News Category: Child

Osteosarcoma (bone cancer) is the topic of this review article. It’s a rare form of cancer with only about new 560 cases diagnosed each year. But it can have devastating effects and a poor prognosis, so articles like this are very helpful in keeping us up-to-date on the diagnosis and treatment of this disease.

Children and teens are affected most often because of how fast they are growing. Rapid turnover of bone cells goes haywire when tumor-suppressor genes that normally regulate the bone cell cycle get turned off or get side tracked. It doesn’t look like osteosarcoma is an inherited condition, but there are some genetics involved with chromosomal abnormalities and of course, mutation of the tumor-suppressor gene.

There are different subtypes of osteosarcoma. These are divided into conventional, telangiectatic, and low-grade intramedullary. These subtypes are based on the location of the tumor (at the end of the bones versus in the long shaft of the bone), size and shape of the tumor cells, and type of bone cells affected (osteoblasts versus osteoclasts or mixture of both). Conventional osteosarcoma (also known as classic osteosarcoma) is the most common type presenting in 80 per cent of all cases.

There are also surface osteosarcomas. These tumors form on the surface of the long bones rather than inside the intramedullary canal of the bone. Surface osteosarcomas are divided into subgroups labeled parosteal, periosteal, and high-grade. Young adults between the ages of 20 and 30 are affected most often by surface osteosarcomas.

Red flag symptoms for osteosarcoma alert the patient that there is a problem. These include joint pain and loss of joint motion. Sometimes there’s a bony bump that can be felt. There may be redness and warmth of the skin over the affected area. Fastest growing bones are affected most often. The knee is the most common joint where osteosarcoma shows up. The knee joint involves the lower end of the femur (thigh bone) and the upper end of the tibia (lower leg bone). But osteosarcoma can also affect the humerus (upper arm bone), the pelvis, the spine, and the bones of the face and head.

Many times the patient just thinks he or she strained the arm or leg in sports or other recreational activities and waits for it to get better. But the pain doesn’t go away and after several weeks or months, it becomes constant, even waking the person up from sleep at night. If the bone weakens enough from the growing tumor, a fracture can occur and then the diagnosis is finally made. Late signs and symptoms also include weight loss, fatigue, and fever.

X-rays show fractures but don’t always show the full extent of bone tumors. MRIs help pinpoint how far the tumor has invaded into the soft tissues, nerves, blood vessels. They can show how much of the bone marrow has been replaced by the growing tumor. And the MRI helps show if there is metastases (spread) of the cancer. A surgeon will take a core sample of the tumor (called a biopsy) to make the final, specific diagnosis. The pathologist who looks at the sample under a microscope is able to identify the subtype.

Osteosarcoma has a less than optimal prognosis. This is partly caused by the fact that by the time the diagnosis is made, the tumor has spread in 20 per cent of all cases. And that refers to detectable metastases — meaning it can already be seen on imaging studies. Micrometastases (invisible or undetectable but very much present) are very likely present in most other patients. It’s just a matter of time before the tumors spread and grow enough to show up on a diagnostic test. Osteosarcoma spreads through the blood, first to the lungs and then to other bones.

Treatment is aimed at removing the primary (main) tumor and killing off any tumor cells that can’t be seen before they have time to grow. Before a specific treatment plan can be devised, the tumor must be staged. The physician relies on imaging studies (X-rays, MRIs, PET scans, bone scans) to stage the tumor from Grade I (low) to Grade IIB (high) and Grade III (low to high but with metastases already present).

Chemotherapy is often done before surgery to shrink the number of circulating tumor cells. This is important for patients with known metastases and because of the high risk of micrometastases already present. Chemotherapy also helps reduce the amount of blood supply to the tumor, which gives it a chance to shrink the main tumor as well. When chemotherapy has been completed, the body is given a three to four week rest in preparation for surgery. This sounds scary at first — you may think, what if the cancer cells start growing back during that break in time? But studies show no apparent bad effect of waiting in this fashion.

Surgery can be very complex and is meant to save as much of the normal anatomy as possible. This procedure is called limb salvage. Sometimes it just isn’t possible to save the leg or arm and amputation is necessary. Removing as much of the tumor and the metastatic lesions as is possible will improve the prognosis. The decision to have the limb cut off is never easy. But for some patients, by the time the surgeon removes the necessary tissue and begins to do plastic surgery to improve function and appearance, it’s just easier and more functional to have an amputation.

When limb salvage is the treatment direction, the surgeon is faced with many possible decisions, too. What’s the best way to reconstruct the joint? Joint replacement may be necessary to stabilize the limb while keeping as normal biomechanical function as possible. Joint stability is important, but for the growing child/teen, maintaining equal limb lengths is just as important. Specifically designed adjustable growth rods can be placed inside the bone.

Once the tumor has been surgically removed and the limb restored as close to normal as possible, then a second round of chemotherapy is started. The patient, family members, and health care team must now watch for complications from the surgery such as infection, poor wound healing, failure of any mechanical parts, and joint instability. The treatment team does everything it can to reduce the risk of limb loss and cancer recurrence. The results of a multidisciplinary approach to osteosarcoma with improved treatments have really improved survival and quality of life over the last 10 to 20 years.

It used to be that amputation was the only treatment option. Now with limb salvage procedures, that’s not always necessary. Survival rates have increased from 10 to 20 per cent back in the 1960s to almost 80 per cent today. That optimistic figure of 80 per cent applies to patients who don’t have any sign of metastases. The presence of mets changes the prognosis downward toward a shorter lifespan and increased risk of cancer recurrence.

Pre- and postoperative chemotherapy has helped improve results. It is hoped that with continued research, new and better drugs to target the cancer cells will be available in the near future. Right now, the relapse rate is 30 to 40 per cent within three years after treatment. If the cancer returns, the prognosis is not too good — less than two out of every 10 patients with recurrence of osteosarcoma will make it.

Even though that sounds grim, there is cause for optimism. Studies show that removing the new tumor can improve survival rates. Whether or not that patient should have another round of chemotherapy remains a question that is up in the air. One of the big research questions is what kind of chemotherapy (if any) works best for recurrence of osteosarcoma? Scientists believe it is only a matter of time before their efforts to find less toxic drugs that specifically target tumor cells will pay off. When that happens, we should expect to see improved survival rates with fewer limbs amputated and a better cosmetic result in the end.

Sometimes babies are born with defects or anomalies like missing vertebral bones, only half of a vertebral bone formed, fused vertebral bones, and/or fused ribs. These defects result in curvature of the spine called congenital scoliosis. Any time this happens, the parents wonder, What did I do wrong? How did this happen?

At this point, scientists still don’t know the etiology or cause of congenital scoliosis. In this report, Dr. Robert N. Hensinger from the Pediatric Orthopaedic department of the University of Ann Arbor, Michigan presents a review of the information known so far about this condition.

Let’s go right back to the moment of conception. The sperm meets the egg, penetrates, and fertilizes it. Now the cells begin to divide rapidly. By day eight, the beginnings of the spine are already being formed. Whatever causes the vertebrae to develop abnormally occurs early on before the cartilage or bone are even formed. This is the period of embryonic growth referred to as prenatal vertebral growth. It takes place between the third and the fifth week of life. The tiny structures that will eventually be vertebral bodies are called somites.

Shortly after the formation of somites, vertebral defects begin to occur. The developing child in the womb is only about 30 days old and seven to 13 millimeters long from the top of the head to the bottom of the spine (crown to rump). In order for each vertebral bone to form properly, there must be enough blood supply carrying nutrients and oxygen to the area. Without this, malformations occur. The lack of blood vessels (arteries) to each somite or segment prevents the bones from dividing into segments that will become individual vertebral bodies. So, oxygen is important.

What causes a lack of oxygen? Too much carbon monoxide. What causes too much carbon monoxide? Probably some environmental factor like exposure to chemicals but at this point, scientists know much more about the what (what happens) than the why (why it happens). Studies using mice have helped reveal the way the deformities develop, just not always the factors linked with the deformities.

It is thought that there are two main risk factors: environment and genetics. Besides exposure to possible chemicals such as industrial solvents, there could be exposure to cigarette smoke, alcohol, anticonvulsant medication, too much vitamin A, and a lack of folic acid (one of eight B vitamins). The discovery that a lack of folic acid during pregnancy causes vertebral and spinal cord defects resulted in flour, prenatal vitamins, and other foods being fortified with this essential vitamin. The number of cases of spina bifida went down dramatically after that.

That’s as much as we know so far on the environmental side of things. What about genetics? Could congenital scoliosis be an inherited condition? Are there specific genes involved and gene mutations that change how cells are regulated to form the spine?

Again, using mice as a model to help explain what went wrong, scientists have found genes that do regulate the embryonic formation of cells that normally lead to the development of the spinal bones. One particular family of genes (the notch family) has even been identified in humans as responsible for early embryonic development of the spinal column. Another set of genes called the Hox genes are involved in the formation of the skeleton. Research with mice is ongoing to discover the cause and connections between mutations of Notch and Hox genes and vertebral or other bone malformation.

Sometimes there’s more than just the spine involved. Other problems present but not visible might not be readily apparent, so it’s a good idea to examine the child for hidden defects and deformities. Children with several problems along with congenital scoliosis may have a well-known and recognized syndrome. Some of these syndromes include Klippel-Feil syndrome, Sprengel’s deformity, Goldenhar syndrome, and the VACTERL, which stands for the various problems involved (V for vertebral defects, A for anal atresia, T for tracheo-esophageal fistula and atresia, R for renal deformities, and L for limb defects).

Not only are there vertebral anomalies, but deformities can occur at the top of the spine at the foramen magnum (hole for the spinal cord) and at the bottom of the spine sacrum. The bottom portion of the brain inside the skull is called the cerebellum. The cerebellum is connected directly to the spinal cord. The bottom of the cerebellum sits on the base of the cranium (skull) and the spinal cord goes down through the foramen magnum. Narrowing of the foramen magnum or the opposite problem (too large of a hole) can cause problems. Too small of an opening puts pressure on the spinal cord. With too large of a hole, the cerebellum starts to slip down through the hole. This is called a Chiari malformation. That can occur at the upper portion of the spine.

