FAQ Category: Child

You heard right! Young children should not go down a playground slide while sitting on another person’s lap. This was the conclusion of a study looking at playground injuries. In particular, one pediatric surgeon reviewed the records of 58 children who sustained a tibial fracture over an 11-month period of time. The tibia is the larger of the two bones in the lower leg. Eight of those fractures occurred while going down the slide on the lap of an adult (usually the parent).

How is it possible for a toddler to fracture the lower leg while sitting on an adult’s lap? Any sudden movement of the young child can result in the child’s foot getting stuck under the adult, twisted, or held flat against the surface of the slide. The continued forward movement of the adult with the child puts enough pressure and load on the lower leg to cause the bone to give.

Even though most of today’s playgrounds have been designed with safety in mind, there are some things that can’t be designed away. One of those is playground equipment like the slide that requires a certain size and level of developmental skill. If the child cannot sit up alone with enough strength and balance to move forward down a slide, then the child should be restricted from the slide. The child must be able to safely climb the ladder, sit down at the top of the slide, and make it to the bottom without difficulty before being allowed to do the slide alone.

Infants under the age of six months are treated for developmental dysplasia of the hip (DDH) with a Pavlik harness. The idea is to take a child with a poorly formed hip socket or dislocated hip joint and position the head of the femur (thigh bone) right in the hip socket. Then hold it there until the joint forms properly. That’s where the Pavlik harness comes in. This soft harness positions and holds the infant/child with the hips bent or flexed and abducted (leg apart).

Studies show that this conservative method of treatment works about 79 to 96 per cent of the time. But that’s a pretty broad range of success. Researchers are looking for some specific predictive factors like age or gender that make the difference in outcomes.

The goal in finding predictive factors of failure in the conservative treatment of developmental dysplasia of the hip is to identify children who will benefit from therapy with the harness versus those who won’t be helped. No sense using a treatment that you know right from the beginning won’t work.

Some of the most commonly studied factors include the child’s age, gender, side of the hip dysplasia, severity of the dislocation, and ability to reduce the hip before treatment. Amount of hip abduction (leg moved away from the midline) and distance of the femoral head from the hip socket (as measured by X-rays) are also taken into consideration when looking at children as potential candidates for conservative care with the harness.

In a recent study on this topic, an analysis of over 200 children with this condition showed that age at the time of treatment was not a predictor of failure. This was true so long as the child was younger than six months when use of the harness was started. Having a bilateral condition (present in both hips) was a predictor of harness failure. Children with developmental dysplasia in both hips were six times more likely to fail to get reduction of the hip using the harness when compared with children who had only one hip involved.

The starting position of the hip (as seen on X-ray before treatment) was a negative predictive factor. In other words, the farther the hip was from the socket, the less likely it would reduce with the harness and then remain stable in the hip socket. Of the two directions tested (hip displaced proximally or upwards versus hip displaced laterally — away from the socket), reduction was more likely to fail using a Pavlik harness when proximal displacement was a bigger problem.

One other factor that helped predict who would have a failed versus successful response to the Pavlik harness was how far the child’s hips would abduct (move away from the midline). Loss of hip abduction is usually a sign of an adduction contracture. Contracture means the muscle is so tightly contracted, the leg can’t move (or moves minimally). The fact that the hip could not be reduced manually by moving the leg into a flexed and abducted position before treatment had no bearing on the success of the harness to accomplish reduction over time.

And finally, even though one-third of the children with developmental dysplasia of the hip had a family history of this condition, family predisposition was not a predictor of treatment success with the Pavlik harness. In other words, having a family history of dysplasia didn’t necessarily mean treatment would fail.

Look at all the predictive factors and talk with your physician about your child’s case. He or she may have a better idea what to expect given all of the individual variables to consider and how your child falls in the range of possibilities for a successful treatment.

Your grandson may have a condition known as developmental dysplasia of the hip (DDH), previously known as congenital hip dysplasia. This is a common disorder affecting infants and young children. The change in name reflects the fact that DDH is a developmental process that occurs over time. It develops either in utero (in the uterus) or during the first year of life. It may or may not be present at birth.

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 subluxation.

Mild cases are treated with double or triple diapering. This forces the hips into a position of flexion and abduction (legs apart). When the hips are in this position, the head of the femur is directed more into the socket and kept there. The pressure of one bone against the other helps form the socket more fully.

