FAQ Category: Child

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.

It sounds like your son may have a supracondylar humerus fracture, a fracture of the bone right by the elbow. When this bone breaks, there can be damage done to the arteries that pass by the elbow, the brachial artery. The artery brings fresh, oxygenated blood from the heart to the body tissues to provide nutrients. If the artery is damaged, the amount of blood flow is compromised and damage can occur to the cells that are starving for nutrition.

One way to tell is if your son had a pulse at the wrist. If he didn’t, and his hand was cool to touch, he could have this type of damage. On the other hand, he could have a pink, warm hand but still no pulse – this has a high chance of still having damage to the artery. If the doctor knows there is damage, surgery must be done as soon as possible to prevent that further damage.

Without knowing your daughter’s history, it would be impossible to tell you if you are right or wrong about the surgery. However, perhaps some explanation may help you decide. When a child breaks his or her elbow, it is possible that the damage isn’t restricted to just the bone. The brachial artery, the blood vessel that supplies fresh blood from the heart to the tissues in the lower arm and hand, could also be damaged. It could be pinched or nicked a bit. This damage would prevent the blood flow from going on full force, as your body is used to. By leaving the artery untreated, there could be significant complications.

While it would make sense that the hand would be cool and no longer pink if there is no pulse, this isn’t always the case with an elbow fracture. In fact, it’s not uncommon to have a warm hand but no pulse. If this is left untreated, again, there could be severe complications. In other words, if the hand is cool and has poor color, and there is no pulse, there is likely arterial damage. However, for there to be arterial damage, the hand doesn’t have to be cool or bluish.

It used to be that doctors would not do surgery for clavicle fractures (collarbone) if they seemed to be in line and there was not other apparent damage. It was felt that it wasn’t usually a big issue if the bones didn’t meet exactly together again, as long as the patient could once again use his or her arm properly.

What has happened, though, is the doctors have found that if the bone doesn’t join properly, malunion, this can cause problems in pain, mobility, and strength. As a result, they are starting to perform more surgery on collarbone fractures, particularly if they are displaced, where the ends of the bone have moved away from each other.

Surgical correction of clubfeet is done if the casting doesn’t work or it works, but not completely. While the shape and positioning of the foot may look fairly normal after surgery, there may be some internal issues that can’t be corrected. This may result in the foot not being equally as strong as an unaffected food.

Research that has followed adults who did have clubfoot surgery as children found that the adults do mostly have good use of their foot to perform regular everyday tasks. However, the studies also find that the clubfoot does tend to tire more easily, doesn’t have the strength of the other foot, and it is limited somewhat in it’s ability to move (range of motion). This means it may be more difficult to put stress on the foot, such as when running, for example.

Clubfeet are often treated with serial casting – that means a cast is put on to help reposition the foot, but as the child is growing rapidly, the casting gets changed regularly to accommodate both the growth and the movement of the foot.

While this works frequently, there are times when it doesn’t work or when surgery is needed just to do the final little bit that the casting couldn’t or didn’t do.

Children don’t suffer from the joint aches and pains experienced by older adults plagued by arthritis. Instead, they have sports injuries (or other traumatic injuries), orthopedic problems they might be born with (e.g., developmental dysplasia of the hip, clubfoot), and tumors. The recent increase in antibiotic resistant bacteria leading to skin and muscle infections has affected children as well as adults.

There aren’t pediatric orthopedic specialists in every town in America. But any large area and especially any pediatric hospital will have a pediatric orthopedic surgeon (specialist) on staff.

Sometimes an orthopedic surgeon will do a pediatric fellowship. That means after training to be an orthopedic surgeon (and maybe even working for awhile in that capacity the surgeon goes back to school to learn about children’s orthopedic problems. Then it’s possible to offer his or her services to children and teens as a subspecialty while still seeing adults.

Surgery for hip dysplasia (the top of the thigh bone not fitting properly into the socket) can only correct the mechanics of the problem. The muscles around the hip are affected by both the initial displacement and the surgery itself. As the muscles heal, they will only be able to do what is demanded of them, so if your daughter does not do her exercises, they cannot strengthen as they could.

Not doing physiotherapy exercises can delay her recovery and make recovery more difficult.

All patients recover from surgery in their own way, some quickly, some slowly. In general, however, patients who have surgery on their hip are not allowed to do full weight-bearing for several weeks (often about six weeks), when they can then begin to bear weight slowly.

