FAQ Category: Child

Each couple’s dynamics are different but it’s important for both parents to be on the same wavelength when it comes to helping a child who has chronic pain, such as your son. It’s known that how a parent reacts to a child’s pain will affect the child and it’s been suggested that if a parent copes negatively with the situation, the child may as well.

Have you spoken with your wife about how she feels and why she feels the way she does? It may be worth discussing your goals for your son, your ideas of how to handle him when he’s having pain and also when he’s not having pain. After all, he is the same child with or without pain. It could be worth it to sit down with your child’s doctor as well to see how much he should be able to do when he’s having pain, according to the doctor’s point of view. This may help even things out for everyone all around.

Most people are familiar with strep throat or a staph infection in children. But these bacteria can enter the bloodstream and travel throughout the body. For some as yet unknown reason, the bacteria take up residence in the joints and cause a septic (infectious) arthritic response.

The child develops a fever and joint pain. Most often the hip or knee is affected. But sometimes the shoulder or elbow becomes septic. Movement of the affected extremity can hurt. If the arm is affected, the child may stop using it. If the leg is affected, the child may develop a limp or stop standing/walking on that side.

Treatment is imperative in order to avoid complications like bone deformity, joint dislocation, osteomyelitis (bone infection), and halting growth that can result in limb length differences of the infected arm or leg. So, if your grandson is hospitalized, he is likely getting everything he needs to prevent further complications. The family can offer love, prayers, and support — that can go a long way sometimes.

If the antibiotic he’s on doesn’t work, a different antibiotic can be tried. Surgical drainage of the joint helps clear out as much local infection as possible while the antibiotic works both systemically (throughout the entire body) and locally (at the affected joint).

In a recent study comparing children with hip versus shoulder septic arthritis, more children with shoulder involvement developed osteomyelitis. Those with hip infection were less likely to develop this complication. Should osteomyelitis develop, intravenous antibiotic therapy will be extended for four to six weeks. When the blood work shows success with normal inflammatory markers, then the child can be switched to an oral (pill taken by mouth) antibiotic. The oral antibiotic is usually taken until symptoms have resolved, blood remains clear, and X-rays are normal.

Joint infection called infectious arthritis or septic arthritis can be cause for hospitalization. Early diagnosis and teatment is important for successful results. Antibiotics and surgical drainage are the gold standard for this condition. Without adequate treatment, complications can occur.

The infection can travel deep into the bone causing osteomyelitis (bone infection) with the potential for bone deformity, joint dislocation, and arrest of bone growth that can result in limb length differences of the infected arm or leg. If unsuccessful, surgery to drain the pus and infection from the joint and clean it out may have to be repeated more than once.

Response to treatment the first time depends on how long the infection was present before treatment was started. With more time to multiply, bacteria can reproduce and gain in strength. Some bacteria are simply more powerful or virulent. Left alone, they can do quite a bit of damage.

Children with hip or knee septic arthritis are more likely to respond after one operation (compared with shoulder septic arthritis). That’s probably because shoulder septic arthritis is harder to diagnose than hip septic arthritis. So, the diagnosis can be delayed. Failure to respond to treatment is recognized by persistent fever, continued large amounts of infectious drainage from the joint, and serum (blood) inflammatory markers unimproved. That’s when a second (repeat) procedure is considered. Some children may require up to four procedures before the expected (successful) outcomes are achieved.

Osteochondritis dissecans (OCD) of the elbow is a condition in which the layer of joint cartilage just above the bone has separated and pulled away from the first layer of bone called the subchondral bone. The result is pain, swelling, and loss of motion — all of which lead to loss of function as well.

Mosaicplasty is a fairly new procedure for the elbow that has been used with good results for ankle and knee OCD. The surgeon removes any loose fragments of cartilage in the elbow. Any rough or frayed portions of the joint surface are shaved and smoothed down. Then the surgeon drills what look like tiny postholes in the articular surface of the elbow joint. Using plugs of bone harvested from the knee opposite the elbow, the holes are filled in and the surface smoothed over.

The donor plugs are taken from an area of the knee where there’s less pressure when standing and walking to avoid any knee problems. The holes left by removing the plugs are filled in with a special bone wax to prevent bleeding. Within two days, the patients are usually up and about putting partial weight on the knee and gradually returning to full weight-bearing status by the end of a week’s time. The elbow is placed in a cast in a position of 90-degree flexion for two weeks. This allows some time for healing before starting to move it again.

