FAQ Category: Child

In the past back pain in a child or adolescent was thought to be uncommon and always considered a serious problem. Studies now show that children have more episodes of back pain than ever known. Even so, back pain in young people is still a yellow (warning) flag.

Certain symptoms are especially predictive of a more serious problem. Fever, night sweats, constant pain, and night pain fall into this category. When two or more of these symptoms occur together, cause for concern rises. The presence of all four symptoms must be medically evaluated.

Pain that is not relieved with analgesics or change in position also requires a medical exam. Likewise, pain that is made better or worse by eating is also a red flag. Check your son’s temperature during the day and at night when he wakes up. Ask about symptoms with eating and any changes in bowel movements or patterns.

Your doctor will want to know anything like this out of the ordinary. Make an appointment as soon as possible. A specific diagnosis is needed before you can know what’s causing this unusual symptom.

The onset of puberty is certainly a possible cause of intermittent low back pain. Both the stress and hormonal changes at this time in a young person’s life can lead to back pain. A medical exam is really needed to make a specific diagnosis.

The doctor will take a history and perform certain tests and measures of motion, strength, and neurologic function. The patient’s signs and symptoms combined with the exam findings often point to the exact cause of the problem. The correct treatment can’t be applied until this happens.

In some cases, blood tests are needed to rule out infection or leukemia. The doctor may think an X-ray is needed. Doctors are careful to avoid unnecessary radiation exposure and expense so these tests are not ordered routinely.

If the X-ray is negative, then an MRI may be needed. MRIs have replaced bone scans as a better way to identify problems in the spine.

A wait-and-see approach is often used for symptoms that come and go and have no known cause. Over time the symptoms may get better on their own. If a disease process is present, eventually the patient will get worse. Medical follow-up from the start of symptoms (a baseline) helps identify important changes that could lead to a diagnosis.

There’s no evidence of a genetic link with Perthes disease. Your children have the same chances of getting it as anyone. And scientists still don’t know what causes it. Poor nutrition is one possible theory. Abnormal blood clotting increases the chances of Perthes.

In this condition, the blood supply to the growth plate at the top of the femur (thighbone) is blocked. Forming blood that clots easier and faster than normal may lead to blockage of the small arteries going to the femoral head.

Be sure and let your pediatrician know of your own medical history of Perthes. Watch for any unusual signs and symptoms such as hip pain or limp when walking. When the doctor examines the hip, the motion of the hip is abnormal and restricted. Turning the leg inward causes pain. This usually means that the hip is inflamed and may have inflammatory fluid (called an effusion) present in the hip joint.

Sometimes problems in the hip cause knee pain instead of the hip pain. A child with knee pain and no obvious reason for it, or an abnormal walking pattern, should be examined for possible Perthes disease. X-rays of the hips are usually taken to make sure that Perthes disease is not missed.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. It’s also known as Legg-Calvé-Perthes disease in honor of the three physicians who each separately described the disease back in 1910.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. Over time, the blood supply comes back and the bone heals. This condition can lead to serious problems in the hip joint later in life. How the bone heals determines the final result.

Studies show a key factor in Perthes disease is the shape of the acetabulum (hip socket). The acetabulum is a cup-shaped, curved part of the pelvis that forms the socket. It forms a cover or shelf over the femoral head to hold the hip in the socket.

In Perthes disease, the femoral head disintegrates from lack of blood. As this happens, the acetabulum starts to change shape too. The lateral or outside margin flattens out and can even slope upwards. Without a deep socket, the femur can slip out or dislocate.

To rebuild the acetabular shelf, the surgeon will take a pie-shaped piece of bone from the patient’s pelvis and wedge it in above the acetabulum. The extra bone hangs over the femoral head and extends the coverage. With less likelihood of dislocation, the hip motion is saved, and there’s a better chance the acetabulum and the femoral head will keep their original shape.

Based on what you’ve told us, it sounds like your daughter may have a problem called slipped capital femoral epiphysis (SCFE). The capital femoral epiphysis is a growth plate at the top of the femur (thighbone).

The epiphysis is made up of cartilage until the bone stops growing. Then it hardens and becomes part of the bone. If shear forces are strong enough, this cap of cartilage can actually slip off the top of the bone.

According to data from the studies done so far, SCFE occurs as a result of obesity. If a girl is overweight, she has an increased risk of developing SCFE. Most cases begin around age 12 but this condition can occur as early as nine years old or as late as 16.

Racial differences may have more to do with socioeconomic factors than ethnicity. Since obesity is linked with SCFE, then poor diet associated with low income may be a key factor. Other factors may be at play in cases of SCFE in normal weight or underweight children.

Slipped capital femoral epiphysis (SCFE) is a hip condition that affects children ages nine to 16 most often. At the top of the femur (hip bone) is a growth plate (epiphysis). The epiphysis is made of cartilage until the bone stops growing and reaches full maturity. In SCFE, the femoral head fails at the weakest point, through the growth plate. As a result, a condition similar to a stress fracture develops. The top part of the femur actually slips away from the rest of the bone.

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.

The average age for the onset of SCFE is around 12-years old. Boys are affected more often than girls, especially black or Hispanic boys. There may be a genetic link but data collected so far point’s race, gender, seasonal variation, and geographic location as being more important factors.

For example, there are more cases reported in the Northeast and West compared to the Midwest and South. The reasons for this are unknown at this time. There are seasonal differences, too. In the north, there are more cases of SCFE during the summer. In the south, more than half the cases occur during the winter months between October and March.

Be sure and ask your pediatrician to check your son for this at his next check-up. Watch for symptoms of hip pain, limping, or loss of motion and report these right away. A simple X-ray can diagnose or rule out this condition.

Snapping hip syndrome is occasionally reported by dancers and other athletes such as long distance runners and soccer players. The condition is caused by a thick portion of the iliotibial band (ITB) flipping back and forth over the hipbone. The iliotibial band is a long band of fascia or connective tissue that goes from the side of the hip down to the side of the knee.

Girls and women are affected more often than boys and men. This is probably because of differences in the hip shape and contour of most females versus males.

Treatment is usually conservative with antiinflammatory drugs, stretching, and physical therapy. Steroid injections may help. Sometimes only one injection is needed. In other cases, the symptoms respond after a series of injections. The number must be limited due to local effects of the steroids.

If treatment fails, then surgery may be considered. The surgeon can make a Z-shaped incision to release or lengthen the ITB. Some surgeons cut out a diamond-shape portion of the ITB. This is done right over the greater trochanter, the place on the bone where the ITB is rubbing.

The surgery can be done with an arthroscope and a very small incision. This type of operation is called minimally invasive. It’s still surgery with potential complications, so nonsurgical treatment is always suggested first.

Your child may have a condition called trigger thumb. The joints of the thumb may be stuck in flexion. Another term for this is flexion contracture.

Several studies have been done to identify the nature of this problem. Is it congenital or does it develop as the child grows? The results of a recent study in Japan suggest that trigger thumb is not present at birth but occurs later. Some children develop trigger thumb in the first 12 months. For others, the onset was in the second or even third year.

Occasionally trigger thumb is linked with a chromosomal anomaly like trisomy 13. Regardless of the cause, treatment is required. Early intervention may take care of the problem. Surgery is needed when exercise, positioning, and splinting don’t work.

Researchers aren’t sure what is the cause of trigger thumb for most children. Does the child hold the thumb inside the palm because she can’t straighten it? Or does it get stuck in a flexed position because she doesn’t move it often enough?

It may be that the fingers are holding the thumb in a deeply flexed position. The position irritates the flexor tendon near the flexor tendon pulley mechanism. The tendon is covered with a lining called the tendon sheath. The beginning of the sheath is called the A-1 tendon pulley. The purpose of the pulley is to keep the tendons close to the bone. As the finger bends or flexes, the pulley keeps the tendons from sagging away from the bone.

Irritation leads to inflammation and closes off the space between the tendon and the tendon sheath. The tendon can no longer glide smoothly and gets stuck.

Treatment for this problem may include steroid injections, splinting, and passive and active motion to keep the tendon sliding and gliding. If these measures don’t work, surgery to release the pulley may be needed.

The first step is a medical exam with X-rays. Finding out the cause of the problem will guide you and the doctor in making treatment decisions. There could be a missing bone, an extra piece of bone, or even a fused joint. Most cases turn out to be one of three types of problems.

In Type one the bones of the thumb are normal but there is an extra triangular shaped bone. This extra bone is called an ossicle. It is wedged between the tip and the middle bone of the thumb pushing the tip to one side.

In Type two the bone at the tip of the thumb (called the distal phalanx) is abnormal. The growth plate at the end of the bone has a missing corner causing an angular deformity of the thumb.

In Type three, the middle bone of the thumb is abnormal. The growth center is triangular-shaped causing the bones to tip to one side.

Studies suggest early treatment gives the best result. Depending on the cause, he may not grow out of it. In fact, surgery to correct the problem may be needed. But again, a medical exam is needed before you can go any further with the “what ifs” of the situation.

Angular deformity of the thumb from abnormal triangular epiphysis isn’t a common problem. There are a few studies of children who have had corrective surgery and the results.

Some surgeons recommend taking out the abnormal epiphysis (growth plate). Careful removal of the cartilage is required with this surgery. Others suggest a partial excision of the odd-shaped bone for a better correction of the deformity.

Corrective wedge-osteotomy is another option. A pie-shaped piece of bone is inserted or wedged into the bone to tilt the bone in the opposite direction.

There are some problems with each operation. Removing the cartilage can result in early arthritis. Wedge-osteotomies can overcorrect the thumb causing a tilt in the opposite direction. Or the deformity can be undercorrected and the child ends up with a permanent tilt anyway.

Surgery before age five is best. It gives the bone and joints a chance to adapt and avoids shortening of the bone and narrowing of the joint.

Researchers have not been able to pinpoint the cause of back pain in many children and adolescents. Heavy back packs, too much time on the couch or chair watching television, and sports have all been blamed. There’s no proof yet that any of these is the problem.

Night pain is often considered a red flag for something more serious. But, in fact, a closer look may help explain what’s going on. Some simple things may be at fault. Take a look at the bed. Is the mattress old and broken down or does it give firm (but not too much) support?

Check the pillow as well. And try having your child sleep with a firm pillow between his lower legs. It should be turned lengthwise to support both the knees and the ankles. The pillow will probably fall out at some point but even some use can help. Keeping the legs in good alignment takes pressure off the spine by keeping the hips or pelvis level and without rotation.

Is your son wearing loose-fitting clothes to bed at night? Children sleeping in clothes with a tight fit or tight waistband can experience night pain and not realize what’s causing it.

If taking some simple measures of this type doesn’t help, then see a doctor. Medical tests may be able to identify an underlying physical problem.

In the past back pain in children was considered a major red flag. Doctors were concerned about infection or malignancy. Those are real possibilities but don’t occur very often.

In fact, it turns out children and adolescents up to age 18 have back pain just like adults. When the symptoms are linked to soft tissue or postural structures, it’s called mechanicalback pain or back ache.

If symptoms persist then it’s time to take a second look. Blood tests, X-rays, and possibly a bone scan may be in order. Blood tests can give an indication of infection or inflammation in the body. X-rays may show changes in the bone. Bone scans don’t always pick up primary bone tumors but they are very good at showing metastases to the bones from some other location.

Make a follow-up appointment with the doctor for your daughter. Express your concerns and ask for a re-evaluation of her problem.

Correction of deformity was the most likely use for ankle fusion or ankle arthrodesis in years past. The operation has been improved over the years. Its uses have expanded to include post-traumatic arthritis. Patients with other conditions causing pain and instability are also potential candidates for this operation.

Surgeons have better ways to position the fused ankle for optimum fusion and function. Besides bone graft, screws are also used to hold the ankle in place. Most patients report good results with the operation as it is done today.

Muscle atrophy of the calf is common after ankle arthrodesis. The major problem that occurs is degeneration in the other joints of the ankle and foot. Studies show that motion at the hip and foot is decreased after ankle fusion. Motion at the pelvis and knee don’t seem to change.

There may be some long-term results of these effects. More study is needed to see just what happens and to find ways to prevent future problems.

The new elastic stable intramedullary nailing (ESIN) system for long bone fractures have revolutionized treatment of femur fractures in children. By placing two curved rods inside the bone, opposing forces are placed on the bone to “reset” it during healing. This saves the family months and months of time in traction and casting. It also saves on the pocketbook in terms of overall costs.

The cost does go up, however, if and when the rods are removed. There’s still much controversy over this point. Not all surgeons agree. Some say to leave them in if they aren’t bothering the child. Others suggest there isn’t enough proof that it’s okay to leave them in. They should be removed to prevent future problems until we know better.

There is some concern that leaving the nails in a child will result in movement or migration of the nails as the child grows. They may end up sticking out of the femur causing pain or even a new fracture.

For now, there’s no right or wrong decision on this. Each surgeon and family must decide based on what seems best for the individual child.

It’s families and situations like yours for which a new system was designed. A new, flexible and curved rod system can be inserted down through the bone to hold it in place while it heals. The rod or nail (as surgeons refer to it) is called the Nancy nail.

Once in place this nailing system placed opposing forces on the bone. Such forces reduce or correct the fracture and stabilize or hold in place the entire bone. Sometimes called elastic stable intramedullary nailing or ESIN, this system has been around for the last 20 years.

Ask your surgeon about this method of treatment. There may be some reason why your child wouldn’t qualify but if not, it’s an option worth considering.

Scoliosis is an abnormal curvature of the spine. There are two main types of scoliosis. The first is called idiopathic scoliosis or IS. The cause of IS is unknown. It appears to affect adolescent girls more often than boys. The children with this type of scoliosis are in good health otherwise.

The second type of scoliosis is called neuromuscular scoliosis or NMS. There is usually an underlying systemic illness or other disease with this kind of scoliosis. Children with genetic conditions, cerebral palsy, muscular dystrophy, or spina bifida often have NMS.

Your family may welcome a chance to talk with someone close about this problem. If the time seems right, you may want to ask for an explanation of what the diagnosis means. Other questions such as, “Are there any other problems that come with neuromuscular scoliosis?” may help draw them out. Even if you are far away from the family, expressing interest and concern are often very helpful during this stressful time of a new diagnosis.

You probably remember the old song ‘Dem bones’ with the line “the hip bone’s connected to the thigh bone.” The entire leg is connected from top to bottom with each segment affecting the one above or below. Experts call this the kinetic chain.

Studies have shown weakness in the hip muscles with ankle injuries. For a long time researchers wondered if this reduced hip strength was what caused the ankle sprain or the other way around — maybe the ankle injury resulted in muscle weakness around the hip.

Either way rehab specialist such as your physical therapist test, measure, and treat the entire kinetic chain including hip strengthening with athletes coming back from an ankle sprain.

A recent study may have finally answered the cause or effect question. High school athletes from six different sports were tested preseason for two years. Hip strength and standing balance were the main measures.

By comparing hip strength in athletes who sprained their ankles with those who didn’t they found that hip weakness was most likely caused by the injury and not a cause of the injury.

Unfortunately, there hasn’t been one final result to hang our hats on. Researchers are still sorting out differences in sport type, training, anatomy, age, body mass index (BMI) and many other possible factors.

There’s been some concern that girls don’t increase in strength like boys do, and this may be contributing to the knee ligament injuries. The anterior cruciate ligament (ACL) seems to be at greatest risk. Landing jumps with the knees too close together has been studied as a possible cause of ACL injuries, too.

One of the most recent large studies of young athletes (ages 9 to 17) compared strength and lower limb control and alignment by age and gender. Leg strength and alignment were measured in over 1,000 young athletes (boys and girls). Three specific tests were carried out.

The results showed that girls’ hamstring strength stops increasing around age 11. Boys’ strength continues to increase until age 14. This may be a factor in the rate of ACL injuries. Lower limb (and especially knee) alignment didn’t change with increasing age or strength. Boys and girls were very similar in this area. Other studies have shown differences in the force of landings between boys and girls.

It’s likely that gender differences in ACL injuries is multifactorial — in other words, caused by many things combined together. It remains to be seen which factors are most important.

Legg-Calve-Perthes disease (also referred to as Perthes) is a condition affecting the hip in some young children. Boys and girls can both have Perthes but boys outnumber girls by five to one. Whites are affected 10 times more often than Blacks.

Perthes affects the top of the thighbone called the femoral head. That’s where a growth plate called the capital femoral epiphysis (CFE) is located in children. The growth plate is made of a special type of cartilage that allows the bone to lengthen as we grow.

In this condition the blood supply to the CFE is disturbed, causing the bone in this area to die. The femoral head flattens and collapses. The hip can dislocate leading to other problems. Cheilectomy is the removal of part or all of the femoral head.

Cheilectomy isn’t a common way to treat Perthes. A report of five cases from Korea confirmed it offers short-term relief of painful limping but doesn’t prevent problems later in adulthood.

With the top of the bone removed, one leg is shorter than the other. Limping developed even when wearing a shoe lift. All five patients in the study developed painful hip osteoarthritis (OA) by the time they were 30 years old. The authors concluded cheilectomy doesn’t help prevent OA in patients with Perthes.