FAQ Category: Child

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.

Parents like you are increasingly expressing their concerns to teachers, principals, and school board members about the dangers of children wearing heavy backpacks. But before making a case for change in school policies around the use and wearing of heavy packs, some research would be helpful.

Several different studies have been done looking at various aspects of backpack usage in school-aged children. Most recently, researchers from the University of California (San Diego) teamed up with doctors from Rady Children’s Hospital (also in San Diego) to conduct an experiment. They used standing magnetic resonance imaging (MRIs) to measure the physical effects on children’s spines from wearing backpacks of differing weights. Boys and girls between the ages of nine and 14 were loaded down with 12, 22, and 32 pound backpack loads. That’s about 10, 20, and 30 per cent of their body weight. MRIs were taken with each of these weights.

Two MRI measurements were made: disc height and spine curvature. The researchers were expecting to see narrowing of the lumbar discs as a sign that the vertebral bodies were compressed under increasing loads. And that’s exactly what they saw. They also saw lumbar asymmetry (curvature of the spine in the low back region). And when they had the children report and rate their level of back pain, there was a significant increase in low back pain linked with wearing these heavy loads.

This was the first study using radiographic imaging to provide solid evidence that high contact pressures from heavy backpacks leads to back pain and abnormal compressive forces on the spine. Measurements taken showed that there was increased load throughout the lumbar spine (from T12-L1 all the way down to L5-S1). The greatest load was recorded at the L5-S1 segment. And as the children adjusted their posture to higher loads, the spine started to curve to one side or the other. The children shifted the load to the right shoulder most often in an attempt to balance their center of gravity with the heavier loads.

The results of this study highlight the effects of heavy backpack loads on the lumbar spine. And that was with wearing the pack on both shoulders at the same time. Other studies have used the same two-strap pack configuration but looked at pelvic position. The pelvis also shifts to accommodate loads causing asymmetry (unevenness) and rotation of the pelvis below the lumbar spine. It is assumed that these responses to backpack load would change even more dramatically when the backpack is worn on just one shoulder. That’s the way many children wear their backpacks most often.

Whether or not there is a direct link between backpack use and the development of scoliosis (curvature of the spine) has not been proven. But studies like this one offer some evidence that there is a direct effect of wearing a backpack with heavy loads on spinal alignment. No doubt more studies will be carried out and published in the near future as this topic is of major concern to physicians, parents, and school officials.

Many parents and patients play the coulda-woulda-shoulda game over and over after an event like this. If only I had … (you fill in the blank). I should have… I could have… It doesn’t change the final outcome but our human minds have a hard time accepting that and moving on. So we play that tape over and over, wondering what went wrong and how could it have been prevented. This is perfectly natural and maybe even a necessary part of processing the event in our minds.

But there comes a time even in the process of grieving the loss when acceptance is the next important step in moving on. There is a recent study that might help put some of this into perspective for you. It had to do with the timing of treatment for severe leg injuries like your son had. They found that patients who were able to make it to the trauma center within two hours of the injury had the lowest risk of infection (the major complication of concern after an injury of this type).

Anyone who went to a local hospital first and then had to be transferred to a trauma facility was at increased risk of infection. Anyone in either group (those who went to the trauma unit directly and those who were transported there after going to another clinic or hospital first) who didn’t get there in the first two hours had five times more infections than patients who arrived in the first two hours.

Clearly, it was not possible in your situation to get past that delay. Once the person is finally transported, the medical staff perform what’s called triage. They assess the patient’s condition and decide what has the highest priority. Sometimes, a crushed or mangled limb is ignored while the team tries to resuscitate the patient and save his or her life. There can be other medical emergencies such as blood loss, punctured lungs, severe burns, and so on that command attention even before a severely damaged leg gets the attention it needs and deserves.

It might be helpful if you sit down with the hospital social worker, case manager, or even the surgeon and review the sequence of events. Understanding what happened, how the timing affected decisions made, and all other factors that affected the final outcome may help you close this chapter of your lives.

In this condition there is a disruption in the normal relationship between the head of the femur (thigh bone) and
the acetabulum (hip socket). Sometimes the acetabulum is too shallow or sloping rather than a normal cup shape. It
cannot hold the femoral head in place. Hip dysplasia 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.