Compliance with the diapering routine is important. If given enough time, the hip socket can be helped to form as it should with this method. It may take several weeks to several months to get the desired results. The pediatrician will follow the baby closely and let the parents know when it is safe to go back to single diapering.

If this approach isn’t successful, it may be necessary to use a special harness called a Pavlik harness. This padded sling puts the baby into the desired position of hip flexion and abduction. For babies under the age of six months, this technique can be quite effective. Reduction (restoring the natural position of the hip) can occur as quickly as one to two weeks.

You may be noticing what’s called a bone callus. When a bone fracture is healing, the body creates extra bone to fill in the break. A bridge of bone actually forms across the fracture site. The cast you wore kept the ends of the bone still while this bridge was being formed and helped prevent any shifting or displacement of the fractured edges of the bone.

In growing teens, it’s not uncommon for the healing bone growth to exceed the amount you really need. As the bone builds up around the fracture site, you can end up with a bony bump like you are describing. Usually, the bone remodels itself but it can take several months up to a year to complete this process.

There are other potential causes of bone bumps that can be more serious (e.g., cysts, tumors). It would be a good idea to make a follow-up appointment with your orthopedic surgeon to have this checked out. A simple exam and X-ray will probably be all that’s needed to find out what’s going on. If there’s something else involved, early detection and treatment can improve the chances for a good result.

It sounds like your son has a humeral lateral condyle fracture. Humeral refers to the upper arm bone. Lateral tells us it is on the outside of the elbow (medial would mean it was along the inside next to the body). Condyle is the term used for the round end of the humerus that helps form the upper portion of the elbow joint.

Pediatric humeral lateral condyle fractures make up 12 per cent of all elbow fractures in children. When it’s just a fracture without bone separation, treatment is with a cast or splint to immobilize the arm. The bone is kept still so it can heal and fill in the fractured area with new bone growth. If the end of the humerus starts to pull apart, it may be necessary to pin the two bones back together. Immobilization is still required until healing takes place.

But if the bones separate enough to disrupt the joint and the broken piece of the condyle twists or rotates away from the joint, then open surgery is needed. The surgeon will reduce the fracture (meaning put the bone pieces back together like a puzzle) and then wire them in place. Once again, a cast is put on the arm for about six weeks.

The results of this treatment can vary with complications occurring in some children. Those complications can be minor (e.g., infection treated with antibiotic) or major (fracture doesn’t heal or bone refractures). But just exactly why these complications occur isn’t always clear.

Your question is a reasonable one: will problems develop because treatment was delayed? Well, even if complications do occur, how would we know if it wasn’t because the force of the injury was severe enough to create additional problems later? Or maybe the age of the child and the stage of bone development was the defining factor in why complications developed.

At least one study from Children’s Orthopaedic Center in Los Angeles reported that there was no link between age, length of time between injury and treatment, or length of time in a cast and the final outcomes in over 150 children with this type of fracture requiring surgery. There’s still plenty of room for future studies to look into various factors that might increase the risk of poor results from cases like your son’s. Right now, the evidence doesn’t suggest that a delay in treatment necessarily means further trouble later.

You may not be at fault in any way. Sometimes nature takes its own course and it has nothing to do with our actions or inactions.

Sacral agenesis (the absence of a sacral bone at the base of the spine) is uncommon, but not unheard of. About one in every 25,000 children born have some kind of sacral anomaly or defect. Sometimes, the bone is completely missing as with your child. In other cases, only half of the sacrum is present or there may be a part missing on both sides.

Depending on the type of sacral agenesis that is present, there may be bowel or bladder problems as well. Again, no one is exactly sure why this deformity occurs. There’s a link between mothers with diabetes and children born with sacral agenesis. But what the connection is to diabetic-related insulin deficiency (if there is one), remains a mystery.

Scientists have also identified specific genetic mutations that may be inherited. In families with this trait, there may be more than one child born with sacral agenesis. There have also been reports of certain drugs being linked with sacral agenesis. For example, the antiobiotics minoxidil and septra and other drugs such as appetite suppressants have been associated with this birth defect.

