FAQ Category: Child

The prognosis for healing of femoral fractures in children is extemely good. At his age, he most likely has not completed full (skeletal) growth or maturity. That’s to his advantage in terms of healing capacity. There are some other variables that may influence the final outcome.

For example, children who have severe fractures (especially if they are large children) may face some challenges other might not. The force and load of the leg itself and the body weight can limit some of the types of treatments available to smaller individuals.

Instead of a flexible rod placed down inside the bone, a rigid locked intramedullary nails often used for adults may be selected 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 so that’s an advantage.

During the healing process the concern is for a nice union of the bone ends or fragments without rotation of the bone, loss of bone length, or evidence of growth disturbance. Barring any unforseen problems your son will probably be back on his feet with full weight-bearing seven or eight weeks after the surgery. It may take another four to six weeks to regain full strength and mobility. Unless the surgeon has suggested some reason why he might not resume sports with full participation, he should expect to be back in full action by next season.

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). The selection of nonoperative versus operative care hinges on whether or not the fracture is displaced (separated) and by how much.

Surgery is required for open fractures (through the skin), fracture-dislocations, and unstable fractures (often those that go through the joint surface). Any sign of nerve or blood vessel damage must also be addressed surgically and quickly. One other reason why surgery might be needed is if the bones have separated apart (called displacement). But there’s no cut off point between when surgery is needed and when it’s not. What one surgeon may consider a “significant” amount of displacement may be not the same for another.

Age and size of the bone fracture fragment help guide the surgeon choose the best surgical treatment approach. Younger children are treated with bone fixation using wires. Older children and teens are more likely to be able to handle having a screw put in place to hold the fracture until healing takes place. Pins (rather than screws or wires) are used when there are small bone fragments.

Many studies report the good success of treatment when following these guidelines for both conservative care and operative treatment. Loss of elbow extension (ability to straighten the elbow) is the number one limitation after this surgery. Starting elbow and arm movement right away after the cast comes off is the best way to deal with this problem.

There are some areas where further studies would help clear up a few questions. For example, just how much displacement is an indicator that surgery is needed? Do children get back to their beloved sports activity faster when treated with surgery instead of the immobilization used during nonoperative care. Does the high level of play and intensity of activity suggest fixation should be considered more often than not?

It’s easy to see that a severe fracture and unstable elbow requires surgery. The cases that fall in between are the ones that require individual consideration of all factors. The surgeon’s own experience and expertise certainly fall into that category. Patient age, activity level, X-ray findings, and patient goals are additional factors.

There’s more than one way to approach the treatment of pediatric radial neck fractures. A recent report from Dr. M. E. Pring at the University of California’s Department of Pediatric Orthopedic Surgery brings us up to date on what techniques can be used to treat this problem in children. Problems that can arise and what to do about them are also presented.

The radial head is a round, disc-shaped top to the radius bone (the smaller of two bones in the forearm). The radial head sits next to and articulates (moves) with the lower portion of the humerus (upper arm bone). The position of the radius is on the outside of the elbow (side away from the body).

The mechanism of injury is usually a fall on an outstretched arm. The force of the impact can be enough to snap the top of the radius right off. If the broken piece shifts away from the main bone, it is considered a displaced fracture. If the radial head moves off to the side and away from the shaft of the bone, it is a translation of the head in relation to the shaft.

If the radial head tips over and forms an angle with the radial shaft, it is considered both displaced and angulated. The amount of angulation will be an indication of severity of the fracture and also direct treatment. Angulation is easier to treat than translation. In younger children (up to age six), angulated radial neck fractures correct by themselves during the healing process.

General guidelines are: 1) less than 30 degrees of angulation can correct in children of all ages. 2) Displacement less than two millimeters does not require surgery. 3) More than 60 degrees of angulation must be treated surgically no matter how young the child is. 4) Angulation between 30 and 60 degrees is a gray area. There are no clear guidelines. In general, the younger the child, the greater the chances for healing and correction.

When selecting treatment options for radial neck fractures, there are other factors to consider. In one-third up to one-half of all children, there are other injuries that occur at the same time. For example, there can be other fractures in and around the elbow, torn ligaments, and damage to the joint surface. Sometimes the broken and displaced radial head flips over on itself and appears to be in the correct place but isn’t. This situation must be identified and corrected or the joint will be destroyed.

