FAQ Category: Child

You are asking a very good question and one that doesn’t have a very good answer just yet. Here are a few details that might help you understand the problem. The condition, called slipped capital femoral epiphysis (SCFE) affects the hip in teenagers between the ages of 12 and 16 most often. Cases have been reported as early as age nine years old. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thigh bone).

If untreated this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. But what is the best treatment for this problem? And what evidence do we have to support treatment as “best”? That is the topic of a recent literature review from two orthopedic surgeons (one from the University of Iowa and another from the University of Indiana).

The goals of treatment are to 1) keep the problem from getting worse, 2) avoid complications, 3) improve hip motion, and 4) delay or prevent the development of degenerative hip disease. With that many different kinds of goals, you can imagine treatment may be varied (different for each child).

One approach is to provide treatment based on whether the condition is stable or unstable. Stable SCFE means the child can put weight on the leg and walk (with or without crutches). Unstable SCFE is defined by the child’s inability to walk with or without crutches due to severe pain. Surgery is usually necessary to stabilize the hip and prevent the situation from getting worse.

In this study, current best evidence is reported on treatment for stable versus unstable SCFE and treatment involving surgical dislocation. There are easily a half dozen ways to treat a stable SCFE. But the consensus is that the best way to treat stable SCFE is with a single, large screw into the epiphysis to hold it in place.

The best treatment for unstable SCFE isn’t as clear. In fact, the treatment for this type of SCFE is quite controversial. The risk of avascular necrosis (AVN; loss of blood to the hip with death of the bone) must be taken into consideration. This complication is the number one reason why patients with SCFE end up with a total hip replacement.

The timing of surgical treatment for unstable SCFE is also hotly debated among and between surgeons from the U.S. and Europe. The risk of necrosis is one reason why some surgeons insist on early treatment. But others think that surgical stabilization can lead to avascular necrosis. Right now, the best evidence suggests that the need for surgery is “urgent” in children with unstable SCFE. This approach has the lowest rates of necrosis.

Then the final decision is whether or not to dislocate the hip during surgery. Hip dislocation is done in order to better realign the epiphysis and therefore improve hip function. But there is concern that surgical dislocation can also increase the rate of avascular necrosis. Surgeons must also weigh other risks that come with surgical dislocation such as damage to the hip cartilage, labrum, joint surface, and/or bone.

According to this review, there is no evidence to support the more aggressive approach of surgical dislocation and epiphyseal realignment for stable SCFE. The single screw fixation method should remain the treatment of choice for these patients. As for surgical dislocation to treat unstable SCFE — caution is advised. This is a newer treatment method that hasn’t stood the test of time. There aren’t enough studies to report on long-term results. For now (and until better evidence is available), gentle surgical reduction with internal fixation is advised.

As more and more children and teens participate in organized sports at a younger age, it is no surprise that knee injuries are on the rise. A pediatric orthopedic surgeon from UCLA School of Medicine recently reviewed four specific injuries that might be of interest to you in your report. These include: 1) anterior cruciate ligament (ACL) injury, 2) symptomatic discoid lateral meniscus, 3) juvenile osteochondritis dissecans, and 4) traumatic patellofemoral instability.

The injuries themselves are unique in that they affect a knee that is not skeletally mature. This refers to the middle-school age group who have not completed their full growth. Prevention of long-term complications such as stiffness and growth arrest are special concerns that must be addressed during treatment.

Let’s take a brief look at each of these four knee injuries in the youth athlete. In youths, anterior cruciate ligament ACL injuries can create knee joint instability, damage to the meniscus (knee cartilage), and chondral injury (damage to the bone). The ACL is one of two ligaments that criss-cross inside the knee. Together, these two ligaments stabilize and hold the knee together. When the ACL is torn during pivoting activities of the leg in this age group, two things can happen.

First, the place where the growth plate and bone meet (called the condroepiphyseal attachment) is damaged. This, in turn, can cause a fracture of the tibial spine (place where the ACL attaches to the bone). And like all fractures, the bone can be separated and displaced (shifted).

Next, injury to the discoid lateral meniscus is only treated when there are painful symptoms with snapping or clunking of the knee and/or loss of full knee extension. Children affected most often by this type of injury are usually under the age of 10. As with adults, the current thinking on this injury is NOT to remove the torn cartilage. Instead, the tissue is repaired as much as possible in order to prevent arthritic changes later.