At the bottom end of the spine, sacral agenesis can be another problem. Complete sacral agenesis means there is no sacrum — it just doesn’t form. In less severe forms, only half of the sacrum is present or there may be a part missing on both sides. Depending on the type of sacral agenesis that is present, there may be bowel or bladder problems as well. Again, no one is exactly sure why this deformity occurs. There’s a link between mothers with diabetes and children born with sacral agenesis. But what the connection is to diabetic-related insulin deficiency (if there is one), remains a mystery.

As you can see from this summary of Dr. Hensinger’s publication, there are more unknowns than knowns in the understanding of congenital scoliosis. Efforts to find environmental or genetic links have only been partially successful in explaining what went wrong and why. Correcting some vitamin deficiencies has helped but the problem still occurs. As with many unusual physical problems, it’s likely that several (or even many) factors combined together result in this potentially serious condition. Future research will continue looking for answers to this puzzling problem.

Orthopedic surgeons have to keep up with the latest research and trends in treatment for many, many problems, conditions, and diseases affecting the musculoskeletal system. Pediatric orthopedic surgeons face some problems not seen in the adult population. And often, pediatric problems like diaphyseal femur fractures (a break in the long shaft of the thigh bone) are only seen occasionally, making it even more difficult to know what to do to get the optimum results.

That’s why the American Academy of Orthopaedic Surgeons (AAOS) has started researching and reviewing various topics with the purpose of developing clinical practice guidelines (CPGs). These guidelines help surgeons stay up with current evidence and provide the best treatment plan for each individual patient. The guidelines don’t tell the doctor how to treat everyone. They are simply recommendations based on studies, expert opinion, and trends observed over the years.

The surgeon must still take many factors into consideration when developing a plan of care. The child’s age, location and severity of the fracture, cause of the fracture (car accident, possible abuse, sports injury), family dynamics, and other social factors are all things that affect the decision-making process. Abuse is considered a possibility in any child under the age of five who has a fracture of this type. Sometimes the child’s temperament and activity level are also important to weigh in on the decision whether to treat conservatively (nonoperatively) versus surgically.

Femoral fractures in children is an area where the research is lacking. The 14 guidelines provided in this article are based on the scientific data available at this time. But the author makes note of the fact that clearly, more and better research is needed in this area. Although there has been a trend toward surgical care instead of traction and prolonged casting, high-quality studies comparing the two approaches have not been done. The guidelines are strictly for children who are still growing.

The recommendations are broken down by age groups: 1) infants, 2) six months up to five years, 3) five to 11 years old, and 4) 11 years old up to skeletal maturity. Size of the child (including whether or not obesity is an issue) can make a difference if he or she falls outside the standard range for their age. Age compared with size is a variable the surgeon must take into consideration. To help the surgeon who consults the guidelines, the AAOS lists the level of evidence next to each of the 14 recommendations. That gives the surgeon an idea of how strong the evidence is to support the particular guideline of interest.

For example, Level I means the evidence comes from high-quality randomized and controlled trials. The higher the number, the lower the evidence until at Level IV and V, we are relying on the results of case series (several individual patients viewed one at a time) and expert opinion. Expert opinion may be the published opinion(s) of one or more surgeons with experience in this area. Sometimes, it’s more the case of a panel of doctors discussing the problem and providing consensus (what they all agree on).

Treatment recommendations based on age makes sense because of the differences in level of skeletal maturity and muscular development from group-to-group. For example, the first recommendation is to consider abuse in any child younger than five years old, but especially any child three years old and younger. Another recommendation is that certain treatment approaches (e.g., Pavlik harness) can only be used with young children. Older children (13 and older) are better candidates for instrumentation using nails, pins, or metal plates. They have more skeletal maturity and strong enough bones to hold rigid supports of this type.

Some of the treatment recommendations are based on the severity of the injury. One of the recommendations deals with difficult cases that present with a wide separation of the two ends of the bone. Separation of more than two centimeters (half an inch) is more likely to require surgery to reduce the fracture (bring the ends of the bone back together). Otherwise, the risk of a leg length difference increases. The surgeon will still have to decide whether to use rigid or flexible nails/pins or locked versus unlocked plates. There just isn’t enough evidence to support one over the other or to guide surgeons as to which patients would do better with one over the other. They are all treatment options available for consideration.

Likewise, there isn’t a recommendation that says surgical implants should or shouldn’t be removed once the leg is healed. This guideline really refers to children who have no symptoms related to the plates, pins, or screws. Those who are in pain from the fixation devices may require follow-up surgery. Symptoms are more likely to develop when the implants break, loosen, or migrate (move).

Some of the guidelines are given a status of inconclusive when the evidence is lacking, insufficient, or conflicting. Physical therapy to help improve function after diaphyseal femoral fractures in children makes good common sense, but there are no studies comparing children in one group who had physical therapy (PT) with another group who didn’t have PT. Sometimes the ethics of conducting such research prevents it from taking place (i.e., withholding physical therapy from a child who might benefit is not acceptable, even for the sake of science).

In this summary, the full explanation for how each recommendation was determined is not included. The author suggests that any reader who is interested in the details and rationale for the guidelines can visit the AAOS website at www.aaosnow.org. For all areas where the evidence is weak or inconclusive, more research is needed. The current clinical guidelines may be changed or further clarified as a result of any new data that comes available over the next 10 years. For right now, the guidelines are meant to be used as one tool in making treatment decisions. They are not developed enough to be used as the only source of information regarding treatment.

Suggested topics for future study include answering the questions Can casting be delayed or must it be done right away for the six months old to six years old age group? At what age can flexible nailing be used inside the bone instead of the full spica (waist to toe) cast currently in use? What kind of instrumentation is best for the age group six years to skeletal maturity: flexible nail, rigid nail, or metal plate? When does the family situation enter into the decision? It would seem that family function does make a difference in their ability to care for a child who is laid up with a full spica cast for weeks to months. These are just a few of the suggested topics for future study.

Parents of teens with osteochondritis dissecans (OCD) and any adult who ever had OCD as a teenager will find this review of interest. Diagnosis, prognosis, and treatment of OCD are the key features. A special focus on surgical options brings us up-to-date on the treatment of OCD.

Osteochondritis dissecans (OCD) describes an injury to the area of bone just under the cartilage surface, an area called the subchondral bone. OCD affects the knee most often and develops in active teens between the ages of 10 and 15 years old. Repetitive trauma (usually from sports such as skateboarding, snowboarding, or skiing) is the primary risk factor and leads to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

The problem occurs most often where the cartilage of the knee attaches to the bone underneath. The end of the femur (thigh bone) is the most common location, but the patella (knee cap) or top of the tibia (lower leg bone as it meets the femur to form the knee joint) can also be affected. It is possible to develop OCD in other joints such as the elbow, wrist, ankle, and top of the femur.

Anyone who has ever had OCD as a teenager is also at increased risk for a return of this condition called adult osteochondritis dissecans or AOCD. The juvenile form in teens is called juvenile osteochondritis dissecans (JOCD). The adult form really is just a failure to heal from the juvenile form. The adults most likely to develop AOCD are those who never knew they had the juvenile form. There were no symptoms.

When symptoms do develop, the patient reports knee pain and swelling that comes on with activity. If a piece of cartilage has broken off and is present inside the joint, there can be mechanical symptoms such as locking or catching of the joint. Many patients have tenderness along the front/middle portion of the joint line. To take pressure off this area, they limp or turn the lower leg outward.

Diagnosis begins with the patient’s history and a physical exam followed up by imaging studies. X-rays show the location of the problem. MRIs show the extent or severity of the condition. For example, the amount of swelling or edema can be seen on MRIs as well as the condition of the cartilage and whether or not the cartilage has separated from the bone.

Once the diagnosis has been made, the decision about treatment is next. Treatment depends on the grade of the subchondral bone. Grade 1 is normal cartilage but early changes observed in the subchondral bone. Grade 2 means the cartilage has fragmented but it hasn’t detached or moved, and grade 3 refers to a partial detachment of the damaged cartilage. Grade 4 is the most severe form of OCD with damage to the bone and complete detachment of the overlying cartilage, which is now loose inside the joint.

For grades 3 and 4, osteoarthritis will occur without surgical treatment to repair or reconstruct the cartilage. The larger the size of lesion, the more likely osteoarthritis will develop later. Grade 2 lesions can sometimes be treated with conservative measures, but that means staying off the joint and no longer participating in any activities that aggravate the problem. Healing is most likely to occur when the lesion is not in an area of the bone that gets compressed and there’s no friction from the two bones rubbing against each other. Young patients with stable OCD have the best chance for full recovery.

Conservative care has evolved over time with evidence from studies to suggest optimal ways of supporting natural healing. At first, the approach was to prescribe immobilization and non-weightbearing of the leg. But it was quickly realized that this method left the patient with a stiff and weak knee that starts to lose bone mass from disuse. Today, the leg is still placed in an immobilizer, but partial weight-bearing is allowed until the patient no longer has any pain. That usually takes about six weeks.

The next phase of rehab involves increasing the weight put on the foot and leg and adding low-impact strengthening exercises. No one is allowed to participate in sports activities until X-rays show the bone is healed, there are no symptoms, and the patient has completed the full course of rehabilitation under the supervision of a physical therapist.

If conservative care fails, then surgery is still an option. In all cases, the surgeon tries to preserve the natural cartilage by repairing the damage rather than removing and replacing the torn cartilage. Studies have shown that removing the torn fragment may give the patient relief from the pain and symptoms, but it doesn’t last. Only one in four patients treated this way go on to heal completely. But sometimes repair just isn’t possible and the damaged cartilage must be removed and replaced.

In those cases, the surgeon has quite a few options to choose from. Procedures to repair the damage include drilling holes in the subchondral bone to open up channels for blood to get to the area and get the healing process going. Or the surgeon may think reattaching the fragmented cartilage, a procedure called internal fixation is what the patient needs. Teens are more likely to respond well to the drilling technique. Adults rarely experience spontaneous healing this way and must rely on internal fixation for a successful outcome.

If the least invasive surgery fails to restore the cartilage, then bone grafting might be considered as the next step. The surgeon uses plugs of cartilage and subchondral bone from a non-weight-bearing area of the patient’s knee as the graft. This is still an attempt to stabilize and salvage the damaged area without removing tissue. This approach is more likely to be successful when the lesion is small or in areas with less pressure and friction.

