News Category: Child

Children are involved in sports more than ever before. Year-round practice and competitive play have increased the number of orthopedic conditions and injuries reported. One of those conditions is osteochondritis dissecans (OCD) or JOCD when juveniles (children and teens) are affected.

OCD mostly affects the femoral condyles of the knee. The femoral condyle is the rounded end of the lower thighbone, or 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.

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 actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

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. It also means that the lesions cause pain and 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.

Parents of active children with JOCD are faced with an interesting challenge. The nonoperative treatment is rest and inactivity until the bone heals. But the physical, social, and emotional downside of inactivity for these sports-minded youth can be a problem.

Is there some way to preserve the bone without prolonged immobility that gets these athletes back on their feet and playing or performing again? In this study, sports medicine physicians and surgeons from the University of Michigan (Ann Arbor) look to see if drilling into the lesion might speed up the healing process.

Drilling is done using arthroscopy and fluoroscopy. These techniques allow the surgeon to see inside the joint while guiding surgical tools and completing the drilling process. Drilling is done with K-wires that poke holes through the hardened rim of bone that develops around the softened bone.

Once the hard shell around the lesion has been breached, new blood supply to the area starts the healing process. The surgeon must be careful not to drill into the knee joint or into areas of healthy knee joint cartilage. That type of drilling approach is referred to as intraarticular technique. The drilling used in this study avoided the cartilage and is called extraarticular drilling.

One of the advantages of the extraarticular drilling technique is that motion is not restricted. The patients were allowed to stand and walk with crutches. Weight-bearing was limited on that side for six weeks. Physical therapy to restore motion and stimulate bone healing through the proper exercises and activities was started. When signs of healing were observed on X-ray, the exercise program was progressed to include light resistance and gradual impact loading.

Swimming and cycling were allowed but running, jumping, and twisting were limited until MRI or CT scan showed evidence of good healing. Once the patient was pain free with good leg muscle strength, then the training program was stepped up to include full return to activities.

How well did this treatment approach work? Fifteen children were included in the study. All were active athletes in year-round training and competition. Ages ranged from nine to 15. Everyone had open physes. That means they were still growing and the growth plate had not yet hardened and turned into bone. Their bone lesions were soft and did not extend down into the deeper bone.

Surgery to perform the drilling technique was done without any follow-up problems or complications. Everyone was able to return to full sports participation. Some were back on the field sooner than others. The earliest return-to-play was five months. The longest time period for recovery was 14.5 months.

The results of this and other studies may challenge the current practice of treating JOCD nonoperatively for at least six months before attempting surgery. There’s evidence that early surgical treatment may provide a better result. This is especially true in older children who are close to bone maturity. Operative treatment after the growth plates have closed is not as successful as when it’s done in skeletally immature patients.

Conservative care with prolonged immobilization can result in muscle weakness and atrophy, joint stiffness, and worse cartilage degeneration. Delaying surgery too long may not be the best idea.
The authors suggest that extraarticular drilling for JOCD is best used when there are unstable lesions, when the child is close to bone maturity, or for children who have tried nonoperative treatment for stable lesions without success.

Extraarticular drilling is a good treatment option for the active athlete with JOCD who might otherwise make the lesion worse with high-impact activities. This may be an acceptable treatment plan for the young athlete who refuses to reduce activity level and risks further damaging the joint.

Fractures of the long thigh bone (femur) in children can be difficult to repair and stabilize. Although there are many methods for fixation (holding the broken pieces together until the bone heals), there are also lots of advantages and disadvantages to each one.

In this study, a pediatric orthopedic specialist designed a new nail to help improve outcomes in children with femoral shaft fractures. The device, a flexible interlocking intramedullary nail (FIIN) is made of a titanium alloy and has a slight give to it.

This give (also referred to as plastic deformation) makes it possible to thread the nail into the femoral canal (down the middle of the bone) starting from the top of the femur. There’s a slight bend or curve the surgeon must pass the nail through to get to the main part of the bone shaft. Having that slight plastic give makes it possible to accomplish this. The nail is also designed to allow either a right-handed or a left-handed surgeon to use it.

The hope was that the FIIN would reduce complications, improve healing time, and restore function faster than the other fixation procedures (OFPs). One of the most common and difficult problems with treating femoral shaft fractures using OFPs is limb-length discrepancy. Malunion of the fracture, pain, infection, and refracture are other concerns with OFPs. The authors hope to reduce the incidence of these with the new FIIN.

All children included in the study were between the ages of seven and 18 with femoral shaft fractures. There were two groups matched by age, weight, and fracture patterns: those who received the FIIN and a second group who received an OFP. X-rays were used to judge the location of the fracture as well as the diameter of the canal inside the femoral shaft where the nail would be placed.

There wasn’t a standard OFP used in the children in the OFP group. Surgeons chose the method of fixation that was best for each patient. Some used titanium elastic nails, while others placed an external fixator (outside the skin with nails through the skin and bone). In some cases, a metal plate and screws were used to hold the bones together.

For those patients who received a FIIN, there were two different sizes for the surgeon to choose from. Smaller diameter FIINs (5.5 mm) were used in children who weighed up to 100 pounds. A larger diameter nail was developed and used with children who weighed more than 100 pounds. The surgical procedure was described in detail for surgeons considering using these nails.

The FIIN is inserted in a slightly different place along the side of the hip from the standard entry point for OFPs. Location of the necessary incisions are provided in the article. Techniques to make it easier to pass the nail through the skin and steer it into the bone are also described.

The surgeon uses fluoroscopy (X-rays that show what’s going on inside the body) to complete this task. This type of imaging makes it possible to avoid overbending the nail tip, rotate the nail at just the right time, and get it in the best position to line up the broken ends of the bone. Once everything is in place, the pin is locked in place. Fluoroscopy confirms it’s time to close the incision and bring the patient out of the anesthesia.

