FAQ Category: Child

Age is a very telling factor when it comes to spinal tumors. Most tumors that start in the cervical spine (neck) are benign when the patient is younger than 20 years old. Malignancy is much more likely as we age and most common in older adults.

But a benign tumor can be a serious condition. The size and location can cause major complications. Pressure on blood vessels or the nerves can cause disabling symptoms. Surgery may be needed to remove the tumor.

The surgeon’s goal is to remove the tumor en bloc. This means the entire tumor with a margin of normal tissue around the tumor is cut away carefully. The surgeon will follow-up with you and your daughter to make sure there are no signs of cancer recurrence.

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).

Hip dysplasia also known as developmental dysplasia of the hip or DDH refers to a hip deformity that can result in hip dislocation. The hip socket is shallow allowing the hip to slide up and out. This slippage is called a hip subluxation.

In the case of subluxation, the top or head of the femur (thigh bone) remains in contact with some part of the acetabulum or hip socket. Dislocation occurs when the femoral head is completely out of the socket.

Risk factors for the development of DDH include a positive family history of DDH and breech position at birth. You didn’t mention if either of those describe your situation. Other risk factors include female sex, growth problems while inside the mother’s uterus, older age of the mother, and high birth weight of the child.

None of these are related to having a home birth. The condition may have been identified faster in a hospital but a midwife or birth assistant can easily perform tests for hip dysplasia at birth and during well-baby check ups.

Untreated and unresolved hip dislocation is a rare problem. Treatment options are wide ranging from no treatment to closed reduction to open reduction or other surgeries.

If services are available, the first thing the child will need is an X-ray to assess the condition. The physician will have to look at the type of dislocation and the presence of any other complications. The first step in treatment may be to apply traction to pull the leg down and reset it in the socket. This is what’s referred to as closed reduction.

The child must remain in a full hip spica cast (waist to foot) for about six weeks. Physical therapy is advised after the cast comes off to restore motion, function, and gait (walking). If that doesn’t work, then surgery may be needed. Several operations can be considered.

The first one mentioned is an open reduction. This accomplishes the same thing as traction but requires making an incision and releasing the soft tissues around the hip to bring it back down into the socket.

If the hip doesn’t stay in the socket and dislocates again, then a hip fusion may be needed. Bone graft is used around the joint to stop motion at the joint and hold the hip in place. Hip joint replacement is a final option but may not be available where resources are limited.

Traumatic dislocation of the hip in children is a rare problem. There aren’t a lot of studies on this condition. The long-term results of treatment are unknown. A recent report from Nepal suggested traction first and then surgery if that doesn’t work.

Traction is used to pull the hip down and help guide it back into the socket. If that doesn’t work, then open surgery to do the same thing can be tried. The operation is called an open reduction. Other operations are possible but have more potential problems compared to an open reduction.

The decision must be made based on the child’s symptoms, physical findings, X-ray results, and the desires of the family. If the child has no pain but limps when walking, treatment may be different than if the child is already handicapped by the condition with pain, loss of motion, and loss of function.

You ask good questions that there may not be complete answers to as yet. Orthopedic surgeons debate the best timing of treatment for developmental dysplasia of the hip (DDH).

Some say treatment should be delayed until the growth center of the femoral head (top of the thigh bone) is developed. This area is called the ossific center. It has a protective effect on the hip to keep the blood flow going. Without it, the child is at risk for avascular necrosis (AVN) or death of the bone from a lack of blood.

There are experts who disagree. They say it doesn’t matter if the ossific center isn’t there. Early treatment is best because it gives the joint a longer chance to remodel and shape the femoral head in the hip socket. The hip that is in the center with a round head and socket will have the best results in the long run.

A recent study from the Alfred I. duPont Hospital for Children in Delaware reports the results of early treatment for DDH after Pavlik harness failure. Children who had either an open or closed reduction of the hip before the age of three months had no AVN.

