What do you think is the best way to treat a spinal cord injury in a youung child (five years old): body cast and then bracing or surgery straightaway? We’ve already made the choice but I’m curious to know what you would have recommended.

There was a recent review of studies done in this topic area. Two of the largest studies involving 122 and 179 children both showed significantly improved results in at least 80 per cent of the cases. Children with mild injuries and no neurologic damage are more likely to recover fully.

Two of the most important factors that influence the management and outcomes of serious spinal injuries include the extensive bone and soft tissue remodeling that goes on and the fact that the child is still growing. The growth factor alone can make deformities and complications better or worse.

“Serious” spinal injury in children is defined as vertebral fractures with or without dislocation and/or spinal cord injury. Spinal cord injury without radiographic abnormality (SCIWORA) is the term used to describe spinal cord injury without bone fracture. And one of the later developments of a spinal cord injury in children without apparent bone involvement is spinal deformity (scoliosis). This type of subsequent deformity can be very severe.

Treatment of children with spinal cord injuries is not by a cookbook or cookie cutter approach. Early surgery is recommended to stabilize a rapidly progressing spinal deformity. But if the child is still growing, experts advise waiting to do a spinal fusion until the spine has reached near maturity.

Whenever possible, a nonoperative treatment approach should be taken. This could involve bracing or growth-sparing (growing) rods. When the spine can’t be stabilized by conservative means, then nonfusion surgery may be appropriate. The surgeon lines everything up as normal as possible and uses instrumentation (pins, rods, wires, screws) to hold it in place. As soon as bone healing occurs (as seen on X-ray), the form of fixation used is quickly removed to avoid (spontaneous) spinal fusion.

Studies show that stable vertebral fractures treated conservatively (without surgery) can be successful. Long-term follow-up did not show any faster or greater disc degeneration in these children as adults (compared with other adults who never had this type of serious spine injury).

Individual case reports also suggest that conservative care of fracture-dislocations of the thoracolumbar vertebrae in young children can also be quite successful. It is possible to preserve normal spinal motion and spinal stability. In general, the results (and therefore prognosis) are quite good in children under the age of 10. They heal and recover quickly. The potential for remodeling and regaining normal vertebral height without deformity and without neurologic involvement is also greater in this age group. The exception is the child with a serious neurologic injury right from the start.

How is it possible that kids (even babies) can end up with a spinal cord injury? I thought this age group was pretty flexible, more like rubber and not quite rigid yet like adults.

Car accidents, falls from a height, and sports trauma are the three most common causes of such serious injuries in children. The lack of strength, increased laxity and mobility, and decreased spinal stability in children (as compared with adults) are additional reasons why pediatric and adult spinal injuries differ.

In children, ligamentous laxity in the spine is greater than the ability of the spinal cord to stretch. In other words, the ligaments can stretch with the force of the distraction from the injury but the spinal cord only has so much give before it is injured as well.

Likewise, the growth plate (physis) can be damaged but the discs and bony vertebra remain unharmed. The result can be a spinal cord injury without fracture of the surrounding bone. This type of injury has been reported in children as young as six months old resulting in permanent paralysis.

As with other pediatric injuries that can also affect adults, spinal injuries in the very young aren’t the same as in the fully grown adult. There are different anatomical features to consider along with differences in healing responses to trauma.

Two of the most important factors that influence the management and outcomes of serious spinal injuries include the extensive bone and soft tissue remodeling that goes on and the fact that the child is still growing. The growth factor alone can make deformities and complications better or worse.

A “serious” spinal injury has been described as vertebral fractures with or without dislocation and/or with or without spinal cord injury. Spinal cord injury without radiographic abnormality (SCIWORA) is the term used to describe spinal cord injury without bone fracture. And one of the later developments of a spinal cord injury in children without apparent bone involvement is spinal deformity (scoliosis). This type of subsequent deformity can be very severe.

Our “baby” (two years, three months old) has a leg problem called Blount disease. We are trying braces but if this doesn’t work, what happens then?

As you have probably learned, Blount disease is a condition also referred to as “bowlegs”. The medical term is tibia varum (singular) or tibia vara (plural). Tibia refers to the lower leg or “shin” bone. Varum is the Latin word for bow-legged. This condition is common in toddlers and young children.

The condition is called physiologic tibia varum when it’s a normal variation and the child will grow out of it. Most toddlers have bowlegs from positioning in utero (in the uterus). This curvature remains until the muscles of the lower back and legs are strong enough to support them in the upright position.

In some cases abnormal growth of the bone causes the bowing to get worse instead of better over time. That’s when it is called Blount’s disease or pathologic tibia varum. Blount’s disease becomes obvious between the ages of two and four as the bowing gets worse. Overweight adolescents or teenagers can also develop Blount’s disease.

All of a sudden, growth at the proximal end of the tibia (upper portion of the lower leg at the knee) slows down or even stops. This change in growth is referred to as physeal arrest). Along with physeal arrest comes a curving (bowing) or varus deformity and internal rotation (“torsion”) of the tibia.

Treatment for infantile Blount disease is on a continuum from wait-and-see (sometimes the problem corrects itself) to conservative (nonoperative) care using braces and finally, surgery to correct the deformity. According to an expert in this area (Dr. J. G. Birch from Texas Scottish Rite Hospital for Children), treating infantile Blount disease with bracing can be used effectively for children up to age three. This fits with your situation.

Children who do not respond to the bracing are candidates for growth modulation or surgical correction of the deformity. Growth modulation refers to the use of small tension band plates and screws to guide growth and correction of the deformity. The most common surgical procedure done (before permanent damage occurs) is called a tibial osteotomy.