Anyone who has hip surgery, such as repair of dysplasia, will be given physiotherapy exercises to strengthen the muscles around the hip. If the hip dysplasia has been present for a while, the muscles were not being used properly and then the surgery affects the muscle strength and ability as well.

Your daughter will be followed and assessed by the surgeon, using x-rays and some tests, such as measuring her gait, to see how her progress is going.

It sounds like your niece may have macrodactyly, although it would be impossible to say for sure without seeing her or reviewing her medical records. In macrodactyly, one or more toes becomes significantly larger than the others; all the parts of the toe are larger, from the bone to the fat, and everything else.

When a doctor decides on treatment, the issues at hand are:

Is the toe causing pain or disability?
Which toe is affected?
What is the goal?
What are the options for this particular patient?

Amputation may seem like a simple answer, but it isn’t. You have your toes for a reason – they help you balance as you walk and run. Depending on which toe is removed, this could have a significant impact on the foot on the whole. Your niece’s parents should be discussing this with her doctor, seeing what the options are and what they feel would be the best approach.

Pain along the back of the hip is a fairly rare problem and affects athletes involved in golf, dance, or soccer most often. The most likely causes of posterior hip pain in athletes include: 1) pain coming from the lumbar spine, 2) problems in the sacroiliac joint, 3) muscle pain, 4) piriformis syndrome, 5) hamstring rupture, and 6) femoroacetabular impingement.

Let’s take a quick look at each one of these problems. Herniated discs that put pressure on the sciatic nerve are the most common cause of referred pain from the lumbar spine. Hip pain occurs in this instance because the L3 lumbar nerve root that can be pinched by a bulging or herniated disc also supplies sensation in the hip. A problem at L3 can produce symptoms in both places: the low back and the hip. The tip off is that with sciatica, there is back, buttock, and often leg pain.

Next is the sacroiliac joint. This is where the triangular-shaped sacrum is wedged between the two pelvic bones. Any problem with ligament strains, infection, fractures, or alignment in this area can cause what is felt as posterior hip pain. This problem can also send pain down the back of the leg, so further testing is often needed to tell the difference between pain coming from lumbar spine versus the sacroiliac joint.

Strain, overuse, or tear of any of the muscles that insert into the hip, low back, or sacroiliac area can cause posterior hip pain. Palpating for tenderness and testing hip muscle strength are the key diagnostic tests here. One muscle in particular to check for is the piriformis. The piriformis rotates the leg outward, a movement referred to as external rotation.

For some people, contraction of the piriformis muscle presses on the sciatic nerve. This is another problem that can refer pain down the leg. But it’s one problem that doesn’t show up well on X-rays, MRIs, CT scans, or other imaging studies. The physician may try treating the symptoms conservatively with antiinflammatories and physical therapy. If the symptoms don’t go away, then it might be necessary to perform electrodiagnostic tests to confirm the diagnosis.

Ruptured hamstring muscles are much easier to diagnose. First of all, there is usually a history of trauma or specific injury the athlete can remember as the starting point of the problem. Muscle weakness is common with partial or complete tears. Surgery (as early as possible) is the most effective treatment for this problem.

And finally, there’s femoroacetabular impingement. This refers to pinching of the soft tissues somewhere around the hip joint — usually along the backside of the joint when the symptoms present in the buttock area. Certain hip motions will reproduce the pain and that’s the main test for the problem. MRIs or CT scans are helpful in looking at the anatomy and seeing what might be contributing to the impingement problem.

Today’s improved testing methods, updated technology, and better understanding of anatomy have made it possible to identify differences between and among these six possible causes of posterior hip pain.

Your specialist will perform a systematic examination and evaluation. The clinical workup will lead to an accurate diagnosis. The most appropriate treatment will follow based on identification of the underlying cause of the problem.

When it comes to holding a broken femur together, there are four different ways to surgically fix (hold in place) the broken bones. The four methods of fixation include: 1) elastic stable intramedullary nail fixation, 2) external fixation, 3) rigid intramedullary nail fixation, and 4) plate fixation.

Intramedullary nails such as you describe are often used when there is a femoral fracture that has been displaced (ends of the bone shift). The nail is designed to hold the bone steady as healing takes place.

With any type of fixation method for broken bones, there are some standard types of complications that can occur. For example, infection, refracture, delayed union, malunion, shortening or lengthening of the bone, and loss of reduction are the most common complications. Loss of reduction means that the bones shifted apart after the fractured edges were brought back together and held in place with hardware.

