FAQ Category: Child

Children often fall and break their arms. The forearm with its two bones (radius and ulna) is one of the most common childhood fractures. Most of the time these types of breaks are clean and simple. The physician can line the bones back up without surgery.

The child wears a splint or cast for four to six weeks while the bone remodels and heals. And quite honestly, if the child has not yet completed his or her full growth and has not yet reached skeletal maturity, the bone does a remarkable job healing and even restoring normal anatomy.

But there are those cases we call bad actors: problematic forearm fractures that require recognition and special treatment. In the simplest of cases, the bones are displaced (separated). There may be a hidden dislocation along with the fracture that doesn’t show up on a plain X-ray.

Or there could be a fracture with bone rotation so the ends no longer line up as they should. Putting the arm in a cast without realigning the bones could result in permanent loss of wrist and forearm motion. Sometimes one or both of the bones break and leave the bone at an angle. This type of deformity won’t realign on its own. To add to that list, there could be cases where the forearm fracture affects the alignment of the elbow. It sounds like this may be the case for your daughter.

It’s important to make sure the child has full forearm rotation before considering the case closed. It’s all too easy for a child with limited forearm movement to make up the loss by compensating with the wrist and shoulder. The loss of forearm rotation (palm up and palm down) may not be evident until years later when they start to participate in sports and can’t move as needed. This could be the case for your child.

It is possible that soft tissue restrictions are contributing to the problem and could respond to conservative care. A physical therapist can mobilize the soft tissue and joint in an effort to restore normal movement. The therapist can check to see if there are compensations in the shoulder and address those as well. It may be a simple matter of teaching your daughter some stretches or other exercises she can do to gradually restore full motion.

Corrective surgery may be needed if the desired range-of-motion cannot be gained. Even with surgery, there is a risk that with soft tissue scarring and shortening, full motion won’t be possible with corrective surgery. At this point, an orthopedic surgeon will be able to advise you. Some imaging studies (e.g., X-rays, CT scans, MRIs) may be needed to complete the clinical assessment and provide you with a potential treatment plan.

A little refresher of pelvic anatomy may help. The pelvis is made up of your two hip bones (the ones you rest your hands on just below the waist). Each one of these bones on either side is called the ilium. At the bottom of each ilium is the place you bear weight when sitting. This is called the ischium. The place where the two pelvic bones meet in the front is called the pubis or pubic bone.

Before puberty (which means before the bones stop growing and before skeletal maturity), these three bones (ilium, ischium, pubis) are separate and have not yet fused together like in adults. Sandwiched between the two hip bones is the wedge- or pie-shaped sacrum. The place where the ilium meets the sacrum posteriorly (from the back) on both sides is called the sacroiliac joint.

High-energy trauma from car accidents can cause severe pelvic fractures — severe enough to break and separate the bones in one or more places. Such a fracture can occur through the ilium above the hip joint causing a hip dislocation in addition to the fracture. Sometimes the pelvis is fractured in more than one place.

The jagged edges of the separated bone can cut into soft tissues, blood vessels, nerves, and even organs in the pelvic cavity. Trauma teams know that such an injury can cause more problems from internal bleeding than even spinal cord or head injuries. Every effort is made to stabilize the fracture to keep the bones from shifting and causing further damage while the surgeon works on the spinal cord injury.

The danger comes when all eyes and attention are on the other bodily injury or injuries and no one realizes the pelvis is fractured and potentially unstable. The fact that your trauma team recognizes the presence of a pelvic fracture and possible hemorrhaging is actually a very positive thing. Careful attention to all injuries right from the start help assure the best results possible.

Pelvic fractures in children are classified according to severity based on X-rays. Two orthopedic surgeons by the names of Torode and Zeig first introduced this method back in 1985. Since that time, it has become a standard method of determining treatment.

According to this scheme (now just referred to as the Torode classification), there are four grades (or severities) of pelvic fractures. The grades include I, II, III, and IV based on location and amount of bone disruption.

As you might guess, Type I are the least serious injuries and Type IV the most serious. Type IV fractures are considered unstable and include disruption of the pelvic anatomy, hip dislocations, and/or more than one fracture affecting the pelvis and hip.

More recently, surgeons at Children’s Hospital in Boston (associated with Harvard Medical School) have added one modification to this model. They have introduced two subgroups of the Type III fractures (Type IIIA and Type IIIB).

The modified groups (Type IIIA and Type IIIB) help to identify fractures that are more like Type II (labeled Type IIIA) or more like Type IV (labeled Type IIIB). This distinction is helpful because it tells the surgeon that children with Type IIIB are more serious, more likely to need a blood transfusion, and more likely to need a longer hospital stay.

Torode I and II pelvic fractures are avulsion (piece of bone breaks off) somewhere along the pelvic crest. With a Type I fracture, a separation occurs in the growth plate, which is still cartilaginous. Type I is much smaller in size than Type II.

Type III fractures affect the lower portion of the pelvis that bear our weight when we sit down. The symphysis pubis (where the two pelvic bones meet in the front of the body) may be involved. This part of the pelvis helps form a bony ring and pelvic “bowl” that support the bladder. The new Type III A/B designation gives an A if just the front or anterior portion of the ring is broken. Type IIIB indicates both the front (anterior) and back (posterior) portions of the ring are fractured.