Juvenile osteochondritis dissecans (OCD) is the third condition of interest. OCD is a problem that affects the knee at the end of the big bone of the thigh (the femur). 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. This area of dead bone is referred to as the osteochondritis lesion.

Treatment of OCD can be nonsurgical with immobilization and change in activity until healing is seen on X-rays. When healing doesn’t occur, the surgeon can drill tiny holes in the joint surface to cause bleeding and stimulate healing. If the joint cartilage is broken off with a bit of bone still attached, it may be necessary to reattach the fragment or remove it and fill in the hole left behind. Treatment really depends on the patient’s age and skeletal maturity, how long the condition has been present, and how stable (or unstable) the lesion is.

And finally, the last of our four knee disorders: traumatic patellofemoral instability. This refers to a chronically dislocating knee cap. Most of the youths who suffer this problem have some type of anatomic abnormality that puts them at risk for this condition. Most of these cases have to be treated conservatively without surgery because a good method of surgical repair has not been discovered yet. Techniques for successful reconstruction of ligaments around the knee cap are being investigated.

You can find much more information about pediatric knee problems on our website (www.eorthopod.com/public). The information we have provided here and additional information available on the website should give you plenty to work with. Good luck with your report!

As more and more children and teens participate in organized sports at a younger age, it is no surprise that knee injuries are on the rise. Fractures and overuse injuries top the list but tears of the anterior cruciate ligament (ACL) are becoming more common as well. And many times if the trauma creates enough force to tear the ACL, it’s enough to injure the soft tissues such as the meniscus (cartilage).

But as you have found out, studies do show that ACL reconstruction with meniscal repair in younger patients have better results than in adults. By younger patients, we are referring to children and teens who have not reached full bone growth. They are said to be skeletally immature.

It’s likely that while younger patients are still in the growth phase of development, their ability to heal is increased compared with adults. Growth hormones and other growth factors that aid in bone growth also assist in recovery from injuries.

There is also another reason why patients with ACL injuries combined with meniscal tears have better results now. And that is the improved surgical techniques designed to minimize trauma to the growth plate. In the past, any disruption to the growth plate (whether from surgical trauma or injury), could result in chronic joint stiffness and even growth arrest. If the bone stops growing prematurely for any reason, the child or teen can end up with one leg shorter than the other.

Surgeons are still researching the best way to repair or reconstruct torn ligaments and soft tissues of the knee in skeletally immature patients. Efforts to avoid the growth plate do seem to pay off with better results in the short-term. Long-term studies are not available yet. More research is needed to find the best way to treat each type of traumatic knee injury in this age group.

Sometimes it seems like children are made of rubber. They fall or they injure themselves in some way but they get up and bounce back as if nothing ever happened. But in reality, that’s not always the case. And with more children and teens participating in sports activities, there has been a rise in the number of musculoskeletal injuries in this age group.

One of those injuries is what your son experienced — a tear of the anterior cruciate ligament (ACL). The ACL is one of two ligaments that criss-cross inside the knee to give it stability. The ACL helps the knee bear the weight or load of our body while we move, twist, jump and turn.

A recent review of medical records for 371 pediatric patients who had surgery to reconstruct a torn ACL showed that being overweight is a risk factor for injury. And not just the primary (main) ACL injury, but also damage to the meniscus and chondral (cartilage) surface of the joint.

This type of study has been done in adults and found that the longer the patient waits between ACL injury and surgery, the greater the risk of meniscal and chondral damage. And that can mean damage that can’t be repaired and that leads to arthritis and loss of knee function in time. A study like this could potentially save children from the same fate. And this is the first study this large to really help answer some of these questions.

They found three factors that increase the risk of poor outcomes and degenerative changes in the knee. The first was a time delay between when the injury happened and when treatment was received. Children who had surgery in the first 150 days (five months) had fewer meniscal tears compared with children whose surgery took place later.

And as we already mentioned, obese children putting greater load on the damaged tissue were more likely to experience additional injury to the meniscus and chondral surface of the joint. In all children, the presence of a meniscal tear also increased the risk of further chondral damage. Pediatric patients older than 15 years had a higher rate of meniscal tears.

You are right to be concerned about your son’s excess weight. Obesity is becoming a major public health problem in all ages — including our youngsters. Exercise is essential in preventing early-onset of diabetes and later problems such as heart disease. Obese individuals (children and adults) are at increased risk for musculoskeletal injuries. Such physical injuries can have a lifelong impact.

