FAQ Category: Child

You are correct. Dr. G. Drehmann, a German physician first described what he called Drehmann’s sign back in 1903. Dr. G. Drehmann has since passed but another physician by the name of F. Drehman has since reviewed the first Dr. Drehmann’s finding and suggested that a positive Drehmann’s sign is a sign of femoroacetabular (hip) impingement.

Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). With SCFE, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). The altered shape of the femoral head can contribute to impingement.

Surgery to correct SCFE often changes the shape, position, and angle of the proximal (upper end) femur. With only minimal surgical remodeling of the hip, there can be a larger angle called the alpha angle. And the larger the alpha-angle, the greater the chance of impingement occurring even after corrective surgery.

Here’s how the test is done. With the patient lying supine (on his or her back), the examiner bends the patient’s leg up toward the belly button. If the leg automatically rotates outward (external rotation) and moves away from the body (abduction), there is a positive Drehmann sign. These are the movements the body makes in order to avoid hip impingement.

Sounds like one of the physicians at the hospital where you take your son is testing his or her patients after surgery for the presence of the Drehmann sign. Children with a positive Drehmann’s are more likely to report hip pain and a limp when walking. A positive Drehmann’s sign is direct confirmation of impingement.

Some experts suggest that Drehmann’s sign should be tested after surgery to correct slipped capital femoral epiphysis (SCFE). Even a mildly positive sign is an indication of hip impingement that should be treated. Eliminating impingement will help prevent the development of osteoarthritis later.

Slipped capital femoral epiphysis (SCFE) is a condition in which the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). 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.

In general, the most common problem later in life is the development of arthritis in the hip joint. The type of arthritis that develops in the hip is osteoarthritis (also known as wear-and-tear arthritis). This complication can occur even after surgery so surgeons must keep a close eye on these children as they grow into adults. Further surgery may be needed to improve alignment and prevent osteoarthritis.

Children with SCFE often develop something called femoro-acetabular impingement or FAI. Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

Surgery to correct SCFE changes the shape, position, and angle of the proximal (upper end) femur. With minimal remodeling of the hip, there can be a larger angle called the alpha angle. And the larger the alpha-angle, the greater the chance of impingement occurring.

One way to monitor patients for impingement and the beginnings of osteoarthritis is by imaging studies such as X-rays and CT scans. But there’s another way that doesn’t involve the cost of imaging or exposure to X-rays. A clinical test can be done by an examiner looking for a positive Drehmann Sign. As you might guess, Drehmann sign was named after the physician who first described it back in 1903.

With the patient lying supine (on his or her back), the examiner bends the patient’s leg up toward the belly button. If the leg automatically rotates outward (external rotation) and moves away from the body (abduction), there is a positive Drehmann sign. These are the movements the body makes in order to avoid hip impingement.

You may have stumbled on a recent study from Japan. In order to confirm the relationship between Drehmann sign and impingement, Japanese surgeons looked at X-rays of 92 hips with SCFE. They compared the number of patients who had femoroacetabular impingement as seen on X-rays with the number who also had a positive Drehmann’s sign.

They found a direct relationship between a larger alpha-angle, Drehmann’s sign, and impingement. Patients with a positive Drehmann’s were also more likely to report hip pain and a limp when walking. Patients with a negative Drehmann’s sign never experienced either one of these symptoms. This is helpful information because femoroacetabular impingement doesn’t show up very well on X-rays. A positive Drehmann’s sign is direct confirmation of impingement.

Dreymann’s sign is something your surgeon can evaluate. Using the clinical test along with three-dimensional CT scans that don’t involve X-rays may provide useful information. The Japanese surgeons who conducted that study concluded that Dreymann’s sign will help reveal the presence of hip impingement. And eliminating impingement will help prevent the development of osteoarthritis later.

It is a reasonable question and assumption made by many parents facing a wide range of personal and family stressors including job loss, poor health, and/or change in marital status (getting married, remarried, or divorced).

The prevalence of chronic, persistent, or recurrent pain in children has grabbed the attention of the health care world. Studies from 20 years ago repeated again recently show an increasing trend in headache, stomach/abdominal, back, and musculoskeletal pain among the children and teens around the world. This is not an isolated, United States, Canada, or North American phenomenon.