Animal research has linked certain solvents and chemicals (e.g., sulfamides, lithium, retinoic acid) with sacral defects. But there doesn’t seem to be one particular cause that is consistently linked with this problem. It may be multifactorial, meaning that when several factors are present at the same time or combined together, then something gets disrupted in the formation of this part of the body.

It sounds like your child had what’s called a diaphyseal femoral fracture — a break in the middle of the shaft of the upper thigh bone. This is an uncommon injury in a young child. Usually, there is a traumatic cause — either a car accident or unfortunately, in someone this age, possibly child abuse.

Older children may sustain this type of fracture as a result of a sports injury. The cause as you describe it certainly accounts for the trauma that could break a young child’s bone. In any case, according to the American Academy of Orthopaedic Surgeons (AAOS), any child under the age of five (and especially any child younger than three) should be examined carefully for the potential of child abuse.

Your patience with the process was probably appreciated greatly by the hospital staff. No one likes to be asked those questions or have to be the one to ask them. But you can understand the importance of finding out for the safety of the injured child if, in fact, there is anything more than the accidental trauma described.

Osteosarcoma, also known as osteogenic sarcoma, is a rare malignant tumor that targets fast growing bone cells, which is why children and teens are affected most often. Edward Kennedy, Jr., lost his right leg due to bone cancer at the age of twelve in 1973. Much has changed since then in terms of treatment.

Now surgeons can offer a procedure called limb salvage. Instead of amputation, the tumor is removed and the leg (or arm) reconstructed as close to normal as possible. This is an option now because chemotherapy is done before surgery to shrink the number of circulating tumor cells.

This is important for patients with known metastases and because of the high risk of micrometastases already present. Chemotherapy also helps reduce the amount of blood supply to the tumor, which gives it a chance to shrink the main tumor as well. When chemotherapy has been completed, the body is given a three to four week rest in preparation for surgery. This sounds scary at first — you may think, what if the cancer cells start growing back during that break in time? But studies show no apparent bad effect of waiting in this fashion.

Sometimes it just isn’t possible to save the leg (or arm) and amputation is necessary. Removing as much of the tumor and the metastatic lesions as is possible will improve the prognosis. The decision to have the limb cut off is never easy. But for some patients, by the time the surgeon removes the necessary tissue and begins to do plastic surgery to improve function and appearance, it’s just easier and more functional to have an amputation.

Once the tumor has been removed and the limb restored as close to normal as possible, then a second round of chemotherapy is started. The patient, family members, and health care team must now watch for complications from the surgery such as infection, poor wound healing, failure of any mechanical parts, and joint instability. The treatment team does everything it can to reduce the risk of limb loss and cancer recurrence. The results of a multidisciplinary approach to osteosarcoma with improved treatments have greatly improved survival and quality of life since young Kennedy’s diagnosis.

Osteosarcoma (bone cancer) is a rare form of cancer with only about new 560 cases diagnosed each year. Children and teens are affected most often because of how fast they are growing. Rapid turnover of bone cells goes haywire when tumor-suppressor genes that normally regulate the bone cell cycle get turned off or get side tracked. It doesn’t look like osteosarcoma is an inherited condition, but there are some genetics involved with chromosomal abnormalities and of course, mutation of the tumor-suppressor gene.

Osteosarcoma has a difficult prognosis. If the diagnosis is delayed, the tumor has often spread. Experts estimate that this is the case in 20 per cent of all patients. There is also the chance that micrometastases (invisible or undetectable) are present at the time of diagnosis.

Early treatment can help prevent the growth and spread of tumors. Osteosarcoma spreads through the blood, first to the lungs and then to other bones. Treatment is aimed at removing the primary (main) tumor and killing off any tumor cells that can’t be seen before they have time to grow.

The results of a multidisciplinary approach to osteosarcoma with improved treatments have really improved survival and quality of life over the last 10 to 20 years. Survival rates have increased from 10 to 20 per cent back in the 1960s to almost 80 per cent today. That optimistic figure of 80 per cent applies to patients who don’t have any sign of metastases. The presence of mets changes the prognosis downward toward a shorter lifespan and increased risk of cancer recurrence.