A Type IV fracture has multiple different pelvic fracture locations. All involve complete disruption of the bone, nearby joints, and/or the hip (dislocation). Once you have the specific classification your daughter has been diagnosed with, then you will have a better understanding of how involved the pelvis is and the severity of the fracture(s).

There was a recent study at the Mayo Clinic in Rochester, Minnesota that may have some information to answer your questions. They took a look at the long-term results for patients who were treated for slipped capital femoral epiphysis (SCFE) with in situ pinning.

In situ pinning means to pin the epiphysis “in position” where it has slipped. But it is not put back in its normal anatomic place. So there are some questions about how well this approach works. What happens years down the road when the growth center fuses in a nonanatomic position?

The Mayo surgeons observed that patients who had the in situ pinning still complained of persistent pain, stiffness, and difficulty with movement. This was true even when the slip was considered “mild.” To find out more about why this might be happening, they reviewed the medical records (including X-rays) and telephoned 105 patients who had in situ pinning of the hip as children/teens. Patients were interviewed and completed surveys over the phone answering questions about pain, mental and physical health, and hip stiffness and dysfunction.

They gathered information about patients who had to have further surgery after the pinning procedure. The type of surgeries were reported (femoral osteotomy, surgical hip dislocation, total hip replacement). They also evaluated the data to find risk factors that might predict who would have ongoing pain and disability. Here’s a quick summary of what they found:

By “slipped epiphysis” you are probably referring to sipped capital femoral epiphysis (SCFE). SCFE is a condition that affects the growth center of the hip (the capital femoral epiphysis). This section of the joint actually slips backwards on the top of the femur (the thighbone).

SCFE affects the hip in teenagers between the ages of 12 and 16 most often. Cases have been reported as early as age nine years old. If untreated this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. Surgery is usually necessary to stabilize the hip and prevent the situation from getting worse.

The pinning procedure you mentioned is called in situ pinning and refers to a surgical procedure that is often used in early treatment. The surgeon uses a special type of real-time X-ray called fluoroscopy to stabilize the slipped epiphysis. The growth area is pinned in place where it has slipped to keep it from slipping further.

In situ pinning is used most often for children who have mild slips. More severe slips may require more extensive (corrective) surgical intervention. Studies show excellent results for in situ pinning of mild slips.

But the growth center (epiphysis) is not put back in its normal anatomic place. So there are some concerns and questions about how well this approach works. What happens years down the road when the growth center fuses in a nonanatomic (misaligned) position? The Mayo Clinic is actually spearheading studies to take a look at this.

Mayo surgeons are asking which children will benefit the most from in situ pinning? And who should have surgery early on to correct the deformity? Early reconstructive surgery is designed to prevent disabling hip pain and stiffness from early arthritis. Is there some way to predict early on who might end up with these complications?

Surgeons at the Mayo Clinic say there is a need to further understand SCFE and the results of current management while developing improved treatment techniques. But on the basis of their studies, they still use in situ pinning for mild SCFE. They save the realignment procedures for young adults with disabling symptoms.

If you are working with children, it’s likely that you have heard of (or seen) “staph infections” referring to infections caused by the bacteria known as staphylococcus aurous. In recent years, this bacterium has become resistant to antibiotics traditionally used to treat the problem. And the number of cases in children has risen at the same time. Studies are underway to identify how often and why this is happening among children and young teens with skin and soft tissue infections.

The term Methicillin-resistant Staphylococcus aureus (MRSA) has been adopted to indicate the bacteria is resistant to a number of antibiotics including penicillin, methicillin, and cephalosporins. The bacteria have mutated (changed) so they are no longer able to be damaged or disabled by these previously effective medications.

MRSA is very powerful and can cause a large number of serious illnesses that do not respond well to current medical treatment. As you pointed out, MRSA was always hospital-acquired — in other words patients developed MRSA infections when they went to the hospital to be treated for something else. But over time, community-acquired MRSA (known as CA-MRSA) developed. CA-MRSA is defined as MRSA that occurs outside the hospital setting.

A recent hospital-based study was done to see how many children are affected by CA-MRSA and why? In this study, the researchers reviewed their records for 10 years (2001-2010) and pulled the medical charts of any patient 0 to 14 years old who presented with hand infections at their hospital.

By studying the information about each case, they were able to see some patterns that might be helpful in better understanding CA-MRSA in children. Overall incidence of CA-MRSA in the group was 25 per cent. That means one in every four children admitted to the hospital for a skin infection already had CA-MRSA before even coming to the hospital. This is much higher than the recommended rate of no higher than 10 to 15 per cent set by the Centers for Disease Control and Prevention (CDC).

By analyzing the children’s charts, they were able to identify risk factors — variables that put the children at increased risk for developing CA-MRSA. Instead of the typical risk factors reported for adults (e.g., older age, poor health, abscess drainage in a surgical setting, history of trauma, previous history or MRSA), they found children had a different set of risk factors.