When your son recovers from this episode, perhaps swimming, biking, or some other noncontact sport might be a helpful way to lose weight without serious injury.

You should really ask your doctor these two questions. And you don’t necessarily have to go back for another appointment before discussing these important issues. You can call the physician’s office and ask to speak to the doctor’s nurse or assistant. Tell that person you would like to speak to the doctor and explain why. You will find most medical staff very willing to answer patient’s questions and help guide you through the process.

The decision to have surgery or try conservative care first (usually medications and physical therapy) is based on many factors. Your age, weight, and presence of other health problems (like diabetes) are important.

The surgeon usually checks carefully for any sign of other injury to the knee. It’s not uncommon for the force of an injury that is strong enough to tear the ACL to also be strong enough to damage the meniscus (knee cartilage) or the cartilage that lines the joint (referred to as chondral tissue). If that’s the case, then surgery is considered sooner or later.

It is important to prevent additional injury to the knee. An unrepaired, damaged joint can eventually develop painful arthritis. And at an early age at the time of injury, that could happen long before you become the age of a grandmother.

So, whatever your physician advises you, we would strongly encourage you to follow carefully. A little time at this end protecting the joint (which may mean not riding for awhile) will pay off in the end. And being a horse lover myself, I know there’s plenty to do for and with them everyday that doesn’t involve riding. So you don’t have to give up everything all at once or forever!

Age 55 used to be considered “too young” for a total hip replacement. Concerns about how long the implant would last, bone loss with future surgeries, and a high rate of complications often meant patients in pain just had to tough it out and wait. Now patients as young as 14 years old are having hip replacement surgery. There are many challenges and complexities involved with total hip replacement in young patients but the results seem to be well worth it.

Most of these surgeries are being done for young adults who have severe hip damage or deformity. Such significant changes to the hip are mostly caused by osteonecrosis (bone death), osteoarthritis (usually the result of a previous injury), or juvenile rheumatoid arthritis. The goals of surgery are to relieve pain, improve motion, and restore function.

One of the reasons total hip replacements are now possible in young adults has been the switch from cemented to noncemented implant (called component) parts. Cementless cups and heads means less bone is lost when removing the implants if and when they need to be redone after 10 or 15 years. Bone loss often means leg length shortening so this feature helps reduce leg length differences, too.

A second reason results are better these days making earlier hip replacement possible is the advancement of surgical techniques. Minimally invasive approaches, muscle preservation, imaging studies to help identify structural deformities also help produce improved outcomes.

If your granddaughter has had previous surgeries there can be scar tissue to deal with and the presence of other hardware (pins, screws, metal plates). You mentioned the presence of severe muscle and joint contractures (stiffness) as the reason for the hip replacement so we know that is a factor. Careful evaluation and pre-operative planning is advised (more than is needed for older adults who just have degenerative osteoarthritic joint changes).

The surgeon must choose the best approach and implant possible for each patient. Sometimes this decision requires special imaging studies. Magnified X-rays, MRIs, and CT scans give the surgeon a three-dimensional (3-D) understanding of the joint angles, deformities, bone condition, and bone/joint size. Special thought and care goes into removal of previously used hardware before implanting the new hip joint.

Patients can expect some bumps along the road due to the possibility of complications, which still remain high in many cases. But with today’s more modern approaches, results are excellent.

Young children with a fractured femur (thigh bone) can be treated in a number of different ways. Most involve casting of some sort. To prevent movement and allow the bone to heal, a spica cast is used most often. This type of cast starts at the waist and goes all the way down to the toes.

The spica cast may be single leg or double-leg. The single leg cast ends above the hip on the uninjured side. This type of cast leaves the uninjured leg free to move. The double leg cast immobilizes the injured leg from waist to toes and covers the other hip down to just above the knee. Not being able to bend at the hips (and knee) for four to six weeks presents some difficulties for families caring for young children.

Treatment of femoral fractures like the kind you described is with spica casting. This is considered “best practice” based on recommendations from the American Academy of Orthopaedic Surgeons (AAOS). Cast immobilization avoids surgery with anesthesia, scarring, and the possibility of complications.

Surgeons recognize that casting has its downsides. Caring for a child in such a bulky cast is no easy task. Transporting the child in the car seat or car, toileting, and lifting and carrying the child are some of the challenges the family members or caretakers face.

