FAQ Category: Child

It sounds like he may have a displaced supracondylar humeral fracture. Displaced means that after the bone broke, it separated or pulled apart. Pins are usually used to hold the bone ends together until they heal. That’s important in this type of fracture because the jagged edges of bone can poke into nerves in and around the elbow causing nerve damage.

For those who don’t know, a supracondylar humeral fracture is a break in the upper arm bone just above the elbow. It’s the most common type of elbow fracture in children but is relatively rare in adults. In fact, at least half and as many as 70 per cent of elbow fractures in children are supracondylar humeral fractures.

The fracture is caused most often by a fall on an outstretched hand. As the hand hits the ground, the elbow is hyperextended or hyperflexed resulting in fracture above the condyles. The condyles are the bumps you feel on either side of your elbow. Supracondylar means the break is just above those bumps (condyles).

Pin fixation isn’t needed when the bone is broken but remains reduced (together). In that case, a cast may be all that’s needed to treat the break. Pins stabilize the fracture but the cast is also necessary to keep the arm from moving and disrupting the healing fracture site.

Nerve injuries called neuropraxia associated with elbow fractures occur for one of two reasons. The first is from damage done to the nerve by the jagged edges of the displaced (separated) broken bones. The second is from pins used to hold the bone together while it heals.

Studies show that about 11 per cent of all children who have this type of elbow fracture also develop traumatic neuropraxia affecting one or more of the nerves (median, anterior interosseous, posterior interosseous, radial, ulnar). About four per cent develop nerve damage from the pins touching, compressing, or puncturing the nerve.

A little bit of information about neuropraxia here might help explain what happens to the patients with this type of fracture-induced (traumatic) or pin-induced (iatrogenic) injury. Iatrogenic means the problem developed as a result of the treatment. Neuropraxia describes nerve damage without disruption of the nerve or its sheath (covering). There is enough damage done that the messages sent along the nerve are interrupted. This causes a temporary loss of sensation and motor function that can last hours to weeks to months. Recovery does occur but can take six to eight weeks or longer.

Pin placement determines which nerve(s) is/are affected. For example, placing the pin through the lateral side of the bone (side away from the body) is more likely to cause median nerve injury. Pin placement through the medial side (inside of the elbow) increases the risk of ulnar nerve damage. Both of these nerves have sensory and motor functions so the patient experiences loss of sensation and muscle weakness or even paralysis.

Surgeons are aware that these kinds of complications can occur and make every effort to avoid causing iatrogenic neuropraxia. With a little time and patience, recovery is reported in 100 per cent of cases.

Carrying out a staged procedure (one repair followed later by a second surgery) is sometimes suggested if it looks like the patient could recover function through a rehab program.

The meniscus is a C- or horse shoe-shaped piece of thick cartilage that doesn’t heal well on its own. Experience has shown us that repairing the torn area yields the best long-term results. The practice of years past was to remove the damaged cartilage. But taking the meniscus out (called a meniscectomy) can lead to early arthritic changes in that knee. So surgeons try to repair, rather than remove, the meniscus now whenever possible.

The anterior cruciate ligament (ACL) doesn’t have a lot of reparative power either. But the muscles around the joint can be strengthened to support and stabilize the knee while the tear fills in with scar tissue. A torn ACL can be treated this way in some patients, whereas, a fully ruptured ligament requires reconstructive surgery — especially in young, active patients.

For young athletes with complex injuries like this (meaning a torn meniscus AND a torn ligament), the best results are found when everything is repaired at one time. If it were just a meniscus or just an ACL tear, the approach would be different. But the risk of reinjury is higher when all damage to the knee isn’t repaired adequately.

Fortunately, young patients like your daughter seem to have amazing recuperative powers. Their rate of healing and recovery far surpasses those of adults with similar injuries. If you are still unsure what to do, consider getting a second opinion. Surgery is a major affair and being confident you are doing the right thing is important.

Congenital proximal radioulnar synostosis is a very rare condition that often goes unnoticed until an injury or trauma of some kind occurs. To explain the condition, let’s take a look at the label.

Congenital means the child was born with this problem. As we said, it isn’t always obvious at first. Sleeping too long with the elbow fully flexed or some type of injury or trauma are the most common reasons the problem gets diagnosed. The child shows up at the orthopedic surgeon’s office with an elbow stuck in flexion and/or with sudden, severe pain. There can be swelling around the joint but often it looks perfectly normal (except it’s bent).

Radioulnar refers to the two bones in your forearm: the radius and the ulna. Proximal tells us the elbow is involved — specifically where the ulna and the radius meet at the elbow. These two bones also meet at the wrist. Synostosis just means there’s an abnormality in the joint.