Rehab is a slow, but steady process that takes place over a period of six months to a year. X-rays and sometimes MRIs are used to evaluate the condition of the joint surface. A recent Japanese study of 19 teenage athletes with this condition who had elbow mosaicplasty reported good to excellent results for all the athletes. Only one athlete had (mild) residual pain after the procedure. A few chose to switch to a different sport, but all returned to the playing field with full elbow function.

The authors of that study concluded that mosaicplasty is a very good treatment choice for teenage athletes suffering from advanced osteochondritis dissecans of the elbow. The procedure may work best in younger players who have smaller defects requiring smaller grafts but more research is needed to confirm this finding. Although no one in the study showed any signs of osteoarthritis, long-term studies are still needed to see if there are later developments of this kind.

Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to a condition called osteochondritis dissecans (OCD). Although the exact cause remains unknown, it is suspected that the forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off.

In the past, this condition was called Little Leaguer’s elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, primarily gymnastics and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes.

The first-line of treatment is just as you describe. Athletes are advised to stop their usual sport activities. This gives the elbow a rest so that healing can begin. The doctor may prescribe anti-inflammatory medicine to help reduce pain and swelling. Patients are shown how to apply ice to the area. When sport activities are resumed, ice treatments should be used after activity. Ice treatments are simple to do. Place a wet towel on the elbow. Then lay an ice pack or bag of ice over the elbow for 10 to 15 minutes.

The doctor may also suggest working with a physical therapist. Physical therapists might use ice, heat, or ultrasound to control inflammation and pain. As symptoms ease, the physical therapist works on flexibility, strength, and muscle balance in the elbow. Therapists also work with athletes to help them improve their form in ways that reduce strain on the elbow during sports. Pitchers and racket-sport players might benefit from keeping the elbow aligned correctly, instead of angled outward, during the acceleration phase of the pitch or swing.

Most of the time, this approach works well. There’s no way to predict who will get better or how quickly. Patience is the key to a successful outcome. If the condition doesn’t improve, athletes may need to make changes that require less overhand activity. For example, pitchers could shift to playing first base. Gymnasts focus on maneuvers that don’t stress the sore elbow. However, if the piece of bone is loose but still attached, all sports activities must be stopped.

Sports can begin again when the patient has no pain and shows full elbow movement. You don’t want to jump right back in full speed ahead.
As symptoms ease and elbow movement improves, a guided program of strengthening and sport training is advised. Your doctor and therapist will keep you on track for as quick a recovery as possible but with care to avoid further damage to the joint.

There are many factors that go into the decision when to release a child from the hospital after a serious infection like cellulitis and now osteomyelitis (bone infection). Age, type of organism causing the infection, and response to antibiotic therapy are the main considerations.

If the child doesn’t respond to antibiotic treatment, then surgery may be needed. This can delay hospital discharge. Is the infection caused by MRSA— methicillin-resistive staphylococcus aureus? MRSA is a staph infection that has become resistant to all but one antibiotic. And there’s evidence that the bacteria is continuing to mutate (change) with at least one strain now resistant to all antibiotics.

Children who are infected with MRSA are more likely to develop blood clots that can travel to the lungs, a potential cause of death. This reason alone may require a longer period of hospitalization and close monitoring. Blood tests help reveal the presence and type of infection and show which children are at risk for blood clot formation.

One study has shown that children nine years old and older who have MRSA-related osteomyelitis have a 40 per cent incidence of blood clots when the C-reactive protein (CRP) level is more than 6 mg/dL. CRP is a protein found in the blood. CRP levels rise in response to inflammation. Once the CRP level has dropped to 2.0 or less, discharge is more likely. But again, this depends on the child’s symptoms and blood cultures.

When the blood is no longer positive for infection on two separate tests (repeated over time), then the child is switched from intravenous antibiotics to an oral (pill) form. This is when discharge plans can be formulated. Children are hospitalized on average anywhere from three days up to 11 days. Longer hospitalization (several weeks) may be required when multiple surgeries are done and/or when the infection is slow to resolve. The medical staff should be able to provide you with a reasonable estimate of how much time might be needed. Of course, things can change (hopefully for the better!) altering the predicted timeline.

