FAQ Category: Child

Single bone fixation for double bone fractures of the forearm is considered safe and effective. As with all surgical procedures, there is always a risk that something may go wrong. To help study complications of single bone intramedullary fixation of the forearm, hand surgeons from Children’s Hospital in Boston tried this technique. They used it in 48 cases of fractures of the ulna and radius in children ages four to 14.

One of the goals of the study was to identify possible risk factors for failed cases. In this way, it might be possible to screen children ahead of time and only perform the double rod fixation when absolutely needed or when the patient is at risk for malunion or nonunion.

In all 48 patients, only the ulna was stabilized with the rod. Surgeons with special training in pediatric medicine did the surgeries. Special imaging X-rays called fluoroscopy was done in the operating room to make sure the bones were stable and in place before putting a cast on the arm.

After collecting all the data on each case and analyzing the post-operative results, they found two potential risk factors for complications after single rod fixation for double bone fracture. The first was an open fracture. Open fracture refers to the fact that the two ends of the broken bone have not only moved apart but separated sideways so that they no longer line up. When this happens, the soft tissue structures around the broken ends are also affected, making it more difficult to maintain reduction.

Another potential risk factor is the cast that is applied after surgical reduction and fixation. If the cast is molded around the forearm too tightly, a condition called compartment syndrome can develop. Swelling and pressure on the soft tissue structures from a too-tight cast can cause more problems including death of tissue. Applying a cast that is too loose increases the risk of forearm movement inside the cast. During the early days of healing, movement can cause the fractured bones to distract even more. Either complication leads to a second surgery.

After looking over the results of their own study as well as the results of other studies examining single-rod fixation, the authors also saw that younger patients seem to be the best candidates for this approach. Surgeons can use these newly identified risk factors to carefully select who can be treated with the less invasive single-rod fixation for a double-bone forearm fracture.

The results of this study support the idea that single-rod fixation can be used with double bone fractures in the forearm. Fluoroscopy can be used during the surgery to confirm that the fractures are lined up and stable. Careful patient selection for this surgical technique is advised. Loss of bone reduction can result in a bone angle that limits forearm rotation. Some of this angulation can be prevented with intramedullary fixation and proper cast molding.

More studies are needed to determine long-term results of a single rod to support double forearm fractures. It would be good to have some studies that directly compare patients who are treated with a single rod vs. those who have a rod placed down through both bones. For now, it looks like certain patients can benefit from single-rod intramedullary fixation for fractures of both the radius and ulna.

Developmental dysplasia of the hip (DDH)? is a condition in which there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). The socket is shallow and the femoral head doesn’t stay in the socket.

DDH can affect one or both hips. It can be mild to severe. In mild cases called unstable hip dysplasia, the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called subluxation.

For 50 years, children born with developmental dysplasia of the hip (DDH) have been treated successfully with the Pavlik harness. But occasionally for any number of reasons, the treatment works for one side, but not the other.

It’s possible that applying traction to the leg will help reposition the hip. This type of treatment is called closed reduction. The use of traction may require hospitalization as it takes several weeks to draw the hip down and into the socket. If that doesn’t work, then surgery may be needed.

Young children have incredible powers of healing. Because the skeleton is still forming, many of the changes created at surgery will remodel dramatically and create a hip socket that will serve the child well into adulthood with minimal problems.

The first step is to go back to the orthopedic surgeon who has been following you. See what he or she would recommend based on your child’s individual characteristics. Find out what all the treatment options are before making a final decision about what to do next.

For 50 years, children born with developmental dysplasia of the hip (DDH) have been treated successfully with the Pavlik harness. Most studies show that the earlier the treatment, the better the results.

The goal of treatment with the harness is to keep the femoral head in good contact with the acetabulum. A stable hip encourages the development of a normally shaped socket and rounded head of the femur. The hip should be flexed to 95 degrees and abducted (apart) at least 90 degrees. This position keeps the ball (the femoral head) in the best position and allows the ligaments and joint capsule to tighten up.

As you saw from your Internet search, the Pavlik harness is not usually recommended for older infants (six months of age or older). But the results of a recent study may suggest differently. Twenty-four children between the ages of nine months and 23 months (almost two years old) were placed in the Pavlik harness despite the late diagnosis.

Almost half (46 per cent) had a successful result and did not need any additional surgery. Results were obtained in the first six weeks if the harness was going to work. The harness was augmented by a dynamic abduction splint in about half of the group. But the results were not any better with the dynamic abduction splint than without. Children with the most severe dysplasia did not respond to the harness. Surgery was still required for them.

The Pavlik harness can be used successfully to treat developmental dysplsia of the hip with carefully selected older infants and children. A delayed diagnosis is not always an immediate passport to surgery. Surgery can be delayed by six weeks to see if the harness will work in older children. If the harness fails, then surgery can be done.

You may want to have your granddaughter evaluated by an orthopedic surgeon to find out how severe is her condition and whether a six-week delay would be okay while you try the harness.

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.

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.

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.

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.