FAQ Category: Child

Clubfoot deformity is also known as equinovarus. Equino means “like a horse.” Varus refers to the inward curve of the foot. The horse’s hoof is like a large toenail. The rest of the horse’s joint at the hoof points backward and looks like a human heel. The term “clubfoot” more accurately describes the shape of the foot as a whole before correction of the deformity.

Most clubfoot deformities (95 per cent) occur because the bone of the forefoot shift toward the big toe side and point downward. The foot looks twisted in an abnormal position. In other cases, the heel or calcaneus shifts position.

In other words, sometimes just the toes of the forefoot are affected. In other patients, the forefoot and the heel are involved. This gives each child a slightly different looking foot and may be what you are seeing.

It’s normal to have some discomfort in the area of the tendon repair site. It will gradually go away over the next few months. In some patients, it takes up to six months to completely ease.

Your surgeon has probably told you what activities to avoid during the healing period. It’s important to follow these directions carefully. Patellar tendon rupture is a serious complication of this surgery. It’s most likely to occur during the early healing phase.

Most often the healing tendon is protected with a splint after surgery and a gradual return to activity, exercise, and sports. A full six months of strengthening and training is required before returning to sports.

When in doubt, it’s always best to ask. Check with your orthopedic surgeon and see if your symptoms are within normal limits. The type and extent of surgery and postoperative management are all factors in how you feel.

“Jumper’s knee” or patellar tendinitis is a common problem in athletes who repeatedly jump. The landing puts stress loads of up to 11 times the volleyball player’s body weight on the extensor (knee) mechanism.

Without enough time to heal, microtearing of the patellar tendon from frequent loading results in chronic tendinitis. Continued sports participation will only aggravate the condition. Steroid injections may put the tendon at risk for rupture. They are not advised unless everything else has been tried without success.

If you have tried the usual treatment of rest, physical therapy, taping or bracing, and antiinflammatory drugs, then further treatment may be needed. Experts advise using warm, moist heat before activity. Wear an elastic knee support during play.

Once the inflammation is under control, then a special exercise program can be started. The physical therapist will instruct you in eccentric strengthening exercises. Warm-up and stretching before the main program of exercises should be followed by cool down stretching and ice. Ice is used on the patellar tendon for five minutes after the program.

If you have a more advanced condition, then treatment may include shockwave therapy or surgery. Shockwave therapy is still an experimental type of treatment. Surgery to clean the tendon of all inflammation and dead tissue is a final effort to help stimulate healing. Surgical treatment is only advised for patients with persistent, disabling pain who have had at least six months (or more) conservative care.

You may want to ask your doctor about consulting with an orthopedic surgeon. Perhaps one who specializes in children and adolescents would be best. The surgeon will repeat the history and physical exam already done by your family physician. A second look is never out of line.

If X-rays have already been taken, then more advanced imaging studies may be needed. For example, a bone scan or MRI may be helpful. Single photon emission computed tomography (SPECT) of the lumbar and sacral spines can look at nerve roots, discs, and bone. Defects in the bone, slippage of the bone, and changes in soft tissues can be seen with these tests.

Once the proper diagnosis is made, then ways to treat or manage the synmptoms can be suggested.

Your surgeon will be the best one to advise you based on your son’s symptoms and X-ray results. Failure to fuse is a problem in many cases of high-grade spondylolisthesis. Successful fusion can be difficult with that much forward slippage of the vertebra. It doesn’t seem to matter what method is used to do the fusion. Patients who are put in a body cast after fusion do seem to have better overall results.

The next step may be careful watching. If your son is not having any painful symptoms, then no treatment is needed. Watch for low back pain, deformity, or changes in the way he walks. Other red flags include hamstring spasm or tightness and neurologic symptoms like numbness, tingling, or weakness.

For the patient who has pain or any of the other symptoms described, a second surgery may be needed. The fusion may have to be done again. Metal rods and screws may be used if they weren’t put in the first time. The extra reinforcement may increase the chances for a successful surgery.

Osteochondritis dissecans is a problem with the cartilage and layer of bone just under the cartilage. The cartilage and bone separate from each other and sometimes pull away from the main bone, too. The stress of repetitive force from throwing balls is a common cause of this problem.