Some of the variables linked with this type of pain in children have been identified. For example, girls definitely have higher rates of chronic pain than boys for all age groups. Lower socioeconomic status and lower quality of life both appear to be linked with pain in children.

Marital status hasn’t been studied widely. In a recent systematic review of chronic pain in children, marital status of the children’s’ parents was only reported in one (Spanish) study. It did not appear to be a factor but further study of this variable is really needed before any firm conclusions can be made.

The important thing is to recognize there is a problem and address the symptoms even if the underlying cause isn’t obvious at first. Being aware of all possible factors (not just marital status) will give you more of a big picture view of the problem. Your daughter’s pediatrician is probably the best one to help advise you on this.

Certainly, there is nothing wrong with counseling for you and/or your daughter at a time like this. Ask your doctor what his or her recommendation is in this area. There are many approaches to chronic pain. Behavioral counseling is just one of many with the potential for positive change.

As you have now discovered, young athletes like your daughter who have anterior cruciate ligament (ACL) tears face a unique problem. Surgery to repair or reconstruct the damage can disturb bone growth. But delaying surgery until bone growth is completed can put the joint at risk of further damage without a stable ligament.

Parents facing this dilemma ask the same question. A recent study from Children’s Hospital of Philadelphia (CHOP) may shed some light on the problem and the solution. Orthopedic surgeons treating children at this hospital went back and looked at the records of 70 children treated for complete ACL tears.

All patients included in the study were 10 to 14 years old. They all had surgery to reconstruct the knee. The key feature reviewed was the timing of the surgery (early or late after injury). Results were analyzed and compared for timing between injury and surgery.

All kinds of other information was gathered and evaluated as well. For example, data collected included the usual demographic information (age, gender, history of injury, side of injury). It was also noted if the child had episodes of the knee “giving way” or “shifting” (a sense of knee instability). And, of course, observations of other knee injuries (e.g., meniscus, articular cartilage) from X-rays or surgeon visual inspection during surgery were also noted.

After sorting through all the data and making many calculations, it was determined that delaying surgery more than 12 weeks from the time of injury may create many more problems than it solves. There is a greater risk of damage to other areas of the knee (e.g., the meniscus). In fact, the number of massive meniscal tears that cannot be repaired increased dramatically in the children who had delayed knee reconstructive surgery.

The cut-off time seemed to be 12 weeks. In other words, children who had knee reconstructive surgery within 12 weeks of their ACL tears had less risk of other injuries, less severe damage, and better overall results.

One other observation made during this study had to do with return-to-sports before surgery. Children treated for ACL tears at this hospital were routinely told not to engage in any activities that could put their already injured knee at risk for further damage. They were advised to avoid running, jumping, or any activities that involved pivoting or cutting motions of the knee.

Despite these guidelines, significant additional injuries were reported. It’s not clear if this is because the children ignored the counsel of their surgeons or if the everyday activities of children this age are enough to cause ongoing damage.

There is a tendency for children this age to have more ligamentous laxity (looseness) anyway, so it’s possible that without an intact ACL, just normal movement increased the risk of other soft tissue injury. And, of course, the surgeons are aware that children find interesting and creative ways to do what they want to without exactly violating the surgeon’s warnings and perhaps without realizing the full effect of their actions.

Weighing the potential risk of disturbing growth centers against further injury and more severe damage to the knee, the authors concluded that delaying treatment until skeletal maturity is not advised in all cases. The risk of further meniscal damage creating an unstable knee with delays past 12 weeks must be considered on a case-by-case basis.

Managing complete ACL tears in children is a challenging affair. Your child’s surgeon is still the best one to advise you. All factors and variables must be taken into consideration including the presence and severity or future risk of associated soft tissue damage.

More and more children are showing up with ACL tears. This may be because there are more children participating in sports, in more demanding contact sports, and in year-round sports activity. With better diagnostic imaging, earlier diagnosis is now possible.