Length of hospital stay was about the same for both groups. Amount of blood lost was greater in the OFP group but this may have been because of multiple trauma and more complex injuries. Patients were allowed to put weight on the operated leg when X-rays showed signs of bone healing. Usually, this was around three weeks after the surgery with the FIIN.

Full weight bearing was possible in the FIIN group 10 to 12 weeks after surgery. This was a full month sooner than for patients in the OFP group. The difference in time to weight-bearing was even more obvious in patients with multiple trauma. They were up and going twice as fast as the OFP group.

Only minor complications were reported with the FIIN. There were no cases of pain or skin problems. This was compared with both minor and major complications with the OFPs. Of course, comminuted fractures (many tiny pieces of bone) were more difficult to treat without complications in either group. Overall, the incidence (number of complications) for FIIN versus OFP was about the same and not considered statistically significant.

Complications within the OFP group included infection, osteomyelitis (bone formation in the soft tissues around the bone), refracture, or loss of blood supply to the bone. Children who weighed less than 100 pounds in the OFP group were eight times more likely to suffer one (or more) of these complications.

The authors conclude that less blood loss, shorter recovery time, and faster return to function, along with fewer complications makes their new device (the FIIN) a good choice when surgically treating femoral shaft fractures in children. And the FIIN can be removed nine months to a year later.

The increased rate of osteomyelitis with FIIN may be caused by the way the new nail is inserted into the bone. More study is needed to understand this problem. The fact that smaller children are especially likely to have better results with the FIIN over the OFPs will be also investigated further.

Children with rheumatologic diseases such as arthritis are living longer and better thanks to a team approach to patient care. Combining the knowledge and efforts of the patient, family, and many health care professionals makes all the difference. New disease-modifying drugs are available. Death rates are down. Function is up.

But what is the child’s responsibility versus the parents or the specialists who are part of the team? That’s the focus of this article reviewing the latest advances in the care and feeding of children with juvenile arthritis.

One big change has been what we call these diseases. The term juvenile rheumatoid arthritis (JRA) has been replaced by juvenile chronic arthritis (JCA) and juvenile idiopathic arthritis (JIA).

This classification scheme still recognizes the three major types of arthritis in children: 1) systemic, 2) polyarticular, and 3) pauciarticular. The name change reflects efforts to standardize research, so that everyone is talking about the same thing when reporting new findings.

The physician’s role is to diagnose the problem as early and as accurately as possible. From there, a specific treatment plan of appropriate medications is next. The new disease-modifying antirheumatic drugs (DMARDs) can be used along with nonsteroidal antiinflammatory drugs (NSAIDs) and/or biologic response modifiers (BRMs). The physician takes into account the risks and benefits of each drug, the needs of the child, and the proper dosage for the best results with the fewest side effects.

Flare-ups of arthritis symptoms require careful medical evaluation. Often the primary care physician and rheumatologist consult together to decide what changes are needed in the treatment plan. Other team members such as the physical and occupational therapist, psychologist, dietician, and nurse provide skills and services to improve overall health, function, and quality of life.

More than ever before, children with arthritis can attend school on a daily basis with few absences. And they can participate in after school activities of all kinds. These are major milestones from even just 10 years ago.

What are the responsibilities of the child in all this? Compliance is the key word. This refers to the child’s willingness and follow-through when it comes to abiding by the recommendations of the team. They must take their medications as prescribed, get regular rest and sleep, and eat healthy foods. There’s plenty of research to support the effectiveness of each of these routines in chronic diseases like arthritis.

Weight control and exercise go hand in hand. Joints are stressed by the disease. Adding extra load from being overweight combined with poor muscle strength puts an added burden on already compromised joints and soft tissues around the joints.

Here’s where the family comes in. Family members can (and should) join in on the fun. They can exercise together: walk, bike, swim, play tennis, or engage in other activities everyone enjoys. Parents or guardians can provide nutritious snacks and limit the availability of unhealthy food items and snacks kept on the shelf.

Everyone benefits with improved health — now and in the future. Proper diet and nutrition ensures good bone health for years to come. Fewer fractures, less back pain, and improved immune system function are just a few examples of the positive outcomes from following a plan of this type.

The authors offer some specific tips for children with rheumatologic disease (and their caregivers) including:

Every parent knows that if their child wants to participate in organized sports, a preparticipation exam is required. The athlete must see a physician, have a form filled out, and turn the form in. While it may seem like we are jumping through hoops, the medical doctor must take this exercise very seriously.

Every year, there are reports of athletes suffering fatal heart or other life-threatening conditions on the field. Hypertrophic cardiomyopathy, (HCM or HOCM) is the most famous as a leading cause of sudden cardiac death in young athletes. Hypertrophic cardiomyopathy is a disease of the myocardium (heart muscle). Part of the myocardium becomes hypertrophied (thickened) without any obvious cause.

To help physicians perform an effective exam, a proposed preparticipation exam has been developed. A consensus approach was used to formulate the evaluation. Consensus means the opinions of many experts were gathered. Items agreed upon by the majority of doctors were included.

This article presents a summary of the consensus report along with specific cardiac recommendations from the American Heart Association. Many well-known medical groups contributed to the process. For example, the American Family of Family Physicians, American College of Sports Medicine, American Academy of Pediatrics, and American Orthopaedic Society for Sports Medicine participated (to name a few).

Guidelines for preparticipation screening of athletes are designed to ensure the health and safety of the 10 million school age and collegiate athletes who train and compete each year. The goal is to identify risk factors for injury, illness, and even sudden death.