But the good news is that a single-leg spica cast is possible for some children with this type of injury. They must not have more than a 25 mm shortening of the bone or surgery to pin or plate the bone. A recent study from The Johns Hopkins Hospital in Baltimore, Maryland reported on the benefits of a single-leg spica cast. They said their patients’ parents and care givers reported taking fewer days off from work to care for the child.

The single leg cast could also be molded with enough hip and knee flexion (bend) to allow the child to sit in a special car seat. And the children with single-leg spica casts could sit in chairs more comfortably. Children in this type of cast could even walk a little bit. Attendance at school should be possible but your surgeon will advise you according to what your child needs. You may want to let the school know of any special needs your child will have during this time of immobility.

Clubfoot also known as Congenital Talipes Equinovarus describes a position of the foot a baby is born with. The foot is turned under and towards the other foot. When broken down into its parts, equinovarus means that the toes are pointed down (equinus) with the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

This twisted position of the foot causes problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight, stiff foot that cannot be placed flat on the ground for walking. To walk, the child must walk on the outside edge of the foot rather than on the sole of the foot.

Until recently, most experts believed that the deformity was due to the foot being stuck in the wrong position in the womb. As development progressed, the foot could not grow normally because it was turned under and held in that position. Today, most information suggests that clubfoot is hereditary, meaning that it runs in families. It is not clear what genetic defect causes the problem. But just because your uncle has this condition is not a guarantee that your baby will have it, too.

The successful treatment of clubfoot today relies on a noninvasive method named for the surgeon who developed it: the Ponseti Method. This type of treatment is started as soon as possible. The foot is manipulated (moved) to stretch and loosen the tight structures. The foot is then placed in a cast to hold it in a corrected position. This is repeated every one or two weeks until the deformity is corrected or surgery is performed.

Sometimes a minor surgical procedure is required to lengthen the heel cord (fascia or connective tissue that connects the calf muscle to the heel bone). After casting is completed, the child wears a brace for several years. In the end, the results are excellent and amputation is not required. This treatment is a definite shift in how clubfoot is handled compared with when your uncle was a child.

Clubfoot is not a rare or new condition. This condition has been described in medical literature since the ancient Egyptians. It is a congenital problem, which means the condition is present at birth and occurred during fetal development. The condition affects both feet in about half of the infants born with clubfoot. Clubfoot affects twice as many males as females.

Clubfoot is a term that describes the position of the foot your baby was born with. The foot is turned under and towards the other foot. The medical term for this problem is equinovarus. When broken down into its parts, equinovarus means that the toes are pointed down (equinus) with the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

This twisted position of the foot causes problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight, stiff foot that cannot be placed flat on the ground for walking. To walk, the child must walk on the outside edge of the foot rather than on the sole of the foot.

Fortunately, treatment is quite successful using a method developed by Dr. Ponseti. This type of treatment is started as soon as possible (usually within the first week after birth). The foot is manipulated (moved) to stretch and loosen the tight structures. The foot is then placed in a cast to hold it in a corrected position. This is repeated every one or two weeks until the deformity is corrected.

Your pediatrician will guide you through this process. You will be referred to an orthopedic surgeon immediately — often while the baby is still in the hospital. Treatment may even begin before you take the baby home but if not, then within the first week. If this is not what happens where you are, then seek the services of an orthopedic surgeon who has experience with the Ponseti method. Studies show excellent long-term results with this treatment.

You are not alone in your concerns. Orthopedic surgeons treating these injuries have expressed concern publicly. Even so, the number of ATV sales has continued to rise and along with it the number of children and teens riding these vehicles. Not only that, but the vehicles have become heavier, larger, and faster. Roll-over accidents resulting in spine injuries increased by 476 per cent between 1997 and 2006.

Children are more likely than adults to be injured in an ATV accident for several reasons. Of course, they are usually smaller in size compared with adults. They are no match for a 500 pound (half ton) machine. In this study, only 14 per cent of the group was wearing a helmet. This is typical of what has been reported in other similar studies as well.

Children and younger teens have less muscle strength compared with adults. Other factors include decreased depth perception, level of emotional maturity and cognitive ability, and experience. Females are more likely to experience a spine injury due to a phenomenon referred to as vehicle-rider mismatch. They are simply outweighed by these machines and have more trouble correcting or preventing accidents, especially rollovers.

Older teens were more likely to have spine injuries. This may be explained by the fact that they have reached full growth (skeletal maturity) and have less flexible bone structures. Their spines are more adult-like with less ligamentous laxity (looseness) and more upright (vertical) positioning of the spinal (facet) joints.

