FAQ Category: Child

Many parents face this challenge of a noncompliant child who has osteochondritis dissecans (OCD). There’s a very good chance that healing can occur when treated with nonoperative care. But that does mean limiting activities — especially weight-bearing, high-impact, twisting, and turning.

OCD mostly affects the femoral condyles of the knee. The femoral condyle is the rounded end of the lower thighbone, or femur. Each knee has two femoral condyles, referred to as the medial femoral condyle (on the inside of the knee) and the lateral femoral condyle (on the outside). Like most joint surfaces, the femoral condyles are covered in articular cartilage. Articular cartilage is a smooth, rubbery covering that allows the bones of a joint to slide smoothly against one another.

The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

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. It also means that the lesions cause pain and problems when walking and putting weight on the knee. It is more common for the lesions to occur on the medial femoral condyle, because the inside of the knee bears more weight.

The nonoperative treatment is rest and inactivity until the bone heals. But the physical, social, and emotional downside of inactivity for these sports-minded youth can be a problem. Parents, children, and surgeons have asked the same question: is there some way to preserve the bone without prolonged immobility that gets these athletes back on their feet and playing or performing again?

A technique called extraarticular drilling may be possible. Drilling is done using arthroscopy and fluoroscopy. These techniques allow the surgeon to see inside the joint while guiding surgical tools and completing the drilling process. Drilling is done with K-wires that poke holes through the hardened rim of bone that develops around the softened lesion in the bone.

Once the hard shell around the lesion has been breached, new blood supply to the area starts the healing process. The surgeon must be careful not to drill into the knee joint or into areas of healthy knee joint cartilage. That type of drilling approach is referred to as intraarticular technique. Extraarticular drilling avoids the cartilage.

One of the advantages of the extraarticular drilling technique is that motion is not restricted. After the procedure, patients are allowed to stand and walk with crutches. Weight-bearing may be limited on that side for six weeks. Physical therapy to restore motion and stimulate bone healing through the proper exercises and activities can be started. When signs of healing are observed on X-ray, the exercise program is progressed to include light resistance and gradual impact loading.

Swimming and cycling are allowed but running, jumping, and twisting are limited until MRI or CT scan show evidence of good healing. Once the patient is pain free with good leg muscle strength, then the training program can be stepped up to include full return to activities. It still takes some time, but it may speed up the process by months to even a full year.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calvé-Perthes disease in honor of the three physicians who each separately described the disease.

In this condition, the blood supply to the capital femoral epiphysis (growth center of the hip) is disturbed. The bone in this area becomes necrotic (starts to die) without blood. The blood supply eventually returns, and the bone heals. How the bone heals determines how much problem the condition will cause in later life. This condition can lead to joint deformity and a poorly functioning hip.

The primary goal of treatment for Perthes disease is to help the femoral head recover and grow to a normal shape. All treatment options for Perthes disease try to position and hold the hip in the acetabulum as much as possible. This healing process is referred to as containment. Treatment success can take several years. If conservative (nonoperative) care is not successful, then surgery may be needed.

There are some long-term studies following children with Perthes disease into adulthood. Results seem to depend on the age of the child at the time of diagnosis. Early onset of Perthes (younger than five) may have a better prognosis. On the other hand, children who have surgery later (after age five) have better results than younger children.

Surgeons have different ways of classifying and categorizing Perthes disease. They use X-rays to grade the severity of the disease. Amount of growth plate and bone involvement is a factor. So is the shape of the femoral head. The flatter the head and the more bone involved, the worse the prognosis.

But this is not a life-threatening condition. The long-term effects can include limp (from one leg being shorter than the other) and hip arthritis. In some cases, further surgery and eventually hip replacement may be needed. But this is the exception rather than the rule.

Children are involved in sports more than ever before. Year-round practice and competitive play have increased the number of orthopedic conditions and injuries reported. One of those conditions is the condition you mentioned: osteochondritis dissecans (OCD) or JOCD when juveniles (children and teens) are affected.

OCD mostly affects the femoral condyles of the knee. The femoral condyle is the rounded end of the lower thighbone, or femur. Each knee has two femoral condyles, referred to as the medial femoral condyle (on the inside of the knee) and the lateral femoral condyle (on the outside). Like most joint surfaces, the femoral condyles are covered in articular cartilage. Articular cartilage is a smooth, rubbery covering that allows the bones of a joint to slide smoothly against one another.

