FAQ Category: Child

Perthes disease (sometimes referred to as Legg-Calvé-Perthes) is the collapse of the hip joint due to a loss of blood supply to the capital femoral epiphysis (growth center of the hip). It occurs most often in children between the ages of four and eight.

The blood supply eventually returns, and the bone heals. How the bone heals determines how much problem the condition will cause. This condition can lead to serious problems in the hip joint later in life.

To help prevent deformity and keep a stable hip, surgery may be needed. If the acetabulum is too vertical (socket if facing outward rather than downward), an osteotomy is advised. A wedge- or pie-shaped piece of bone is removed to change the angle of the femur (thigh bone). This creates a sharper angle and aligns the femoral head more sharply into the acetabulum (hip socket).

Coverage of the femoral head by the acetabulum is important during growth and development of the hip. Weight-bearing and pressure are two forces that join together to form and shape the round femoral head. These forces help match up the surface shape and configuration of the acetabulum with the femoral head.

Sometimes, if the acetabulum is too shallow, another surgery is needed to reshape the socket. The surgeon chooses the best way to manage this problem based on symptoms and severity of the condition.

The term coxa comes from the Latin and refers to the hip. Vara refers to the angle of the neck at the top of the femur (thigh bone) between the shaft of the long bone and the round head at the top.

The femoral neck angle is usually about 150 degrees at birth. With time, growth and development, and weight-bearing, this angle decreases. By adulthood, it is more in the range of 125 to 135 degrees.

Some experts suggest coxa vara occurs when the angle between the ball and the shaft of the femur is less than 120 degree (in adults). This figure is closer to 110 degrees in children. The condition may or may not be painful but usually results in a limp because one leg is shorter than the other.

Surgery is done to help restore a more normal angle. The hope is to reduce any pain that may be present, improve hip motion, and get rid of the limp. The exact procedure that is done depends on the cause, location, and extent of the problem.

Children with a straightforward coxa vara deformity have a fairly good prognosis. Results improve function and are long-lasting. Prognosis is poor for children with multiple other deformities associated with the coxa vara. Abnormal features of the bone and cartilage cause hip instability in children.

If surgery is done too early, further growth spurts cause the problem to recur (come back). It’s not uncommon for these children to develop degenerative arthritis in early adulthood. You would need further details about your nephew to know what kinds of results are expected. Hopefully, all will go well with a good result. The surgeon will have a better idea what to expect after the operation is completed.

Osteochondrodysplasia is a general term for a disorder in the development (dysplasia) of bone (osteo) and cartilage (chondro). Hip, spine, and limb deformities are commonly linked with this condition.

A common hip problem is coxa vara. Coxa vara refers to the angle of the femur (thigh bone) as it supports the femoral head in the hip socket. The normal femoral neck angle is about 150 degrees at birth.

As the bones grow and develop, the shape changes. By the time we are adults, this angle is about 125 degrees. Less than 110-degrees creates this condition of coxa vara. The opposite (too much angle) is called coxa valga. Coxa valga is very rare with osteochondrodysplasia.

Surgery is advised when there is pain, loss of hip motion, and a leg-length discrepancy. With a loss of femoral neck angulation the femoral neck is short. In some cases, the hip socket is flat. The head of the femur may be in pieces rather than one solid, round feature. All of these changes cause the affected leg to be shorter than the uninvolved limb. The result is often a noticeable limp when walking.

If the coxa valga doesn’t improve and/or if the other symptoms mentioned become a problem, surgery may be needed. Usually, this is put off for as long as possible in order to ensure a successful result. Surgery too early when the bones are still growing and shifting can cause recurrence of the problem and development of arthritis later. The surgeon will use X-rays to measure the angle and keep track of its progress as the child grows and develops.

It sounds like the type of injury your granddaughter had was a supracondylar fracture. These can be tricky to treat because of the difficulty manipulating the bones back into normal alignment.

With the new fluoroscopic X-ray imaging, the procedure can be done without an incision. This is called closed reduction. Once the bones are in place, special wires called Kirschner (K-wires) are used to hold it in place until healing occurs.

The surgery is usually done with the child in the supine position (on his or her back). But there are problems using this position. It’s difficult to hold the bone in place while inserting the wire.

The elbow must be fully flexed making it difficult to get the fluoroscope arm around it. The arm must be rotated externally (outward) to get the proper view. Even with two people working together, it’s difficult to keep the fracture reduced.

The location of the ulnar nerve so close to the edge of the bone puts it at risk for damage during this procedure. When there’s swelling, it can be difficult to see or feel the nerve. It’s very easy to poke the ulnar nerve with the wire and cause nerve damage. In fact this type of complication occurs in up to six per cent of all cases.