Pre- and postoperative chemotherapy has helped improve results. It is hoped that with continued research, new and better drugs to target the cancer cells will be available in the near future. Before a specific treatment plan can be devised, the tumor must be staged. The physician relies on imaging studies (X-rays, MRIs, PET scans, bone scans) to stage the tumor from Grade I (low) to Grade IIB (high) and Grade III (low to high but with metastases already present). The prognosis is often linked with the stage of the cancer. This is where your oncologist can help you map out a course of treatment and expected outcomes.

Sometimes babies are born with defects or anomalies like missing vertebral bones, only half of a vertebral bone formed, fused vertebral bones, and/or fused ribs. These defects result in curvature of the spine called congenital scoliosis.

At this point, scientists still don’t know the etiology or cause of congenital scoliosis. To help understand this condition, let’s go right back to the moment of conception. The sperm meets the egg, penetrates, and fertilizes it.

Now the cells begin to divide rapidly. By day eight, the beginnings of the spine are already being formed. Whatever causes the vertebrae to develop abnormally occurs early on before the cartilage or bone are even formed. This is the period of embryonic growth referred to as prenatal vertebral growth. It takes place between the third and the fifth week of life. The tiny structures that will eventually be vertebral bodies are called somites.

Shortly after the formation of somites, vertebral defects begin to occur. The developing child in the womb is only about 30 days old and seven to 13 millimeters long from the top of the head to the bottom of the spine (crown to rump). In order for each vertebral bone to form properly, there must be enough blood supply carrying nutrients and oxygen to the area. Without this, malformations occur. The lack of blood vessels (arteries) to each somite or segment prevents the bones from dividing into segments that will become individual vertebral bodies. So, oxygen is important.

What causes a lack of oxygen? Too much carbon monoxide. What causes too much carbon monoxide? Probably some environmental factor like exposure to chemicals but at this point, scientists know much more about the what (what happens) than the why (why it happens). Studies using mice have helped reveal the way the deformities develop, just not always the factors linked with the deformities.

It is thought that there are two main risk factors: environment and genetics. Besides exposure to possible chemicals such as industrial solvents, there could be exposure to cigarette smoke, alcohol, anticonvulsant medication, too much vitamin A, and a lack of folic acid (one of eight B vitamins). The discovery that a lack of folic acid during pregnancy causes vertebral and spinal cord defects resulted in flour, prenatal vitamins, and other foods being fortified with this essential vitamin. The number of cases of spina bifida went down dramatically after that.

That’s as much as we know so far on the environmental side of things. What about genetics? Could congenital scoliosis be an inherited condition? Are there specific genes involved and gene mutations that change how cells are regulated to form the spine?

Again, using mice as a model to help explain what went wrong, scientists have found genes that do regulate the embryonic formation of cells that normally lead to the development of the spinal bones. One particular family of genes (the notch family) has even been identified in humans as responsible for early embryonic development of the spinal column. Another set of genes called the Hox genes are involved in the formation of the skeleton. Research with mice is ongoing to discover the cause and connections between mutations of Notch and Hox genes and vertebral or other bone malformation.

Sometimes there’s more than just the spine involved. Other problems present but not visible might not be readily apparent. That’s why the medical staff is testing for other problems. Right now, there are more unknowns than knowns in the understanding of congenital scoliosis.

Efforts to find environmental or genetic links have only been partially successful in explaining what went wrong and why. Correcting some vitamin deficiencies has helped but the problem still occurs. As with many unusual physical problems, it’s likely that several (or even many) factors combined together result in this potentially serious condition. Future research will continue looking for answers to this puzzling problem.

Osteochondritis dissecans (OCD) is the destruction of joint cartilage and the first layer of bone under the cartilage (subchondral bone). It affects the knee most often and develops in active teens between the ages of 10 and 15 years old. Repetitive trauma (usually from sports such as skateboarding, snowboarding, or skiing) is the primary risk factor.

The end of the femur (thigh bone) is the most common location, but the patella (knee cap) or top of the tibia (lower leg bone as it meets the femur to form the knee joint) can also be affected. It is possible to develop OCD in other joints such as the elbow, wrist, ankle, and top of the femur.

Anyone who has ever had OCD as a teenager is also at increased risk for a return of this condition called adult osteochondritis dissecans or AOCD. The juvenile form in teens is called juvenile osteochondritis dissecans (JOCD). The adult form really is just a failure to heal from the juvenile form. The adults most likely to develop AOCD are those who never knew they had the juvenile form. There were no symptoms.