Treatment is designed to reduce pain and return the athlete to his previous level of play. Preventing arthritis is a long-term goal. If you’ve spent six months or more trying to get a handle on this problem with poor results, then surgery is the next step.

There are different ways to treat this problem surgically. It sounds like your son is having an autologous osteochondral mosaicplasty. Loose pieces of bone and cartilage are removed. Holes are drilled where the damage occurred. Bone plugs are taken from the bottom part of the femur (thigh bone) and inserted into the holes.

Autologous means the patient donated the bone graft to himself. ‘Osteo’ refers to bone and ‘chondral’ refers to the cartilage. Mosaicplasty is the grafting of osteochondral tissue to help the healing process.

Graft rejection is always a concern with donated tissue. With mosaicplasty, there’s a high rate of graft survival to ensure success. The main problem with this procedure is pain and swelling at the donor site. In time, this improves and healing completes in both the graft and the donor sites.

One of the main disadvantages of the treatment your son had is the left over effects at the donor site for the graft. Plugs of bone and cartilage are taken from the least used weight-bearing surface of the knee. The cartilage is thicker there and holds up better over time.

The donor tunnels are slow to heal. First, the holes where the plugs are taken out heal over but the cylinder-shaped harvest sites remain empty.

Excessive bleeding from the donor tunnels can cause pain and swelling. Bone infection can also occur and must be watched for. Studies show that symptoms can persist for five weeks or more. Slowly, over time, complete healing does occur.

Several studies have shown a link between getting enough exercise and improved academic performance. The key is “getting enough” exercise. Students enrolled in physical education (PE) classes don’t have an academic edge.

Children who participate in sports teams or who get two hours of PE each day do better. The activity level must be vigorous. Minimal to moderate levels of physical activity and exercise aren’t enough to influence a student’s grades.

Scientists think there are several reasons for this effect. First, increased activity at a level described as ‘vigorous’ increases arousal and may reduce boredom. The result is an increased attention span and better ability to concentrate.

Self-esteem may be improved with increased levels of activity. Improved classroom behavior is a natural outcome of improved self-esteem.

Researchers suggest there may be a threshold level required to induce arousal and other desirable effects. Further studies are needed to find out just exactly how much exercise is needed to make a difference.

Studies do suggest that the quantity and especially the quality of school physical education programs have a big effect on the fitness of children and adolescents. Increasing children’s participation in moderate to vigorous activities improves their health. Whether or not physical activity and exercise improves academic performance is still a hot topic for debate.

A recent study from Michigan State University looked at academic grades of middle school students who were in a physical education (PE) class. They compared these results to students who were not in PE. They also compared the grades of students in PE with those students who took PE and who were also on a sports team.

The findings suggested that regular PE class does not impact school grades. Although the physical activity may have health benefits, it’s not vigorous enough to improve academic performance. Only students with vigorous levels of activity showed improved grades.

Vigorous physical activity was defined as rhythmic, repetitive physical activities that use large muscle groups at 70 percent or more of maximum heart rate for age. This definition has been proposed by the Healthy People 2010 program.

An exercise heart rate of 70 percent of maximum heart rate for age is enough to increase conditioning of the heart and lungs. Examples of vigorous physical activities include jogging/running, lap swimming, cycling, aerobic dancing, skating, rowing, jumping rope, cross-country skiing, hiking/backpacking, and racquet sports. Competitive group sports such as soccer, baseball, volleyball, and basketball also provide vigorous levels of activity.

For more information on guidelines recommended by Healthy People 2010 go to http://www.healthypeople.gov.

When it comes to fractures, the best outcome occurs when bones are in the most accurate anatomical position to heal. Without a good line up there’s a risk of delayed healing or even nonunion.

When the bones are lined back up, it’s called reduction. Good reduction isn’t always needed in children. Children have the unique characteristic of growing bone to help in the process. There’s also a step called bone remodeling. When new bone forms around the fracture, there’s usually more than is needed. The body then starts to remodel the bone to remove the excess bone.

Each person (child) is different. Sometimes the fracture healing and remodeling is so perfect it takes a skilled radiologist to detect it on X-ray years later. In other cases, a callus of bone around the fracture site remains.

There is a chance that the bones will heal in a deformed position. Studies show this kind of healing will affect function. Surgery to reduce the bones has its risks too. Nerve damage, infection, and poor healing can result from surgery.