The authors of a recent study on ATV-related injuries in children from the University of Tennessee concluded that ATV-related injuries are high-energy resulting in multiple (and often very serious) injuries. Almost half of the children involved were younger than 16 and were not wearing a helmet. Surgery was required for more than half the group at a cost of nearly $75,000 per patient!

Your concerns are well-founded. These facts suggest the need for more education and legislative efforts to change this pattern of behavior.

It is a fact that thousands of children are being seriously injured in all-terrain vehicle (ATV) accidents every year. The number of accidents and injuries has doubled in the last 10 years. Children are less likely to be riding ATVs compared with adults but they make up a full one-third of all injuries. And some of those accidents result in death.

Orthopedic surgeons treating these injuries have expressed concern publicly. Even so, the number of ATV sales has continued to rise and along with it the number of children and teens riding these vehicles. Not only that, but the vehicles have become heavier, larger, and faster. Roll-over accidents resulting in spine injuries increased by 476 per cent between 1997 and 2006.

In a recent study from the University of Tennessee, surgeons compiled information from their records to get an idea of how many and what kind of ATV-related injuries are being treated at their clinic. They divided them up by age (birth to 15 years and 16 to 18 years) and by type of injury (head/skull, trunk/abdomen, nonspinal orthopedic).

Some children had more than one type of injury including spine and nonspinal locations. Most of the spine injuries were single level injuries. In a smaller number of children, multiple spine injuries (fractures, spinal cord injuries, nerve root injuries) were recorded. More than half the children in the study required surgery.

Children are more likely than adults to be injured in an ATV accident for several reasons. Of course, they are usually smaller in size compared with adults. They are no match for a 500 pound (half ton) machine. In this study, only 14 per cent of the group was wearing a helmet. This is typical of what has been reported in other similar studies as well.

Children and younger teens have less muscle strength compared with adults. Other factors include decreased depth perception, level of emotional maturity and cognitive ability, and experience. Females are more likely to experience a spine injury due to a phenomenon referred to as vehicle-rider mismatch. They are simply outweighed by these machines and have more trouble correcting or preventing accidents, especially rollovers.

There are different treatment methods used for femur (thigh bone) fractures depending on the child’s age, location and severity of the fracture, need for traction or surgery, and so on.

The American Academy of Orthopaedic Surgeons (AAOS) has recommended the use of the double-leg cast called a spica cast for diaphyseal (shaft or long part of the bone) fracture of the femur. To prevent movement and allow the bone to heal, the spica cast is used most often. This type of cast starts at the waist and goes all the way down to the toes.

A single leg cast can be used in some situation. This type of cast ends above the hip on the uninjured side and leaves the uninjured leg free to move. The double leg cast immobilizes the injured leg from waist to toes and covers the other hip down to just above the knee. By anchoring both hips and thighs, better control over the fracture site is possible.

The ages of children who would benefit most from spica cast treatment for are between six months and five years old. This approach is actually referred to as “best practice” medicine based on available evidence. Cast immobilization avoids surgery with anesthesia, scarring, and the possibility of complications.

Surgeons recognize that even casting has its downside. Skin problems can develop under the cast. Too much pressure can cause swelling causing a compartment syndrome. And, of course, caring for a child in such a bulky cast is no easy task. Transporting the child in the car seat or car, toileting, and lifting and carrying the child are some of the challenges the family members or caretakers face.

Children with shortening of the bone due to the fracture will require reduction
(restoring the length of the bone) before casting. More than 25 mm of shortening should not be put in a cast until reduction has been done. Surgeons evaluate each individual child when making the decision about treatment. You can certainly bring this question up next time you see the surgeon and find out why the double-leg cast was required. There is likely one or more reasons why this was the recommended treatment.

Falls and throwing injuries are the two most common causes of medial epicondyle (elbow) fractures in children and teens between the ages of seven and 15. The medial epicondyle is located on the inside of the elbow. It is the place where several muscles and ligaments of the forearm attach (flexor muscles, pronator teres, medial collateral ligament).

The mechanism of injury is usually a valgus force on the elbow strong enough to pull these muscles and ligament off the bone taking with it a piece of bone. A valgus force goes from the lateral or outside edge of the elbow to the medial or inside of the elbow. This type of injury with a bone fragment attached to soft tissue is referred to as an avulsion fracture.