The guidelines include timing of the evaluation, appropriate setting for the exam, questions to be asked, and tests to be performed. The preparticipation exam should be completed in the doctor’s office at least six weeks before preseason activities. This allows enough time for follow-up if referral or consultation is needed.

Many schools require the preparticipation exam every year for liability reasons. There isn’t any real data collected to show that this is necessary. Studies are needed to confirm that performing an annual exam actually reduces the risk of injury or death in student athletes.

The medical societies recommend an exam every two years for younger athletes, and every two-to-three years in older athletes. Specific ages have not been standardized as yet. A thorough exam is advised at the start of new phases (e.g., upon entering middle school, at the start of high school, when participating in sports for the first time).

A modified and less thorough update exam can be performed each year in-between major transition periods. Any important health changes can be noted at that time. This might include changes in height and weight, any new personal/family history of injury or illness, and current blood pressure.

Physicians are encouraged to obtain the most accurate history possible. This means interviewing both the athlete and his or her parent/guardian. Areas to include are: past hospitalizations and surgeries, current medications, allergies, and use of vitamins or other supplements. A social history is equally important with questions about tobacco use and alcohol or other drug use. A past history of medical disqualification raises a red flag requiring further investigation.

The physician follows a typical comprehensive physical exam including a systems review: head; ears, nose, throat; skin; gastrointestinal; and genitourinary function. Certain body systems require a closer look than others. For example, the cardiovascular, pulmonary, neurologic, and musculoskeletal systems must be reviewed in detail. Nutrition is also very important as well as looking for specific signs and symptoms that might suggest an eating disorder or risk factors for delayed growth.

Each of these areas is described in detail for physicians reviewing the current guidelines. Samples of forms and checklists with multiple questions are included for the reader. Drawings of tests used in the general musculoskeletal screening exam are provided. Tests for range-of-motion, muscle strength, scoliosis screening, balance, and flexibility are included.

There’s still some debate about the need for special tests such as electrocardiograms (EKGs). Studies from Europe support the need for all competitive athletes to have routine EKGs. They report 90 per cent fewer deaths from cardiovascular causes.

But the American Heart Association says that a normal EKG doesn’t mean the athlete won’t have a significant heart-related event. These tests just aren’t sensitive enough to detect all abnormalities, and they are expensive to conduct on everyone involved. False-positive tests lead to more tests that may be unnecessary. At the present time, there are too few athletes for whom this type of testing is really needed. There’s no need to subject everyone to the test for the sake of a very few who might be affected.

It may be more effective to find tests and measures that are likely to predict a potentially life-threatening condition. For now, the American Heart Association encourages physicians to watch out for the following red flags:

Should metal plates and screws used in orthopedic surgery be removed in children once the bone is healed? Is there any evidence for or against this practice? In this article, pediatric orthopedic surgeons gather up all the data possible to answer the question. By combining the results of smaller studies, it’s possible to gain better insight into the dilemma.

Medical decisions are driven by evidence from research. Evidence-based treatment is the current trend. Studies are rated on the basis of their evidence from one to five. Level I is a high-quality study with conclusive evidence. Level II tell us the evidence is strong but the quality of the study is not top knotch.

Both Level I and Level II studies are randomized controlled trials (RCTs). RCTs involve placing patients in different groups in no particular order and without a specific reason to be in one group or another. The RCT approach ensures that both known and unknown factors that could affect the results are evenly distributed among all the treatment groups.

Level III gives us moderate evidence from well-designed trials but the studies are not randomized. In other words, patients aren’t randomly placed in different groups. There’s usually just one group with measurements taken before and after treatment.

Level IV studies provide limited evidence from well-designed studies. Usually there’s more than one center or research group involved. Often these are case series or case-controlled studies. Everyone is intentionally placed in the group they are in, so it is considered nonrandomized.

And Level V gives intermediate evidence based on comparative studies without control subjects. Level V evidence may also come from the opinions of well-respected authorities. The opinions are the result of clinical experience or reports of expert committees.

After reviewing all the data available in the English medical database, the authors of this review report a lack of sufficient evidence to make a blanket statement to guide surgeons. Basically, there was no evidence one way or the other to support keeping or removing the implants.

They did find that there’s about a 10 per cent complication rate associated with surgery to remove implants. Problems reported included infection, fracture, and delayed wound healing. In some cases, failure to remove all of the implant was counted as a complication. Many of the cases where complications occurred were in children with slipped capital femoral epiphysis (SCFE).

In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). Surgery is usually necessary to stop the epiphysis from slipping further. A large screw is placed into the epiphysis to hold it in place. Removing the screw takes twice as long as putting it in. There is a risk of breaking or stripping the screw during the attempted removal. Titanium screws seem to have the worst results.

Most of the time, implants are left in and removal is not an issue. But what’s the evidence that problems can occur because of implant retention? The authors report there were no studies reporting the long-term results of implants left in children.

The fear that an allergic response to the implant, infections, or malignancy caused by the implant weren’t confirmed. The incidence of these complications is very, very low. And there was no real proof that the implant actually caused these problems. Fractures around the retained plate are much less likely than fractures from removing the plate. There were no reported cases of bone fracture in children from implant removal.

There’s one final thing to consider about leaving implants in children. What happens if, as an adult, that child eventually needs a joint replacement? How will having an implant left in since childhood affect the replacement surgery?

There is a general concern that the bone will grow around the implant making further surgery difficult. But there’s no real data to support or deny this theory. A few case studies have reported that bone remodeling around the implant placed the device inside the bone shaft. Such a situation could complicate bone removal and joint replacement.

The authors conclude that until further evidence is available, the decision to keep or remove hardware in children must be done on a case-by-case basis. If the child is having pain or other symptoms from the implant, then the benefits of removing it may outweigh the possible risks.