For the children in this study, low income living conditions, poor personal hygiene, and crowded settings with close personal contact were the main risk factors. The presence of an abscess that needed surgical draining was an additional risk factor. The deeper the abscess, the greater the chances the child had a positive case of CA-MRSA. Any one of these risk factors or a combination of them could explain why the little girl in your care developed this problem.

A recent study from the University of Kentucky College of Medicine may have some information to help you. They reviewed their records for 10 years (2001-2010) and pulled the medical charts of any patient 0 to 14 years old who presented with hand infections at their hospital. They were able to see some patterns that might be helpful in better understanding CA-MRSA in children.

Overall incidence of CA-MRSA in the group was 25 per cent. That means one in every four children admitted to the hospital for a skin infection already had CA-MRSA before even coming to the hospital. This is much higher than the recommended rate of no higher than 10 to 15 per cent set by the Centers for Disease Control and Prevention (CDC).

Data collected from hospital charts included patient age, medical problems, treatment for the hand infection, and number of days in the hospital. Of course the infection was cultured (sent to the lab) to identify the specific type of bacteria present. The lab tests are able to test the microorganisms and determine which antibiotics will work.

By analyzing the children’s charts, they were able to identify risk factors — variables that put the children at increased risk for developing CA-MRSA. Instead of the typical risk factors reported for adults (e.g., older age, poor health, abscess drainage in a surgical setting, history of trauma, previous history or MRSA), they found children had a different set of risk factors.

For the children in this study, low income living conditions, poor personal hygiene, and crowded settings with close personal contact were the main risk factors. The presence of an abscess that needed surgical draining was an additional risk factor. The deeper the abscess, the greater the chances the child had a positive case of CA-MRSA.

Of course, the question comes up: what can be done about this alarming rise in CA-MRSA among children and young teens? The authors outline their recommendations. These may be helpful to your staff:

Young children in good health are known to heal quickly. This is generally true for many conditions from bug bites to bone fractures. Some bone fractures can be complicated by infection or joint dislocation. Forearm fractures affecting both bones in the forearm (the radius and the ulna) can present some unique problems. A delay in union like your daughter has is one of those complications.

Uncomplicated bone fractures of the forearm usually show X-ray evidence of a healing bone formation called a callus at the fracture site four weeks after the injury. Complete healing is often present by the end of eight weeks. Failure to callus formation or healing at the fracture site by 11 weeks is a signal that there is a delay in bone union.

There are some known risk factors that can contribute to this problem in some children. Infection, surgery, dislocation, multiple bone fragments account for most of the delays in healing. Surgery to correct the problem can also be a significant risk factor. There is some evidence that open reduction is a strong predictor of delays in healing forearm fractures. Open reduction means that an incision is made and the bones are realigned. Then the bones are held in place with hardware such as a metal plate, screws, and/or pins.

Children with stable fractures who wae treated conservatively with a forearm cast are much less likely to develop delayed bone union. Children who have unstable fractures requiring open surgery are the patients most likely to have delayed bone healing.

With this type of surgical approach, there is more risk of damage to the periosteum (outer covering of bone) and/or blood vessels in the area. Disruption of either of these anatomic features could contribute to the delayed healing observed with open reduction.

There may be other risk factors already identified that are specific or unique to your child. Your surgeon is probably the best one to give you an idea why this is happening (if there is a known reason). Sometimes there is no obvious reason. Other factors such as nutrition may be important. You may want to bring this up to your surgeon and possibly address any nutritional deficiencies in the next few weeks.

OCD of the knee stands for osteochondritis dissecans, which is also known as juvenile OCD (or JOCD) when it occurs in children and teens. This condition occurs most often in athletes but can affect any physically active individual.

The forceful and repeated actions of sports can strain the immature surface of the knee joint in children and teens. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off.

With rest and activity modification, the joint can begin the healing process. Surgery is usually reserved for children with more severe cases of JOCD or when conservative (nonoperative) care has failed to change the symptoms.

Studies show that the best way to get a good look at the condition of the joint surface and cartilage is to do an MRI. X-rays may look normal early in the condition when there is, in fact, a real problem. As the condition worsens, the X-ray image shows changes in the bone and joint.

The normal shape of the bony knob at the end of the femur (thigh bone) called the femoral condyle may appear irregular. In bad cases of knee juvenile OCD, the condyle might even look like it has flattened out, suggesting that the bone has collapsed. The X-ray could show a crack in the bone or even a loose body.

A magnetic resonance imaging (MRI) scan may show more detail. The MRI can give an idea of the size of the affected area. It can show bone irregularities and also help detect swelling. Doctors may repeat the MRI test at various times to see if the area is healing. MRIs are also very helpful when considering and/or planning surgery.

MRIs are “reliably sensitive” to articular (joint) surface lesions associated with juvenile osteochondritis dissecans (JOCD). Thickening of the articular cartilage and cracks or fissures in the cartilage are visible. Loose fragments of tissue and the hole or “defect” where the tissue came from are also visible.

The value of MRIs in children with OCD is that those who have unusual (atypical) lesions can get treatment early. MRIs help identify early changes that might go undetected otherwise. Untreated, OCD lesions can gradually get worse and lead to early joint arthritis.