Children treated for ACL tears are routinely told not to engage in any activities that could put their already injured knee at risk for further damage. Like your son, they are advised to avoid running, jumping, or any activities that involved pivoting or cutting motions of the knee.

Despite these guidelines, significant additional injuries are still reported. It’s not clear if this is because the children ignore the counsel of their surgeons or if the everyday activities of children this age are enough to cause ongoing damage.

There is a tendency for children this age to have more ligamentous laxity (looseness) anyway, so it’s possible that without an intact ACL, just normal movement increased the risk of other soft tissue injury. And, of course, everyone is aware that children find interesting and creative ways to do what they want to without exactly violating the activity guidelines given to them. And perhaps they do so without realizing the full effect of their actions.

The idea that “kids will be kids” is hard to get away from. Their decision-making processes are not adult and studies show we can’t expect them to function like mini-adults.

Although rare, serious causes of back pain such as tumors, infection, and disc herniations must be considered in children. Girls younger than 16 years old are more likely than boys of any age to develop disc herniations. This may have to do with sudden growth spurts in girls that occur earlier than in boys.

Risk factors include heavy lifting, previous back injuries, and repetitive motions. Falls associated with athletic and sports activities are additional risk factors. For other patients, sudden increases in training, poor conditioning, or decreased spine range-of-motion increase the risk of disc herniation. It’s possible that congenital defects (present at birth) contribute to disc herniations but this hasn’t been proven directly.

Motions that put stress on the disc and increase pressure within the disc itself are more likely to lead to injury of the disc. For example, repeated flexion (bending) of the lumbar spine (low back), compression down through the spine, and spinal rotation or twisting can tear the outer covering of the disc. This area is called the annulus fibrosis.

Activities girls are more likely to be involved in (e.g., gymnastics, ballet, cheerleading) often require repetitive bending, extension, and twisting. If there is a family history of disc herniation, the soft tissues and connective tissue may be weak and more susceptible to damage and injury than in the general population.

There may be other reasons girls younger than 16 have more disc herniations than other age groups. Further research and discovery are needed to uncover all the potential risk factors. The important thing is to get your daughter the treatment she needs in order to have a full recovery.

Prognosis is excellent. More than 90 per cent of the children receiving conservative care recover fully. Pain relief is immediate and long-lasting. Only a small portion of children with disc herniations actually end up needing surgery. And only a few of the surgical cases (estimated at approximately one per cent of all children with disc herniations) need further surgery in the short-term (first 12 months).

Leg pain and numbness down the leg (without back pain) is actually the most common symptom reported by children who have disc herniations. Stiffness and loss of motion are common. A history of trauma or injury associated with sports is an important clue.

Most of the time, conservative (nonsurgical) care is the primary focus of treatment. This approach begins with antiinflammatory medications and physical therapy. If the painful back and/or leg symptoms don’t resolve, then a steroid injection may be considered. In a small number of cases, surgery is required.

Risk factors include heavy lifting, previous back injuries, and repetitive motions. Falls associated with athletic and sports activities are additional risk factors. For other patients, sudden increases in training, poor conditioning, or decreased spine range-of-motion increase the risk of disc herniation. It’s possible that congenital defects (present at birth) contribute to disc herniations but this hasn’t been proven directly.

Motions that put stress on the disc and increase pressure within the disc itself are more likely to lead to injury of the disc. For example, repeated flexion (bending) of the lumbar spine (low back), compression down through the spine, and spinal rotation or twisting can tear the outer covering of the disc. This area is called the annulus fibrosis.

Rest from all repetitive, sports, and recreational activities is advised. Patients should not strain, bend, extend, or sit for long periods of time. These positions and activities increase pressure on the discs.

A physical therapist will help guide patients through exercises designed to gently nudge the protruding disc back into its normal anatomic space. Core training to stabilize the spine is another important program the therapist will provide and supervise.

For patients who do not have neurologic symptoms (e.g., numbness, tingling, loss of bowel or bladder control, muscle weakness, foot drop), conservative care is usually very successful. Anytime a conservative approach fails to produce the desired results, more aggressive treatment may be needed.