More studies are needed to understand the long-term effects of orthopedic implants. Even studies that just observe what happens over time would be helpful. The authors also point out the need for a study on joint replacements in patients with implants already in place.

This is a report on the use of arthroscopy in the treatment of femoracetabular impingement (FAI) in children. FAI refers to a pinching of the soft tissues around the hip joint where the femoral head (top of the thigh bone) bumps up against the acetabulum (hip socket). Athletes between the ages of 11 and 16 years old with different types of FAI were included.

The reason FAI occurs is because there is an abnormal relationship between the femoral head and neck. The junction where these two structures meet is shortened or rotated from normal. This change from normal is referred to as the femoral head-neck offset.

The most common causes of this problem are pediatric conditions such as Legg-Calvé-Perthes disease and Slipped Capital Femoral Epiphysis (SCFE). In some cases, FAI occurs because of the way the bones are formed with slight variations from the norm. The children in this study had no obvious secondary cause of their FAI. It was most likely the result of anatomic variations of unknown origin.

Repeated flexion (bending) of the hip is the movement that makes the impingement the worst. Over time, it can lead to tears of the labrum and early signs of arthritis. The labrum is a dense ring of fibrocartilage that is attached around the rim of the acetabulum. It helps make the socket deeper and more stable for the femoral head.

FAI can be treated conservatively. In fact, nonoperative care is always recommended first. This usually consists of at least six weeks of nonsteroidal antiinflammatory drugs (NSAIDs), steroid injections, physical therapy, and activity modification.

Children who continue to have disabling pain despite conservative care may consider surgery as the next option. Pain severe enough to keep an athlete on the bench and unable to participate is the most common reason for surgery to correct this problem.

Arthroscopy is routinely used in surgeries for adults with FAI. But the anatomy of children is different enough that the same techniques can’t be used in exactly the same way. The advantage of arthroscopy for this procedure is that it allows the surgeon to move the hip and test to make sure the impingement is no longer present.

The exact surgical technique used with the 16 adolescents in this study depended on what the surgeon found during the procedure. Femoral head-neck osteoplasty was performed most often. Osteoplasty means surgical repair or alteration of the bone.

In some cases, the labrum and acetabular rim were trimmed to prevent further impingement. If the labrum was torn, suture anchors were used to reattach it to the acetabular rim. If there was too much capsular material, the surgeon removed a portion of it. Any defects in the joint surface were repaired at the same time. This procedure is called a chondroplasty. About half the patients had a chondroplasty of the femoral head. The other half had a chondroplasty of the acetabulum.

After surgery, patients were placed in a special brace to control hip motion. Walking was allowed with crutches. Scar tissue formation was minimized by using a continuous passive motion (CPM) machine for the first two weeks.

Everyone was supervised by a physical therapist for their postoperative rehabilitation program. The therapist progressed each child through motion and strengthening exercises with a return-to-sports within three months’ time.

Results were measured using function, activity level, return-to-sports, and patient satisfaction. The children were followed at regular intervals for two full years. Everyone was able to return to their favorite sports activities. They were able to do so at a level equal to their ability before the surgery. Satisfaction was very high. For those children who were still growing, the surgery did not interfere with further bone growth.

The authors conclude that arthroscopic repair of FAI in older children and teens is both safe and effective. With newer surgical instruments and improved arthroscopic techniques, surgeons can repair defects in the hip (including impingement) without an open incision.

Arthroscopic repair is even possible in children whose growth plates are still open and have not completely fused yet. Most of the repair is done on the acetabular side of the joint. The authors suggest this approach will help prevent the development of other problems, especially deformity and stopped growth of the physis (growth plate).

Spinal cord defects such as myelomenigocele can cause foot deformities as a result of muscle imbalance. Myelomeningocele is a protrusion of the meninges and spinal cord. Meninges is the covering around the spinal cord. In this condition, the meninges fail to close when the child is developing in the womb.

This type of defect is called a neural tube disorder. The neural tube is the protective sheath of bone and meninges that encase the entire spinal cord. It is formed early in utero (around the 19th day in the womb). The most common neural tube defect is called spina bifida occulta. This refers to an incomplete closure (incomplete fusion) of the arch of bone around the spinal cord.

Myelomeningocele is more severe than spina bifida. There is a failure of the bone to close around the spinal cord (like in spina bifida), but there is also a failure of the meninges to cover and protect the spinal cord. Generally these defects occur in the lumbosacral area. Children with an L4 myelomeningocele often have foot deformities requiring treatment.

One of those foot deformities is the topic of this study. The use of a posterior transfer of the anterior tibial tendon to rebalance the foot and ankle was investigated. The anterior tibial tendon normally pulls the ankle up toward the face. Without the opposing muscle, the foot is pulled up so far, the child is walking just on the calcaneus (heel bone). The patient can’t point the toe or roll over the foot and push-off with the big toe when walking. In order to swing the foot forward without scuffing the heel every time, the affected individual exaggerates motion at the knee, hip, and pelvis.

Surgical treatment isn’t always successful. The reason(s) for this aren’t entirely clear. It was once thought that the problems were all related to muscle imbalances. Weakness from the neurologic impairment of one set of muscles in the leg can lead to the stronger muscles pulling the foot in one direction.

Over time, the constant uneven muscle pull can result in a foot and/or ankle deformity. More recent studies have also shown that external forces acting on the foot are important, too. Gravity and ground reaction forces are the most likely external factors to contribute to the problem.

Given this new information, surgeons are rethinking the best approach to the problem. Just releasing the overactive (unopposed) tendon and bracing the foot has not had good results for everyone. Studies show that there may be a specific subset of children who can benefit the most from this technique.