The best thing to do is present the surgeon with your question. Given the information that insurance is not covering these expenses (and therefore finances are a consideration) it may be MRIs can be avoided. But the surgeon may have his or her reasons for requesting MRIs, especially if surgery is being planned. Get the full level of information before making your decision. Most imaging centers are willing to work with families to ensure full payment by spreading them over several months’ time.

The lives of children and teens with a condition known as spondylolisthesis can be negatively affected by the consequences of this problem. According to a recent study from Canada, spondylolisthesis in teens lowers their physical quality of life. They have back pain, tight hamstrings, and neurologic symptoms. The greater the angle of the lumbar vertebra on the sacrum, the higher the grade of spondylolisthesis and the lower the physical quality of life. This may be describing your son.

Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful.

Any of the vertebrae can slip forward but in young people (under 20 years old), spondylolisthesis usually involves slippage of the fifth lumbar vertebra over the top of the sacrum. There are several reasons for this.

First, the connection of L5 and the sacrum forms an angle that is tilted slightly forward, mainly because the top of the sacrum slopes forward. This angle is referred to as the lumbosacral kyphosis or LSK. Second, the slight inward curve of the lumbar spine creates an additional forward tilt where L5 meets the sacrum. Finally, gravity attempts to pull L5 in a forward direction. All three of these bony alignments can be measured using X-rays.

In this study, 96 adolescents (teens) with spondylolisthesis were X-rayed using a digital radiographic system. Then they were given an opportunity to answer some questions in order to measure their physical quality of life. The slip angle, the lumbosacral angle, and the lumbosacral joint angle were all calculated using the X-rays.

Then scores from the health questionnaires were compared to each radiograph. They found a definite link between lumbosacral angles and quality of life. High-grade slippage (defined as more than 50 per cent of the vertebral body is slipped forward over the vertebra underneath it) was significantly linked with low quality of life.

The results of this study point out clearly (for the first time) how much a lumbosacral kyphosis impacts the lives of affected teens. The less contact there is between the surface of the L5 vertebra and the sacrum (S1), the greater the chances that individual will have changes the body can no longer compensate for.

For example, not only do the bones shift forward but when they shift that far forward, they can start to twist or rotate. This altered alignment can put increased pressure on the spinal nerves as they leave the spinal cord. The end-result can be severe deformity and neurologic impairment.

Physicians treating adolescents with spondylolisthesis are advised to routinely assess each child for the presence (and severity) of lumbosacral kyphosis. The three angles visible on radiographs are an important feature when determining the best plan of treatment for that patient. If your son’s spine has become more unstable (contributing to a worsening of symptoms), it may be time to consider a more aggressive approach to treatment.

Don’t hesitate to ask your son’s surgeon to explain his or her thinking in ordering more X-rays. You may be thinking the problem is just depression whereas the surgeon may be making a connection between severity of the spondylolisthesis on quality of life. In this case, what looks like depression may have more to it than just a mood disorder.

First, a quick explanation of spondylolisthesis might be helpful. Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful.

The reason this type of slippage develops isn’t always clear. Spondylolisthesis may very rarely be congenital, which means it is present at birth. It can also occur in childhood as a result of injury. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis

Any of the vertebrae can slip forward but in young people (under 20 years old), spondylolisthesis usually involves slippage of the fifth lumbar vertebra over the top of the sacrum. There are several reasons for this.

First, the connection of L5 and the sacrum forms an angle that is tilted slightly forward, mainly because the top of the sacrum slopes forward. This angle is referred to as the lumbosacral kyphosis or LSK. Second, the slight inward curve of the lumbar spine creates an additional forward tilt where L5 meets the sacrum. Finally, gravity attempts to pull L5 in a forward direction, which can be seen on X-ray as the slip angle.

All three of these bony alignments can be measured using X-rays. It can be confusing when the surgeon tries to explain all three angles and changes from previous X-rays to the present. The bottom-line is that the more severe these angles are, the more severe the spinal deformity. Keeping an eye on the measurements for each one of these angles helps the surgeon see if and when the problem is getting worse instead of better. At that point, surgical treatment becomes a consideration.

As you probably know from going through all this with your daughter, developmental dysplasia of the hip or DDH is a condition where there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket).

DDH can affect one or both hips. It can be mild to severe. In mild cases called unstable hip dysplasia, the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called a subluxation.

Most of the acetabulum is cartilage at birth. The right amount of pressure and contact between the surfaces of these two parts helps make sure the hip joint develops normally. The head of the femur inside the acetabulum helps shape the joint as it continues to form. In DDH the usual contact between the femoral head and the acetabulum is disrupted. An abnormal position of the femoral head can result in a dysplastic hip. Sometimes the acetabulum is too shallow or sloping rather than a normal cup shape. It cannot hold the femoral head in place.

If the problem is not diagnosed and treated early, the soft tissues around the hip start to stretch out. There can be changes in the blood supply to the hip. Surgery to reshape the hip socket and reposition the head of the femur in the socket is usually done early in the child’s life. For some children, that is all that is needed. They develop normally and achieve skeletal maturity (full bone growth) without further problems.

