News Category: Child

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.

As physical activity drops among North American children, doctors are seeing a rise in disorders, such as type 2 diabetes, coronary heart disease, and stroke later on in life. Back pain is also something doctors are seeing more of, as early as childhood. Because doctors and researchers are constantly trying to find ways to prevent illness. the authors of this article wanted to see if there was a relationship between physical activity in children and back pain in their teen years.

Researchers assessed 364 9-year-old children to check their baseline – how their back was at the start of the study – and then again after three years. Physical activity was measured with a device called a CSA accelerometer, which is worn on a belt and measures how active the child is.

The results showed that of the 364 children, the data showed that only 265 children were active for at least 10 hours per day for at least three days. The average amount of time the device was worn was about 4.8 days. Whether the child was wearing the device or not had no bearing on their size or if they had back pain already.

The researchers found that there was a relationship between how often the children moved about actively and reported back pain three years later. In other words, the children with the highest level of activity had the lower their risk of having back pain later on. The least active the children were most likely to have back pain. But, there was no difference most who were moderately active and fit. Statistically, this came to about 6 percent of highly active children developed back pain but 68 percent of the least active did.

For children who complained of back pain at the start of the study, the highly active children appeared to help treat the pain, resulting in fewer children complaining of back pain three years later.

The authors concluded that high levels of physical activity appeared to help prevent, and even treat, back pain in early adolescence. They suggest that further studies be done to verify the findings and to go deeper into the possible causes. The authors would also like to investigate if high activity intensity could cause problems in the long run, instead of being helpful.

Despite all the focus on childhood obesity, there are still a large number of teens involved in physical activity and exercise. For example, last year, more than seven million high school students participated in some kind of sports activity. That’s more than half of all high school students. And records show the trend is on the rise. That’s the good news. The downside of this good news is that along with increased involvement in sports (especially high-demand activities) comes an increase in injuries.

The focus on this article is shoulder injuries in adolescents. The material presented is part of an instructional course lecture sponsored by the American Academy of Orthopaedic Surgeons (AAOS). Physicians and surgeons treating athletes of all kinds must stay current on the type of shoulder injuries athletes experience and the treatment for them.

Two areas of specific study included: 1) fractures of the clavicle (collar bone) and 2) throwing injuries such as Little Leaguer’s shoulder and shoulder instability. An unstable shoulder means the joint subluxes (partially dislocates) or has dislocated at least once if not more often.

With all joint injuries in young people, there’s always a concern about damage to the growth plate. Disruption of this important structure can lead to chronic problems. Recognizing the possible effects of chronic overuse in overhead throwing sports has been an important step in setting up efforts to prevent such injuries.

Providing educational programs for overhead throwing athletes on proper pitching is essential. Putting limits on the number of pitches during practices and games is one step that has been taken. Requiring physician approval before resuming sports after an acute shoulder injury is also necessary. Too many athletes return to sports too soon and end up with a reinjury of the same shoulder or another kind of shoulder injury.

When injury does occur, treatment depends on type, location, and severity of the injury. Most clavicle injuries in this age group are in the middle of the bone. If the two ends of the broken bone stay in place and don’t move apart, a simple sling can be used to immobilize the area until healing occurs. This type of nonoperative care is especially effective in younger athletes (less than 12 years old) because of their good potential for rapid bone growth.

Before these athletes can jump back into action, the surgeon must see that the child can move the arm fully and has strength equal to the uninvolved arm. X-rays must show that the bones have been knit back together. Older athletes with a displaced clavicular fracture may need a longer period of time for rehab and recovery.

In some ways, having a displaced fracture in an older individual has its advantages. Surgery to pin the bones together usually results in a more normal union of the fracture and faster return to sports. Nonunion (fracture doesn’t heal) or malunion (heals with deformity) are more common in the nonoperative group.

Fractures of the humerus (upper arm bone) are much less common than injuries to the clavicle but no less concerning. The most common area for humeral fractures are proximal (at the top of the humerus). More specifically, it’s the physis or growth plate that’s affected in the adolescent age group (teens). In the younger athlete, rapid growth in this area means healing and bone remodeling is much faster than in athletes who have reached skeletal (bone) maturity.

Conservative (nonoperative) care is the usual mode of treatment unless the fracture is severely displaced, unstable, or misaligned. Surgery is done to reduce the fracture. This means the surgeon lines the bones back up and pins them in place.

Throwing injuries from repetitive microtrauma increases as the number of pitches increases over time (and with increasing age). Curve balls, sliders, and breaking balls increase the risk of shoulder (and/or elbow) pain and dysfunction. This is the kind of data that help baseball coaches and trainers see the need to start limiting the number and type of pitches thrown at an early age. Athletes should not be allowed to play in multiple leagues as a means of avoiding these limits. And proper pitching mechanics must be taught and practiced.

Despite Little League rules limiting the maximum number of pitches each day, Little Leaguer’s shoulder is a definite problem for overhead athletes. It’s a multifactorial injury based on repetitive, rotational forces overloading undeveloped muscles at a young age. Once again, the authors stress the importance of proper pitching mechanics and a preseason conditioning program.

And finally, a thorough review of shoulder instability was presented. There isn’t agreement on the best way to treat this problem. Treatment may depend on whether the injury was from trauma, structural damage present, and where the athlete was in the growth cycle. The goal is to prevent recurrence (future dislocations). But whether a conservative plan of care is better than results from surgery is still the subject of much debate. Younger players who are skeletally immature are at the greatest risk for redislocations. If a program of conservative care is unsuccessful in restoring full, pain free shoulder motion, then surgery is advised.

Young, high-level athletes participating in high-risk sports may be the best candidates for surgery. The one exception to this is the athlete with joint laxity (loose ligaments). The type of instability these athletes face is multidirectional (in more than one direction). A strengthening program is still the best way to go with this group.

In summary, the authors recommend a total shoulder program including year-round stretching, strengthening, and coordination exercises involving the entire body (not just the pitching arm). Strengthening the core muscle groups helps spread the load. Stretching to prevent areas of tightness helps maintain proper shoulder mechanics and thereby prevent injuries.

Fortunately orthopedic problems at birth or during the first few months of life are rare. But when they occur, an orthopedic surgeon is consulted. Knowing what’s normal at this age and what can happen to cause musculoskeletal problems is important.

But even a specialist in children’s orthopedic problems may be challenged. The conditions presented in this article occur infrequently, but the surgeon must be prepared to deal with them and be ready to answer parents’ questions. The authors, who are orthopedic surgeons from Children’s Hospital in Los Angeles, offer information that will help.

The first thing they say to remember is that children are not little adults. And newborns are not just little children. They have unique anatomy and physiology that requires some special attention. The first step is to perform an exam. Proper lighting in the exam area and positioning of the baby are important.

The exam begins with observation of the skin and body contours. The surgeon feels or palpates the soft tissues and bones looking for any signs of damage such as fractures, dislocations, or loss of motion. Movement is observed and infant reflexes are tested. Three of the more common primitive reflexes (e.g., grasp reflex, Moro reflex, and walking or stepping reflex) along with testing procedures for each are described.

