FAQ Category: Child

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.

The Pavlik harness is a special device worn over the clothing in infants and babies who have a shallow hip socket in danger of dislocation. The condition is called developmental dysplasia of the hip or DDH.

The harness was first introduced in 1946 by Dr. A. Pavlik and has been in continued use ever since. It puts the child in a frog-leg position with the hips flexed and opened wide. In this position the head of the femur (thigh bone) is in its most stable spot inside the shallow hip socket. This helps keep it from dislocating while the bone and cartilage are forming.

In mild cases parents are often instructed to double or triple diaper in place of the harness. For some babies that method works just fine. The harness offers a high rate of successful results when used correctly. It must be used early on during the first weeks after birth or as soon as the condition is discovered.

The device is worn for at least two months, sometimes longer. Then there’s a weaning period when the Pavlik harness is slowly phased out. Usually the doctor has the parents go from using the harness to double or triple diapering and gradually phasing the diapering step out, too.

If the hip won’t stay in the socket then the harness isn’t going to work. A more rigid splint will be needed.

The Pavlik splint you are using holds the infant’s legs open wide and bent at the hips. This puts the head of the hip joint right into the hip socket.

The problem of developmental dysplasia of the hip or DDH is that the hip socket is too shallow. Keeping the ball of the joint up in the socket helps it form properly with the right amount of bony coverage. That’s important to prevent the ball from slipping out of the socket, a problem called hip dislocation.

The earlier the harness is started, the better her chances for a good result. At least one study showed waiting more than 16 days had a higher failure rate. Taking the harness off too early can also spell disaster. Children must be followed for up to five years to make sure the results are good. A successful result with the Pavlik harness can turn into failure even years later.

About 85 percent of the infants affected by DDH are indeed females. That leaves a smaller 15 percent to the males. It’s not clear why there is this gender difference. For the most part it looks like DDH occurs as a result of outside factors. In other words, although it can develop in utero, it can also occur during the first year of life.

Breech delivery, large babies, and multiple births seem to be some of the risk factors. Family history and first pregnancies are also factors.

As far as results go there doesn’t appear to be any difference in success or failure rates based on gender. The condition of the hip cartilage seems to be the clearest predictive factor. If the covering or roof of the hip socket has started to harden into fibrocartilage, then the prognosis is not as good. The long-term results are better if the cartilage is the softer hyaline cartilage.

Slipped capital femoral epiphysis (SCFE) is most common in children between the ages of 11 or 12 and 15 or 16. It has more to do with being overweight or obese than gender. Doctors think the increased weight puts a shear force on the bones during peak growth times. This is why SCFE is more likely to occur during a rapid growth spurt in obese children.

In the growing child, the femoral head has special plates made of cartilage that grow and lengthen the bone. On either side of the growth plate are special areas of bone called the epiphysis and metaphysis. This cartilage plate isn’t as strong as bone. Increased forces on the hip from obesity can cause the epiphysis to slip backward on the femoral neck. This leaves a very unstable hip with possible blood loss to the joint.

SCFE can affect one or both hips in boys and girls. Children of various ethnic backgrounds can be affected. Cases have been reported in Caucasians, African Americans, Native Americans, and Hispanics. Neither gender nor ethnicity is as important as body weight and size.

You are quite right about the importance of calcium in building strong bones for the future. It might help your girls to think about their bones as bone banks. Right now they can make deposits of calcium to build bone mineral density. Later in life no further deposits are allowed. That’s when the body starts withdrawing bone leading to conditions like osteopenia and osteoporosis.

It’s also true that although teenagers can stop growing taller, bone mass hasn’t peaked yet. Skimping on calories should be done by eliminating sugar-filled food items, not calcium-rich foods. Yogurt instead of ice cream or low-fat milk instead of milk shakes is advised.

If your girls won’t listen to you, make an appointment with their pediatrician or your family doctor. Explain your concerns ahead of time and let the health care experts take it from there. Your children may not change their eating patterns, but you will have done everything you can and should do as a parent. The rest is up to them.

Passive thumb movement in the first two weeks is vital to the success of the operation. The thumb can start triggering again in the first week. A recent study of a group of children under age six who had this operation reported success in all but one case with sufficient mobilization.