According to Dr. Lawson Copley, a professor of orthopedic surgery at the University of Texas Southwestern (Dallas, Texas), serious bone and soft tissue infections in children are on the rise and have become more serious and more complex than ever before. Pediatric musculoskeletal infections can be deep, wide spread, and deadly.

What has changed to bring this all about? MRSA— methicillin-resistive staphylococcus aureus infection. MRSA is a staph infection that has become resistant to all but one antibiotic. Early, accurate diagnosis is very important. Recognizing telltale symptoms gets the process started. Pain, tenderness, swelling, redness, loss of motion, and a distinct limp or difficulty walking are common first symptoms.

The diagnosis can be delayed when medical staff is fooled into thinking the child has a superficial (skin deep) infection called cellulitis. Or it may look like an isolated and contained abscess when, in fact, there is a deeper, more widespread and invasive infection. Sometimes it goes clear to the bone as in the case of osteomyelitis (bone infection). Areas affected most often include the spine, pelvis, and arms or legs. In some cases, it isn’t until a bone fracture or visible deformity occurs that the diagnosis is made.

Lab studies are done to identify the specific bacteria and help direct which antibiotic to use. Blood is drawn and studied. Blood tests help reveal the presence and type of infection. Whenever possible, fluid is also removed from the affected joint or a bit of the affected tissue is taken for laboratory analysis. The information gained from these tests also helps aid in selecting an antibiotic that will be most effective.

The use of MRIs today has helped identify the full extent of these infections. Other imaging studies with X-rays, CT scans, ultrasonography, and bone scans provide vital details about the location, size, and depth of infection. Any part of the soft tissues can be affected including skin, muscle, joint, and/or bone. Antibiotics and surgery remain the mainstay of treatment.

It sounds like you are describing the Pavlik harness, first designed and used by Dr. Arnold Pavlik in the 1940s. It’s not exactly new, but it’s not from the dark ages, either. In fact, it’s been around long enough to show how successful it really is. Success rates range from 61 per cent up to 99 per cent. The harness has become the number one treatment choice for babies birth to three months old.

The harness is used for dislocated hips. It places the hips in a flexed and abducted (legs apart) position. The goal is to reduce the hip(s) (put the dislocated hip back in the socket) and keep it there. Usually, the treatment works well within the first three to four weeks. It is safe, simple, and comfortable for the child. And you don’t have to take it off to change the baby’s diaper.

Without treatment, the hip socket will not fully develop and become deep enough to hold the head of the femur (thigh bone) in place. Untreated, it’s likely that surgery may be necessary. And that’s much more expensive, complex, and traumatic than the short term solution provided by the harness.

Developmental dysplasia of the hip (DDH) is a common disorder affecting infants and young children. In this condition, there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip 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 a subluxation.

Sixty years ago, Dr. Arnold Pavlik designed a special harness for the treatment of developmental dysplasia of the hip. It is still in use today as the number one choice for this condition in babies. The harness holds the child’s hips in a flexed and abducted (legs apart) position. This places the round head of the femur (thigh bone) right in the hip socket. The contact and pressure help form a deeper, more stable hip joint. At the same time, hip muscles are stretched, which reduces the pull on the hips and helps keep the femoral head in the acetabulum (hip socket).

The harness is most effective when used early on in the child’s life (e.g., the first three months following diagnosis). For the parents/family who know their child was born with a hip dislocation, treatment is usually effective in the first three weeks. It must be worn everyday all day.

Studies have shown some factors to be predictive of treatment failure with the harness. Those factors include putting the harness on wrong, not using the harness as described, positive family history of developmental dysplasia of the hip, and breech position (feet or bottom first) at birth. Starting treatment too late is also a risk factor. And children whose hips don’t reduce or relocate at the time of diagnosis are less likely to be helped by the harness.

A recent study comparing results using a Pavlik harness between children with unilateral (one hip) involvement versus bilateral (both hips affected) showed no difference in results. Successful results were achieved in both groups on average between three and four months.