With congenital proximal radioulnar synostosis, there can be a wide range of deformities contributing to the problem. For example, he joint may be dislocated. In other words, the bones aren’t in the right place to allow for normal joint motion. In some cases, the top of the radial bone (called the radial head) doesn’t form properly.

Instead of being a firm, round bone that moves smoothly to allow elbow motion, it’s made up of a stiff fibrous piece of cartilage. Sometimes the shape of the radial head is all wrong — instead of looking like a miniature drum, it looks like a fat mushroom. An overgrown radial head pushes the annular ligament up and over itself resulting in a rubberband-like effect preventing full elbow extension.

Any change in the size or shape of the radial head is going to mean problems with normal elbow motion. You may recall from looking at the X-rays and listening to the surgeon’s explanation just what is causing your daughter’s synostosis.

If it’s still not clear in your mind, when you go for a follow-up visit, ask the surgeon to show you the X-ray and explain again what’s causing your daughter’s problem. With the information presented here, it may make more sense.

Clubfoot, a deformity of the foot, is the most common foot deformity and it can be mild or it can be severe. While many children only have one clubfoot, it is very possible that both feet are affected. In fact, statistics show that between 30 percent and 50 percent of children with clubfoot do have it on both.

Doctors don’t know what causes idiopathic clubfoot, the type of clubfoot that a baby may be born with. The clubfoot presents with the foot pointing down and inwards and the baby is not able to straighten the foot to put it in the normal position.

Some children are born with their foot or feet pointing downward that may look like a clubfoot, but after x-rays and examinations, it is just the foot is in that position because of the baby’s position in the uterus. This does not need the same type of treatment as a true clubfoot. If your sister’s baby has a true clubfoot, it’s highly doubtful that it occurred because of crowding in the uterus.

Developmental dysplasia of the hip, dislocation, is a fairly common disorder among babies and young children. It is a condition they are born with but it isn’t always noticeable right away. According to statistics, hip dysplasia at birth occurs in about one out of every thousand children. Some of the features that doctors have found among many children with dislocated hips at birth is they are often the first born, girls, born breech, and/or they have a family history of the problem.

Development dysplasia of the hip is a condition where the hip is dislocated – sometimes mildly, sometimes severely. Because it can be relatively mild, it isn’t always obvious early on if a child has this problem. Often, this is picked up at a well-baby check, just as yours was. The symptoms include:

– Uneven legs – they aren’t symmetrical
– Affected leg isn’t moved as much by the baby as the other leg
– Affected leg is shorter than the other
– When looking at the folds fat in the thigh, they are uneven, comparing the affected hip with the other
– Affected leg may outward, particularly in older children

Most people think of arthritis as something older adults often suffer from. But juvenile idiopathic arthritis (JIA) affecting children is not uncommon. This condition used to be called juvenile rheumatoid arthritis (JRA) but new findings have shifted the name to reflect numerous subtypes of the disease.

First of all, who is affected by this potentially disabling disease? It first appears in children at a very young age (between one and three years old). It can develop later but rarely presents in babies before age six months. Early diagnosis and treatment can help prevent long-term complications but there is no cure. In some children, it disappears as mysteriously as it came. In others, active disease accompanies them right into adulthood.

What causes juvenile idiopathic arthritis (JIA)? No one knows for sure. There are probably multiple factors including genetics, confusion within the immune system, environmental agents, bacteria or viruses, trauma, and irregular hormone function. JIA is considered an autoimmune because the immune system fails to recognize self from nonself, identifies the joint as a foreign substance, and attacks itself.

How is it diagnosed? There isn’t one single individual lab test that can be relied upon to identify JIA as the underlying problem for all affected patients. That’s why doctors have to depend on the child’s symptoms, history (including family history), X-rays, and other imaging studies to make the diagnosis. There are a couple of blood tests that can help (e.g., presence of antinuclear antibodies or ANAs and rheumatoid factor (RF), but they aren’t positive in everyone.

There are seven subtypes of JIA. These include oligoarticular JIA, polyarticular RF-positive JIA, polyarticular RF-negative JIA, systemic JIA, psoriatic JIA, enthesitis-related or ERA arthritis, and finally, undifferentiated arthritis. These are listed in descending order of frequency. Oligoarticular JIA (affecting more than one joint) is the most common subtype. ERA and undifferentiated arthritis are much more rare.

You’ll want to find out which subtype your child has in order to find out more about the characteristics of that form. With this information, it will be easier to investigate what to expect, how to treat or manage it, and long-term prognosis.

Throughout the search to find out what’s wrong, the goal is to treat early and quickly in order to reduce pain, minimize joint damage, and help the child maintain a normal lifestyle. Adequate management over the course of the disease process is important in order to improve quality of life measures as well.

There are two types of slipped capital femoral epiphysis, a hip problem. The top of the thigh bone, the femur slips backwards for an unknown reason, usually in teens around the time of puberty.