Surgery to remove the bulging disc or disc fragments may be advised. This procedure called a discectomy must be done carefully in the pediatric population. The growing spine must be protected to preserve spinal stability. For this reason, open incision discectomy is the standard technique used to give the surgeon better visual access and control of the surgical area.

Although obesity is becoming a problem among school children around the world, the incidence of low back pain has really caught the eye of public health officials. In China, according to a recent survey of 2100 school-aged children (ages 10 to 17), one-fourth of all boys and one-third of all girls (same ages) reported low back pain.

And since we know there is a correlation between low back pain in childhood and back pain in adults, it’s likely that many of these children will continue to suffer low back pain later on in life.

Although sitting in front of a computer or bending over a desk for long periods of time may increase the risk of low back pain, Chinese children are not the only ones reporting a problem. According to studies around the world, there are similar patterns among British, American, Danish, and Japanese children.

The Chinese study (survey) we mentioned did not analyze the why but the authors suggested a few possibilities. Heavier backpacks, longer study time, and greater numbers of children affected by anxiety and/or depression might be contributing factors. The reaons for the rising rates of low back pain in our children needs further investigation. We must identify risk factors and begin to take steps to prevent back pain at such an early age.

Studies around the world are starting to report an increased prevalance of low back pain among school-aged children. For example, there is a 22 per cent prevalence rate of low back pain in British children, 30 per cent in American children, and 50 per cent in Danish children. Japanese children have a much lower point prevalence reported of 10 per cent but a 29 per cent lifetime prevalence.

Prevalence refers to the number of people who report low back pain at one specific point (day) in time or over a short period of time (e.g., three weeks or three months). As the name suggests, lifetime prevalence refers to how often this condition develops anytime in your entire life.

Girls do consistently report low back pain more often than boys though the girls are less likely to seek medical assistance for their painful symptoms. The reasons for the differences between boys and girls remain unknown. Some experts suggest theories that include the effect of earlier puberty among girls, greater spinal flexibility in girls, and different activity levels.

If activity is a preventive factor and girls are less active, then perhaps increased activity among girls will help. One other factor of potential importance is the tendency among girls to worry. According to one study, comparing back pain between boys and girls, girls tend to worry more about their back pain. Worry may actually increase the perception of pain.

Efforts are underway to research the increasing problem of low back pain among school-aged children. Differences based on gender, age, body-mass index, and any other factors will be examined carefully. You may see more information and explanations in the near future to answer your questions.

In the meantime, if any of your children tells you they are experiencing back pain, pay attention and report concerns to their primary care physician. The presence of fever may suggest infection. A report of recent trauma or injury along with severe or debilitating pain should be investigated and the possibility of fracture ruled out. General, mild low back pain may go away without further problems with a little time and TLC (tender loving care).

It may surprise you to find out that teenagers around the world are suffering more chronic pain than we ever realized before. Thanks to a recent study of over 7,000 participants, we know that 44 per cent of adolescents between the ages of 13 and 18 report chronic idiopathic pain.

At least that’s the case in Norway where the study was conducted. But it does support similar findings from other studies in other countries.

Chronic idiopathic pain was defined as pain anywhere in the body of unknown cause that was present at least once a week for the last three months. Idiopathic means there’s been no known injury, disease, or other cause of the pain.

Ten per cent of the group said they have pain every single day. Girls had more pain than boys and the number of girls affected increased as they got older. The location of the pain reported by girls was most often the head (migraines) and abdomen (stomach ache). In fact, twice as many girls as boys reported migraine headaches. Three times as many girls as boys reported abdominal pain.

Younger children of either sex were more likely to say they had leg pain. Headaches combined with neck and shoulder pain was the most common pain pattern reported by everyone no matter what age or sex they were.

So it seems your children aren’t alone but that doesn’t make this a normal occurrence. Pain is pain and it can be very limiting. As this Norwegian study showed, as much as one quarter of our children report pain in at least two places (e.g., headaches, neck and/or shoulder pain, stomach pain, other muscle or joint pain). More than half the children in this particular study (58.5 per cent) judged themselves to have trouble completing daily tasks.