In young children like your daughter (up to age five), the radial head isn’t even made of bone yet — it is still mostly cartilage. X-rays won’t always show damage to this area. With the possibility of additional soft tissue injuries, CT scans or MRIs may be needed to identify all potential problems make a complete diagnosis.

That’s when the surgeon rolls up his or sleeves so-to-speak and gets to work on a treatment plan. The first question is always: conservative (nonoperative) care or surgery? For radial neck fractures with less than 30 degrees of angulation and less than two millimeters of separation, a cast for two to three weeks works just fine.

As a final test in this decision-making process, the surgeon will check forearm motion. If the child has full supination (palm up) and full pronation (palm down) motions, simple immobilization in a cast is acceptable. Any limitations or blocks to these rotational movements is a sign that reduction (correcting alignment) is needed.

Fractures in skeletally immature children can lead to some complex and challenging problems — especially if the extent of the injury is not recognized right away. For example, separation of the bone from the joint can result in a finger dislocation if not treated properly at the start.

The growth plate can be damaged affecting finger growth. The bones may twist or rotate after breaking and shifting apart. The fracture itself might be unstable and the bones easily bent or angled. If the growth plate at the end of the bone is broken and the nail plate is avulsed (pulled away from the skin fold), the broken bone can be left open to infection-causing bacteria. This type of break is called a Seymour fracture.

Additional problems develop when a Seymour fracture is not recognized and the finger is splinted or immobilized. Healing will not occur, infections are common, and the fracture remains unstable. Surgery is necessary to pull the nail plate off and get the area cleaned out (a procedure referred to as irrigation and debridement). Only then will the fracture heal and nail bed repair itself.

Certain types of finger fractures in children will require surgery to avoid malunion. These include phalangeal neck and condyle fractures. A phalangeal neck fracture occurs in the bone just outside the finger joint. A condyle fracture refers to a similar break but one that does affect the joint. Undetected, either one of these fractures will result in malunion and joint dysfunction if not treated surgically (reduction and fixation procedure).

Early detection of the full extent of finger fractures and soft tissue damage in children is the key to disrupting finger growth and restoring full joint and finger function. Immobilizing an injury that is unstable instead of doing surgery to reduce and realign the bones can delay recovery. In the end, surgery will still be needed further delaying healing and recovery.

If your child is having surgery for some type of finger fracture, then there is likely a specific reason (type of trauma) that would not respond well to conservative (nonoperative) care. Don’t hesitate to ask the surgeon to explain what was done and why.

Seymour bone fractures can affect children, teens, and adults. It is defined as an extra-articular transverse fracture of the base of the distal phalanx. We will break that down for you.

Each of the three separate bones that make up the finger is called a phalanges or phalanx. The distal phalanx is the far end of the middle phalanx. This is located at the base of the phalanx that forms the tip of the finger. So essentially, the fracture occurs between the bone that makes up the tip of the finger and the middle bone.

Extraarticular tells us the fracture is outside the joint. Transverse means the break goes through the area sideways (horizontal rather than vertical).

In children and skeletally immature adolescents (teens) the fracture line is usually entirely through the metaphyses, just past the growth plate. In adults, the fracture line is just distal to (past) where the extensor tendon attaches.

The nail bed is avulsed separated from the soft tissue but doesn’t always look avulsed. The surgeon must assess the injury carefully before just splinting the finger. The full length of the nail must be inspected. The nail bed could be torn underneath. If the cuticle seal is broken there may be an open fracture underneath.

Bleeding around the nail bed is a sign of an open fracture. X-rays should be examined closely for physeal (growth plate) injury in children. Additional problems develop when a Seymour fracture is not recognized and the finger is splinted or immobilized. Healing will not occur, infections are common, and the fracture remains unstable.

Surgery is necessary to pull the nail plate off and get the area cleaned out (a procedure referred to as irrigation and debridement). Only then will the fracture heal and nail bed repair itself. The recovery time is usually three to four weeks.

If your son has a Jakob fracture, then he has broken the round knob at the end of his humerus (upper arm bone) on the outside of the elbow/arm. The Jakob classification is a tool used by surgeons to help them determine how severe the fracture is and what type of treatment is necessary.

This classification scheme defines joint alignment (displaced vs. nondisplaced, malrotated, and whether or not the growth plate was affected). A displaced fracture is one that has separated. How much distance there is between the bone fragments is one indication of the severity of the fracture. There are three basic groups in this classification.

