FAQ Category: Child

Keinbock’s disease, a disorder where the lunate bone in the wrist is deprived of blood, causing bone cell death, rarely happens in children and teens, although it does from time to time. Because it is rare in children, doctors don’t have specific guidelines for treated the disorder in that population.

The latest research is showing that a procedure called the temporary scaphotrapezoidal joint fixation, using pins to fix the joint firmly in place, has excellent results in treating younger people with Kienbrock’s. Of course, many physicians may want to treat the disorder conservatively first, using splints or casts, to see if they can avoid surgery.

In the past, these injuries were left alone to heal on their own. Patients might have been given a simple sling to wear for a while. They were probably told what motions to avoid during the healing process. But that traditional view is no longer accepted. Now we know that these injuries occur on a continuum. Some patients may need special care.

Studies show that complex fractures don’t always just heal with good alignment and function. There are many types of clavicular (collar bone) fractures. Some are undisplaced (broken bones do not separate or pull apart). Those respond best to the type of conservative (nonoperative) care that was prescribed for your daughter.

Patients with displaced (two ends of bone shift apart), intra-articular (at the joint) or extra-articular (outside the joint) are more likely to need surgery to hold the pieces of bone together while they heal. The same is true for fractures that are angulated, wedge-shaped, or comminuted (multiple fragments).

There’s enough new evidence to suggest that patients with displaced fractures are at increased risk for a poor outcome. This is especially true for displaced fractures with shortening of the bone. These patients can end up with shoulder weakness and decreased staying power (endurance) for activities requiring shoulder strength.

Those are the people who need more than the traditional approach. Surgery may be needed sooner than later. There are many ways the surgeon can approach the problem. A metal plate can be used along the top of the clavicle to hold things together while the bone heals. A newer invention is the site-specific precontoured locking plate. This plate was designed to remain inside the body (no removal required). It is less prominent (sticks up less) and can be used with older adults who have osteoporosis (brittle bones).

Sometimes the curved shape of the clavicle doesn’t allow the use of plates. The surgeon may have to use a nail or pin that is narrow and flexible enough to pass through the bone lengthwise. At the same time, it has to be strong enough to hold the bone together during healing despite forces placed upon it. This technique is called intramedullary fixation. The nails offer a minimally invasive way to treat patients who have many other injuries in the shoulder and arm.

If you have any doubts about the prescribed treatment for your daughter, make a follow-up appointment with an orthopedic surgeon. He or she can evaluate the situation and advise you as to the best treatment plan.

All sports activities at the competitive level have a risk of injury. Repetitive physical loading of tendons, ligaments, muscles, and bones is especially problematic. There are reports of elite athletes who have trained for many years developing low back pain and degenerative disc disease (DDD).

Each sport has its own specific associated postures and motions. But the ones with frequent rotations of the trunk, frequent jumps, repetitive flexion and extension of the spine, and frequent kick motions seem to have the highest incidence of back problems. This seems to include baseball, gymnasts basketball, soccer, high-load swimmers, and kick boxers most often.

Athletes involved in activities such as running and low-load swimming had the lowest rate of degenerative disc disease.

Given the high rate of obesity and increasing incidence of diabetes among young children today, encouraging physical activity and exercise of any and all kinds seems to be the way to go. For those children who may eventually become elite athletes, a careful training program and prevention techniques may help reduce the risk of injury. More studies will be done and results reported on that will guide athletes and their trainers.

Some children are born with a problem called developmental dysplasia of the hip, which is an abnormal development of the hip where the ball part doesn’t stay firmly in place above the femur, or thigh bone. This can make the hip too flexible and prone to dislocating.

The brace you saw is likely a Pavlic harness. This harness keeps the baby’s hips in position so the hips form or develop normally. After a few months, if the treatment is successful, the baby will not need the harness any longer.

Spica casts are specially designed casts hold the hips and thighs firmly in place to help healing but there are several types of spica casts. Some start at the chest and cover one or both legs, while others may cover on leg on one side but only part of the leg on the other.

They used to be very heavy and cumbersome, but in many places, they are now available in a much lighter weight fiberglass material.

Spica casts are used for a few problems, such as dislocated hips in younger children. They are also used when a young child has a fracture of the femur or thigh bone.