The most common areas for problems to develop (or appear at birth) include the arm, foot, hip, knee, and neck. The authors discuss several of the major diseases and disorders to watch out for. These include flail extremity, infection, brachial plexus palsy, and fracture.

Specific conditions of the foot are presented separately. These include metatarsus adductus, clubfoot, calcaneovalgus foot, and congenital vertical talus. Hip or knee dislocation, torticollis (of the head and neck), and unusual findings on X-rays round out the contents of this report. Let’s take a look at some of these topics.

Flail limb or extremity refers to an arm or leg that the child doesn’t seem to be moving. The cause of the problem must be determined. It could be a broken bone, damaged nerve (resulting in a condition called brachial plexus palsy), or infection. X-rays may help rule out fractures or dislocations. Lab values can be used to assess for infections. An undiagnosed infection can spread and cause considerable bone and joint damage, so time is of the essence.

Damage at birth to the nerves in the upper limb can cause brachial plexus injuries. The child doesn’t move the affected arm and the arm may be in a characteristic position that tips the examiner off as to the underlying problem. For example, with damage to the nerves at C5 and C6 in the neck, the wrist and hand may end up stuck in the waiter’s tip position. The wrist is bent and the forearm is turned with the hand facing backwards (as if holding the hand out behind the back waiting for a tip).

A painful broken bone anywhere from the collarbone down can be the reason a child doesn’t move the arm. The cause of bone fractures must be determined. It could be from prolonged labor, forceps delivery, or child abuse.

Fortunately, bone healing is fast in infants this young. A makeshift sling out of soft stockinette may be all that’s needed in the way of treatment. Even easier and possibly safer is to pin the sleeve of the infant’s shirt to the main body of the shirt.

Next, the authors take a look at foot problems in the newborn. These are the most common deformities present at birth. Metatarsus adductus refers to a bean shape of the foot as the forefoot curves outward. This foot deformity occurs as a result of positioning during development inside the uterus (mother’s womb).

Many people have heard of clubfoot. The medical term for this deformity is talipes equinovarus. The foot is positioned in a toe pointed down position and ankle curved inward. It may occur by itself or it could be part of a bigger congenital problem (present at birth). Congenital conditions such as arthrogryposis, spina bifida, or Larsen syndrome often come with clubfoot deformities.

With all of these foot problems, treatment is started early with gentle stretching, serial casting, serial manipulation and casting, and sometimes surgery. For very mild problems, a wait-and-see approach may be all that’s needed.

Calcaneovalgus foot and congenital vertical talus describe two separate conditions of misalignment of the bones of the foot. Both of these problems are easily recognizable just by looking at the child’s foot. In the case of calcaneovalgus foot, the bones and soft tissues are still flexible. With a vertical talus, the bone is dislocated resulting in a rigid deformity requiring surgery.

Hip dislocations are not uncommon, occurring in about one out of every 1000 births. A more common hip problem is hip dysplasia, a shallow hip socket with partial dislocation of the hip. One or two simple tests are performed on every newborn to check for this problem. If there’s suspicion of an early developmental dysplasia of the hip, X-rays or ultrasound can be used to tell for sure.

In the first month, a special soft harness called the Pavlik harness is used to position the leg and hip to help hold it in place. If the harness fails to correct the problem, then an abduction brace is tried. If all else fails, then surgery may be needed to put the hip back in place and/or reconstruct the hip socket to help hold it there.

Only rarely is a baby born with a dislocated knee. No one knows for sure what causes this to happen. There is some soft tissue involvement as the quadriceps muscle along the front of the thigh is tightly contracted.

Knee dislocation is usually accompanied by other orthopedic problems such as clubfoot or hip dislocation on the same side. Treatment ranges from nonoperative manipulation and traction techniques to serial casting to surgery for cases that don’t get better with conservative care.

The last congenital problem presented in this review article is congenital muscular torticollis. The head is tilted to one side and the chin turned toward the opposite side. The muscles are tight holding the head and neck in this position. The problem develops while the child is developing in-utero (inside the mother’s womb).

Physical therapy is the first step in treatment. The therapist will teach the parents or care giver how to massage, stretch, and move the tight muscles. Positioning in bed, car seat, backpack, and stroller are important strategies in this condition. The therapist will also provide tips on techniques for holding and handling the baby that will help overcome this positional fault. Problems that persist may require surgery later on.

In summary, the authors of this article provide a review of orthopedic conditions that can be present at birth or develop shortly after birth. Knowing how to examine, identify, and diagnose the problem is the orthopedic surgeon’s responsibility.

Once the diagnosis has been made (the earlier the better), then treatment can be determined and delivered. Management of most of these conditions is a process over time. As the child grows, treatment such as stretching, serial manipulation, and serial casting is reapplied to help shape the structures and keep them in neutral alignment. When the child is older, surgery may be required.

The information presented in this article should be enough to get the surgeon started. Further investigation and study may be needed for conditions rarely encountered.

There’s been a trend in medicine to provide evidence that a particular treatment works for any given medical condition. Likewise, guidelines for the accurate diagnosis of conditions like low back pain are based on evidence when it’s available. But no such guidelines exist for dealing with low back pain in children and teens.

Developing evidence-based diagnostic and treatment guidelines for adults is one thing. Providing the same for children is something else entirely. When there’s a lack of evidence, then physicians rely on what’s called consensus-based evidence. They gather panels of experts who collectively compare opinions and experiences and develop something they can all agree on until proven true or false.

When a consensus-based approach is used, the next step is to gather case reports and case series of patients presenting with a particular problem. This approach is not ideal but it’s necessary until larger studies can be done.

What have these case series told us so far? First, back pain in children and teens is far more common than ever thought before. Second, there’s rarely a known (pathologic) cause such as a tumor, fracture, or infection. Alternately stated, most children with back pain don’t have a definitive diagnosis.

Even with careful examination and evaluation, only 18 to 36 per cent of the children have a specific diagnosis. Most of the time, they are labeled with a condition called nonspecific low back pain. So, the question has been raised: is it necessary to do extensive and exhaustive tests and studies on children to come up with a diagnosis for low back pain?

Again, there are no large-scale studies to answer this question. Physicians are currently relying on information from case series. And only a few case series are even available. The best evidence available suggests that a history, exam, X-rays and other imaging studies, and lab work is simply overkill for most cases of low back pain in this younger age group.

Based on two case series of 73 and 86 children, here’s what the current decision-making process looks like:

Kienbock’s disease, a condition where the lunate bone in the wrist is deprived of blood, is usually found in adults from 20 years old to 40. Although it’s rare, the disease does happen in adolescents (older children and teens) however, and guidelines for treatment are few and far between.