The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

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. It also means that the lesions cause pain and problems when walking and putting weight on the knee. It is more common for the lesions to occur on the medial femoral condyle, because the inside of the knee bears more weight.

Until recently, boys were affected more often than girls. But last year, over three million girls were participating in organized sports. And they are joining in at a much younger age. With year-round sports opportunities and increased frequency and intensity of practice and play, we can expect to see more of these types of injuries.

Prevention depends on identifying risk factors and modifying them. But right now, we only have guesses about what leads up to OCD. If it were just the training and play schedule, then everyone would have this problem. But it’s not. So that means there are other influences. Genetics, growth spurts, bone abnormalities, and decreased blood supply are just a few possibilities.

Scientists are studying the problem and may be able to offer some insights in the near future. Until then, keep a record of each girl’s training schedule, number of minutes played each week, and amount of time engaged in other sports activities. It may be possible to look back at the records and find a common factor among those girls who develop OCD. Finding a way to prevent the problem becomes much easier when the causative risk factors are identified.

The use of all-terrain vehicles (ATVs) has increased dramatically in the last 10 years. Injuries (even fatal ones) have increased, too. Forty per cent of all ATV-related deaths are children. Studies have shown that children under the age of 16 are three times more likely to get hurt than older riders/driver.

There are recommendations about children and ATV use. The American Academy of Pediatrics (AAP), the American College of Surgeons (ACS), and the American Academy of Orthopaedic Surgeons (AAOS) all agree:

Enough studies have been done now to verify how dangerous these machines are with children on them. Even so, many states do not have even a minimum age or training requirements for operating these devices.

Even when states have a mandatory helmet law, less than 10 per cent of injured children wear them. Head injuries are the number one cause of death for children riding on all-terrain vehicles (ATVs). Helmets have been proven to reduce the risk and decrease the severity of all head, neck, and face injuries.

Increasing public awareness of the dangers of ATV, improving safety measures, and improved ATV design are key factors in preventing and minimizing these kinds of accidents. Adults must be informed that manufacturers marketing the so-called Children’s ATV cannot guarantee the safety of these machines. Smaller, less powerful units in the hands of a young rider can lead to fatalities such as you are reporting.

A new pediatric orthopedic locking nail was developed by a pediatric orthopedic surgeon who practices in the Orlando area. The device or implant is called a flexible interlocking intramedullary nail or FIIN. It is a long pin made of titanium alloy with a little give to it.

This subrigid device is designed to enter the inside of the femur (thigh bone) from the side of the hip. It curves through the entry and into the femoral canal where it is locked in place to support and stabilize the broken bone.

Studies show that the FIIN is a good choice when surgically treating femoral shaft fractures in children. The advantages of this new type of implant is that there is less blood loss during the procedure, shorter recovery time, and faster return to function. There are also fewer complications with this new device compared with other fixation procedures. And it can be removed nine months to a year later.

There are a few disadvantages to the FIIN implant. There is an increased rate of osteomyelitis with the FIIN device. Osteomyelitis (also referred to as heterotropic ossification) is the formation of bone in the soft tissues surrounding bone.

When osteomyelitis develops after the placement of a FIIN for femoral shaft fractures, it may be caused by the way the new nail is inserted into the bone. More study is needed to understand this problem. Children who weigh more than 100 pounds are not as likely to have as good of results as lighter weight children. The reason for this is unknown but will be the topic of another future study.

The femur is your thigh bone. It’s the longest bone in the body. The main part of the bone (between the top and bottom) is referred to as the shaft. Femoral shaft fractures occur most often in the middle third of the shaft as a result of a fall or car accident.

In younger children (12 and under), the car accident is more likely a pedestrian-vehicle accident (in other words, they got hit by a car). Older children with this type of fracture are more likely to have come by the injury as a result of a car accident in which they were passengers in the vehicle.

Most of the time, this type of injury requires surgery. This is especially true if the bone is displaced. A displaced bone fracture is one in which the broken pieces have separated and/or moved apart. Sometimes the fracture is comminuted, which means there are many tiny bone pieces at the site of the fracture.