The child may feel or hear a popping sensation at the time of the injury. This will be followed by pain. Elbow dislocation is common and nerve damage is seen in up to 15 per cent of all patients with this type of fracture.

The goal of treatment is to heal the fracture, of course, but also to help the child regain normal motion, strength, and function. In the case of an athlete, return-to-sport and play at a preinjury level is ideal. The surgeon will use X-rays to guide the initial treatment decision.

Some children will be able to be treated with a conservative course of care (no surgery required). It sounds like this describes your nephew’s situation. If there are no complicating factors, he will likely be in the cast for four to six weeks. Reported results are usually quite excellent.

He will have to keep the cast dry, which limits water activities. In some situations (e.g., showering, possibly boating) a plastic bag can be taped around the arm to keep it dry. The hospital staff will give you a sheet of instructions. Follow those closely and report any new or unusual symptoms that might develop (hand swelling, finger numbness and tingling, cold fingers).

Many cultures have practiced swaddling their babies. Native Americans used a cradleboard or “papoose” carrier. More modern use of this positioning relies on a blanket or diapers. The child is placed in a straight position with arms and legs held to the sides. The effect is to create neutral warmth, which is calming to the nervous system. There is evidence to support the idea that babies sleep better and cry less in swaddles. There is also evidence of decreased risk of sudden infant child syndrome (SIDS) for babies who are swaddled.

But the question has been raised about the potential harm this positioning may have on the hips. A straight position held too long can lead to hip subluxation (partial dislocation) or even full dislocation. Children’s hips need the opportunity to move in all directions, especially hip abduction (away from the body) in order to fully form a deep, stable hip socket.

In order to study the effect of swaddling, researchers from China swaddled baby rats. Studying this problem in humans would not be considered ethical so animal studies are the next best way to investigate potential harm to humans. They used four groups of rats.

One group (control group) was not swaddled at all. The other three groups were swaddled for varying lengths of time using surgical tape to hold the hind legs together against the body. Group two (early swaddling) was held in the swaddling position immediately after birth and for the first five days of life. Group three was swaddled for the second five days. Group four was swaddled early (first five days) and for a prolonged or extended period of time (total of 10 days).

The rats were allowed to return to normal movements for three months and then the hips were X-rayed and examined with dissection. They found that the rats who were swaddled the earliest and longest had more cases of small, deformed femoral heads (round bone at the top of the thigh bone that fits into the hip socket). This group was also most likely to have hip subluxations and/or dislocations. And the cartilage growth that forms the hip socket was deformed or distorted.

At the other end of the continuum, the control group had perfectly formed hips with no problems of any kind. In the two remaining groups, the early swaddling group had the worst results with more hip dysplasia (shallow hip sockets), more subluxations, and more dislocations compared with the late swaddling group. Female rats were more likely to have hip problems in general but especially in the early swaddling group.

The value of this study is to help prevent developmental dysplasia from forming in human babies. The authors suggest that the practice of swaddling should be avoided in humans because of the potential negative effect on hip development. It is important to find other ways to achieve the same benefits of swaddling without binding the hips/legs.

The authors were unable to explain why some hips subluxed or dislocated while others did not. Further studies are needed to examine some of the reasons why some rats developed problems and others didn’t. There may be a way to predict which babies can be swaddled safely and those who must rely on other means of calming and relaxation.

Developmental dysplasia of the hip (DDH) develops either in utero (in the uterus) or during the first year of life. It may or may not be present at birth. In this condition there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket).

DDH can be mild to severe. In mild cases called unstable hip dysplasia, the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called subluxation. DDH can affect one or both hips but you are right that the left hip is affected more often.

The reason for this may be the position of the child while in the mother’s uterus. Ultrasound images show a tendency for babies’ left hips to be pressed up against the mother’s sacrum. This effect could contribute to the greater number of cases of left hip dysplasia in infants.

There is a recent summary of current treatment recommendations put out by members of the American Academy of Orthopaedic Surgeons. The summary provides a 16-point clinical practice guideline for the treatment of osteochondritis dissecans (OCD). Although OCD can affect several areas of the body (ankle, elbow, knee), this review is strictly limited to the diagnosis and treatment of the knee.

The guidelines are meant to inform physicians and surgeons of the best practice recommended for this condition. The idea is to present what the evidence shows from studies so far that can aid them in helping patients obtain the best results possible. The problem is that so much of the evidence is weak or inconclusive. Where there is agreement (called consensus), it is usually based on expert opinion not necessarily hard evidence.