A lot of how a child’s bone heals depends on the age of the child, how he broke the bone, how bad the break is, if there are other injuries, and the type of treatment chosen. In this case, it’s very difficult to say if a shortened leg is normal after a break, but it’s not abnormal either.

Researchers have been studying ways to adapt treatments to minimize the chances of leaving a bone shorter when it heals, but it still happens, depending on the circumstances.

Blount disease is a disorder that affects children and teens. It’s not understood what causes it, but there seems to be a connection between how the top part of the shin bone, the tibia, forms due to the weight on the growth plate. As the child grows, the leg bows out like bowlegs and keeps getting worse.

Children who are affected can be treated with bracing if they’re young enough (usually under 3 years old) but surgery is usually needed for older children.

Blount disease seems to happen more often in African American children and also in children who are quite overweight.

When a child grows, not all of the bone parts grow. There is a soft part to the bone that is called the growth plate. These are found at the ends of the bones are the weakest parts of the bone. If a child has a fracture in the growth plate, it’s essential that it be treated properly to promote good healing or the bone could be affected for life.

Buckle or torus fractures are compression injuries. In children, at the end of the bone is a growth center that consists of several layers of growing bone. The force of the impact from a traumatic injury or fall that compresses this area can cause the area around it to buckle outward.

It’s actually a subcategory of a larger classification of breaks called greenstick fractures. The bone bends and partially breaks. This kind of fracture only occurs in young, soft bone. Once bones become harder and more brittle with age, the bone may give a little, but it doesn’t bend.

You’ve probably seen this phenomenon yourself if you’ve ever tried to break a stick of green wood in half. It bends and bends and bends but doesn’t snap in half like older, dryer wood.

In the last 10 years, surgeons have revisited the question of whether or not casting is sufficient for these types of fractures. There’s been some suggestion that surgery to pin the healing bones might be a better option than just cast immobilization. The thinking behind this has come as a result of the many cases where the fracture reduction was lost with casting.

Loss of fracture reduction is so common, it appears that at least one-third of all forearm fractures (and as many as 90 per cent of cases) are affected. The first step in understanding how to keep this from happening is to look for risk factors.

Some of the factors that have been shown to increase the risk of loss of fracture reduction include: 1) type of fracture displacement, 2) amount of displacement (more than 50 per cent), 3) location of the fracture (closer to the wrist), 3) increased angle of the bone, and 4) fracture of both bones in the forearm bone (radius and ulna).

Other factors that may contribute to the loss of fracture reduction have been suggested. Muscle atrophy (wasting) and decreased swelling while in the cast can make a difference. The arm moves around too much inside the loose cast to keep the fracture firmly in place while healing. Movement of the arm can cause the fractured ends of the bones to separate again.

There’s been some question as to whether a short-arm (below the elbow) versus long-arm (above the elbow) cast makes a difference. Studies show that even more important than the type of maneuver used to reduce the fracture or the type of cast (short versus long) is the casting technique used. Serial X-rays taken once a week can help identify when a problem with reduction is occurring.

At the same time, there were some studies done to look at the outcomes when using surgery to pin the fracture sites. The final results showed that patients didn’t fare any better after surgical fixation than they did with nonoperative casting. So the conclusion was to continue using short-arm casts applied with good technique and follow the patient with serial (weekly) X-rays until complete healing occurs.

If these steps are not enough to prevent loss of reduction, then surgery is advised. Reduction with pin fixation is also considered appropriate when there is a fracture through the metaphysis (growth plate), but it’s not recommended for every fracture. Other reasons open surgery might be done include open fractures (bone pokes through the skin), fractures that overlap and can’t be reduced, and fractures that are pressing on nerves or blood vessels.

Traumatic hip dislocations are challenging in children. They don’t occur very often. And there are many associated injuries that can occur at the same time that go unnoticed at first. A careful examination must be done before any treatment is started.

Associated injuries of the nerves, blood vessels, growth plate, and soft tissues must be identified. In a five-year-old, there is the problem of the growth plate and typical laxity (looseness) of the soft tissues around the hip present in children. For best results, reduction must begin within six hours of the injury.