Elbow dislocations are a common arm injury and they often happen with breaks at the same time. For this reason, there are a few things that need to be repaired and monitored. Most often, a dislocation can be put back into place (reduced) with just some local anesthetic and then the arm is braced or casted for healing. If the dislocation is complicated or, for some reason, won’t respond to that type of reduction, the doctor may have to opt for an open reduction, which is done in surgery.

However, surgery requires a general anesthetic and surgeons are reluctant to use if it’s not necessary. General anesthetic has risks of its own. Without knowing exactly what happened, it is likely that once they got to the operating room, the surgeons had your son in a relaxed state and decided to try one more time at reducing the fracture and elbow before preparing for the surgery.

According to researchers at the University of Southern California, injuries are more common than you might expect. They conducted a five-year study of children ages one to 15 treated for inflatable bouncer-related fractures.

They found that fractures of the arms and legs were most common. Colliding with another child, falling, or twisting motions were the most likely mechanisms of injury. Boys were injured three times more often than girls.

These inflatable houses are padded and enclosed. That makes them appear safer than they are. Records kept by the Consumer Product Safety Commission show that the number of injuries linked with these bouncers is steadily increasing. Not all injuries are reported, so the numbers may be an underestimate of actual cases. The number of cases that are reported are equal to the number of injuries incurred on a trampoline.

Most of the time, there was no adult supervision when using the inflatable bouncer. Other risk factors included having too many children jumping at one time and mixing children of different ages. When an older and larger child collides with a younger child, the risk of injury goes up. And falling out of the bouncer is more common than you might think.

Other less common causes of injuries occur as a result of wind gusts blowing over a bouncer that’s not tied down properly and rapid loss of air inside bouncers that have a slide feature.

Most of these problems can be prevented with a little adult supervision. Matching up groups by size is first. Limiting the number of children using the bouncer at the same time is next. The number of children allowed depends on the age, size, and skill level of each group.

Awareness of the potential dangers and common sense supervision may be all that are needed to keep this potentially unsafe activity from becoming a real hazard.

There isn’t a lot of information available on the safe use of these devices. The manufacturer provides standard warnings about maintaining proper inflation levels and the need for adult supervision.

But inflatable bouncers are not subject to any safety regulations. Device failures, accidents, and injuries do not have to be reported in most states. A recent study from the University of Southern California may be the first to offer any data to help guide the use of these toys.

They reviewed all emergency department visits for children from birth to 17 years of age. Forty-nine cases were identified as bouncer-related injuries. Fractures of the arms and legs were most common.

Injuries occurred when children of different ages and sizes crashed into each other. Boys were three times more likely to get hurt than girls. Smaller children were at greater risk of falling out of the bouncer without colliding with someone else.

Sometimes the force was enough to throw the child out of the bouncer. Landing on a hard object caused a bone fracture or other soft tissue injury. Sometimes the inflatable device lost air and collapsed. The sudden loss of support caused injuries as well.

Slipping and getting the leg trapped in a twisted position was a typical pattern of leg injury. Whether or not this could happen when sleeping in the device was not tested or reported.

The authors suggest (based on their findings) that there are ways to prevent injuries. Adult supervision is important. Keep children of similar ages and sizes in groups. Parents and other adults must be on hand to provide guidance and supervision at all times.

Only small groups should be allowed inside at one time. Rough-housing and deliberate pushing or bumping into one another must be limited. The bouncer must be inflated to the recommended pounds per square inch at all times.

It does seem a little strange that you can get an infection in a closed joint like a knee or hip, but it does happen. If you have an infection in another part of your body, such as a urinary tract infection, the bacteria that caused the infection may enter your blood stream and move about your body. Because your joints aren’t built to resist infection, there isn’t much protection from the bacteria if it makes its way to the joint. Once it reaches the joint, it can cause an infection in the fluid that usually lubricates the area, allowing for smooth movement.

It has been assumed that the adult guidelines of keeping all protective gear on during transport applies to children, too. But EMTs, athletic trainers, and physicians are giving this a second thought.

Studies show that young children have an increased head-to-torso size ratio compared to adults. Variable growth rates make this ratio different from child to child. Maybe this ratio difference doesn’t matter but until recently, we had no evidence to support or negate the idea.

But thanks to a group at the University of Virginia, we now have some reliable recommendations for emergency transportation for children ages eight to 14. They X-rayed a group of 31 young athletes involved in football. Three radiographic views were taken.

The base of the skull and cervical spine were the main focus areas. The child was placed supine (on his back) and X-rayed without the protective equipment. The second X-ray was taken in the same position with shoulder pads only. The third view was with helmet and shoulder pads.