Jakob I means the fracture is not displaced or separated and can be treated with conservative (nonoperative) care. Jakob II fractures are displaced by more than two millimeters but without any rotation. Jakob III describes a fracture that is separated completely AND rotated. Jakob II and III elbow fractures of the lateral condyle will require surgery to reduce and stabilize them.

Since your son is currently in surgery, we can assume he has a Jakob type II or III type lateral condylar (elbow) fracture. As with other bone fractures, these kinds of elbow injuries can be treated with open or closed reduction. The type of fixation device used (plate, screw, pin, wire) depends on the location of the fracture, severity, and whether or not the growth plate has been disrupted.

Open reduction is typically required when there is significant malalignment and malrotation. While the patient is still under anesthesia, the surgeon makes sure the joint surfaces are lined up properly and the joint moves fully and freely. The surgery can be very complex and challenging in some cases but most children do just fine and heal quickly. We hope your son will be in this group!

The goal of all treatment for this type of elbow fracture is to restore joint alignment as close to normal as possible. Bone fractures in children near a joint (the elbow in this case) raise additional concerns because of the potential to affect the growth plate and thereby stunt growth.

If the joint surface is disrupted (no longer lined up properly), treatment is directed toward realigning the bones and joint (called reduction). At the same time, the surgeon will stabilize the bone fracture (i.e., hold the bones together) while healing takes place. Fixation of the fracture is usually done with hardware such as a metal plate, screws, or wires.

In the case of a simple lateral condylarfracture (which is what it sounds like your granddaughter has) nonoperative care may be enough. The lateral condyle is the round end of the humerus (upper arm bone) that forms the upper part of the elbow joint. The arm is put in a cast or splint to immobilize it during healing. Close follow-up is important in order to make sure the bones keep their good alignment without displacement (separation), malunion, or malrotation.

So now the waiting begins. During the six to eight weeks it usually takes bones to heal in children, the surgeon will follow her closely to make sure (by X-rays) that everything is healing correctly in good alignment. Any sign that the bone fragments are separating, rotating, or cutting into the nearby soft tissues, blood vessels, or nerves will be cause for re-evaluating the treatment plan and possibly doing surgery.

When she comes out of the cast, the arm may be stiff but with regular movement and daily use, she will most likely regain her full motion and strength.

Any new symptoms after a fracture and especially in someone who has been placed in a cast should be reported to the physician immediately and evaluated. Not all fractures show up on X-rays and soft tissue damage doesn’t show at all so further evaluation is important at this time.

It is possible that the cast is too tight. Swelling may put pressure on the local blood vessels and nerves causing additional symptoms. A special tool called a Doppler can be used to test arteries for adequate blood flow. The treatment may be as simple as taking the cast off and recasting.

X-rays and possibly CT scans may be advised to check the status of the healing fracture and to look for any other potential causes for these new symptoms. One of the biggest concerns for children with ankle fractures is the risk of damage to the growth plate called physeal arrest. Surgeons evaluating children with physeal fractures of the lower leg bones (tibia and fibula) must be very careful to identify the specific type of fracture and all other areas that might also be injured (e.g., soft tissues such as cartilage, tendons, ligaments).

Successful treatment depends on an accurate diagnosis. Placing a child in a leg cast when there is a large gap in the bone can result in pain and failure to heal. A swollen muscle trapped between the bone and another anatomic part or a piece of flap of bone jammed in the fracture space must be surgically removed before fracture healing can occur.

It might be best to pick up the phone and place a call today to the orthopedic surgeon or other physician who treated your son initially. Someone from that hospital, clinic, or office will be able to advise you what to do.

Tillaux ankle fracture occurs in teens and affects the closing (but not fully closed yet) growth plate. The front (anterior) and outside (lateral) portion of the lower tibia (lower leg bone) is broken off (called avulsion) while still attached to the anterior inferior tibial-fibula ligament.

The fragment is avulsed when the ankle is turned out (supinated) and an external rotational force is applied through the leg to the ankle. This injury is rarely seen in adults, because the ligament gives way instead of avulsing the tibial fragment from its epiphyseal attachment, which is what occurs in teens. The bone fracture and ligament injury are known as a Tillaux lesion.