Reduction refers to putting the round head of the femur (thigh bone) back in to the acetabulum (hip socket). In younger children (up to age 10), gentle traction may be all that’s needed to reduce the hip. This can be done as a closed reduction. With a closed reduction, no surgery is required.

Applying traction and pulling the leg down far enough to reduce it is not always a simple procedure. Femoral head epiphysiolysis can complicate matters. This refers to a fracture and then separation of the epiphysis (growth plate) at the upper end of the femoral head.

If the physician is unaware of the physeal injury and attempts to reduce the hip with a closed reduction technique, the growth plate can get displaced. The result is can be an unstable hip and eventual osteonecrosis (loss of blood supply and death of the bone).

There are many other factors to consider when attempting to reduce a traumatic hip dislocation in a young child. Reduction in the first few hours after dislocation is ideal to prevent other complications. Emergency department personnel are trained and make every effort to minimize problems. Even under the best of circumstances and with the highest trained individuals, successful reduction with a simple closed procedure just isn’t possible.

Groin pain can be caused by a variety of causes. After an injury of this type, persistent pain should be evaluated by the orthopedic surgeon. There could be a incongruous reduction. Incongruous reduction means the hip has returned to its natural, anatomic position, but cartilage, capsular tissue, or a bone fragment has lodged itself between the femoral head and the acetabulum.

This will prevent normal movement and can lead to osteonecrosis of the femoral head (death of the bone due to loss of blood supply). Repeat X-rays may be needed to check for this.

Even when a hip dislocation has been treated, other problems can develop. For instance, there may be other injuries that are subtle. Fractures of the acetabulum, femoral head, or greater trochanter (bump on the femoral bone where muscles attach) may not be recognized because the focus and attention was on the pelvic fracture and hip dislocation.

Groin pain often signals true hip pathology. The surgeon will investigate for possible recurrent hip dislocation, nerve damage, or osteonecrosis. It could be nothing more serious than a tight muscle that needs stretching or a slight imbalance in pelvic alignment.

But first things first and that’s to get a diagnosis. Early intervention will always yield the best results. Make an appointment today for follow-up as soon as possible.

Well baby check-ups are an important part of your grandchild’s healthcare. These are the times when doctors may be able to pick up on disorders or problems that may otherwise be missed if the child is only being seen when he is sick.

One of the problems that doctors look for in young children is a hip problem called developmental dysplasia of the hip. Children who have this problem may dislocate their hips easily and/or develop hip pain and arthritis as early as their teens.

If the dysplasia is found when the child is young, there are some treatments that may help stabilize the hip, such as using a special harness to hold the hip in proper position.

It may seem that the doctor is being rough, but what he is doing is seeing how far the hip can move before he meets resistance. If it moves too much, this could mean that the baby has hip dysplasia.

Everyone feels pain differently. One person may be able to walk to the doctor on a broken ankle, while others will pass out or vomit because of the pain. Some people can have dental work without anesthetic, others need to be as frozen as is possible. Since everyone feels pain differently, it isn’t possible to say how a child feels pain. A child’s perception of pain may be totally different from that of an adult.

Without examining your daughter, no-one can say what may be going on. However, unless causes of pain have been ruled out by a doctor, no pain should be dismissed or not taken seriously.

While it is possible that the pains are not caused by anything specific, if your daughter feels pain, she is feeling it for a reason. Seeing a doctor and discussing the various issues she may be dealing with may help the doctor understand, as well as a thorough physical exam and perhaps some tests.

Your orthopedic surgeon is the best one to advise you on this. Surgery to pin the bone is usually done if the fracture is displaced. This means the two ends of the bone have separated and no longer line up with each other. If there is a great deal of soft tissue injury around the joint, one or two screws are used to hold everything together until healing occurs.

In a growing child, care must be taken to preserve the growth plate. Screws can be placed through this area (sideways) but not across the plate. The screws can be metal (removed later) or bioabsorbable (dissolve and don’t require removal).

Sometimes the decision of how to stabilize the joint is based on how cooperative the child is. Children must keep their weight off the broken ankle for the first seven to 10 days. There is a risk that the bioabsorbable screws can break if loaded before bone growth and repair can take place. If that happens, then a second surgery is required. The dissolvable screws are replaced with metal screws. The cost and risk of problems increases with the second operation.