Based on the current X-rays and experience with past cases of this type, your surgeon can give you the best odds for healing with or without surgery. If you decide to go with casting and bypass surgery, then you can have the arm X-rayed every couple of weeks to see how the healing is progressing.

Doctors are aware of any potential risk of X-rays, especially in a growing child. They also keep in mind the cost of additional imaging studies. If they suggest X-rays at regular intervals, it’s usually for a specific reason.

Most likely the type of fracture your daughter has requires careful management. Poor healing or healing in a deformed position will be trouble later. X-rays can show if the cast is too loose and needs to be replaced. Any angle of deformity will also show up.

Nonunion or too much deformity may be a signal that further treatment is needed. Sometimes surgery is needed to further reduce or stabilize the fracture. Reduction means to line the bones up evenly for optimal healing. If the cast isn’t enough to do this, then wires, screws, or a metal plate may be needed.

The surgeon may also be treating your daughter with a slightly different plan of care based on her involvement in gymnastics. Good function and strength needed for back flips and other types of gymnastic activities requires healing in a good position.

Spondylosis is a defect in the pars interarticularis of the vertebra of the spine. Some experts say it’s a stress reaction or stress fracture of the bony support of the spine. Children, teens, and adults can have this condition.

Stress reactions of this area of the spine have been reported in many athletes. Gymnastics, diving, football, and rowing seem to have the highest number. It’s likely that loading the spine over and over while in a position of extension and rotation is the cause of the condition.

Bracing is used to immobilize the spine. Healing can occur, especially if the stress reaction or fracture is only on one side of the vertebra and it hasn’t separated. Once the fracture separates, then the main body of the vertebra can slide forward over the bone below. Many more problems occur with this situation.

Expect a healing time of six to eight weeks. Your son should start to have less pain and improved spinal motion by the end of this time. Hamstring spasm will decrease as well. He will be allowed to start back with activities under the supervision of a physical therapist (PT) and the team sports physician.

Your son should be advised to continue with the specific exercises prescribed by the PT as long as he continues to train and dive. The muscles around the lumbar spine must be strengthened to maintain stability at each segment around the spondylolysis.

Follow-up X-rays and/or CT scans will help keep an eye on any progression of the condition. Any recurrence of symptoms should be reported immediately. Early treatment is really the key to avoiding further problems and complications. With the proper treatment and training, he should be able to go back to a full training schedule.

Spondylolisthesis is a condition in which a fracture of the pars interarticularis separates. The pars interarticularis is part of the bony ring that surrounds the spinal cord. It forms part of the supporting spinal column. When displacement of the bone occurs, the body of the vertebra moves forward over the bone below it.

If caught early enough, this condition can be treated with bracing, rest or activity modification, and specific exercises. When pain persists despite this conservative treatment, then surgery may be the next step. A minimum of six months of nonsurgical treatment is advised.

Other reasons to consider surgery include: worsening of the bone position or neurologic symptoms that get worse instead of better. This could be numbness and tingling down the leg. It could even cause changes in bowel or bladder function.

The orthopedic specialist will help you make this decision. Repeated X-rays and CT scans taken over time will show the progression of the spondylolisthesis. If bony healing doesn’t occur and the vertebra continues to slip forward, then it may be time to consider surgery.

Slipped disc more correctly referred to as disc protrusion or disc herniation is rare in children, especially under the age of 12. Disc herniation in older children and teens (ages 12 to 17) has been reported. The actual incidence is unknown but reports are between 0.5 and 4 percent.

It is difficult to diagnose disc problems in young people. The symptoms seem to come and go and aren’t always the same as for an adult. Many times their back and/or leg pain is passed off as hamstring tightness or muscle sprain. Back stiffness with scoliosis (curve in the spine) may develop.

X-rays are often negative even when there is a disc problem. CT scan and MRI are much more reliable but not often ordered in this age group.

It may be helpful to ask the physician how the diagnosis was reached. If more advanced imaging has not been ordered, then this may be the next best step to confirm the diagnosis.

Scheuermann’s disease is characterized by a painful upper back fixed in a position of spinal forward curvature called kyphosis. It usually runs a fairly benign course. Symptoms go away when the patient stops growing and reaches skeletal maturity.