Between ages 12 and 15 the growth plate starts to fuse with the bone. But it does so in a rather uneven, asymmetric fashion. First the middle portion hardens and stops growing, and then the medial or inside edge completes its growth phase. The lateral (outside) edge is the last to solidify. The area that is still open is usually where the fractures occur.

If the lateral force is strong enough, not only does the bone fracture but the fracture also displaces (separates). This displacement leaves a gap or “step-off” when the bones shift. When this happens, the bones no longer line up, which means the two sides of the ankle joint are no longer evenly matched. Such a situation has to be treated or the uneven weight-bearing surface will be painful. Down the road, arthritis will develop causing further problems.

Fortunately, since this fracture occurs in adolescents with near full growth (almost skeletally mature), there is minimal risk of deformity otherwise caused by growth plate injury in younger individuals. Surgery is still advised if the gap is more than two millimeters wide.

Triplane fractures of the ankle affect three sections of the lower part of the tibia (lower leg bone). That’s why they are called “triplane.” The force of injury is strong enough to split the joint surface, fracture the epiphysis (round end of the tibia), move through the growth plate, and go out the metaphysis (area between the main part of the bone and the epiphysis at the end of the bone). The growth plate is contained within the metaphysis.

The location and severity of triplane fractures cannot be fully assessed from plain X-rays. CT scans must be taken in order to show the fracture line through multiple planes and angles of the tibia. Different fracture lines will be seen when viewed from the front/back (coronal view), side (sagittal view), and above (axial or transverse view). This is what is meant by a fracture that is triplanar.

A major complication in treating triplanar ankle fractures is the gap or step-off that can occur if the bones shift. When this happens, the bones no longer line up, which means the two sides of the ankle joint is no longer evenly matched. Such a situation has to be treated or the uneven weight-bearing surface will be painful. Down the road, arthritis will develop causing further problems.

These fractures can be treated with closed reduction (without an incision) if the patient makes it to the surgeon within the first 72 hours. General anesthesia is still used to put the patient to sleep when this is done. Open surgery is only required when efforts to traction and place the bones in correct position fail. Any of these fractures that are not stable will need some type of fixation (metal plate, screws, pins, wires).

The surgeon will have many decisions to make from what tests to order, whether surgery is needed, what type of surgery, and specific techniques to use for these complex and challenging types of injuries. In the meantime, your nephew may be experiencing pain or discomfort, fear about the treatment, and there is always the need to pray there are no complications with the injury, the surgery, and during the recovery.

Situations like this one can be difficult to judge. Some of the decision may depend on your daughter’s temperament (prone to dramatic complaining versus rarely complains), the type of fracture (simple, compound, open, closed, one bone or both bones in the lower leg), and how long ago the leg was casted (recently or sometime ago).

The biggest concern with something like this is the risk and potential for a condition known as compartment syndrome. Compartment syndrome describes a condition in which fluid (swelling or blood) builds up inside one or more of the individual compartments of the leg. Traumatic injuries, especially bone fractures that puncture the soft tissues are a common cause of compartment syndrome.

There is no way to know for sure if she is developing this condition. Some of the symptoms may include pain way out of proportion to the injury, pain that isn’t relieved by medications, and increased use of pain medication (e.g., narcotics) are early signs of a potential problem.

Has she been given any pain relieving medication? Does she need a change in position? Anyone experiencing numbness or partial paralysis of the toes, foot, or leg must be seen by a medical professional immediately. In cases like this with the risk of compartment syndrome, it’s better to err on the side of caution and at least have someone check her over. It may be an extra hour in the return trip but a lifetime of disability if compartment syndrome causes death of the tissue and loss of limb.

The radial head is a round, disc-shaped top to the radius bone (the smaller of two bones in the forearm). The radial head sits next to and articulates (moves) with the lower portion of the humerus (upper arm bone). The position of the radius is on the outside of the elbow (side away from the body).

The mechanism of injury for radial neck fractures is usually a fall on an outstretched arm. The force of the impact can be enough to snap the top of the radius right off. If the broken piece shifts away from the main bone, it is considered a displaced fracture. If the radial head moves off to the side and away from the shaft of the bone, it is a translation of the head in relation to the shaft.

If the radial head tips over and forms an angle with the radial shaft, it is considered both displaced and angulated. The amount of angulation will be an indication of severity of the fracture and also direct treatment. Angulation is easier to treat than translation. In younger children (up to age six), angulated radial neck fractures correct by themselves during the healing process.