Delaying the surgery may protect the femoral head from loss of blood supply from excess compressive force. But the risk of AVN goes up with time delays and reduces the remodeling potential of the hip. There is less chance for normal growth and development.

According to the results of the duPont study, reducing the hip at the earliest opportunity can help prevent irreversible degenerative changes later.

There’s still some debate about the best treatment for this disorder. Some may think the wait-and-see approach is adequate for very mild cases, where others suggest early intervention for the best results. There’s nothing wrong with seeking a second opinion from an orthopedic surgeon who specializes in pediatrics to help you make this decision.

Some of the more effective treatment approaches today involve correction of the foot with serial casts and/or splints. The child’s foot is moved as close to neutral as possible and held in place. As the ligaments and soft tissues stretch, the foot can be corrected even more. A new cast or modification of the splint is made to accomodate this new position.

Over a period of weeks to months, the foot is realigned without scar tissue while avoiding major surgery. Some children will need minor surgery to lengthen tight tendons. The length of time and methods used to treat clubfoot may vary depending on the severity of the condition.

Clubfoot deformity (the foot curves in and points down) is a common birth defect. About half the children have unilateral clubfoot, meaning it only affects one foot. The other half have bilateral clubfoot, affecting both feet.

Without treatment, the child walks on the sides of the feet. If severe enough, the child may even walk on the ankle instead of the bottom of the foot.

Early treatment to balance the soft tissues and realign the bones is needed to restore the normal anatomy of the foot and ankle. Treatment may begin with a series of casts and splints used to bring the foot and ankle back into a midline or neutral position. Minor surgery to release tendons in the area may be needed. When the child is older, a tendon transfer to correct a persistent muscle imbalance may be required.

Most children with corrected clubfoot appear to walk quite normally. Sometimes the affected foot (if unilateral) may be smaller than the other foot. The calf can be noticeably smaller than the normal side.

Specific testing of children with unilateral clubfoot compared to children without clubfoot has been done. The researchers found that the weight-bearing pattern for children with unilateral clubfoot was different on both sides compared to children who don’t have this condition.

It appears the leg and the nervous system have some compensatory mechanisms to ensure the child stays symmetrical (even) from side to side. None of this is noticeable to the child or the observer.

You may be describing a residual foot position called forefoot adduction. This is the most common reason parents are dissatisfied after surgery to correct clubfeet.

Doctors aren’t sure what causes FFA. Obviously there is a shift in the normal position of the bones in the foot and/or ankle. But which bone is the kingpin? And what can be done about it? These are questions researchers are actively seeking answers to.

A recent study from Sweden used ultrasound to look at the position of one particular bone called the navicular. It’s located on the medial (inner) side of the foot. It has connections to the talus bone in the ankle and the three bones of the forefoot. It’s unique position makes it the most likely place to start looking for the cause of FFA.

But the results of the study actually showed the position of the navicular bone is NOT linked with the severity of FFA. More study is needed of the foot and ankle to find the cause and ways to prevent or correct FFA.

In the meantime, you may want to go back to the surgeon who has been helping you. There may be something that can be done for your child now to improve her foot form and function while she’s still so young.

The Ponseti Method is a nonsurgical treatment for clubfoot deformity. It was first used and described by Dr. Ignacio Ponseti in the 1950s and has become popular in the last few years.

There are reports that the Ponseti method is successful 95 per cent of the time in correcting clubfeet when done by an experienced physician. The method involves moving the foot into a position as close to neutral as possible and putting a plaster cast on the leg to hold it in place. As the ligaments and soft tissues stretch, the cast is removed, the foot is repositioned (again, as close to neutral as possible), and another cast applied.

This procedure is repeated until the deformity is corrected. The child wears a special splint called a Dennis Brown Bar to hold the correction. The splint is kept on 23 hours/day for at least three months. Young children are very adept at getting around with the splint on. It does not seem to hamper their development or mobility.