We can give you a brief summary of the current treatment guidelines. You can read the full, detailed summary (with explanations) at: http://www.aaos.org/research/guidelines/OCD_guideline.pdf. The committee was unable to recommend for or against nonoperative care for children with OCD that does not cause pain or other symptoms. Likewise, the committee was unable to recommend for or against surgical drilling in patients with symptoms after nonoperative care but with a stable lesion.

Other areas where the research remains inconclusive include: 1) whether or not to take X-rays of the other knee once OCD has been discovered, 2) which type of cartilage repair works best when surgery is needed, 3) whether to treat patient with or without symptoms who are fully grown (skeletally mature) in a similar fashion, and 4) whether or not patients should have repeat or follow-up MRIs when they are skeletally mature without symptoms.

There are some areas where the committee could offer guidelines based on agreement (referred to as consensus). Consensus means the committee agrees on the recommendation even though there isn’t enough reliable evidence to prove the guideline is accurate. For example, most experts agree that skeletally immature patients should be offered surgical correction when the lesion is unstable or shifted but still salvageable.

Likewise, the committee agreed that symptomatic patients who are skeletally mature should be offered surgery when the lesion is unstable or displaced. After surgery, all patients should be provided with physical therapy. X-rays and/or MRIs should be taken to assess healing after treatment, especially for those who are still experiencing painful symptoms.

The lack of strong, conclusive evidence shows us the need for better designed (and more) studies in this area of medicine. Even with the current evidence and recommendations, each patient must be evaluated and treated on an individual basis. Decisions made about management and treatment techniques to use are determined by the patient in consultation with the physician.

When osteochondritis dissecans (OCD) affects the knee, it’s mostly at the end of the big bone of the thigh (an area called the femoral condyles. A joint surface damaged by OCD doesn’t heal naturally. Even with surgery, OCD can lead to future joint problems, including degenerative arthritis and osteoarthritis.

That’s why the care and management of this problem are important. Getting the best results possible may help prevent problems later. 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. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

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. It also means that the lesions cause pain and problems when walking and putting weight on the knee. It is more common for the lesions to occur on the medial femoral condyle, because the inside of the knee bears more weight.

Nonsurgical treatments help in about half the cases of OCD affecting children (called juvenile OCD or JOCD). The goal is to help the lesions heal before growth stops in the thighbone. Even if imaging tests show that growth has already stopped, it is usually worth trying nonsurgical treatments. When these treatments work, the knee seems as good as new, and the JOCD doesn’t seem to lead to arthritis.

Some patients who are too near the end of bone growth may not benefit with nonsurgical treatment. Surgery may also be advised if and when the lesion becomes totally or partially detached. There are several ways to fix it in place. In some cases, the loose fragment will just have to be removed.

Repeat imaging studies help surgeons see where the lesion is and how deep, large, or severe it may be. This information can be extremely valuable in planning the next step in treatment. Although there isn’t enough reliable evidence to support this practice, experts who treat OCD agree that serial X-rays and/or MRIs to assess healing are advised for patients who still have symptoms even after the first round of treatments.

Any fracture affecting the growth plate of bones in children can result in stopping growth. Disturbance of growth after fracture of the distal femur (bottom end of the thigh bone just above the knee) is a particularly vexing problem. That’s because this is where the fastest growth plate in the body is located. Young children can experience as much as a three-inch difference in leg length from a fracture of this type.

Assessment isn’t always easy. There can be more damage present than is visible with standard X-rays. If the radiologist sees a slight fleck of bone next to the growth plate or a little bit of widening or other irregularity of the growth plate, a CT scan may be ordered. As a precaution, any suspicion of growth plate disruption is treated with a full leg cast (up to the groin) for four weeks. Obese or young patients may need a full hip-to-foot (spica) cast to hold the leg still during the healing phase.

Growth plate fractures are diagnosed and classified using a standard model called the Salter-Harris (SH) classification. Fractures in this area are divided into four groups (SH I, II, III, and IV) depending on severity. Severity is determined by the number of bone fragments, presence of displacement (separation), and size of displacement.

As you might imagine, more severe fractures (SH III and IV) are the most likely to develop growth arrest, arthritis, and other complications. Surgery is advised whenever the fracture is displaced. For a child who was put in a cast now needing surgery, there must be a reason for this decision. Has the fracture separated or failed to heal? Perhaps the bone is healing with poor alignment putting your child at increased risk for posttraumatic arthritis.