Treatment is always advised because of the risk of recurrence and/or the development of osteoarthritis later in life. Progressive destruction of the affected joint can be painful and disabling. Treatment for OCD of the knee is most successful when the condition is caught early and treated before long-lasting damage can be done.

The surgeon makes the treatment decision with the patient’s interests in mind but by taking into consideration the size and depth of the lesion. Conservative (nonoperative) care may be possible. The presence of loose fragments complicates the decision, making surgery almost inevitable. Most people do not heal on their own and require some kind of intervention. The patient should expect a long recovery of many months to several years.

The accuracy and speed of the pitch depend on many, many actions such as the foot position and orientation (turned out/turned in), shoulder and pelvis rotation, knee extension, and trunk motion and position.

All of these movements together form a concept of biomechanics referred to as kinematics. Baseball pitchers like you are very interested in the kinematics of pitching. They want to increase the ball velocity and improve their performance without adding stress to the pitching arm or ending up with an injury.

Pitching speed isn’t just about the pitching arm. The entire body (arms, legs, trunk) is involved. The legs are really the foundational support for every pitch and should be the first place to start in improving ball velocity. For example, when the pitching foot leads off, is it pointed straight, turned out, or turned in? Even the smallest degrees of motion can make a difference. The foot position causes rotation of the pelvis. Too much rotation, too soon can slow the ball and ruin a pitch. Foot position transfers energy through the pelvis to the arm affecting force at the elbow and shoulder.

The force of the push-off of the throwing leg is directly linked with wrist velocity. Too short of a stride length can actually slow down the forward momentum of a ball. Studies show that pelvis and trunk rotation must be coordinated together to improve ball velocity. Greater pelvic rotation is needed to improve ball speed.

The lower body and trunk create the power that is channeled up the kinetic chain to the pitching arm. Each pitcher must work to find his or her own unique rhythm of movement, joint positions, and coordinated motion to produce an explosive pitch. They must do so without injuring themselves. Studies show that injuries are most likely to occur as a result of force on vulnerable soft tissues from repetitive pitches. And it’s the moment of transition from one position to another, one movement to another that should be the focus of training and practice.

It may be helpful to you to have someone videotape a series of your pitches from beginning to end of practice (or game). You can watch these videos in slow motion and analyze each movement in the pitch. Look at the transitions between each phase from windup to stride, arm cocking, arm acceleration, and ball release to follow through. Watch for places where you may not be completely balanced. Starting from the bottom up, observe joint motion and position of the foot, knee, hip, wrist, elbow, and shoulder. Watch again and observe pelvis, trunk, and shoulder rotation during each phase.

Work with your coach, trainer, and/or a sports movement specialist such as a physical therapist or exercise physiologist to make changes in your pitch. Be prepared to practice, videotape, analyze, make changes, and practice some more. Then repeat the cycle until you achieve the results you desire. Be careful to avoid/prevent injuries by counting pitches and limiting the number per practice/week.

It’s clear now to sports professionals that pitching every inning of every game is no longer a good idea. But that’s how it was done in the early days of baseball and for many years after. Fatigue (no matter how strong the athlete is) can lead to injury. Researchers have studied this problem trying to determine a formula whereby a pitcher would be able to calculate exactly how many pitches would be safe.

Younger, less developed pitchers are especially at risk for pain and injury from over-pitching. High-pitch counts (more than 75 per game or more than 600 per season) are to be avoided. Pitching when the arm is fatigued is also a no-no. Children must be trained from early on to let the coach know when he or she is tired. They must be taught that a fatigue-related injury can be prevented. They may think one more pitch is going to win the game, but in the long-run, they are not helping the team out if they end up injured. This can be a difficult concept for any athlete, especially young ones.

The coaches must also take it upon themselves to monitor their pitchers. Loss of pitch speed and pitching inaccuracies are clear signals of fatigue. Counting pitches and staying under the evidence-based guidelines determined by research is an easy and effective way to prevent injuries. And pitchers don’t just injure their elbows and shoulders. Pitchers are also at increased risk for groin injuries, abdominal muscle strain, and knee and back soreness.