In an osteotomy, a wedge-shaped piece of bone is removed from the medial (inner) side of the femur (thigh bone). It’s then inserted into the tibia to replace the broken down inner edge of the bone. Hardware such as pins and screws may be used to hold everything in place. If the fixation is used inside the leg, it’s called internal fixation osteotomy. External fixation osteotomy describes a special circular wire frame on the outside of the leg with pins to hold the device in place.

Your surgeon will advise you regarding your child’s growth and progress. If all goes well, there will be no need for anything further after bracing. Your child will need ongoing observation and evaluation to make any corrections needed as he (or she) grows. The condition can come back, so if that happens, early intervention is always encouraged.

My 10-year-old was perfectly fine until about two months when I noticed he was walking funny and he started complaining that his right knee hurt. He’s been diagnosed with Blount’s disease. The pediatrician thinks it’s because he gained a lot of weight and is about 80 pounds overweight. If he loses weight will this problem go away?

It’s a fact that more and more children, pre-teens, and teens are obese and facing problems they wouldn’t otherwise deal with. You may have heard that diabetes is one of those problems. But diabetes isn’t the only problem overweight children and adolescents face. As your child is now experiencing, Blount disease (bowlegged deformity) is another possible adverse effect of obesity. And it can lead to growth arrest at the knees, leg length differences, and early degenerative arthritis, so treatment is important.

Adolescents who develop Blount disease are usually treated surgically as the condition does not resolve or correct itself and bracing is not effective. Weight loss is a big help in many ways and essential overall, but once the damage is done at the joint, it is irreversible at this age. The most common surgical procedure is an osteotomy. This procedure is done before permanent damage occurs.

In an osteotomy, a wedge-shaped piece of bone is removed from the medial (inner) side of the femur (thigh bone). It’s then inserted into the tibia to replace the broken down inner edge of the bone. Hardware such as pins and screws may be used to hold everything in place.

If the fixation is used inside the leg, it’s called internal fixation osteotomy. External fixation osteotomy describes a special circular wire frame on the outside of the leg with pins to hold the device in place. Growth modulation is an alternative approach to refers to the use of small tension band plates and screws to guide growth and correction of the deformity. For more details on treatment, see our publication A Patient’s Guide to Blount’s Disease in Children and Adolescents.

What is the current recommendation for rotator cuff tears in children? Leave them alone and see if they can heal on their own? Or do surgery to repair the damaged structures?

Reports indicate that more and more children are developing sports-related shoulder injuries previously only seen in the adult population. Rotator cuff tears are among those problems. Though uncommon, these incidences are on the rise.

Right now, partial-thickness tears of the rotator cuff in children and teens are treated conservatively (nonoperative care). Full-thickness tears may be better off with a surgical repair but this remains unproven as yet.

With so little data, so few studies, and the rarity of this injury, we simply don’t know if nonsurgical healing of rotator cuff tears is even possible in this age group. The surgeon may adopt a wait-and-see approach. If painful symptoms, loss of motion, weakness, and decreased function remain bothersome, then surgical repair may be considered.

With more and more sports injuries, the use of arthroscopic examination and treatment in this age group is on the rise. There are many advantages of arthroscopic surgery. Arthroscopic examination gives the surgeon the opportunity to carefully and thoroughly examine the shoulder. As a result, damage or injury to the shoulder structures that might have gone undetected is identified and treated.

With smaller incisions possible, there is less pain and stiffness following arthroscopic procedures (compared with open incision surgeries). Other advantages of arthroscopic surgery include shorter rehab time, a more cosmetically appealing result, and less postoperative pain.
And studies show that with arthroscopic stabilization of a chronically dislocating shoulder, there are fewer recurrences of dislocation after arthroscopic surgery compared with nonsurgical treatment.

My wife is Japanese but married to me (an American) and we live in the U.S. She arranged for a sabbatical year in Japan at her job and we (myself and two children) went with her. While we were there, it was discovered that our 10-year-old daughter has a form of scoliosis they call “idiopathic”. The Japanese doctors there seemed really on top of the treatment of this condition. Now that we are back in the U.S., I can’t help but wonder if our doctor here knows as much as the Spine Group in Japan. How can I determine whether she is getting the same kind of care here as she got in Japan?

Idiopathic scoliosis is not an uncommon problem. Many primary care physicians and orthopedic surgeons see children of all ages with this condition. Idiopathic means the cause is unknown. In other words, the curvature does not occur because there is a neuromuscular disease, bone deformities of the vertebrae, or other condition scoliosis might be associated with.

Efforts are being made by physicians around the world who treat children with idiopathic scoliosis to improve treatment. In fact, ten years ago, a group known as the Growing Spine Study Group (GSSG) was started in just such an effort to deal more effectively with early-onset scoliosis (scoliosis present before age six).

Since that time, 22 Spine Centers in seven countries have joined forces to collect data on childhood and adolescent scoliosis. One of those countries happens to be Japan. The United States is also one of the countries involved in this work. The group is made up of 36 specialized surgeons trained in the treatment of complex spinal deformities among the younger pediatric population (birth to age five).

The GSSG engages in comprehensive, multicenter, prospective research studies. They are committed to an international effort to perform and publish results from the highest quality research studies. Their current focus is on new techniques for spinal deformity surgery.