Larger lesions in less active patients may respond to a technique called microfracture. The surgeon places tiny holes all around the outside of the damaged area and then in toward the center of the damaged area. This technique works best for high-demand individuals with small lesions, low-demand patients with slightly larger lesions, and when the subchondral bone is not damaged. Microfracture resurfaces the defect but does not restore subchondral bone.

Autologous chondrocyte implantation (ACI) is the final treatment option discussed. The surgeon removes healthy cartilage cells from a non-weight-bearing area of the joint and sends them to a lab where they are multiplied in number. When there are enough new, healthy cells, the surgeon performs the second part of this two-part operation and places the new cells in the damaged area. The goal of this method is to produce a graft that is close to natural cartilage cells in form and function. If the defect is really deep, the surgeon may have to inject cells into the area in stages over time. Fortunately, the healthy cells created in the lab last up to five years when kept very cold.

The authors conclude by saying that treatment for OCD of the knee is most successful when the condition is caught early and treated before long-lasting damage can be done. The surgeon makes the treatment decision with the patient’s interests in mind but by taking into consideration the size and depth of the lesion. The presence of loose fragments complicates the decision, making surgery almost inevitable. Most people do not heal on their own and require some kind of intervention. The patient should expect a long recovery of many months to several years.

Orthopedic surgeons are often faced with the frustration of knowing that a commonly accepted and used surgical technique doesn’t always work. In this article, surgeons who treat children for a problem called calcaneonavicular coalition present their technique for dealing with this condition.

Calcaneonavicular coalition refers to the fusing of two bones in the foot: the calcaneus (heel bone) and the navicular bone. The navicular is an important bone because it joins with many other bones in the foot and ankle. It is located on the medial side of the foot (side closest to the other foot). It articulates (moves against) the four and sometimes five other ankle bones.

When calcaneonavicular coalition occurs, the affected individual (usually a child between the ages of eight to 12 years old) reports ankle pain with loss of motion. They are no longer able to point the foot down all the way. Turning the foot and ankle inward can also be limited. The loss of these motions makes it difficult to walk, run, and participate in daily activities at school.

It appears that the bones are fused or held together with a thick, binding cartilage. It’s likely the child was born with this problem but sudden, rapid growth during the later childhood years just before puberty brings it to the attention of parent or child. Sometimes ankle or foot injuries (sprains or fractures) occur because of reduced hindfoot motion. An X-ray brings to light the cause of the underlying loss of motion as the coalition is visible with radiographs.

Treatment is usually surgical with resection (removal) of the extra bone. Left untreated, besides being painful and limiting, the joint eventually develops degenerative arthritis. Removing the cartilage that bridges the two bones leaves a deep hole in the foot. The hole that is filled with muscle from the extensor digitorum brevis (EDB) in the foot. The muscle is detached and pulled into the hole with its tendon rolled up to fill the space.

The problem is that in some patients, the coalition grows back. And even for those whose bone doesn’t grow back, the bump that’s left after surgery is unsightly and rubs against the shoes. In this study, they tried using a fat graft instead of the muscle and tendon, thinking it would fill the hole more completely and prevent regrowth. But even with more than enough fat to fill the area, there were still a fair number of recurrences.

The surgeons asked, Why? What happened? If they were careful to get all of the coalition, why did it grow back, a process called reossification? Patients with regrowth had good results at first with the excision and fat graft. Everything looked good on X-rays and then foot pain returned and loss of motion developed.

The surgeons had hoped that using fat instead of the muscle/tendon to fill the hole would be a better way to prevent regrowth. And, in fact, there were fewer cases of regrowth when using a fat graft compared with tendon, but fibrous regrowth still occurred. The use of fat as a filler has several advantages over tendon interposition. For one thing, the tendon really isn’t long enough to fill the entire hole. Fat is always plentiful. For another, it’s easier to shape the results with fat, avoiding cosmetic disasters, such as obvious lumps and bumps that rub against shoes and sandals.

The authors conclude that fat grafts have better overall results than tendons to fill the hole left by excision of the calcaneonavicular coalition. But the outcomes aren’t perfect yet, so further study is needed to find out why not. Is it something about the individual patient that could be predicted ahead of time? Is there a better technique than even the fat graft? What is it that stimulates regrowth of the coalition? These and other questions will help guide future studies in this area.

Treating idiopathic scoliosis in a very young child is a challenge. Whatever treatment is used must allow for growth and development because most of the children affected are less than three years old. They still have a lot of growing to do — not just the spine, but also the muscles, ribs, and internal organs. Fusing the spine (an effective treatment for other forms of scoliosis) is not an option until much later. The earliest fusion can be considered is around 10 years old.

Idiopathic scoliosis is a curvature of the spine with no known cause. By definition, the curve is at least 20 degrees. Boys are affected more often than girls and a left-sided curve is the rule rather than the exception. It might be said that most children with idiopathic scoliosis outgrow this condition, as it seems to resolve in up to 90 per cent of children.

Treatment can consist of bracing, body cast, or more recently, the Vertical Expandable Prosthetic Titanium Rib or VEPTR. Bracing was done using a rigid plastic orthosis that supported the thoracic, lumbar, and sacral spine. This type of bracing is called a thoracolumbosacral orthosis (TLSO). It is worn as close to 23 hours per day as possible with breaks for bathing and skin care.

Casting required surgery under general anesthesia. While the child was relaxed under the effects of the anesthetic, the spine was straightened as much as possible. The cast was applied over two layers of a protective material called stockinette. Every two months, the cast was removed and replaced until maximum correction of the curve was obtained. When the curve was decreased to less than 10-degrees, then a brace could be used instead.

The VEPTR also known as the titanium rib is a vertical titanium rod that can be expanded as the child grows (about every six months or so). The rod is curved to match the curve of the rib cage. The upper end of the rod is clamped around a rib above the spinal curve. The lower end is attached to a rib (or the pelvis) below the curve. As the child grows taller, the telescoping rod can be lengthened. The goal is to separate and support the chest, giving the lungs room to expand and grow.

Which treatment option works best: casting, bracing, or the expandable rod? How does the surgeon know what to choose? Pediatric orthopedic surgeons from the Shriners Hospital in Philadelphia offer their thoughts on this subject. They used the results of 31 children treated with one of these three methods. Standard Cobb angle measurements from X-rays were used to determine the degree of curvature. Before and after measurements were taken for each child.

Only children with idiopathic scoliosis and no other deformities or known cause of the scoliosis were included in the study. Ages ranged from three months up to seven years of age. Slightly more than half the group was put in a brace. Ten children received a body cast, which was changed as the spine straightened up. They call this approach serial casting. Another 10 had the VEPTR device implanted. Each expansion procedure required surgery and a four-to-seven day hospital stay.

After comparing measurements before and after for each procedure and comparing the results of one procedure to another, here’s what they found:

There’s a simple way to avoid shoulder injuries in Little League pitchers. In this article, sports medicine specialists present a few tips to help in this area. There are known guidelines for injury prevention. The first is: don’t overdo it. Second, players, parents, and coaches must work together to keep track of the number of pitches a pitcher throws per practice, per game, per week, and per season.

The maximum number of allowed pitches varies depending on the age of the pitcher. Pitch count (number of pitches per inning) is used rather than the number of innings. A young pitcher can pitch as many as 45 pitches in a single inning. That stresses the arm as much as a 75-pitch game throwing 15 pitches per inning.

The real issue is the number of high-intensity pitches that young players throw. Just as important as the number of pitches is the amount of time the pitching/throwing arm is allowed to rest afterwards. This rest period gives the soft tissues time to recover and repair damage from microtrauma. Players must be encouraged to report (not hide) a sore arm, elbow tenderness, or shoulder pain when it begins.

When young players can throw with speeds of 85 MPH or more, the immature soft tissue structures may not be able to handle the stress. That’s why even the length of time needed to rest is predetermined. For example, Little League players 16 years old and younger must rest three days after throwing 61 or more pitches. Even minor injuries need this much time to recover at the cellular level.

Trainers and coaches are encouraged to help young pitchers learn proper technique. Motion analysis studies show that incorrect form when throwing increases the rotational torque and force on the shoulder and elbow. Some pitches are more problematic than others. For example, breaking pitches such as curveballs or sliders (when thrown improperly) increase the risk of arm pain and injury by 50 to 85 per cent.

During the preseason, and between seasons (off-season), a strengthening and conditioning program of exercises is essential. Such a program is the best insurance to reduce the risk of injury to the throwing arm. The authors present a fitness/rehab program that prevents a weight lifting program from further endangering players. This is especially important in the skeletally immature child. They call their approach a functional conditioning program.

The program is presented in a pyramid form. The basic foundation (at the bottom) is the bulk of the program. This begins with physical fitness. Overall fitness provides stability, flexibility, and balanced posture. The athlete doesn’t progress to the next level until foundational fitness is demonstrated. This concept is important to prevent joint break down when moving to the next level in the pyramid, which is called joint integrity. At this level, plyometrics (e.g., plyoball training) is used to increase endurance during repetitive movements. Plyometrics refers to a type of exercise training designed to produce fast, powerful movements, and improve the functions of the nervous system.

From there the athlete is progressed to machine work to build up speed and power. Free weights are used to further reinforce speed and power. At the top of the pyramid is the practice of overloading and underloading training work. These activities further enhance speed or velocity.

Throughout the functional conditioning pyramid, there is an effort to train opposing muscle groups equally. The authors stress the idea of muscle balance for young pitchers. The act of throwing training requires the coordination of many muscles working together with perfect timing. Problems can develop if even one muscle is fatigued or overloaded.

Young pitchers who overtrain are at risk for developing a condition called SICK. Overload and fatigue lead to Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and scapular dysKinesis. SICK with all its components listed here refers to an altered position and movement of the scapula (shoulder blade). The scapula is an important part of the total shoulder movement complex during the pitch.

A second common injury from poor throwing mechanics is called the dead arm syndrome. The player experiences limited shoulder internal rotation and fatigue. He or she is unable to locate pitches. The posterior shoulder capsule gets tight and cannot protect the shoulder fully.