But for others, avascular necrosis (AVN) (loss of blood to the hip) develops. Other problems that can occur over time include recurrence of the dysplasia, subluxation, or redislocation. These kinds of problems tend to show up when children are between the ages of five and eight. The challenge becomes identifying when a child needs a second surgery to maintain good hip alignment and when it is a watch-and-wait situation because the problem can correct itself over time. This is where you find yourselves at this time.

A study recently published may offer some information that could help you. A group of surgeons took a look back over 17 cases when the children were grown and skeletally mature. All the children were surgically corrected before the age of 18 months.

None of the children had a second surgery. All reached skeletal maturity with only the first corrective surgery. Twenty independent surgeons (they had nothing to do with treating these children) conducted an evaluation of these cases. They reviewed patient records and X-rays including mid-term and final outcomes.

They found there was a 12 per cent risk that hips would need a second surgery that in fact turned out to be normal at the end of the growth cycle. If surgery had been done, it would have been unnecessary. Performing a second surgery was not needed in this group — even when it looked like it might be necessary during that five to eight year old age span. There was also a 40 per cent chance that surgery would not be performed on a group who should have a second surgery. This group would go on to develop hip dysplasia by the time the bones matured fully.

Surgeons do not make decisions about second surgeries for hip dysplasia without specific reasons. X-ray findings of hip angle, slope of the hip socket, and the amount of femoral head covered by the acetabulum (socket) are just some of the factors taken into consideration when making the decision about a second surgery. Knowing that the top of the femur stops growing around age 10 but the acetabulum (socket) continues to develop until the child reaches full skeletal maturity also weighs in on the decision.

Surgeons know that if the head of the femur remains spherical in shape (nice and round) and stays firmly inside the hip socket by age eight, it is likely that the child will have normal hip development when fully grown. But they also know that a child can look good on X-ray at that mid-term check up and still develop hip dysplasia during their teen years. Again, that’s because changes can occur in the growth and shape of the acetabulum right up until skeletal maturity.

The surgeons who conducted this study offer their opinion on this decision dilemma. They say it is better to delay the second surgery when there is no sign of blood loss or hip instability at the mid-term point. There is no way to tell with 100 per cent accuracy from the X-rays whether this is the right decision or not.

The most challenging cases are those like your daughter who have X-ray changes close to abnormal but still within “normal range.” There is general agreement from studies and from consensus of surgeons based on experience that the acetabular index angle or AIA (as seen on X-rays) is the most reliable guideline at this time.

This is where you will need to rely on your surgeon to guide you. He or she will be able to review the X-rays and look for specific indicators that a second surgery is needed now. If those indicators are not present, it may be safe to adopt a watchful attitude with frequent rechecks to see how things are going. Progressive changes in the wrong direction (toward hip redislocation or loss of blood supply) would be a signal that a second surgery is needed.

There’s never anything wrong getting a second opinion. Sometimes the voice of experience can be very helpful to either confirm what you have already been told or offer a different option. There are some studies that actually address this issue.

For example, surgeons from Turkey asked the question: is the level of surgeon experience linked to decisions made regarding second surgeries for hip dysplasia in children? In other words, are the more experienced surgeons more (or less) likely to perform a second procedure in children with this problem? Or is it the less experienced surgeons who opt for second surgeries.

Let’s see why that question is important and what they found out. With hip dysplasiathere is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). DDH can affect one or both hips. It can be mild to severe. In mild cases called unstable hip dysplasia, the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called a subluxation.

Most of the acetabulum is cartilage at birth. The right amount of pressure and contact between the surfaces of these two parts helps make sure the hip joint develops normally. The head of the femur inside the acetabulum helps shape the joint as it continues to form. In DDH the usual contact between the femoral head and the acetabulum is disrupted. An abnormal position of the femoral head can result in a dysplastic hip. Sometimes the acetabulum is too shallow or sloping rather than a normal cup shape. It cannot hold the femoral head in place.

If the problem is not diagnosed and treated early, the soft tissues around the hip start to stretch out. There can be changes in the blood supply to the hip. Surgery to reshape the hip socket and reposition the head of the femur in the socket is usually done early in the child’s life. For some children, that is all that is needed. They develop normally and achieve skeletal maturity (full bone growth) without further problems.

But for others, avascular necrosis (AVN) (loss of blood to the hip) develops. Other problems that can occur over time include recurrence of the dysplasia, subluxation, or redislocation. These kinds of problems tend to show up when children are between the ages of five and eight. The challenge becomes identifying when a child needs a second surgery to maintain good hip alignment and when it is a watch-and-wait situation because the problem can correct itself over time.

Looking back over cases when the children are grown and skeletally mature and evaluating the results is one way to study this problem. Evaluating individual risk factors (e.g., surgeon experience) in making the decision helps identify ways to improve results.

There were 17 children with developmental dysplasia of the hips in the Turkish study we mentioned. There was a total of 21 hips surgically corrected before the age of 18 months. None of the children had a second surgery. All reached skeletal maturity with only the first corrective surgery. Twenty independent surgeons (they had nothing to do with treating these children) conducted the evaluation.

They reviewed patient records and X-rays including mid-term and final outcomes. They compared the results against the level of the surgeons’ experience who made the mid-term decision whether the child needed a second surgery or not. They found that more experienced surgeons were less likely to perform surgery (and more likely to recommend conservative care). But the level of surgeon experience was not linked to the decisions made in these 17 cases (21 hips).