Early diagnosis in the newborn and young infant is important. If the problem is not diagnosed and treated early, the soft tissues around the hip start to stretch out. There can be changes in the blood supply to the hip. Sometimes the hip joint tries to form another hip socket called a false acetabulum. Without the proper ligaments, soft tissues, and joint capsule to hold the femoral head in place, the false acetabulum creates even more problems.

Using the Pavlik harness to hold the hip firmly in the socket helps form the soft cartilage around the hip and deepen the socket to hold the femoral head. But in about 40 per cent of all cases, the harness doesn’t work. It’s not entirely clear why the treatment works for some, but not all infants. A recent study from the Texas Scottish Rite Hospital for Children in Dallas, Texas might shed some light on the subject.

They used ultrasound studies to examine the hips of children with hip dysplasia who were being treated with a Pavlik harness. By comparing the hips of children who had success with the treatment to children who had a failed response, they were able to see some possible anatomical reasons that might explain differences in response to treatment.

They found that the failure group had an inverted labrum. The labrum is a rim of fibrous cartilage around the hip socket. It is designed to
give the socket a little bit more depth to hold the head of the femur in place and prevent subluxation or dislocation. Instead of acting as a buttress or barrier to movement, the labrum in the failure group was inverted (turned inward) and blunted (short). The angle of the labrum didn’t help stabilize the femoral head in the socket. Without this added support, the harness treatment only kept the hip in its socket while the harness was in place. Once the harness was removed, the hips slid out of the socket.

More study is needed to confirm these findings and possibly look for additional factors that might affect the success or failure of the Pavlik harness. For now, it is recommended that if treatment with the harness doesn’t show improvement within the first four weeks, the treatment approach must be changed. It may be necessary to switch to a different type of brace called an abduction brace. If that fails, then surgery is a last resort.

The hip socket is a soft, rubbery cartilage at birth and some children have greater laxity or looseness naturally. This laxity means the hip moves in and out of the socket fairly easily — just like in the child who has the anatomic changes associated hip dysplasia–but without any actual changes in the bone structure.

Hip dysplasia is first considered when the pediatrician performs a newborn exam. One of the special tests used most often to look for signs of an unstable hip is the Ortolani maneuver. This test is designed to detect if the hip is sliding in and out of the acetabulum. To perform the test, the doctor places the infant on a table in a supine position (on his or her back). The doctor then abducts the hips by moving the bent hips and knees apart. If the hip feels like it can be pushed out the back of the socket, this is considered abnormal. This is a sign of instability in the hip. As the hip is abducted further, the doctor might feel the ball portion (the femoral head) slide forward as it slips back into the socket. This is a positive Ortolani Maneuver and is also a sign of hip instability.

If the test is positive, the child will be watched closely or immediately placed in a special brace called a Pavlik harness. Treatment isn’t always required as some children seem to grow out of it. The Ortolani test doesn’t differentiate between children with true hip dysplasia and those who just have loose hips. Recently, the use of ultrasonography as an imaging tool has come into play with hip dysplasia. Ultrasound testing might also help doctors recognize who has a true case of hip dysplasia and is a good candidate for the harness treatment.

Two angles in particular can be measured with ultrasound images: femoral head displacement relative to the labrum (FHD-L) and total femoral head displacement (FHD-T). Children with an FHD-L of zero degrees (normal relationship of femoral head to the labrum) are more likely to have successful results with the Pavlik harness. These children probably just had loose cartilage and the head of the femur could slip into the socket easily. They may not have even needed the harness. By the time the harness was removed, the cartilage had tightened up and the hip remained in the socket without the harness.

In one recent study using ultrasound measurements, children with FHD-T angles less than -30 to -40 all failed treatment with the Pavlik harness. This angle indicates that the femoral head was displaced out and up away from the socket too far to be reduced by positioning with the harness. Additional treatment was needed — either with a wider hip angle using an abduction brace or with corrective surgery.

Without a clear way to really recognize children with very loose joints early on, a little prevention is advised. Double or triple diapering may be all that’s needed to ensure good hip socket position. The Pavlik harness does the same thing but holds the hips more effectively than the diapering. Ultrasound studies are not used routinely to confirm the diagnosis. If the Ortolani test is still positive after three or four weeks using the harness, then additional imaging studies might be helpful to guide further treatment. Hopefully in a month’s time, you will be able to move past this problem with no further intervention required.

