FAQ Category: Child

Septic arthritis is caused by bacteria. The bacteria invade the joint causing inflammation of the joint and possible destruction of the cartilage.

Recently, there has been a move to pull back from the overuse of antibiotics. Doctors are more careful now to avoid using antibiotics when the problem is caused by a virus. As a result of using antibiotics for conditions that are not caused by bacteria, bacteria have become resistant to many of the commonly used antibiotics.

In the case of septic hip arthritis, antibiotics are advised and appropriate. Without treatment, the joint can be destroyed. Hip dislocation is possible. Damage to the joint can cause a leg length difference from side to side.

Early treatment is needed to avoid permanent damage to the joint. Even with antibiotics, there can be some long-term problems. The use of antibiotics can help reduce the risk of many complications associated with septic or bacterial arthritis.

Your surgeon may have put a drain in the hip. This allows fluid in the joint to drain out while the child is lying on his back. The drain is taken out after the first 24-hours.

This is a new technique surgeons are advised to use. It allows them to operate from the front (called an anterior approach but drain out the back. The drain can be threaded through the anterior opening with just a small stab wound to let it out the other side.

The anterior approach is safer with less risk of damage to the nerves and blood vessels. Less muscle is disrupted, too. And the anterior method gives the surgeon quick and easy access to the joint.

Coxa is the latin word for hip. Arthrosis is another medical term for osteoarthritis. Simply put, coxarthrosis means hip arthritis.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip most often in teenagers between the ages of 12 and 16. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). If untreated, this can lead to serious problems in the hip joint later in life.

Even with treatment, there can be a certain amount of hip deformity that is not corrected. This residual deformity is often seen on X-ray as an increased angle where the femoral head and shaft meet. The greater the angle, the more likely that problems can develop.

In a small number of patients, pain, tenderness, limping, and leg length difference are observed years later. But studies show that although not perfect, the results are much better than if no treatment was done.

SCFE stands for: slipped capital femoral epiphysis. This is a condition that affects the hip. Teenagers, especially males, between the ages of 12 and 16 are the most likely to develop this condition. The actual cause or causes aren’t known.

With SCFE, the growth center of the hip called the capital femoral epiphysis slips backwards on the top of the femur (thighbone). Surgery is often needed to correct this deformity and prevent problems later.

The limp or change in your son’s gait pattern may be what’s called a Trendelenburg gait. Some people describe this as a lurching movement from side to side (or to one side if only one hip is affected).

This change can occur as a result of hip muscle weakness and/or residual deformity in the hip after the surgery. If the angle of the femoral head and neck isn’t perfect, the gluteus medius hip muscle can’t function at its best. Without a strong gluteus medius muscle, the pelvis drops giving the person the appearance of a limp.

An X-ray and a muscle test should help decide what’s causing the limp. It’s possible that an exercise program is all that’s needed. If the problem is in the hip joint, your son may be at increased risk for early arthritis. Now would be a good time to find out what’s going on and prevent future complications.

Clubfoot is a fairly common foot deformity that often requires early surgical treatment to correct. The bones in the foot are out of place and the foot is in a twisted, toe pointed-down position.

In recent years, many changes have been made to improve the surgical techniques used. The high rate of wound complications (up to 30 per cent) has brought about some of these changes.

Failure of the skin to close called wound dehiscence is the first problem to watch for. Sometimes the skin sloughs away so there isn’t enough tissue to keep the edges together to heal.

Infection and drainage are two other complications that prevent or delay wound healing. Too much swelling after the operation can also put tension on the wound. Your granddaughter’s surgeon will keep a close eye on this situation.

The family will be given a sheet of instructions to follow after the operation. This usually includes what to watch for in case of infection or problems with wound healing. Be sure and report any suspicious signs and symptoms. It’s also important that the child is taken to each of the scheduled follow-up visits.

There is still quite a bit of debate and controversy over the treatment of clubfoot (also known as talipes equinovarus). Should surgery be done at all? When’s the best time to do it? What type of incision should be used? Should the leg be immobilized in a cast right away and for how long?

Some surgeons correct the foot deformity but wait a week to put a cast on the leg. They do use a removable splint to hold the foot in a neutral position. This allows them to check the wound for infection, swelling, and any other problems with healing.

Others prefer to use a leg cast to hold the foot firmly in place. The cast is removed and replaced at regular intervals until healing takes place. This allows the surgeon to periodically check the wound site and gradually move the foot into a neutral position. The skin doesn’t get pulled quite so much so quickly with the serial casting.

Some of the decision-making depends on the age of the child when the surgery takes place. There can be a wide range from infancy to adolescence. Some children only have the clubfoot deformity. Others have other conditions as well such as hip dysplasia, spina bifida, or arthrogryposis. When and how the surgery is done may vary based on these other factors.