Surgeons do not make decisions about second surgeries for hip dysplasia without specific reasons. X-ray findings of hip angle, slope of the hip socket, and the amount of femoral head covered by the acetabulum (socket) are just some of the factors taken into consideration when making the decision about a second surgery. Knowing that the top of the femur stops growing around age 10 but the acetabulum (socket) continues to develop until the child reaches full skeletal maturity also weighs in on the decision.

Surgeons know that if the head of the femur remains spherical in shape (nice and round) and stays firmly inside the hip socket by age eight, it is likely that the child will have normal hip development when fully grown. But they also know that a child can look good on X-ray at that mid-term check up and still develop hip dysplasia during their teen years. Again, that’s because changes can occur in the growth and shape of the acetabulum right up until skeletal maturity.

The surgeons who conducted this study offer their opinion on this decision dilemma. They say it is better to delay the second surgery when there is no sign of blood loss or hip instability at the mid-term point. There is no way to tell with 100 per cent accuracy from the X-rays whether this is the right decision or not.

The most challenging cases are those that have X-ray changes close to abnormal but still within “normal range.” There is general agreement from studies and from consensus of surgeons based on experience that the acetabular index angle or AIA (as seen on X-rays) is the most reliable guideline at this time.

Until we have clear guidelines that can be applied to all children at different ages, there is always a risk that the wrong decision has been made. This study showed there is a 12 per cent chance that surgery would be done unnecessarily.

There might be some indications that a second surgery was needed but, in fact, when left alone the child self-corrected spontaneously. There is also a 40 per cent chance that surgery would not be performed when a second surgery should be done. This group would go on to develop hip dysplasia by the time the bones matured fully.

The authors concluded that more study is needed to clearly identify ways to predict the need for a second surgery during the mid-term developmental stage (ages five to eight). Further study may be able to pinpoint predictive factors of prognosis to help guide surgeons’ decisions about second surgeries for children with developmental dysplasia of the hip.

Here in the United States, a club foot deformity (known as congenital talipes equinovarus) in a baby or young child is treated quite successfully. A special treatment technique called the Ponsetti method is used with good to excellent results.

But in Third World or developing countries, such foot deformities may not be treated at all or inadequately treated. The result is a rigid, deformed foot and ankle. Often these children cannot walk, squat, or even wear shoes to protect their feet.

In a recent report, surgeons from Abu Dhabi capital city of the United Arab Emirates (UAE) on the Persian Gulf describe their attempts to correct this neglected foot deformity in nine children over the age of six. They treated a total of 11 feet using a combination of staged surgeries, traction, and a device called the Taylor spatial frame (TSF). They report that these rigid foot deformities in older children can be safely and successfully corrected with this treatment approach.

Before planning the surgery, a complete assessment of each child is necessary. The orthopedic surgeon you are planning to see will likely examine your adoopted daughter’s foot to look for flexibility and correctibility. Tendons and ligaments will be tested to see if they are shortened or contracted (fixed and unable to stretch or move). X-rays, CT scans, and MRIs may be ordered to look for bone or joint fusions.

Surgical procedures for this type of uncorrected deformity often include soft tissue releases of contracted ligaments, tendon lengthening, tendon transfers, bone osteotomies, and limb lengthening. For most of the children in the study we mentioned, it was necessary to make corrections carefully by using slow, gradual, steady traction to provide an additional three-dimensional force.

A special computer program calculated exactly how much force could be applied to the foot following surgery. The Taylor spatial frame made it possible to start with just 30 per cent surgical correction of the bones. By providing a slow change rather than a sudden shift in anatomical alignment, damage could be avoided to the nerves and blood vessels in the area.

After surgery and one week of traction, the lower leg was kept in the Taylor spatial frame. That made it possible to avoid using a lower leg cast, thus maintaining good blood circulation and nerve function that was easy to monitor.

Some children could go home with their families and continue the treatment under adult supervision. For other children, a six-week hospital stay was required to complete treatment in the frame. The children were allowed to walk wearing the Taylor frame. When the foot and ankle were fully realigned, the child was transferred from the frame into a lower leg (walking) cast for an additional month. The cast was designed to help maintain the improved alignment.

The surgeons summarized their report by saying that it is possible to salvage rigid foot deformities from untreated or poorly treated (severe) clubfoot. The three-prong approach they suggested with staged-surgeries, traction, and the use of the Taylor spatial frame is a safe and effective way to treat fixed foot deformities in children over the age of six. The Taylor frame is an essential key in making the anatomic corrections slowly enough to avoid problems while restoring limb length.

Your surgeon may have other suggestions and ideas to offer. This information should at least give you some ideas of what to ask and what to expect. There is help for these children. You are taking the best first step to have her evaluated and go from there.

The device you mentioned called the Taylor spatial frame is used to help correct severe foot deformities in the fastest time possible with the fewest side effects, problems, or risks. In remote areas of the undeveloped countries, children born with clubfoot (known as congenital talipes equinovarus) often don’t get the early, traditional treatment provided our children in the United States.

The clubfoot is unmistakable. The foot is turned under and towards the other foot. The medical terminology for this position is equinus and varus. 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.