There is a second group called another group called the Harms Study Group that collects data on children with adolescent idiopathic scoliosis (AIS) (children ages 10 to 18 years old). The two groups are similar in that they collect data and information and compile it to looks for patterns, trends, and outcomes in treatment to guide treatment of this problem in all ages. Treatment approaches and surgical techniques with the best outcomes are the focus of these multicenter research studies.

You may want to look for a surgeon in your area who is treating children with idiopathic scoliosis and who is part of the work of one of these two research groups. The physician you saw in Japan may be a part of this type of research. He or she could possibly even refer you to someone in the U.S.

If there is no one in your area with connections to spine center or spine research, that doesn’t mean there isn’t an expert in the field where you live. Your primary care physician or pediatrician is the best one to recommend someone who can offer expertise at a local level.

Is there any difference in the way scoliosis is treated based on age? Why I am wondering is because our five-year-old granddaughter has been diagnosed with this problem out of the blue. They say it’s pretty severe and she may even need surgery. But my neighbor has a granddaughter who is slightly older and they haven’t said anything about surgery yet. Is it better to do the surgery while they are younger and fix the problem. Or should we adopt more of a wait-and-see approach? After all, she could outgrow this, right?

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. Adolescent presents between 10 years and when growth is complete.

In a recent study from an international spine study group, X-ray results after surgery were compared for children with idiopathic early-onset scoliosis (IEOS) and adolescent idiopathic scoliosis (AIS). Idiopathic means the cause of the spinal curve is unknown. This type of scoliosis can develop at any age and is therefore named according when it occurs.

For example, spinal curvatures that develop between the ages of birth and three years is referred to as infantile idiopathic scoliosis or IIS. Juvenile idiopathic scoliosis or JIS is first seen in children between the ages of four and nine. And scoliosis that develops between the ages of 10 and 18 is referred to as adolescent idiopathic scoliosis (AIS). The added term “early-onset” refers to children five years old and younger.

This study group called Growing Spine Study Group (GSSG) was started in an effort to improve treatment for early-onset scoliosis. Since that time, 22 Spine Centers in seven countries have joined forces to collect data on childhood and adolescent scoliosis. The group is made up of 36 specialized surgeons trained in the treatment of complex spinal deformities among the younger pediatric population (birth to age five).

Using the GSSG database of collected information, the authors reviewed the X-rays before and after spinal surgery for children diagnosed with idiopathic early-onset scoliosis (IEOS) and compared the results against a second (older) group. They used the records from another (separate) database (the Harms Study Group) for the second group of patients. The Harms Study Group collects data on children with adolescent idiopathic scoliosis (AIS).

In this way, they could identify differences in the characteristics of the spinal curvatures between these two age groups (birth to age five from the Growing Spine Study Group and 10 years to 18 years from the Harms Study Group). Various spinal angles, lines, curve directions and curve locations (thoracic spine, lumbar spine, thoracolumbar spine), and severity (magnitude) of spinal curves were measured and compared.

Their findings suggest that curves in younger children are present more often in the lower spine and may require a more distal (lower down) spinal fusion. There are some distinct disadvantages or drawbacks (as the authors refer to them) in doing spinal fusion surgery in the lower lumbar spine. For example, this type of fusion limits spinal flexibility and movement while concentrating stress on one area of the spine. These are important considerations when performing spinal surgery on the very young.

There is also evidence that in the idiopathic early-onset group, there is a larger degree of kyphosis (forward curve of the spine). And with a larger kyphosis, there is a greater chance for pull-out anchors used in the fusion surgery to pull out. This can create a less-than-stable result. Surgeons are careful to use proximal anchors in such cases.

Larger curves in the younger children may suggest a tendency to delay surgery in younger groups. This is the finding we thought most useful for you. But the question is usually asked: what’s best for the child in the long-term? Does postponing surgery except in the most severe spinal deformities create more problems later? We don’t know yet — these are questions that must be addressed in future studies.

Treatment approaches and surgical techniques with the best outcomes are the current focus of multicenter research studies. Information is published as studies come available to aid physicians in advising families what is best for each individual child. Some of this depends on the type of scoliosis, severity of the curve, age of the child, and any other medical conditions that may be present.

When I look in the mirror, I notice there is a “bump” on my collar bone. It is just on the left side even though I am right handed. I don’t remember ever injurying that side. What could be causing this?

You may possibly be looking at what is referred to as a fracture bump from a previous (unrecalled) injury of the clavicle (collar bone). The only way to know for sure is to have the area X-rayed. But if you are not experiencing any pain or other symptoms, X-rays may not be needed. Unnecessary exposure to radiation is always to be avoided.

The age at which fractures of the main portion of the clavicle (called the clavicular shaft) occur is a key factor in how it heals and looks. Bone remodeling is more likely aat younger ages. For example, after age 10 (for girls) and age 12 (for boys) remodeling is less likely and less predictable.

There is also a possibility that you have an uneven pull of the muscles that attach to the clavicle contributing to this bump. There are any number of reasons why this type of asymmetry might occur (e.g., posture, malalignment, difference in clavicular length from one side to the other present at birth).

Consider seeing your physician if you are experiencing shoulder pain, loss of shoulder motion, or loss of shoulder strength. Otherwise, chalk this one up to unknown forces/reasons.

Yes or no? Is surgery needed for a clear break (and separation) of the collar-bone in a 13-year-old boy? He’s eager to get back to skate boarding and BMX racing. Surgery would really hold him back. What do you think?

There is a recent study from Rady Children’s Hospital in San Diego, California that may be the first to report detailed results of conservative (nonoperative) care of midshaft clavicular factures in adolescents.