The procedure may be needed to put any pieces of nonhealing or poorly aligned bone back in place. Everything will be held together with wires, pins, or screws until healing has occurred. Wires are used for small fragments. Pins and screws are used for large bone fragments. The surgeon can place the hardware through the growth plate but must try and avoid going through the knee joint itself. The child is then put back in a cast for at least a month (up to six weeks).

With this information in mind, you should be able to ask the surgeon to explain (maybe for a second time — that’s okay, too) the need for a change in treatment from nonoperative to operative care. Don’t hesitate to ask additional questions until you understand fully what’s going on and why.

Experts in orthopedic medicine do advise monitoring for complications and especially for growth arrest for up to 12 months following a distal femur fracture in children who have not reached their full growth yet. Fracture position is also monitored with serial X-rays (taken weekly) during the first eight to 10 weeks. Any sign that the fracture is not healing or healing in a misaligned position is an indication that surgery is needed.

Every effort should be made to line up the joint surface during treatment for fractures of the distal femur. This will reduce the risk of growth arrest and/or the development of posttraumatic arthritis in young children who have not yet reached full skeletal maturity (i.e., they are still growing). Patients must be closely monitored for any potential complications including infection, loss of reduction (the fracture opens up again), loss of blood supply, and of course, growth arrest.

Any fracture affecting the growth plate of bones in children can result in stopping growth. Disturbance of growth after fracture of the distal femur (bottom end of the thigh bone just above the knee) is a particularly vexing problem. That’s because this is where the fastest growth plate in the body is located. Young children can experience as much as a three-inch difference in leg length from a fracture of this type.

In addition to creating a difference in leg length from one side to the other, growth arrest affecting the distal femur can cause a change in the angle of the knee. Later, posttraumatic arthritis can occur because of the affect of the fracture on the joint itself. That’s why weekly X-rays are taken in an effort to monitor and prevent any of these potentially serious problems from developing.

Your team of physicians will be trying to find the best way to stabilize the femoral fracture while minimizing pain, maximizing comfort, and preventing scarring or complications. The two basic treatment options are: conservative (nonoperative) care with the cast you mentioned and surgery. The operation is designed to apply some type of hardware to help hold the broken pieces together while the bone heals. This process is referred to as surgical fixation.

But before we fill you in on the surgical side of femoral fracture fixation, let’s take a quick look at nonoperative management. Cast immobilization is a possibility for some children. The cast goes from hip to toes and is called a spica or hip spica cast. Conservative care of this type is possible when the patient is a young child or a small child (up to 60 pounds).

The benefits of this type of treatment include no surgery, very short time in the hospital, avoiding scars from surgical incisions, and preventing infection. The downside of cast immobilization includes the child has to wear a hot, bulky cast and you as the parents have to care for the child who can’t bend at the waist, roll over, use a toilet, or walk.

There is also the possibility that the fracture will heal improperly when only held in place by a cast. The fracture might separate, a process called “loss of reduction.” Or the broken bones could shift the other way, overlapping each other causing shortening of the leg. But, if it doesn’t work, the child could always still have surgery.

Now let’s consider the pros and cons of surgical fixation. There are two common choices here as well: elastic stable intramedullary nailing and locked intramedullary nails. Elastic, slightly flexible long nails have been the most popular choice for the last 20 years. Titanium has replaced stainless steel making it possible to have a narrow, lighter, less rigid rod down the center of the bone. The child does not have to be in a cast or brace and that is a big advantage. The flexibility of the nail(s) makes it possible for the fracture to withstand some load or force without losing stabilization.

There is some debate about whether or not the nails should be removed after the fracture has healed fully. Pulling the nails back out means another set of small incisions. Sometimes the nail doesn’t come out easily or breaks in the process. That can add another dimension of complexity. While the nails are in place, there can be some irritation and pain at the site where the nail was inserted.

The more rigid locked intramedullary nails are used for adults but also work well for older children/teens or heavier children. They are also the best choice when the fracture site is broken into many little pieces of bone or unstable for any other reason. This type of fixation does not have to be removed.

The surgeon will weigh all of the pros and cons of each approach and evaluate each child individually when deciding what is best. Factors that must be taken into consideration include the child’s age, weight and size, and type and severity of fracture. The surgeon’s own level of experience and expertise will make a difference along with any other injuries (especially soft tissue trauma) affecting the leg.