Likewise, tendon transfers (using one tendon in place of another to prevent or correct a deformity) are only successful in one-third to one-half of all cases. There are difficulties in studying these surgical approaches. Not all children with myelomeningocele have the spinal deformity at the same spinal level. The level of impairment determines which muscles are weak or imbalanced.

Moving the strong anterior tibialis muscle posteriorly allows it to function instead as a plantar flexor muscle (pulls toes down toward the floor). In this study, there were eighteen children with L5- or sacral-level myelomeningocele who had a posterior transfer of the anterior tibial tendon. They could all walk without the use of a walker or crutches. The posterior anterior tibial transfer was done by one surgeon. The surgical technique was described step-by-step.

Whenever necessary, the front part of the joint capsule was also cut to release the ankle. This procedure is called an anterior capsulotomy. In some cases, other muscles around the ankle had to be lengthened. This approach was used to keep the ankle from rolling inward causing a valgus deformity.

After the operation, the children were put in a long-leg cast for six weeks. This means the cast included the foot and ankle and went up over the knee. The ankle was held in a position of 20-degrees of plantar flexion (toe pointed downward) and 20-degrees of knee flexion.

When the cast came off, a special plastic brace called an ankle-foot orthosis was worn. The orthosis was designed to perform several functions. It helped with ankle plantar flexion, prevented the lower leg from moving forward too far when standing, and kept the child in an upright position by preventing the foot and ankle from moving too much into dorsiflexion (toes toward face).

Two different orthotics were available. The one selected for each child was chosen depending on whether there was a need to control upright posture and prevent a crouch position or to reduce ground-floor reaction.

After surgery, the children were further divided into two groups based on pre-operative testing. Group one had normal pelvic rotation when walking, especially during the single-limb stance phase (standing on one leg while swinging the other leg forward). Group two had increased pelvic rotation. The surgeons were interested in knowing if the procedure had any effect on pelvic motion.

Pressure distribution along the bottom of the foot was measured and compared to before the surgery. They also analyzed differences in the way each child walked, a process called gait analysis.

Kinematic studies using a motion analysis system with six infrared cameras were used to examine changes in the way the knee, hip, and pelvis moved from before to after surgery. In addition to the kinematic studies, X-rays were taken before and after surgery to measure bone and joint angles while standing.

They were also able to use a special platform that measures ground reaction forces. This is the force that comes up through the ground as the foot comes in contact with the floor. Ground reaction forces are important because there’s more than just the foot and ankle affected when walking.

Any change caused by deformity in one joint will affect all the other joints in the kinetic chain. Any contact between the foot and the floor transfers the load to the knee, hip, pelvis, and spine. The change The change in where the contact occurs and with how much force is applied are both good before and after measures of the effect of the tendon transfer.

Using the Xrays, gait analysis, foot-pressure measurements, and changes in pelvic motion as measures of outcomes, here’s what they found:

Little by little, doctors are learning more about an ankle condition called multiple cartilaginous exostoses (MCE). The results of this study added new information about MCE.

First, what is multiple cartilaginous exostoses (MCE)? And what causes it? Overgrowth of bone is called exostosis or exostoses (plural form). In MCE, there are many bony projections or exostoses. They are covered or capped by cartilage. The bones affected most often are the long tubular bones of the forearm and lower leg. Sometimes flat bones, vertebrae, ribs, and short tubular bones can be affected, too.

The condition is inherited and is present in childhood. Deformity of the bones in the lower leg is often accompanied by an ankle problem called ankle valgus. Valgus refers to the way the side of the ankle that is closest to the other leg drops down toward the floor. This happens because the tibia (larger of the two lower leg bones) is tapered at the bottom. At the same time, the fibula (smaller bone on the outside of the lower leg) is shortened. When the bones shift in response to these changes, ankle valgus occurs. A second potential problem in MCE is deformity of the forearm bones.

Using the knowledge available so far, researchers have tried to come up with a way to classify MCE. It’s called the Taniguchi classification. This classification method is based on the presence of three groups. Group I is MCE alone. Children in group II have MCE with forearm involvement but the bones in the forearm (radius and ulna) are normal in length. And Group III refers to children with MCE and shortening of the radius and ulna. Alternately stated, these groups could be labeled mild, moderate, or severe. The more severe cases have worse valgus deformity with many more bone growths (exostoses).

New research shows that there are two gene mutations associated with MCE (EXT1, EXT2). Children with EXT2 mutations have more severe cases of MCE. But not all children have these mutations, so they couldn’t classify MCE using gene mutations. The authors of this study go the next step to look for links between the ankle and forearm deformities to help understand this problem.

They were able to find 33 children with MCE to study. None of the children had any surgery to correct the problem. X-rays were used as the main measuring tool.

The children were all assigned to a classification group (I, II, III). Angle measurements of the ankle were calculated using the X-rays. The location of the exostoses was also categorized by the bone affected (tibia or fibula) and the location of the bone growths on each bone (medial or lateral). Medial always refers to the side closest to the body midline (or in the case of ankle MCE, the other leg). Lateral is the side away from the other leg.

The authors looked for other factors that might predict the presence of both bone deformities (ankle valgus and forearm deformity/shortening). For example, age and gender were considered as possible contributing factors. They also compared degree of ankle valgus deformity within each of the three Taniguchi groups.

They found a distinct correlation (link) between Taniguchi Group III and ankle valgus. Most of the extra bone growth was between the two bones of the lower leg (tibia and fibula). Boys were affected more often and with greater severity compared with girls.

Shortening of the fibula was present in all Group III children. The result was severe ankle valgus. At the same time, the researchers noticed that children in Group III with the shorter fibulae also had shortening of the ulnar bones in the forearm. The fibula in the lower leg and ulna in the forearm are the smaller of the two bones in both locations.