There were sixteen adolescents enrolled in the study in a 4:1 ratio of males to females (i.e., 12 males and 4 females). The majority of teens (13 of the 16) broke the clavicle on the nondominant side.

Treatment was with the arm on the affected side in a sling until X-rays showed healing had occurred. Measurements were taken before and after treatment of shoulder motion, length of the clavicle (fractured bone compared to the other side), and strength (isometric muscle testing). Each of these measurements was compared to the normal side.

There were very few differences after treatment between the fractured side and the uninvolved arm. Slight differences were noted in external rotation strength and abduction endurance. Despite changes in the length of the clavicle (longer or shorter) on the fractured side, there was a 100 per cent rate of union (healing of the two fractured ends of the clavicle).

Only one of the 16 patients was unhappy with the results and that was because that particular person still had shoulder pain. And everyone returned to their full activity level, even those who were involved in sports.

The results of this study support Mercer Rang’s axiom, If the two ends of the clavicle are in the same room, they will heal. Reliable healing with few long-term symptoms is possible and even probable because the bone will remodel successfully in this age group.

There is a minimal loss of strength due to biomechanical changes in clavicular length. This has the potential to put stress on the joints of the shoulder and decrease the force generated by the muscles for strength. Even so, these teens were still able to function fully in all daily and sports activities.

The authors of this particular study suggest if surgery can be avoided with conservative care only, it may be possible to eliminate complications such as numbness from the incision and/or infection. Likewise, with conservative care, there is no need for fixation with metal plates or other hardware that may need to be removed later in a second surgery.

This study confirmed that the nonoperative approach can be successful with midshaft clavicle fractures in teens. If there are any reasons why surgery is recommended for your son, the surgeon will outline these for you. A decision can be reached based on all factors present.

What can you tell us about Madelung deformity in children? We have a boy (age 12) who has just been diagnosed with this problem. Evidently, it is rare and even moreso in boys. We’ve just started our search on-line for information and hope you can help us.

Two orthopedic surgeons from the University of Washington (Seattle) Medical Center recently reviewed this wrist deformity and offered their opinions and preferred treatment. As you have discovered, it is, indeed, a rare wrist deformity affecting females four times more often than males. And as the name might suggest, it was named for the German physician who first described it back in 1878.

Both wrists are usually involved and although the condition is present at birth, it may not become evident until later in life after growth has taken place. Two distinct features of this problem include: 1) the presence of a ligament (Vickers ligament) that holds the lunate bone of the wrist to the bottom of the radius and 2) growth arrest at the growth plate (physis) where the radius joins the wrist. Vickers ligament is named after the physician who first identified this extra soft tissue structure. It is believed that the ligament may be the cause (or at least a contributing factor) to the deformity because of the pressure (compression) it places on the bones.

The deformity gives the wrist a pyramid shape. Bowing of the radius (bone in the forearm) is what gives the forearm the appearance of a deformity. Of course, what to do about it is a big question among the orthopedic community. There is quite a controversy over when to do surgery. The question comes up: should surgery be done to correct the appearance when there are no symptoms? If the patient does report pain and/or loss of motion, is surgery warranted if there is only mild loss of function? And what type of surgery should be done?

After describing various types of surgeries used by others (e.g., soft tissue releases, radial dome osteotomy and physiolysis, combined radial and ulnar osteotomies, isolated radial osteotomy, isolated ulnar osteotomy, arthroplasty), the surgeons from the University of Washington offered their preferred treatment. We thought you might be interested in their comments.

They suggested surgery should be done when there are limiting symptoms rather than just for cosmetic purposes. A growing child who has no symptoms should be watched and re-checked each year. Only when the deformity is getting worse, the wrist is unstable, and/or the wrist is jammed together should surgery be planned.

Type of surgery is still under debate and study. Factors that must be considered when planning a surgical procedure include age (whether the patient is still growing), the presence of a difference in bone length between the two bones of the forearm, and severity of the radial bowing. Three basic surgical approaches include: release/removal of the Vickers ligament with corrective osteotomy, wrist arthroplasty (joint replacement), or arthrodesis (wrist fusion).

Because there just isn’t enough evidence to guide management of this rare condition, more studies are needed to identify the best treatment approach. Finding successful nonsurgical ways to treat the problem is always preferred in the growing child. Early joint replacement is not advised because of the limited time the implant will last, thus requiring additional surgery later.

Surgery that does not improve wrist motion or relieve pain may not be the best way to treat Madelung deformity. Patient preferences and dissatisfaction with the appearance of the forearm and wrist are important considerations as well. Older adults who have experienced additional complications from this condition (e.g., tendon rupture, wrist subluxation or dislocation) may require surgical reconstruction of the wrist.

Our nine-year-old son was injured playing baseball, which turned out to be a good thing because when they X-rayed his arm for fractures, they found a tumor the size of a golf ball. They think it is a lipoma (fat tumor). We had no idea. He hasn’t had any pain and there’s nothing on the outside more than a slight bump to suggest a problem. We are waiting to see the orthopedic surgeon about this. What can you tell us while we wait?

Tumors of the arms and legs in children are actually fairly common. Fortunately, they are also usually benign. A careful and accurate diagnosis is still important as your orthopedic surgeon will probably tell you.

The physician making the diagnosis in these cases must be very thorough as many cases can be extremely challenging. Diagnostic information must be gathered from multiple sources including the clinical presentation, imaging, and tissue biopsy and cell histology. This level of detailed diagnostic information also guides non-surgical management as well as treatment with all other modalities (radiation, chemotherapy, surgery).