The authors of that study concluded that bilateral hip dislocations associated with developmental dysplasia of the hip does not increase the risk of treatment failure using the Pavlik harness. Families can expect to use the harness for a period of time that is equal to two times the age of the child. For example, if the child is two months old, then treatment will likely last four months. Age used in the calculation is the age of the child when the harness was first applied. There’s some evidence that treatment takes a little longer when both hips are dislocated, but further study is needed to confirm this idea.

Blount disease is a condition of bowlegged knees, also known as tibia vara in medical lingo. Surgical correction aims to create a more normal angle between the lower end of the femur (thigh bone) and the upper portion of the tibia (lower leg bone). Children with Blounts disease often need surgery to restore normal knee alignment and reduce pain. The result is decreased disability and improved function.

Two angles used to diagnosis Blount disease are measured on X-rays: the metaphyseal-diaphyseal angle (MDA) and femoral-tibial angle (FTA). A MDA angle between 11 and 15 degrees is borderline tibia vara. More than 15 degrees increases the risk that tibia vara (the bowlegged position of the knee) will continue to get worse over time. For optimal results and patient satisfaction, surgeons try to achieve a metaphyseal-diaphyseal angle between -5 and +5 degrees and a femoral-tibial angle anywhere from zero and +5 degrees.

When these angles are lined up, there is a more normal and even distribution of weight and load on the upper tibia. Without correction, too much pressure is placed on the lateral (outside edge) of the knee. Ligaments on the inside (medial) edge of the knee get stretched out to the point that the knee can become unstable. In a growing child, these uneven pressures can create a leg length difference and even more deformity.

Studies show patient satisfaction increases as pain decreases and as function improves. That’s why restoring more normal anatomical angles is so important. The decisions you make as parents today may affect your daughter’s quality of life in years to come. Your surgeon will help you make the best choice based on current evidence available at this time and the severity of your daughter’s condition.

Patient satisfaction surveys are becoming more and more common all the time. Hospital administrators, insurance companies, and even surgeons want some way to measure the results of the procedures performed. Patient satisfaction and quality of life ratings can be ways to measure success.

Depending on the instructions provided with the survey, the agency sending it to you may have expected you (the parent(s)) to complete the questions to the best of your ability. Using your observations and judgment, you can provide some feedback otherwise unavailable to them.

There are questionnaires specifically designed for parents and children (e.g., AAOS Pediatrics Parent/Child Outcome Instrument). Sometimes these surveys are modified for a specific condition as in the case of Blount’s Outcome Questionnaire, a survey based on the AAOS Pediatrics tool just mentioned.

Sometimes it depends on the age of the child and level of maturity. Some children are quite capable of analyzing their feelings, symptoms, function, and perceived results of treatment. Others wouldn’t have a clue and would need their parent(s) to complete any such forms. If the organization sending you the survey listed a phone number, you could telephone them and clear up any confusion about how to complete the form.

You raise a valid concern about intraobserver and interobserver reliability. Intraobserver reliability refers to how well one person can make the same measurement more than once. Interobserver reliability is the accuracy of those measurements when more than one person measures the same thing.

So, even if the same person makes the measurements, there’s room for error. Using the same method of measuring helps improve reliability of the studies when more than one person is making the measurements. The more advanced imaging technology with computerized radiograms (rather than the old standard X-ray films) is helping to improve the results, cutting down on errors.

Let the orthopedic surgeon who is following your daughter’s case know of your concerns. He or she can certainly do a review of all the films available from the beginning to the present. It’s even possible that although the films were taken by different radiology staff, your surgeon was the one reading them all anyway. Check it out and see what you find.

There are many advantages of the updated digitized and computerized technology used to measure scoliosis (curvature of the spine) compared with standard X-rays. In both methods, a measurement called the Cobb angle is determined.

The Cobb angle is defined as the angle formed between a line drawn parallel to the superior endplate of one vertebra above the curve and a line drawn parallel to the inferior endplate of the vertebra one level below the curve. Superior means above and inferior refers to below. The endplate is a flat piece of cartilage that comes in direct contact with the disc as it sits in between two vertebrae.

Using standard X-rays, the orthopedic surgeon or radiologist uses a special tool called a protractor to calculate the angle. They mark right on the X-ray with special pencils and markers where the top of the curve begins and where the bottom of the curve ends. Sometimes different sized protractors are required and markers of varying widths are used. Anytime tools of this type are used, there’s an added element of error possible. These are eliminated with the computerized/digitized programs.