When the blood supply to the lunate is cut off, the bone cells are deprived of nutrition and they begin to die. This causes pain in the wrist and difficulty moving it. Treatment usually involves surgery, but with no guidelines for children and teens, the authors of this article investigated the outcomes of teens who were treated by having a temporary joint fixation.

The researchers followed six adolescents who were between 9 and 17 years old when they had surgery (the joint fixation) because of Kienbock’s disease. Two of the patients had been treated with splints before the surgery. After a follow up of between seven to 48 months, the researchers checked to see how the patients were doing. The researchers measured how much the adolescents could bend and extend their wrist, tested the grip strength and asked about the pain levels. X-rays and magnetic resonance images were also taken and compared with copies from before the surgery.

The results showed that the adolescents were able to bend and extend their wrist significantly better after surgery than before, as did the grip strength. All six patients reported good relief from pain. There were complications with one patient – the pins used to fix the joint became infected, but this was treated with antibiotics. Another patient had to have the surgery done again as there was movement of the hardware in the wrist.

The x-rays showed that the area no longer had any signs of active disease.

The authors concluded that this approach was effective and provided excellent outcomes in children and teens who develop Kienbock’s disease.

Blount disease, a disorder that affects the growth of the tibia (shin bone), can make children with the disease look like they have a bowleg.
To correct this, surgeons work on fixing the tibia to straighten it, choosing one of several available techniques. One such technique is called the Orthofix eight-Plate, which is a tension band device designed to repair and straighten the bone, and strengthen it.

The authors of this article studied 24 patients (total of 31 deformities) to see how effective the Orthofix eight-Plate treatment was. Sixteen of the patients (18 legs total) had Blount disease and the other patients had deformities due to other reasons. All the patients had plates put on the tibia (shin bone) and 10 also received plates on the femur (thigh bone). The usual follow-up was about 17 months for the patients, with the shortest period being a year.

The results of the review found that the implant failed 26 percent of the time (in 8 cases) and all eight were among the patients who had Blount disease. The part that was broken in each case was a screw in the tibia and it usually happened around 13.6 months after surgery. No failures were found with the rest of the patients, those who didn’t have Blount’s disease.

To investigate possible causes, the researchers looked at the children’s weights. The mean weight of the children whose repair failed was 95.3 kilograms (210 lbs) and the non-failure group mean weight was 76.8 kg or 169 lbs. The children with Blount disease, whether in the failure group or not, was 93.2 kg or 200 lbs, compared with 65.4 kg, or 144 lbs, in the children who didn’t have Blount disease. However, within the group with Blount disease, the weight of a child didn’t seem to have any connection to whether the procedure was a failure.

The authors concluded that while the Orthofix eight-Plate procedure was acceptable for correction of the deformities in children who didn’t have Blount disease, the failure rate among Blount disease children was unacceptable.

No one is too surprised when an older adult is hampered by hip pain. Usually it’s arthritis-related and we know just what to do. But when it happens to someone in their 30s or 40s, it creates more of a stir. Preventing hip osteoarthritis as early as possible is important, so hip pain early on must be attended to.

In this report, surgeons from the American Academy of Orthopaedic Surgeons (AAOS) present an instructional course lecture to other surgeons on the recognition and treatment of a painful hip impingement in younger adults. Understanding the types and causes of hip impingement is important in planning the optimal treatment approach.

The full medical term for this problem is femoroacetabular impingement. Impingement just means pinching. Femoroacetabular refers to the place in the hip where the round head of the femur (thigh bone) comes in contact with the acetabulum or hip socket. Two types of impingement are known to cause pinching of the soft tissues in this area.

The first is called cam-type impingement. This occurs when the round head of the femur isn’t as round as it should be. It’s more of a pistol grip shape. It’s even referred to as a pistol grip deformity. The femoral head isn’t round enough on one side and it’s too round on the other side to move properly inside the socket.

The result is a shearing force on the labrum and articular cartilage, which is located next to the labrum. The labrum is a dense ring of fibrocartilage firmly attached around the acetabulum (socket). It provides depth and stability to the socket. The articular cartilage is the protective covering over the hip joint surface.

Sometimes cam-type impingement occurs as a result of some other hip problem (e.g., Legg-Calvé-Perthes disease, slipped capital femoral epiphysis or SCFE). But most of the time, it occurs by itself and is the main problem.

The second type of impingement is called pincer-type. In this type, the socket covers too much of the femoral head. As the hip moves, the labrum comes in contact with the femoral neck just below the femoral head. Repeated microtrauma at this site can cause the bone to overgrow, a condition called heterotopic bone growth.

Pincer-type impingement is usually caused by some other problem. It could be as a result of 1) hip dysplasia, 2) a complication after osteotomy surgery to correct hip dysplasia, or 3) an abnormal position of the acetabulum called retroversion. Hip dysplasia is a deformity of the hip (either of the femoral head or the acetabulum, or both) that can lead to hip dislocation.

Identifying hip impingement as the cause of painful groin symptoms starts with a patient history and physical exam. Most patients report the pain occurs when the hip is bent or flexed. Although the condition is often present on both sides, the symptoms are usually only felt on one side. In some cases, the groin pain doesn’t start until the person has been sitting and starts to stand up. There is often a slight limp because of pain and limited motion.

Through a series of questions and clinical exam, the surgeon is able to rule out referred pain (coming from someplace other than the hip but felt in the hip). One test that can be performed in the physician’s office for this problem is called the impingement sign.

The patient lies on the table on his or her back. The examiner bends the leg up, internally rotates the hip, and presses the knee toward the other leg. This position puts the hip in such a position that impingement occurs and reproduces the painful symptoms.

If this sign is positive, then X-rays may be needed. Regular X-rays don’t always show this condition. So, the authors advise surgeons on the specific X-ray views required (e.g., Dunn view, cross-table lateral view). The details of X-ray findings are presented in depth with photos to demonstrate what to look for.

Retroversion is confirmed by the presence of three signs seen on X-rays: the crossover sign, the posterior wall sign, and the ischial sign. Photographs of X-rays with each of these signs are presented in the article.

More advanced imaging such as MRIs, CT scans, and dye-enhanced arthrography may be needed before surgery. The details offered from these tests help the surgeon plan the best approach to the problem. MRIs in particular alert the surgeon to the presence of other problems such as labral tears, cysts, or damage to the articular cartilage. The presence of any of these additional problems can complicate surgery.

But before surgery is done, patients are advised to try nonoperative therapy first. They are given antiinflammatory medications and physical therapy. Whether or not this is the best approach remains to be seen. Studies have not been done to see if delaying surgery in this way has a good or bad (or any) effect on the problem.

Once it has been decided that surgery is the way to go, the surgeon has three choices: 1) full open incision and correction of the problem, 2) arthroscopic surgery, and 3) osteotomy. With the fully open surgical procedure, the head of the femur is dislocated from the socket to make the changes and corrections. With arthroscopic surgery, dislocation is not required. Osteotomy (reshaping the socket) is done for pincer-type impingement.