Treatment principles of soft tissue masses in children depend on several factors. These include the type of tumor (benign versus malignant, slow versus fast growing), symptoms, and age of the child. For example, small, benign tumors that are not causing any symptoms or problems may be watched and monitored without doing anything. Most benign but symptomatic tumors are removed surgically.

Lipoma is a relatively uncommon benign tumor in children and involves the overproduction of fat cells. Benign means nonmetastasizing (does not spread to other parts of the body) but local growth can put pressure on other tissues creating other problems. And tumors can become large enough to present cosmetic problems. Every effort is made to provide treatment that leaves the extremity intact and as normal appearing as possible. Even with surgical excision (removal), these tumors can grow back requiring additional surgery to remove them when necessary.

My 15-year-old daughter may have a malignant tumor in the muscles of her leg. The clinic where I took her wants to do a whole body MRI. I’m concerned about several things. First, does she really need such a thing? And second, she’s just 15 and still developing. Will this cause harm or even keep her from having children later on?

Whole body MRI is used to help stage a cancerous tumor. It is a very common and important practice these days. Staging refers to determining how far along (or “advanced”) is the tumor.

The results provided by this type of testing has greatly improved physicians’ accuracy in making a diagnosis. Whole body MRI makes it possible to detect tumors elsewhere in the body that would otherwise remain unknown. Finding tumors and treating them as early as possible is the key to successful results.

Experts in the field suggest that the physician making the diagnosis in these cases must be very thorough as many cases are extremely challenging. Diagnostic information must be gathered from multiple sources including the clinical presentation, imaging such as whole body MRI, and tissue biopsy and cell histology.

Cell histology involves the pathologic study of the tumor cells using techniques such as immunohistochemistry, flow cytometry, and cytogenetic studies. This type of careful microscopic examination is helping researchers understand how tumors develop. This knowledge may eventually make it possible to specifically target and kill tumors without damaging the surrounding tissue.

As for your concerns about magnetic resonance imaging (MRI) in a growing/developing teenager — it is a good question! However, you will be relieved to know that MRI does not contain any ionizing radiation. It is the use of magnetic energy, which has no known adverse hormonal or reproductive effects.

Arm wrestling. This is the newest, latest craze among the teenagers in our area (including my two teen boys). I’m hearing a lot about elbow fractures on the inside of the elbow for the winners! Evidently, slam dunking the opponents arm down can put enough pressure on the funny bone of the winner to actually break it off. What else can you tell me about this kind of injury? How is it treated?

Arm wrestlers, gymnasts, football quarterbacks, and baseball pitchers along with cheerleaders, runners, swimmers, and hockey players were the subjects of a recent study you might find of interest. These athletes all had one thing in common: a medial epicondyle fractures (fracture along the inside of the elbow).

Many factors go into treatment decisions for these patients. How did the fracture occur (referred to as the injury mechanism)? Did the fracture separate (called displacement)? Is the elbow stable or unstable? What are the athlete’s goals, wishes, and desires? For young athletes, discussion and involvement of the patient and family may be important.

These are all the variables discussed by surgeons at The Children’s Hospital of Philadelphia in a recent article on these kinds of injuries. They bring to this article their experience, expertise, and results of treating 20 young athletes (ages nine to 15) with this diagnosis. They were particularly interested in rates of return to sports performance comparing conservative (nonoperative) care versus surgical treatment.

Criteria for surgery included elbow fracture displacement and/or dislocation and an unstable joint. Trauma was enough to cause more than a simple fracture or avulsion (piece of bone breaks off with soft tissue still attached). The surgeon reattached the bone fragment using hardware such as a single screw (sometimes with a washer).

Patients with a nondisplaced (or minimally displaced) but stable fracture (no joint laxity or looseness) were cared for following a nonoperative management approach. This included placing the arm in a cast for three or four weeks. The elbow was kept flexed or bent approximately 70 to 90 degrees in the cast.

When the cast was removed, a splint was worn for another two to four weeks during which time the athletes were to have someone move the arm for them three to five times each day. Active motion was allowed when the medial epicondyle (fracture site — the bony bump along the inside of the elbow) was no longer tender to touch/pressure. Physical therapy was needed when full elbow motion was still not present six weeks after conservative care was started.

The results were very positive for both groups confirming what the surgeons thought at the time of evaluation: careful patient selection for each type of treatment is important. The two main considerations were 1) injury mechanism (traumatic/high-energy versus nontraumatic/low-energy) and 2) elbow laxity or instability.

Children who had a nondisplaced fracture of the medial epicondyle without apparent joint laxity did well with conservative (nonoperative) care. Other young athletes with a high energy trauma elbow fracture with instability or laxity had good outcomes with operative care. All athletes in this study returned to full participation in their sport and were very satisfied with the results.

Our little granddaughter (only nine years old) is quite a budding gymnast. But this week, she fell and broke her funny bone, which, as it turns out, is not so funny! They put her in a cast and didn’t have to operate so we’re thinking that’s a good sign. But I’m wondering if there’s a downside to all this. Will she, in fact, recover fully?

From the studies done on medial epicondyle elbow fractures (of the “funny” bone), the chances are very good for full recovery when the fracture is not displaced (separated) and the joint is stable. Those are the two main criteria for placement of the arm in a cast.

Some surgeons warn that standard X-rays may not provide enough information when making the decision regarding surgery versus no-surgery. Specialized stress radiographic views and 3D-CT scans may be needed to obtain a full understanding of the type of injury/fracture present. In this way, significant trauma to the soft tissues around the elbow can be identified and treated as well. This approach helps avoid long-term complications from undiagnosed nerve damage, capsular involvement, or fragments of bone or cartilage in the joint.