A special brace called a Milwaukee brace has been shown to help relieve pain and correct smaller curves as the child is growing. Even at age 18, your son may not be done growing. X-rays can be used to show if the growth plates have closed fully indicating the end of the growth phase.

Some studies have shown that curves can continue to get worse even after age 30. Treatment with surgery is advised for curves greater than 75 degrees. Surgery is also suggested for patients who are concerned about their appearance or who have pain or health issues. For example, heart and lung function can be impaired from the forward bent position of the spine keeping the chest from expanding.

Your orthopedic surgeon will be able to advise you in several ways. He or she will be able to assess your son’s growth potential. The degree of curve can be calculated from X-rays. Treatment is planned based on this measurement. The goal is to keep the curve from getting worse as the patient grows or ages. Bracing and spinal fusion are the two main ways to accomplish this.

Compared to adults, disc herniation in young children and teens is fairly rare. Less than four per cent of the population ages 12 to 17 have disc herniations. Trauma is the most likely cause — either direct to the spine or indirectly from an athletic activity.

Surprisingly, according to a recent study in Israel, almost half of the patients with a disc herniation also had a first-degree relative who had a disc herniation. First-degree relations include the parents, child, or siblings.

These findings suggest there may be a family predisposition or hereditary factors with disc herniation in adolescents. More studies are needed to confirm this figure.

C-reactive protein is a measure of inflammation. During the acute phase of an infection or injury, the C-reactive protein is elevated in the blood. In fact, the C-reactive protein levels rise in the first six to eight hours after the start of inflammation, injury, or infection.

In the past, doctors relied on another test called the sedimentation (sed) rate. The sed rate is another measure of inflammation or cell death. It is the rate at which red blood cells fall to the bottom of the test tube in one hour. The faster the red cells fall, the higher the sed rate.

Studies show that C-reactive protein is a better measure of inflammation than the sed rate. It is increased in collagen diseases, infections, inflammatory diseases, and cancer. Its use to help diagnose septic hip arthritis has also been confirmed by doctors at The Children’s Hospital of Philadelphia (CHOP).

Recently, scientists have found elevated C-reactive protein may be useful as a predictor of heart disease as well. This remains very controversial and under continued study.

Septic arthritis of the hip in children is a painful joint condition caused by a bacterial infection. Synovitis is an inflammation of the synovial fluid protecting the joint.

Either condition can occur in children. Synovitis tends to go away on its own without damaging the hip joint. Septic hip arthritis can leave permanent damage to the cartilage, growth plate, and even cause death of the bone. Early treatment is very important in a septic condition.

After observing the child and conducting a physical exam, the doctor will order blood tests and possible X-rays. The lab tests will measure white blood cells, the sed rate, and possibly C-reactive protein levels. If all three tests are positive, chances are your child has a septic hip rather than synovitis.

The presence of fever (99 degrees or higher) is also a red flag. Children rarely have a fever with synovitis but almost always have one with a septic hip. If the tests still aren’t conclusive, then the doctor can remove some fluid from the hip and test it for bacteria. This is called joint fluid aspiration. The child must be anesthetized and a needle inserted into the joint to remove the fluid. The test is 100 percent conclusive but invasive so doctors try to make the diagnosis without this step.

More and more young baseball athletes are reporting arm injuries. As a result, many studies have been done on adolescent baseball pitchers. Using the results as a guideline, the USA Baseball Medical and Safety Advisory Committee has put out some guidelines for young pitchers.

The goal is to avoid injury. Parents are advised to pay attention and respond to any arm pain or discomfort reported by the players. Athletes are encouraged to notify coaches and parents of any problems. They are not to cover up the symptoms with ice and antiinflammatories and still play.

Pitch counts should be tabulated daily in games and practices (not just games). The following specific pitch numbers are recommended for the safety of adolescent baseball pitchers:

Showcase games are important opportunities for athletes to show off their talent. Pitchers get a chance to see how fast their pitching times are using a radar gun. Runners are timed around the bases. Batters’ statistics are posted. Everyone gets to perform in front of scouts from schools or professional groups.

Young, talented pitchers are actually discouraged from throwing breaking pitches in competition until they reach puberty. They are also advised to avoid pitching in showcases. The intent is to prevent serious injury.

Safety recommendations are based on results of research conducted so far. Whether or not following these guidelines makes a difference is still up for debate.