Two physicians independently measured angles of the cervical spine. They used the standard Cobb measurement for C1 to C7 and the Gore measurement from C2 to C7. The angles were then compared among the three radiographic views. Each child’s height, weight, and age were factored into the analysis.

Based on their findings, the authors recommended transporting pediatric patients with a potential neck injury with helmet and shoulder pads in place. The equipment aligns the cervical spine better than just one or the other. These guidelines only apply to football players. Further study is needed to identify the best way to manage and/or transport ice hockey or lacrosse players with cervical spine injuries.

This is a concern shared by many parents. Injuries do occur in any sports activity at any age. Young children seem especially vulnerable. And the number of kids participating in all kinds of sports is steadily increasing. So the risk of injury is also increasing.

Head and neck injuries are rare in this age group. But the National Pediatric Trauma Registry does report 1.5 per cent of all pediatric trauma patients are seen for a cervical spine (neck) injury. And 20 per cent of those injuries in children aged eight years and older were sports related. Other causes included car accidents and falls.

The rising number of children engaged in sports activities suggests a need for specific guidelines in managing emergency situations and injuries. Researchers are just beginning to take a look at some of the issues.

Size difference can certainly make a difference. As you suggest, children come in all sizes and shapes. Their body sizes develop at different rates. The growth curve is variable within a small age range (e.g., eight to 10 or 10 to 12). Add the weight of football equipment such as helmet and shoulder pads and the picture can change.

It would be a good idea to bring your concerns to the coaches and organizers of the program. Most likely they have many safety measures built into the program. If not, your questions, concerns, and participation in developing appropriate guidelines would be very timely.

Osteomyelitis is an infection of the bone caused by a bacteria, fungi, parasites, or virus. Staphylococcus aureus (staph infection) is the most common cause.

The infectious agent enters the body through an open wound or the gastrointestinal (GI) tract. The infection has the capability to spread quickly through the bloodstream, resulting in septicemia (blood poisoning) or an infectious joint.

African-American children do seem more susceptible than Caucasians. The reason for this isn’t clear. Some experts have suggested an economic basis. But Hispanic children have less chance of developing osteomyelitis and their economic situation usually isn’t any different than the African-American population.

The most common risk factors for acute osteomyelitis in children include puncture wounds, burns, open fracture or other trauma. Surgery especially with implanted orthopedic devices (metal plates, screws, joint replacements) are additional factors that can increase the risk of developing osteomyelitis.

A preexisting infection such as impetigo, boils, chickenpox, or sinus, ear, dental, soft tissue, or respiratory infection starts the process. If untreated, if treatment is delayed, or if the person’s immune system is compromised, the infection can spread through the blood system to other parts of the body.

The overuse of antibiotics has led to bacteria that are resistant to most antibiotics. In the hospitals, this has been a major concern. Patients admitted are often already at risk for infection. And hospitals are a breeding ground for many infections.

These are referred to as hospital-acquired infections. Methicillin-resistant Staphylococcus aureus (MRSA) is the most important cause of hospital-acquired infections. S. aureus is a bacterium known by its shorter, abbreviated form: staph infection.

MRSA refers to the fact that S. aureus is resistant to most penicillins. For a long time, Methicillin (a penicillin derivative) was the only drug that could combat this infection. Eventually the staph bacteria became resistant to Methicillin.

Methicillin is no longer on the market but the term MRSA is still used. Other similar drugs (e.g., flucloxacillin, dicloxacillin, clindamycin) are now in use instead. If staph becomes resistant to all antibiotics, there may be no way to treat simple infections.

Doctors are scaling back their use of antibiotics these days in hopes that this will help. Scientists are developing new and better blood tests to determine whether antibiotics are needed for infections. Any infection caused by a virus won’t respond to an antibiotic. Avoiding the use of these medications for viral-induced illnesses is an important first step in this process.

Achondroplasia is a genetic disorder that results in a common type of dwarfism. The condition may be inherited. But in most cases (80 per cent), there is a spontaneous mutation of the gene that controls bone and cartilage growth. The cause is unknown. Older age of parents at the time of conception (35 years old or older) may be a risk factor.

Children who are born with this condition have a variety of deformities, including several in the spine. Common spinal manifestations include foramen magnum stenosis, thoracolumbar kyphosis, lumbosacral hyperlordosis, and spinal stenosis.Thoracolumbar kyphosis is a curved mid-lower back from the way the children slump-sit.