When the cast was removed, a splint is usually worn for another two to four weeks during which time the athletes have someone move the arm for them three to five times each day. Active motion is allowed when the medial epicondyle (fracture site — the bony bump along the inside of the elbow) is no longer tender to touch/pressure. Physical therapy may be needed if full elbow motion is still not present six weeks after conservative care was started.

A recent study from The Children’s Hospital of Philadelphia comparing nonoperative versus operative care for these kinds of injuries showed that the results were very positive for both groups. This confirmed what the surgeons thought at the time of evaluation: careful patient selection for each type of treatment is important. The two main considerations were 1) injury mechanism (traumatic/high-energy versus nontraumatic/low-energy) and 2) elbow laxity or instability.

Children who had a nondisplaced fracture of the medial epicondyle without apparent joint laxity did well with conservative (nonoperative) care. Other young athletes with a high energy trauma elbow fracture with instability or laxity had good outcomes with operative care. All athletes in the study returned to full participation in their sport and were very satisfied with the results.

There were no cases of growth disturbance of the still growing children. That is always a concern with bony injuries in young athletes. Temporary, transient (comes and goes) numbness was reported by half of the patients treated with surgery. This symptom occurred most often when the elbow was fully flexed (bent) with compression and did not affect their sports participation. No one had any motor weakness at the final outcome (follow-up was a minimum of two years).

Just came back from the surgeon’s office where our 14-year-old daughter was examined for a patellar dislocation (three times now!) and MPFL rupture (MRI results).The surgeon made certain we knew what all the possible complications might be from the surgery (reconstruction of the ligament using her hamstring tendon). One of the biggies was “patellar fracture.” What would cause the knee cap to break during surgery and how likely is that?

Athletes of all ages are at risk for knee injuries, including young children and teens. One of the soft tissue injuries currently under study is the medial patellofemoral ligament (MPFL). This ligament is the main reason the patella (knee cap) stays in front of the knee joint and doesn’t shift off to the side.

Trauma or injury that results in patellar dislocation usually also disrupts the medial patellofemoral ligament (MPFL). And since ligaments don’t heal well on their own, surgery is often needed to repair (or more often) reconstruct the torn tissue. Medial patellofemoral ligament (MPFL) reconstruction is a fairly new procedure.

Reports of complications early after surgery are rare. But recently, a large case series (179 knees) was published. This is the first report of its kind. And although it offers level four evidence (low level), it is still significant in the information offered. One surgeon performed all of the procedures using a single medial-sided patellar tunnel screw fixation.

The tissue graft used to replace the MPFL came from the hamstring tendon. Although there are other graft choices, this is the most commonly used harvest site for the needed tissue. Statistically, 16 per cent of the group had complications. Most of those were major problems (i.e., requiring further treatment, most often another surgery).

The list of both major and minor complications included patellar fracture, hematoma, patellar instability (subluxation or dislocation), poor wound healing, scar formation, pain, reaction to the sutures, blood clots, and complex regional pain syndrome.

Almost half of all complications (47 per cent) for all 179 knees were the result of surgical technical factors. Placement of the tunnel drilled through the bone for the graft and graft tension were the most common technical problems leading to patellar fracture.

The surgeon considered these complications to be the result of improper technique and therefore preventable. The surgeons have already changed their surgical technique based on these outcomes. They may make other changes if/when long-term results indicate the need for further refinements of surgical technique.

Patients who had both knees (MPFL ligament) reconstructed at the same time were at the greatest risk for complications. One other risk factor that was considered statistically significant included gender (females at greater risk than males). Most likely anatomic differences in the shape of the patella contribute to the gender difference.

Age did not seem to be an important variable in the number or type of complications that developed. This information is significant because younger patients who have not completed growth are at risk for growth disturbance with any surgery around the growth plate. There were no cases of growth disturbance observed in this study — at least not in the first three years.

What went wrong? My grandson had surgery about six months ago for a chronically dislocating knee cap. They kept the same knee cap but took a piece of his hamstring tendon to replace the ligament that usually holds the knee cap in place. Everything seemed to go well and then the knee cap popped off again. We are wondering what went wrong? Can they get this problem fixed?

The use of graft tendon to replace the torn medial patellofemoral ligament (MPFL) is a fairly new procedure. Most of the results reported so far come from small studies. Reports of postoperative complications like this one are few and far between. But a recent study from Cincinnati Children’s Hospital may have some helpful information.

This large case series (179 knees) is the first report of its kind. And although it offers level four evidence (low level), it is still significant in the information offered. One surgeon performed all of the procedures using a single medial-sided patellar tunnel screw fixation. The tissue graft used to replace the MPFL came from the hamstring tendon.

Statistically, 16 per cent of the group had complications. Most of those were major problems (i.e., requiring further treatment, most often another surgery). The list of both major and minor complications included patellar fracture, hematoma, patellar instability (subluxation or dislocation), poor wound healing, scar formation, pain, reaction to the sutures, blood clots, and complex regional pain syndrome.

Almost half of all complications (47 per cent) for all 179 knees were the result of surgical technical factors. Placement of the tunnel drilled through the bone for the graft and graft tension were the most common technical problems. The surgeon considered these complications to be the result of improper technique and therefore preventable.

Patients who had both knees (MPFL ligament) reconstructed at the same time were at the greatest risk for complications. One other risk factor that was considered statistically significant included gender (females at greater risk than males). Most likely anatomic differences in the shape of the patella contribute to the gender difference.