The surgeon reduces the fracture by lining up the two ends of the broken bones and holding them in place until healing takes place. The process of holding the bones together is called fixation.

There are many ways to accomplish fixation including metal plates and screws, pins attached to an external frame. The frame is on the outside of the body. The pins go through the skin and into the bone and secure the bone to the frame. Sometimes it’s necessary to use traction first to pull the bones apart and then apply the fixation device.

Each child is treated according to the location, type, and severity of the fracture. The surgeon tries to avoid disrupting the growth plate in any child who has not stopped growing yet. And every effort is made to prevent a limb-length difference.

Stay calm and be patient. You’ve probably heard the saying that it takes a village to raise a child. Well, remember it takes a team to manage rheumatoid arthritis. You have done your job in educating your daughter and providing a healthful environment. Let the team members help you out during this transition stage between childhood and adulthood.

You can do this by keeping regularly scheduled appointments with the primary care physician, rheumatologist, physical and occupational therapists, and counselors. There’s nothing wrong with letting the team know what your concerns are and asking them to address the issues with your child. They can do this in a way that reinforces what you’ve been saying but without letting on that you had a hand in it.

The child still has some responsibility in all this. Compliance (cooperation) is essential. If the teen just isn’t willing to follow-through in abiding by the recommendations of the team, you may have to wait it out. The team will reinforce the need to take their medications as prescribed, to get regular rest and sleep, and to eat healthy foods. There’s plenty of research to support the effectiveness of each of these routines in chronic diseases like arthritis.

Weight control and exercise go hand in hand. Joints are stressed by the disease. Adding extra load from being overweight combined with poor muscle strength puts an added burden on already compromised joints and soft tissues around the joints.

The family can still make a difference by example. Family members can organize activities together: walk, bike, swim, play tennis, or engage in other activities everyone enjoys. Parents or guardians can provide nutritious snacks and limit the availability of unhealthy food items and snacks kept on the shelf.

Don’t force — just make it available. A bowl of cut up fruit placed on the table for the after school hunger will likely get eaten. A dish of mixed nuts, air-popped popcorn, or carrots left on the table after supper may help reduce the munchies for chips, cookies, and other high-fat food items.

When it’s all said and done, you do the best you can. Offer encouragement and support without nagging. Sometimes the goal in the teenage years is to get through them with the least damage possible. Most teens who are suffering will modify their behavior when they see and feel the difference. The health care team can help them make the connection and in this way, take some of the load off the caregiver’s shoulders.

Finally, if there is a support group in your area — go to some of the meetings. Getting in touch with other parents and family members who are facing the same challenges can be very helpful. Often, they can offer tips on what works for them that might help you. And just knowing you aren’t alone in the process can be very uplifting.

One of the biggest challenges in the management of rheumatoid arthritis is gaining control of the arthritic symptoms. Medications can help but in a growing child, they must be monitored closely. Flare-ups should be evaluated by the physician right away.

Make sure the child is taking his or her medications everyday as prescribed. Activity and exercise during the day are keys to restful, restorative sleep at night. If land activities aren’t possible because of painful joints, see if you can find a swimming program in your community.

Experts agree that a regular bedtime and a bedtime routine or ritual are essential in cases like this. Make sure the child is getting enough sleep. If going to bed is an issue, take steps to create a bedtime that works. It may be later than you like and earlier than the child likes, but it’s a start.

At age eight, your child may still enjoy a bedtime story. Chapter books read by the parent can be a focal point of the bedtime ritual. Once the teeth are brushed, the pajamas on, and the room ready, then comes story time. Try to find books that engage the imagination without stirring up fears and worries that can cause bad dreams or disrupt sleep.

Provide a soothing bedroom environment with soft lights (if needed), background noise (a tape of water running or a small fountain made for this purpose) or calming music. A physical therapist can help your child learn some relaxation exercises. A specific type of program for this is called Physiologic Quieting®. This program helps balance the nervous system and can help with joint and muscle pain as well as sleep.

Getting a good sleep routine can take time. It may require patience and persistence. At the end of a long day, parents/care givers are tired while the kids are still wired. Putting effort into this program on top of everything else you are doing can seem overwhelming.