One useful tool in helping the young pitcher practice without overdoing it is the use of a lightweight (instead of standard-weight) baseball. As the pitcher trains and develops, he or she will advance from one type of pitch to another. There are many pitch types to learn such as fastballs, cutters, curves, sliders, sinkers, changeups, and knuckleballs. But it’s always advised that young pitchers learn the fundamentals of fastballs first, then changeups and third, curveballs. Each pitch type requires its own unique combination of movements to achieve speed and accuracy.

Talk to the coach about his or her philosophy and thoughts on developing young pitchers. Don’t hesitate to express your concerns and ask what can be done to help with this situation. It’s likely this is a concern for other parents and players. Your questions may help develop some team strategies and foster player education that will benefit the entire team.

Not necessarily. While it’s true that many athletes do get injured, there are ways to protect children and prevent some of these injuries. Here’s what we know so far. First, to give you an idea of how common sports participation is — there are over seven million high school students involved in athletics each year in the United States. And about two million injuries each year as well. About one in 10 of those injuries is really a repeat or recurrent injury.

There is an on-line database of information about high school athletes that gives some idea of types and patterns of injuries. It’s called the National High School Sports-Related Injury Surveillance System. Independent researchers use this information to gather information and analyze the data.

In a recent study from Ohio State University, data was collected on high school sports injuries for a three-year period of time (2005-2008). researchers at the Center for Injury Research and Policy at the university were specifically looking for information and trends about injury recurrence. Their goal is to prevent injuries and develop strategies to prevent injury recurrence as well. With more and more students participating in organized sports, injury prevention and especially preventing repeat or recurring injuries is important.

Here’s a quick summary of their major findings. These findings were based on 100 high schools randomly selected to contribute information to the database about sports injuries. New injuries were much more common than recurrent ones. Recurrent injuries occurred more often during competition than in practice.

Football had the highest rate of competition-based recurrent injuries. Volleyball had the lowest rate of competition-based recurrent injuries. Volleyball players were more likely to injure themselves during practice. Basketball was the sport with the top number of recurrent injuries for boys and girls. Boys reinjured themselves more often than girls. In sports played by both sexes (volleyball, soccer, basketball, softball, baseball), girls had more recurrent injuries playing soccer.

Second injuries are usually worse than the first. For example, if a muscle or tendon was partially torn the first time, it ruptures fully the next. A second (or even third) concussion can lead to more severe symptoms and can even result in death. Recurrent concussions resulting in a life-threatening condition are called second-impact syndrome. Disability or death from second-impact syndrome is certainly a good reason to find ways to prevent sports injuries.

What can be done to reduce the rate of injuries and especially reinjuries? The first place to start is with the use of protective equipment in adolescent athletes. Balance and strength training to protect muscles and joints are essential for all sports. Athletes who have suffered one concussion may want to think about discontinuing participation in that sport and maybe trying something else with a lower concussion-injury risk. When appropriate, athletes should be encouraged to complete a rehab program before jumping right back in to practice and competition.

More research is needed to fully define what needs to be done to prevent injuries and put a stop to recurrent injuries. The role of surgery for first time injuries needs to be explored more fully. It’s possible that surgery to repair/restore damaged soft tissues that are partially torn could save athletes from second injuries that result in complete tears. Shoulder injuries seem especially prone to reinjury. Shoulder braces are being redesigned with this in mind.

As a parent, do what you can; control what you can. You can make sure that your child/children have the appropriate equipment needed and that it is in good condition. Don’t skimp on training camps to prepare for their sports or on rehab if/when an injury does occur. The rest is, as you say, out of your control.

Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). Repetitive motion, compression, and friction causes damage to the first layer of bone underneath the cartilage called subchondral bone.

As the condition becomes worse, the area of bone that is affected may collapse, causing a notch to form in the smooth joint surface. The cartilage over this dead section of bone may become damaged. This can cause a snapping or catching feeling as the knee joint moves across the notched area. In some cases the dead area of bone may actually become detached from the rest of the femur, forming what is called a loose body. This loose body may float around inside of the knee joint. The knee may catch or lock when it is moved if the loose body gets in the way.

