News Category: Child

The clavicle, or collar bone, is the most commonly broken bone among children up to the age of 18 years and representing between 10 percent to 15 percent of bone injuries in children under the age of 10 years. The clavicle can be broken by a direct hit to the bone, but it is a fracture that is most often the result of an indirect injury – when someone falls on their shoulder or on an outstretched hand, intended to break a fall. Some children are born with broken clavicles too.

Although it is important for all broken bones to heal properly, the clavicle needs to be strong enough and functioning well enough to support the arm and to help it be as mobile as possible. Usual treatment for a broken clavicle is applying a sling that keeps the affected arm still, allowing the clavicle to set. Surgery is not a common option, as doctors feel that slings are the way to go. But, although it is strongly believed that this type of treatment is enough and that slings just about always result in a healed, joined bone, there hasn’t been a lot of research on it. Seeing as bones grow and change throughout childhood, it is possible that this could affect clavicle healing. As a result, the authors of this study wanted to look at the postnatal (since birth) growth pattern of the collar bone.

To do the study, researchers examined chest x-rays of 961 patients who were 18 years old or younger and who had been diagnosed with a fractured clavicle. The researchers divided the patients into 19 groups: newborn to 11 months and then one group for each year of age. Each of these groups was divided again by male/female lines.

Evaluating the clavicle involved measuring the length in millimeters by three researchers to ensure consistency in the measurements. Throughout the study, some people were measured in different groups, as they grew older: although 850 were measured only once, 94 were measured twice, 12 three times, three four times, and two five times.

The findings showed that among 18 years olds, the average length of the clavicle was 149 mm, give or take 12 mm for girls, but in boys it was 161 mm, give or take 11 mm. The researchers noticed that both boys and girls had a steady growth rate after the age of 12 years, but slower for the girls (2.9 mm per year) than the boys (5.4 mm per year).

Looking at the younger ages, the researchers determined that among girls, the majority of the clavicle growth (80 percent) was done by the time they were nine years old. In boys, the majority (80 percent) was by the age of 12 years. This finding shows that the healing of a fractured clavicle may not be as easy in older children as it is in younger children – there is not as much bone formation going on in the older children years. In this case, other treatments may be a more viable option.

Chance fractures are fractures of the lumbar (lower) and thoracic (mid-upper) spine and are most often seen in adults who have been in a motor vehicle accident and who were wearing only lap belts as restraints. Chance fractures in children are not common because of the safety restraints used in cars these days, but they do happen. When children do sustain Chance fractures, there is a slight risk of neurological (nerve) issues that result but, usually, doctors find it more common for the children to sustain serious injuries in the abdomen instead, intra-abdominal injuries.

Children who sustain Chance fractures do so usually because they were using lap belts in cars rather than the three-point restraints that hold the chest back, preventing them from bending forward at the waist. The authors of this article write about a family who was in a motor vehicle accident at a high speed. Three of the four siblings (aged 15, 13 and 12 years) were not wearing their three-point restraints properly because they had removed the chest strap during the drive. The children had been reclined in their seats, sleeping in their minivan at the time of the accident. The three sustained Chance fractures and two of the three also developed serious intra-abdominal injuries.

The 15-year-old, a girl, had severe face and head injuries, although she was conscious when she arrived in the emergency room. She also complained of abdominal pain, where there was an obvious seatbelt mark. Her neurological tests were normal but a computed tomography scan (CT scan) of her abdomen and pelvis showed that her colon had been perforated and there was a Chance fracture at the L3 level of her lower back.

Her surgery included repairing the intestine, removing food and fluid from the abdominal cavity and repairing any other internal tears. Two days later, she underwent surgery again to repair facial fractures and when she was physically ready, she was placed in a Risser castto stabilize her back. She has since healed from the spinal fracture and abdominal injuries, but she continues to need several procedures to repair the damage to her face, jaws and teeth.

The 13-year-old sibling, a boy, was also conscious on arrival at the emergency room and also complained of facial pain, back pain and mild abdominal pain. He, too, had a visible seatbelt mark on his abdomen. The boy’s neurological examination was normal and, for the most part, his CT scan was normal, except for some fluid in his pelvis. The spine had sustained a Chance fracture at the L2 and L3 level of the lower back.

Surgery was done immediately to repair his complex facial injuries and surgeons also took a look inside the boy’s abdomen, but did not find any injuries. He was also placed in a Risser cast, but earlier than his sister, only six days after the accident. The boy has since healed and returned to his normal pre-accident activities.

The third sibling was a 12-year-old boy. He was also conscious on arrival at the emergency room, complaining of significant back pain and severe abdominal pain. He, too, had a large seatbelt mark on his abdomen. His neurological signs were normal, despite the complaints of back pain. His abdominal injuries, as seen by CT scan, showed a right-sided pneumothorax, air in the chest that has collapsed the lung. He also had internal bruising and there was fluid in the pelvis. When surgery was performed that night, the surgeons found a tear in the common bile duct (part that exits the liver) and they repaired this and they also inserted a chest tube to treat the pneumothorax. No other abdominal injuries were found. It was only the next day, with another CT scan, that the doctors found that this sibling had also sustained a Chance fracture, this time in the lower level of the mid-upper spine. He was also placed in a Risser cast after this chest tube was removed.

The authors used these cases to show the importance of proper restraints in a motor vehicle. The incidence of Chance fractures have gone down with the wider spread use of three-point restraints, but as shown by this case, they still do happen, usually when the three-point restraints are not being used properly. The authors also pointed out that “up to two-thirds of Chance fractures have associated intra-abdominal injuries, with 25 percent to 58 percent of these injuries requiring surgical treatment.”

Knee injuries involving the meniscus (cartilage) are well-known in adults, especially athletes. But meniscal tears in children are becoming almost as common. And there are two reasons for that. One is the increased sports participation among young children and young adolescents and two is the presence of a discoid meniscus. The first reason probably comes as no surprise to you and needs no explanation. But discoid meniscal tears aren’t something you read about in the daily news.

Most of the time, knee meniscus (menisci is the plural form of the word) has a standard C-shape. Placed on either side of the knee (medial for the inside/lateral for the outside), it forms two horseshoe-like structures to support the joint and provide smooth movement. But like all things in the human body, there can be differences in the size, shape, and structure of the menisci. Unusual meniscal shapes in the knee are called discoid meniscus. They are most common in the lateral meniscus and create instability that can result in injury from trauma.

Usually, the menisci are even, symmetrical and about the same thickness and width throughout. But the discoid meniscus, instead of being a curved crescent shape, tends to be block-shaped. The discoid meniscus is thicker than normal but the fibers that form the meniscus tend to be disorganized and form more of a haphazard pattern. They are large enough to cover the entire lateral side of the joint (the normal lateral meniscus covers up to 80 per cent of the surface). Usually, the normal meniscus is held in place by a series of ligaments. But in the discoid meniscus, the absence of some of these ligaments allows the meniscus to move around. That excess movement called hypermobility pulls the meniscus out of place causing a snapping, popping, or clicking sensation called the snapping knee syndrome.

In this article, orthopedic surgeons specializing in sports medicine (and in particular, children’s sports medicine), provide a very thorough discussion of meniscus injuries in young athletes. They provide a review of the normal anatomy of the meniscus as well as the unusual changes present in discoid menisci. With colorful drawings, photos taken during arthroscopic surgery, and MRIs, the reader gets a clear view of the normal anatomy as well as the what-can-go-wrong depiction of discoid menisci and menisci damaged from injuries.

A second focus of the article is the diagnosis and treatment of these conditions. The patient’s history comes first. In many of the nondiscoid meniscal tears, there is a twisting injury during sports participation that traumatizes the knee. Bleeding into the joint, meniscal tears, and ruptures of the anterior cruciate ligament (ACL) are the most common patterns reported.

The examiner will then perform several special tests to assess the integrity of the soft tissue structures. The exam may be limited by the child’s pain and swelling. Whenever possible, two tests: the McMurray maneuver and the Lachman test are done. McMurray’s maneuver helps show the status of the menisci, while the Lachman test is used to find ACL tears.

Imaging studies such as X-rays and MRI scans are useful to look for fractures, dislocation, loose fragments of bone or cartilage, and bleeding into the joint. MRIs are less reliable in children under the age of 12 because of the immature bone and soft tissues. What looks like a meniscal tear may just be the extra blood supply to the area normally present in a growing child.

Once the diagnosis has been made, then the decision about what to do comes next. Unlike adults, children have a much greater chance of healing from a meniscal tear (even large tears), again because of the increased blood supply to the area. Even surgery in children is likely to be more successful because the meniscus is not degenerating with age like it is in older adults. When necessary, the meniscus is sewn back in place. Surgical removal of the meniscus called a meniscectomy may be needed if the meniscus just can’t be saved. Surgeons avoid removing any part of the meniscus as much as possible because studies show that the loss of the meniscus results in continued pain and early arthritic changes even in children.

The authors provide surgeons with a detailed discussion of repair techniques for meniscal tears as well as repair or reconstruction of any other damage that occurred at the time of the injury. The advantages and disadvantages of various meniscal repair systems used during surgery are also presented. Special considerations for the surgeon along with guidelines for postoperative care (both based on type and extent of the meniscal tear) are also reviewed.

Discoid menisci that aren’t injured or that do not cause pain and/or instability are left alone. When surgical repair is advised, an arthroscopic approach is possible. The meniscus is reshaped and smoothed down, a procedure called saucerization. The goal is to create a stable, yet functional, meniscus. There is some concern that the remaining discoid meniscus won’t function properly because of its abnormalities, but studies done so far have shown that children seem to adapt. Long-term studies are needed to see what happens over time.

What can these children expect after surgery? As mentioned, younger children seem to have the best success rate. Actual studies of results based on age have not been published yet. It’s difficult to compare results when there is such a wide range of injury types — some children just have meniscal tears but others have additional soft tissue damage. Failure to recognize and repair other ligamentous injuries is the biggest reason why surgical results to repair torn menisci fail or are less successful than hoped for. And long-term studies have not been done to show if younger, more active patients with meniscal injuries that are repaired will develop arthritic changes later like adults do.

The authors conclude that results are good-to-excellent for most children (75 to 87 per cent) with any type of meniscal injury following repair. They suggest there is plenty of room for further research in the area of meniscal tears in young athletes. Until it’s clear the best approach to take, surgeons are advised to conduct a careful history and exam in order to accurately diagnose knee injuries and plan treatment accordingly.

Lower extremity (leg) angular deformities are commonly seen by pediatric orthopedic surgeons, bone surgeons. They can be coronal, the invisible division from front to back, sagittal, dividing left from right, or transverse, dividing top from bottom. While some deformities don’t change, others are progressive, they get worse with time. The progressive deformities can have an impact on how the child walks (his gait), cause pain, and possibly cause other problems down the road, such as arthritis.

Deformities of the leg can be congenital, meaning the child was born with it, idiopathic, no reason why the deformity occurred, or acquired, it happened after birth. The causes include certain health issues that affect the minerals in the body that strengthen bone, skeletal problems, traumas, or infections, to name a few. For example, one disease, Blount’s disease is a common cause for both young children and adolescents. In Blount’s disease, the inner part of the shin, just below the knee, doesn’t develop as it should and this results in bowed legs.

When a doctor is looking at an angular deformity, he or she must take a thorough medical history and perform a physical evaluation. The history includes information such as when (if) the child began walking, any family history of such problems, the child’s birth, nutritional status, any infections or previous bone breaks, and so on. The doctor should watch the child walk to look for any signs. Certain signs, such as the Trendelenburg sign can suggest a problem with the hip and the leg, for example.

Standard testing includes x-rays, usually a standing x-ray. When a child is lying down to have an x-ray of the leg, the leg isn’t being stressed as it is when the child is standing. Therefore, a standing x-ray would be more reliable. Blood tests may be done if the doctor suspects a nutritional problem or an issue with minerals or hormones. However, these are not routine tests.

Treating the deformities is as individual as the causes and the diagnosis. Options range from bracing (non-surgical treatment) all the way to surgery. And, even if a particular deformity is often treated surgically, it isn’t always. For instance, Blount’s disease can be treated surgically, but only if the angle of the deformity has reached a certain height. Under that, bracing is the first choice treatment. Ring fixators are another treatment option. These are wires and rods that are surgically inserted into the bone and come out through the skin. They are then attached to a frame and this stabilizes the bone. While this treatment has advantages, there are risks involved – the most common one being infection where the rod enters/exits the skin.

The authors of this article concluded that there still is much research to be done in this area. The use of computers to help find the best angle for correction is one step and this can be compared with more traditional treatment to see which is best and in which circumstances.

Children are known for getting into scrapes and often enough, breaking bones. Statistics show that about 10 to 25 percent of all injuries among children are bone fractures (breaks). But, despite fractures being relatively common, not much research has been done about the best way to treat these fractures nor how frequently certain fractures occur.

The authors of this study wanted to look at how often children broke bones and how the breaks were treated. To do this, researchers evaluated the records of Finnish children who had been admitted to a hospital because of a fracture between 1997 and 2006. It was found that more children had fractures in the later part of the study period – 13.5 percent difference at the end of the study, compared with beginning. Although the rate of lower extremity fractures remained about the same throughout the nine years, there was a 23 percent increase in upper extremity fractures.

The children were divided into four groups:

– non-ambulatory (younger than one year)
– pre-school age (one to six years)
– school age not licensed to drive (seven to 14 years)
– school aged, licensed to drive a light motorcycle or scooter, but not a car (15 to 17)

The researchers were looking for the type of fracture (diagnosis), how it happened (mechanism), the type of surgery, and length of hospital stay. The results showed that there were 37,271 fractures that required admission to hospital. Among them 28,870 required surgery. The rate of surgery increased over time by 20 percent from the first year (1997) to the last (2006). The most common age group to have surgery was among those younger than 15 years (23 percent) compared with older adolescents (15 to 17 years), with only a 4.6 percent increase.

Surgery for forearm fractures showed a 62 percent increase; upper arm increased by 18 percent. Breaking down the groups for these surgeries, those children between one and seven years old had an increase of 29 percent for forearm surgery; 78 percent increase in the eight to 14 age group; and 90 percent in the 15 and older age group.

While not strictly surgery, some children have to go under general anesthetic to have their broken bones set or reduced. This treatment, called closed reduction, because it doesn’t involve surgery, didn’t increase over the study period. Usually, this is the usual method of treating forearm fractures. It has also been found to be quite effective in treating upper arm fractures, with lower complication rates than surgery.

Not forgetting lower-extremity fractures, the researchers found that the slight increase in that type of surgery is understandable. Better use of x-rays and other imaging equipment allows doctors to have a better look at what they are dealing with. However, it still has not yet been proven that the surgery is superior to reduction.

When looking at the frequency and types of surgeries, the researchers searched for ways to predict who would have to have surgery. They found that upper extremity fractures needed more surgical procedures than lower extremity and that surgery was more likely in adolescents aged 15 to 17 years.

The study also looked at re-interventions, situations that required a repeat treatment or surgery. Re-interventions increased by 46 percent overall, 28 percent if the reason was for misalignment of the bone. Hospital stays varied in length, dropping from 44 percent to 38 percent.

In conclusion, the study’s authors concluded that more surgeries were being done to treat fractures among children, particularly over the past 10 years. However, there didn’t seem to be any supporting evidence as to why the surgical procedures increased so much. The authors wrote, “On the basis of current knowledge, the increase surgery rate for upper-extremity fractures is difficult to support. In addition, we did not find that the rate of re-reductions of fractures had decreased, despite the increased rate of surgery.”

Low back pain is a common complaints among adults. Whether the pain is caused by work or something else, it’s estimated that about 75 percent to 85 percent of adults will experience lower back pain at least once in their lifetime. The unlucky ones experience it more often. Unlike adults, back pain in children doesn’t seem to be as common. In fact, it used to be thought that if a child had back pain, it had to have been caused by a terrible illness or deformity. This belief is backed up by earlier study findings that suggested that 50 percent of the children who presented with back pain had a specific spinal disease. Of course, this also means that 50 percent did not.

There are many conditions that can cause back pain in children and the authors of this review article focused on the causes and risk factors for children developing back pain, as well as diagnosis and treatment options.

While there has been a good bit of research on children and back pain over the past 30 years or so, there hasn’t been any consistency or standardization of data or even the definitions of back pain. The researchers found a recent review article that discovered that although much research had been done in the area of back pain prevention and education, there haven’t been any substantial studies that looked at the effectiveness of back pain prevention in children and adolescents.

Although there have been many studies that have looked at the risk factors of back pain, there hasn’t been much in the way of putting them all together. Interestingly, some of the studies have contradicting findings. Several studies came to the conclusion that girls had more back pain than boys. Other studies found no difference between boys and girls with back pain. Yet, a study by Burton and colleagues found that boys, because of increased sports activities, had a higher risk of back pain. Family history, often an issue in medical problems, has been found to be a factor in some studies, but not in others. Environmental issues could also play a role, as shown in a study of twins, by El-Metwally and colleagues.

Other issues that could play a role in low back pain in children include physical activities. Even the legs have been implicated in lower back pain. One study found that tight quadraceps (upper leg muscles) and hamstrings could cause lower back pain. Lack of exercise can cause lower back pain as well. A few studies have looked at the amount of time children spend playing video games. One found that those who played two hours per day had more back pain than children who just watched television for two hours. Their posture while game playing is one aspect that the researchers felt could contribute to back pain.

Obesity is another issue that not only contributes to lower back pain, but other health issues as well. Finally, a problem that has been identified over the past decade or so, is the increased weight of the backpacks many children use to bring school work and books between school and home. Children are not only carrying very heavy weights on their back, many children are not using/wearing their backpacks correctly, increasing their risk of developing back pain.

The researchers write that we can’t forget psychosocial issues as well. Children who are happier and appear to be well adjusted tended to have fewer incidences of lower back pain, compared with children who weren’t doing so well. A study by Diepenmaat and colleagues found that children who showed signs of depression also reported more back pain than children who weren’t depressed.

Diagnosing lower back pain in children should begin with a full physical exam and a complete medical history. This information can rule out some issues and point the doctors in the direction of others. If no definite diagnosis can be made, a diagnosis of non-specific lower back pain, NSLBP, can be made. However, before this diagnosis is made, it’s essential that testing be done.

The generally accepted procedure for investigation begins with the physical exam and history, which then could lead towards having x-rays taken of the lower back. If the x-rays show something, a diagnosis could likely be made. If the x-rays don’t show anything, and the child is complaining of only occasional pain, it’s likely non-specific pain and it can be treated as that. However, if the pain is constant, at night, radiating (down to the legs), or the child is having neurological (nerve) problems as well, than a magnetic resonance imaging test should be done. This test allows for a more detailed view of the spine. Again, if this is negative, then it’s likely non-specific pain. If it’s positive, a diagnosis may be made.

Treating lower back pain can be as complicated as diagnosing it. Non-specific lower back pain has no specific cause that can be treated, therefore, the symptoms have to be treated. This could include education on preventing back pain, physical therapy, and exercise programs, although some studies say that physical therapy and exercise does not have the same positive effects on children as they do in adults.

The authors of the article point out that treatment may not even be necessary. Lower back pain isn’t always reported to doctors and is often dealt with at home, if at all.

In conclusion, the researchers found that although there is a better understanding that children do experience lower back pain and it’s not always caused by something serious, not much is known about the non-specific lower back pain. More research needs to be done in order to help prevent, diagnose and treat it.

Children who break a leg don’t always have a specialized children’s hospital to go to for the latest in care. Orthopedic surgeons around the country treating pediatric diaphyseal femur fractures aren’t always pediatric specialists or if they are, they don’t see 100s of these cases each year.

In order to help all orthopedic surgeons follow the best evidence in treating these traumatic injuries, the American Academy of Orthopaedic Surgeons (AAOS) has published this list of 14 clinical practice guidelines. They are specific to children from infancy to skeletal maturity who have broken the shaft of the femur (long bone of the thigh). That’s what pediatric diaphyseal femur fractures refers to.

A group of 16 pediatric experts worked together to review all published studies from 1996 through 2008 dealing with the treatment of diaphyseal femur fractures in four age groups. The ages were divided into 1) infants, 2) children from six months up to five years, 3) children five to 11 years, and 4) ages 11 to skeletal maturity. Skeletal maturity means the bones have stopped growing. This is determined by X-rays of the bones. Pediatric orthopedic surgeons from children’s clinics and hospitals all over the country (Texas, Ohio, Colorado, New York, Boston, Seattle, St. Louis, Illinois, and more!) participated in this project.

In the course of reviewing treatment results and recommendations, they noticed a trend over the past 10 years. Treatment seems to have shifted away from conservative (nonoperative) care more toward surgical intervention to stabilize the leg. Nonsurgical options include Pavlik harness for infants, and traction or casting in a waist-high cast called a hip spica cast for all other ages. Surgery can include placing a nail (long metal rod) down through the bone, and/or special submuscular plating. Different types of nails can be used. Some are rigid, others are more flexible. Pain management may be required no matter what type of treatment is used.

The specific treatment plan selected depends on many factors such as the child’s age, type of fracture (severity, location, displaced versus nondisplaced), and the family’s social and economic situation. Surgeons are encouraged to follow these guidelines but within the context of all other factors present. All decisions are made together by the family and physician with the patient’s best interests in mind.

Each of the guidelines was graded according to the level of evidence available from Grade A Level I recommendations to Grade B Level II or III suggestions, and grade C Level IV or V options. The first recommendation is always to evaluate young children for potential child abuse. Age less than three years of age and not yet walking are two big red flags for child abuse when the diagnosis is diaphyseal femur fracture. Infants up to age six months can be treated with a special harness called a Pavlik harness. The harness holds the hips and knees in a flexed position and abducted (knees apart) position. It works best for younger infants. A spica cast is also an option but there can be some problems with skin rashes and sores under the cast. Either treatment option yields an equally good bone healing response.

Other recommendations center around children with shortening of the femur as a result of the fracture. Traction to pull the bone back into a normal position followed by spica casting is recommended depending on whether the bone ends have separated apart more than two centimeters. Sometimes children can be put in a spica cast without the traction. There are no studies comparing these two forms of treatment to tell us if one is better than the other. Likewise, there are no studies comparing one treatment over the other based on age or body weight. Those are wide open areas for future research.

X-rays should be repeated during treatment to follow the bone’s progress in healing. If the surgeon sees that the bones are shifting too close together, too far apart, or rotating too much, then the treatment plan might have to be changed. The goal is to avoid a significant leg length difference (one leg shorter or longer than the other). But the problem is no one knows how much of a shift is too much. And with any bone fracture, there can be an overproduction of bone as the body strengthens the break and later remodels that overgrowth. This phenomenon is more dramatic in children than in adults and hard to predict the final outcome.

Surgeons have a choice between flexible versus rigid rods (nails) depending on the age of the child. Younger children who have not yet finished growing are better candidates for the flexible nails. There are fewer issues with complications, the children leave the hospital and get back to school faster, and with shorter hospital stays (compared with traction and casting), the costs are less. With a more flexible (less rigid) support system, there is always the concern that children who weigh more may have problems. But there haven’t been any studies to investigate this yet.

Older and heavier children are more likely to need a rigid (rod or nail) stabilization system. Additional metal plates and screws and/or external fixation (rods placed outside the leg attached with pins) may be considered in this group as well. Of course, the use of any of these surgical implants begs the question: should they be removed after the fracture is healed? There is a risk for the bone to break again without the stabilization system. Routine removal isn’t usually practiced but again, there’s not enough evidence for the committee to recommend for or against implant removal.

What about physical therapy? Can these children benefit from a rehab program to recover strength and function? No one has studied this yet. Next question: what’s the best way to control pain levels? Sometimes when placing the pins, plates, or screws in place, a nerve can get pinched or poked causing distracting and even disabling pain. Only one study has addressed this issue. The use of a nerve block was very effective in reducing pain for patients who fall into this category.

And finally, of concern to any parent who has had to take care of a child in a spica cast, is there some way to protect the child’s skin from chafing and scratching caused by the cast? Waterproof cast liners have been developed for this purpose but they have only been used with children in spica casts for reasons other than a femur fracture. The liners do work in those cases, so perhaps they could be tried with femoral fractures as well.

That pretty much sums it up for best practice and clinical practice guidelines in the treatment of pediatric diaphyseal femur fractures. The committee concludes there’s plenty of room for future research and study around this topic. The quality of currently available studies is not sufficient to make strong recommendations. At this point, the guidelines are more suggestion than recommendation. The American Academy of Orthopaedic Surgeons will review these again in another five years. By then, other studies will be published and new technology may change current treatment approaches.

Sixty years ago, Dr. Arnold Pavlik designed a special harness for the treatment of developmental dysplasia of the hip (DDH). It is still in use today as the number one choice for this condition in babies.

Developmental dysplasia of the hip is a common disorder affecting infants and young children. In this condition 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 subluxation.

Studies show that the Pavlik harness is successful in reducing hips that are already dislocated (but can be put back into the socket), hips that can be dislocated with certain positions, and subluxated hips 61 to 99 per cent of the time. The harness treatment is easy and inexpensive.

The harness holds the child’s hips in a flexed and abducted (legs apart) position. This places the round head of the femur (thigh bone) right in the hip socket. The contact and pressure help form a deeper, more stable hip joint. And best of all for the parents, the harness does not have to be removed for diapering.

In this study, two groups of infants ages birth to three months with developmental dysplasia of the hip (DDH) were treated with the Pavlik harness. Children in group one had DDH in both hips. This is referred to as bilateral DDH. Children in group two had unilateral (one-sided) DDH. The purpose of the study was to see if children with DDH have a worse outcome when treated with the Pavlik harness compared to children with only one hip affected who are treated in the same way.

Previous studies have shown other factors to be predictive of treatment failure with the harness. Those factors include putting the harness on wrong, not using the harness as described (all day, everyday), positive family history of developmental dysplasia of the hip, and breech position (feet or bottom first) at birth. Starting treatment too late is also a risk factor. And children whose hips don’t reduce or relocate at the time of diagnosis are less likely to be helped by the harness.

So, is having bilateral DDH yet another factor that predicts failure with conservative (nonoperative) treatment? The results of this study suggest no. The 29 children in group one (bilateral DDH) had equal results to the 38 children in group two. Treatment with a Pavlik harness was the same for both groups. Criteria for being in the study was the same, too: DDH in one or both hips that could be relocated or reduced. No one who had a hip that wouldn’t go back into the socket was allowed in the study. Ultrasound imaging was used to diagnose DDH, confirm reducibility, and monitor results over time.

The children in both groups were supposed to wear the Pavlik harness at all times except for bathing. Parents or a family member brought the children into the clinic once a week to check their progress and make sure the harness was being used properly. Not enough hip abduction could result in dislocation. Too much hip abduction can cut off the blood supply to the head of the femur causing a condition called avascular necrosis (death of bone from lack of blood supply). The acceptable position between 35 and 75 degrees of hip abduction is called the safety zone.

As mentioned, analysis of the results showed that there was no difference in success or failure rates between the two groups. Successful results were achieved in both groups on average between three and four months. The failure rate was slightly more than half for both groups — 58 to 59 per cent of the children in both groups were not helped by the harness. The harness was worn until X-rays and sonographs showed a stable, mature hip position without the harness. Full hip range of motion was present and the hip did not slide out of the joint when tested. Those who failed treatment with the harness went on to have surgery.

The authors concludes that bilateral hip dislocations associated with developmental dysplasia of the hip does not increase the risk of treatment failure using the Pavlik harness. Families can expect to use the harness for a period of time that is equal to two times the age of the child. For example, if the child is two months old, then treatment will likely last four months. Age used in the calculation is the age of the child when the harness was first applied. There’s some evidence that treatment takes a little longer when both hips are dislocated, but further study is needed to confirm this idea.

Previous studies have suggested that bilateral involvement is more severe and that this risk factor contributes to poor treatment results. The selection of patients in this study included fully dislocated hips in all patients. Results were equally poor in both groups (only a 41 per cent success rate) — far below the average reported by other studies. The authors suggest the poor overall outcomes in this study are because all of the hips were fully dislocated (not in the socket but easily dislocated and not subluxed) and the harness was used much longer without measurable results than the recommended three weeks when treatment should be reassessed and surgery considered.

For many years, X-rays have been used to diagnose and measure scoliosis (curvature of the spine). No matter how young or old the patient is or where the curve is located, this technique has continued to be simple and reliable. In this study, researchers from the Scoliosis Research Institute in Korea take another look at the Cobb angle measurement. They compare two different starting and ending points used in measuring the angle of the curve.

The Cobb angle is defined as the angle formed between a line drawn parallel to the superior endplate of one vertebra above the curve and a line drawn parallel to the inferior endplate of the vertebra one level below the curve. Superior means above and inferior refers to below. The endplate is a flat piece of cartilage that comes in direct contact with the disc as it sits in between two vertebrae.

An alternate way to measure the Cobb angle is by using the pedicles as the bony landmark instead of the endplates. The pedicles are used when the endplates don’t show up distinctly on X-rays (usually because of the young age of the developing child). The pedicle connects the body of the vertebra to the vertebral arch or ring behind the vertebral body. The vertebral arch goes around the spinal cord to protect it, leaving an opening called the spinal canal for the spinal cord to travel from the brain down to the bottom of the spine.

This is the first study to compare the results using both the endplate and the pedicle method of measuring the Cobb angle. The authors thought perhaps age and location of the curve might make a difference in the Cobb measurements. But as it turns out, after measuring over 300 X-rays using both methods, there was no statistical difference between the two methods. And to make sure the results were accurate, there were three different examiners using a digitized computer system to make the measurements and compare them. Each measurement was calculated three separate times by each of the three examiners. The examiners included two spine surgeons and a spine fellow with years of experience reading X-rays.

Only children with a thoracic (middle spine) scoliosis were included and only one curve (the major or biggest one) was measured. The researchers paid attention to the ages of the children and the location of the curves for each age group. The groups were divided into under seven years old, seven to 10 years old, and older than 10. The curves were divided into mild, moderate, and severe categories affecting the upper, middle, or lower thoracic spine.

They even analyzed how accurate each examiner was from one measurement to the other (since they had to repeat each angle three times). This is called intraobserver reliability. In order to be accurate enough to consider the measurements reliable, the measurements must be the same (or very close) each time. And then they compared interobserver reliability — that’s to see how close the three examiners came to each other in their measurements.

The results were still the same: no statistical difference using pedicle versus endplate as the top and bottom for the angles. Minor differences were noted that didn’t amount to much. For example, there was less intraobserver variability when the pedicle method was used. And the reliability seemed to improve when using the pedicle method for the youngest group (less than seven years old). Interobserver results were pretty much the same no matter which method was used and for all age groups and curve locations. Larger curves (more than 40 degrees) seemed to be easier to measure reliably and accurately using the pedicle method.

The authors make note of the fact that they tried to eliminate as many places for error as possible in the study. Instead of letting the examiners choose where to begin and end the measurements, everyone was told which vertebrae to use as the top and bottom. Using digital radiographs also helped by eliminating the need for special tools (e.g., protractors for measuring angles), pencils, and markers. The consistency in measurements obtained may really directly link these factors.

Cobb angles are important when evaluating scoliosis because they help guide the surgeon in making treatment recommendations. Regardless of the method used to measure the Cobb angle, there are still challenges to face. Indistinct landmarks, vertebral bodies that are tilted, and unusual shapes of the endplates can affect measurements that rely on the endplate method. Having an alternate method using the pedicles may be helpful in some cases. Without digital computerized radiograms, the authors cannot guarantee the methods will yield the same results. That would require another study making these same comparisons without the availability of a digitized system by using standard (noncomputerized) X-rays.

Most people are familiar with strep throat or a staph infection in children. But these bacteria can enter the bloodstream and travel throughout the body. For some as yet unknown reason, the bacteria take up residence in the joints and cause a septic (infectious) arthritic response. The child develops a fever and joint pain. Most often the hip or knee is affected. But sometimes the shoulder or elbow becomes septic. Movement of the affected extremity can hurt. If the arm is affected, the child may stop using it. If the leg is affected, the child may develop a limp or stop standing/walking on that side.

This is the first published study comparing the results of treatment for the more common hip septic arthritis versus the rare shoulder septic arthritis. The results are based on a small group of children (23 total) treated over a period of six years in two children’s hospitals in Texas. All of the children were between ages seven months to 12 years old. They were all treated with antibiotics and surgical drainage.

Treatment is imperative in order to avoid complications like bone deformity, joint dislocation, osteomyelitis (bone infection), and halting growth that can result in limb length differences of the infected arm or leg. Surgery to drain the pus and infection from the joint and clean it out may have to be repeated more than once. In this study, up to four procedures were needed for some of the children with septic arthritis of the shoulder. Children with hip septic arthritis were more likely to respond after one operation. That’s probably because shoulder septic arthritis is harder to diagnose than hip septic arthritis. So, the diagnosis can be delayed. By that time, the infection is much more powerful with more bacteria present.

Clinical results were measured by pain, range-of-motion, joint stability, and number/severity of complications. X-rays were compared looking at the presence of osteomyelitis, joint destruction, and pathologic fractures. Other data collected and compared included blood lab values (indicators of inflammation and infection), number of surgical procedures needed, number of days in the hospital, and type and duration of antibiotics used.

In general, shoulder septic arthritis was much more problematic. The children in the shoulder group had more complications, stayed in the hospital longer, and suffered more pathologic fractures. Pathologic fractures means the bone breaks without any trauma. Children with shoulder septic arthritis were more likely to have other joints infected as well. Osteomyelitis is more common in patients with shoulder septic arthritis. Treatment takes longer with the shoulder but in the final analysis, the results seem to even out.

At the final follow-up none of the children in either group (hip or shoulder) had any evidence of active infection. Their blood values had returned to normal. The authors suggest that earlier diagnosis of shoulder septic arthritis would probably make a difference. But right now, there is no way to predict with accuracy when septic arthritis of the shoulder is developing. There is a clinical prediction rule for the hip. Once that was developed, the rate of complications with hip septic arthritis dropped from 40 per cent down to five per cent. Early recognition of the problem and treatment meant less damage to the growth plate of the joint and better final outcomes in terms of hip motion and function.

Until a similar guideline can be developed for the shoulder, there are some general risk factors to pay attention to for septic arthritis in any joint. Children with diabetes, sickle cell disorders, and immune system deficiency seem to be at greater risk of staph and strep infections that can then spread to the joints. Babies (less than three months old) are more likely to have a poor result even with treatment. Anyone who develops osteomyelitis or who has been infected with penicillinase-producing bacteria is more likely to develop complications and problems that can delay recovery.

More research is needed in this area. This study is just the start but provides some unique and important insight into infectious arthritis among children. Physicians are now alerted that the hip and knee are not the only joints that can be affected by infections. The shoulder (though rare) is a potential target and should be considered as a possible diagnosis when children present with suspicious signs and symptoms of infection, fever, joint pain, and loss of arm or leg function.

Parenting a child who is living with chronic pain can be a difficult task. As a parent, you feel as if you must be able to help your child at all costs, especially removing something that is causing illness or pain. Sadly, this isn’t always possible and it can make a parent feel helpless, leading to other issues down the road. The authors of this article wanted to look at how having a child with chronic pain affects parents, how the parents affect the child’s adjustment to living with chronic pain, and how parents react to their children who have severe chronic illnesses other than chronic pain.

There are not a lot of studies that have been done on the effects of childhood chronic pain on the parents of the children. From the research that has been done, researchers have found that parents of children with chronic pain, particularly mothers, had high levels of stress and anxiety, and symptoms of depression. As well, the care required for their children can cause significant social, emotional and financial impact on the family, and it can put stress on parental relationships. There is also the aspect of wondering about or working on finding cures for their children’s pain, which can lead to further distress if they aren’t successful.

How parents affect their children’s adjustment to chronic pain also hasn’t been studied very much yet. In the research that has been done, there have been signs that a mother’s stress level could directly affect a child’s pain level. For example, one study examined children with juvenile arthritis and the researchers found that children with arthritis reported more pain if their mother had more difficulty coping emotionally than children of mothers who were in less psychological distress. Another study found similar findings with headaches in children. Other approaches found maladaptive outcomes as well. For example, parents who allowed their children to get out of more everyday activities due to pain symptoms actually could make their children complain more often about pain.

Chronic medical conditions may produce pain but not necessarily the chronic pain of arthritis. Illnesses, such as cancer or diabetes, still may – and usually do – cause significant emotional and/or psychological stress on parents. According to the article’s authors, stress is usually related to “the child’s treatment, medical adverse effects, changes in daily activities, disruption of social and family roles, and burden associated with adhering to a treatment regimen. The every day demands of parenting and managing employment, finances, and a household are greatly increased.”

If parents don’t come together to work on the stress, this could be a good indicator that the child will be less likely to adjust to the illness. While it may be tempting to believe that parental stress is a normal reaction to a child’s illness, the different levels of stress can make the difference of a child living successfully with a disease or having great difficulty in managing. It’s important to help parents reduce their own stresses in order for the children to work on theirs.

What does this mean for research and for hands-on management? There needs to be more investigation into why parents react they the way they do and how to help parents manage their reactions. Investigators need to look at how to help parents cope, particularly when there is a change in the parent/child relationship, as often happens when a chronic illness is diagnosed or a child lives with chronic pain. It’s important to understand how mothers and fathers differ in their reactions, as well. Finally, studies must be done to find ways to not only identify these issues but to deal with them effectively.

Japanese researchers may have an answer to the problem of osteochondritis dissecans (OCD). This painful knee condition affects teens and young adults who are usually still growing. That means the growth plates around the joints have not closed completely yet. Damage to the joint cartilage and first layer of bone (called subchondral bone) occurs causing knee pain with activity. Until now, it’s been unclear just what happens to cause this condition.

Rest from activity and walking with crutches (nonweight-bearing status) is the first-line of treatment. Surgery may be needed to fix or hold any pieces or fragments of cartilage/subchondral bone that may have broken off. It was during 12 of these operations that the surgeons who conducted this study removed a plug of cartilage and bone for close examination. The plug was taken right from the center of the osteochondritis dissecans (OCD) lesion and then examined under a microscope.

All 12 plugs were taken from the same anatomic location (medial femoral condyle) of the knee. This area is located along the bottom of the femur (thighbone) on the side closest to the other knee. When they took a closer look at the plugs of bone, they found a cleft (division) in the specimens.

The cleft divided the plug into two parts (upper fragment and lower base piece). The surface of the base portion was covered with a fibrous cartilage tissue. Underneath that was active bone cells trying to repair the damage. The bottom of the upper fragment was also covered in the same kind of dense fibrocartilage. The top of the fragment had normal articular cartilage like you would see covering the surface of any joint. But underneath was dead or dying bone cells. Some specimens didn’t have any bone tissue left (alive or dead) — just cartilage cells.

Examining cells from bone and cartilage under a microscope is called a histologic study. Histologic findings can help explain how and why osteochondritis dissecans develops. The goal, of course, is to find better ways to treat this problem.

The results of this histologic study suggest a series of steps in the breakdown of cartilage and bone. First, repetitive stress from activitiy appears to cause a fracture of the subchondral bone. The subchondral bone has a limited supply of blood normally. This feature combined with trauma to the subchondral areas (from continued movement) results in osteonecrosis (death of bone). The necrosis affects the trabeculae, a scaffold or framework of bone cells in the subchondral layer.

The body’s natural response to any cell death is to remove or resorb those dead cells. That’s when the fibrous tissue is formed in an attempt to repair the damage. Deeper areas remodel to form cartilage or bone. Bone formation is more likely when there’s no separation or only a partial separation of the subchondral bone. A full division seems to cut off the body’s ability to mend the area with the necessary bone.

Even with this new histologic information, researchers still don’t know why osteonecrosis (bone death) occurs. Is it because the osteochondritis dissecans (OCD) fragment detaches and loses all blood supply? Is it an automatic response after a subchondral fracture? Is the poor blood supply to this area a cause or effect of the fracture? More study is needed to look into the mechanisms of this condition.

What this study shows is why certain treatment technques do or don’t work. For example, patients with cartilage and trabecular bone can recover with nonoperative care. The presence of trabecular bone makes it possible to restore the natural layer of cartilage with the underlying subchondral bone. Without this trabecular bridge, fragments that are made up of just cartilage may not reunite with bone even after surgery. Those type of injuries seem to only be able to make more fibrous cartilage, which isn’t enough to repair the damage and restore the cartilage to subchondral interface.

If researchers can find a way to examine the tissue types that make up the osteochondritis dissecans (OCD) fragments without doing surgery to remove a plug, then it might be possible to predict which treatment plan would work best for each patient. Special MRI studies using contrast dye might give this information. Three-dimensional (3-D) CT scans are another diagnostic possibility.

For now, we know more about the pathologic process of osteochondritis dissecans (OCD). Future studies may give more information about the cause of this problem so that instead of looking for optimal treatment techniques, it may be possible to prevent OCD instead.

Imagine you are a teenage male athlete heavily involved in baseball. Now imagine how you would feel if severe, constant pain was keeping you out of the game. You have a condition called osteochondritis dissecans (OCD) of the elbow. For some unknown reason, the layer of joint cartilage just above the bone has separated and pulled away from the bone. No treatment has helped. Despite six months of conservative care (think: doing nothing — no throwing, no lifting, no sports activities), there’s been no change in your symptoms. Anyone in this situation will welcome the news from this study.

Nineteen boys between 11 and 19 years of age with severe osteochondritis dissecans (OCD) of the elbow had a surgical procedure called mosaicplasty. The surgeon removed any loose fragments of cartilage in the elbow. Any rough or frayed portions of the joint surface was shaved and smoothed down. Then the surgeon drilled what look like tiny postholes in the articular surface of the elbow joint. Using plugs of bone harvested from the knee opposite the elbow, the holes were filled in and the surface smoothed over.

The donor plugs were taken from an area of the knee where there’s less pressure when standing and walking to avoid any knee problems. The holes left by removing the plugs were filled in with a special bone wax to prevent bleeding. Within two days, the patients were up and about putting partial weight on the knee and gradually returning to full weight-bearing status by the end of a week’s time. The elbow was placed in a cast in a position of 90-degree flexion for two weeks. This allowed some time for healing before starting to move it again.

For those baseball players who could return to the game, it was a wait of eight to 12 months depending on the position played. Pitchers who would stress the surgical site more had to wait longer than fielders. During that wait, rehab under the supervision of a physical therapist focused on regaining motion, strength, and full function.

This mosaicplasty technique has been used with success in the knee and ankle. Its use with the elbow is fairly new, so the results of this study are important. The authors used a variety of ways to measure this success. X-rays, elbow range-of-motion, pain, and function were the main outcome measures. Players were asked about any locking and/or catching of the elbow during movement and activity. Function included return-to-sports activity at a level equal to previous play before the OCD developed. Patients were followed for at least two years (some as long as long as seven years), which makes this a midterm study.

In terms of pain, motion, and function, all but one patient had a good result. Everyone was pain free with the exception of that one player who still had mild elbow pain. Elbow range of motion (flexion and extension) increased significantly for most of the players. Forearm rotation (palm up and palm down) was unaffected by the condition or the surgery. A few didn’t get full elbow extension, which affected throwing but not catching the ball.

A quick check of the donor knee showed that only one patient had any problems and that was just a mild bit of pain when going up and down stairs. Follow-up X-rays and MRIs of the elbows and the knees of all players showed near-normal to normal joint surfaces. A mild thickening of the elbow grafts was observed but this did not seem to cause any symptoms or problems. The big fear was that osteoarthritis would develop in the affected elbows, but at least in the midterm follow-up, that was not the case. No one had any signs of developing osteoarthritis.

Seventeen of the 19 players went back to competitive sports at a level equal to their previous playing ability. The two who did not go back to baseball switched to rugby or soccer. Their results were considered good enough to play baseball again, but they made a conscious choice to change playing fields. Compared to other surgical methods used for OCD (e.g., arthroscopic chondroplasty, abrasion arthroplasty, wiring loose fragments of cartilage back in place), mosaicplasty had much better return-to-play results.

The authors concluded that mosaicplasty is a very good treatment choice for teenage athletes suffering from advanced osteochondritis dissecans of the elbow. The procedure may work best in younger players who have smaller defects requiring smaller grafts but more research is needed to confirm this finding. Although no one in this study showed any signs of osteoarthritis, long-term studies are still needed to see if there are later developments of this kind. Comparing results using graft donors from different sites is another area of suggested study.

Children born with a foot deformity called clubfoot can be treated without surgery when they are just a few months old. In fact, success is much greater when treatment is applied before the child is three months old. The most successful nonoperative method of treatment has been the Ponseti Method. Now a new method called the French Functional (Physiotherapy) Method is available. In this study, results of the two methods are compared in a group of babies who had similar severity of the deformity.

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 (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in a varus position when you try to put the soles of your feet together. Clubfoot primarily affects three bones: the calcaneus, talus, and navicular. Other bones can be involved as the deformity can affect the growth of the entire foot to some degree.

Uncorrected, this twisted position of the foot can cause 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 would have to walk on the outside edge of the foot rather than on the sole of the foot. The two treatment methods described in this article can change all of that.

This study was carried out at the Texas Scottish Rite Hospital for Children in Dallas, Texas. A team of two physicians, a nurse, and a physical therapist carried out the procedures. The specific steps for each treatment were explained to the parents who then decided which approach to take.

The Ponseti method involves placing the foot in as neutral a position as possible and holding it there with a cast. The bones are manipulated into place one at a time until the full correction has taken place. The cast is removed each week, the foot and ankle position corrected, and a new cast is put on to hold the new position. It takes five to eight of these sessions to get the desired results. The authors provide photos and a complete description of each manipulation performed on the foot. The correction occurs with gradual stretching of the soft tissues while holding the bones in their proper place (or as close to it as possible with each session).

The French Functional Method stretches the soft tissue and bony structures along the inside (medial) edge of the foot. Then the muscles along the outside (lateral) side of the foot are stimulated to contract to help actively correct the foot placement. Exercises, elastic taping, and splinting are part of a daily home program that requires parents to participate. At first, the family must bring the child into the physical therapist’s clinic daily for hands-on therapy. Gradually, the parents take over the program and visits to the therapist decrease to a more manageable once a week trip.

Again, the authors provided color photos of a child with severe clubfoot who had the French Functional Method. Correct foot positions, stimulation of the muscles, and taping methods are clearly depicted. The therapist also makes each child a special ankle-foot orthosis (AFO) that fits over the tape and holds the foot in the best alignment obtained with the treatment. This brace is worn 22 hours a day until correction is achieved. Once the foot is in normal alignment, then the AFO can be limited to naps and nighttime use until the child is two years old.

There are advantages and disadvantages for each method. The Ponseti method relies less on parents and more on therapists making the corrections and casting the affected feet from week to week. The French Functional Method requires daily dedication on the part of the parents. Either method can be successful. The choice depends on what works best for the family. If they choose one method and it doesn’t seem to be working out, they can always crossover or switch to the other method.

The results of this study showed that the correction rate was about 94 to 95 per cent for all the babies no matter how they were treated. Slightly more than one-third of the children in the Ponseti group (37 per cent) had a relapse (the foot drifted back into a clubfoot position) after treatment. Slightly less than one-third of the French Functional group (29 per cent) had a relapse. Relapse required surgical intervention for both groups. Long-term results were slightly better for the Ponseti group (72 per cent considered good for Ponseti compared with 67 per cent good for the French method).

More families selected the Ponseti method over the French Functional approach. This is understandable since the Ponseti method relies on the medical staff rather than the parents for the positive results. With either method, there are times when surgery is needed to release the Achilles tendon. This procedure is called an Achilles tenotomy. The procedure can be done under a local anesthetic on an outpatient basis. Once the tendon is released, the ankle moves more freely into a dorsiflexed position (toes up toward face rather than toes pointed down like a ballerina).

Timing is crucial for the treatment of clubfoot. Treatment too aggressive too early can result in a foot deformity called rocker-bottom. Alignment of the midfoot is such that the bones drop down and instead of forming a nice upward foot arch, the bottom of the foot becomes curved like the bottom of a rocking chair. Failure to stick to the scheduled brace or splint schedule can lead to failure to maintain the foot and ankle correction.

No matter which treatment approach the family prefers, a close working relationship with the medical team is essential. The therapist is the key figure in the ongoing serial treatments. He or she must educate the parents about the importance of treatment and cheer them on when they stick with the program.

It’s the therapist’s responsibility to assess the results and recommend a change in the treatment plan when the foot position is not as expected. The physician will see the child every two or three months at first and less often after treatment has ended. Long-term follow-up is advised. Further treatment may not be needed but if it is needed, the child can can get the help needed sooner than later when being watched closely.

According to Dr. Lawson Copley, a professor of orthopedic surgery at the University of Texas Southwestern (Dallas, Texas), serious bone and soft tissue infections in children are on the rise and have become more serious and more complex than ever before. In this article, Dr. Copley takes us down the path of evaluation, diagnosis, and treatment of deep infections involving the musculoskeletal system in children.

He stresses the importance of a team approach involving a full complement of health care professionals. Parents/family head the list along with physicians from a variety of specialties (emergency, infectious disease, pediatricians, radiologists, emergency doctors), nursing, and laboratory staff. The most successful results come when all members of the team participate in the decision-making process. Communication is key to efficient and effective treatment.

That sounds all very serious and it is because these pediatric musculoskeletal infections can be deep, wide spread, and deadly. What has changed to bring this all about? MRSA— methicillin-resistive staphylococcus aureus infection. MRSA is a staph infection that has become resistant to all but one antibiotic. And there’s evidence that the bacteria is continuing to mutate (change) with at least one strain now resistant to all antibiotics. Children who are infected with MRSA are more likely to develop blood clots that can travel to the lungs, a potential cause of death.

Early, accurate diagnosis is very important. Recognizing telltale symptoms gets the process started. Pain, tenderness, swelling, redness, loss of motion, and a distinct limp or difficulty walking are common first symptoms. The diagnosis can be delayed when medical staff is fooled into thinking the child has a superficial (skin deep) infection called cellulitis. Or it may look like an isolated and contained abscess when, in fact, there is a deeper, more widespread and invasive infection. Sometimes it goes clear to the bone as in the case of osteomyelitis (bone infection). Areas affected most often include the spine, pelvis, and arms or legs. In some cases, it isn’t until a bone fracture or visible deformity occurs that the diagnosis is made.

The use of MRIs today has helped identify the full extent of these infections. Other imaging studies with X-rays, CT scans, ultrasonography, and bone scans provide vital details about the location, size, and depth of infection. Any part of the soft tissues can be affected including skin, muscle, joint, and/or bone. Antibiotics and surgery remain the mainstay of treatment.

Lab studies are done to identify the specific bacteria and help direct which antibiotic to use. Blood is drawn and studied. Blood tests help reveal the presence and type of infection and show which children are at risk for blood clot formation. One study has shown that children nine years old and older who have MRSA-related osteomyelitis have a 40 per cent incidence of blood clots when the C-reactive protein (CRP) level is more than 6 mg/dL. CRP is a protein found in the blood. CRP levels rise in response to inflammation. Whenever possible, fluid is also removed from the affected joint or a bit of the affected tissue is taken for laboratory analysis. The information gained from these tests also helps aid in selecting an antibiotic that will be most effective.

Hospitalization is almost always required for these infections. When the specific bacteria present can be identified, then antibiotic treatment usually begins. At first, antibiotics are delivered intravenously (directly into the bloodstream) with follow-up treatment using oral (pill form) antibiotics.

The author presents a table with antibiotic recommendations with type, dose, route of administration, and frequency based on age. Timing and duration of antibiotic administration is still more difficult to figure out. There are no evidence-based guidelines published yet. It has been suggested that the physician can change the child from an intravenous antibiotic to an oral form when symptoms improve and CRP levels drop. Repeat blood cultures may also help determine when this change can take place. Usually the child can be released from the hospital when the intravenous antibiotic is discontinued. Oral antibiotics are often continued at home for at least another six weeks, depending on the child’s response, any adverse side effects of the medication, and lab values.

Surgery may be needed to clean out pockets of infection and pus. This procedure is referred to as debridement. Abscesses don’t always clear up even with antibiotics. Surgical drainage helps the antibiotic get into the area of infection once the abscess is removed. Joints that are affected by infection may respond to a procedure called aspiration and lavage. The infected fluid is drawn out of the joint and a saline solution is used to flush out any remaining infection and bacteria.

Bone infections require a different surgical technique. The surgeon may have to cut out a window in the outer surface of the bone to gain access to the infection. Debridement must be done carefully to avoid damage to the area of bone that is still growing. Drains are put in place to continue removing blood and infected fluids that accumulate in the area. The author suggests removing the drains when fluid output is five milliliters or less.

No matter what type of surgery is performed, failure to improve may mean a second surgery to repeat the process. Time in the hospital can range anywhere from three days to three weeks. With successful treatment, the final step is hospital discharge. The child is carefully followedas an outpatient to make sure the infection is truly gone and doesn’t come back.

The authors conclude by saying doctors must work with hospital staff and administrators to establish guidelines for the evaluation and treatment of children with musculoskeletal infections of this type. Every effort should be made to follow the guidelines in order to reduce trauma to the child, speed up recovery, and limit hospitalization. When MRSA infection is recognized and treated early, complications can be reduced. Deformities, damage to musculoskeletal tissues, and disruption of the growth plates can be minimized.

Children with Blount disease often need surgery to restore normal knee alignment and reduce pain. The result is decreased disability and improved function. Blount disease is a condition of bowlegged knees, also known as tibia vara in medical lingo. Surgical correction aims to create a more normal angle between the lower end of the femur (thigh bone) and the upper portion of the tibia (lower leg bone).

Two angles used to diagnosis Blount disease are measured on X-rays: the metaphyseal-diaphyseal angle (MDA) and femoral-tibial angle (FTA). A MDA angle between 11 and 15 degrees is borderline tibia vara. More than 15 degrees increases the risk that tibia vara (the bowlegged position of the knee) will continue to get worse over time.

Everyone is concerned about restoring a more normal angle at the knee for children with Blount disease. But no one has looked at the effect of metaphyseal-diaphyseal angles (MDAs) after surgery on patient satisfaction. The surgeon is happy everything lines up nicely. But are the patients pleased with the results? Does it solve their knee deformity and disability? The authors of this study looked at pain, function, and satisfaction months to years after the operation was done in a group of 41 patients (total of 50 knees).

In order to find out how patients felt after surgery for Blount disease, a group treated at two hospitals were asked to fill out a survey called the Blount’s Outcome Questionnaire. The survey was specifically designed for this study by modifying a previously existing tool called the AAOS Pediatrics Parent/Child Outcome Instrument. The patients also rated their knee pain on a scale from zero (no pain) to 10 (worst pain). When pain was present bilaterally (on both sides), pain levels were recorded separately for each knee.

Average age of the children who participated in the study was between nine and 10 years old. Most of the children were born with Blount disease. This type is called infantile Blount disease. There were also children included who had juvenile Blount disease (developed during the teen years) and insidious disease (exact date of onset was unknown).

When the scores were added up and the results were analyzed, the overall rate of satisfaction for the entire group was 93 per cent. Patients who had more than one surgery had lower satisfaction rates. The lowest pain ratings were reported when the metaphyseal-diaphyseal angle (MDA) was between zero and -10 degrees and when the femoral-tibial angle (FTA) was between zero and +5 degrees. The higher the MDA, the more varus or leg bowing that’s present. There was a link between both the MDA and the FTA and patient satisfaction. Small changes in the FTA lead to big changes in satisfaction.

What does all that mean? Basically, optimal surgical correction as outlined (measured angles between -10 and +5 degrees) does bring about greater patient satisfaction. Correction isn’t just to look good on X-ray or in a bathing suit. When these angles are lined up, there is a more normal and even distribution of weight and load on the upper tibia. Without correction, too much pressure is placed on the lateral (outside edge) of the knee. Ligaments on the inside (medial) edge of the knee get stretched out to the point that the knee can become unstable. In a growing child, these uneven pressures can create a leg length difference and even more deformity.

Two other factors affecting pain and patient satisfaction were observed in this study: obesity and female sex. Being overweight to the point of obesity and being female increased the risk of a less than satisfactory result. Greater pain responses were noted in both of these groups.

The authors conclude that surgeons should aim for a specific range of correction when treating Blount disease surgically. Both the metaphyseal-diaphyseal angle and the femoral-tibial angle can be used as effective and reliable guidelines for optimal correction. The authors were pleased with the information gathered in this study. They plan to expand their investigation and look more closely at the relationship between surgical results and patient satisfaction. Since the questionnaires were filled out by parents for their children, results may not be the same as if the children completed their own surveys.

Studies like this one conducted some time after the surgery may also be biased by the patient’s ability to recall details after surgery that was performed some time ago. Collecting data directly during the recovery and early post-operative phase might yield different (possible even more accurate) findings.

The surgical treatment of large spinal (scoliosis) curves in children has evolved over the past four decades. In the 1960s, rods were used to distract or separate the vertebral bodies, put them in good alignment, and hold them there while the child or teen grew. But a better way was found to correct the spinal curve in all three planes (3-D correction) and that was with segmental wires and hooks. Instead of a long rod holding the spine in place, these smaller components linked several segments together. Hooks proved to be safe, easy to place, and effective.

In the last 10 years, the surgical correction of scoliosis has taken another turn. Now pedicle screws are used to achieve fusion in all three planes and improve correction of spinal deformity in children with adolescent idiopathic scoliosis. This type of spinal curvature occurs in older children and teens with no known cause. That’s what idiopathic means (unknown).

Pedicle screws are placed posteriorly (from the back of the spine) into a column of bone called the pedicle. The pedicle connects the body of the vertebra to the vertebral arch or ring behind the vertebral body. The vertebral arch goes around the spinal cord to protect it, leaving an opening called the spinal canal for the spinal cord to travel from the brain down to the bottom of the spine.

In this review article, the benefits and disadvantages of an all-pedicle-screw treatment for severe scoliosis are presented. Most of the information comes from expert opinion and consensus (agreement) of many orthopedic surgeons rather than from Level I evidence. Level I evidence is the highest form of research and in this case would be based on comparative studies (results using rods versus hooks versus pedicle screws). For now, studies of the all-pedicle-screw approach are confined to case series and cadaver studies. Cadaver studies involve experimentation on spines preserved after death for scientific study.

Despite some concerns about the safety of pedicle screws, they have been found to be completely safe as well as effective in correcting spinal deformity and maintaining that correction. Surgeons have found that it is possible to get better correction in all three planes of spinal deformity by using pedicle screw fixation. Studies show the screws are stronger than hooks and better able to resist being pulled out of the bone (again when compared with hooks). The procedure can be done without an anterior (from the front of the spine) incision. That feature alone is very helpful in reducing the risk of complications (e.g., damage to nerves and major blood vessels).

Best of all, patients can get up sooner and have fewer complications like nonunion or fusion failures. There is also evidence that lung function improves with pedicle screw correction. There is a hope that with all these benefits, the child/teen will not need further (revision) surgery or develop degeneration of the vertebrae above and below the fusion where there is more motion.

The downside of an all-pedicle-screw approach is that successful long-term results depend on very skillful, careful surgical work. Part of the vertebral bone must be removed without causing any spinal cord or spinal nerve damage. Accurate placement of the screws is important, especially in the thoracic spine because there’s no safety zone between the pedicle and the dura (outer covering of the spinal cord). If the screw is put in the wrong place, it can go through the bone right into the spinal canal. A breach of this kind can cause serious neurologic damage.

To help surgeons avoid such potential complications, the authors provide a detailed review of pedicle anatomy and surgical techniques for the placement of thoracic pedicle screws. A description is given and photos are included to show how pedicle screws are used to correct the rotation of the vertebral bodies. Pressure from the screws helps derotate the vertebrae. The screw is placed through a special post to lock the vertebrae in the derotated position.

Bone grafting is used to help the fusion process and performing this part of the procedure requires another set of unique skills in order to be successful. And the cost is much higher for the pedicle procedure, though it’s possible that with fewer complications and less chance of a second surgery, the benefits may even things out cost-wise.

The authors conclude that there’s no doubt the all-pedicle-screw treatment of severe adolescent idiopathic scoliosis is safe and successful. Long-term studies are still needed to show what happens over time with this approach. It’s clear that this type of surgery is best done by spine surgeons with complete knowledge and understanding of spinal anatomy and advanced specialized training. It is a potentially dangerous procedure with risk of serious complications. High-volume centers where large numbers of patients are treated this way have the best results.

Infants under the age of six months are treated for developmental dysplasia of the hip (DDH) with a Pavlik harness. The idea is to take a child with a poorly formed hip socket or dislocated hip joint and position the head of the femur (thigh bone) right in the hip socket. Then hold it there until the joint forms properly. That’s where the Pavlik harness comes in. This soft harness positions and holds the infant/child with the hips bent or flexed and abducted (leg apart).

Studies show that this conservative method of treatment works about 79 to 96 per cent of the time. But that’s a pretty broad range of success. The authors of this report asked the question, Why did the children in the 96 percentile have a successful response to the harness? Are there some specific predictive factors like age or gender that make the difference?

To find out what they could about possible predictive factors of success or failure of the Pavlik harness, they reviewed the records of over 200 children younger than six months treated this way. They compared children who had a successful reduction (placing the hip back in the socket after being fully dislocated) or subluxed (partial dislocation) to those who failed to achieve adequate reduction.

They took it one step further, too and also looked at the children who developed avascular necrosis (loss of blood supply to the head of the femur). They hoped to find factors that might predict which children would develop AVN. The harness can be tightened too much, pulling the legs apart too much. Too much force into abduction can block the blood supply to the femoral head causing loss of blood flow and necrosis. This is a serious complication that can prolong the treatment of the hip and may lead to other problems. In the general population of children with developmental dysplasia of the hip, anywhere from zero to 22 per cent develop avascular necrosis. In this study, 16 of the children who had a successful hip reduction with the harness still went on to develop necrosis. That’s about a nine per cent rate.

The goal in finding predictive factors of failure in the conservative treatment of developmental dysplasia of the hip is to identify children who will benefit from therapy with the harness versus those who won’t be helped. No sense using a treatment that you know right from the beginning won’t work. It’s also important to single out those children who might develop necrosis and be proactive in treatment. Necrosis can lead to deformity and even death of the bone. Where does one begin with a project like this?

Well, the authors reviewed the literature to find the results of other similar studies and see what they used for possible predictive criteria. The child’s age, gender, side of the hip dysplasia, severity of the dislocation, and ability to reduce the hip before treatment are clearly the most commonly used factors. But in this study, they chose two additional factors: amount of hip abduction (leg moved away from the midline) and distance of the femoral head from the hip socket (as measured by X-rays). In fact, two separate X-ray measures were used: how far the femur was displaced proximally (up toward/past the hip socket) and how far the femur was displaced laterally (away from the midline).

Since this study was a retrospective study (taking a look back using medical records), they excluded (left out) anyone who did not have before and after X-rays, children with a neuromuscular condition causing the problem, and families that didn’t complete the treatment as instructed. With a retrospective study, it’s also possible to calculate how long each child wore the Pavlik harness and how long it took to reduce the hip. This type of information can help orthopedic surgeons advise patients on how long to keep the harness on the child and when to give up trying to get good results with this treatment tool.

Physical exam, X-rays, and ultrasound were used to tell if the hips were reduced and/or if avascular necrosis had developed. The children were checked by physical exam every few days at first for a sign that the hip had slipped back into the socket where it belonged. There’s a specific test for this called the Ortolani maneuver. The overall rate of successful reduction with the harness in this patient group was almost 82 per cent. Most of the infants responded to the harness within one or two weeks. They were re-checked every two weeks for two months and then every month after that.

An analysis of all the variables considered showed that age at the time of treatment was not a predictor of failure. This was true so long as the child was younger than six months when use of the harness was started. Having a bilateral condition (present in both hips) was a predictor of harness failure. Children with developmental dysplasia in both hips were six times more likely to fail to get reduction of the hip using the harness when compared with children who had only one hip involved.

The starting position of the hip (as seen on X-ray before treatment) was a negative predictive factor. In other words, the farther the hip was from the socket, the less likely it would reduce with the harness and then remain stable in the hip socket. Of the two directions tested (hip displaced proximally/upwards versus hip displaced laterally/away from the socket), reduction was more likely to fail using a Pavlik harness when proximal displacement was a bigger problem.

One other factor that helped predict who would have a failed versus successful response to the Pavlik harness was how far the child’s hips would abduct (move away from the midline). Loss of hip abduction is usually a sign of an adduction contracture. Contracture means the muscle is so tightly contracted, the leg can’t move (or moves minimally). The fact that the hip could not be reduced manually by moving the leg into a flexed and abducted position before treatment had no bearing on the success of the harness to accomplish reduction over time.

And finally, even though one-third of the children with developmental dysplasia of the hip had a family history of this condition, family predisposition was not a predictor of treatment success with the Pavlik harness. In other words, having a family history of dysplasia didn’t necessarily mean treatment would fail.

Taking a look at all the data, the authors concluded that the strongest predictor of harness failure was the proximal distance of the femur from the hip as seen on X-rays. The most reliable predictor of avascular necrosis was the presence of a severe hip adduction contracture (unable to move the affected leg away from the other leg).

What does this information mean in terms of treatment? Basically, although the Pavlik harness is safe to use, it isn’t always effective. The more severe the dislocation and the tighter the muscles around the hip are, the more likely it is that treatment with the harness will fail. Consideration may be given for other treatment first (e.g., possibly surgery to release tight muscles or traction to pull the femur down) before applying the harness. Children with dysplasia in both hips are also less likely to benefit from a Pavlik harness. Children who get a good reduction but then develop avascular necrosis pose a real treatment challenge.

Young children should not go down a playground slide while sitting on another person’s lap. This was the conclusion of a study looking at playground injuries. In particular, one pediatric surgeon reviewed the records of 58 children who sustained a tibialfracture over an 11-month period of time. The tibia is the larger of the two bones in the lower leg. Eight of those fractures occurred while going down the slide on the lap of an adult (usually the parent).

Imagine how upset and frustrated the parents were when they thought they were protecting their child only to have them break a leg in the process. How is it possible for a toddler to fracture the lower leg while sitting on an adult’s lap? Any sudden movement of the young child can result in the child’s foot getting stuck under the adult, twisted, or held flat against the surface of the slide. The continued forward movement of the adult with the child puts enough pressure and load on the lower leg to cause the bone to give.

In this study, all of the children were under the age of three years old. They all had a simple break of the shaft of the tibia that could be treated with a leg cast. The fibula (smaller bone in the lower leg) was not broken. And the tibial fracture was nondisplaced (not separated). Everyone healed well and resumed walking with the cast on within a week’s time.

X-rays were needed to confirm the diagnosis because with a nondisplaced fracture, the leg doesn’t look broken. There are no bones protruding against the skin or poking out through the skin. Sometimes the parent can hear a cracking or popping sound when the break happens. But in all cases, the child develops sudden pain and can no longer put weight on that side. Swelling is also a common reaction to the fracture.

Even though most of today’s playgrounds have been designed with safety in mind, there are some things that can’t be designed away. One of those is playground equipment like the slide that requires a certain size and level of developmental skill. If the child cannot sit up alone with enough strength and balance to move forward down a slide, then the child should be restricted from the slide. The child must be able to safely climb the ladder, sit down at the top of the slide, and make it to the bottom without difficulty before being allowed to do the slide alone.

Attention can be focused on other, developmentally appropriate equipment. Children may put up a fuss and even stage a glorious temper tantrum. But the parent is still the parent and safety should be their first concern. As a result of this study doctors are urged to tell parents not to hold a toddler on the lap while going down the slide. It may seem like you have everything under control until that wiggling bundle of toddler energy suddenly shifts position. It all happens so fast, the parent or adult can’t react quickly enough to avert disaster.

Unexpected injuries can happen on any playground. Knowing a few key risk factors such as the one presented in this article can guide parent action and help prevent childhood playground injuries. Avoiding the slide and playing on other age-appropriate equipment until the child is developmentally ready will create a safer environment while still providing fun for the child.

Surgeons evaluate problems like elbow fractures and classify them in some way to help direct treatment. In the case of humeral lateral condyle fractures, the current classification system isn’t working. It doesn’t predict which fractures should be treated with pins to hold the bones together and which fractures need to be wired back together.

A humeral lateral condyle fracture involves the lower part of the upper arm bone (the humerus). The condyle is the round end of the humerus that slides and glides against the bones of the forearm to form the elbow joint. Lateral fractures refer to the condyle on the outside of the elbow (medial would refer to the side of the elbow closest to the body). Humeral lateral condyle elbow fractures are fairly common in children. For every 100 cases of elbow fracture, 12 of them will be humeral lateral condyle fractures (12 per cent).

The new proposed classification scheme comes from pediatric orthopedic surgeons at the University of Southern California School of Medicine in conjunction with the Children’s Orthopaedic Center at the Children’s Hospital of Los Angeles. The surgeons there suggest using X-rays and arthrograms to place the fractures in one of three categories. Type I is a fracture with less than two millimeters (mm) of displacement (bone separation). The separated ends of the fractured condyle remain in place and have not shifted. These kinds of fractures can be treated with immobilization (casting or splinting).

Type 2 (two or more millimeters of displacement) and Type 3 (two or more millimeters of separation and the two ends of the fractured bone have shifted away from the normal alignment) require surgical treatment. With type 3 humeral lateral condyle fractures, the elbow joint is disrupted. When the joint is no longer lined up and able to move properly, there is no longer articular congruity (a medical term that means the joint surfaces don’t line up).

Most type 2 humeral lateral condyle fractures can be pinned back together. But type 3 fractures must be reduced (ends of the bones fit back together where they belong) and wired together to hold them in place during the healing process. Children with type 2 or 3 elbow fractures of this kind are immobilized after surgery as well.

The question posed in this study was: could this new classification system be used to predict what kind of treatment to use and to look at the number and type of surgical complications for each group? To find out, the authors went back and used this system on all cases of humeral lateral condyle fractures in children treated at their hospital between 1996 and 2003. A total of 158 children had type 2 or 3 fractures requiring surgery. Their medical records were reviewed for type of complications, age, number of days between fracture and surgery, and length of time in a cast.

When the data was analyzed, they found an overall surgical complication rate (major and minor problems) of 25 per cent. Most of those were minor problems that were easily treated like infections (treated with antibiotics). Others didn’t need any further treatment (e.g., bony bump felt on the outside of the elbow or thickened scar). Only six per cent of the patients had a major complication (e.g., malunion or nonunion of the fracture, stiffness, refracture) requiring further surgery. Further analysis showed that there was no link between the age of the patient, number of days between fracture and surgery, or length of time in a cast and the complication rate.

Type 3 humeral lateral condyle fractures had more significantly major and minor complications compared with type 2 fractures. In fact the risk of complications was three times higher for children with type 3 elbow fractures of this kind compared with children who had the type 2 fractures. The exact reason for this is unknown. It could be linked to the amount of energy transferred through the joint at the time of injury. Or it might be related to the fact that type 3 fractures were treated with open surgery. Type 2 fractures could be pinned percutaneously (through the skin without an open incision). More study will be needed to identify cause and effect.

The authors pointed out several other findings from this study. All the children with type 3 fractures had more than four millimeters of separation (not just two millimeters, the cut off point suggested by the authors). There were a fair number of children who had a stiff elbow with loss of motion (17 per cent) after treatment. A closer look showed that loss of motion was not linked with the type of fracture or the length of time in a cast. No one was able to identify risk factors that might account for this complication.

The findings in this study support the use of this new classification system based on degree of fracture displacement and articular congruity both to predict complications and to direct surgical treatment. None of the methods currently used to classify these fractures recommend treatment or predict the results. Other studies are still needed to follow-up children to see what the long-term effects are of this treatment. The authors also suggest another study to see if type 2 fractures with more than four millimeters of separation could be treated with closed (percutaneous) pinning.