Pick one or two things you know you can do and do these consistently. Slowly add other elements in as you feel able. Consider keeping a journal or chart to help you see if and when you are making progress. This can help motivate you to stick with it. Once your child is sleeping better, you will get more rest, too.

Every parent knows that if their child wants to participate in organized sports, a preparticipation exam is required. The athlete must see a physician, have a form filled out, and turn the form in. While it may seem like we are jumping through hoops, the medical doctor must take this exercise very seriously.

Every year, there are reports of athletes suffering fatal heart or other life-threatening conditions on the field. Hypertrophic cardiomyopathy, (HCM or HOCM) is the most famous as a leading cause of sudden cardiac death in young athletes. Hypertrophic cardiomyopathy is a disease of the myocardium (heart muscle). Part of the myocardium becomes hypertrophied (thickened) without any obvious cause.

Various medical societies recommend an exam every two years for younger athletes, and every two-to-three years in older athletes. Specific ages have not been standardized as yet. A thorough exam is advised at the start of new phases (e.g., upon entering middle school, at the start of high school, when participating in sports for the first time).

A modified and less thorough update exam can be performed each year in-between major transition periods. Any important health changes can be noted at that time. This might include changes in height and weight, any new personal/family history of injury or illness, and current blood pressure.

Many schools require the preparticipation exam every year for liability reasons. There isn’t any real data collected to show that this is necessary. Studies are needed to confirm that performing an annual exam actually reduces the risk of injury or death in student athletes.
There’s still some debate about the need for special tests such as electrocardiograms (EKGs). Studies from Europe support the need for all competitive athletes to have routine EKGs. They report 90 per cent fewer deaths from cardiovascular causes.

But the American Heart Association says that a normal EKG doesn’t mean the athlete won’t have a significant heart-related event. These tests just aren’t sensitive enough to detect all abnormalities and they are expensive to conduct on everyone involved. One false-positive test leads to more tests that may be unnecessary. At the present time, there are too few athletes for whom this type of testing is really needed. There’s no need to subject everyone to the test for the sake of a very few who might be affected.

Many schools require the preparticipation exam every year for liability reasons. Guidelines for preparticipation screening of athletes are designed to ensure the health and safety of the 10 million school age and collegiate athletes who train and compete each year.

The goal is to identify risk factors for injury, illness, and even sudden death. The preparticipation exam should be completed at least six weeks before preseason activities. This allows enough time for follow-up if referral or consultation is needed.

To help physicians perform an effective exam, a proposed preparticipation exam has been developed. A consensus approach was used to formulate the evaluation. Consensus means the opinions of many experts were gathered. Items agreed upon by the majority of doctors were included.

The consensus report comes from many well-known medical groups. For example, the American Family of Family Physicians, American College of Sports Medicine, American Academy of Pediatrics, and American Orthopaedic Society for Sports Medicine participated (to name a few). Specific cardiac recommendations have been added by the American Heart Association.

Physicians are encouraged to obtain the most accurate history possible. This means interviewing both the athlete and his or her parent/guardian. Areas to include are: past hospitalizations and surgeries, current medications, allergies, and use of vitamins or other supplements. A social history is equally important with questions about tobacco use and alcohol or other drug use. A past history of medical disqualification raises a red flag requiring further investigation.

The physician follows a typical comprehensive physical exam including a systems review: head; ears, nose, throat; skin; gastrointestinal; and genitourinary function. Certain body systems require a closer look than others. For example, the cardiovascular, pulmonary, neurologic, and musculoskeletal systems must be reviewed in detail. Nutrition is also very important as well as looking for specific signs and symptoms that might suggest an eating disorder or risk factors for delayed growth.

Each of these areas is described in detail for physicians reviewing the current guidelines. Samples of forms and checklists with multiple questions are included for the reader. Drawings of tests used in the general musculoskeletal screening exam are provided. Tests for range-of-motion, muscle strength, scoliosis screening, balance, and flexibility are included.

Ask your physician what format he or she uses for the physical exam. A full exam may not be needed every time. Current recommendations are for an exam every two years for younger athletes, and every two-to-three years in older athletes. Specific ages have not been standardized as yet. A thorough exam is advised at the start of new phases (e.g., upon entering middle school, at the start of high school, when participating in sports for the first time).