Foramen magnum stenosis refers to narrowing of the opening at the base of the skull where the spinal cord exits. Lumbosacral hyperlordosis is an increase in the normal swayback position of the low back area. The more thoracic kyphosis is present, the more the body tries to compensate with increased lordosis. When viewed from the side, the child with these two features combined has a prominent abdomen (belly) and buttocks.

Spinal stenosis (narrowing of the spinal canal) can occur at the cervical (neck) level or in the lumbar (low back) area. There are other manifestations of achondroplasia. The children (and adults) are usually short in height with a characteristic look because of changes in the bones of the face. Children have frequent ear infections. There are some deformities of the arms and legs.

Disc herniation is rather rare in young children and teens. But it is not unheard of. Usually, any force (traumatic or repetitive) that’s enough to cause disc protrusion can also damage the apophyseal ring.

The ring is a tough, fibrous structure around the outer portion of the vertebral body next to the disc. It is attached to the outer portion of the disc called the anulus fibrosis. The ring apophysis attaches the anulus fibrosus to the vertebra. The ring provides an area of denser, stronger bone for the edge around the vertebral bone.

A fracture of the ring indicates that the fibrous ring (along with a small piece of bone still attached) has pulled away from the vertebra. This can occur along the upper (above) or lower (below) endplate of the affected disc. It appears to be caused more by repetitive stress rather than a single traumatic event. Many of the athletes who have a ring apophysis fracture don’t even know it.

The ring hardens into more of a bone-like substance around six years of age. By the end of puberty or around age 17, the apophysis fuses with the vertebral body. Until then, there is a weak point between the ring and the apophysis. A traction force on this area during movement of the spine can be strong enough to cause a disc herniation and an apophyseal ring fracture.

Clubfoot means that the toes are pointed down and the feet are turned inward toward each other. The ankle is in varus when you try to put the soles of your feet together.

The most commonly used treatment in the newborn and infant for this problem is manipulation and casting. This is started as soon as possible. The greatest chance for correction of deformity occurs early in life when there is so much growth occurring.

The foot is manipulated to stretch and loosen the tight structures. The foot is then placed in a cast to hold it in a corrected position. This is repeated every one or two weeks until the deformity is corrected or surgery is performed.

The success of treatment of clubfoot by manipulation and casting alone varies greatly. The majority of infants will eventually require surgery. But, the manipulation and casting begins the process of guiding the foot towards a more normal form. In the infant that eventually needs surgery, the manipulation and casting are still required to obtain as much correction as possible prior to the surgery.

When it is clear that manipulation and casting alone will not result in success, surgery will be recommended by your surgeon. The main question is when to perform the surgery. The earlier the surgery is performed, the more growth remains in the foot. The more growth remaining, the more the deformity can be corrected. But, a smaller foot is much harder to operate on effectively. The surgery is much harder and the risk of damage to the nerves, blood vessels, and bones is much higher.

Most surgeons recommend waiting until the foot is about eight cm (three inches) long. This usually occurs when the infant is about nine months old. Most surgeons agree that it is ideal to have the surgery over and healed before the infant starts to try and walk. Surgery performed at nine months usually will accomplish this as well.

Arthrogrypotic clubfoot deformity can be difficult to treat without surgery. The tight, inflexible joint from arthrogryposis combined with the turned in foot position of the clubfoot present quite a treatment challenge. Studies support early surgery to correct both problems.

A new report from the Washington University School of Medicine was recently published on this topic. The researchers used the Ponseti method usually used with clubfoot on a group of 12 infants with arthrogrypotic clubfoot.

In the past, multiple surgeries to release the soft tissues around the contracted foot have been the main treatment for clubfoot associated with Arthrogryposis. Scar tissue often prevents a good outcome and results in repeated surgeries.

The Ponseti method combines a soft tissue release of the Achilles’ tendon with serial casting followed by bracing. Serial casting means the foot is held in as neutral a position as possible then put in a cast to hold it there.

Once the foot accepts this new position, the cast is removed and replaced with a new cast. Again, the foot is moved to a more neutral position and recast. This process is repeated until a normal ankle and foot position is achieved. That’s when the treatment switches from casting to bracing.

The initial surgery to release the tendon is very simple and can often be done as an outpatient with only a local anesthetic. This is a minimally invasive way to accomplish the first step of the treatment procedure. If the surgeons have not considered this approach, it may be worth asking about possible alternatives to the more traditional surgery for arthrogryposis.

Osteochondral fracture means that the cartilage covering the end of the femur (thigh bone) or in any joint is torn. The fracture creates bone or cartilage fragments that can range in size and in depth. Depending on the depth of the injury, this may be referred to as a partial-thickness or full-thickness tear.