For some children, the condition doesn’t cause too much of a problem other than some pain and stiffness, which goes away on its own. This is the stable version. Other children develop the unstable version, which is extremely painful. When this happens, it is important that the child not move the leg to avoid further dislocation. The unstable form is usually treated with surgery as the hip must be stabilized with a screw to keep it in place.

Juvenile idiopathic arthritis (JIA) affecting children is not uncommon. This condition used to be called juvenile rheumatoid arthritis (JRA) but new findings have shifted the name to reflect numerous subtypes of the disease.

Most children are identified as having some form of juvenile arthritis early on (between ages one and three) but it can develop anytime during childhood or adolescence. There are seven different subtypes of juvenile idiopathic arthritis. The prognosis depends somewhat on which type she has been diagnosed with.

Some types affect a single joint while others can cause pain, swelling, and inflammation of multiple joints. The systemic subtype affects multiple joints and multiple systems within the body including skin, heart, lungs, liver, and spleen. Many of these children go into remission (recover) but they have some long-lasting joint problems.

At least half of all children with juvenile idiopathic arthritis remain affected by the disease into adulthood. That’s when treatment becomes a matter of management rather than cure or recovery. The earlier the diagnosis is made, the better the chances are for minimizing the effects of this condition. Today’s treatments are more effective than in the past and quality of life for these children is much better than even 10 years ago.

Physicians at trauma centers and hopsital emergency departments must be prepared for the weird, the unusual, and the rare cases of everything because they see everything in all three of these categories. Even so, sacral fractures are so rare, there are only nine cases that have ever been reported in the literature.

The lack of information about how to recognize, diagnose, and treat this type of injury can make it difficult to always get the right treatment quickly. X-rays of the sacrum may not clearly show the fracture line as separate from some of the other lines seen on the sacrum. And if the CT scan is taken right at the fracture line, the CT cut is parallel to the fracture and the image looks perfectly normal.

The added expense of an MRI might not seem required at the time given that two tests were already negative. Only after symptoms get worse or new symptoms develop does it become clear that a complete diagnosis has not been made. Further testing and/or imaging are usually done at that time. The result can be an unfortunate, but not always preventable, delay in diagnosis.

A condition like osteochondritis dissecans of the knee is puzzling to doctors. The condition occurs when the blood supply to bone cells is disrupted and the doctors don’t understand why this happens.

As with many medical conditions and disorders, there are different ways to approach treatment of osteochondritis dissecans. Doctors are divided as to whether it should be treated conservatively (limited movement, anti-inflammatory medications, physical therapy) or surgery. Of course, surgery is a serious procedure, one that shouldn’t be taken lightly. Therefore, doctors usually prefer to try conservative treatments before suggesting surgery.

Unfortunately, the conservative treatments don’t always work and then surgery does become necessary. Research is on-going to see if there are ways to tell ahead of time which patients would be more likely to respond to conservative treatment and who may benefit from going straight to surgery.

Osteochondritis dissecans is a condition that affects the bone. For some unknown reason, the blood supply to a part of the bone is cut off and if the patient is symptomatic (having pain, decreased ability to move the joint, for example), treatment needs to be initiated to prevent further damage.

The most common approach to osteochondritis dissecans of the knee is conservative, taking a wait and see approach, while keeping the knee from being too active. The doctors do follow-up x-rays to see if there is any healing and may adjust the conservative treatment. However, if there is no progress, surgery may be done to help the healing process.

In your grandson’s case, it sounds like the doctor prefers the conservative approach. However, there is no reason why his parents or guardian can’t discuss the issue with the doctor and see what the plan is.

Slipped capital femoral epiphysis is a condition that affect the hip. It occurs when the top of the femur (thigh bone) slips backwards and out of place. It most often affect teens, likely just after a growth spurt, around when puberty hits.

The disorder does affect more boys than girls and for some reason, African Americans are affected more often than caucasians.

Disc herniation in children is rare because the discs are strong with no age-related deterioration. When damaged by trauma such as a sports injury, new bone growth surrounds the disc to protect it. But sometimes the disc continues to protrude enough to compress the spinal cord or spinal nerve roots causing painful back and/or leg symptoms (sciatica).

Conservative care such as your son has had with epidural steroid injections (ESIs) often relieve the painful symptoms enough that they can go to physical therapy and recover. But for those with intractable leg pain, surgery is advised before permanent nerve damage occurs. Since the number of children with disc herniations is low and the majority respond well to nonoperative care, there aren’t a lot of studies and statistics to share about those who do have surgery.

There is a recent study from Children’s Hospital Boston looking at the results of 87 pediatric patients who had microdiscectomies to remove the herniated disc. The procedure was successful and the reported results good. Complications such as infection, neurologic symptoms, and cerebrospinal fluid leakage from this procedure were few and far between. In fact, only one per cent of the group had any problems of this sort. A few more (six per cent) ended up having a second surgery because not all of the disc material was removed the first time causing further painful symptoms.

