has this disorder.

Loeys-Dietz affects multiple body systems including the skeletal system, the heart (cardiac) and blood vessels (circulatory system), and the skin. This problem is caused by a genetic mutation. They’ve even found the gene that has gone bad: TGF-ßR1 or TGF-ßR2. This particular gene is responsible for coding the growth factor-beta receptor.

For the affected child, the genetic mutation can mean the formation of aneurysms (weak blood vessel walls that can burst and bleed), scoliosis (spinal curvature), very thin skin, chest deformities, and severe foot deformities (clubfoot). Other problems observed in children with Loeys-Dietz include an unstable cervical spine (neck), small jaw, cleft palate, hip dysplasia, and many other skeletal deformities.

Some features of this disorder are very distinctive (e.g., cleft palate, clubfoot). There may be a condition called hypertelorism, which is an abnormal distance between the eyes.

Craniosynostosis is another telltale skeletal feature. This refers to the premature fusion of the cranial (skull) bones. Early fusion of this type prevents the brain from growing normally. The child ends up with an abnormally shaped head and face. Delays in development (especially motor skills) are also common when brain growth is restricted.

We are not painting a very rosy picture here. But before thinking the worst, find out more about how this condition has affected your grandson. The fact that the diagnosis has been made so early is very positive. Early treatment of some of the associated conditions can change the picture for these children (in a positive way).

You may be seeing some indications of a connective tissue disorder. The one that comes to mind first is something called Marfan syndrome. If you’ve ever seen a photograph of Abraham Lincoln you know he had a long, thin face. He was thin and tall, and he had long arms and long fingers.

There has been some thought that he might have had Marfan syndrome. All of these physical features are typical with Marfan syndrome. Newer evidence suggests he had a different (but very similar) disorder. But the association of Abraham Lincoln’s name with Marfan Syndrome has forever put this condition on the map.

There are a couple of physical tests that can be helpful in identifying Marfan syndrome. One is the positive thumb or Steinberg sign. The other is the positive wrist or Walker-Murdoch sign.

Your nephew may be demonstrating a positive thumb sign. Just as you described, if the patient puts the thumb across the palm and closes the fingers and the thumb pokes out the other (little finger) side, it’s a positive thumb sign. If the patient can circle the forearm with the thumb and little finger of the other hand and cover the entire nail of the little finger with the thumb, there is a positive wrist sign.

X-rays are an easy and fairly inexpensive way to look for evidence of Marfan syndrome. Besides the skeletal features already mentioned, the presence of acetabular protrusio is diagnostic. Acetabular protrusio means the acetabulum or hip socket is too deep and may protrude into the pelvis.

It’s a simple thing to ask the pediatrician or primary care doctor to take a look at the physical features. He or she will be able to see if they are significant or just the way your nephew is put together. If there is a problem, it’s better to find out sooner than later to prevent potential serious complications and ensure a healthy, long life.

Marfan syndrome is a genetic disorder of the connective tissue that results in a variety of possible physical features and deformities. These can include defects of the heart valves and aorta.

It can also affect the lungs, eyes, the dural sac surrounding the spinal cord, the skeleton, and the hard palate. A family history is helpful but sometimes it doesn’t come until a family member dies of heart complications from Marfan syndrome. This is obviously the case in your family.

Genetic testing is one way to find out if someone has Marfan syndrome. But genetic testing is expensive and doctors have to identify who might have this disorder before sending anyone and everyone to the genetics expert.

And it gets more complicated than that because many children (people) have one or even more of the telltale characteristics of Marfan syndrome — but they don’t actually have this connective tissue disorder. And just as many folks who actually have the syndrome have invisible signs (like the heart problems) that could lead to their premature death.

This diagnostic dilemma is one that researchers are working on. Marfan syndrome is not a common problem so finding enough patients with a known diagnosis to use for comparison studies has been difficult. The good news is that your child has been identified and can get the medical care needed to prevent serious problems.

There are three major nerves to the muscles of the arm: the radial nerve, ulnar nerve, and median nerve. There can be a high nerve injury (above the elbow) or low nerve injury (below the elbow).

An injury to any of these nerves produces a predictable loss of hand and/or arm function depending on which muscles have been affected. Whether it is a high or low nerve injury also determines what muscle function has been lost or altered.

If the nerve has not been completely cut and if the damage done is not too severe, it can regenerate. This process of reinnervation and recovery is very slow. Often, it is a wait-and-see proposition. By watching for signs of muscle function, surgeons can gauge how long the patient must wait for complete recovery and whether or not surgery is needed.

Electrodiagnostic testing can be done. The two main tests available are electromyography (EMG) and nerve conduction velocity (NCV). The EMG test measures the electrical impulses to the muscle (that’s what makes them contract). The NCV shows where the signal is moving (or stopping) along the nerves.

With repeated tests over time, it’s possible to see progress as the signal moves farther down the nerve and/or creates a stronger muscle contraction. If no change is registered over time, then surgery is considered to repair the nerve or possibly transfer a working tendon to replace the tendon/muscle unit no longer working because of nerve damage.

It sounds like the type of fracture was a lateral condylar fracture of the distal humerus. The distal humerus is at the bottom of the upper arm.

The humerus flares at the bottom on both sides forming a part of the bone called the condyle. The lateral condyle is the bony projection along the outside of the elbow (side farthest away from the body). Fractures of the lateral condyle are fairly common in children. Finding the most effective treatment with the fewest complications is an important goal.

The choices in treatment include: putting the arm in a cast from the hand to the top of the upper arm. That’s called a long arm cast. Casting without surgery is possible when the break is intact and hasn’t separated or displaced.