With photos and a detailed description, the authors walk the reader through each of these surgeries. They describe recommended techniques for surgical dislocation. When to use each procedure (based on type of impingement and imaging findings) is outlined. The results of these operations as reported in other studies are also reported.

Complications such as overcorrection or undercorrection, loss of correction, joint or wound infection, nerve or blood vessel injury, and unintended bone fracture are a few of the complications discussed. Results are compared between open incision and arthroscopy. The use of arthroscopic techniques for this problem is still new enough that long-term results aren’t available yet.

Whenever possible, the surgeon tries to save the hip. But when there is extensive damage to the cartilage, hip resurfacing or total joint replacement may be needed. There are many factors to consider when making this decision. The patient’s age, findings on imaging studies, type and severity of deformity, and presence of arthritic changes are important.

The best time for surgery isn’t known. Delays may result in even worse cartilage damage that can’t be repaired. But waiting can also give the patient a better chance for the development of better choices in the future, such as cartilage grafting or computer-assisted surgery. Less invasive approaches to hip surgery are being developed all the time. Young patients with minimal signs of osteoarthritis may want to take the chance and wait to see what comes in the future.

Developmental dysplasia of the hip is an abnormal development of the hip where the ball part doesn’t stay firmly in place above the femur, or thigh bone. When a baby is being examined during a well-baby check-up, the physician usually moves the baby’s hips around and this is what the physician is looking for. In some children, the joint may be just a little loose, but in others, it can be worse. As well, as the child gets older, the ligaments may loosen even more.

What researchers don’t understand is if the child isn’t having pain early in life, what causes the pain to appear as the child reaches his or her teens? For this reason, the authors of this article studied the intraarticular pathology, how the hip appears inside the joint, in teens (adolescents) who have this problem.

Researchers studied 22 patients (23 hips in all) with arthroscopy, surgery that uses very small incisions and allows surgeons to insert long narrow instruments with a camera. Using the camera and instruments, surgeons can perform repairs that used to only be done with a large incision.

Fourteen patients (14 hips) had a history of developmental dysplasia as young children. Eight of them had been treated with the Pavlik harness, a harness that is fit to the baby or child and holds the hip or hips in the correct position. They were used on the children for between three to 12 months. This system didn’t work for four patients who ended up having surgery to fully correct the problem. Two were diagnosed and treated at age 12 and 15 months. Eighteen hips were pre-arthritic, five were in the early stage.

After the researchers looked at the hips using arthroscopy, they found that there was degeneration or deterioration of cartilage in all of the affected hips and highest in almost 78 percent of the pre-arthritic hips. In most of the hips, over 72 percent, the damage was seen in the acetabulum, the part of the hip that is the hollowed out area covering the head of the femur, making the ball-and-socket joint. Of the damage in the acetabulum, more than half was at the top front part.

The researchers also found in the pre-arthritic hips that most had labral tears, which are tears in the cartilage that line the hip joint and provide protection between the bones. For the adolescents who had early arthritis, their tears were worse than those who had pre-arthritis.

All these findings led the researchers to conclude that there is a high rate of deterioration in adolescents who have developmental dysplasia of the hip, even in the pre-arthritic stage, not just in the early arthritis stage.

One of the so-called super-bugs, MRSA (methicillin-resistant Staphylococcus aureus, is one of the most common causes of bone infections, called osteomyelitis, as well as other infections in the musculoskeletal system of children. MRSA is very difficult to treat with antibiotics, compared with methicillin-sensitive, Staphylococcus aureus (MSSA). Infections with MRSA usually result in longer hospital stays and poorer outcomes.

The authors of this article wanted to investigate the differences between MRSA infections and others. To do this, they reviewed 97 records of children (aged four months to 19 years) who had varying types of osteomyelitis to find out information such as how long the children were sick, how sick they were, how long it took them to recover, and if there were any lasting effects from the infection.

The researchers found that 21 of the patients had infections caused by MRSA, 27 by MSSA, 34 by another cause, and 15 didn’t have an infection. When children had osteomyelitis, the ones who were infected with MRSA had significantly worse infections than those with MSSA or other bacteria. The severity was judged by taking the children’s temperature, checking the length of the hospital stay, blood test findings, surgery if needed, how often they had to be hospitalized, and the number of antibiotics and how long they had to be taken.

The children with MRSA infections usually had higher fevers, longer hospital stays, and more initial treatments. However, there wasn’t a big difference between them in terms of the number of antibiotics and how long they were taken or in the number of times they were admitted to the hospital. One child with MRSA infection, a three-year-old, died after receiving several treatments with antibiotics.

The authors wrote that around 60 percent of staphylococcal infections in the United States are MRSA and that it’s known that MRSA infections are more severe than MSSA or other bacterial infections. This is even more so if the infection is hospital-acquired. Earlier studies have weighed in on both sides though – some found that people with MRSA osteomyelitis were sicker than those with MSSA, but other studies didn’t. As well, some studies found that there wasn’t a significant difference between the number of people with MRSA who died compared with those with MSSA.

Diagnosing osteomyelitis MRSA versus another type can be done by blood in about 60 percent of patients but by taking specimens from the infection itself, the rate is about 80 percent. Some doctors feel that surgery is the best way to diagnose and can be used to start treatment at the same time.

Treating osteomyelitis usually starts with removing the dead or necrotic tissue. The area is usually irrigated or washed out, as well. Intravenous antibiotics are called for and this may be for as long as almost six weeks. However, the antibiotic may be switched to pill form after a while, depending on the progress of the treatment and the doctor’s usual treatment. Sometimes, further surgery is needed, but that’s not a usual next step. In fact, of the children studied, the 35 who were from the Children’s Hospital, didn’t have any surgery other than the original biopsy for the diagnosis.

In conclusion, the authors wrote that they did have a strong association between MRSA infections and lengthier and more difficult treatments. They recommend that if a child’s biopsy comes back as positive for MRSA, that aggressive treatment begin immediately.

Young children usually heal quickly when they have a broken or fractured bone. However, they still may be left with some problems after healing has finished. This means that the treating physicians need to choose their treatments carefully, depending on the children’s age, how they were injured, how the fracture is, any other injuries, how much treatment will cost, and how the treatment affects other family members.

One type of fracture that can be tricky to treat is the femoral or thigh bone fracture, particularly in younger children. One method favored by most orthopedic surgeons, the doctors who repair these fractures, is the spica cast, according to a survey done in the late 1990s. These casts hold the hips and thighs firmly in place to help healing but there are several types of spica casts. Some start at the chest and cover one or both legs, while others may cover on leg on one side but only part of the leg on the other.

Usually, femoral fractures heal well, especially with spica casts, but there is a common complication for many children: shortening of the broken femur. Surgeons have tried to avoid this by adapting the spica cast, but with only limited success.

One group of researchers, lead by Beuhler, tried to use a so-called telescope test to see if they could identify children at risk of shortening before the casts were applied. They found that if the broken part of the bone overlapped by more than three centimeters before correction, then they had a high likelihood of having a shortened femur after treatment. The authors of this article felt that if they used this test to identify children at risk for shortening, they could use a special spica cast that may help reduce the risk.