Try to make it a game with your son playing patty-cake or the eensy-weensy spider. Put some music on and pretend to dance while holding hands and especially extending the thumb. Make up a dance and call it the “hitchhiker”. Use a lamp without the shade to cast finger shadows on the wall. You can help your child make a butterfly by hooking the thumbs together in extension. Wiggle the fingers to make the butterfly fly.

Gentle motion is needed to avoid swelling or over stretching the area. Make sure you go to all the follow-up visits even if everything looks fine. The doctor may see something important that you haven’t noticed in those early months to years.

In the next few days to weeks infection is always possible. No doubt your doctor or the nurse gave you some instructions about what to watch for: fever, pain, swelling, and redness.

In the next few weeks to months keep an eye on any signs of partial triggering recurring. Make sure you and/or your daughter stretch the thumb out many times throughout the day. This is especially important if she is busy in school. Teach her to sit with her hand flat on her desk and the thumb gently pulled down. Her index finger and thumb should form the letter ‘L’ (it will be a backwards ‘L’ if it’s her right hand and thumb).

To maintain full motion in both directions (flexion and extension), she can open and close her fist several times each hour. As time goes by she will stop doing the exercises. That’s okay if she still has her full motion and no sign of triggering.

Every once in a while ask your daughter is she is having any numbness, pain, or pins and needles sensation in her thumb. This may be a sign of nerve damage. Make an appointment with the surgeon if this happens or if you see any signs that she doesn’t have full motion.

Most doctors agree that “careful neglect” is the standard treatment for a young child. This means parents and doctor keep an eye on the problem and consider surgery if it gets worse. In rare cases, it can go away on its own. Physical therapy treatment may help. The therapist will give you a special splint for your son to wear to bed at night. You will also be taught how to do some simple exercises with your child every day.

Children ages three and older who still have a locked and flexed thumb can have an operation. Surgery is done to release the pulley mechanism that is binding the tendon and keeping it from pulling the thumb into extension.

If your doctor didn’t explain all these things then make another appointment and ask about options. If you’ve heard all this information then follow the advice of your doctor. Do the exercises and give time a chance. If things seem to be getting worse then make an earlier follow-up appointment.

You didn’t mention what might be causing your daughter’s injury. Stress injuries are common in athletes, especially when there’s been a recent increase in sports activity or training.

Navicular fractures or stress injuries aren’t rare, but unlike other stress injuries they may require special treatment. Having bilateral navicular injuries is relatively rare.

Most stress fractures get better with rest from the activity and removal or change in any risk factors. Preventing stress injuries or re-injuries is also important. Once again, finding and changing risk factors is the key.

Preventing or correcting training errors is one of the most important ways to avoid injuries. Many stress injuries are the result of sudden increase in frequency, intensity, or duration of practice or play. Worn out equipment (including shoes) is another factor. For the runner, changing from an asphalt to cement surface can be the problem.

Girls face some extra challenges. Many girls diet and restrict calories while training. The result can be a loss of bone density leading to fracture. Whether your daughter is an athlete or not, a close look at diet and nutrition is a good idea in maintaining good bone strength. If she is an athlete, then a careful review of her training methods might be helpful.

Several studies have included left versus right-sided dominance as a factor in the number of sports injuries. The results of a recent Canadian study of 21 teenaged soccer teams support this idea. More than 300 boys and girls ages 12 to 18 were included.

A few studies have focused on this topic. One study reported left-handers saw a doctor for injuries more than right-handers. The study covered a year’s time. A higher number of the left-handers were hospitalized for treatment of injuries during that year. And more left-handers than right-handers reported having surgery for treatment of an injury.

More parents of left-handers say their children are clumsier than the average child. Overall left-side dominance seems to be a risk factor for injury among school-aged athletes. Scientists aren’t sure why this is true. It may be related to left-sided dominant people living and playing in a right-handed world. Perhaps there are neurologic differences that translate into functional differences.

The number of soccer injuries is increasing every year just based on the increased numbers of players. Injuries are also linked with increased amount of play time, number of soccer sessions per week, and level of play (beginner to elite).

Elite players are more likely to get injured. This is probably because the level of competition and aggressive action is much higher in the older, more elite groups.

Injury rates by gender (boys versus girls) don’t seem to be different. Both groups have ankle and knee injuries most often. There is one big difference between the two groups. Knee ligament sprains are five times more common in girls than boys.