The authors conclude that young pitchers can stay healthy and return to play quickly after injury by following guidelines set up by the Little League organization. Keeping track of pitch count and pitch type, getting proper rest, and avoiding overparticipation are important. Equally important is a proper conditioning program as described.

Over three million young children are victims of child abuse in the United States each year. One-third of all child abuse cases will suffer a bone fracture and need to see an orthopedic surgeon. That’s why orthopedic surgeons must be aware of the possibility of child abuse and watch for it. This study provides some added information to help them know what to look for that might raise the suspicion of abuse.

Hospital records of children with physical injuries were used as the basis of this study. Information on two groups of patients was compared: those with injuries caused by known child abuse and those with injuries without the diagnosis of child abuse (accidental injuries). The second group were considered the control (normal) group.

By looking at child demographics, injury pattern, and time periods when injuries occurred, they were able to identify some factors that might predict injuries caused by child abuse. This new information should provide guidance to physicians examining children with physical injuries. The authors note that these predictive risk factors aren’t the only way child abuse can be recognized and diagnosed. They are just an added piece of the assessment that can raise the suspicion of abuse-related injuries.

The data collected came from all regions of the United States, making this a nationally-based study. The South and Midwest regions had the largest number of cases. Child abuse appears to be statistically more likely in urban (versus rural) settings. But there’s some question that maybe this is because rural health care teams aren’t trained to look for and recognize traumatic injuries that occur as a result of abuse.

The strongest predictor of abuse is young age with two groups especially at risk: birth to one year and one year up to two years of age. The second predictive factor was type or pattern of injury. Fractures affecting the bones of the head, neck, and trunk were most common. But fractures of the long bones of the arms and legs must be closely assessed, too. This includes the femur in the thigh, tibia or fibula of the lower leg, humerus of the upper arm, and radius or ulna of the forearm. The one area of fracture that proved to almost always be accidental was a pelvic fracture. More than even fractures, an important physical sign is a contusion. A contusion is a visible bruise or large black and blue mark.

The third predictive factor of abuse-related injury was the specific period of time when the injury took place. Weekdays and during the winter seemed to be a common pattern for child abuse. Weekends might be less stressful with more adult supervision available. Or possibly the attendance of church services influences behavior.

It was thought that perhaps with colder weather and being indoors more in the winter, children would be more likely to spend time with the caregivers who were the abusers. Being outside less during winter months might also lower the risk of accidental injuries making it seem like there are more cases of injuries from abuse than from accidents during the winter.

The researchers also looked at socioeconomic level to see if there was a link there. They couldn’t use family income as a marker because it wasn’t always reported. So they looked at who was paying for the medical charges. They found that more families on Medicaid than on private insurance were involved in child maltreatment. Medicaid suggests a lower family income.

The authors conclude it isn’t always easy to tell when an injury is accidental or the result of child abuse. But physicians examining children with physical injuries must always keep the possibility of abuse in the back of their minds.

Having a few guidelines like those offered in this article can be helpful when looking for any clues to help in making the diagnosis. Using a national data registry made it possible to find common characteristics of child abuse to help raise a red flag during the examination and evaluation.

Hopefully, by recognizing minor injuries caused by child abuse, it may be possible to prevent more serious injuries. Hospitalization to protect the child during investigation and getting Child Protective Agencies involved are two strategies alert physicians can use. These steps can be taken when confronted by any of these predictive factors that point to child abuse as a possible (even probable) cause of physical injury.

When it comes to the nonoperative (Ponseti) treatment of clubfoot in children, does it matter if a physical therapist manages care versus the orthopedic surgeon? According to this study, quality of care improved when directed by the physical therapist compared to the surgeon. If this proves true in general, it could free surgeons up to do more of the technical surgical work they are trained for. Delivery of care for clubfoot could be left up to physical therapists, nurse practitioners, and physician assistants.

Clubfoot is a congenital (present at birth) deformity that causes the feet to point down and turn inwards. Left untreated, this condition prevents normal foot and ankle motion needed for walking and running. The Ponseti method developed by Dr. I. Ponseti was first tried 50 years ago. Since that time, it has been proven effective and is used around the world.

The method involves gentle manipulations of the feet and casting. The treatment is based on an accurate understanding of the functional anatomy of the foot and of the biological responses possible in the musculoskeletal system. Muscles, ligaments and bones respond in six to eight weeks to corrective position changes gradually obtained by manipulation and casting.

Manipulation and casting refers to moving the bones through the full available motion and then putting a cast on the foot, ankle, and lower leg to hold them in place. Once the soft tissues and bones get used to that position, the cast is removed and the foot and ankle are manipulated (moved) a little further, again putting a cast on to maintain the new position. This process is repeated each week until the deformity is overcome.

This method has made it possible to move from a surgical to nonsurgical treatment with faster results and fewer complications. Years ago, extensive surgery was done to restructure the foot and ankle. This change in treatment is good news in countries like Canada and the United States because it can reduce the cost of health care for this problem. But it’s even better news for undeveloped countries where there are few (sometimes no) specialists.

In this study, the results of 25 children treated by surgeons using the Ponseti method were compared with 95 children treated by physical therapists trained to use the same approach. Each child in both groups was placed in a semirigid fiberglass cast, which was removed (and replaced) weekly.

With each cast removal, the foot position was corrected as close to neutral (normal) as possible before reapplying another cast. This was repeated until the forefoot could be moved away from the midline at least 70 degrees. The hindfoot was also being corrected making it possible to move the calcaneus (heel bone) inward, a motion needed for normal walking.

If the hindfoot did not correct fully, the surgeon performed a percutaneous tenotomy. This is a release of the Achilles tendon through the skin without doing open surgery. After casting and/or tenotomy, the next step was to place the child in a Denis-Browne splint.

This orthotic has a pair of open-toed shoes attached to a bar. The shoes are placed at an angle to hold the correction. The shoe on the corrected side is placed at 70-degrees of external rotation. If the child had bilateral clubfeet (both sides involved), then both shoes were set at this angle. If only one foot was affected, the uninvolved shoe was placed at a 45-degree angle.

Parent/family education is a key element of the Ponseti method. Once the child is in a removable brace of this type, compliance is very important. For best results, the child must wear the Denis-Browne brace everyday (full-time, day and night) for three months.

After that, it can be removed during the day and just put on during naps and nighttime. But this schedule must be kept up until the child is four years old. The family must also bring the child to the clinic on a regular basis for follow-up. This is especially important as the bones of the foot (and the child) grow larger. The examiner can make any adjustments needed or resize the brace as the child grows and changes.

Success or failure? Which group did better? Treatment success was defined as a straight foot that could be put flat on the ground or floor when walking. The child could wear a regular shoe comfortably and use a heel-toe gait (walking) pattern. The final outcome also included at least 10 degrees of ankle dorsiflexion with the knee straight. Dorsiflexion refers to motion at the ankle that pulls the toes toward the face.

Failure occurred when the child’s foot could not be fully corrected using the Ponseti treatment. Somewhere between success and failure was recurrence. In these cases, the Ponseti method worked but the correction was not maintained. The child ended up needing another series of casts and/or surgery to get back the good results originally obtained with treatment.

Besides rating each case as a success or failure, data was collected on the number of casts used to achieve normal alignment, the number of children who needed an Achilles tenotomy, and the rate of recurrence and/or need for another surgery. There was no difference between the groups in terms of number of casts used, number of Achilles tenotomies, or the failure rate.

However, the group treated by physical therapists had a significantly lower recurrence rate and fewer repeat Achilles tenotomies required. When recurrence did occur, it happened earlier in the course of treatment in the therapist-directed group. This made it possible to redirect treatment sooner. Most of the time, repeat cast treatment was all that the children needed for a successful recovery.

Statistical analysis also showed that children under the care of the physical therapist were less likely to have a recurrence during the two years of follow-up. And fewer children in the physical therapist group required additional surgical procedures.

The authors have set up a clubfoot clinic at their hospital run by physical therapists specially trained by the orthopaedic surgeons to treat children with clubfoot deformity. Although the surgeon makes the initial assessment, the therapist directs and carries out the treatment. The use of fiberglass tape to make the casts instead of plaster saves time and doesn’t negatively affect the final results. The parents remove the cast and bathe the child the morning of their follow-up appointment.

Physical therapists with their knowledge of anatomy and mobilization skills can learn the Ponseti manipulation and casting technique for clubfoot deformity. Some hands-on training and direct supervision will be needed at first. By having all children in a wide regional area come to the same clinic, the therapists gain the experience needed to provide expert care for this problem.

One other advantage of the physical therapist-directed program reported by the authors was the improved communication between parents and therapists. Parents were able to telephone or email the therapist with any questions or problems.

Patients got in to see the therapist right away when any problems developed. This was very helpful for families with children who just couldn’t tolerate wearing the foot brace at night. Early communication made it possible to head off any problems and make the treatment more tolerable for the child. This factor may be what led to the improved results in the therapist-directed group. Data was not collected on this aspect of treatment, so future studies are needed to find the most effective way(s) to improve patient/family compliance.

Back pain in adults is so common, eight out of 10 people will experience it at least once (and often more than once) in their lifetime. Most of the time, no one even knows what’s causing it — the condition is said to be idiopathic. It’s nothing serious and treatment isn’t even needed. The patient is told to stay as active as possible. Recovery occurs in seven to 10 days. But back pain in children is something else altogether.

Idiopathic back pain in children and especially in young athletes is much less common. There is usually a very specific reason for the pain. It could be an infection, tumor, or inflammatory condition. More often, it’s an injury from a traumatic event or from repetitive motion causing microtrauma. Telling the child to remain active is the wrong advice.

In this article, physicians who treat children review the types of sports activities that lead to back pain most often. The most common injuries are presented along with risk factors and typical history. Identifying the underlying cause of the problem is very important. Treatment without delay is often needed to prevent a minor back injury from becoming a major problem.

As might be expected, high-energy, contact sports such as football, rugby, and soccer increase the risk of an acute traumatic event. But noncontact activities such as gymnastics and figure skating require repetitive bending, extending, and twisting or rotating the spine. Overuse injuries are more common in these groups of athletes.