Despite the unique challenges to microdiscectomy in children, the procedure is safe and effective in this age group. Almost all of the 87 children in this particular study were pain free and able to return to their regular activities including sports eight to 12 weeks after surgery. The authors predicted that these early disc problems will NOT put the children at risk for future back problems but this remains to be seen. The children will be followed into adulthood and long-term results studied.

You will need a medical examination and possible X-rays (these are painless) to find out what’s going on. With a known injury and the changes you’ve observed, it’s best not to wait. Let your parents (or guardian) know right away what’s going on. Early diagnosis and treatment can save you a lot of time and trouble later on and possibly get you back to your regular daily and sports activities sooner than later.

Although rare, it’s possible you have a disc compressing the spinal cord or spinal nerve root. Intervertebral discs are the round cushions between each vertebra. They support the spine and function as shock absorbers. The discs also help transfer load so that no single spinal segment bears the full burden of your body weight or sudden spinal movements. But with enough force from outside (e.g., getting hit by another player) even healthy, strong body parts like discs can get injured.

There are other possible causes for your symptoms but the change in posture is somewhat typical of a disc problem. This is called a nonfixed reactive scoliosis. Nonfixed means it’s not a structural change that will be present forever — it will only be present as long as the disc is pressing on the nerve. Reactive means the body is responding to this nerve compression by moving away from the nerve. That’s what causes the scoliosis (curvature of the spine).

Another common symptom with disc problems is a difficulty lifting the straight leg up when lying on your back. This is actually called a straight leg raise. It’s a test used to see if there’s pressure on the sciatic nerve. A positive straight-leg raise occurs in 95 per cent of young people with a disc protrusion or herniation. Other symptoms can include muscle weakness, numbness, tingling, and even bowel and bladder changes. Make a note of any symptoms you are having and report to your doctor any changes in your symptoms (especially if they get worse or you develop new symptoms you didn’t have before).

Back and leg pain are rare in children but there have been cases reported among young athletes. The pain down your leg is a sign that a nerve is being pinched or compressed somewhere in the low back area. Leg pain of this type is sometimes referred to as sciatica because it’s the sciatic nerve in the leg that is getting irritated.

In medical terms, nerve impingement is called radiculopathy. Radiulopathy is not an inherited condition. Anything that presses on the spinal nerve or causes irritation of the nerve can cause radiculopathy. It could be a cyst, tumor, disc problem, or even a bone spur. Bone spurs are more common in older adults associated with arthritic changes of the spine. But a fracture in the spine can also develop a bone callus or osteophyte as part of the healing response that can press against the nerve causing irritation and leg pain.

The best plan is to bring this to your parents’ attention. If the symptoms don’t go away after a short period of time (two or three weeks at most), then a medical evaluation may be needed. The doctor will ask you some questions and perform some clinical tests to check your posture, strength, and reflexes. It may be necessary to take an X-ray or order more advanced images such as CT scans or MRIs.

When diagnosed early, treatment is often simple with rest, sometimes a back brace, and possibly some specific exercises. It all depends on the underlying cause of the problem.

Spondylolysis is a medical term to describe a stress fracture of a supporting column of bone in the vertebra called the pars interarticularis. The most common place for this type of fracture is at the last lumbar level (L5).

Once the fracture occurs, the body sets up a healing response. Bone fills in around the fracture site forming a bone callus or osteophyte. There is usually bleeding around the fracture site forming a hematoma (pocket of blood) and a local response with swelling (edema) as the immune system sets up a healing inflammatory response.

Most bone fractures take four to six weeks to heal. But fractures of the spine take longer. It’s more difficult to immobilize the area. The brace will help and should be worn as instructed. Usually, X-rays or more advanced imaging studies such as CT scans or MRIs will be done periodically to document the healing process. Studies show the spondylolysis will heal, the hematoma and edema will resolve (go away). This can take four to six months from start to finish.

But the good news is that surgery usually isn’t required. Young athletes can and do heal spontaneously. For this reason, the condition is referred to as self-limiting. Your daughter may have to sit out the rest of the season, but she should be able to get back into the game with no further problems.

A clubfoot, a condition where a child is born with one or both feet pointing inward and downward, can be treated in a few different ways. One way has the child being casted for several weeks before surgery is done, as it seems is happening with your nephew. Once the child’s foot is casted, it is being manipulated into a certain position, so as the foot moves and grows, the cast needs to be changed to accommodate the changes and to apply pressure on different parts of the foot so it can be directed into the right position.

Although bracing does play a role in some treatments of clubfoot, the cast is needed to put the needed pressure on 24 hours per day, seven days per week. Braces can be more difficult to handle and are not always kept on for the specified amounts of time.