FAQ Category: Child

With so many more children participating in sports, the chances of serious injuries are bound to go up. It’s estimated that 30 million kids are active in organized sports program in the United States. Studies show there are 20 million injuries per year among this group.

There’s no doubt that proper nutrition and adequate hydration are two key factors in injury prevention. But other factors come into play as well. Bone fractures are more common in younger children who have softer and more porous bones. They do seem like they are made of “rubber.” This is because their tendons and ligaments are stronger than their bones. The soft tissue structures covering and connecting the bones offers a strong protective barrier to injury.

The improper use of protective gear (or not wearing protective gear at all) may also contribute to the rise in sports injuries. The cost of such equipment can seem prohibitive until we look at the cost of visits to the emergency department (1.8 billion dollars each year).

Groups like the American College of Sports Medicine, American Medical Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine are actively looking for ways to help prevent pediatric sports-related injuries. One-fourth of those injuries are bone fractures. They are taking all factors into account, including diet and nutrition. We expect to hear more about this as further evidence comes to light.

Your child may have a form of scoliosis called Juvenile Idiopathic Scoliosis (JIS). Juvenile means it occurs before the child enters puberty (around age 13). Most children with JIS present with signs or symptoms between three and 10 years of age.

That means a long course of treatment until the child reaches skeletal maturity. Scoliosis tends to get worse during growth spurts. So children must be monitored closely and treated sooner than later.

The Charleston nighttime brace works well because it can be worn while the child is sleeping. It does not have to be worn during the day, at school, or during social or athletic events. This makes compliance with nighttime wear more likely.

The brace is made based on measurements and fittings taken by an orthotist (brace maker). The child is bent to the opposite side of the curve. The brace is formed to the body in this position. The idea is to try and hold the spine in a neutral position as much as possible while the child is relaxed in sleep.

Expect that your child will be wearing a part-time brace for at least one year. The average length of brace wear time is more like three or four years. The brace may have to be redone as the child grows.

Selective thoracic fusion (just fusing a portion of the thoracic spine) works well for some children with adolescent idiopathic scoliosis (AIS). Idiopathic refers to the fact that there is no known cause for the scoliosis.

Surgeons use measurements taken from X-rays to calculate angles, magnitude, and flexibility of the curves. From this information, they are able to determine who would be a good candidate for selective thoracic fusion.

You can expect the surgery to correct the thoracic deformity (both the spinal curve and the rotation of the vertebrae). The surgeon will preserve as much motion as possible above and below the fused area. In most cases, the lumbar curve corrects itself. This is referred to as spontaneous lumbar curve correction (SLCC).

Spontaneous correction occurs even when the first lumbar curve is included in the fusion. The more flexible the thoracic curve is, the more likely the lumbar curve will self-correct. More studies are needed to find out how much of the thoracic (and lumbar) vertebrae should be included to get the best results.

Surgeons evaluate each case very carefully in order to avoid overcorrection or undercorrection. They use the results of the clinical exam and X-rays to carefully plan each step of the procedure.

For example, angles, flexibility, and magnitude are calculated for each curve. In your niece’s case, it sounds like there may be more than one curve. This is fairly common. When one curve progresses far enough, a second spinal curve will develop. The body tries to keep the head and sacrum in the middle. This means the spine makes the necessary adjustments to accomplish that goal.

Undercorrecting the spine can lead to chronic deformity. The surgeon isn’t always able to get 100 per cent correction. Overcorrecting may off-balance the head and spine’s position over the sacrum. Experience helps guide the surgeon in avoiding either of these errors. X-rays are used throughout the procedure to check and double check spine position, angles, and correction.

Rib resection (removal) in spine surgery for scoliosis usually involves part of four or five (up to eight) ribs. A piece about two inches long is removed and ground up. The ground up pieces are then used to help fuse the spine.

The ribs are still connected to the rest of the rib cage by soft tissue attachments. And the affected ribs still come around to the front and connect to the sternum (breast bone). The ends of the removed ribs are left alone (not repaired).

Usually the ribs will grow back and/or fill in with fibrous cartilage. This takes about three to six months after surgery. The patient doesn’t experience any pain from the loss or the regrowth of tissue.