General guidelines are: 1) less than 30 degrees of angulation can correct in children of all ages. 2) Displacement less than two millimeters does not require surgery. 3) More than 60 degrees of angulation must be treated surgically no matter how young the child is. 4) Angulation between 30 and 60 degrees is a gray area. There are nio clear guidelines. In general, the younger the child, the greater the chances for healing and correction.

How does this happen exactly? The remodeling process of bone in children is not completely understood. But because they are not skeletally mature (bone is still growing), the body has a way of producing bone and shaping it according to the needs of the child.

In the case of bone fracture, enough bone is laid down around the fracture site to form a callus. Often this is much more bone than is actually needed. Once the fracture site is stable, then the body goes about the business of remodeling the callus. In the end, there is usually just enough change in the bone to see on X-ray that there was a break but it can be very subtle.

Conservative care with cast immobilization is still needed to allow the healing process to complete itself uninterrupted. Outside forces and even the stress and load of normal movement could disrupt the healing process. It usually takes about four to six weeks for complete bone healing in children. Many will show a solid union in two to three weeks.

Parental compliance with medical treatment is the number one factor that either leads to success or failure. Treatment for clubfoot usually starts at birth. Treatment in the majority of infants will require both non-surgical treatment and surgery.

The most commonly used treatment in the newborn and infant is manipulation and casting. This is started as soon as possible. The foot is manipulated 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.

As any parent knows, the newborn grows rapidly after birth. The technique of manipulation and casting the foot is used to guide the growth of the foot towards the normal alignment. Without this guidance, the foot will remain deformed and may actually get worse. The greatest chance for correction of deformity occurs early in life when there is so much growth occurring.

There have been many different techniques proposed for the way the foot is manipulated and the way the casts are applied. Treatment of the infant with clubfoot is definitely one of the arts of medicine. Successful treatment requires patience and attention to detail.

The success of treatment of clubfoot by manipulation and casting alone varies greatly. The majority of infants will eventually require surgery. But, the manipulation and casting begins the process of guiding the foot towards a more normal form. The use of a special abduction brace at home is equally important. Your role in performing the necessary exercises and appylying the brace as prescribed is extremely important.

In the infant that eventually needs surgery, the manipulation and casting are still required to obtain as much correction as possible prior to the surgery. So don’t view the need for surgery necessarily a failure on your part. If you have followed your surgeon’s suggestions, then just accept the surgical intervention as the next step to a successful correction of the foot and ankle alignment.

Before you hit the panic button consider this: about 80 per cent of young children who have the standard Ponseti method of treatment (manipulation of the foot and casting) also need a release of the Achilles tendon. Often the forefoot correction is successful with the casting treatment but the hind foot remains rigidly in an equinus and varus position.

Equinus means that the toes are pointed down and the ankle flexed forward (sort of 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.

Not all babies or young children with clubfoot treated with the Ponseti Method will need a tenotomy. In many cases, this additional procedure is needed when the abduction brace required after casting isn’t used diligently. It is only during the final stages of the Ponseti manipulation and serial casting, that a tenotomy to release the Achilles tendon (the tendon pulls on the hind foot) is considered. This procedure is most helpful if the hind foot remains uncorrected.

If and when a tenotomy is needed, it is safe to perform the operation as an office procedure. The skin is numbed with a topical agent and the area around the tendon numbed with a local anesthetic. The child does not feel anything more than a sense of pressure (if even that much). It isn’t necessary to put them to sleep. The tendon is released safely and effectively without complications. The foot is put in a cast for three weeks and bracing is continued after the cast comes off.

When the parents follow-up diligently with the home program, the results are excellent. With good parental compliance, the need for a second tenotomy is eliminated. The most helpful thing family members can do is love and support the parents going through this with their child. Your efforts to obtain additional information is very excellent. Encouraging parents to follow-up with any recommendations made by the surgeon (especially use of the special brace) may be the best thing you can do to come alongside them at this time.

Fractures of the clavicle (collar bone) are common and this question comes up often. Unfortunately, there is no simple answer. To the best of our knowledge, there is very little scientific evidence to support one over the other — or even to suggest immobilization over doing nothing is better.

Most often, pain guides the treatment. If there is no displacement (separation) of the fracture, then nonoperative care with immobilization helps support the arm and ease the pain. The sling or brace may also serve as a reminder to limit activities that might cause fracture displacement in the early days of healing and bone remodeling.