Exactly what went wrong in the case of your grandson isn’t clear from your description. Experts agree that recurrent patellar dislocation following reconstruction surgery is probably multifactorial (i.e., many factors are present contributing to the problem). Getting the proper placement of the graft and tension on the graft tissue are very important. This depends on the experience and skill of the surgeon.

Patient compliance (following postoperative instructions) is also a key factor. Too much load too soon on the healing tissue can disrupt the surgical site leading to recurrent patellar dislocation. The surgeon is the most likely one to be able to explain (if it is even clearly known) what went wrong. Follow-up arthroscopic examination, X-rays, and/or MRIs can help identify potential causes but in some cases, it’s simply unclear where the problem lies.

When I was a teenager, I had scoliosis and took it upon myself to learn as much as I could about the condition. At that time, the surgeon always showed me the X-rays and explained the measurements and angles used to determine severity. Now my daughter is being evaluated for scoliosis. But instead of the Cobb angles we used to use, they showed us “centroid” angles. What happened to the old Cobb method?

For many years, X-rays have been used to diagnose and measure scoliosis (curvature of the spine). No matter how young or old the patient was or where the curve was located, this technique was used because it was simple and reliable.

Then in the mid-2000s, researchers from the Scoliosis Research Institute in Korea took another look at the Cobb angle measurement. They compared two different starting and ending points used in measuring the angle of the curve and reported on the results. More recently, they compared using the Cobb method versus the centroid method in different age groups (teens versus adults 60 years old and older).

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. The Cobb method measures the maximum curvature.

The centroid angle is defined as the angle between the lines connecting the centroids of each vertebral body. The centroid is the center point of the vertebral body. It is the center point created by two diagonal lines drawn across the vertebra from one top corner to the opposite bottom corner of the bone. The two lines drawn form an X. The centroid is the place in the middle where the two lines cross.

Results of studies from the Scoliosis Research Institute have shown that the Cobb method is more reliable with older patients. The centroid method has greater reliability with younger patients. The centroid method is not as reliable with older adults. This is because of the way centroid measurements are taken. Distortions of the vertebra or endplates (present in the older degenerated spine) create too much variability and thus decrease reliability.

The Cobb method relies on selecting the most appropriate vertebrae to begin and end the measuring process. Degenerative changes causing thicker endplates present in older adults (but not in adolescents) make it easier to determine where to draw the lines that form the angles in the Cobb method of measuring.

The bottom line is that changes in the vertebrae between young and old with scoliosis are different enough to warrant different methods of measuring the severity.

Can you give me a quick run-down on best practice for osteomyelitis in a nine-year-old girl? I’m not a medical person but I am a CEO of a large company and want to help my family navigate her care so it goes smoothly with the best possible results.

Osteomyelitis (deep bone and/or muscle infection) is a condition that requires close communication and coordination of many hospital services (e.g., admission department, medical staff, laboratory and imaging studies, surgical staff, and discharge processing). A common sense approach is always welcomed. But evidence-based guidelines for evaluation, diagnosis, and treatment are needed to ensure optimal treatment and results.

You might be interested in the efforts of staff at Children’s Medical Center of Dallas Texas to create evidence-based clinical practice guidelines (CPGs) and then test the impact of following these CPGs. They worked together as a multidisciplinary team to develop and put into practice a method for dealing with children admitted to their hospital with possible musculoskeletal infections. The group included staff members from admissions, orthopedics, pediatrics, anesthesiology, hematology, radiology, emergency department, infectious disease, nursing, and social work.

First, they developed a flow-chart (algorithm) to use when evaluating children with suspicious signs of osteomyelitis. This is the sort of approach you might appreciate as the head of a large company yourself. The report they published of their results includes a printed copy of this chart from initial admission to final discharge. They used this method with 61 children admitted over a period of one year.

The results of treatment were then compared with 210 children who were treated for the same problem before the clinical practice guidelines (CPGs) were developed. The two groups were carefully matched so they were similar in ages, sex (boys and girls), and diagnosis. Areas of study to evaluate outcomes included length of hospital stay, rates of positive cultures for bacteria causing the infection, timing of MRI studies (from admission to MRI), type of antibiotic used, and rate of readmission to the hospital.

There were four areas where differences were noted between the two groups after treatment: 1) causative organism (specific bacteria responsible for the infection), 2) antibiotic selection, duration, and changes, 3) orders for advanced imaging such as MRI and time from admission to MRI, and 4) surgical intervention, length of hospital stay, and readmission rate.

The results were so dramatic (significantly improved outcomes in group II) that the following recommendations were made and started at this hospital. This information may help you observe and monitor the care your family member receives:

  • Tissue cultures and blood work were ordered immediately.
  • A special time slot was saved each day in the radiology department for any child suspected of osteomyelitis needing an MRI; this greatly decreased the time between admission and proper diagnosis and treatment.
  • All children suspected of osteomyelitis were placed in the same hospital unit (rather than being spread out in different units around the hospital). This allowed for improvements in communication and coordination of care.
  • Daily meetings (called “rounds”) were held by the core medical staff regarding each child in the unit. This constant monitoring of each child’s response to treatment made it possible to discharge them sooner with fewer complications. Information about treatment decisions made during this meeting was relayed to the families each day.
  • The primary pediatric attending physician was recognized as the final decision-maker with authority to make decisions when disagreements among the team occurred.