Familial idiopathic scoliosis is the type of curvature of the spine that runs in families and has no known cause (idiopathic). While both boys and girls are pretty well equal in number with the mild curves in the spine, the girls begin to outnumber the boys significantly with the moderate to severe curves.

It isn’t understood why girls are affected more than boys, but boys can develop moderate to severe scoliosis and may also require bracing or surgery, just as the girls may.

What you are likely referring to is called familial idiopathic scoliosis. The term refers to a curvature of the spine (scoliosis) that runs in families (familial) but is of unknown cause (idiopathic).

Since researchers can’t find what the cause of the disorder is, they have started looking into the genes, chromosomes, and DNA, to see if they can find any abnormalities that may be occurring on that level. At this point, the research is encouraging as some researchers have found some abnormalities on chromosome 17, which may lead to further findings.

Osteoid osteoma is a tumor and it does sound scary. However, it’s not something that you need to be scared of because osteoid osteoma is a benign tumor, which means it is not cancer. It is also very rare that it ever develops into something more serious.

Surgery is the recommended treatment for osteoid osteoma so the surgeon can go in and be sure that the whole thing is removed. The size of the mass is usually less than a centimeter, but it can cause a lot of pain for the person who has it.

Osteoid osteoma, as you said, is not serious but it does cause a lot of pain, which is why surgery is done to remove it. Most often, it appears in children and young adults who are between five and 24 years old and more in boys than in girls. Usually, it is the long bones that are affected.

Scoliosis, curvature of the spine, can be either one curve, a “C” shape, or two, an “S” shape. Those with the “S” shapes may not seem to have as many problems because they may balance out somewhat, but usually one curve is bigger than the other, still throwing the body’s balance out of whack.

Adolescent idiopathic scoliosis, curvature of the spine with no known cause, is very common. Up to three people out of every 100 have curves in their spine to some degree. It most often is detected in the early teens and more girls are found with it than boys, although it’s not uncommon in boys.

Playing sports will not cause scoliosis as it isn’t caused by trauma or bone weakness. It is something that doctors don’t yet know why it happens.

Scoliosis, curvature of the spine, is not uncommon. Between three to five percent of children in the western hemisphere have familial idiopathic scolisis, or scoliosis of unknown cause.

Treatments for scoliosis vary from patient to patient and doctor to doctor, and while the curve size is an important factor in deciding treatment, it’s not the only one. The decision to brace or to do surgery will be based on how quickly the curve is getting worse, if it is, how the curve is affecting the child’s body, if one type of treatment (such as bracing) hasn’t worked, or even if the patient is cooperating by wearing the brace for the prescribed number of hours per day.

In other words, even though two people may have seemingly similar problems, their treatments could be very different, as in the case of these two girls.

Magnetic resonance imaging (MRIs) do not use any form of radiation. This imaging device is a perfect tool for measuring the effect of heavy loads on the spine without exposing children to radiation. And, in fact, the new standing MRI devices have already been used by one group of researchers from the University of California (San Diego) for just this purpose.

They used standing magnetic resonance imaging (MRIs) to measure the physical effects on children’s spines from wearing backpacks of differing weights. Boys and girls between the ages of nine and 14 were loaded down with 12, 22, and 32 pound backpack loads. That’s about 10, 20, and 30 per cent of their body weight. MRIs were taken with each of these weights.

Two MRI measurements were made: disc height and spine curvature. The researchers were expecting to see narrowing of the lumbar discs as a sign that the vertebral bodies were compressed under increasing loads. And that’s exactly what they saw. They also saw lumbar asymmetry (curvature of the spine in the low back region). And when they had the children report and rate their level of back pain, there was a significant increase in low back pain linked with wearing these heavy loads.

This is the first study using radiographic imaging to provide solid evidence that high contact pressures from heavy backpacks leads to back pain and abnormal compressive forces on the spine. There’s a need now to repeat this study as well as expand on data collected over time to identify the full extent of the problem.

Before signing your children up, get a copy of the study design and read over the paperwork that describes any potential harm that might come to study participants. If you are satisfied that it looks safe but still have questions, you can talk with the PTA representative who is sending out the flyers and get more information. As parents we do have a responsibility to protect and safeguard our children. That’s what the study is all about too — protecting children from the effects of carrying heavy loads day after day. Good luck!