What’s the connection here? This is not clear yet. More study is needed to understand why extra bone growth or deformity occurs in each location (fibula, tibia, ulna, radius) and at which site (medial versus lateral). Exploring these variables might help determine how to predict who will have severe MCE and when and how (and when) to treat it.

In this study, surgeons look into the cause of toeing-in or toeing-out while walking for children with Perthes disease. Nine children with this condition were included. They didn’t develop this change in how they walked until they were older (between seven and 15-years old). Perthes disease is a condition that first affects the hip in children between the ages of four and eight.

The condition is also referred to as Legg-Calve-Perthes disease. The full name is in honor of the three physicians who each separately described the disease. In Perthes disease, the blood supply to the capital femoral epiphysis (growth center of the hip) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals. How the bone heals determines how the condition will affect the child later in life.

The main problem with Perthes disease is that it changes the structure of the hip joint. The amount and type of deformity will determine way the hip joint works. The greater the deformity after the condition has healed, the more difficulties the child may have with walking. The nine children included in this study started toeing-in or toeing-out because of a hump deformity of the femoral head left over after treatment.

Instead of a nice, smooth, round head at the top of the femur (thigh bone), the disease left them with a misshapen femoral head. It was more of an oval or egg shape. The leg rotated in or out in order to avoid pinching the hump part of the uneven femoral head against rim of the acetabulum (hip socket). This type of pinching during hip movement is referred to as impingement. Because of its location in the hip, the impingement was labeled femoroacetabular impingement (FAI).

Using three-dimensional (3-D) CT scans, they found that in-toeing was to compensate for a laterally deviated(rotated) femoral hump. And out-toeing occurred in hips with an anteriorly deviated femoral hump. Lateral means the hump was to the side. Anteriorly tells us the hump was more forward along the front of the femoral head. By comparing the deformed side to the normal hip, they were able to measure how much rotation there was of the femur in relation to the acetabulum.

The 3-D CT scans were helpful because they took cross-sectional slices of the femoral head and hip joint as if viewed from above (bird’s-eye view). The shape of the femoral head was clearly seen. The size, shape, and location of the hump was measured and described. Hip range-of-motion measurements were taken and compared to the impingement pattern based on whether the child toed-in or toed-out during walking.

They found that the hips of children who toed-out rotated out on the affected side when they walked while the pelvis rotated in on the other (unaffected) side. At the same time, hip flexion on the involved side was decreased compared to the uninvolved hip. Several children in the toe-out group also had limited hip extension.

The opposite was true for the in-toeing group. The affected hips were internally rotated while the pelvis on the opposite side was externally rotated. There was a significant loss of external rotation in the Perthes hip of the in-toeing patients. An equal number of children in the in-toeing group had a loss of hip extension. Movement of the leg away from the body called abduction was also limited in all children in the in-toeing group.

The authors make note of the fact that out-toeing and especially in-toeing are normally rare in children with Perthes disease. The fact that there were only nine children over nine years at their clinic with this problem was proof of that. This type of abnormal gait pattern comes about because of changes in the shape of the femoral head. The location, shape, and size of the hump determines where and how much femoroacetabular impingement occurs. The upper portion of the femur rotates as a way to avoid impingement when walking.

If the hump is small enough, no changes occur. But when a large enough anterior hump is present (toward the front of the femoral head), the hump comes up against the rim of the hip socket, thus preventing further hip flexion. A large hump along the lateral (outside) half of the femoral head limits hip abduction. As the leg moves away from the body, now the laterally located hump bumps up against the acetabulum. Rotating the femur changes the location of the hump in the socket and reduces or eliminates the impingement.

The 3-D CT scan helped the researchers understand the biomechanical changes in the hips of children with Perthes who had an in-toed or out-toeing gait pattern. Basically, the hump deformity of the femoral head forces the upper part of the femur to adapt to keep motion as normal as possible. The pattern of change will depend entirely on the hump size, shape, and location.

The authors suggest using 3-D CT to map details of the femoral head before surgery. Getting an even, round shape of the femoral head is important in the treatment of advanced Perthes. Avoiding an ovoid-shaped deformity of the femoral head can also prevent gait disturbances.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip in teenagers between the ages of 12 and 16 most often. Cases have been reported as early as age nine years old. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone).

If untreated, serious problems can occur in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. Surgery is done to manipulate or reduce the epiphysis. This means the surgeon puts the slipped part of the growing bone back in place. It’s held there with long pins or screws. The procedure helps stabilize the hip and prevent the situation from getting worse.

The subject of this study is the unstable SCFE. Without good placement of the capital femoral epiphysis, loss of blood supply to the area can result in osteonecrosis (death of bone). In fact, six out of 10 children with an unstable SCFE develop osteonecrosis. The long-term effects of osteonecrosis can be very severe.

Surgeons have developed a way to treat an unstable SCFE. They decompress the hip by performing an arthrotomy. Decompression takes pressure off the joint. During an arthrotomy, the surgeon cuts into the joint and may remove some or all of the joint capsule surrounding the joint. When the joint capsule is cut away or removed, it’s called a capsulotomy. Reducing pressure inside the joint with an arthrotomy and capsulotomy greatly reduces the risk of osteonecrosis.

The theory behind this approach is that high pressure in the hip joint is present with unstable SCFE. Bleeding occurs into the joint forming a hematoma (pocket of blood). Releasing the build up of pressure from this intracapsular blood by doing an arthrotomy reduces the risk of osteonecrosis.

In this study, orthopedic surgeons measured the pressure inside the hip joint of 13 children with unstable SCFE. They also measured the pressure inside the hip capsule on the uninvolved side for comparison. Both measurements were taken twice to confirm the reproducibility of the test.