Researchers studied 47 patients ranging in age from 18 months to six years. All had fracture femurs and after having the telescope test, they were divided into two groups: one group consisted of patients who have a bone overlap of three centimeters or more, the other group with smaller overlaps. All patients had the same hip spica cast applied within eight hours of the injury and they were all followed with weekly x-rays during the first month, where doctors looked for unacceptable shortening of the femur.

The mean shortening after treatment that the researchers felt was acceptable, was 2.9 millimeters. Sixteen patients in the first group (with more than three centimeters overlap) had femur shortening but only seven patients in the other group did. The researchers felt that any shortening over 25 millimeters (2.5 centimeters) was unacceptable and this did not happen in either group. The alignment for the bone healing was also acceptable in both groups along the front of the bone, but the side of the bone did have a bit of malalignment in several patients in the first group.

The authors concluded that the hip spica cast to treat femoral fractures in young children, which was a first choice treatment for many orthopedic surgeons, could help avoid shortening of the femur during healing. However, the hip spica cast didn’t eliminate all problems as seen by the malalignment in some patients.

Children who experience chronic pain often cope in ways different from adults. One method for assessing how children and adolescents (teens) cope is the Pain Response Inventory (PRI), which is used to predict how the pain affects the children’s functioning. The authors of this study wanted to evaluate how well the pain coping profile worked among children who had a variety of painful conditions.

Researchers enrolled 254 patients, aged from 12 to 17 years, who had complained of pain for at least three months. The majority of the patients were white (90.7 percent) and female (76.8 percent). The complaints of pain included headaches (33.7 percent), neuropathic (nerve) pain (24.8 percent), muscle, bone, and/or joint pain (21.5 percent), abdominal pain (11.8 percent), diffuse (all over) pain (4.5 percent) and “other” (3.7 percent).

The children were asked to complete the PRI, which includes 60 questions that look into how the children respond to pain. The questions were answered on a scale of zero to 10, with zero meaning never or none and 10 meaning always or the worst or most. The children were also asked to complete the Functional Disability Inventory (FDI), which looks into the children’s physical and psychosocial functioning two weeks before answering the questions. The scales range from zero (no trouble) to four (impossible).

The Children’s Somatization inventory (CSI) looks at how severe the somatic symptoms are. These include dizziness and weakness, for example. There were 35 symptoms that were evaluated on a scale of zero (not at all) to four (a whole lot). Anxiety was also measured using the revised children’s manifest anxiety scale (RCMAS), which used 37 questions with a yes (0)/no (1) response. Depression was measured with the Children’s depression inventory (CDI), a 27-question test from zero to three, with zero being the lowest in symptoms and three being the highest.

Finally, pain intensity was measured through an interview with a psychologist and measured on a scale of zero (no pain) to 10 (worst pain possible).

After the questionnaires were completed, the patients underwent a physical exam and saw a physician, physical therapist, and clinical psychologist.

The results of the surveys showed that Avoidant copers (37 patients) isolated themselves. They scored higher levels of self-isolation, disengagement and stoicism. They had lower levels of seeking social support and discontinuing activities, as well as they hid their feelings. On the flip side, they also had more pain and catastrophizing than any other group.

Fifty-four patients fell into the Dependent copers group. They had high levels of catastrophizing the pain, although not as much as Avoidant copers. Dependent copers scored higher in seeking help and less in seeking isolation. Dependent copers also scored high for depression. Self-reliant copers (57 patients) most frequently used strategies to cope such a self-encouragement, acceptance, and minimization. They scored significantly lower on resting, disengagement and catastrophizing. They also scored lower for depression and anxiety.

A smaller group of 29 patients, the Engaged copers rated high in problem solving and asking for help, self-encouragement and distraction. They also had less depression and anxiety. Another large group of 69 patients, the Infrequent copers, did not score well on any type of coping strategy, but they also scored low on pain, disability, somatic symptoms, anxiety and depression. The authors write that perhaps this group of patients don’t see pain as a significant stressor or, if that isn’t it, they could be using coping mechanisms that weren’t discussed in the PRI.

The authors conclude that their study confirmed the PRI’s usefulness in assessing children who have chronic pain. They suggest that future studies of pain in adolescents look at behavior outcomes (absenteeism, use of medical services) to obtain a broader view of the issue.

In this article, Dr. D. S. Bae, a children’s orthopedic surgeon from Harvard University reviews the treatment of forearm fractures. In particular distal radial forearm fractures are the focus of this report. Distal refers to the end of the bone near the wrist. The bone affected most often is the radius (one of two bones in the forearm). Although children often heal quickly, displaced (separated) fractures and fractures affecting any part of the growth plate can create some very challenging problems.

In the last 10 years, surgeons have revisited the question of whether or not casting is sufficient for these types of fractures. There’s been some suggestion that surgery to pin the healing bones might be a better option than just cast immobilization. The thinking behind this has come as a result of the many cases where the fracture reduction was lost with casting.

Loss of fracture reduction is so common, it appears that at least one-third of all distal radial fractures (and as many as 90 per cent of cases) are affected. The first step in understanding how to keep this from happening is to look for risk factors.

Some of the factors that have been shown to increase the risk of loss of fracture reduction include: 1) type of fracture displacement, 2) amount of displacement (more than 50 per cent), 3) location of the fracture, 3) increased angle of the bone, and 4) fracture of the other forearm bone (ulna).

Other factors that may contribute to the loss of fracture reduction have been suggested. Muscle atrophy (wasting) and decreased swelling while in the cast can make a difference. The arm moves around too much inside the loose cast to keep the fracture firmly in place while healing. Movement of the arm can cause the fractured ends of the bones to separate again.

There’s been some question as to whether a short-arm (below the elbow) versus long-arm (above the elbow) cast makes a difference. Studies show that even more important than the type of maneuver used to reduce the fracture or the type of cast (short versus long) is the casting technique used. Serial X-rays taken once a week can help identify when a problem with reduction is occurring.

At the same time, there were some studies done to look at the results when using surgery to pin the fracture sites. The final outcome was that patients didn’t fare any better after surgical fixation than they did with nonoperative casting.

Reduction with pin fixation isn’t recommended for every fracture. It is considered most appropriate when there is a fracture through the metaphysis (growth plate). Other reasons open surgery might be done include open fractures (bone pokes through the skin), fractures that overlap and can’t be reduced, and fractures that are pressing on nerves or blood vessels.

Open fractures involve more damage to the periosteum (hard, outer covering of bone) and greater disruption of the surrounding soft tissues. The risk of nerve damage and compartment syndromes is much higher with open fractures. When a long nail or pin is placed down through the bone, complete reduction is not done first. Instead, the implant is put in place first while gently reducing the bones as much as possible and finishing the process after the pin is in place.