    These new guidelines made it possible to quickly and positively identify the bacteria causing the problem and then choose the best antibiotic to combat the infection. The majority of children in group II had excellent results with full and quick recovery. They returned to normal function and did not have chronic or returning infections.

    These results speak for themselves as to the value and importance of an evidence-based team approach. A short (five to 10-minute) meeting at the beginning of the day improved coordinated communication among the many departments involved in the care of these children. The trend toward shorter hospital stays means lower costs and less suffering for the child.

  • I am a frustrated parent of a six-year-old child who is currently in the hospital for a bone infection. It seems like there are too many cooks in the kitchen. The pediatrician, the orthopedic surgeon, and the nurses all seem to have different opinions about how to handle this case. How in the world does a parent navigate this kind of situation? I’m at my wit’s end.

    You may have heard (or even used) the expression: easier said than done. That phrase is never truer than when changing the way complex health problems are addressed in a hospital setting. And that is especially true for osteomyelitis (deep infection of bone and/or muscle) in children.

    This is a condition that requires close communication and coordination of many hospital services (e.g., admission department, medical staff, laboratory and imaging studies, surgical staff, and discharge processing). A common sense approach is always welcomed. But evidence-based guidelines for evaluation, diagnosis, and treatment are needed to ensure optimal treatment and results.

    That’s why the staff at Children’s Medical Center of Dallas Texas created their own evidence-based clinical practice guidelines (CPGs) and then tested the impact of following these CPGs. They worked together as a multidisciplinary team to develop and put into practice a method for dealing with children admitted to their hospital with possible musculoskeletal infections. The group included staff members from admissions, orthopedics, pediatrics, anesthesiology, hematology, radiology, emergency department, infectious disease, nursing, and social work.

    They developed a flow-chart (algorithm) to use when evaluating children with suspicious signs of osteomyelitis. The report they published of their results includes a printed copy of this chart from initial admission to final discharge. They used this method with 61 children admitted over a period of one year.

    One of the reasons the group put together their own clinical practice guidelines (CPGs) is because they observed wide variations in how children were evaluated, diagnosed, and treated for this condition in their own hospital. For example, there were 33 different antibiotics used in Group I (the 210 children with osteomyelitis treated before the CPGs were developed). The results were so dramatic (significantly improved outcomes in group II) that the following recommendations were made and started at this hospital:

  • Tissue cultures and blood work were ordered immediately.
  • A special time slot was saved each day in the radiology department for any child suspected of osteomyelitis needing an MRI; this greatly decreased the time between admission and proper diagnosis and treatment.
  • All children suspected of osteomyelitis were placed in the same hospital unit (rather than being spread out in different units around the hospital). This allowed for improvements in communication and coordination of care.
  • Daily meetings (called “rounds”) were held by the core medical staff regarding each child in the unit. This constant monitoring of each child’s response to treatment made it possible to discharge them sooner with fewer complications. Information about treatment decisions made during this meeting was relayed to the families each day.
  • The primary pediatric attending physician was recognized as the final decision-maker with authority to make decisions when disagreements among the team occurred.

    These new guidelines made it possible to quickly and positively identify the bacteria causing the problem and then choose the best antibiotic to combat the infection. The majority of children in group II had excellent results with full and quick recovery. They returned to normal function and did not have chronic or returning infections.

    These results speak for themselves as to the value and importance of an evidence-based team approach. A short (five to 10-minute) meeting at the beginning of the day improved coordinated communication among the many departments involved in the care of these children. The trend toward shorter hospital stays means lower costs and less suffering for the child.

    You can probably understand better from hearing about the efforts of this group the difficulties you are facing in communication and coordination of care. Without knowing how the medical facility your child is in functions, it might be helpful if you contacted the hospital social worker or unit coordinator in charge of your child’s case. Having this information might enable you to ask questions about the coordination of medical decisions being made on behalf of your child and perhaps express your concerns and frustrations.

  • Do you think it is okay for a child with a broken ankle to have to wait a week or more before having surgery to fix it? I don’t understand why the doctors are dilly dallying when the X-ray clearly shows the bone is broken. Can you please explain this to me?

    Ankle fractures can be challenging injuries in a child because there may still be an open physis (growth plate) that could be disrupted. The result can be deformity, a leg length difference, impingement, and overload of one side of the ankle.

    When planning the most appropriate treatment, pediatric orthopedic surgeons often use a classification system known as the Salter-Harris Classification method. It is used to determine type of fracture, amount of displacement, amount of growth left, and the best way to manage the problem.

    When using the Salter-Harris classification system, there are five major types of ankle fractures (I through V). Each number signifies the severity of the injury and the amount of growth plate involvement. The classification numbers also give an idea of the risk of growth arrest (e.g., low risk with Type I fractures, high risk with Type V). Fortunately, Type V fractures are rare.

    The two main goals of treatment are to maintain optimum function and limit risk of physeal (growth plate) damage. Besides damage to the growth plate, trauma to the surrounding soft tissues must be assessed as well. Ligamentous damage can create an unstable ankle. But usually, the ligaments are stronger than the weak, growing physis. So in the growing child, physeal injury is more common than ligamentous damage.

    The surgeon will look for any damage to the blood vessels, nerves, tendons, and muscles, and also rule out the presence of other bone fractures in the foot. A large amount of swelling may mean a delay in surgical correction or cast immobilization. The risk of infection and difficulties with wound healing are too great to intervene with early surgery. This may be the case for the child you are asking about. If you are the parent of guardian of this child, you can certainly ask this question of the attending physician(s). There is likely a very reasonable explanation for the planned delay.