Risk factors for injury more important than gender include having a previous injury and playing before the injury is healed. Left-leg dominant players are also more likely to get hurt compared with right-leg dominant players.

The “terrible triad” is a term that can be applied to many joints including the shoulder, knee, or elbow. It always refers to three areas of damage or injury in the same joint.

For example the terrible triad for the shoulder includes shoulder dislocation, nerve injury, and tendon tear. In the knee, it’s ligament and cartilage damage. In all cases, the joint is unstable and needs surgical intervention.

In the elbow the terrible triad refers to ligament tears, bone fractures, and dislocation. More specifically, there’s a posterior dislocation of the elbow joint with fracture of both the radial head and the coronoid process.

The radial head is the top of the radius (one of two forearm bones). The coronoid process is a lip of bone at the top of the ulna (the other forearm bone) that is part of the elbow joint.

Treatment of the terrible triad for any joint is complex and lengthy. In a young person of your daughter’s age the chances of recovery are much better than in an older adult.

Doctors know the right questions to ask to get to the bottom of a problem. Snapping, clicking, popping joints have a couple of possible causes. In the case of the hip, it could be the tendon popping back and forth over the bone. That would be outside the joint. If the joint cartilage is torn, a locking or catching sensation in the groin occurs.

The doctor will look at your range of motion. The loss of motion in certain positions or directions can help narrow down the problem. Posture and gait pattern will be assessed. Muscle strength can be tested. The legs can be measured for a leg length difference.

Other special tests can be done to look for pinching of the soft tissue structures, loose bodies in the joint, and labral tears. When needed imaging studies can be done. X-rays show changes in the bone and joint. CT scans or MRIs help define the size, shape, and location of problems.

Truthfully, even with all the right questions and tests, it isn’t always possible to pinpoint the exact problem. Sometimes the doctor takes a conservative route to treatment and waits to see if the patient gets better. The exact cause of the problem isn’t always known.

Quite simply it means the hip socket (acetabulum) is too deep. The acetabulum covers the round head of the femur that fits into the socket. Too much coverage causes pinching of the bone against the acetabulum and its cartilage.

Coxa profunda can cause increased stress on the inner (medial) section of the acetabulum. This results in painful motion and eventual degeneration of the hip. Early arthritis is common.

Sometimes surgery is needed to change the direction of force in the hip joint and prevent these problems.

Body Mass Index or BMI is an easy way to measure obesity in adults. Specific BMI values are labeled “normal,” “overweight,” and “obese.” BMI for children up to age 20 is measured as a percentile based on growth charts. The charts are available through the Centers for Disease Control and Prevention (CDC) (www.cdc.gov/growthcharts/).

These charts include BMI for age and gender and make it easier to track the growth pattern of children. Besides the CDC website, Medscape offers additional information on the growth charts that may be helpful (http://www.medscape.com/viewprogram/2560).

Since obesity is affecting more and more children with many long-term consequences, use of the growth charts is a very good idea for all parents.

Slipped capital femoral epiphysis (SCFE) occurs most often between the ages of eight or nine and 18. It’s during this time that the physeal (growth) plate is still open in the femur (thigh bone).

Obesity increases the shear stress across the physeal plate. Over time this area is traumatized enough it eventually leads to separation of the bone from the cartilage and growth plate at the top of the femur. Some doctors say on X-ray it looks like the top of an ice cream cone has fallen off the cone.

A recent study from New York City showed that obesity (measured by Body Mass Index or BMI) is clearly linked with SCFE. Children who are in the normal weight range rarely get SCFE. If they do, it’s more likely caused by an underlying endocrine problem.

All three of those imaging methods are equally accurate for measuring limb length. X-rays do expose the person to some radiation. For a single X-ray that isn’t much but if he will need repeated X-rays over time then an MRI might be better (no radiation).

MRIs also give detailed information about the bones and soft tissues. That might be helpful in your son’s case. MRIs are more expensive than X-rays. You might want to check your insurance coverage as part of your decision-making process.

CT scans have decreased radiation exposure compared to X-rays. Their only other real advantage is in assessing leg length difference when the knee can’t straighten out all the way. If that’s not a problem, then X-ray or MRI may be your best bet.