Osteochondritis dissecans (OCD) is a problem that develops in the knee. When it affects young children who are still growing, it is called juvenile OCD or JOCD. Many doctors think that JOCD is caused by repeated stress to the bone.

Most young people with JOCD have been involved in competitive sports since they were very young. A heavy schedule of training and competing can stress the femur in a way that leads to JOCD. In some cases, other muscle or bone problems can cause extra stress and contribute to JOCD.

Grade I is a mild lesion — it is small in size and does not involve the underlying articular cartilage. Articular cartilage is a smooth, rubbery covering that allows the bones of a joint to slide smoothly against one another. This type of lesion has the best chance for healing. Conservative care with activity modification and possible casting, splinting, or bracing of the knee are the two main nonoperative approaches to this problem.

The lesions usually occur in the part of the joint that holds most of the body’s weight. This means that the problem area is under constant stress and doesn’t get time to heal. Only one-third up to one-half of children treated conservatively have a successful outcome. It’s very important that your son follows the doctors advice and doesn’t push beyond what’s recommended. Putting weight on the healing area too soon can further damage the joint and result in failure to recover.

Osteochondritis dissecans (OCD) is a problem that affects the end of the femur (thigh bone) at the knee. The joint surface is damaged and doesn’t heal naturally. The problem occurs where the cartilage of the knee attaches to the bone underneath.

The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion. A bone fragment with the layer of articular cartilage covering it detaches from the bone.

Six months of conservative care with activity restriction and casting or bracing for the first six to 12 weeks is the standard approach to this problem. If the lesion is small and stable (no disruption of the cartilage), the chances of healing are much greater than if there is a big chunk of bone and attached cartilage that has pulled away from the bone.

Your orthopedic surgeon will advise you regarding progression of activity. His or her decision is based on your son’s symptoms and results of imaging studies. Don’t be surprised if you are asked to get X-rays and MRIs several times over the next six months.

Serial images every six to eight weeks is the best way to assess healing in lesions of this type. And both X-rays and MRIs offer a different view of the healing structures. They are both essential in the diagnosis, treatment, and follow-up.

Young children who are still growing must be watched very carefully. Any disruption of the growth plate can disturb bone growth leading to a leg-length discrepancy. MRIs are especially helpful in showing changes in the signal intensity between the lesion and the growth plate. This information will be used to guide treatment. If the lesion is too severe and/or not showing any signs of healing, then surgery may be the next step.

Fractures at the distal tibia (ankle) in children pose a special challenge. This is especially true if the fracture goes through the epiphysis (growth plate) or separates the growth plate from the joint. Surgery to hold it all together while it heals may be needed. Metal screws are often used that can be removed later.

But transepiphyseal metal implants (through the growth plate) change the way the ankle is loaded during weight-bearing (standing and walking). Over time, the increased pressure leads to breakdown of the joint. Pain and disability can be the final outcome.

One way to avoid this problem is to use bioabsorbable screws. These implants serve the same function as metal screws: to maintain a closed position of the fracture while the bone heals. But the screws dissolve and are absorbed by the body over the next two to four years.

Several studies report success with this approach. The screws go through the growth plate, but they don’t go across the growth plate. In this way, growth is not disrupted. The long-term tissue response to these bioabsorbable implants is under investigation.

So far, only animal studies have been done. But there have been no signs of reactive inflammation and no obvious problems. The implant slowly dissolves over a period of time (usually months to years). Bone fills in the spot where the implant was located. Sometimes fibrous tissue forms as well.

There’s no reason to believe further problems will develop over time. In fact, the use of bioabsorbable screws is expected to reduce the risk of degenerative joint problems that can occur with metal screws.

Upper back injuries in children often are undetected for quite a while because it takes the spine until the teens to be fully hardened. Certain parts of the spine will be finished before other parts.

There are some disorders or anomalies in the upper spine and neck that might not be obvious until a child is four or five years old because that’s when the vertebrae finish fusing together. Unless a child has a specific disorder, like Down’s syndrome, that commonly has anomalies like this, or unless a child has an injury or problems that make doctors examine that part of the spine, it’s entirely possible that the problem go undetected for quite a while.