Most experts advise immobilization if surgery is not needed. The sling or brace can be worn for two or three weeks while limiting activity levels. The patient can then gently ease back into action a little bit at a time according to his or her tolerance.

X-rays can be used to check the status of the healing bone and provide some guidance as to how long to wear the sling. When the X-ray shows the bone is knitted back together correctly, then the sling or brace can be weaned away. Some people just wear it for vigorous activities to continue protecting the bone while others wear it during the day and take it off at night. Wearing schedule should be patient driven but under the guidance of the physician.

The clavicle known more commonly as the “collar bone” is the most commonly fractured bone in children. No surprise there since falling on the point of the shoulder is the way the bone gets broken in the first place and falling is what young children do so well!

Treatment choices are usually between nonoperative care and surgery. The decision can be easy in some cases (e.g., a simple undisplaced fracture) or complex due to other injuries or the severity of the fracture.

Children do have a very thick outer covering of bone around the clavicle limiting displacement (separation) of the broken bones. They also have excellent ability to heal and remodel bone compared with adults. A sling or figure-8 brace may be all that’s needed for a few weeks before easing back into full activities.

Sometimes surgery is necessary for children. The indications for operative treatment include multiple trauma to the body (usually signaling a more severe clavicular fracture), other shoulder injuries, shortened fractures (the two ends of the bones telescope onto each other), or comminuted fractures (many bone pieces).

When surgery is needed, there isn’t one operative method that works best for all children. The surgeon must consider the needs of the child and the concerns of the parents or family. The surgeon’s own experience and expertise also play a role in decisions about treatment.

Many decisions go into the operative care of children. Age, size, growth status, location and type of clavicular fracture, and activity level are just a few factors. Then type of fixation (e.g., metal plate, screws, pins, wires), type of incision, and potential for complications must be considered.

There’s no cookie cutter recipe for the treatment of clavicular fractures in young children and teens. The fact that many of these patients are still growing plays a huge role in the decision about what kind of treatment is best. It sounds like the team treating your godchild is carefully considering all options and possible factors that could affect treatment and outcomes.

A forearm shaft fracture is a break in the middle of the two long bones in the forearm (radius and ulna). A simple fracture without displacement (separation of the bones) can be successfully treated with cast immobilization. But displacement and angulation (bones shift and are no longer straight but instead form a V- or angular-shape) may be severe enough to require surgery.

Although there are some guidelines about treating a problem like this, each and every patient must be considered individually. Treatment should be customized based on patient factors and surgeon opinion. There may be some aspects of the break the parents haven’t shared with you that are challenging and require the careful consultation and planning that is going on.

Making the decision to perform surgery is just the beginning of the process. Now the surgeon must decide whether to use fixation on one or both bones and what type of fixation to use. The two most commonly considered options are a metal plate or a long nail down the shaft of the bone (called intramedullary fixation or IM).

Choice of fixation device goes hand-in-hand with type of procedure: open or closed reduction. As the names suggest, an open reduction means the surgeon makes an incision to open the arm. A closed procedure is done through the skin (percutaneously) or other minimally invasive approach.

Follow-up treatment involves post-operative care selecting either a long or short arm case, length of time in the cast, and if/when to remove the hardware after healing is complete. Removing fixation devices too soon can cause failure to heal and even loss of reduction and reangulation.

Surgeons are encouraged to reduce the bone that is easiest first. If it looks like a toss-up between the two bones, then the straighter bone (the ulna) is reduced first. The surgeons will likely discuss how and where to insert the nail for best results when intramedullary nailing is the treatment choice.

Failure to gain access down the middle of the bone with the nail is a possibility. Repeated efforts to accomplish the task can result in significant soft tissue damage. At that point, the surgeon should switch to an open reduction procedure.Planning ahead for every possibility and discussing these things with other surgeons provides ideas and the benefit of others’ experience.

Perhaps when it’s all over, you will be able to ask some additional questions. Hopefully, the information here will help you know what questions you might like to pose.

It sounds like your child has a forearm shaft fracture or as you described it: a break in the middle of the two long bones in the forearm (radius and ulna). A simple fracture without displacement (separation of the bones) can be successfully treated with cast immobilization. But displacement and angulation (bones shift and are no longer straight but instead form a V- or angular-shape) may be severe enough to require surgery.