Conservative care has evolved over time with evidence from studies to suggest optimal ways of supporting natural healing. At first, the approach was to prescribe immobilization and non-weightbearing of the leg. But it was quickly realized that this method left the patient with a stiff and weak knee that starts to lose bone mass from disuse. Today, the leg is still placed in an immobilizer, but partial weight-bearing is allowed until the patient no longer has any pain. That usually takes about six weeks.

The next phase of rehab involves increasing the weight put on the foot and leg and adding low-impact strengthening exercises. No one is allowed to participate in sports activities until X-rays show the bone is healed, there are no symptoms, and the patient has completed the full course of rehabilitation under the supervision of a physical therapist.

If conservative care fails, then surgery is still an option. In all cases, the surgeon tries to preserve the natural cartilage by repairing the damage rather than removing and replacing the torn cartilage. Studies have shown that removing the torn fragment may give the patient relief from the pain and symptoms, but it doesn’t last. Only one in four patients treated this way go on to heal completely. But sometimes repair just isn’t possible and the damaged cartilage must be removed and replaced.

Treating idiopathic scoliosis in a very young child is a challenge. Whatever treatment is used must allow for growth and development because most of the children affected are less than three years old. They still have a lot of growing to do — not just the spine, but also the muscles, ribs, and internal organs. Fusing the spine (an effective treatment for other forms of scoliosis) is not an option until much later. The earliest fusion can be considered is around 10 years old.

Treatment can consist of bracing, body cast, or more recently, the Vertical Expandable Prosthetic Titanium Rib or VEPTR. Bracing is done using a rigid plastic orthosis that supports the thoracic, lumbar, and sacral spine. This type of bracing is called a thoracolumbosacral orthosis (TLSO). It is worn as close to 23 hours per day as possible with short breaks for bathing and skin care.

Casting requires surgery under general anesthesia. The child must be healthy with good lung function to have surgery. While the child is relaxed under the effects of the anesthetic, the spine is straightened as much as possible. A cast is applied over two layers of a protective material called stockinette. Every two months, the cast is removed and replaced until maximum correction of the curve is obtained. When the curve is decreased to less than 10-degrees, then a brace can be used instead.

The VEPTR also known as the titanium rib is a vertical titanium rod that can be expanded as the child grows (about every four to six months or so). The rod is curved to match the curve of the rib cage. The upper end of the rod is clamped around a rib above the spinal curve. The lower end is attached to a rib (or the pelvis) below the curve. As the child grows taller, the telescoping rod can be lengthened. The goal is to separate and support the chest, giving the lungs room to expand and grow. Each expansion procedure requires surgery and a four-to-seven day hospital stay.

Young children with flexible curves seem to respond the best to casting. The growing rod is a great idea but doesn’t seem to yield as good of results as casting. Rod failure is a potential problem. Sometimes the rod eats through the rib, requiring reattachment to another rib. On the positive side, any correction obtained with the rod system seems to hold and doesn’t slip back after the rod is removed.

Given the results of a recent study comparing results of these three treatment techniques for idiopathic scoliosis, surgeons at Shriners in Philadelphia suggest using casting for children whose curves are between 30 and 60 degrees (larger and stiffer). If the curves are larger than that, they may go from casting to the VEPTR system or directly to the VEPTR. The VEPTR has some advantages over other types of growing rods. Since it’s not attached directly to the spine, there is less risk that the spine will fuse itself. Care must be taken when placing the rod not to jam it up against a nerve in the brachial plexus, a collection of nerves that supply the neck and arms. If symptoms of nerve irritation or compression develop, tension on the rod can be reduced.

Idiopathic scoliosis is a curvature of the spine with no known cause. By definition, the curve is at least 20 degrees. Boys are affected more often than girls and a left-sided curve is the rule rather than the exception. It might be said that most children with idiopathic scoliosis outgrow this condition, as it seems to resolve in up to 90 per cent of children.

Although there are no other deformities or diseases this condition could be associated with, many children with this condition do have a developmental hip dislocation as well. Developmental means they weren’t born with the problem; it just developed over time.

If there’s a link between the two anomalies, no one knows quite what it might be yet. Research is ongoing to find out what causes this problem, how to treat it, and even how to prevent it. Right now, studies show that the problem resolves itself in 90 per cent of all cases. Whether or not it should be treated and how to best manage it remain under investigation.