Most people think kids are made like rubber — they can bend every which way with no difficulty. But the fact is, that soft tissues (e.g., muscles, ligaments, tendons) can’t always stretch and elongate to keep up with growing bone. Muscles get tight or may be off balance at certain times of rapid growth. This is a major risk factor for injury.

Doctors know that girls tend to mature faster than boys. Full bone growth may be completed in some girls by the time they reach puberty. Boys are more likely to reach maximum height and growth several years after girls. Hormones are shifting rapidly during growth phases, too.

Intense training during any of these periods of growth and change can lead to injuries. In fact, overuse injuries can be very unpredictable. A training schedule that worked one month may not be tolerated by the body the next month resulting in an unexpected injury. Since every child’s growth rate and maturation is different and their size and strength also vary, it’s impossible to come up with a training program that is one-size-fits-all.

Doctors must go back to the patient history and conduct a thorough physical exam in order to make an accurate diagnosis. Prevention of back pain in this age group would be even better. A review of risk factors combined with a physical exam and knowledge of the most common specific injuries would alert the physician of the need to intervene as soon as possible.

The authors help doctors out by providing a list of things to look for and tests to conduct to assess the spine. For example, posture, spinal range-of-motion, nerve tension tests, and muscle strength are all evaluated carefully. Specific tests such as the FABER test, Adam’s forward bend test, Gaenslen sign, straight-leg raise, and the single-legged hyperextension are described. Photos of each test are also included.

Each test is looking for a specific problem. Understanding what kind of spinal disorders can occur in athletes helps the examiner recognize the significance of test results. Spondylolysis, a stress fracture in the vertebra is the most common cause of back pain in teenagers. Almost half of all back pain episodes in children are caused by spondylolysis. The second most common cause of low back pain in teens is posterior element overuse syndrome.

With posterior element overuse syndrome, too much spinal extension and rotation cause damage to the area where the muscles and tendons connect. The ligaments, spinal joints, and joint capsules at the level of the repetitive trauma are damaged. The child/teen ends up with too much extension, called hyperlordosis. Less common are disc herniation, Scheuermann’s disease, osteomyelitis (bone infection), and bone tumors.

Scheuermann’s disease (also called Scheuermann’s kyphosis) is a condition that starts in childhood. It affects less than one percent of the population and occurs mostly in children by the age of 11. It affects boys and girls equally. Those who do not get proper treatment for the condition during childhood often experience back pain as adults.

With enough repetitive spinal flexion and extension, the ring apophysis can get damaged along with disc herniation. The apophyseal ring is located along the front of the vertebral body where the disc is attached between the two vertebral bones.

With enough force, this cartilaginous structure can break and become displaced (moved). It pushes the disc back until both structures end up in the spinal canal along the back of the vertebra. This is called a vertebral body apophyseal avulsion fracture. The athletes affected most often are involved in gymnastics, wrestling, volleyball, and weight-lifting.

X-rays and other more advanced imaging such as CT scans, MRIs, or bone scans may be needed to identify the specific vertebral level, location (right or left side), and severity of damage. If the physician suspects an inflammatory or infectious process, blood tests may also be ordered.

Once the diagnosis has been made, conservative (nonoperative) care is tried first. Physical therapy is helpful to restore more neutral posture and muscle balance. Core training of the trunk and abdomen along with temporary bracing can be helpful for many of these conditions. Each problem is handled slightly differently depending on the underlying damage. Activity modification and reduced activity referred to as relative rest aid the healing process and help prevent re-injury and repeat microtrauma.

For pain and disability that does not respond to conservative care, surgery is an option. With or without surgery, the athletes must retrain and rehab before returning to their full sports activity. Full pain free range-of-motion and strength are required. Sport-specific training under the supervision of a physical therapist is advised.

The authors conclude by saying all of this information is well and good, but it would still be better to reduce the risk of injuries and prevent injuries. What can be done? Coaches, trainers, and sports therapists can conduct preseason screening. A past history of injury, muscle weakness, or sign of muscle tightness should be examined closely before allowing the athlete to engage in sports activities.

Athletes’ height and weight should be measured and recorded. It may be necessary to change the training intensity during obvious periods of growth. Monitoring frequency, intensity, and duration of training sessions may help improve safety and reduce injuries in adolescent athletes. Limiting the number of times certain movements are made is another good idea. For example, extreme spine extension used by gymnasts and figure skaters should be limited if there is pain or evidence of a growth spurt.

The bottom line is: back pain in children and teens is never normal. This is the body’s way to signal that there is a problem. Young athletes should be coached not to hide their pain but to report it. Early diagnosis and intervention can help prevent significant injury and long delays getting back to the game or sport.

Many young sports athletes are tripped up by their own skeletal system. Traumatic and overuse injuries affecting the physes (growth plates) can result in permanent deformity. Undiagnosed, untreated, and neglected injuries to the physes can put an end to a budding career. These are the findings of a study from the Cincinnati Sports Medicine Research Foundation in Ohio.

Who is affected most often? The young, skeletally immature athlete. Skeletally immature means the bones are still growing. And as long as the bones are still growing, there are growth plates at the ends of the bones to allow for the bone to get longer until growth stops.

Girls usually stop growing sooner than boys. Therefore, boys are at greater risk for injury longer than girls. The exception to this is gymnasts and ballet dancers. They seem to experience full growth later so can be older when they are injured.

The seriousness of physeal (growth plate) and epiphyseal (areas adjacent to the growth plate) injuries can’t be emphasized enough. The repeated stress of sports is the major cause. Unknown or unrecognized trauma is a secondary cause.

The severity of the condition (or more likely the consequences of the injury) is directly linked to delayed diagnosis and treatment. The longer the athlete plays with an injury to the open growth plate, the greater the risk of permanent, disabling results. That’s why we must pay attention anytime an athlete reports tenderness at the joint that is brought on or made worse with palpation (pressure) or stretch of a muscle that attaches to the joint.

Sports doctors must watch out for the following overuse injuries in young athletes: radial epiphysitis, elbow overuse injuries, humeral epiphysitis (Little Leaguer’s Shoulder), and overuse injuries of the skeletally immature spine and pelvis. Other common problems in this age group include Osgood-Schlatter disease, Sever’s disease, and Iselin’s disease.

Each of these conditions is discussed at length in this article. Most common age and sports athletes affected by each problem are presented. Diagnostic findings, time to heal, and standard treatment protocols are also provided. Here’s a brief summary of each one.

Distal radial epiphysitis. Radial refers to the radius is one of two bones in the forearm. The distal end is the bottom of the bone where it attaches to the wrist. Epiphysitis is a compression or shear injury most common in gymnasts.

Wrist pain associated with distal radial epiphysitis comes on gradually. It is made worse by any activity that requires weight through the extended wrist. For a gymnast, that can mean putting a stop to tumbling routines, vaulting, and back walkovers.

Permanent bone changes with shortening of the radius can occur when athletes continue to practice and compete with this condition. Early intervention with casting and rest for four weeks is the minimum time to heal. This problem can take up to six months to recover from if involvement is severe.

Elbow overuse injuries. Repetitive throwing and putting weight through the elbows can cause microtrauma in baseball players, gymnasts, and weight lifters. Shearing stresses at the elbow damage the cartilage around the growth plates. The location of the pain (medial or lateral elbow) depends on the activity and type of load placed on the elbow. Baseball pitchers develop medial pain. Gymnasts are more likely to have lateral pain.

The athlete notices it is difficult to throw or lift as much as before. Elbow pain gets their attention. If caught early, treatment doesn’t have to be complete immobilization. The athlete can rest for four to six weeks.

Throwing athletes can avoid aggravating pitches. Daily stress on the elbow (whether from throwing or weight-bearing) causes damage to get worse quickly. Rest and recovery may take longer for children and young teens who have closed physes. The still growing elbow (open physes) tends to bounce back after repetitive stress better than more mature bone.

Humeral Epiphysitis. Little Leaguer’s shoulder affects more than just young kids in Little League. It is very common in pitchers older than 12. To understand this condition, think about the round top of the humerus (upper arm bone) as it attaches to the shaft of the main bone. The bone at this meeting place isn’t fully mature until the athlete is around 20 years old.

The force of a pitched ball distracting and twisting the bone can be strong enough to pull the growth plate away from the bone. Bone fracture or local inflammation is a natural response to fatigue in this area from repetitive overuse. Using any means of immobilization will only make it worse. The shoulder and elbow can get too stiff. Instead, a very gentle program of rest, range of motion, and strengthening with gradual return to sports is indicated. This can take up to a full year.

Spine and Pelvis. Overuse of the immature spine and pelvis can lead to low back pain from small fractures of the vertebra or hip pain from repetitive muscle pull on the unfused iliac (pelvic bone) apophysis.

The apophysis is a bony outgrowth that has not fully joined the rest of the bone. The iliac apophysis forms the curved crest along the upper portion of the pelvic bone. Once again, gymnasts are at risk for either of these injuries. Long distance runners, wrestlers, dancers, and football players develop pelvic overuse injuries. If the traction of the muscle pull is strong enough, it can pull a piece of bone along with the tendon away from the iliac (pelvic) bone. This injury is called an avulsion fracture.

Treatment for spine or pelvis problems begins with restricted activities, especially anything involving weight-bearing. With rest and activity modification, symptoms can go away in about three to four weeks. With avulsion fractures of the hamstring muscle (pulling away from the ischial apophyses), crutches are needed during walking activities. Return to sports with spine or pelvic injuries must be monitored carefully. Retiring too soon (before full healing and recovery) can result in reinjury.

Each of the other common apophyseal injuries occur in the same way: either traction or compression/shearing forces. Osgood-Schlatter disease affects the knee and is caused by repeated knee extension. Usually there is an underlying anatomic reason why this develops — either the athlete has flat feet, knock knees, or a slight torsion of the lower leg.

Sever’s disease occurs in the foot at the back of the heel. The Achilles tendon or the plantar fascia pulls away from the bone. The affected individual reports heel pain that’s worse when walking or putting weight on the heel. Sometimes there is pain in the midfoot and/or discomfort in the ankle. Athletes who develop this problem usually have a pronated (flat) foot.

Athletes are usually frustrated with the recommended treatment approach. They must stop all running and rest the affected foot for at least a month. Some experts recommend the use of a cast to help ensure the patient’s cooperation and give the fastest road to recovery.

And finally, Iselin’s disease affects the base of the little toe. The tendon attachment of the peroneus brevis muscle in the lower leg becomes inflamed from repetitive use. The weak apophyseal cartilage can’t hold up under the traction stress. Inflammation of the apophysis occurs when the athlete enters a rapid growth spurt. Anyone with an ankle sprain affecting the soft tissues of the lateral ankle (outside along the little toe side) is at risk for Iselin’s disease.

With any of these overuse injuries, sports participation with repetitive motions during a growth spurt seem to be the major risk factors. Anatomic variations from the norm may add to the risk. The actions required by certain sports seem to be a part of the equation as well. Knowing that the growing athlete has an increased risk for these types of injuries should alert all who work with them to pay attention to any reports of joint or bone tenderness or pain.

Early referral to a sports physician or orthopedic surgeon is always advised. The diagnosis isn’t always so easy. There are many sports injuries that can present with the same (or similar) kinds of pain patterns. A history, physical exam, and clinical tests along with X-rays or other more advanced imaging give the physician clues as to the real problem. The sooner an accurate diagnosis is made and treatment is started, the faster the athlete can recover. Delays in diagnosis extend out the treatment time and can result in further injury and/or deformity.

More children have strokes than people realize; it’s not an uncommon thing. In fact, childhood (or pediatric) strokes are among the top 10 reasons for death in children in the United States. Unfortunately though, little research has been done when compared to the research for strokes in adults.

Luckily, children who have had a stroke have a better chance of improving and regaining their pre-stroke level of function (37 percent) than their adult counterparts (25 percent). This difference is significant because it tells researchers that there are issues in childhood strokes that don’t affect adults and without proper research among children, they can’t be discovered.

When adults have a stroke, if they’re going to have a good outcome and return of function, it usually happens within the first three months after the stroke occurs. The next three months may see some minor improvements too though. Without knowing if this is true among children, it’s harder to predict how things will turn out among them. The authors of this article wanted to review cases of children who had strokes to see if they could establish a pattern of development and improvement over time.

Researchers reviewed the charts of 44 children who had an arterial stroke (blockage in the artery, causing stroke). The children were followed from the time they were hospitalized (inpatient care) through to outpatient care. The researchers used the Modified Brunnstrom Scale to evaluate the muscle tone in patients who had hemiplegic (half the body, right or left) arm muscle tone and to check for changes. Stage 1 meant the arm was completely flaccid (limp), Stage 2 had no active movement but had reflexes and sometimes resisted movement by someone else. Stage 3 included movement on the child’s behalf, up to 50 percent of normal in at least one joint. Stage 4 was 50 percent or more of movement involving one part of the arm or one joint, and Stage 5 was full range of motion but not completely full, while Stage 6 was fairly close to total movement.

The Gross Motor Function Classification System (GMFCS) evaluated Level 1: walking or running without help but slower with difficulty in balance, speed and coordination; Level 2: walking with an assistive device for more than 250 feet but needs help for more activity; Level 3: walking with or without assistive device but requires close supervision or a contact guard; Level 4: requiring mostly to be transported but is able to walk with or without an assistive device for a few steps while requiring close supervision or contact guard; and Level 5: must be moved, can manage electric or power wheelchair independently.

The patients were also checked for bathroom habits: incontinent, continent, or combined. Speech and ability to swallow were evaluated, as were activities of daily living (grooming, bathing, dressing, etc.). School was assessed as Level 1: maximum assistance required or totally dependent; Level 2: Moderate assistance required; Level 3: some special support needed; and Level 4: return to school independently.

The results of the review showed that the children ranged in age from 8 months to 17 years and their average length of stay in the hospital was 20.7 days, ranging from five to 131 days. Most children had non-hemmorhagic strokes (bleeding in the brain) while only 17 had hemmorhagic strokes – these children tended to be older. Lesions on the left side of the brain were more common than the right or both.

Among the effects of the strokes,. 27 had flaccid arms (Brunnstrom), eight were Stage 2, two were Stage 6 when the stroke happened. The eight of the 27 children who had flaccid arms progressed to stage 6 within an average of 58.5 days. The other 19 didn’t make it to Stage 6.

Twenty two of the children weren’t able to control their bowel or bladder when they had their stroke. At the end of the evaluation, all but seven had become continent again, usually regained at around 23.3 days after the stroke. All but five patients had difficulty swallowing after the stroke, which improved for 39 by an average of 17.7 days.

Speech was severely affected in 19 of the children and 17 were somewhat affected. When the researchers looked at mobility, they found that 19 of the patients were able to walk with a brace or minor assistance on an average of 50.3 days after the stroke and 18 were able to be completely independent in walking. Five of these patients were able to sit up and stay sitting when they had their stroke and they were also the ones who were able to walk independently the earliest of all the patients who were not able to keep their balance while sitting.

Activities of daily living is another way of evaluating how a patient is progressing. At the end of the study, 20 patients were able to do most of the ADLs alone. Looking at education progress, 10 children were not yet in school. Of the remaining students, 33 were enrolled in a regular school program at the time of their stroke and one was receiving special education because of a diagnosis of autism. At the end of the studies, 32 of the patients were able to return to their schools; 14 were independent and 18 needed assistance.

The authors concluded that although there isn’t a lot of data on children recovering from strokes, there seems to be a general idea that children are more able to bounce back after a stroke, more so than adults. But, with the findings the researchers studied, the length of recovery and speed (mostly within three months) is the same as adults. In addition, they wrote that because of their immature brain, children may actually have more brain damage from the stroke and have further to go to recuperate. Results of studies in children are often contradictory, including when recovery of functions may be expected. An interesting finding is that children who had a stroke before they were a year old had a harder time gaining speech-language function.

More research is needed to truly understand the effects of stroke on children, their recovery, and prognosis.

Scoliosis (curvature of the spine) is managed based on the type and severity of curve. A smaller curve (mild scoliosis) can be treated conservatively without surgery. A larger curve (moderate to severe scoliosis) often requires fusion to straighten it as much as possible and keep it from getting worse. X-rays are used to determine the degree of the main curve. An angle called the Cobb angle is measured and used as a guide to conservative versus surgical treatment.

In this study, curve shape is determined using three-dimensional views of the spine. The data collected on 110 patients was used to see if a different classification scheme could further define treatment. The authors set out to classify patients seen at a scoliosis clinic into distinct groups based on a three-dimensional curve shape. The goal was to help plan when to do surgery.

The patients all had idiopathic scoliosis. Idiopathic means the cause of the curvature is unknown. In all cases, there were two scoliosis curves located between T4 of the thoracic spine and L3 of the lumbar spine. But the patients’ curves were considered very diverse in their characteristics. By diverse, we mean there were a wide range of Cobb angle measurements as well as a wide range of curve locations between those two segments.

Classifying scoliosis patients based on curve regions and spinal shape is a complex task. Whatever approach is used must include everyone who has scoliosis without overlap (placing patients in more than one group). The method used should be quick and easy. The same results should be obtained for each patient no matter who is doing the measuring.

Other classification methods (e.g., King, Lenke) have been studied with a specific question in mind. For example, how long (how many vertebral segments) should the surgical fusion be? What levels of the spine should be fused? Maybe by looking at this from a broader perspective (based on patterns of curvature), it will be possible to find a classification scheme that could be used for all patients.

Stereoradiography was performed on each patient in the standing position. Stereoradiography is a technique for producing X-rays that give a three-dimensional view of an internal body structure (in this case, the spine). The stereoradiographs are produced by combining two separate X-ray films. Each X-ray is taken from a slightly different angle. The developed films are then viewed through a device that allows the two images to be seen as one three-dimensional object.

Measurements of spinal shape including curvature and rotation were made from all angles (side, front, top). The spinal axis system technology was advanced enough to make all of the spinal shape measurements digitally by using physical landmarks and three-dimensional coordinates.

The data showed four basic groups based on the plane of maximum curvature (PMC). Group 1 had the standard (most common) right upper curve and left lower curve. Rotation of the vertebrae was counterclockwise (as seen from above) for both curves. Group 2 had the same curve direction but with a clockwise rotation of the PMC in the lower curve.

Group 3 was the opposite of group 1 with a left upper curve and right lower curve and both curves going in a clockwise direction. And group 4 (smallest group) had a mix of right upper/left lower curve pattern or left upper/right lower curve pattern. But the rotational direction was clockwise in all cases.

What does this all mean? Well, it means that it is possible to group patients seen in a scoliosis clinic according to curve region and direction of rotation. The cluster analysis showed a natural division at T10 defining patients with curves above T10 as having an upper curve and patients with curves below T10 with a lower curve. This is the first study to use the direction of rotation as a guiding factor when planning treatment.

It appears that the rotation of the plane of maximum curvature (PMC) increases with even small changes in the spinal curvature. That’s one reason why the authors think this measurement is more important than previously thought. In fact, other classification methods don’t even use the PMC to divide patients into groups.

Up until now, the main way to view treatment was based on size of the curve (small versus large). Small curves can be treated conservatively with bracing when needed. Large curves are more likely to require surgery. Although rotation of the curve can’t be used as the only guiding factor, size shouldn’t be the only determining point either. The authors suggest that treatment or management decisions for all patients with scoliosis must be made on a case-by-case basis using both methods of classification (curvature size and pattern).

Blount disease, is a disorder of the tibia, or shin bone. It causes the lower leg to turn inwards, much like a bowleg. The difference is, however, that bowlegs may straighten out, but Blount disease will continue to get worse if there’s no treatment. Blount disease is also called tibia vara. While Blount disease can be idiopathic (born with it) or acquired, this article focuses on the idiopathic type.

Usually, treatment of Blount disease is the same, regardless of what type it is. Surgeons fix the tibia to stabilize it with hardware. But, there are drawbacks to the surgery. Once the surgery has been completed, there’s little room for revision or correction if it’s needed, and there are many complications that could occur, in addition to the usual surgical problems. These include damage to the nerves (nerve palsy), uneven leg length, return of the problem, and so on.

For doctors or families that don’t want surgery performed, there are other methods, such as putting a wire brace around the leg and in the bone to stretch it into place (external fixation) and bracing. These treatments need a lot of cooperation from the patient and family though. The authors of this article wanted to review studies that looked at treatment of Blount’s disease to see if one was better than the other.

After searching the medical literature for pertinent studies, the researchers evaluated the studies that they’d found. The studies all had varying approaches. One group of 12 studies looked at acute correction. One small study (by Rab) compared 6 tibia and their correction with screw and casting. Another larger one of 23 tibia (by Hayek) looked at surgery for initial correction with external fixation, and so on. The second, smaller group of studies (four) looked at gradual correction. One study of 20 tibias (by de Pablos) looked at correction with a one-sided frame, while another larger study of 69 tibias (by Alekberov) looked at gradual correction with a circular frame, for example.

One problem with many studies like this is the size. When a study is low in numbers, it’s difficult to provide accurate conclusions. Blount disease isn’t a common disorder, so it may not be possible to do a large study. Another critique of these studies was the follow-up time of the patients was too short, leaving it impossible for the researchers to learn of the long-term outcomes.

Not all is lost though. Regardless of the type of treatment chosen, the complication rate was low, even among the patients who had surgery to remove part of the bone (osteotomy).

The authors admit that the best type of study would be a trial where people are enrolled specifically for the trial and then randomized to treatment (put in one group or the other). But, as mentioned earlier, the disease isn’t common and the length of time plus substantial follow up may be just too long to accomplish this.

After looking at the available studies, the authors concluded that there was little difference between the outcomes of patients who had acute correction compared with those who had gradual correction.

Inside of your knee are are 2 pieces of cartilage (meniscus for one, menisci for more than one) that support and cushion the knee joint itself. Normally, they are a half-moon or C-shaped. The lateral meniscus, the one along the outside of the knee, and sometimes, the shape is more disc-like than curved and this can cause a popping sensation in the knee and pain in some people. In children, it can cause problems because the disc-shape is thicker than the C shape.

The authors of this study wanted to compare the results of a procedure called a mini-arthrotomy with one called arthroscopy. An arthrotomy is an open incision into the joint, while an arthroscopy uses very small incisions to insert long instruments and a camera, to do the surgery.

Researchers followed 40 children, who among them had 48 knees with lateral discoid meniscus. The children had either part or all of the meniscus removed by mini-athrotomy or arthroscopy. Seventeen children (20 knees) made up Group 1 (mini-arthrotomy) and 23 children (28 knees) made up group 2 (arthroscopy). Before surgery, the children had tried bracing the knee, restricting activities, and doing strengthening exercises. The surgery was done if the pain and popping or snapping didn’t get better after trying these other treatments within six months, or earlier if the knee began to lock or there was persistent pain and swelling.

After the surgery, the patients were tested on their range of motion in their knee, limp, pain, stair climbing, and so on. X-rays and magnetic resonance images (MRIs) from before surgery were compared to those from after surgery.

The results showed that there weren’t any outstanding differences between the two surgeries, although there was a slight advantage seen with the mini-arthrotomy. The authors suggested that this might be because of the small size of the joint, making it more difficult for the surgeon to see with the arthroscope and the mini-arthrotomy allows the surgeon to see the whole joint all at once.

Infants can (and should) be tested early and treated for developmental dysplasia of the hip (DDH). DDH represents a group of hip disorders involving partial or complete dislocation of the femoral head. The femoral head is a round ball of bone at the top of the femur or thigh bone. Normally, it fits inside the acetabulum (hip socket). But with DDH, the femoral head slips partially or completely out of the socket.

Over the last 25 years, the treatment program for this problem has changed. In this study, pediatric orthopedic surgeons who have been following children with DDH report on how successful these changes have been in improving outcomes.

They were able to review patient charts for two groups of infants (all younger than six months old) with reducible hips. Reducible means that the dislocated hip can be put back in place with the right maneuver (hip movement). The first group was treated during the 10-year time span between 1984 and 1994. The second group was seen between 1997 and 2007.

All children were treated at the Rady’s Children’s Hospital in San Diego, California. The earlier group was treated with a Pavlik harness full-time for at least three months. The Pavlik harness holds the child’s hips and knees in a position of flexion. The hips are also abducted (held wide apart).

While wearing the harness, the child cannot straighten the legs, which means he or she cannot extend the hip. The goal is to keep the femoral head in the socket and keep it from shifting or slipping out of the acetabulum. Studies show that it works — but maybe not good enough. One-third up to 40 per cent of the children still dislocate the hip when out of the harness. They need surgery to correct the problem.

In an effort to improve results, the authors of this study added a step to the treatment. The second group (starting in 1997) was also given the Pavlik harness first. But if the hip was still unstable after three weeks, they were put in a hip abduction orthosis. The orthosis is a special brace that is semi-rigid. It holds the hips in the same position as the Pavlik harness but with less wiggle room for the leg to move and the hip to slip out of joint.

The main reason this second step was even possible was because of improved technology. In the first group, only clinical exam and X-rays were used to check the stability of the hip. If the harness couldn’t keep the femoral head in the socket, then it was discontinued and usually surgery was done next.

But office-based ultrasound studies became possible making it much easier to confirm the position of the hip early on. The ultrasound could be done with the child in the harness. Using serial (weekly) ultrasound studies, they found that if the hip was going to stabilize in the Pavlik harness, it did so in the first week of wear.

The child still wore the Pavlik harness 23.5 hours a day for the next three months. It was removed only to bathe the child. If the hip(s) remained stable, then the time on could be slowly reduced until the child was only wearing it at night and for naps. After another couple of months, it could be discontinued altogether.

For children who were switched from the Pavlik harness to the abduction orthosis, weekly clinical and ultrasound exams were still done. When it was clear that the hips were stable, then the children were put back into the Pavlik harness. Surgery to correct unstable hips was scheduled after four to five weeks of treatment for the second group. That was much sooner than for children treated in the earlier (first) group.

The results of the new treatment protocol (group 2) were significantly better than the old (group 1). The success rate went from 85 per cent up to 93 per cent. At the same time, the number of children needing surgery went down by half. The authors say that the success of their treatment depends on several key factors.

The parents must be on board with the treatment. If they don’t use the harness (and use it properly), the chances that treatment will succeed go way down. Both the Pavlik harness and the abduction orthosis (when needed) must be in good condition. This is essential to hold the hips properly in place.

Normal growth and development is possible by properly applying and using the Pavlik harness. Treatment errors are reduced with early detection of continued instability. Keeping the harness on for too long and especially with the hip in the wrong position can cause further complications.

In fact, the head of the femur can get lodged outside of the socket and stuck to the back of the hip capsule. In the hip, the capsule is a group of strong ligaments that help hold the hip in place. Without an ultrasound to show the position of the hip, this kind of condition can go unnoticed and untreated.

They suggest serial in-office ultrasound imaging for all children who have a dislocating hip that can be reduced (put back in place by hand). This has been very helpful in showing them that some children need to wear the harness longer than others. The child may not need the abduction brace, but if there is some laxity (looseness) in the joint, then three months of harness wear may not be long enough. Ultrasound testing makes it possible to identify children who need extended time in the harness.

Ultrasound can be used right at birth for infants at risk or with suspicious clinical findings. It is safe, does not expose the child to radiation, and seems to be well-tolerated. Such an early diagnosis makes it possible to achieve better results with less intervention.

Another potential problem could be ligaments that are too loose so that even with the Pavlik harness, the result would not be good. That child needs the semirigid brace. The use of ultrasound makes it possible to see these things quickly and make necessary changes in the treatment approach.

One other benefit of in-office ultrasound evaluation is the ability to monitor the child wearing the abduction orthosis for a condition called avascular necrosis (AVN). This is a loss of blood supply to the femoral head that causes the bone to die. The authors note that none of the children in either group of this study developed AVN. That’s an important result because other studies have reported rates of AVN as high as 40 per cent in the children who had to have surgery.

Some adolescents, teens, develop a hip disorder called slipped capital femoral epiphysis (SCFE). It’s one of the most common hip disorders in this age group affecting between two and 10 out of every 100,000 people in the United States.

Doctors aren’t sure what causes the problem. The ball at the top of the thigh bone (the femur) slips backwards, usually during so-called growth spurts, such as just after puberty starts. Unstable SCFE is diagnosed when the disorder makes it too difficult for the patient to walk, even with crutches. Unfortunately, patients with the unstable SCFE have a high rate (47 percent) of developing osteonecrosis, or bone death. This doesn’t happen when it’s stable.

Treatment for SCFE is to stabilize the area and prevent further movement and damage, but the best way to do this still isn’t known. One method, called in situ fixation – In situ means in place. In article written by Loder and colleagues, recommended that doctors try closed reduction (putting it back into place without surgery), decompression, or using screws to stabilize the hip. After this surgery, the patients need to keep weight off the hip, using crutches for at least six to eight weeks.

Spontaneous reduction is a reduction that happens by chance. For quite a while, intentional reduction of SCFE wasn’t done because of the reported high risk of osteoporosis so it it’s not encouraged. Unintentional spontaneous reduction can happen when the patient is under anesthetic.

One suggested treatment is called modified surgical hip dislocation, and doctors use this to treat two complications that can arise from SCFE: the osteonecrosis and deformity. The surgery involves shortening the neck of the femur and removing the thickening, or callused area. Although there haven’t been any large studies or series of studies to show the procedure’s effectiveness, smaller studies have found that it is a successful treatment.

When to treat SCFE is also a question. If it’s an unstable case, the hip should be stabilized within 24 hours of the first symptoms if possible. If the patient isn’t seen within that 24 hours, usually doctors wait for about a week before treating.

The authors of this article concluded that the population affected by SCFE is changing. Doctors are finding it more often in younger children and among more girls than boys. What hasn’t changed is that many of the children affected are also obese. Treatments have changed too. While intentional reduction was once avoided, it is now being done more often, but will have to be studied further to identify the pros and cons of the procedure.