This isn’t the first study to take a look at pain reported by children. Others have studied this problem and found that chronic pain in teens has a negative social, financial, and psychologic impact on this group. Many go on into adulthood still affected by their pain problem. Now that the high prevalence of chronic pain in youngsters has been confirmed, research is needed to identify the cause and find ways to prevent or eliminate the problem and the pain.

Chronic idiopathic pain has been defined by some pain experts as pain anywhere in the body of unknown cause that is present at least once a week for the last three months. Idiopathic means there’s been no known injury, disease, or other cause of the pain. There may be a specific cause of the pain but no one has been able to pinpoint what it is.

Scientists who conduct research on pain and pain management point out that not all experts agree this is the most accurate or best way to define chronic pain. But it was a starting point in gathering information for some studies.

Three months’ duration of painful symptoms does seem to be the cut-off point used by most physicians. This is based on research and publications put out by the International Association for the Study of Pain (IASP).

The frequency of that pain tends to vary from center-to-center and study group-to-study group. For example, some researchers use pain that occurs at least once a month for more than three months as chronic pain. Others look at how long the pain lasts (more than 24 hours) at least once a week for the last three months as the definition of chronic pain.

Whether pain is daily, weekly, lasts more than an hour or affects more than one place in the body, definitions vary according to who is measuring pain and why the information is being collected. Most likely you will have to ask the physician who made the diagnosis and labeled your pain as chronic what criterion he or she is using.

As you have now discovered, children are at risk for Chance spinal fractures when they are not properly restrained or only partially restrained with seatbelts. Chance fractures are described as flexion-distraction fractures. They occur in the thoracic (mid) spine most often in children. The same type of fracture can occur in adults but usually affects the lumbar spine (low back).

Chance fractures are also referred to as a traumatic horizontal splitting of the spine. The force of the impact throws the child’s weight forward against the seatbelt. The vertebral bone splits in half from side-to-side. The split goes through the main body of the vertebral bone and extends all the way back through the spinouts process (that’s the bump you feel along the back of your spine).

Like your granddaughter, there are often other injuries that occur along with the Chance fracture. These associated injuries include abdominal injury (the “seat belt sign”) and neurologic (nerve) damage. The risk of damaging the spinal cord (creating significant neurologic problems) is very real. This is because the underdeveloped bones and spinal ligaments stretch easily but the spinal cord does not.In accidents like these, there can also be other fractures and head injuries.

According to a recent study of Chance fractures in children, neurologic complications are permanent in about half of all cases. Other studies have suggested a slightly lower percentage (30 per cent) of neurologic injuries are permanent. Neurologic complications can refer to a wide range of symptoms and severity. Paralysis is the more extreme end of the spectrum. Children who weren’t seatbelted in at all seem to be the most likely to suffer permanent injury.

Chance fractures of the spine occur most often as a result of car accidents. Adults and children can be affected. The improper use of restraints (lap belts without a shoulder harness, shoulder harness without the lap belt, or no belt at all) increase the risk of a Chance fracture. Sometimes people move the shoulder harness behind them because it crosses too high across their bodies making it uncomfortable.

Chance fractures are also referred to as a traumatic horizontal splitting of the spine. The force of the impact throws the person’s weight forward against the seatbelt. The vertebral bone splits in half from side-to-side. The split goes through the main body of the vertebral bone and extends all the way back through the spinouts process (that’s the bump you feel along the back of your spine).

The type of treatment given may make a difference in the final results. Yet, right now there doesn’t appear to be a standard way to approach treatment for Chance fractures. Sometimes surgeons try placing the child in a cast or brace that holds the spine straight or in slight extension.

In other cases (usually in the case of more severe fractures and more forward flexion of the spine), surgery is done to fuse the spine. Rods, hooks, screws, and/or wires are used to hold the spine in good alignment during healing and recovery. Some surgeons suggest that children with a forward-flexed spine (called kyphosis) of more than 20 degrees are more likely to need surgery in order to have a good final outcome.

Further studies are needed to compare the results of different treatment approaches. For example, it’s possible that even one variable (e.g., location of the fracture(s), severity of fracture(s), age of the child, severity of kyphosis, presence of other injuries) could make a difference in selecting the most successful treatment.