The decision between cast immobilization and surgical reduction and fixation depends on a number of factors. First, there are guidelines for what is acceptable versus unacceptable angulation and displacement. For example, children under the age of nine can still be treated with cast immobilization when there is complete displacement but only up to 15 degrees of angulation and 45 degrees of malrotation. The reason children with these changes in alignment can still be treated conservatively (nonoperative care) is that they are still growing and the bones will reform, reshape, and realign on their own.

Surgery to realign (reduce) the bones and hold them together with hardware (fixation) is recommended when it would be difficult to keep the fractured bones lined up and held in place with a simple cast. This is often the case when the bones are in a severe V- or angular position referred to as bayonet apposition. Surgery is also required anytime the fracture site is unstable or an acceptable reduction position cannot be reached.

Making the decision to perform surgery is just the beginning of the process. The surgeon will be making other decisions about the type of surgery, technique to use, and whether to perform an open (with incisions) or closed (through the skin) procedure. Not all children need fixation so the challenge becomes the ability to evaluate each child and make the best decision for that patient. Having your pre-approval aids the process so that the surgeon can assess what needs to be done at the time of the surgical procedure.

Compartment syndrome describes a condition in which fluid (swelling or blood) builds up inside one or more of the individual compartments of the leg (or arm). Traumatic injuries, especially bone fractures that puncture the soft tissues are a common cause of compartment syndrome. Pain out of proportion to the injury, pain that isn’t relieved by medications, and increased use of pain medication (e.g., narcotics) are early signs of a potential problem.

Usually an X-ray will show if the bones have shifted position from when your son was placed in the cast. But even with an X-ray, it isn’t always possible to detect compartment syndrome. The next step will be to remove the cast. Usually the surgeon or emergency department physician/staff will bivalve the cast (cut it in half, lengthwise) and just remove the front portion. If taking pressure off the leg relieves the symptoms, it’s a sign that your son may have been experiencing the start of a compartment syndrome.

Failure to experience relief of symptoms with half-cast removal is a red flag for compartment syndrome. An emergency fasciotomy is done. In this procedure, the surgeon cuts through the fascia or connective tissue around the muscles of the leg forming four distinct compartments. The purpose is to take pressure off the soft tissues.

Yes, relapse deformities even after successful clubfoot treatment are possible. In fact, there have been enough reports of this happening that surgeons are taking a second look. It is important to find out if there’s any way to prevent this from occurring. The first step is to follow children long enough to report cases of recurrence. Then risk factors can be identified and a plan put in place for both prevention and successful treatment of the relapsed condition.

A recent study from the Ponseti Center for Clubfoot Treatment at the University of Iowa has gotten a start on gathering this type of information. Thirty-nine (39) children with relapsing clubfoot were included in the study. Some children had both feet affected so the total number of clubfeet was 60. All the children had been treated at this Ponseti center from early on (some as early as three days after birth, others later but before age two). Everyone was prescribed the required abduction brace, which was supposed to be used up until age four.

There were differences in the timing of relapse among the children. Some lost the initial correction early on while others didn’t relapse until much later after treatment. By studying what happened to the children with later relapses, the authors were able to identify some trends that might help guide prevention and treatment for other children affected by this problem in the future.

Treatment for late-relapses also varied and ranged from 1) observation only to 2) bracing, or 3) casting followed by bracing, 4) casting to prepare the feet for surgery followed by surgery then bracing, and 5) surgery. Most of the children (no matter how they were treated for the relapse) ended up having surgery to correct the deformity. The most common surgical procedure was a tendon transfer called TATT for tibialis anterior tendon transfer.

Continued follow-up of these children showed that almost all of them could wear normal shoes. Some of the children were limited in what they could do as they got older because of their feet. Complaints of pain with activity or aching at the end of the day were reported by 44 per cent of the group.

The authors present these findings to help identify the prevalence of late relapse after successful treatment of clubfoot deformities in children using the Ponseti method. Although the Ponseti method seems to be successful early on, children should be followed routinely to recognize early signs of relapse.

We know that relapses don’t recover on their own without intervention. If you are noticing change in the affected foot, make an appointment with your surgeon right away. Follow-up treatment may be needed.
Research is needed to determine the best treatment for late relapses and to identify risk factors for relapse. Currently, poor compliance with abduction bracing is the only known risk factor. Changes in the brace angle and wearing schedule have already been implemented, which may account for the decline in relapse rates from even 10 years ago.