This twisted position of the foot causes other problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight stiff foot that cannot be placed flat on the ground for walking. To walk, the child must walk on the outside edge of the foot rather than on the sole of the foot. Over time the foot becomes even more deformed from the force of the child’s body weight on the foot while standing and walking.

The Taylor spatial frame comes into play when surgery has been done to realign the bones. The frame combined with traction applies a slow, gradual corrective three-dimensional force. This device makes it possible for the surgeon to start with just 30 per cent surgical correction of the bones. By providing a slow change rather than a sudden shift in anatomical alignment, damage can be avoided to the nerves and blood vessels in the area.

After surgery and a short time in traction, the lower leg is kept in the Taylor spatial frame. That makes it possible to avoid using a lower leg cast but still allow the child to stand up and even walk. The open frame (instead of the closed cast) makes it possible to maintain good blood circulation to the foot and toes. They can also monitor pulses, toe movement, skin color, and skin temperature.

Eventually the child will be transferred to leg braces to help hold the improved alignment of ankle bones and soft tissues.

Pain is never really “normal” and is a signal that should not be ignored. Though not “normal,” research shows that chronic, persistent, recurring pain (daily, weekly, or monthly) is a common pattern among children.

In fact, it has been suggested that one-third of all children around the world are experiencing pain of this type at any given point in time. A recent systematic review was performed by a group of researchers in Canada. A systematic review refers to a search (and analysis) of all published studies on this topic.

Using predetermined criteria for what would qualify as a high-quality, appropriate study, the researchers sorted through 185 published papers from around the world. They ended up with 41 that could be included.
Looking at the studies that are available, here’s what they found.

The first thing they noticed was the wide range of prevalence reported. For example, studies of headache in children showed a range from 23 to 51 per cent. That broad of a range was also reported for stomach pain, back pain, musculoskeletal pain, and pain from other sources (including multiple pains).

Let’s take a closer look at the data on headache. Tension headaches were reported much more often than migraines with an obvious increase starting in second grade. Children in families with low levels of education and children who attend daycare are more likely to develop headaches.

There is a worldwide trend of increasing prevalence of headache over a long period of time. The reason(s) for this trend remain a mystery at the present time but are considered “worrisome” by experts who study pain and pain patterns. Future research is needed to further explore this finding.

The authors of this review say we should realize that persistent (chronic) pain in children and teens is more of a problem than we realized and should be considered a major health concern. Studies of health must shift focus to include children in this area and look for ways to reduce risks. Treatment to intervene as early as possible should be established and results studied to look for evidence-based success.

Studies across the developmental life cycles (children to adults) may help reduce the numbers of adults who end up with chronic pain problems. Better designed, higher-quality studies are needed to make this research relevant and accurate. The authors also suggest that understanding why girls suffer more pain than boys across the years should be a focus of future studies as well.

Many people of all ages suffer from a condition known as recurrent patellar dislocation or patellar instability. In this condition, the patella or kneecap as it is more commonly referred to pops off to the side (usually to the lateral side away from the other knee). It may or may not pop back in place, a movement called reduction.

Early on in the acute phase, treatment is likely to be conservative care with taping or bracing, and exercises. But with repeated episodes causing pain and loss of knee function, surgery may be necessary. Children and teens with this problem must be treated carefully to avoid damaging the growth plate when full growth has not been reached yet.

In a recent study, the results of two surgical techniques for recurrent patellar dislocation in teenagers was compared. One method (medial retinaculum plication) or MRP is minimally invasive using an arthroscopic approach. That means instead of making a long cut to open your knee up, the surgeon inserts a tube or scope through several small holes around the knee. There is a tiny TV camera on the end of the scope that gives the surgeon an idea of what your knee looks like inside.

The second surgery (vastus medialis plasty) or VMP is done with an open incision. Both of these treatment approaches are physis-sparing (they don’t affect the growth plate) so there are no leg length differences after surgery. This would be very important for someone your age.

Medial retinaculum plication refers to a procedure in which the medial (side closest to the other knee) retinaculum (connective tissue that holds the knee cap in the middle) is tied back using three sutures. At the same time, the lateral retinaculum on the other side of the knee (outer edge) is cut or “released” so that it can no longer pull the knee cap off center.

The vastus medialis plasty is a more complex procedure. The surgeon still releases the lateral retinaculum. But instead of tying the medial retinaculum back and holding it firmly in place, the medial portion of the hamstrings and connecting joint capsule (also on the medial side) are cut, released, and moved over to the opposite side of the knee. The idea is to suture these structures in place so that they continue to exert a pull on the kneecap to keep it in the midline (middle of the knee joint).

The question these surgeons wanted an answer to was this: which one of these two surgical techniques work better? They usually use the open medial vastus medialis plasty (VMP) but if the less invasive medial retinaculum plication (MRP) would work just as well, then the cosmetic appeal (no scars) might tip the scales in favor of the arthroscopic MRP approach.

To compare results of these two procedures, one surgeon performed all 60 surgeries (30 teens in each treatment group). Then they followed each patient for two years at regular intervals. This type of multiple series of evaluations helps show any hidden factors that might help determine the best treatment approach for these children.