All four types of fixation methods mentioned here give equally satisfactory results. External fixation is the one method that seems to have the highest number of complications. With external fixation, there are pins through the skin and muscle into the bone. Pins are placed above and below the fracture site with a rigid bar outside the body holding the bone in place.

Fractures treated with external fixation take much longer to heal. That finding doesn’t necessarily mean surgeons shouldn’t use external fixation in adolescents with femoral fractures.

This particular complication could be the result of the treatment method, but it could also reflect the fact that this type of fixation is used for the more severe (open) fractures. And we know that open fractures (bone broken and protruding through the muscle and skin) take longer to heal than closed fractures (bone broken but not displaced through the skin).

Hopefully, your daughter won’t experience any complications. But should you notice anything suspicious, don’t hesitate to contact your surgeon’s office and let them know your concerns. The earlier any complications can be addressed, the better the outcomes.

Broken bones are a common calamity among children. But young children seem to have an amazing ability to heal and heal well. Fractures of the femur (thigh bone) become more problematic as children get older, larger in size, and heavier.

Studies have been done in younger children with femoral fractures to determine the best way to surgically restore bone alignment with pins, nails, plates, and screws. But surgeons can’t rely on that data when working with older children and teens.

In order to find the optimal way to hold the broken pieces together in more complex femoral fractures in teens, surgeons from The Hospital for Sick Children in Toronto, Ontario (Canada) conducted this study. They went back into their medical records and pulled the medical records of all children ages 11 to 18 who had traumatic femoral fractures.

They compared the results of treatment based on four different ways to surgically fix (hold in place) the broken bones. The four methods of fixation included: 1) elastic stable intramedullary nail fixation, 2) external fixation, 3) rigid intramedullary nail fixation, and 4) plate fixation.

Results were measured using length of hospital stay, time to heal (bone union), development of complications, and the need for a second operation. X-rays taken at the time of surgery and postoperatively were reviewed. They also looked at the type and number of complications associated with each fixation method.

The elastic titanium nails are meant to have some give so that the force of the bone lengthening with a growth spurt won’t cause a problem. But they can potentially bend, shift, and even break under the load of some heavier patients.

The study mentioned here didn’t find any problem with using the elastic titanium nails even in patients who weighed up to 225 pounds. Children who are treated with an external fixation device (pins in the bone, rod outside the leg) seem to have the most problems.

Patient and family preferences are always important in major surgical decisions. But sometimes when you are just outside your comfort zone and lack the knowledge needed, it’s wise to trust the expertise and experience of your surgeon who will be making the final decision.

No doubt you will soon have an answer to that question. The surgeon’s examination will likely include X-rays or some other type of imaging to see what’s affecting the bone and joint.

Two common problems that present with joint deformity and loss of motion in children are undiagnosed displaced (and possibly even healed by now) fracture or bone overgrowth. One of the most common causes of bone overgrowth in children is a benign bone tumor called osteochondroma.

Benign means the tumor isn’t cancerous and won’t travel elsewhere in the body causing harm. But it’s not benign in the sense that the loss of motion can affect hand function. And the deformity can lead to painful, limiting osteoarthritis.

The surgeon will also another possible diagnosis called Trevor disease. That’s a developmental disorder with excessive bone growth — usually just on one side of the bone. With any of these conditions, when the joint is involved, it is called an intraarticular (within the joint) problem. When the bone is affected without the joint, it is referred to as extraarticular (outside and not including the joint).

Your role as a grandparent is very important — both in terms of supporting your daughter but also encouraging your grandson. The condition known as Navajo Familial Neurogenic Arthropathy is uncommon so finding a physician to follow him who is familiar with the condition and appropriate treatment will be important.

Neurogenic refers to the loss of sensation to deep pain. Without that protective response, the child can develop joint deformities and problems with limb alignment (especially in the legs). Arthropathy is another term to mean joint disease.

The symptoms are similar from case to case. Bone fractures, joint destruction, and progressive deformities of the arms, legs, and spine are common and need the attention of an orthopedic surgeon. Although the focus is on the orthopedic (bone and joint) problems faced by these children, there are other problems. Anhidrosis (inability to sweat) is one of those problems. These children can’t tolerate high temperatures.

Each child is treated according to his or her injuries or deformities but the results are often disappointing. Surgeons have learned to limit the amount of surgery done as a treatment measure and to rely more heavily on conservative (nonoperative) care.