A modified and less thorough update exam can be performed each year in-between major transition periods. Any important health changes can be noted at that time. This might include changes in height and weight, any new personal/family history of injury or illness, and current blood pressure.

The decision to treat musculoskeletal abscesses surgically is usually based on modern diagnostic techniques. Ultrasound and MRIs make it possible now to see when the condition is serious enough to recommend surgery. In some cases, early surgery results in fewer complications and problems.

Fluid in the joints called effusion seen on MRIs indicate the start of septic arthritis (joint infection). Likewise, an abscess in the bone can be identified with this type of advanced imaging. The spread of the bacteria from the abscess to other parts of the body is not uncommon. But it can be a serious problem. Bone infections are often accompanied by blood clots. Both the infectious process and the blood clot can be life-threatening — even in a young child.

Studies have shown that early signs of joint effusion tells the doctor that antibiotic treatment alone is not likely to be effective. That’s when combining drug treatment with surgery is advised. It sounds like your physician helped you make the best treatment decision possible under the circumstances.

Best practice based on the most up-to-date evidence requires the use of antibiotics for musculoskeletal infections. The real decision is which antibiotic is best for the bacteria present and whether the drug should be oral (taken by mouth) or intravenous. You can rely on your physician to make this decision.

Metal plates, pins, and screws referred to as instrumentation or orthopedic implants are sometimes used to stabilize fractures or hold a fusion site together until healing can take place.

Although uncommon, complications such as infection, allergic response, or even malignancy (tumor) around the implants can occur. There’s no real evidence that these complications were caused by the implant. The fact that the implant is present makes it a likely suspect when anything out of the ordinary occurs.

There’s no evidence that someone who has allergic responses in general is more likely to develop an allergy to an implant. Skin sensitivity to nickel and chromium occurs in a small percentage of the general population. A skin reaction called dermatitis can develop.

Whether or not these same individuals would react to an internal implant is unknown. Pain would be the most likely symptom to develop. The implant might loosen as a result of the body’s defense reaction against the device. Again, pain would be the first sign of a problem.

Let the surgeon know of your concerns. He or she will monitor the child more closely and let you know what to watch for as a suspicious sign of anything that requires further follow-up.

From your description, it sounds like you may be referring to a problem called slipped capital femoral epiphysis (SCFE). In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone).

Surgery is usually necessary to stop the epiphysis from slipping further. A large screw is placed into the epiphysis to hold it in place. Most of the time, implants are left in and removal is not an issue.

The surgeon will take X-rays during the follow up visits to make sure that the screw remains in the right place. The X-rays are also required to determine when the epiphyseal plate fuses. At that point, there won’t be any chance that the slip will get worse. When this is known, the follow up visits will be focused on whether the abnormality is likely to need any additional surgery to realign the hip.

Opinions differ on the need to remove the screw once the epiphysis has fused. Removing the screw requires a second surgery that can be expensive and carries a slight risk due to the need for anesthesia.

Removing the screw takes twice as long as putting it in. There is a risk of breaking or stripping the screw during the attempted removal. Titanium screws seem to have the worst results. The hole left when the screw is removed also increases the risk of fracture after the screw is taken out. Many surgeons feel that the screw should be left in place if it isn’t causing problems.

Femoracetabular impingement (FAI) refers to a pinching of the soft tissues around the hip joint where the femoral head (top of the thigh bone) bumps up against the acetabulum (hip socket).

The reason FAI occurs is because there is an abnormal relationship between the femoral head and neck. The junction where these two structures meet is shortened or rotated from normal. This change from normal is referred to as the femoral head-neck offset.

The most common causes of this problem in children are pediatric conditions such as Legg-Calvé-Perthes disease and Slipped Capital Femoral Epiphysis (SCFE). In some cases, FAI occurs when the bones are formed with slight variations from the norm. This is referred to as idiopathic anatomic variations. Idiopathic means no one knows what causes it to happen — the child is just born that way.

Repeated flexion (bending) of the hip is the movement that makes the impingement the worst. Over time, it can lead to tears of the labrum and early signs of arthritis. The labrum is a dense ring of fibrocartilage that is attached around the rim of the acetabulum. It helps make the socket deeper and more stable for the femoral head.