Positron-emission tomography (PET) scans give a sharp 3-D image of the spine. A short-acting radioactive dye is injected into the blood stream. After waiting for 30 minutes to two hours, enough of the dye has accumulated in the tissues to scan the body.

Sometimes the dye is called a tracer. It tends to gather at areas where tissue is active and under repair such as an fracture site or area of inflammation. PET scans are often used to look for bone metastases from cancer. They are also widely used to map out the heart or brain.

Research has been done at Harvard Medical School using PET scans to diagnose children with low back pain. An older dye used back in the 1960s (Fluorine-18 sodium fluoride or 18F NaF) was used as the tracer.

The advantages of this dye are that it has smaller particles that cross into the blood vessels faster and easier. The result is that the scan can be started 30 minutes after injection instead of the usual three- to four-hour delay.

This is a definite plus when working with children because they have to hold still for the scan. Any movement (even breathing) can cause what are called artifacts in the image making diagnosis more difficult.

But a PET scan may not be needed if the X-ray is sufficient. The physician also relies on the patient’s history and physical exam to suggest when further testing is needed. Nuclear scanning using positron-emission tomography is expensive and not always available, so it’s not used routinely.

Nuclear medicine using positron-emission tomography or PET scan does involve the injection of a radioactive dye that can be traced using a special camera. The dye is injected into the blood stream using an intravenous (IV) line. It then moves through the blood vessels throughout the body.

Each tracer has its own affinity for tissues. For example some are more likely to attach to areas of bone and can be used to look at the spine. Any increased area of cell growth or tissue repair will usually mean increased concentration of the tracer.

Fractures or other injuries to the bone show up as a hot-spot seen easily on the image. This represents a place where there is an increase or build-up of the dye.

Nuclear scanning is non-invasive, but it does involve exposure to ionizing radiation. And exposure to radiation does have the potential to cause problems. Damage to the DNA and the possibility of cancer are the major concerns.

However, based on studies to date, the radiation doses delivered to a patient in this type of imaging have a very small chance of causing cancer. The total dose of radiation is small — more than a chest x-ray but less than a CT scan of the chest. The difference is that the dose using nuclear imaging with a PET scan is delivered internally rather than externally from the X-ray.

SCFE stands for slipped capital femoral epiphysis. Before a child has completed growing, the tops of the bones are in sections to allow the bones to get longer.

The growth area is called the growth plate or the epiphysis. At the top of the femur (thigh bone), the epiphysis can actually slip backwards. This condition is called SCFE. Standard treatment for this problem is to hold the epiphysis in place with a screw until growth is complete.

In moderate-to-severe cases, the screw placement can cause problems. When the hip is flexed or abducted (moved away from the body), the head of the screw bumps up against the rim of the acetabulum (hip socket). This is called screw head impingement.

Limited, painful hip motion and altered gait (walking) pattern occur with screw impingement. The solution may be to remove the screw (if growth is complete) or to change the position of the screw.

Your next step is to make a follow-up appointment with the surgeon. An X-ray will show the position of the screw and help identify the exact problem. The solution will depend on what’s causing the symptoms. Screw head impingement is a possibility but there may be other underlying causes of these symptoms.

Slipped capital femoral epiphysis (SCFE) is a fairly common hip disorder. It affects the hip in teenagers between the ages of 12 and 16. Treatment of SCFE usually requires surgery.

The main goal of the treatment is to stop any further slippage of the capital femoral epiphysis. The epiphysis is the growth plate at the top of the femur (thigh bone). The less slip, the lower the risk of problems in the hip during the child’s life. Surgery usually speeds up the process of epiphysis closure.

For the child, pain relief and restoring hip function are the immediate benefits of surgery. Long-term results of treatment include preserving the joint and preventing degeneration and arthritis.

Studies show that even mild SCFE can cause changes in the shape of the joint. Arthritis can develop later on. Unless the surgeon agrees that a wait-and-see approach is acceptable, immediate surgery is the accepted standard of care. This recommendation is supported by many long-term studies showing the safety and functional outcomes of treatment.

Scoliosis or curvature of the spine affects about 1.5 per cent of the adolescent population. When it occurs for no apparent reason, it is called idiopathic scoliosis.

Newer testing procedures may be shedding some light on the causes of scoliosis. There is some evidence to suggest that scoliosis may be a neurologic disorder of some sort.

Studies show that some people with scoliosis have other neurologic symptoms that point to a central nervous system (CNS) problem. Ultrasound has also been used to show that the muscles on one side of the spine are larger than on the other side. Muscle testing shows an equal amount of asymmetry in muscle strength from one side to the other.