This injury occurs most often in young athletes along weight-bearing surfaces such as the end of the femur. Other areas affected include under the patella (knee cap) or along the talus bone in the ankle. Less often, this type of fracture can affect the metatarsal bone of the foot.

Femoral osteochondral fractures are the result of a shearing force when the foot is planted on the ground and the knee twists over the foot. The lesion involves both the articular (joint) cartilage and the bone underneath. There may be one large fragment displaced or several tiny fractures and defects.

Signs and symptoms of this type of injury can include pain, swelling, and bruising. Some patients report crepitus (grating feeling with movement), weakness, or instability of the joint (knee gives way when standing or walking).

Imagine you have a gun in your hand and you are about to pull the trigger. Look at the position that your finger is in. Your finger is bent inwards, folded toward your hand. This is because you’ve pulled on the finger and the tendons, the tissue that connect muscles to bones, responded by pulling the finger down.

In trigger finger, the tendons have pulled but not at your command – they are doing this involuntarily. Sometimes the finger will stay that way all the time unless there is surgery and sometimes it loosens up a bit with some activity.

Treatment for trigger finger varies. If it’s mild or doesn’t bother your daughter too much, her doctor may suggest injecting a corticosteroid into the finger to help relax it. If it is bothersome however, the doctor may suggest surgery to release the tendons and relax the finger.

Peter G. Fitzgibbons, MD and Arnold-Peter C. Weiss, MD. Hand Manifestations of Diabetes Mellitus. In Journal of Hand Surgery. June 2008. Vol. 33. No. 5. Pp. 771-775.

My mother has had diabetes for many years. She takes insulin every day and takes very good care of herself. Unfortunately, that’s not helping much because she’s developing a whole bunch of complications from her eyes to her kidneys. Her latest one is that she is having trouble straightening out her hands. She was sure it was arthritis, but her doctor said it was something else. I can’t recall the name, but it was something about the joints and he said that a lot of diabetics get it. Would you know what I’m talking about?

It’s very likely that your mother has what is called limited joint mobility or LMJ. This could be mistaken for arthritis if you’re looking at her hands and how she is limited as to how she can bend her fingers. However, this is a different issue. In LMJ, there doesn’t seem to be pain, just the inability to straighten out the fingers as much as before. For example, if someone without LMJ or any joint problems puts their hand palm down flat on a table, their fingers would naturally spread out as the hand goes flat. For someone with LMJ, if they put their hand flat, their fingers won’t spread out and they can’t put their fingers and palm on the table at the same time.

Studies done by orthopedic surgeons show that more than half of shoulder and back pain reports in children is caused by heavy backpacks. Some of this is related to the way the backpack is worn — either low over the buttocks or slung over one shoulder.

The distribution of load has a direct effect on the pressure over shoulders and back. Uneven or excessive loads can create enough pressure to actually cut off blood flow to the skin under the straps.

Postural changes occur even when backpacks are worn evenly on both shoulders. For example, children commonly raise the right shoulder up when wearing a backpack. This movement is even more exaggerated when the pack is only worn over the right shoulder. It’s possible that with chronic use of a backpack over one shoulder (usually the right), the shoulder responds with the same movement pattern even when the pack is worn over both shoulders.

Back pain has been reported more often among children who wear a backpack with one strap instead of both straps. If the pack is worn low enough, then the weight is supported by the low back and/or buttocks. It is suspected that this pattern may be part of the problem leading to back pain in younger children.

Heelys are shoes for children that have rolling wheels in the heels. They were first sold on the market during the 2000 Christmas season. They quickly caught on in the United States and even around the world. More than 4.5 million pairs have been sold in 60 different countries.

The shoe glides along on wheels when the child lifts the toes up. This leaves just the heels in contact with the floor or ground surface. One foot is slightly in front of the other foot. Each shoe may have single or double wheels. The activity is called heeling.

The incidence of injuries from heeling is quite small compared to other activities such as basketball, football, or soccer. Forward falls onto an outstretched hand can cause fractures of the shoulder, forearm, or wrist. That’s one danger.

But there’s another danger — and that’s to the pocketbook. The associated costs can be quite large even with a simple fracture. Total cost of care adds up with the charge for the emergency department visit, X-rays, cast application, follow-up X-rays, and any cast changes needed over time. If surgery were needed, that could drive the cost up even more.

Accidents are going to happen in active children. Heelys don’t really put a child at greater risk of injury than other commonly enjoyed games and sports. However, safety is still a concern. Safety gear is always advised. Helmets can prevent head injuries. Protective pads for wrists, elbows, and knees may reduce the risk of arm or leg fractures. It’s a simple and fairly inexpensive way to protect your child.