The quality of the X-rays can make a difference too. Poor quality pictures can contribute to errors. All of these potential problems don’t exist with digitized programs because the computer software allows the examiner to change the sharpness and brightness and enhance the contrast. More consistent measurements are possible with this method.

As you know, with clubfoot, the foot is turned under and towards the other foot. The medical terminology for this position is equinus and varus. Equinus means that the toes are pointed down and the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in a varus position when you try to put the soles of your feet together. Clubfoot primarily affects three bones: the calcaneus, talus, and navicular. Other bones can be involved as the deformity can affect the growth of the entire foot to some degree.

Uncorrected, this twisted position of the foot can cause other problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight, stiff foot that cannot be placed flat on the ground for walking. To walk, the child would have to walk on the outside edge of the foot rather than on the sole of the foot.

Treatment as you described is called the French Functional Method. The French Functional Method stretches the soft tissue and bony structures along the inside (medial) edge of the foot. Then the muscles along the outside (lateral) side of the foot are stimulated to contract to help actively correct the foot placement. Exercises, elastic taping, and splinting are part of a daily home program that requires parents to participate. At first, the family must bring the child into the physical therapist’s clinic daily for hands-on therapy. Gradually, the parents take over the program and visits to the therapist decrease to a more manageable once a week trip.

Correction of the foot is usually successful with this approach, but it can take several months. If you are unsure of your technique or the results you are getting, make a follow-up appointment with the pediatrician or orthopedic surgeon and get their opinion. The therapist can also review your home program and the way you are applying the steps. If the French Functional Method is really not working as it should, there is a second (also very successful) technique available.

That’s the Ponseti method. The Ponseti method involves placing the foot in as neutral a position as possible and holding it there with a cast. The bones are manipulated into place one at a time by the doctor or therapist until the full correction has taken place. The cast is removed each week, the foot and ankle position corrected, and a new cast is put on to hold the new position. It takes five to eight of these sessions to get the desired results and does not rely on parents involvement (beyond bringing the child to his or her appointments).

Your concern is completely justified. In today’s health care arena, every patient and family member must be an advocate for their own health. And that is especially true with infants and young children who have no way of judging what’s going on. In the case of clubfoot deformity, early treatment is essential to obtain proper foot and ankle alignment needed for walking.

The Ponseti Method of treatment that you described is a well-known and successful approach to clubfoot correction. The therapist carefully manipulates the bones of the foot one at a time in a prescribed order. Casting is used to maintain the correction. A week later, the cast is removed and the next bone is corrected. The manipulation procedure takes one to three minutes and requires correct hand placement and just the right amount of force. This process is repeated five to eight times over a period of five to eight weeks until everything is lined up anatomically as it should be.

Physical therapists are trained to perform these movements. Their skill in anatomy and palpation makes them a good choice to carry out this procedure. Training often involves practice using X-rays of the misaligned bones of the feet and a moveable model of the bones of the foot. The therapist uses these tools to practice the finger placement and amount of pressure to apply over each bone.

Many therapists learn the specific application of these manipulation techniques from orthopedic surgeons or other therapists already experienced in the Ponseti method. Some attend a specific course designed to teach this approach. The success of this method depends, in part, on the skill of the person applying the correction and casting. Don’t be afraid to express your concerns and ask the therapist what kind of training he has received in order to perform these techniques.

Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

Doctors aren’t sure what causes OCD. Many doctors think that OCD in children is caused by repeated stress to the bone. Most young people with juvenile OCD (JOCD) have been involved in competitive sports since they were very young. A heavy schedule of training and competing can stress the femur in a way that leads to JOCD.

But many people who develop OCD don’t have any particular risk factors. In some cases, other muscle or bone problems can cause extra stress and contribute to JOCD. For people like you, symptoms often develop gradually over time. OCD with no known cause can be just as severe as for those individuals with a history of repeated sports events.

There are other causes of knee pain in teens, so it’s important to make sure the diagnosis is correct. The diagnosis of JOCD is usually made by asking many questions about your medical history and current symptoms. The doctor will examine both knees for a comparison.