It’s not clear yet if these changes in muscle size and strength result in the scoliosis or if they occur naturally as a result of the scoliosis. EMG studies are underway to help sort this out.

And in another study, adolescent athletes who used one side more than the other were more likely to develop scoliosis from the uneven use of the muscles. This observation was made in athletes who used single-arm skills. Javelin throwers, tennis players, and swimmers were at greatest risk.

Your son should not stop exercising or participating in sports. He may benefit from a specific exercise program that targets the paraspinal muscles (muscles alongside the spine).

Progressive resistive exercises for the trunk should be done to both sides using exercise equipment for this purpose. He should start out with weight equal to one-fourth his own body weight. When he can easily do 20 repetitions of each exercise, then he can increase the resistance by five per cent. The exercises should be done twice weekly for 15 minutes.

Children’s bones (especially younger children) are much more elastic than adults. The pelvic bones in children have a lot of cartilage and thick ligaments. This gives them the ability to withstand high-energy forces and trauma without injury.

Pelvic fractures in children occur most often as a result of car accidents. The child may be a passenger in the back seat or a pedestrian who gets hit by a car. The force of the accident through the side, rather than from the front or back is most common with pediatric pelvic fractures. A similar force can occur with sports or skiing injuries.

If the force is large enough to cause a pelvic fracture in a child, then other structures may be damaged as well. The medical team will perform a complete assessment looking for other soft-tissue injury.

Most pediatric pelvic fractures heal quickly and quite nicely without medical intervention. Unless there is internal bleeding, nerve damage, or other trauma, nonoperative treatment is best.

X-rays or other imaging tests give the physician an idea of where the fracture is located and what type it is. If the bone and structures are stable, then weight-bearing as tolerated is advised. Pain is the patient’s guide.

After a couple of weeks, the doctor may suggest some simple range of motion exercises to regain motion. Strengthening exercises are gradually added. By the end of eight weeks, the child is often back to normal activity when there are no further complications.

More advanced or complicated fractures may be treated with bed rest or decreased activity. Weight-bearing may have to be avoided until the fracture heals. if the fracture doesn’t heal (called a nonunion fracture) or if the fracture is unstable, then surgery may be needed.

Birthmarks on infants are fairly common. They are usually benign meaning they aren’t a sign of cancer, infection, or other serious condition. They won’t harm the child or cause other problems. They may go away as the child grows.

There are some skin lesions in children that do have significance. Cafe-au-lait lesions are flat with a creamy brown color. Cafe-au-lait is French for milk with coffee since that’s the color of the skin changes.

One or two cafe-au-lait spots may not mean anything. More than five requires further assessment. A neurologic condition called neurofibromatosus may be present. Or an allergic condition called uritcaria pigmentosa can present with skin changes that look like cafe-au-lait spots.

There is also a condition called Cobb syndrome associated with what look like port wine stain birthmarks. These skin changes may be a sign of underlying malformation of the blood vessels. Such a birthmark along the spine may signal bleeding and spinal pathology.

The fact that your grandchild has large birthmarks in more than one place may not mean anything. But your peace of mind is important and further evaluation won’t hurt. Consider asking for an MRI of her spine to rule out any other neurologic problems.

This disorder was first described in 1890. It became more widely known when a physician by the name of Cobb reported it in 1915. As you already know, Cobb syndrome is a rare disorder. It is not genetic or inherited. Males seem to be affected more often than females. There are less than 40 cases reported.

It involves spinal angiomas or arteriovenous malformations (AVMs). Angiomas are benign tumors that are made up of small blood vessels. They are usually seen on the skin and look like port wine stain birthmarks.

AVMs are a tangle of blood vessels made up of arteries and veins. There are abnormal connections instead of the normal tiny capillaries that connect arteries to veins. The AVM is often very fragile and prone to bleeding.

The birthmarks are a red flag that there may be a problem in the spinal cord. Patients with this condition may not have any symptoms. But bleeding from angiomas or AVMs in this area can result in muscle weakness or paralysis.

Early detection and treatment is the key to avoiding serious consequences of this condition. If the abnormal blood vessels are bleeding, the surgeon can stop the bleeding with a procedure called embolization.

What you are talking about is called observational gait assessment (OGA). There are a variety of OGA tools published for use by doctors and therapists with this group of patients. When an up-to-date gait laboratory isn’t available for the average parent or health care professional, then a simple video camera and OGA may be all that’s needed.

There aren’t a lot of studies to show which OGA works best and is most reliable. But since most of these tools are used to measure many children with a wide range of gait patterns, the task is much more difficult than yours. If you are the only one running the videotape and measuring your child, the results are more likely to be consistent and valid.