Many children break their arm, particularly just above the elbow. It’s a common break because it can easily happen when you put your hand out to stop a fall, something that kids do a lot.

When a bone breaks, it could break but still stay aligned or it can break and move out of position. If the bone stays aligned, it is possible that it doesn’t hurt as much as it might if it has moved, if the child isn’t forced to move the arm. Therefore, by babying the arm, but not using it, it is possible to go on without anyone realizing that the bone has actually broken.

Slipped capital femoral epiphysis – or SCFE – is a hip dislocation that can occur without any trauma to the hip. It happens more often to boys than to girls and most often to children who are overweight. The most common age for this to happen is between the ages of 11 to 16 years old. There are two types: stable and unstable. Stable is the most common kind, affecting about 90 percent of children who have the dislocation. A child who has stable slipped capital femoral epiphysis can usually still walk, but may need crutches. This is the type that occurs without an accident to the hip. The other 10 percent, the children with unstable dislocation are unable to walk at all, even with crutches.

Surgery is done and the hip is fixed by implanting a screw to stabilize it. After the healing part, four to six weeks on average, the children are usually able to slowly go back to their regular activities.

It sounds like your nephew was diagnosed with stable slipped capital femoral epiphysis, or SCFE. This type of hip dislocation does happen most often in boys and particularly in boys who are overweight.

The symptoms of this type of dislocation usually begins with stiffness in the hip which may or may not go away for a while. This may be followed later by pain in the groin as the bones start to rub together. The affected leg may turn outward while the child walks and he may have trouble turning it inwards.

Ninety percent of children with this type of dislocation have what is called the stable type. The other 10 percent who have unstable slipped capital femoral epiphysis usually have severe pain and are unable to walk.

In a society like ours today, where children may not be active enough, we are constantly encouraging them to participate in sports, to get outside and play. So, if a child shows an interest in a sport and they are physically able to play, it would be hard to discourage it. That being said, doctors are starting to see overuse injuries in children and adolescents now, something that was restricted pretty well to adults before.

The trick is to ensure that children receive proper training in whatever they are doing. They should also learn alternate activities to give much used joints a rest. We should be encouraging our children to use their whole body rather than to concentrate on one aspect. So, if a child wants to play baseball, for example, and wants to pitch. It’s essential that he or she be taught how to pitch properly, that the child observe mandates to rest a certain number of days between games, and so on. As well, if the child can become interested in playing another position, a break from pitching would do a world of good to his or her shoulder or elbow.

If your child does participate in a sport that requires the same movements again and again, watch for signs of overuse injury, such as stiffness and pain.

It sounds like your son had surgery for an injury called osteochondritis dissecans, where blood flow to the tip of a bone is blocked, causing bone cells to die. When this happens, the dead part can break away and become loose in the joint.

Osteochondritis dissecans can be an overuse injury and doctors are beginning to see it more often in some types of childhood athletes. No-one knows exactly why it happens, but with proper treatment, usually the athlete is able to return to his or her previous level activity in their particular sport.

There has been concern over the years about how safe and effective it is to use screws, called pedicle screws, to fix and/or stabilize the spine in young children. The biggest issue is with children under eight years old, whose spines are still narrower than they are when they are over nine years old or adults.

Studies have been done regarding the use of the screws and the studies have all come out with the same conclusions: using smaller screws for the younger patients accommodates their smaller spine diameter and as they grow, there does not seem to be a problem with the screw placement in the bones.

The field of orthopedics has to do with bones, muscles and other body tissue that holds the body together and helps it move. When orthopedic doctors work with seniors, younger adults or children, they will see some similar issues but many that are specific to that particular age group.

In children, it used to be that orthopedic surgeons worked with children who were born with certain disorders (congenital) or ones that developed over time (developmental). There were some accidents and traumas that would need surgery, but these weren’t as common. The pace of orthopedic surgery had its own rhythm and many surgeons enjoyed it.

As times changed, so did the practice of orthopedic surgery among children. There have been many advances in various therapies and some of the procedures that used to be a staple of pediatric orthopedic surgeons are now less commonly done. However, what is happening more often is children are coming in with orthopedic problems caused by traumas and accidents that require surgery. So, the surgeons are taking on a more trauma surgeon role. This calls for a different mind set and approach to surgery.