FAI can be treated conservatively. In fact, nonoperative care is always recommended first. This usually consists of at least six weeks of nonsteroidal antiinflammatory drugs (NSAIDs), steroid injections, physical therapy, and activity modification. In cases where the pain is severe and unchanged by therapy, surgery may be needed.

The labrum is a dense ring of fibrocartilage that is attached around the rim of the acetabulum (hip socket). It helps make the socket deeper and more stable for the femoral head. The femoral head is the round ball of bone at the top of the femur (thigh bone). The head fits in the socket to form a ball-and-socket type of joint (as opposed to a hinge joint).

Small labral tears can be treated conservatively. In fact, nonoperative care is always recommended first. This usually consists of at least six weeks of nonsteroidal antiinflammatory drugs (NSAIDs), steroid injections, physical therapy, and activity modification.

Athletes who continue to have disabling pain despite conservative care may consider surgery as the next option. Pain severe enough to keep an athlete on the bench and unable to participate is the most common reason for surgery to correct this problem.

If the labrum is frayed or a small piece of tissue has pulled away and formed a flap, there may still be enough normal, healthy tissue to function as nature intended. Surgery to shave or smooth down the edges of the labrum may be necessary. A severe tear can be repaired using suture anchors. These procedures don’t restore the tissue to normal. But it makes it possible for the joint to keep moving smoothly and painfree through its various motions.

The healing ability of the labrum remains under question. Animal studies show it has a promising ability to heal after surgical repair. Human studies are more difficult to conduct. Fibrosis, adhesions, and scar tissue in and around the labrum can help stabilize the joint, but can also cause motion restrictions and pain.

Surgical repair may be accompanied by less chaotic and more evenly distributed scar tissue. Motion, strength, and function can be restored fully. Athletes are able to return-to-sport at a level equal to sports participation prior to the injury.

This type of defect is called a neural tube disorder. The neural tube is the protective sheath of bone and meninges that encase the entire spinal cord. It is formed early in utero (around the 19th day in the womb). There are three major types of neural tube defects.

The most common neural tube defect is called spina bifida or spina bifida occulta. Occulta means hidden. Without an X-ray the defect is unseen. In this condition, there is an incomplete closure (incomplete fusion) of the arch of bone around the spinal cord.

Meningocele is more severe than spina bifida. There is a failure of the bone to close around the spinal cord (like in spina bifida), but there is also a protrusion of the meninges outside the spinal column. Meninges is the covering around the spinal cord. In meningocele, the vertebral arch doesn’t fuse. And the meninges covering the spinal cord expand out because the missing bone doesn’t contain them.

With myelomeningocele, there is spina bifida, meningocele, and a failure of the meninges to cover and protect the spinal cord. The vertebral arch and meninges fail to close when the child is developing in the womb. Both the meninges and the spinal cord are protruding.

Generally these defects occur in the lumbosacral (low back) area. But they may also be found in the sacral, thoracic, and cervical areas. The clinical picture is different depending on the severity and location of the problem. For example, children with myelomeningocele are more likely to have foot and ankle deformities or bowel and bladder problems than children with spina bifida occulta. Myelomeningocele can also be accompanied by hip dislocation, scoliosis, changes in muscle tone, and cognitive impairment.

Myelomeningocele is a protrusion of the meninges and spinal cord. Meninges is the covering around the spinal cord. In this condition, the meninges fail to close when the child is developing in the womb.

This type of defect is called a neural tube disorder. The neural tube is the protective sheath of bone and meninges that encase the entire spinal cord. It is formed early in utero (around the 19th day in the womb). The most common neural tube defect is called spina bifida occulta. This refers to an incomplete closure (incomplete fusion) of the arch of bone around the spinal cord.

Myelomeningocele is more severe than spina bifida. There is a failure of the bone to close around the spinal cord (like in spina bifida), but there is also a failure of the meninges to cover and protect the spinal cord. Generally these defects occur in the lumbosacral area.

Myelomeningocele can cause foot deformities as a result of muscle imbalance. Not all children with an L5S1 level myelomeningocele have foot deformities requiring treatment. When these occur, surgery at an early age is often advised.

Most of the time, the child is put in a cast after surgery for four to six weeks. When the cast is removed, a special plastic brace called an ankle-foot orthosis (AFO) is usually worn. The orthosis is designed to perform several functions. It helps with control ankle position and function. It helps the child stay in an upright position and avoid a crouching position with hips and knees bent.