Calcaneonavicular fusion (sometimes called calcaneonavicular coalition) refers to the fusing of two bones in the foot: the calcaneus (heel bone) and the navicular bone. The navicular is an important bone because it joins with many other bones in the foot and ankle. It is located on the medial side of the foot (side closest to the other foot). It articulates (moves against) the four and sometimes five other ankle bones.

When calcaneonavicular coalition occurs, the affected individual (usually a child between the age 8 and 12 years old) reports ankle pain with loss of motion. They are no longer able to point the foot down all the way. Turning the foot and ankle inward can also be limited. The loss of these motions makes it difficult to walk, run, and participate in daily activities at school.

It appears that the bones are fused or held together with a thick, binding cartilage. The child was probably born with this condition but rapid growth during the pre-pubescent years makes the problem more apparent.

Left untreated, besides being painful and limiting, the joint eventually develops degenerative arthritis. The current standard of care is to remove the cartilage bridging the two bones. The hole that is left is filled with muscle from the extensor digitorum brevis (EDB) in the foot. Some surgeons have tried using fat as a filler instead. Both methods have advantages and disadvantages.

After surgery, the parents and child should be prepared for the fact that the bone might grow back. If that happens, a second surgery may be needed. No one is quite sure why regrowth happens in some children, but not others.

There has been some speculation that damage to the nearby joints and soft tissue structures might be a factor. When surgeons first tried using fat instead of a rolled up tendon to fill in the hole, they hoped it would eliminate the need for revision because of regrowth. But it didn’t, so other factors must be at work. Further research is needed to find the optimal treatment for this problem.

This is a difficult question to answer. An orthopedic evaluation is necessary to see the extent of the problem and evaluate the implications of the condition. Some people with this bony anomaly who never have surgery to correct it, end up developing joint problems and arthritis years later.

Calcaneonavicular coalition refers to the fusing of two bones in the foot: the calcaneus (heel bone) and the navicular bone. A bridge of fibrous cartilage connects the two bones together. The navicular is an important bone because it joins with many other bones in the foot and ankle. It is located on the medial side of the foot (side closest to the other foot). It articulates (moves against) the four and sometimes five other ankle bones.

When calcaneonavicular coalition occurs, the affected individual (usually a child around age 12) reports ankle pain with loss of motion. They are no longer able to point the foot down all the way. Turning the foot and ankle inward can also be limited. The loss of these motions makes it difficult to walk, run, and participate in daily activities at school.

Your surgeon may advise careful watching of the twin without painful symptoms. Follow-up visits every six months may help show any changes that might be occurring. Changes on X-ray or increase symptoms may be signals that it’s time to act.

Surgery to remove the fibrous/bony bridge is the current standard of care. In the past, casting the foot and ankle to immobilize it didn’t help and even made things worse for some patients. Different ways of accomplishing the surgery are being explored.

Usually, a muscle and its attached tendon (the extensor digitorum brevis) are harvested and used to fill the hole left by the surgical removal of the coalition (connecting bridge of fibrous bone). A newer technique using a fat graft is under investigation. Fat might work better because it fills the hole completely where the tendon might not be long enough to do so. Fat also has an ability to be shaped to fit the hole exactly. No unsightly deformity or bony bump is left behind to embarrass the child or rub against shoes.

When to do surgery on an anterior cruciate ligament (ACL) tear varies from patient to patient (of any age) and even from surgeon to surgeon. Surgeons often delay surgery of this type in children until the growth plates have sealed up and the bone is fully mature.

Some surgeons follow the guideline of waiting until the child is at least 14 years old and/or reached skeletal maturity before reconstructive surgery is done. Studies show that this idea is probably a good one. Anything that can damage the growth plates increases the risk of growth delays and/or leg length differences. Fortunately, the delay does not seem to enhance the risk of meniscal and/or cartilage lesions.

That’s not always true for adults who for every month that goes by without surgery after an ACL tear, the risk of a cartilage lesion increases by one per cent. Meniscal tears are much more common in adults who have reconstructive surgery late (12 months or more after the injury) compared to those who had the operation within the first year. This relationship is true for adults but not for children.

For now, children who have not completed growing are given the option of a rehab program to help them get back into daily activities and especially sports participation for those who are athletes. Activity modification and a knee brace may be advised. It depends on the type of activities you engage in and the level of demand placed on the knee.