Children who are born with a clubfoot have to receive treatment to allow their foot to grow properly and bear the body’s weight as it should. One method that’s used is called the Ponseti method, which seems to be effective in more than 95 percent of cases. When examining the reasons why the treatment may fail in some children, research suggests that parents may not be compliant in some cases, which could be caused by their educational level. Non compliance can be discontinuation of the treatment before it’s finished or even due to the brace no longer fitting properly and the parents not wanting the child to suffer, for example. The authors of this article wanted to examine how large rural areas and economic and ethnic diversity may have an effect on how successful Ponseti treatment is.

Researchers recruited 100 infants who, among them all, had 138 clubfeet. Fifty patients (68 clubfeet) lived in an urban area and the remaining 50 patients (70 clubfeet) lived in an urban area. The researchers examined the severity of the clubfeet. The condition was mild if it was between 0.5 and 2 points on a rating scale, moderate between 2 to 4 (including 4), or severe, more than 4 points. The family provided information of how often the braces were used. They also used questionnaires such as the Pediatric Outcomes Data Collection Instrument (PODCI), measures how the parents see the child’s function after treatment.

At the beginning of treatment, each family was given written instructions, in English, that described the treatment, the cast and the process, and the importance of compliance. They were also given an article that was about the success of the treatment, as well as several websites to use as resources. At every follow-up visit, the caregiver was reminded about the importance of compliance and the procedure again.

Treatment for the clubfeet was provided by one of three surgeons and the children were treated by the Ponseti guidelines. The children visited the clinic every week when the physician examined the foot while manipulating and stretching it. A new molded cast was then applied. Most of the children required surgery to loosen the Achilles tendon. After the final cast was removed, the children then received a brace to be worn full-time for three full months. After that, it was to be worn at nap and night time.

The results of the study showed that initially, 131 of the 138 feet were corrected completely. Seven weren’t completely corrected by the initial cast treatment and they needed surgery to lessen the foot’s stiffness. Looking at the recurrence rates among the other feet, the families of those children with recurrence were much more likely to not be compliant with the treatment, discontinuing the use of the orthotics before the doctor recommended it. The families in this group were most likely to be Native American, unmarried parents, have no insurance or rely on public insurance, have no more than a high school education, and/or have a family income of 20,000 dollars or less. However, Native Americans who lived in urban environments had rates of compliance equal to their non-Native American peers. It was only those in the rural areas who had higher non-compliance rates.

The authors of this study found a 25 percent higher rate of non-compliance than did earlier studies. They wrote, “We believe that cultural factors coupled with the distance from the site of care resulted in this difference in clinical outcome.” Interestingly, they also wrote that Hispanic and non-Hispanics who lived in rural areas didn’t have such a decreased compliance rate.

The findings suggest that the written material and teaching provided to the parents of children with clubfeet is not meeting the needs of certain populations, such as the Native Americans who live in rural areas. In this particular study, they lived in New Mexico, were more likely to follow their traditions, speak their language at home, and rely on native healers in addition to western medicine. Visual learning material may have been more appropriate. As well, the approach should have focused more on the positive than the negative: telling them the good that will result if they comply instead of the bad that will result if they don’t comply.

Bowlegs also known as tibia varum (singular) or tibia vara (plural) are common in toddlers and young children. The condition is called physiologic tibia varum when it’s a normal variation and the child will grow out of it. Most toddlers have bowlegs from positioning in utero (in the uterus). This curvature remains until the muscles of the lower back and legs are strong enough to support them in the upright position.

In some cases abnormal growth of the bone causes the bowing to get worse instead of better over time. This condition is called Blount disease or pathologic tibia varum. Blount disease becomes obvious between the ages of two and four as the bowing gets worse. Overweight adolescents or teenagers can also develop this problem.

Blount disease is more than just a cosmetic deformity. Only the medial or inside edge of the bone is affected. In the early stages of Blount disease, this area of bone breaks down and growth stops. Pain develops along with an uneven leg length, which can lead to an altered gait (walking) pattern, tripping, falls, and injuries.

What can be done about it? Treatment depends on the age of the child and the stage of the disease. Between ages birth and two, careful observation or a trial of bracing (also called orthotics may be done. If the child doesn’t receive treatment, Blount disease will gradually get worse with more and more bowlegged deformity. Surgery may be needed to correct the problem. For the obese child, weight loss is helpful but often difficult.

Surgical correction may be needed especially for the younger child with advanced stages of tibia varum or the older child who has not improved with orthotics. Surgery isn’t usually done on children under the age of two because at this young age, it’s still difficult to tell if the child has Blount disease or just excessive tibial bowing.

When surgery is done, an osteotomy is performed. The surgeon removes a wedge-shaped piece of bone from the medial (inside) portion of the femur (thigh bone). It’s then inserted into the tibia (lower leg bone) to replace the broken down inner edge of the bone. Hardware such as pins and screws may be used to hold everything in place. If the fixation is used inside the leg, it’s called internal fixation osteotomy. External fixation osteotomy describes a special circular wire frame on the outside of the leg with pins to hold the device in place.

Unfortunately, in some patients with adolescent Blount disease, the bowed leg is shorter than the normal or unaffected side. A simple surgery to correct the angle of the deformity isn’t always possible. In such cases an external fixation device is used to provide traction to lengthen the leg while gradually correcting the deformity. This operation is called a distraction osteogenesis. The frame gives the patient stability and allows for weight bearing right away.

All of this information leads us to the purpose of this study: to compare the results of different types of external fixation for older children and teens with severe or recurrent Blount disease. Three types of external fixation were used: Ilizarov, Garche T-clamp fixators, and the Biomet Multi-Axial Correction (MAC) Monolateral External Fixation System.

Each of these devices has its own advantages and disadvantages. The authors were particularly interested in seeing how the MAC fared given its ease of application and use compared to the others. The MAC allows for correction of rotational, length, and angular deformities. The patient makes corrections of deformity and length by turning the screws one at a time, four times each day.

In this study, once the surgical correction was made with an osteotomy, external fixation was put in place to make gradual corrections of the leg length. Before and after X-rays were used as the main measure of results. The goal was to evaluate the correction achieved by each type of fixator. Angles and rotation were measured from the side, front/back, and top.

Most of the children had one or more unsuccessful surgical procedures before entering this study. All surgeries were done by one of two pediatric orthopedic surgeons. The numbers of patients receiving each type of fixator were broken down as follows: 20 MAC fixator, 25 Ilizarov, 12 Garche T-clamp, and one other miscellaneous type.

Before starting to use the MAC fixator, the authors reported using the Ilizarov device for children who needed a large amount of correction. They used the Garche T-clamp for less severe deformities. But after using the MAC for all degrees of deformity, they decided to do this study and see if the results with the MAC system were still as good, if not better than the other types of fixators.

The authors reported no difference in results between children with the MAC fixator and the two other main types of fixators used. Complications (both minor and major) were also equal among the different groups. The number of recurrent deformities was similar for all three fixation devices.

There was one disadvantage in using the MAC fixator device. The hardware makes it difficult to see the tibial correction when viewed from above. The authors suggest extra care must be taken to make sure correction of the tibial rotation is achieved when using the MAC system.

Treatment of children suffering from chronic pain syndromes is the focus of this study. Diagnoses associated with severe disabling pain included problems such as headaches, back and/or neck pain, complex regional pain syndrome, arm or leg pain, and postherpetic (herpes) cheek pain. Past studies have looked at how pain relieving drugs can reduce pain. But other researchers have shown that decreased pain doesn’t always result in increased function or a change in disability. That suggests the link between pain and disability is more complex than it seems on the surface.

The author of this study suggests it may be more helpful to focus on other factors than just alleviating pain. For example, a child’s self-concept of being disabled or fear of re-injury during exercise could be a stumbling block to recovery. Adults have been found to demonstrate fear-avoidance behaviors (FABs). FAB refers to how people stop moving in ways that might recreate their pain or possibly cause a reinjury. It’s possible that children experience the same pattern of FABs as adults do.

The approach used by these researchers was to compare multidisciplinary treatment (MDT) with a cognitive behavioral therapy called Acceptance and Commitment Therapy (ACT). MDT included physical therapy, psychologic counseling, and pain management with medications. Both the patient and the family were involved in discussing pain and disability. All efforts were made toward increasing the level of physical activity. Sometimes this approach is referred to as a biobehavioral treatment.

Acceptance and Commitment Therapy (ACT) is based on the idea that children severely disabled by pain think and act in ways that interfere with normal function. Their thoughts become inflexible and negative. In order to help these children accept their pain and to live well in spite of it, ACT strategies were given a try. ACT assumes everyone can live a full and satisfying life despite having chronic pain. The goal of ACT is to accept chronic pain rather than trying to reduce the pain.

Exposure and acceptance is the name of the ACT intervention used. Psychologists taught the children how to view their pain as inevitable. Since it’s not going to go away, they might as well participate in activities they enjoy anyway. Therapy involved discussing negative thoughts and a tendency to avoid activities. The psychologist also helped the children find ways to value life, notice and accept unpleasant thoughts and emotions, and actually enjoy engaging in activities that could potentially cause pain.

Various tests and measures were used to compare the results of these two treatment approaches. In fact, 11 different primary (main) and secondary variables were considered. These included physical and mental health, quality of life, pain-related functioning, pain intensity, and avoidance of pain. Depression, pain avoidance, coping, and worry about pain or discomfort were also measured and compared.

Children in the ACT group showed major improvement in many areas. After treatment, the ACT group exhibited fewer pain behaviors, less fear of reinjury or movement, and better perceived quality of life. These improvements over time were much better than for the MDT group and the changes lasted. The authors suggested that ACT is the more favorable treatment approach to use with pediatric pain patients. However, they were very critical of their own study.

They pointed out many ways in which the methods used just weren’t good enough. Although their work has made an important contribution in this area, future studies are needed to produce high-quality research. For example, a larger number of children involved (sample size) would allow analysis of the data not possible with this study. And along with self-report as a measure of results, it might be a good idea to find other, equally (if not more) reliable measures for this age group.

Future studies should take a look at costs associated with treatment approaches and conduct a cost-to-benefit ratio analysis. This would help identify cost-effective treatment approaches. For this study, it looked like the ACT approach cost much more than the MDT treatment. But, in actual fact, the MDT group had twice as many sessions as the ACT group. That was unintended but perhaps other studies are needed to see if more sessions are needed using one approach over another.