CT scans were used to look at the position of the patella. The International Knee Documentation Committee (IKDC) tool was used to measure knee function. Results showed that the more invasive open surgery (vastus medialis plasty or VMP) had the better results.

There were fewer re-dislocations in the group of patients who had the VMP procedure. The VMP group also had better clinical outcomes. And in the end, the VMP group had better overall results despite the fact that patients in both groups experienced deterioration of knee stability over time.

They concluded that the more invasive procedure (VMP) is also a more reliable way to treat chronically recurrent patellar (knee cap) dislocations. The medial soft tissue structures just weren’t strong enough to counteract the lateral pull on the knee cap. Even so, there was a high rate of recurrence in both groups.

You’ll want to be seen by a physician if you haven’t already. All treatment options (conservative or nonoperative care as well as surgical intervention) should be explained and explored. It’s possible you only need something as simple as activity modification and/or restriction or perhaps an exercise program. Surgery should always be the last option considered.

The initial treatment for a patellar problem begins by decreasing the inflammation in the knee. If you haven’t already tried rest and anti-inflammatory medications, such as aspirin or ibuprofen, this would be the first step. Conservative care of this type is especially recommended when the problem is coming from overuse.

Another possibility is physical therapy. The physical therapist can help in the early stages by using ultrasound to limit pain and swelling and teaching you how to do ice massage at home. As the pain and inflammation become controlled, your physical therapist will work with you to improve flexibility, strength, and muscle balance in the knee.

Bracing or taping the patella can help you do exercises and activities with less pain. Most braces for patellofemoral problems are made of soft fabric, such as cloth or neoprene. You slide them onto your knee like a sleeve. A small buttress pads the side of the patella to keep it lined up within the groove of the femur.

An alternative to bracing is to tape the patella in place. The therapist applies and adjusts the tape over the knee to help realign the patella. The idea is that by bracing or taping the knee, the patella stays in better alignment within the femoral groove. This in turn is thought to improve the pull of the quadriceps muscle so that the patella stays lined up in the groove. Patients report less pain and improved function with these forms of treatment.

If all efforts to use nonoperative treatment techniques fail, then surgery may be an option. Some younger patients, especially athletes do wait until they have reached full skeletal maturity before having surgery. This is so the growth plate is not disturbed and thus avoiding a leg length difference.

There are some surgeries that do not require disruption of the growth areas. Your surgeon would be the best one to evaluate and advise you as to the best approach to this problem. Your age, bone maturity, and activity level will be taken into consideration. The surgeon will also assess your particular anatomy and other individual risk factors that might be present. Get all the information you can before making a final decision.

You may be referring to the use of titanium elastic nails (TENs). Fractures of the proximal humerus (upper arm near the shoulder) can be very challenging. The break can be very close to the growth plate and sometimes even goes through the growth plate. TENs are used to treat severe, displaced (separated), or irreducible (bone cannot be lined up) fractures.

The technique has been around for 40 years. It was first introduced in 1970 by a French surgeon by the name of Metaizeau. But it has been very successful and is being adopted by surgeons around the world. For appropriate patients, this technique eliminates the need to attempt closed reductions that can be very dangerous. It is a minimally invasive approach to the problem.

Functional results are improved because there is less risk of nerve and blood vessel injury. Being able to stabilize severe fractures also reduces the number of arm deformities and limb shortening. And finally, when compared with conservative (nonoperative) care with immobilization, this operative treatment is preferred by families. Children experience less pain, a shorter healing time, and faster time getting back to their daily activities including recreation and sports.

Fractures of the proximal humerus (upper arm near the shoulder) are not the most common bone breaks in children but they aren’t rare either. Sports injuries, bike accidents, and stunts like jumping or falling out of a two-story window account for many of these fractures. A simple break can be put in a cast or immobilizer until it heals — usually in about six weeks’ time.

Bone fractures in children repair quickly because the already rapidly growing bone aids in this process. A complete fracture that splinters into pieces or separates and then buttonholes (one end of the bone pops through the muscle) cannot be easily put back into place and held there until healing takes place.

Fractures that extend up into the growth plate can be another serious complication. But there are some tools surgeons can use in cases like these to help everything heal up without deformities, limb length differences, or interruption of bone growth.

One tool that is especially helpful is the titanium elastic nail. The nails are very thin and prebent in a slight C-shape to help prevent rotation of the bone and displacement of the healing fracture.

TENs were first used in the early 1970s by a French surgeon. Since that time, the technique has made its way around the world. Using TENs allows the surgeon to perform the surgery procedure without a long incision. This is called a closed reduction.

Studies show that this minimally invasive Metaizeau TEN approach to upper arm fractures involving the growth plate in skeletally immature children and teens has changed the way these injuries are treated around the world. There is no need to make repeated attempts to reduce the fracture without surgery and no need for open incision fracture reduction.

Functional results are improved because there is less risk of nerve and blood vessel injury. Being able to stabilize severe fractures also reduces the number of arm deformities and limb shortening. And finally, when compared with conservative (nonoperative) care with immobilization, this operative treatment is preferred by families. Children experience less pain, a shorter healing time, and faster time getting back to their daily activities including recreation and sports.