Rib bone graft material is preferred over the standard iliac crest bone graft. There are fewer problems at the graft site. Many patients have persistent pain and/or soreness along the iliac crest where the bone was harvested from.

Rib resection is fairly painless and the ribs are highly osteogenic. This means they produce new bone quickly and easily. This is a definite advantage in creating a strong spinal fusion in a young child or teenager.

The best person to advise you is a spine specialist such as an orthopedic surgeon. Perhaps you have already been seeing a surgeon who made the diagnosis. This would be a very good question to pose to him or her at your daughter’s next follow-up appointment.

Young patients and their parents are often concerned when there is a rib prominence (hump). This concern is understandable. For the young individual, appearance and self-image can be negatively affected by such a deformity.

There is also the potential for decreased pulmonary function. The rotation of the spine and ribs presses on the lungs. Compression of this type can reduce airflow and volume of air exchanged.

Surgical treatment may be needed. The spine can be corrected and the ribs derotated. Sometimes the surgeon removes a portion of each rib in the hump. The rib is crushed up and used as a bone graft to fuse the spine.

New correction methods and improved spine instrumentation are available. Special rods and screws can be used to distract, straighten, and derotate the spine. The result is improved spinal alignment and correction of deformity. Patients report being very satisfied with the results and with their appearance. And studies show a potential for improved pulmonary function.

Nighttime bracing for juvenile idiopathic scoliosis (JIS) must be worn at least eight hours during each 24-hour time period to be successful. Most children choose to wear the brace during sleep. That way they don’t have to wear it to school or during social activities.

Brace treatment is considered a failure if either the major or the secondary curve continues to get worse. Progression of more than five degrees requires follow-up treatment. The first thing to do is check to make sure the brace is really being worn as recommended. Then the fit should be double-checked. It’s possible the child has grown and the brace no longer fits properly.

Surgery may be needed but this depends on how close the child is to skeletal maturity. If the child is no longer growing, then curve progression may be stopped. Surgery may not be needed if that’s the case. But if the curve has continued to get worse and now measures more than 45 degrees, then spinal fusion may be needed.

You may be referring to a supracondylar humeral fracture. Supracondylar humeral fractures occur most often in children. In fact, they are the most common type of pediatric elbow fractures. Children between the ages of five and seven are affected most often.

The child falls onto an outstretched hand with the elbow extended. The force of the impact causes a break in the humerus (upper arm bone) just above the elbow. The break doesn’t go all the way through the humerus. The anterior humerus (front part) is sliced open but the posterior (back) portion is still intact. This gives it the look of a hinge joint.

Boys are affected more often than girls but the incidence in girls is rising. This is likely the result of increased sports participation and athleticism among young girls. Treatment may be nonoperative with sling immobilization. Surgery may be needed to restore a normal position of the bone while it heals.

Elbow fractures can be very complex and difficult to treat. There is an increased risk of problems such as blood loss or compartment syndrome from blood vessel and/or nerve damage.

Treatment must be geared toward protecting the blood supply, nerve tissue, and the elbow joint. Traction used to be the standard management tool used for this type of fracture. But the treatment takes two to three weeks. And the rising costs of hospitalization prevent its use.

Surgery to reduce the fracture and stabilize it with pins, wires, and a cast reduce hospitalization to an outpatient procedure. At most, the child may need to stay overnight for observation. Many surgery centers offer 23-hour care to avoid the extra costs of hospitalization.

The accuracy and reliability of X-rays during limb lengthening procedures has come under question. A study was recently published pointing out the problems surgeons face when relying on X-rays to guide treatment of this problem.

The researchers found that there is a tendency for the knee to rotate outwardly when the leg is in the external fixator. This change in alignment affects the angles measured and information from the X-rays used to calculate correction with the fixator. Not only that, but they also noticed the malalignment in the fixator resulted in differences observed in the leg that wasn’t in the fixator.

Overcorrection or undercorrection may occur as a result. This is the first report of this type made available to surgeons. It may be that taking the X-ray with the knee carefully positioned with the patella (kneecap) facing forward will take care of the problem.