Usually the AFO is designed especially for each child depending on whether there is a need to control upright posture and prevent a crouch position or to reduce ground-floor reaction. Ground-floor reaction refers to the force that goes up through the leg when the heel hits the floor while walking.

As you have found out, keeping the braces on can be the biggest challenge for a young child. Finding ways to gain his cooperation can be exhausting. Some parents find it helpful to put up a colorful chart with stickers in each square for every hour the braces are left on.

Others give the child a colored chip for each morning and/or each afternoon that the AFOs stay on. When the child gets a certain predetermined number of chips, then he can exchange them for a special treat. This varies from family to family. It could be an extra book read to him by the parent, a ride outdoors in the wagon, or a special time to listen to music.

Make sure the child isn’t refusing to wear the AFO because they are uncomfortable, pinching, or rubbing. Look at his feet, ankles, and lower leg after the AFO has been worn for 30 minutes. Any signs of redness or marks left by the orthotic are an indication that it needs adjustment.

Make an appointment with the orthotist who made the insert. Have the child wear the brace for at least 30 minutes before the appointment so the orthotist can see where and what is the problem. It may be the problem is as simple as that. But if not, keep trying to keep him in the brace as much as possible.

Early, aggressive care of myelomenigocele has now improved the overall prognosis associated with this condition. Prognosis varies with the degree of neurologic deficit. The child’s motor abilities vary according to the level of the lesion. Delays in motor function (including walking) can be expected in all children with this type of problem.

At present, prognosis is poorest for children who have total paralysis below the lesion. The presence of other problems such as kyphoscoliosis (curvature of the spine) and hydrocephalus (increased fluid in the brain) are common.

Overall developmental delays occur less often as a result of improved medical treatment for these children. Physical and occupational therapy from an early age on help children with this condition to advance their skills and improve function.

A child’s ability to walk outdoors and use a wheelchair by age seven usually suggests a good prognosis for ambulation (walking). If functional ambulation is not present by age seven to nine, it is unlikely to occur later.

A third of all people with myelomeningocele demonstrate a decline in ambulatory status with increasing age, usually around age 12. These losses are often linked with changes that occur during the teen years. For example, increasing body size, loss of strength, or immobilization after surgery or fracture can affect the ability to regain independent ambulation.

As the child matures into adulthood, motor function and balance tend to decline. Many lose the ability to remain independent in ambulation over time.

You may be referring to Methicillin-resistant Staphylococcus aureus (MRSA, pronounced mersa) infection. MRSA is a bacterium responsible for difficult-to-treat staph infections in humans.

It’s resistant to a large group of antibiotics including penicillin and cephalosporin drugs. That makes it a dangerous infection that can spread, even causing unexpected deaths in children and young adults. When it’s acquired outside the hospital or institutional setting, it’s referred to as community acquired MRSA or CA-MRSA.

CA-MRSA was first reported in a group of children back in the 1980s. Then the 2003 death of a college football player brought the disease to everyone’s attention. CA-MRSA starts as a simple skin infection. If it’s found early enough, it can be treated successfully with antibiotics. But if it’s undetected or ignored, the infection can become much more serious. Osteomyelitis (bone infection), necrotizing pneumonia (death of lung tissue), and sepsis (blood infection) can develop as a result of MRSA.

There are some simple steps that can be taken in any setting where overcrowding or close contact can lead to the spread of MRSA. The first is handwashing. Teach your child the importance of proper hand washing. In many cases, the use of hand gels is acceptable (certainly better than nothing).

Children should be taught not to share (or even ask others to share with them) items such as towels, water bottles, brushes/combs, toothbrushes, cups, or other personal items. When they get home from school, have them change their clothes and put on clean clothes. To be extra careful, a full shower or bath with soap, rinse, and toweling off right away is even more effective. This may not be necessary unless there is an active outbreak of MRSA. But it can’t hurt, and it may help.

Most of all, when you or your child is sick, don’t ask for antibiotics if they aren’t recommended. The overuse of antibiotics to treat viruses rather than bacteria has been linked to the mutation of bacteria that are now resistant to previously effective medications such as penicillin.