The presence of other injuries may be as important as the spinal fracture. Multiple fractures, head injuries, and abdominal damage can complicate the picture. This is a rare type of spinal fracture so large studies are not available. In smaller studies, there are isolated (single cases) of death reported.

There is always a risk of long-term problems with these types of injuries. The neurosurgeon will be able to give you a better idea of what to expect after seeing the exact location and severity of injuries. Most children have a good result meaning no chronic pain and no permanent neurologic problems. We hope your son falls into this category.

In cases where the diagnosis is already known, further testing such as CT scans or MRIs may not be helpful and they add quite a bit of expense. These kinds of advanced imaging are more likely to be ordered when the physician is trying to differentiate between various possible causes of joint pain and swelling.

For example, MRIs are helpful when trying to determine whether the cause of the symptoms is synovitis (inflammation of the synovial fluid in the joint), septic (infectious) arthritis, or Lyme disease. Patients with Lyme disease are more likely to have muscle inflammation and swollen lymph glands (as seen on MRIs) whereas patients with septic arthritis have fluid (edema) just under the skin.

There are other tests available to help make a differential diagnosis. Drawing some synovial fluid out from inside the swollen joint may be helpful. Physicians must keep in mind results of reported studies that showed a wide range of results even in known cases of Lyme disease. The test is still important to help rule out (or rule in) bacterial arthritis.

A positive ELISA blood test for Lyme disease helps make the final diagnosis. In rare cases, a positive Lyme test can be a false positive but generally, this is a very helpful test. Inflammatory markers in the blood (high white blood cell count or elevated Sedimentation rate) don’t specifically rule out Lyme disease but do help identify septic arthritis.

There’s an old saying in medicine, “If you hear hoof beats, think horses not zebras.” It means to look for the obvious not search for strange, unusual causes of symptoms. But in the case of hip pain in children, it may be a zebra like Lyme disease. Most of the time, joint pain caused by Lyme disease affects the knee. But in a small number of cases (as you have discovered), Lyme arthritis presents only in the hip.

To help you put this into proper perspective, consider the results of a recent study from Children’s Hospital in Boston. Located in the northeastern region of the United States at the Children’s Hospital, this hospital is in an area where Lyme disease is very high.

Yet out of all the children treated at the hospital between 1995 and 2009, only 73 cases of Lyme disease were reported. And only eight of those cases were hip pain caused by Lyme arthritis. The children in the study ranged in ages from three to 20 years old. The symptoms presented included hip pain (all eight children reported this), refusal to put weight on that leg (five children), and limp (three children).

Fever was not a key feature for most of the children. None of the families were aware of any tick bites or unusual skin rashes. Tests and measures revealed a wide range of results that didn’t necessarily point to Lyme disease. But lab values were suspicious with elevated white blood cell count and sed rate (both indicators of infection and/or inflammation).

The authors reviewed results from other studies and found that as many as 13 per cent of children with Lyme arthritis have hip pain. But in those other cases, the hip pain was part of several different joints that were affected at the same time. This type of Lyme arthritis is called polyarthritis. Hip pain as the only joint involved just isn’t a typical early presentation of Lyme disease in children.

So when physicians are faced with hip pain, a limp, or refusal to put weight on the leg in children, it is better to look for horses (e.g., bacterial arthritis or synovitis) first before searching for zebras (Lyme disease). Either condition must be treated quickly and appropriately in order to get the best results. Whereas septic (bacterial) arthritis may need surgery quickly to save the joint, children with Lyme disease can be spared surgery and treated with antibiotics if and when properly (and quickly) diagnosed.

Galeazzi fractures of the wrist usually occur as a result of a forceful fall onto the hand/wrist of an outstretched arm. The wrist is extended with the palm face down (though this same injury can occur with the arm outstretched and the palm facing upwards). The force of the impact causes the break. Other trauma such as car accidents, electric shock, and blunt trauma can also result in a Galeazzi wrist fracture.

When the force on impact is enough to break the bone and disrupt the distal radioulnar joint or DRUJ, it is called a galeazzi fracture. Galeazzi fractures of the joint between the two bones of the forearm (the radius and the ulna) can affect children and adults.