After the first three months, the splint may still be used at night for much longer, even up to age three or four. In a small number of cases, the Ponseti casting method requires additional minor surgery. Persistent muscle imbalance can be corrected with a percutaneous tenotomy. Pecutaneous means just under the skin. The surgeon is able to make a tiny incision in the skin and release the tendon allowing it to lengthen.

You can watch a short video clip demonstrating the Ponseti Method: http://www.clubfeet.net/video.php.

Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). A joint surface damaged by OCD doesn’t heal naturally.

The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies.

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. In the child who is still growing, the problem is much more likely to heal itself. In the adult, the bones are not growing and take longer to heal. Many 16-year old boys have completed their growth and respond more like an adult to this problem.

Surgery to repair the problem can be successful but healing does take time. If a bone graft is used, healing begins inside the bone. Bone cells begin on the inside and grow outward toward the torn cartilage. Bone graft has the advantage of stimulating blood flow to the area. Pins used to hold the torn fragment in place don’t bring new blood to the area.

Plugs of bone graft used to repair OCD can heal as quickly as three months. If the surgeon is planning to use hardware such as pins, the healing process can take longer.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip in young teenagers. In this condition, the growth center of the hip (the capital femoral epiphysis) 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.

As with your son, the first step is to insert a long screw to stop the epiphysis from slipping further. A special X-ray machine called a fluoroscope is used. The fluoroscope allows the surgeon to see an X-ray image on a TV monitor while doing the surgery. In this way, the surgeon is able to place a screw into the epiphysis using a small incision in the side of the thigh.

If this doesn’t work, greater deformity can occur in the hip. Another operation may be needed to relign the hip and keep the problem from getting worse. In such cases, the most commonly performed operation is the reconstructive or wedge osteotomy.

A wedge-shaped piece of bone is removed and the two remaining pieces of bone are moved closer together. Screws are used to hold everything in place. Exactly where to take the bone from the femur is a matter of debate. Removing any amount of bone alters the way the hip muscles attach and function.

Other problems that can occur include avascular necrosis (AVN). AVN refers to a loss of blood supply to the head of the humerus. The bone can start to die from a lack of oxygen and nutrients. Taking the wedge piece of bone from down lower in the femur can eliminate this problem but increases the risk of muscle imbalance. Each child is evaluated individually to find the best choice for him or her.

Slipped capital femoral epiphysis (SCFE) is a condition that causes the growth center of the hip (the capital femoral epiphysis) to slip backwards on the top of the femur (the thighbone).

If untreated this can lead to serious problems in the hip joint later in life. Fortunately, if recognized and treated early, complications can be avoided or reduced. Surgery is usually necessary to stabilize the hip and keep the epiphysis from slipping even more.

One reason treatment to arrest or stop this condition from getting worse AND to realign the hip in a normal position is to avoid hip deformity. The more slippage, the more likely there will be problems later in life. Abnormal load through or around the hip can also cause a stress fracture.

Children who are overweight are more prone to developing SCFE. This suggests that the main cause of SCFE is from increased force on the hip at a time when the femoral head is not quite ready to support these forces. If your child is overweight or obese, your doctors’ recommendations are all the more important.

Even with surgery, problems can occur. One potential complication is chondrolysis. In this condition, the articular cartilage of the hip joint is destroyed. Articular cartilage is the smooth material that covers the joint surface. It is unclear why this develops. This condition results in a painful, stiff hip.

The other possible complication is called avascular necrosis (AVN). This usually occurs when the blood vessels that provide blood to the epiphysis are damaged, torn, or pinched. The result is that the epiphysis dies and becomes further deformed. AVN can lead to early arthritis in the hip joint.

Snapping hip syndrome is a common problem among ballet dancers (males and females). Studies show that the cause of this snapping or popping sensation is the iliopsoas tendon rolling over the pelvic bone in front of the hip.

Since the iliopsoas is a hip flexor muscle, the snap or pop is most noticeable when the dancer is lifting the leg forward or out to the side. Many dancers recall the problem starting sometime between ages 14 and 16.