The main measure taken is the angle of the hip, knee, and ankle. These measures are made throughout the gait cycle. One gait cycle starts with the heel striking the ground as the person takes the first step. The cycle continues until that second heel strike of the same foot occurs.

Using stop action and slow motion of your video unit, you should be able to make these measurements before, during, and after treatment. Your physical therapist can help you identify how to make the actual joint measurements.

Cerebral palsy (CP) is a neurologic disorder caused by damage to the developing brain. It can occur during pregnancy, during childbirth, or after birth up to about age five.

There are four major groups of CP: spastic, athetoid, ataxic, and mixed. Most children have the spastic type. Spastic CP is further broken down into three other types: hemiplegia, diplegia, and quadriplegia. These categories describe how much of the body is involved.

With hemiplegia, only one arm or one leg has been affected. Diplegia usually means both legs are affected. And quadriplegia refers to all four limbs but usually, the entire body is involved.

Muscle tightness and muscle spasticity are common with spastic CP. Jerking and waving of the arms and legs describes what you see with someone with athetoid CP. Ataxia looks more like someone who has been drinking too much.

With these four groups of CP, there can be a wide variety of gait (walking) patterns. Even with just spastic CP, video and motion analysis of body movements have identified up to 13 different gait styles.

It’s likely that general observation (just watching the children move around) won’t reveal these wide range of differences. Your physician was probably referring to results of studies of gait patterns among children with all kinds of CP.

You have two other treatment options. There is an abuction brace that the infant or young child cannot get out of. It is more cumbersome and restrictive but it seems to do the trick.

Secondly, it may be time to consider reduction to correct the problem. If you can’t keep the harness on and/or it’s not working, then reduction is the next step. There are two ways to reduce or put the hip joint back in its socket.

Closed reduction is done with traction. A weight is attached to the leg and foot and applies a steady pull on the leg. The goal is to pull the leg down enough for the hip to relocate into the socket.

If this fails, then open reduction is indicated. The surgeon makes an incision large enough to be able to reach into the hip area and snip some of the soft tissues around the femur. The leg is pulled back down where it belongs. With either type of reduction procedure, the child wears a cast for six weeks to hold it in place until it heals.

When cerebral palsy (CP) affects just the legs, it’s called spastic diplegia. Spastic refers to the spasticity that is a part of this condition. Spasticity is caused by brain damage associated with the CP. It results in constant increased muscle tone and contractions.

Since we haven’t found a way to improve the brain’s function to overcome spasticity, treatment is focused on the muscles. Surgery to lengthen the muscles is common and works to some extent. Hamstring lengthening can be helpful for the child whose spasticity pulls him or her into a crouched position when standing and walking.

Motion analysis studies of children with spastic diplegia before and after surgery help identify some of the benefits of the operations performed. A group of orthopedic surgeons in Kentucky looked at the effect of hamstring lengthening on hip rotation and the crouch position.

They found that although hip rotation didn’t change when measured, the children were able to walk with more normal hip motion. Some children needed another surgery to release other hip muscles.

The effect doesn’t always last. Gravity exerts a constant downward pull on muscles and bone that are already compromised by this condition. The bones grow longer but the muscles don’t stretch to keep up. A growth spurt can make it look as if the child just got worse.

If your child is starting to crouch again after a period of improvement, it’s likely due to a combination of the reasons stated. Reminders to stand up straight and even attempts to do so don’t usually work.

It may be time for a follow-up appointment with her orthopedic surgeon to see if anything else needs to be done. She may only need some physical therapy to get back on track. Or she may be a candidate for further surgery.

The first step may be to talk with the family. There may be an orthopedic surgeon already involved in this child’s care. The school physical therapist is also an excellent resource.

Increased muscle tone called spasticity from this condition causes the crouch posture and gait (walking) pattern. As the child grows, the bones lengthen but the muscles still maintain their tight hold because of the spasticity. The result is the change in posture you see.

Without intervention, this pattern will likely get worse as the child grows. Physical therapy (PT) and surgery are the two main treatments for this problem. Just exactly what works best still hasn’t been determined.

Numerous studies from both PTs and surgeons show varying results. Sometimes cutting the tight muscles helps stretch them out and restore motion. The therapist works with the child and family to help decrease disability and improve function.

The operation (or another, different procedure) may have to be done more than once as the child grows. For children with spastic diplegia cerebral palsy, just the legs are affected.

A recent study from Shriner’s Hospital in Lexington, Kentucky showed that lengthening the hamstring muscle behind the knee helps improve knee extension and walking. Children who had this procedure were able to straighten up and walk better. They didn’t walk normally, but they were much improved.

Your concerns are valid and should be brought up at the child’s next individual educational planning (IEP) meeting (if not sooner).