X-rays of the knee usually show OCD lesions. If not, a bone scan may be needed. A bone scan involves injecting a special type of dye into the blood stream and then taking pictures of the bones with a special camera. This camera is similar to a Geiger counter and can pick up very small amounts of radiation. The dye that is injected is a very weak radioactive chemical. It attaches itself to areas of bone that are undergoing rapid changes, such as a healing fracture. A bone scan is the best way to see the lesions in the very early stages.

Other imaging tests, such as magnetic resonance imaging (MRI) are able to create pictures that look like slices of the knee. The images clearly show the anatomy and any undetected injuries. These tests may help determine the extent of damage from JOCD. They also help rule out other problems.

If you have any questions about your diagnosis, talk with your doctor. Find out if any further tests are needed to confirm the diagnosis. Sometimes a conservative program of rest and inactivity is all that’s needed to clear up this problem. If that doesn’t help, then the physician may order the next round of tests. Unless you are a candidate for surgery, expensive imaging tests may not be necessary at this time.

Osteochondritis dissecans (OCD) is a painful knee condition that affects teens and young adults who are usually still growing. That means the growth plates around the joints have not closed completely yet. Damage to the joint cartilage and first layer of bone (called subchondral bone) occurs causing knee pain with activity.

Until now, it’s been unclear just what happens to cause this condition. Rest from activity and walking with crutches (nonweight-bearing status) is the first-line of treatment. Surgery may be needed to fix or hold any pieces or fragments of cartilage/subchondral bone that may have broken off. Japanese surgeons conducted a study recently that might help explain why treatment doesn’t always result in the response hoped for.

They removed a plug of cartilage and bone from the center of an osteochondritis dissecans (OCD) lesion in 12 patients and then examined the samples under a microscope. When they took a closer look at the plugs of bone, they found a cleft (division) in the specimens.
The cleft divided the plug into two parts (upper fragment and lower base piece).

The surface of the base portion was covered with a fibrous cartilage tissue. Underneath that were active bone cells trying to repair the damage. The bottom of the upper fragment was also covered in the same kind of dense fibrocartilage. The top of the fragment had normal articular cartilage like you would see covering the surface of any joint. But underneath were dead or dying bone cells. Some specimens didn’t have any bone tissue left (alive or dead) — just cartilage cells.

The results of this study suggest a series of steps in the breakdown of cartilage and bone. First, repetitive stress from activity appears to cause a fracture of the subchondral bone. The subchondral bone has a limited supply of blood normally. This feature combined with trauma to the subchondral areas (from continued movement) results in osteonecrosis (death of bone). The necrosis affects the trabeculae, a scaffold or framework of bone cells in the subchondral layer.

The body’s natural response to any cell death is to remove or resorb those dead cells. That’s when the fibrous tissue is formed in an attempt to repair the damage. Deeper areas remodel to form cartilage or bone. Bone formation is more likely when there’s no separation or only a partial separation of the subchondral bone. A full division seems to cut off the body’s ability to mend the area with the necessary bone.

What this study showed was why certain treatment techniques do or don’t work. For example, patients with cartilage and trabecular bone can recover with nonoperative care. The presence of trabecular bone makes it possible to restore the natural layer of cartilage with the underlying subchondral bone. Without this trabecular bridge, fragments that are made up of just cartilage may not reunite with bone even after surgery. Those types of injuries seem to only be able to make more fibrous cartilage, which isn’t enough to repair the damage and restore the cartilage to subchondral interface.

Your son may have had cartilage fragments that had separated from the bone but with no bone cells remaining. Just reattaching the fragments isn’t enough to create optimal recovery. Without the necessary framework or scaffold, new bone cells couldn’t bridge the gap. Sometimes there is no obvious reason for treatment failure for this condition. Talk with your surgeon about this result. There may be some specific explanation for your son’s failure to respond. Another treatment technique may be needed.

Scoliosis is a deformity in the spine that causes an abnormal C-shaped (one curve) or S-shaped curvature (two curves). The spine is not straight but curves to one or both sides. There are three types of scoliosis depending on when it develops. Infantile occurs from birth to three years of age. Juvenile scoliosis develops between four and nine years of age.

The type your child has is called adolescent idiopathic scoliosis (AIS). AIS presents between 10 years and when growth is complete. Idiopathic means the cause of scoliosis is unknown. Idiopathic scoliosis is the most common type and affects about two to three per cent of the population. It tends to run in families and is more common in girls than in boys. Most often it develops in middle or late childhood during a rapid growth spurt.