The main area affected is the shaft of the radius (forearm bone) down at the end closest to the wrist. Some experts who have studied this problem say Galeazzi fractures occur when the distal one-third of the radial shaft is broken.

Treatment for children is usually with closed reduction and immobilization in a cast that goes up above the elbow. Closed reduction refers to setting the break without cutting the wrist open surgically. Anesthesia is still required to put the child to sleep while performing this procedure and X-rays are used to confirm correct placement of the bones.

If all goes well and the fracture heals, then no further treatment is needed. An excellent outcome has been reported in approximately 75 per cent of all children with this problem. But in some children, the fracture doesn’t heal or the bones shift apart and there is a loss of the reduction. That requires surgery to pin the bones together, recast, and try again.

Many children are amazingly resilient. They come out of the cast with very few problems. Any loss of motion or stiffness is quickly gone and they return to full activity in a matter of days to weeks. Adults with similar injuries often require months of daily rehab to regain functional range of motion and functional ability.

Your surgeon is the best one to advise you on expected outcomes. The location and severity of the fracture along with any complicating associated injuries of the surrounding soft tissue will determine the final result. Family and patient compliance with all instructions provided is another key feature that you can assist with to ensure the best possible results. Good luck!

Legg-Calvé-Perthes (known as Perthes for short) is caused by a loss of blood supply to the epiphysis (growth center) of the hip. Without enough blood to nourish and replenish the bone, necrosis (cell death) occurs.

Deformity of the femoral head (round ball of bone at the top of the thigh bone) occurs. The affected bone starts to break apart (a process called defragmentation) and collapse. The end-result can be a change in the shape from a round femoral head to an oval or ovoid shape.

Instead of a ball in the socket with smooth, circular motion, the patient develops more of a mushroom-shaped hip. The femoral head is no longer encircled fully by the hip socket. Uneven wear on the oval-shaped head eventually leads to degenerative osteoarthritis. In some cases, severe arthritis develops early in adult life.

The goal of treatment is to prevent these complications. But the best way to do this remains unclear. As you experienced with your son, braces have been used to keep the hip fully in the socket and prevent changes in the shape of the femoral head. The idea in mind was to preserve the round head during the regeneration process. Bracing also limited how much weight the child could put on the hip. Less pressure through the hip was thought to help keep the round head of the femur in a spherical shape.

And, in fact, studies have supported the idea of keeping weight off the hip as necessary for a good result. At first, children were kept off their feet altogether. They did daily hip motion exercises and were able to keep the natural shape needed for hip mobility and flexibility. But staying in bed for a young, normally active child can be difficult and doesn’t seem like a really good idea.

Right now, the prevailing thought is that treatment is advised when more than half the epiphysis is affected. Bracing may be recommended if the child is six years old or younger. Surgery may be a better option for children who are seven or older and who have severe disease. Most of the studies support the idea that treatment of any kind just doesn’t seem to make a difference for mild-to-moderate disease in younger children.

So the use of bracing was introduced. Well, actually the first orthopedic surgeons to study this approach (back in the 1970s) used plaster casts on both hips and legs. The child’s legs were held far apart with a bar between the legs. Later a special “hip hinge” was developed to accomplish the same thing but allow better movement. They could walk with a walker and with limited weight through the hips.

The early results were positive and more studies were done trying all sorts of different casting and bracing ideas. Twenty years later (in the 1990s), several studies were done to review the results of this treatment approach. As it turns out, the results were actually pretty poor. Two-thirds of the children were not helped by the bracing. Analysis of the data showed that bracing should not be used with severe deformities.

New questions came up: are the results of using the casting method better, same, or worse compared with using braces? When should bracing be used? How long should braces be used? How can you know when it’s time to start weaning the child off the supports? What factors make for the best results?

More studies were done. Over time, a clearer picture emerged. They found that treatment should be based on a classification system that divides patients by age and severity of disease. Mild disease (determined by X-rays) in younger children (five years old or younger) doesn’t really need active treatment. Careful observation may be all that’s required.

This may be the case with your grandson.