When the mean arterial pressure (MAP) (inside the joint) was more than 30 mm Hg, the joint capsule was released. Intracapsular pressure was measured again after reduction of the SCFE and capsulotomy. In the case of the 13 children in this study, all but one capsulotomy reduced the capsule pressures significantly.

The authors suggest that the results of this study show how manipulation or reduction of the slipped capital epiphysis without decompression is what leads to the loss of blood supply and death of bone. In the past, it was thought that the original injury (not the treatment) was what lead to osteonecrosis.

It is important to stabilize the slipped capital femoral epiphysis but this must be done in such a way as to avoid causing a build up of fluid inside the hip joint. High intraarticular pressures block circulation resulting in osteonecrosis.

Immediate surgical treatment is needed for an unstable SCFE. The authors advise surgeons to perform the capsulotomy even before reducing and fixing the slipped epiphysis. Measurement of capsular pressure should be taken after the capsulotomy to make sure it is below the danger zone. Even with these precautionary steps, osteonecrosis can still occur. The authors advise warning parents of this (and other possible) complications before and after surgery.

Future studies are needed to continue examining this problem. The position of the hip when intraarticular measurements are taken may make a difference in outcomes. For example, in this study, the children’s uninvolved hips were in a position of internal rotation. But the hips with the unstable SCFE were measured in external rotation and slight flexion. This was the position of greatest comfort for the child.

Long-term studies must also be done before adopting this approach for all children routinely. The surgeons who performed the study did think that the short-term data would be of great interest to other surgeons treating children with this problem.

Lumps in soft tissue or over bone always raise the suspicion of a tumor. But some slow-growing tumors may be unseen for several years before discovery. This can cause significant delays in diagnosis and treatment.

That’s what happened in this case of a 13-year-old boy with right knee pain. At first, the pain was mild, but didn’t limit function or sports participation. But overtime, the pain increased until the child was no longer able to walk long distances or run.

When he went to see a pediatric orthopedic surgeon, there was no swelling, redness, or inflammation of the joint or surrounding soft tissues. He had full motion of the ankle, knee, and hip. The physical exam was essentially normal.

A diagnosis of proximal tibial epiphyseal intraosseous schwannoma was made with the help of advanced imaging studies (X-rays, CT scans, MRIs). Proximal means the problem was located near the top of the tibia (lower leg bone). Epiphyseal refers to the growth plate at the end of the bone. And intraosseous means the schwannoma (tumor) was in the bone.

The fact that the tumor turned out to be a schwannoma was significant because schwannomas (also known as neurilemmona) usually occurs in the lining of nerve tissue (not bone). This is the first report of such a problem in a child. So, it’s understandable that a diagnosis of the problem was delayed by several years.

The diagnosis was confirmed by doing an excisional biopsy (removal of the tumor). The tissue was sent to a lab for analysis. They found a soft, yellow, myxoid (mucous-like) tissue mixed with bone. The biopsy was the treatment. Once the tumor was removed, the hole was filled with a combined bone graft and bone substitute. Successful results were reported. The patient was pain free with full motion after one month. He was able to go back to full sports participation. Follow-up showed no recurrence of the condition.

The authors make note of the fact that a diagnosis of intraosseous schwannoma/neurilemmoma was never considered during the workup. Tumors of the nerve sheath are rare and even more so in children.

Doctors aren’t sure how a schwannoma of bone occurs. There are several possible explanations. First, tiny nerve fibers from each spinal nerve are known to enter the bone. These nerve filaments also have their own blood supply. Once the tumor gets started, blood from the nerve filaments is diverted to the tumor.

The tumor cells may originate in the bone marrow where schwannoma cells are found. Or it could come from the nutrient vessel supplying blood to the bone. Sometimes, the tumor comes from the nerve tissue that erodes (eats) into the bone.

The authors point out that schwannomas affecting the growth area of the bone in children are very rare. But as this report shows, they can occur in children and should be part of the list of possible diagnoses.

To help identify intraosseous schwannomas, the authors provided a description of one other similar bone tumor. They compared a typical schwannoma with a chondroblastoma. This may help surgeons consider other potential causes of joint pain when making the diagnosis.

X-rays of a benign chondroblastoma look much like X-rays of this child. And the child’s signs and symptoms were pretty much the same as they would be with a chondroblastoma. Even the location was the same for the most common chondroblastomas (proximal tibia). There were some differences in the signal intensity of the MRIs between an intraosseous schwannoma and a chondroblastoma. But the main difference was the pathology report of the tumor.

The authors conclude that even though intraosseous schwannomas are rare, surgeons should be aware that this could be the potential diagnosis. This case report confirms the need to depend on the pathologist’s report before settling on one diagnosis over another.

Idiopathic scoliosis, side-to-side curving of the spine for no known reason, can be quite severe in some teens. The curve, which is measured by degrees, not only affects the shape of the back, but it can affect breathing and the heart because of the limited space in the chest. As a result, treatment for the more severe curves is important, but there is debate as to which treatment is the best.

Although any surgery has risks, spinal surgery has the additional risk of damaging the nerves and causing neurological complications. Other complications include problems with the hardware (rods, screws, plates) that are used to straighten the back and hold the new shape in place. As a result, many doctors prefer to try traction first, using tension and force, to change the curve of the spine, before attempting surgery. If the curve can be lessened, with traction, this makes it easier to work correct the spine surgically.

To do traction, patients are put in a halo, which is a device where pins are placed in the patient’s skull and attached to a metal ring around the forehead and the back of the head, usually about the level just above the ear. While the patient is in bed, the halo is then attached to a series of weights that will gently pull on the spine to straighten it slowly. The traction must be in place at all times and is attached to a bed but can also be attached to a wheelchair or a specially designed walker. Unfortunately, there are no reliable studies to determine if the traction is a better option than surgery. The authors of this study looked back at previous research to compare the correction of scoliosis in both traction and surgical treatments.