Any part of the spine can be affected by scoliosis including the cervical, thoracic, or lumbar vertebrae. Most often the thoracic and lumbar spine are affected. The vertebrae curve to one side and may rotate, which makes the waist, hips, or shoulders appear uneven. Exactly what causes the spine to start to curve and then rotate remains a mystery even to scientists who have studied this problem for many years.

For a long time, the focus has been on how to treat this problem. Since it’s unknown what causes it, efforts to prevent AIS have taken a back burner. Future research may uncover more specific risk factors and/or pathologic mechanisms associated with this condition. Right now, we have more questions than answers about adolescent idiopathic scoliosis.

The surgical treatment of large spinal (scoliosis) curves in children has evolved over the past four decades. In the 1960s, the Harrington rods were very popular. They were used to distract or separate the vertebral bodies, put them in good alignment, and hold them there while the child or teen grew. But a better way was found to correct the spinal curve in all three planes (3-D correction) and that was with segmental wires and hooks. Instead of a long rod holding the spine in place, these smaller components linked several segments together. Hooks proved to be safe, easy to place, and effective.

In the last 10 years, the surgical correction of scoliosis has taken another turn. Now pedicle screws are used to achieve fusion in all three planes and improve correction of spinal deformity in children with adolescent idiopathic scoliosis. This type of spinal curvature occurs in older children and teens with no known cause. That’s what idiopathic means (unknown).

Pedicle screws are placed posteriorly (from the back of the spine) into a column of bone called the pedicle. The pedicle connects the body of the vertebra to the vertebral arch or ring behind the vertebral body. The vertebral arch goes around the spinal cord to protect it, leaving an opening called the spinal canal for the spinal cord to travel from the brain down to the bottom of the spine.

Despite some concerns about the safety of pedicle screws, they have been found to be completely safe as well as effective in correcting spinal deformity and maintaining that correction. Surgeons have found that it is possible to get better correction in all three planes of spinal deformity by using pedicle screw fixation. Studies show the screws are stronger than hooks and better able to resist being pulled out of the bone (again when compared with hooks). The procedure can be done without an anterior (from the front of the spine) incision, which was required with rod placement. That feature alone is very helpful in reducing the risk of complications (e.g., damage to nerves and major blood vessels).

Best of all, patients can get up sooner and have fewer complications like nonunion or fusion failures. There is also evidence that lung function improves with pedicle screw correction. There is a hope that with all these benefits, the child/teen will not need further (revision) surgery or develop degeneration of the vertebrae above and below the fusion where there is more motion.

Long-term studies have not been completed yet to show the outcomes over time using pedicle screw fixation. But early and midterm studies have shown very positive results even for children with severe deformity.

Despite equipment being designed for public safety, unexpected injuries can happen on any playground. In a recent study by one pediatric surgeon almost 14 per cent of all tibial (lower leg) fractures were caused when a toddler went down a playground slide while sitting on the parent’s lap. It may seem like a safe thing to do to protect the child, but in fact, it is actually a risk factor for fractures of the lower leg while on the slide.

Like in the case of your son, a sudden movement of the young child can result in his or her foot getting stuck under the other person, twisted, or held flat against the surface of the slide. The continued forward movement of the two individuals puts enough pressure and load on the lower leg to cause the bone to give.

As a result of this study doctors are urging parents not to hold a toddler on the lap while going down the slide. Likewise, it is not safe for older children to hold younger children either. It may seem like you have everything under control until that wiggling bundle of toddler energy suddenly shifts position. It all happens so fast, the parent or adult can’t react quickly enough to avert disaster.

X-rays are usually needed to confirm the presence of a fracture because with a nondisplaced fracture, the bones don’t separate at the fracture site and the leg doesn’t look broken. There are no bones protruding against the skin or poking out through the skin. Sometimes the parent can hear a cracking or popping sound when the break happens. But in all cases, the child develops sudden pain and can no longer put weight on that side. Swelling is also a common reaction to the fracture.

It may be a good idea to call your pediatrician and make an appointment today. At least let them know the nature of the injury. They may consider this injury to be a semi-emergency and get your child in to see the doctor right away today or at most by tomorrow.