Children with Perthes disease of the hip may recover fully without further hip problems later. But those with growth disturbance of the femoral head and altered shape of the normally round femoral head (top of the thigh bone) may end up with femoroacetabular impingement (FAI).

Surgery to correct the impingement is a possible treatment option. Careful assessment of all deformities and damage present in the hip complex can be done best with surgical dislocation.

The surgeon must look at both sides of the hip: the femoral head and the acetabulum (socket). It may be necessary to make surgical corrections of both areas. And that means surgically dislocating the hip in order to visually inspect everything and form a surgical plan.

On the femoral side, the surgeon may change the length or angle of the femoral neck. The misshapen and enlarged head may have to be corrected, a procedure called osteochondroplasty. This also requires surgically dislocating the hip. That sounds pretty dramatic but it can be done safely and is quite effective.

While correcting the deformity that causes impingement, the surgeon will also look for any other areas of soft tissue damage. There may be a tear in the labrum that needs attention. The labrum is a rim of cartilage around the hip socket designed to give the socket a little bit more depth and the hip greater stability inside the acetabulum.

The ultimate goal of surgery for femoroacetabular impingement in the Perthes hip is to improve hip joint motion. Reducing pain and improving joint stability are also important. The surgery can become quite complex when there are numerous changes in the hip to be addressed.

Perthes disease of the hip (also known as Legg-Calvé-Perthes) occurs when there is a loss of blood supply to the growth center at the top of the femoral head. Without enough blood, the bone dies, degenerates, and collapses.

Children with Perthes disease of the hip may recover fully without further hip problems later. The body is capable of limiting this disease and growing new bone. But in the meantime for some patients, the weight of the body on the unstable bone can cause the head of the femur to become more oval-shaped.

Children with growth disturbance of the femoral head and altered shape of the normally round femoral head (top of the thigh bone) may end up with femoroacetabular impingement (FAI) (pinching of soft tissue and bone). This problem tends to show up during adolescence (the teen years).

It takes time for changes in shape of the femoral head to occur. As the femoral head is pressed down, the femoral neck (between the shaft of the thigh bone and the femoral head) is shortened. There can be a rotation of the bone as well. All these features add to the likelihood of an impingement problem during adolescence.

X-rays will help show what’s going on. The radiologist and orthopedic surgeon look for something referred to as acetabular coverage. This is a view of how much of the femoral head is inside the socket (called the acetabulum). With impingement from Perthes, it is common to see overcoverage (shelf of the socket hangs down over too much of the femoral head).

If you haven’t seen the X-rays yet (or you saw them but didn’t understand the process), ask your surgeon for a review of your daughter’s case. This will also help you understand the proposed treatment and possible outcomes.

You are quite right that the number of accidents involving all-terrain vehicles (ATVs) has been on the rise for the last 10 years. And many of these accidents are high-energy resulting in some serious injuries (even deaths).

What makes these machines so dangerous? Power, speed and uneven or steep terrain. The first ATV models were seven-horse power. Remember, that means the engine has the pulling power of seven horses hooked up together. Today there are 500 horsepower ATVs available on the market.

What can be done to prevent these life-changing (and life-threatening) injuries? Awareness of the problem is always the first step. Reports on ATV injuries are helpful in pointing out to all of us how significant ATV-related accidents and injuries can be for all age groups.

We need better injury prevention strategies. Drivers who do not have the strength, body mass, and motor control to handle a 500-horsepower machine should not be driving them. Injuries are more likely in younger, smaller individuals, especially children.

They are less able to stop a vehicle roll over. Girls have less strength and often have more ligamentous and joint laxity. These two physical features combined together may have a significant impact on their ability to hold up during a rollover or other ATV accident.

Emotional maturity and judgment are important too but much more difficult to measure(in adults and children). Older children who might be better able to stop a rollover are also going faster and taking more chances. The recommended age for ATV use is 16 and older. Parents and guardians would be wise to enforce this age restriction.

The use of protective helmets that have been sized specifically for each rider must be enforced. Several studies have shown that many people injured in ATV accidents were not wearing a safety helmet. The safest vehicle is only as safe as the owner and operator!