In the future, improved computer technology used to assess X-rays may also help provide a more accurate picture of what’s needed for a perfect surgical result.

Correction of leg length differences and deformity using the circular external fixator has been very helpful for this problem. Establishing (or recreating) normal length and alignment of both legs are the goals.

Radiographic imaging using X-rays is the best way to confirm that everything is placed correctly. X-rays are taken to show if everything is lined up and coming along properly. The surgeon relies on this information to know when and how much to adjust the cage to lengthen the leg. The cage is adjusted to lengthen the leg slowly.

The images provided by the X-rays give the surgeon information needed to evaluate alignment, rotation, and length of the lower extremity. Full-length standing radiographs are taken with and later, without the fixator.

The X-rays can be analyzed to show if optimal alignment has occurred. Some places have computerized equipment that takes all the measurements and makes necessary calculations. While the fixator is in place, adjustments can be made.

Future computer and imaging technology may make it possible to mathematically predict changes in the leg length. X-rays may be taken much less often to confirm corrections made. But for now, an optimal result requires careful follow-up.

Osteopenia is the loss of bone mineral density. Osteopenia can develop anytime bone is wrapped in a cast without normal weight bearing. Weight bearing is needed to stimulate bone growth. Bone loss is an expected consequence of immobilization after orthopedic surgery.

Recently, new information has come to light about this condition. Although bone loss is expected under these conditions, the amount of bone loss is surprising. One study at the University of New Mexico looked at before and after X-rays of children undergoing surgery of the lower extremity. At least four weeks of post-operative immobilization was required.

There was a range of bone loss in the operated leg from one to 34 per cent. The nonoperated leg increased bone density slightly if the child was putting weight on it. Weight bearing is a known factor in stimulating bone growth. Therefore, weight bearing activities is the first step.

Given your daughter’s diagnosis, most likely she has a physical therapist working with her. If she is not ambulatory (walking), the therapist will set her up on a standing program. If she is upright and ambulatory, then restoring weight bearing activities and normal movement is the next step.

Vitamin D and calcium supplementation may be prescribed. Restoration of bone mineral density can take months after surgery. Your surgeon will keep an eye on her progress with follow-up X-rays.

Pain after cast removal should be investigated by the surgeon. If your son has not been seen for this problem, a follow-up visit is advised. An X-ray to rule out bone fracture is the first step. The X-rays can also be reviewed to get an idea of the overall bone condition.

Loss of bone mineral density is common after surgery and prolonged cast immobilization. Bone loss can cause pain. A postoperative program of vitamin D and calcium supplementation may be prescribed. Some physicians also prescribe medications called bisphosphonates to prevent further bone loss.

Weight bearing activities can also be very helpful. If your son isn’t able to walk, a standing program may be beneficial. If the bone pain is caused by bone loss, a program of medications, supplementation, and weight bearing should reduce painful symptoms quickly.

If symptoms are not alleviated, then some other cause of the problem is possible. The physician will conduct further testing to identify and treat the problem.

You may be referring to the use of an electronic medical record (EMR). The EMR has already been introduced in many places. Hospitals, clinics, and other health care organizations are heading in that direction and going green.

Saving time, paper, and money are important goals. Doctors and other health care professionals are also under additional pressures to prove that the treatment provided is beneficial and cost effective.

That means more time is taken to assess the before and after effects of any treatment. Surveys, questionnaires, and various parent- or patient-reports of results are needed to document clinical outcomes.

Finding one evaluation tool that meets the wide range of ages, physical conditions, and diagnoses of patients is very challenging. Researchers have developed a Computerized Adaptive Test (CAT) that will help. This program has the ability to ask a series of questions based on the age, gender, and condition of the patient. Each subsequent question is selected by the computer based on answers to the last question.

For example, questions about children with very low skills will be different than questions presented for older, more independent children. An interactive program of this type helps cut down on unnecessary or repeated questions.

Such tools will also help keep track of changes in patients’ progress. With such a record at his or her disposal, physicians may be able to identify the need to make changes in the treatment program sooner than later. And everyone (patient, family, physician, and insurance company) will recognize smaller increments of improvement sooner.