If the force of injury is strong enough, damage to the triangular fibrocartilage complex (TFCC) can occur along with fractures of the distal forearm. Such injuries can also require surgical repair. The TFCC is an area of strong fibrous cartilage between three of the wrist bones that articulate (move against) the bones of the forearm. Disruption of this soft tissue complex can create a very painful, unstable wrist.

Sometimes open surgery is necessary because the fracture is in such a location that key muscles are in the way. While trying to match the two ends of the bone up, the soft tissue gets caught between the bones. This makes reduction of the fracture difficult, if not impossible, with closed techniques. In all cases, when pin fixation is required, the surgeon tries to avoid or spare the growth plate.

Disrupting the growth plate can result in physeal arrest. This means the bone stops growing. When it’s not possible to avoid the areas of growth at the end of the fractured bone, then pins are placed through the physeal structures rather than across them. Plates and screws are another option to avoid drilling through or across the growth zones.

In younger children, the bone remodels itself nicely without complications or loss of skeletal growth. Older children with less potential for bone remodeling may benefit more from plate fixation. Growing children must be followed closely with periodic X-rays to make sure growth has not been stopped. Any child reporting wrist pain should be evaluated carefully for deformity that suggests loss of fracture reduction.

Even with good treatment (including surgery when needed), complications can occur. The most common problems are fracture malunion, fracture nonunion, disruption of growth, and nerve damage. There’s a high rate of late complications with loss of reduction. Surgeons are advised to keep this in mind and always follow pediatric patients who have distal forearm fractures carefully until complete healing is seen on X-ray.

With proper care, children may only experience a small loss of motion. Usually this is not enough to be noticeable during everyday movements or activities. Open fractures are at risk for infection and must be monitored closely.

Some angulation or malrotation of the bone may occur after healing. Most children aren’t affected by this, and there is little deformity actually visible. If the forearm looks too crooked or there is loss of function, further surgery to re-align the bones may be needed.

Because fractures of the distal radius are so common, an update and review of this kind is important. The wide range of surgical techniques available that might be needed keep the surgeon on his or her toes. Growing children with unpredictable bone remodeling add another dimension to the decision-making process in planning an optimal treatment approach. In addition, increased sports participation and the need for better functional outcomes, along with greater patient and family expectations create new challenges for the surgeon.

Traumatic hip dislocations in children don’t occur very often. But when they do, the emergency room physician or surgeon must be very alert to possible pitfalls. A careful examination must be done first before any treatment is started. Associated injuries of the nerves, blood vessels, growth plate, and soft tissues must be identified. For best results, reduction must begin within six hours of the injury.

Reduction refers to putting the round head of the femur (thigh bone) back in to the acetabulum (hip socket). In younger children (up to age 10), gentle traction may be all that’s needed to reduce the hip. This can be done as a closed reduction. With a closed reduction, no surgery is required. Older children and teens are more likely to develop a transient hip dislocation.

A transient hip dislocation refers to a hip that has dislocated and then partially, but not completely, reduced. Imaging studies before performing a reduction are a must in order to identify the presence of an incomplete reduction, fractures, or bone fragments in the joint space. Any of these features can cause additional complications later.

X-rays will also show any signs of incongruous reduction, another possible pitfall. Incongruous reduction means the hip has returned to its natural, anatomic position, but cartilage, capsular tissue, or a bone fragment has lodged itself between the femoral head and the acetabulum. This will prevent normal movement and can lead to osteonecrosis of the femoral head (death of the bone due to loss of blood supply).

Sometimes a hip injury in a teen athlete dislocates and relocates spontaneously (on its own). The athlete may not even be completely aware of what has happened but develops hip or knee pain later. Imaging studies are needed to rule out the possibility of incongruous reduction. In other children, an unrecognized dislocation can delay treatment. Hip pain, limp, leg length difference, and loss of hip motion offer red flag symptoms that something’s wrong.

Even when a hip dislocation has been diagnosed correctly, other problems can develop. For instance, there may be other injuries that are subtle. Fractures of the acetabulum, femoral head, or greater trochanter (bump on the femoral bone where muscles attach) may not be recognized when the focus and attention is on the hip dislocation. This is especially true for patients who were involved in car accidents where multiple trauma has occurred.

Even with early diagnosis and treatment, complications can occur. The most common (and serious) problem that can develop is femoral head osteonecrosis. Several factors raise the risk of osteonecrosis. The first is femoral head epiphysiolysis.

This refers to a fracture and then separation of the epiphysis (growth plate) at the upper end of the femoral head. If the physician is unaware of the physeal injury and attempts to reduce the hip with a closed reduction technique, the growth plate can get displaced. The result is an unstable hip and eventual osteonecrosis.

Surgeons are advised to ensure complete relaxation of the leg by using a general anesthesia. The fracture may need to be pinned to stabilize it before attempting the reduction. And continuous imaging during the procedure is best to avoid these pitfalls. This can be done using a special dynamic imaging called fluoroscopy. Fluoroscopy allows the surgeon to see what’s going on inside the hip throughout the procedure.

Besides osteonecrosis, other complications include a dislocation that cannot be reduced, recurrent dislocations, osteoarthritis, and nerve damage. An irreducible dislocation and recurrent dislocations may require surgery. Any tears in the labrum (rim of cartilage around the hip socket) should be repaired. Sometimes repeated dislocations can be treated with immobilization using a hip spica cast (from hip to toes).

Children are not as likely to develop hip osteoarthritis as adults are after a traumatic hip dislocation. But when osteonecrosis occurs, the risk of osteoarthritis goes up significantly. Osteoarthritis is also more likely when there have been associated injuries or when an incongruous reduction wasn’t treated.

And finally, injury to the sciatic and gluteal nerves can occur as a result of a stretch placed on the nerve. The force of an injury great enough to dislocate the hip is also strong enough to cause neurologic damage. Quick reduction of the hip helps nerve recovery. With time enough to heal, the nerves should return to normal function.

In summary, although traumatic hip dislocations don’t occur very often, when they do, the physician must act quickly to avoid pitfalls from complications. Even with early diagnosis of the dislocation, a thorough examination and evaluation is needed to find any other areas of injury or damage. Failure to do so can result in serious, long-term complications. Whether the dislocation is a closed or open reduction, the surgeon has numerous risk factors and pitfalls to watch out for.

One-third of children with osteochondritis dissecans (OCD) will not heal with conservative (nonoperative) care. Is it possible to predict who might not benefit from the usual treatment of activity modification and immobilization? That’s the focus of this study of children with OCD of the knee.

OCD is a problem that affects the end of the femur (thigh bone) at the knee. When it affects young children who are still growing, it is called juvenile OCD or JOCD. The joint surface is damaged and doesn’t heal naturally. The problem occurs where the cartilage of the knee attaches to the bone underneath.

The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion. A bone fragment with the layer of articular cartilage covering it detaches from the bone.