It will be helpful for the family to have the following recommendations:

Navajo familial neurogenic arthropathy is a rare problem but one that can have serious consequences for the affected child. Obviously, it is found among people of the Navajo Native American group. This tribe lives in the southwest area of the United States in Arizona, New Mexico, and Utah.

The term familial tells us the problem is inherited but the exact gene or genetic problem is still unknown. The symptoms are similar from case to case. That’s what the name neurogenic arthropathy is all about — the classic symptoms seen in each of these cases.

Neurogenic refers to the loss of sensation to deep pain. Without that protective response, the child can develop joint deformities and problems with limb alignment (especially in the legs). Arthropathy is another term to mean joint disease.

Bone fractures, joint swelling called effusion, joint destruction, and infections are added problems and complications that can develop. Surgical treatment often fails and the problem recurs (comes back) and/or gets worse.

Although the focus is often on the orthopedic (bone and joint) problems faced by these children, there are other problems. Anhidrosis (inability to sweat) is one of those problems. These children can’t tolerate high temperatures. And this heat intolerance is made worse by the fact that they live in a hot, dry desert climate.

Management is the key and good management includes physical and occupational therapy to educate, support, and aid function for these individuals. Assistive devices (e.g., braces, orthotics, walkers, wheelchairs) are an important part of preventing things from getting worse while helping these children stay independent as long as possible.

Steel Syndrome, named for the physician who first reported on this condition in 1993. It is a rare problem among Puerto Rican children. As the word syndrome suggests, each child with this diagnosis has the same features: bilateral hip dislocations, elbow dislocations, short height, scoliosis (curvature of the spine), fused wrists, and abnormally high arches of the feet.

The children have a similar look about them. Besides being short in stature, their faces are long and oval-shaped. The head is slightly larger than normal with a prominent forehead. The ears are small, low, and rotated backwards slightly. The bridge of the nose is broad. Mental (cognitive) abilities are reportedly normal.

Genetic studies have shown that it is probably caused by a genetic mutation. But the specific gene linked with the physical changes seen with this syndrome has not yet been identified.

It doesn’t appear that Steel syndrome develops more in one particular geographic location (place on the island) than another. Boys and girls were affected in equal numbers. And there was no intermarriage among the parents to account for this syndrome.

With the limited number of people affected by this syndrome, future efforts to unravel the genetic connection may be slow. But there is a group of physicians who have been following Dr. Steel’s patients. They have added a few more patients to the group who have been diagnosed with Steel Syndrome. Efforts are underway to follow and report on long-term treatment efforts for the combined groups.

Steel Syndrome, named for the physician who first reported on this condition is a rare problem among Puerto Rican children. As the word syndrome suggests, each child with this diagnosis has the same (or very similar) features: bilateral hip dislocations, elbow dislocations, short height, scoliosis (curvature of the spine), fused wrists, and abnormally high arches of the feet.

At the time that Dr. Steel first studied this syndrome in 1993, there were 23 people identified with this syndrome. Since that time, another 14 people have been added to the group. A total of 32 patients from those two groups have been followed long-term by Dr. Steel’s successors so we have a few results to offer.

When Dr. Steel did the original study, he found that efforts to surgically reduce the dislocated hips (put them back in the socket) were unsuccessful. Remember, that was back in 1993. According to an updated report this year (2010) there is new information that brings us up-to-date on those early patients as well as takes a look at the new patients found with Steel Syndrome.

Comparing patients who had surgery to try and correct the dislocation with those who had no surgery, the group with untreated dislocations had better results. That was true no matter what type of surgery was done (e.g., closed reduction with spica cast, open reduction, osteotomy, skeletal traction, Pavlik harness).

Failure was reported for all patients who had surgery to reduce the dislocated hips. The hips remained either subluxed (partially dislocated) or fully dislocated. Patients in the untreated group had less pain, more function, and less disability. There were also fewer emotional and behavioral problems among the children who had untreated hip dislocations. School performance was better for the untreated group with fewer limitations all the way around.

The authors of the newer report concluded that Dr. Steel was right when he recommended against treatment for hip dislocation in Puerto Rican children with Steel Syndrome. It may seem like unusual advice from a surgeon, but the evidence available so far does not support efforts to reconstruct the hips in this particular group of children.

With this information in mind, the family may want to seek a second opinion before committing to a surgical procedure. This may be one time when conservative (nonoperative) care is really best.