A second treatment alternative is called closed reduction and internal fixation or CRIF. With CRIF, the break can be lined up (reset) without an incision to cut through the skin and open the arm up. And for fractures that have separated too much and/or shifted so the broken ends no longer line up, the third procedure used is called an open reduction and internal fixation (ORIF). With the open reduction, the surgeon makes an incision down to the bone. The bone is put back together and held in place with wires, plates, and/or screws. The arm is placed in a long arm cast until sufficient healing takes place.

Each of these treatment approaches have their pros and cons in terms of complications. Putting a cast on without wiring or screwing the bones back together has a risk of the bones drifting too far apart. Closed reduction and internal fixation may not bring the bones back as close together as needed. The result can be deformity and change in the carrying angle of the arm. Open reduction with internal fixation (ORIF) is really the most accurate treatment but it is also the most invasive.

A wide range of complications can occur from the treatment of lateral condylar fractures. There can be infections, loss of blood supply to the bone, failure of the bones to knit back together (malunion), or just a very slow process of healing (delayed union).

Sometimes the bones shift even with surgery (CRIF or ORIF). If too much shifting occurs, an elbow deformity can develop that affects the carrying angle of the arm. There are cases where growth is stopped or the opposite (too much bone growth) occurs. Stiffness, loss of motion, weakness, and loss of function are all possible problems that can develop.

The best thing to do is keep your regular follow-up appointments with the surgeon. Periodic X-rays may be needed to track your son’s progress and make sure the bone is healing properly. If you notice anything unusual, don’t hesitate to report this to the surgeon for further evaluation.

At the time of the injury, X-rays are used to view broken bones with the specific idea in mind to plan the safest and most effective treatment. If the two ends of the broken bone line up and have not separated apart, then a cast can be applied. In the case of the elbow, a long-arm cast is often needed (from hand to shoulder) to prevent the bones from shifting apart.

Sometimes, the surgeon makes a judgement call. There may be a minor amount of separation called displacement seen on the X-ray. In an effort to avoid surgery, a cast is applied with a wait-and-see approach. The arm is re-Xrayed to check on alignment and bone healing.

If the bones continue to drift apart (and especially if the ends of the bone separate and shift so that they no longer line up), then the cast is removed and surgery is done.
Long-arm casting for elbow fractures is used whenever possible to avoid the invasiveness of surgery.

In a recent large study of lateral condyle elbow fractures, 14 patients of the 39 who were put in a long arm cast without surgery ended up with a gap in the fracture site. This shift in bone alignment required surgical fixation within the first two weeks of casting. That’s almost half of the group, a fairly high percentage.

Future studies may look into predicting who will have separation and require surgery to hold the bone together but for now, the wait-and-see approach has its merits.

Department stores with escalators often have a sign posted that the escalator is not to be played on or ridden for fun when shopping. Safety is the store’s first concern. Injuries can and do happen on escalators. These kinds of signs rarely keep children from taking a joy ride. And even when accompanied by an adult, severe fractures, cuts, and even traumatic toe amputations have been reported in children riding escalators.

Many things have already been done to reduce these kinds of injuries. The manufacturers of rubber clogs have started a safety campaign called the Escalator Safety Awareness Initiative. Tags are attached to the clogs with safety information about escalators. Efforts are being made to improve the design and maintenance of escalators. Safety side plates are now part of newer escalator installations.

Children should never be allowed to sit on the escalator steps (or stand facing backwards) when it is moving. Trying to walk down the up escalator and vice versa is to be strictly forbidden. Any child wearing clogs must be closely supervised.

Young children should be assisted at the top until they have developed the skills needed to step off safely. All of the unfortunate escalator-related injuries involving clogs have been preventable. Parents can help prevent loss of toes, fractures, and crush injuries by following these simple suggestions.

Store managers are advised to ensure safety inspections, routine escalator maintenance, and regular lubrication of moving parts. Parents are reminded to keep children away from the sides of the escalator and face forward. Everyone in the store should always be aware of where the escalator emergency stop button is located.

There are indeed an increasing number of reports of severe foot injuries in children who were wearing the very popular and trendy rubber clogs and got caught in an escalator. Even when accompanied by an adult, severe fractures, cuts, and even traumatic toe amputations can and do occur in children riding escalators.

The front of the clog is wide and gives the impression that the foot is well-protected. But children who don’t pick the feet up to step off the escalator can get the clog stuck in the gap where the last step slides into the comb plate. The side of the clog can also get caught on to the metal side panel. Often the injury is made worse because the escalator keeps going until a store employee finally turns it off.

Younger children are at the greatest risk for these types of injuries. They have small feet that can slip into the comb plate. They tend to stand on the escalator right to the top without actually stepping off. And they fall down a lot, increasing the risk of an injury when the fall occurs while on the escalator. Until young children have developed enough to navigate escalators with ease and coordination, parents, grandparents and any other adults with the children are advised to supervise them closely.

No doubt your surgeon recommended the treatment approach that was best for your daughter given the circumstances. Fractures of both the radius and ulna bones of the forearm can be difficult to treat. If the bones don’t line up straight during the healing process, forearm rotation can suffer.

Without a smooth palm up/palm down motion, there are many movements that become difficult if not impossible. Surgery must be done in such a way that the bones are stabilized (held in place) while preserving forearm rotation.

Placing a metal rod down the middle of each broken bone has been a popular fixation method for many years. Then back in 1996, the first orthopedic surgeon tried using a metal rod just down one of the two broken forearm bones (the ulna). This type of fixation is called single intramedullary fixation.

Since that time, other surgeons have tried the new technique and reported on their results. Most of the time, the single intramedullary rod works just fine. X-rays taken during the surgery confirm good placement of the bones. X-rays taken after the arm is in a cast and healing can be done if there are any questions about maintaining the alignment.