The lesions usually occur in the part of the joint that holds most of the body’s weight. This means that the problem area is under constant stress and doesn’t get time to heal. The lesion causes pain, swelling, locking or clicking at the knee. The patient has problems when walking and putting weight on the knee.
It is more common for the lesions to occur on the medial femoral condyle, because the inside of the knee bears more weight. The femoral condyle is the rounded end of the lower femur. Each knee has two femoral condyles, referred to as the medial femoral condyle (on the inside of the knee) and the lateral femoral condyle (on the outside).

Like most joint surfaces, the femoral condyles are covered in articular cartilage. Articular cartilage is a smooth, rubbery covering that allows the bones of a joint to slide smoothly against one another.

All of the children in this study had juvenile osteochondritis dissecans (JOCD). In children, the growth plates at the end of the bone are still open to allow for continued growth. Healing of osteochondritis lesions is important to prevent damage to the growth plate and to prevent altered bone growth.

Results of previous studies done on healing rates and the associated treatment approaches for JOCD in children have been mixed. The authors suspect this is because other studies included both stable and unstable articular cartilage defects. Unstable refers to the disruption that occurs in the surface of the articular cartilage. The chances for spontaneous healing when the articular surface is involved are low. Further damage is highly likely. Surgery is usually recommended.

But in stable JOCD, the articular cartilage is intact. It’s not uncommon to wait six months and see if healing occurs on its own. The knee may be immobilized in a brace or cast, and the child’s activities are restricted (e.g., no sports). But many of these children end up in surgery six months later when healing doesn’t occur. If physicians could predict which children might need surgery, it could save the child and the family the six months’ worth of stress waiting and wondering if the knee will heal.

In this study, the physicians used a special statistical model to predict the healing response of stable knee JOCD in children and young teens. Predictive factors tested included age, lesion size and location, symptoms, and sex (male or female). The lesions were examined before and after treatment using X-rays and MRIs.

Treatment consisted of six to 12 weeks of immobilization (long leg cast). This was followed by wearing a special brace that allowed weight-bearing. The brace can be adjusted to offload the affected part of the knee. As the lesion healed, each child was allowed to increase weight-bearing and activity level. When the lesion was completely healed, then full participation in sports activities without bracing was allowed. This process of advancing back to full activity took weeks to months.

Everyone’s case was reviewed at the end of six weeks. The children were divided into two groups: those who showed signs of healing (or were healed) and those with no signs of healing. One-third of the group failed to progress toward healing. All lesions in this group were on the medial femoral condyle. The other two-thirds were either completely reossified (restored bone growth) or in the process of healing.

The data was then analyzed to see if they could find common factors among each group to help predict the outcome. It turned out that size does matter. The total surface (length and width) of the lesion combined together was a significant predictive factor. Children with swelling and/or other mechanical symptoms (e.g., locking or giving way of the knee) at the time of diagnosis were also less likely to experience sufficient healing.

In this study, lesions with an average size of 209 mm2 were more likely to heal compared with 288 mm2 in the failure-to-heal group. The authors compared these sizes to the results reported from other studies. There was a wide range of sizes reported with success/failure rates.

In other studies, the average surface area in young patients who healed with nonoperative treatment ranged from 152 mm2 to 309 mm2. The range for lesions that did not heal was from 194 mm2 to 436 mm2. Again, those other studies included both stable and unstable lesions, which could explain the wide ranges of results.

Although other studies have shown that younger children are more likely to heal, this study did not show an effect of age on healing progress. The reason for this difference was unknown. The authors suspect that the 34 per cent failure rate they had will be a larger percentage with long-term follow-up. They base this prediction on the fact that there were signal changes still seen on the final MRIs taken during the follow-up period. They intend to follow these children and see what happens over a period of years (rather than weeks to months).

The authors advise physicians treating children with juvenile osteochondritis dissecans to review MRIs at the time of diagnosis. If the articular cartilage is not disrupted (stable lesion), then a six-month trial of conservative care is advised. But parents should be warned there is a high risk of failure with no healing possible. The surgeon can use the size of the lesion and symptoms present at the time of diagnosis to predict healing potential.

Fractures at the distal tibia (ankle) in children pose a special challenge. This is especially true if the fracture goes through the epiphysis (growth plate) or separates the growth plate from the joint. Surgery to hold it all together while it heals may be needed. Metal screws are used that can be removed later.

But transepiphyseal metal implants (through the growth plate) change the way the ankle is loaded during weight-bearing (standing and walking). Over time, the increased pressure leads to breakdown of the joint. Pain and disability can be the final outcome.

One way to avoid this problem is to use bioabsorbable screws. These implants serve the same function as metal screws: to maintain a closed position of the fracture while the bone heals. But the screws dissolve and are absorbed by the body over the next two to four years.

Before anything new of this type can be used in children, they must be proven both safe and effective. In this study, surgeons from two large children’s hospitals in Texas compared the use of metal versus bioabsorbable screws for fractures of the distal tibia. The tibia is the lower leg bone. The distal tibia describes the bottom of the tibia where it forms the upper half of the ankle joint.

An equal number of children were in each group. The groups were matched by age, gender, type and severity of injury, and time between the injury and surgery. The surgical technique used for bioabsorbable screws was slightly different from metal screws. The bioabsorbable screws cannot cut into the bone and screw into place like metal screws. Threaded wires were used and holes drilled before the partially threaded bioabsorbable screws could be placed.

Results were measured using X-rays and patient report of symptoms and function. Operative time (about 80 minutes) was the same for both groups. Children in both groups were back on their feet in about seven weeks’ time. Full activities were resumed by the end of four months.

There were some complications for both groups but a greater number of problems in the metal screw group. Irregularity of the joint line and disruption of the growth plate causing growth to stop were the two main complications. Both of these were more common in the metal group. None of the children with bioabsorbable implants needed further surgery. Half of the children with metal screws had a second operation to remove them.

Bioabsorbable implants have been used in adults with good results. But this is the first report of their use in a number of skeletally immature children (i.e., they are still growing and have not reached full skeletal maturity) with ankle injuries. The surgeons were careful not to cross the growth plate with the screws in order to avoid disturbing growth.

Future studies need to answer some additional questions. For example, is the bioabsorbable screw strong enough to support more severe fractures? Can it be used across the epiphysis/physis without inhibiting growth? And what are the long-term effects (if any) of an implant left in place?

For now, it appears that bioabsorbable screws can be safely used for distal tibial (ankle) fractures. Results are as good, if not better, than results with metal screws. And it eliminates a second surgery (to remove the implants), which is both cost effective and less risky for the patient.

While lower back pain and disorders are not uncommon among children, especially athletes, upper cervical spine (extreme upper back) disorder are quite rare.

A baby’s back is only starting to harden properly during the first year and continues to do so until the child is about six years old. After that, there is still some progress in the back for another year or so, finishing completely as the child hits his or her teen years.

Upper cervical spine disorders can be one of many and are often a “one-of” type of thing, not associated with any other type of illness or birth defect. However, it’s not unusual for there to be more than one anomaly (defect) so if one is found, physicians should look for more.