Since both boys and girls notice it, hormonal changes are not as likely as the fact that they have finally developed enough strength to lift the leg past 90 degrees. Experts don’t know if this snapping will eventually lead to hip problems later in life. And it’s clear that there isn’t one treatment that works best for everyone.

Some dancers find that rest helps while others stretch the hip flexor muscles for relief of symptoms. More studies are needed to help sort out who’s at risk and how to avoid this problem — especially if it turns out to be the start of other problems later on.

All newborns should be screened for hip dysplasia. Hip dysplasia is a shallow hip socket that may not be able to hold the round head of the femur (thighbone) in place. Partial dislocation called subluxation or complete dislocation can occur.

Dr. Ortolani, an Italian physician, developed a special test to detect hip dislocation in young infants. If the hip is out of the socket, as the doctor moves the child’s leg away from the body, there is a click or clunk felt.

This is the sensation that occurs as the head of the femur slides over the rim of the cartilage around the joint and slips back into the socket. Anytime this hip click is felt, the test is positive for a true hip dislocation.

Sometimes the hip is dislocated and slips back into the socket without the click or clunk. The physician believes the hip is normal based on the Ortolani test. The results would be considered a false negative.

If you have any doubts or would like further confirmation of the test, an ultrasound (US) can be done. The US will show the exact position of the femoral head. Some experts advise doing an US with every child who has a true-positive Ortolani’s test. The US will also show how well the head is reduced in the socket. This information can be helpful in planning treatment.

Developmental dysplasia of the hip (DDH), previously known as congenital hip dysplasia is a common disorder affecting infants and young children. In this condition, the normal relationship between the round head of the femur (thighbone) and the cup-shaped acetabulum (hip socket) is altered. Usually, the acetabulum is too shallow or sloping to hold the femur in place.

A Pavlik harness can be used for three to nine months. The harness keeps the hip in flexion and abduction. The right amount of pressure and contact between the joint surfaces helps make sure the hip joint develops normally. The head of the femur inside the acetabulum helps shape the joint as it continues to form.

The harness is worn until the doctor can no longer move the hip in and out of the socket. Most children caught early (first three months) have good-to-excellent results with this treatment.

In the infant older than 6 months, the Pavlik harness may not work. The child may be too large to wear the harness or may be too active to keep the harness on all day. If the harness doesn’t work or the child is too old for a harness, then surgery may be needed.

All infants should be screened at birth and during the early weeks-to-months of life for hip problems. Hip instability can lead to hip dislocation. The problem is called developmental dysplasia of the hip (DDH).

X-rays are the easiest and most common way to confirm the diagnosis. Your concern about exposure to radiation is understandable. Ultrasound (US) may be an acceptable alternative test.

US uses sound waves to give a picture of the soft tissue and bony structures of the hip. You may have already had an ultrasound of the baby when you were pregnant. Exposure to sound waves is not harmful and there is no radiation involved.

There are some drawbacks in using US for this type of exam. Sometimes it doesn’t show a problem that is really there. This is called a false negative result. There are many reports of dysplasia seen on US that resolve or go away without treatment.

Some experts advise further testing is needed with US before recommending its use routinely. Talk to your physician about your concerns and ask about the possible use of US. He or she will be able to answer any questions you may have and advise you.

The hip click she was referring to isn’t something you hear. It’s a sensation or something the examiner can feel. The test is one used with newborns and young infants to test for hip dislocation.

The click signals that the dislocated hip has slipped back into the socket. The test is most reliable during the first two months after birth. Other tests can be used after that.

All children should be screened at birth and again at regular intervals during the first year of life. Several studies have shown that children can be born with normal hips and develop hip dysplasia later. Dysplasia refers to a flat or shallow hip socket. Without a curved, cup-shaped socket, the head of the femur can slip out of the joint.

If there is any doubt about the results of the test, an X-ray or ultrasound study can be done. Don’t hesitate to ask your pediatrician to double-check the results of the test and to retest your child at your next well-baby checkup.