PEDI stands for Pediatric Evaluation of Disability Inventory. It was developed first developed for use with children with disabilities between the ages of six months and seven years.

Three key areas of function are assessed: self-care, mobility, and social function. There are questions that help assess nine specific sub-categories within those basic three topics. The PEDI relies on parents’ (or caregiver’s) observations and is sensitive to small changes.

Although it was designed for use with younger children, it can also be used to evaluate older children. If their functional abilities are below those of a seven-year-old child without disabilities, then this test can be used.

The PEDI gives a measure and description of the child’s current functional performance. Giving the test as a baseline and repeating it later can provide a means for tracking change across time.

The PEDI has been adapted for use with specific groups. For example,
Researchers at Shriners’ Hospitals for Children in Philadelphia are starting to develop a PEDI-MCAT for children with complex spinal impairments.

MCAT stands for Multidimensional Computerized Adaptive Testing. The computerized test is completed by the parent in the physician’s waiting room. A handheld tablet computer is provided. New questions pop up based on answers given to previous questions. This tool tailors questions to each specific child’s age and functional abilities. You may not answer the same questions for each child.

Many times, when someone breaks their fifth metatarsal, or baby/small toe, there isn’t much that the doctor will do. However, it is still important to get it checked.

While the fracture, or break, may be clean, it could also be more complicated than that and your son could need to have the bone moved back into place. At the same time, the doctor would likely check to see if any other toe is broken as well.

Treatment may involve splinting or “buddy taping.” Buddy taping is when one toe is taped to the next one for support.

You didn’t mention the ages of your athletes. There are some differences between young (nine to 19 year olds) versus older (college aged) athletes. One thing that’s the same between the two groups is the increased number of ulnar collateral ligament (UCL) injuries.

UCL injuries are clearly on the rise. The number of high school pitchers needing UCL reconstruction each year has tripled over the last 10 years. Overuse of the throwing arm and throwing breaking pitches too early may be linked with this problem.

Results of studies comparing volume and type of pitches report that quantity makes a big difference. Type of pitches seems to be more variable in the effect on injuries. Some studies show significant differences between pitchers using breaking pitches and those who don’t. And age when breaking pitches begin may be important but hasn’t been proven yet.

The evidence seems to point to quantity of pitching as the most important risk factor. Arm pain and arm surgeries among young pitchers occur more often based on the total number of pitches delivered over time rather than the type of pitches.

Type of pitches does have its importance. Elbow and shoulder are loaded most with fastball first, then curve ball pitches. Change-up pitches don’t have nearly the same impact as these other two types.

There’s a lot to be said for a good training program that builds up overall strength and endurance for each athlete. Balancing pitching schedules throughout the year is important. This is especially true in those geographic areas where the game is played year-round without a significant break.

Usually, when a child breaks a forearm, there are some signs that it is broken, including the most obvious sign of pain. Sometimes, as in cases like your daughter’s, it’s not so obvious.

The most common signs and symptoms of a broken forearm are:

If there is every any doubt about a fracture, always get it checked in case the fracture is more severe than it seems.

The length of time an arm – or any broken bone, for that matter – is casted depends very largely on what type of fracture or break happened.

Some children have what is called a greenstick fracture, for example. This type of fracture leaves part of the bone intact, like if you bend a young, green stick and it snaps. This type of fracture can heal quickly as the bone has not broken all the way through.

A more severe fracture, however, may require a longer period of time to heal properly. As well, some fractures require surgery to help stabilize the bones, this may add to recovery time.

Each fracture is different in terms of how well it can heal and the type of treatment it may require.

It used to be thought that back pain in children was rare and when it did occur, the pain was usually caused by something serious. Over the years, however, doctors have learned that children and teens can experience back pain at the same rate as adults.

Lower back pain is very common among adults in the developed world and the most recent numbers that have come to light regarding children, is that as many as 36 percent of them may have lower back pain, with the number increasing if the child or teen participates in competitive sports.

Much of lower back pain, for both adults and children, is never diagnosed. As long as your son has been tested and examined for his back pain, and the doctors have not diagnosed an injury or problem, it’s likely that your son’s problem falls into the “unknown” category.