The diagnosis of upper spinal disorders needs x-rays, as well as more advanced imaging, such as magnetic resonance imaging (MRI). Congenital anomalies, ones that children are born with, can be many.

The first cervical vetebral anomalies are at the top of the neck where it meets the skull. The full verbetrae (bone) may not completely ossify (harden) up until a child is four years old but in some children, like those with Down’s syndrome, this is an anomaly. Congential fusions occur when the first cervical vertebrae fuses with the base of the skull, something it’s not supposed to do. In about half of cases, up to 70 percent, if the first vertebrae is fused, it’s most likely the second and third vertebrae are too. This problem results in instability of the neck and some neurologic (nerve) symptoms that may only develop when the person is in their twenties or thirties.

Os odontoideum occurs when the dens (tooth-like projection from the second vertebra in the neck) isn’t connected to the vertebrae as it should be. It may be off to the side or displaced completely. This could result in instability of the neck as well.

Actual instability of the neck can be caused by several issues, as well as the ligaments not being strong enough to hold the neck up. Because it’s not taut, it could also put pressure on the nerves alongside the neck. Torticollis is painful condition that keeps you from turning your head to one side or tilt it down or up. This can be caused by a congenital problem, infection, and different syndromes.

Finally, trauma is also a cause of neck instability but this is rare. Trauma could be from the birth, accidental injury, or falls. These can result in dislocations and/or fractures and require treatment. A Halo brace, the ring that is fit around a patient’s head and connected to a brace, is one way to correct some of the upper cervical spine disorders

The authors of this article concluded that the upper cervical spine injury is not common among children but diagnosis and treatment of the ones that are present is very important to prevent further injury.

Surgeons from Israel tracked 40 patients with Legg-Calvé-Perthes disease over a period of 30 years to see the long-term results of surgery. This is their report of the results for children who had a proximal femoral varus derotational osteotomy (see explanation below).

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calvé-Perthes disease in honor of the three physicians who each separately described the disease.

In this condition, the blood supply to the capital femoral epiphysis (growth center of the hip) is disturbed. The bone in this area becomes necrotic (starts to die) without blood. The blood supply eventually returns, and the bone heals. How the bone heals determines how much problem the condition will cause in later life. This condition can lead to joint deformity and a poorly functioning hip.

The primary goal of treatment for Perthes disease is to help the femoral head recover and grow to a normal shape. All treatment options for Perthes disease try to position and hold the hip in the acetabulum as much as possible (referred to as containment). This healing process can take several years. If conservative (nonoperative) care is not successful, then surgery may be needed.

Surgical treatment for containment usually consists of procedures that realign either the femur (thighbone), the acetabulum (hip socket), or both. Realignment of the femur is the operation being reviewed in this study (femoral osteotomy). This procedure changes the angle of the femoral neck so that the femoral head points more towards the socket.

To perform this procedure, an incision is made in the side of the thigh. The bone of the femur is cut and realigned in a new position. A large metal plate and screws are then inserted to hold the bones in the new position until the bone has healed. The plate and screws may need to be removed once the bone has healed.

The advantages of this operation are that it contains or keeps the hip in the socket and molded into the round shape needed for movement. The idea is to prevent future hip joint deformities. This treatment method also eliminates the need for long periods of bracing and immobilization.

The surgeons used three types of classifications to describe the condition. The first classification scheme (Catterall classification) grouped the patients according to the percentage of changes seen on X-rays of the femoral head before surgery. There were four groups. Group one: only the front part of the growth plate was affected. Group two: 50 per cent of the femoral head was affected. Group three: 75 per cent of the head was involved and group four: the entire epiphysis was affected.

The second classification (Stulberg classification) rated the hip joint anatomy as I (normal hip joint), II (round but larger than normal femoral head), III oval or mushroom-shaped (but not flat) femoral head, IV (flat femoral head, abnormal femoral neck and hip socket), and V (flat femoral head with normal neck and socket).

The third classification model (Tönnis Classification) was used after surgery to identify and describe the development of osteoarthritis. A grade of zero means no sign of osteoarthritis. Grades one, two, and three describe mild, moderate, and severe arthritic changes.

All classifications were made using X-rays. Patients were also examined before and after surgery. Any differences in limb- length were measured and recorded. Pain was used as an additional measure of long-term outcomes.

Overall results were good-to-excellent for about half the group. Mild hip pain, slight limp, and leg length difference were commonly reported. Signs of osteoarthritis were present in about 25 per cent of the group. The Stulberg classification of anatomy (shape of femoral head) was a good predictor of function and development of osteoarthritis later.

As the longest follow-up on record for patients with Perthes who had a femoral osteotomy, this study was able to compare the shape of the femoral head with long-term function and the development of arthritis in later years. The authors report that most of the patients had a favorable result. Only one person had to have a total hip replacement (25 years after the osteotomy). Everyone was gainfully employed. The hip problem did not determine the type of job chosen.

The authors comment that with today’s new tests and knowledge of Perthes disease, some of the children in their study would not have needed surgery. And there was no control group (children matched by severity of condition who didn’t have surgery). These two factors may skew the results a bit. Relying on clinical signs (hip pain, limp) to diagnose arthritis is not advised. X-rays are needed to know for sure as many patients with osteoarthritis have no (or only mild) symptoms.

The authors also address one other criticism of the femoral osteotomy procedure. And that is the leg length shortening that occurs. Although there were mild limb length differences seen in this group, it wasn’t any more or any worse than differences reported in other studies using other forms of treatment. Function was not reduced by the limb-length discrepancy. Another study to look at the effect of limb length difference on the development of osteoarthritis later in life may be helpful.

The use of all-terrain vehicles (ATVs) has increased dramatically in the last 10 years. Injuries (even fatal ones) have increased, too. Forty per cent of all ATV-related deaths are children. What can be done to improve safety in the use of ATVs by children? That’s the focus of this article.

This may be the first study to look at patterns of fractures in ATV accidents among children. Surgeons from the University of Tennessee compiled information on types of injuries in two groups of children involved in ATV accidents. The groups were divided by age: under 13 (group one) and 13 and older (group two).

Information was taken from the medical records of 96 children involved in ATV accidents. The authors looked at age, gender, type and severity of injury, treatment, and body mass index (BMI). The children were all treated at a large regional pediatric trauma center. There was a 2:1 ratio of boys to girls. Ages ranged from two to 16 years old.

Although there are many different types of injuries from ATV accidents (e.g., head, chest, or abdominal injuries), only orthopedic trauma (fractures) was investigated. After reviewing all of the data, they were able to see an age-related pattern. Older children were more likely to have a pelvic fracture. Younger children broke their leg most often (usually the femur or thigh bone).

There are already recommendations about children and ATV use. The American Academy of Pediatrics (AAP), the American College of Surgeons (ACS), and the American Academy of Orthopaedic Surgeons (AAOS) all agree: