FAQ Category: Child

Legg-Calve-Perthes (or just Perthes) disease is a condition that affects the hip in children between the ages of four and eight.Perthes was named in honor of three physicians who each described the disease.

In this condition, bone in the growth center of the hip (the capital femoral epiphysis) dies because of a lack of blood supply. No one knows exactly why this happens. Nutrition may be part of it since children who are malnourished are more likely to develop this condition.

Abnormal blood clotting is part of the problem. Children with Perthes have blood that clots easier and faster than normal. This may lead to blood clotting that blocks the small arteries going to the femoral head. Why just the hip?

Again, scientists aren’t exactly sure. One suggestion is the anatomy of the hip. The veins around the top part of the hip spiral around the arteries in young children. The veins are thin-walled in the upper part of the femoral head.

These two factors put together may result in sluggish blood flow in this area. Blood pooling can lead to blood clotting. Blood clots that clump together can block blood flow to an area.

Slipped capital femoral epiphysis is a condition that affects the hip in growing children. The growth center of the hip (the capital femoral epiphysis) slips backwards on the top of the femur (the thighbone).

Studies show that SCFE affects both hips in up to 63 percent of the cases. Pinning the unaffected side is one way to approach this problem. But there can be problems. Blood supply to the hip joint can get cut off. Bone destruction can occur around the pin used to hold the growth plate in place.

Some doctors suggest prophylactic (preventive) pinning only for children at high-risk for problems in both hips. This includes anyone with kidney problems, hormonal imbalances, or very young age when SCFE is diagnosed.

Since bilateral SCFE is linked with extreme obesity, weight loss and controlling weight gain are important factors to consider. Discuss your daughter’s risk factors with the doctor before making this decision. Ask about possible problems with and without this preventive step.

Spinal surgery for scoliosis can be a very complex operation. Blood loss is common. Studies show transfusion is needed in more than half the cases. The typical patient loses about 22 mL/kg of blood during spinal fusion for scoliosis. This translates to about two pints of blood per 100 pounds.

Children with scoliosis associated with other conditions such as cerebral palsy or muscular dystrophy are more likely to need blood transfusion. Preoperative blood donation is common for this type of patient.

Scoliosis does mean spinal curvature. Infantile refers to the young age of the patient. Idiopathic suggests there’s no known cause of the problem. In some young children scoliosis is part of another condition such as cerebral palsy or muscular dystrophy. Sometimes deformed vertebrae are the basis of the scoliosis.

The doctor’s first step is to search carefully for a primary cause for the scoliosis. MRIs are strongly advised for young children with curves measuring 20 degrees or more. The MRI will help show if there are any other problems with the developing spinal cord or brain.

For those children who truly have no obvious underlying cause, the diagnosis remains “idiopathic.” Boys and children born underweight seem to be at greatest risk for this type of scoliosis. The reason for this remains unknown.

Your child will need regular visits with the doctor during his growth and development. X-rays are usually taken every four to six months to keep an eye on the curve. Treatment is started if the curve gets worse quickly or when it goes past 35 degrees. There are a variety of treatment options depending on the age of the child and severity of the curve.

Doctors and parents are concerned about how many and how invasive surgeries are for some children with scoliosis. Researchers are actively looking for better and easier ways to manage this problem.

The recent development of a dual growing rod system has helped reduce problems with scar adhesion and rod breakage. It also makes it possible for the child’s spine to continue growing. Fusion can be delayed by as much as 10 years or more.

In the late 1990s Japanese scientists tried using a remote control system to lengthen the rods without surgery. The rod contained a motor attached to a radio-controlled receiver. Experiments were done on dogs. Problems occurred with the size of the implants. The receiver had to be put inside the abdominal cavity. No further results have been published.

In the meantime other methods of treatment remain under investigation. Staples along the anterior (front) portion of the spine are being used to stop uneven growth. Rib replacements are available now for children with absent or fused ribs. Studies are underway to reduce the number of operations needed. Finding less invasive ways of scoliosis correction is another goal of research.

Scoliosis of unknown cause in such a young child is called infantile idiopathic scoliosis. It can go away on its own but must be watched carefully until it does.

In the past doctors thought this problem was caused by the way the child was positioned in utero. This theory has been disproven now.

In the 1950s there was some research comparing babies in England versus babies in the U.S. There was some thought that putting the babies on their backs was the problem. At that time American babies were routinely placed prone (face down) to sleep. The incidence of infantile scoliosis was much smaller in these babies.

A recent review of scoliosis in young children brought this point back up. Doctors suggest a need to look at this problem again. Further research on positioning infants and the possible link to scoliosis should be examined.

In the meantime, ask your pediatrician for his or her best advice. A baby monitor is a good idea while also checking often on your baby during naptime.

OCD or osteochondritis dissecans is a condition in which a loose piece of bone and cartilage separates from the end of the bone. It usually affects the knee or elbow.

Standard nonsurgical treatment for this problem is reduced activity and non-weight bearing. The patient is often put in a cast to ensure limited use of the joint.

Cast disease refers to changes that occur in and around a joint that’s been immobilized for long periods of time. The joint becomes stiff. It doesn’t exactly fuse but it starts to act like it’s going to fuse to protect itself. The muscles start to atrophy or waste away from lack of use. The bone can even lose mass.

The best way to prevent this from happening is through movement and activity that doesn’t stress the joint or bone. Range of motion and isometric exercises work well for this problem. Follow your doctor’s advice and see a physical therapist. He or she can give your son a home program to do daily while waiting for healing to take place.

We are assuming that she had the surgery fairly recently. Most patients after spinal fusion for scoliosis wear a brace for the first three months or so. The brace helps hold the spine in neutral alignment while the graft takes hold and healing takes place.

The surgeon will recheck her after three months and take X-rays. The brace is usually stopped at that time. Be aware that the doctor may suggest a weaning schedule to gradually reduce wear time rather than just stop all of a sudden.

This gives the muscles and support structures of the spine time to regroup and take over the job of keeping the spine in good alignment. Exercise and activity is a very important part of rehab during this time. Encourage your daughter to follow all recommendations carefully. Don’t be afraid to ask questions, especially the ‘why’ question if it will help her remain compliant.

Let’s start with why she isn’t wearing the brace. Is it because of peer pressure or self-consciousness about how she looks? Are there skin sores or even ulcers? An ill-fitting brace can be fixed easier than dealing with the social issues.

Education is the next important key. Your daughter should be told how many degrees her curve is and how fast it’s changing (getting worse). The doctor can also estimate how much more growth she has left. This will help her see how much more the curve could progress. And she should be told that the curve could continue to get worse for a while after growth has stopped.

About 10 percent of the patients with AIS do stop wearing the brace. Some have difficulty breathing. Others have nausea while wearing it. Problems with skin breakdown are often named as the main issue. There may be social or psychologic problems.

So far long-term studies have focused more on what happens to patients years after treatment. Without some force to stop the curve it will get worse. Deformity with a visible rib hump is possible. If it gets severe enough the lungs and heart can be compromised affecting general health.

There are different types of scoliosis or curvature of the spine. The most common in older children and adolescents is called adolescent idiopathic scoliosis (AIS). Idiopathic means the cause is unknown.

Most children with AIS are faced with a primarily cosmetic problem (how it looks). The curve rarely progresses to become severe enough to cause problems with breathing and function.

Once the curve moves past 30 degrees some kind of medical treatment is advised. Bracing to stop the curve from getting worse is usually the first approach. If that doesn’t work then spinal fusion to prevent deformity may be needed.

Doctors follow patients with AIS carefully. If the child is still growing and the curve is getting worse rapidly then bracing is started. If the same conditions persist then surgery is planned. The best thing your daughter can do to avoid surgery is to wear the brace as presribed — usually 23 hours/day.

No. It’s a well-known fact that scoliosis or curvature of the spine can get worse after skeletal maturity. Fortunately this doesn’t happen in most cases. Curves greater than 30 degrees are the ones that tend to progress.

Some studies show one type of curve gets worse more often or faster than another but there’s no real overall agreement on this.

Measurements are taken by X-ray. A change of 10 degrees or less is not considered a real or true change. The curve must be more than 10 degrees greater to signal progression.

AIS is a curvature of the spine. It occurs in teenagers and has no known cause. It may gradually get worse or it can stay the same from the time it’s diagnosed into adulthood.

Conservative care is usually with bracing and exercise. Sometimes electrical stimulation is used. More advanced curves may require surgery to stop the curve from getting worse.

During the teen years you may expect to see your daughter have some mild psychologic distress over this problem. This is to be expected. Physical appearances and changes are very stressful to the average teenager without scoliosis. Being self-conscious may lead to low-self esteem. She may refuse to participate in physical activities or sports.

Pain is usually not a problem or only a minor problem with mild curves. Physical disability doesn’t usually occur unless the curve is severe and doesn’t respond to treatment.

Scoliosis or curvature of the spine can be very disabling if it gets worse and worse. Surgery is usually an option for patients whose curves are 45 degrees or more or rapidly changing. It sounds like you may have some time to follow through with the conservative care before making a decision about surgery.

Still, it’s a good idea to explore all options and ask the hard ‘what if’ questions. There are several long-term studies of outcomes for patients with adolescent idiopathic scoliosis (AIS). One such study from Switzerland followed people as long as 60 years after the AIS was first diagnosed.

In general patients did very well. Items used to measure results included pain, disability, and quality of life. For the most part pain was a minor problem and then only for people with curves much larger than your daughter’s. Psychologic distress was much more common during the teenage years compared to later during the adult years.

More intense pain and disability can develop later with larger curves. Lung problems and difficulty breathing are more common with severe curves of the middle back area.

Yes, children and teenagers can and do have lumbar disc herniations. It’s fairly rare as the most commonly affected person is an adult between the ages 40 and 50 years old.

It’s also possible that more children have disc problems than we ever know about. Studies of adults show a fair number of people who have disc damage and even herniations without symptoms. The same may be true for children.

At least one study has been done of children ages 16 and younger with disc herniations. They were followed for years into adulthood to see the outcome of surgery to remove the disc.

More than half had back and/or leg pain later on in life. Almost one-third had to have a second operation for disc problems.

More studies would be helpful since data on this problem is limited. Without a national data base, finding all the individual cases is difficult. As imaging technology continues to improve we may see a wider use of studies in younger groups.

When it comes to injury and bone or tissue repair, the odds are in favor of most children. They heal faster and better than most adults.

Elbow fractures are common injuries leading to nerve damage. Up to 20 percent of all children with an elbow fracture also have nerve injury. Most are mild and heal without treatment in the first weeks to months after the injury. If the broken bone fragment is displaced or moves, then it can cut into the nerve. Surgery may be needed in cases like this.

Your pediatrician and orthopedic surgeon will keep a close eye on her for the next six months. If there is no sign of healing or healing is very slow, then an EMG and nerve conduction tests will be done.

Osteochondritis dissecans or OCD is seen most often in children and young adults. In OCD a piece of joint cartilage pulls away or tears along with the first layer of bone under the cartilage. Sometimes the fragment separates partly from the joint surface. In some cases it is completely separated.

Reports estimate about 20 cases in every 100,000 people so it’s not too common. Children with OCD range in age from seven to 19 or 20 with an average age of onset of 13 years. The condition was first described over 100 years ago.

The cause remains unknown. It could be a combination of defects in how the bone is made, genetic tendencies, trauma, or even loss of blood supply to the area. The shape of the meniscus may have something to do with it, too. According to a recent study in Japan a narrow crescent-shape meniscus instead of a mature crescent-shape is linked with increased numbers of OCD.

More study is needed to find the cause and ways to prevent this condition.

When do you see and hear this snap? It may be there’s a thickened rim of meniscus. As the femur (thigh bone) slides and glides over the tibia (lower leg bone) where the knee forms the round surface of the femur moves across this rim making a noise such as a click or snap.

Sometimes this piece or flap of tissue is torn and gets pushed away from the bone. Other times it’s being pushed back in place. Either direction can cause a sound like you describe. There may not be anything you can do about it now but it should be watched. An X-ray or MRI may be needed.

Over time there’s a danger that trauma from a sports injury or athletic event can cause a tear of this area. In some cases repeated smaller motions (microtrauma) causes the rim to tear.

Chronic pain from a traumatic sternoclavicular joint (SCJ) dislocation can present a real problem. Besides pain the patients have limited use of the arm. They can’t push up with that arm to get out of bed. They can’t push the grocery store door or other heavy door open. Sleeping on that side is difficult if not impossible.

Yet reports so far don’t show the best results with surgery to repair or reconstruct the joint. A recent study from Children’s Hospital in Boston gives us a little better long-term view. They followed 24 patients ages 12 to 23 for up to four years after SJ dislocation and surgical repair.

Most of the patients reported being pain free after the operation. Over 85 percent had to restrict their sports activities. Baseball pitching or other overhead throwing activities, water skiing, and lifting weren’t ever the same. Most patients said they just couldn’t do these activities. Sleeping was still a problem. They couldn’t lie on that side for any length of time.

Based on the results of this study, it’s fair to say that if pain relief is what you’re after then surgery may be just what you need. If you’re expecting to get back to all your former activities, you may be disappointed.

Your decision may be based on cosmetics versus function. Is the doctor advising surgery to prevent the problem from getting worse with possible pain and lost motion? Or are you asking for surgery to shave off the bump because of how it looks? For women the bump may rub on under garments or clothing causing skin problems.

A bump in the front suggests an anterior (forward) dislocation. So you aren’t likely to be at risk for a punctured lung, nerve, or blood vessel. These are potential problems for patients with posteriorly displaced injuries.

Many times a soft figure-eight harness is used early on to bring the collarbone back into a more normal alignment during healing. Since you didn’t mention how long ago your injury occurred, we aren’t sure this treatment will help you.

Conservative care is almost always advised first. There just aren’t a lot of studies done to show that surgery is needed or makes a difference in the final outcome. If appearances are important you must keep in mind that the result may not be perfect. Sometimes the bone grows another bump around the one that was taken off. There’s usually a small scar. Infection is always possible though unlikely.

There are different ways to approach this problem. Some of the choices depend on the patient’s age. As your doctor suggests, a child or young adolescent hasn’t stopped growing yet. The body has very powerful reparative processes at this stage of life. It’s quite true that a bone fracture of the clavicle (collar bone) will remodel itself.

Older patients may be faced with the risk of chronic dislocation or chronic pain from an unstable joint. Surgery to remove part or all of the clavicle may be needed. Other choices include reconstruction. The surgeon can take a tissue graft and wrap it around and through the bone in a figure-eight “suture.”

In the case of a 14-year old, if conservative care doesn’t work then surgery is still an option later.