Researchers found 53 patients who had undergone spine-straightening surgery. Thirty patients had been treated with traction before surgery. These patients had curves in their spine of more than 90 degrees or they were inflexible, being unable to bend more than 25 degrees. The control group included 23 patients who had scoliosis with curves of more than 100 degrees or kyphosis (hunchback) of more than 120 degrees, . These patients did not have traction before surgery. All the patients were under 18 years old and were followed for two years.

The halo traction was applied while the patients were under general anesthetic, according to each child’s size and weight. The traction was started immediately after surgery, starting with light weights and gradually increasing until the weight was, at most, between 33 percent and 50 percent of the patient’s body weight. The patients were allowed out of bed to use specially equipped wheelchairs or walkers that accommodated the traction apparatus. The length of treatment varied between two and 12 weeks, depending on the severity of the curve, the surgeon’s choice, and the patient’s overall health, such as any problems with breathing because of the curvature of the spine.

Two years following treatment, the researchers the angle that the spines had been corrected in all 53 children. In the halo group, the mean correction was 62 percent and in the surgery without traction group, it was 59 percent. The second, compensating curve, was 55 percent in the halo group and 51 percent in the without traction group. Among the children with kyphosis, this curve decreased on an average of 10 percent in the halo group and 21 percent in the non-traction group.

The researchers also looked at the rate of surgical complications. There was one patient in each group who experienced breathing and nerve complications during surgery, but they were fine afterwards. The non-traction group had problems with the hardware during surgery in two patients, while only one in the traction group had similar complications. The article lists the non-traction group as having three “other” complications and the traction group having two “other” complications.

Finally, patients with kyphosis who didn’t have traction had a few more complications than those with scoliosis. The kyphosis group had five patients who had problems with either back and chest pain, difficulty fitting braces, or eating. In the kyphosis group who did have traction, only one complication- further curving of the spine- was reported. When the researchers looked at the 23 patients who had acute idiopathic scoliosis, of whom 15 had halo traction and eight didn’t, they found that the patients who had traction stayed in the hospital almost twice as long as those who did not have traction. After two years, the patients were assessed again. The patients who had had halo traction had a 33 percent rate of complications compared with 25 percent in the non-traction group.

The authors wrote that traction is safe and effective in correcting spinal deformities, with the traction allowing a slow and gradual partial straightening of the spinal curve. This makes it easier for the surgeon when the spinal surgery is performed. In one study done by Mehlman and colleagues, 24 patients had the halo traction before surgery and only one had neurological complications after surgery. Another research team, Qian and colleagues did find that some patients who have halo traction have a complication called temporary brachial plexus palsy, which is a weakening of the nerves and muscles around the arm and shoulder.

In conclusion, the authors wrote that there was no difference between the curve correction, spine length, operating time or complications between the halo traction group and the control group, although there was a significant difference in the length of stay in the hospital. Therefore, when deciding whether to use the halo traction, surgeons must take into account the impact of the treatment. More and more, halo traction isn’t needed because of advanced surgical techniques. However, as the surgeries become more demanding, surgeons need be sure about assessing the patient’s baseline condition (condition as is, before surgery) and being aware of the need of quality monitoring of the patient’s neurological status during the surgery.

Curvature of the spine called scoliosis can occur with no known cause. When older children and teens are affected, it’s called adolescent idiopathic scoliosis (AIS). Despite our many advances in medicine, science, and technology, we still don’t know what causes AIS.

In this study, researchers from Greece explore the possibility that competitive sports activities might be a causative agent. The highly repetitive nature of athletics combined with exercise-related stress on the spine could be a risk factor for this condition. It’s possible that in undeveloped children and teens, the immature musculoskeletal system can’t handle the physical stress.

They conducted an observational study of over 2,000 adolescents (boys and girls). Everyone filled out a survey with information about themselves: their age, gender, daily activities, family history of AIS, and so on. Based on the answers to the questions, each child was put into a group according to his or her activity level. The two groups were labeled athletes and nonathletes.

Athletes were defined as those children who played a sport on a regular basis for at least two years before the study. They trained for at least 10 hours each week and were members of an athletic organization (club or association). Nonathletes did not practice or play in any sport. They could play games for recreation and still be included. Anyone who did not meet the criteria for one of these two groups was excluded from the study.

Then each child was examined by three orthopedic surgeons. The surgeons did not know which group the child was in. Posture, leg length, and general health were assessed. A special forward bending test called Adam’s test was used to screen for any curvature of the spine. Anyone with suspicious signs of scoliosis was sent for X-rays.

There were 99 cases of confirmed scoliosis (defined as a curve measured on X-ray as 10 degrees or more). There were an equal number of children diagnosed with AIS in both groups.

Hours of practice among the athletes averaged about 12 hours each week for boys and 13 hours for girls. Girls were more likely to be involved in gymnastics. The most popular sport with boys was soccer. Otherwise, there were no differences between the two groups.

Height, weight, and activity level did not appear to be linked with the onset of AIS. Being right-handed versus left-handed or strongly dominant with uneven load on the spine did not seem to make a difference in risk for developing AIS.

The authors conclude there probably isn’t a relationship between exercise and the onset of AIS. Previous studies reporting an increased number of athletes with AIS and linked it with delay in maturation and positive family history. One study concluded that activities that involve all the joints and muscles may be protective against scoliosis. The possibility of a genetic factor has been raised but could not be confirmed by this study.

This is the first report of surgical treatment for Perthes disease using shelf acetabuloplasty. The surgery is simple and results were good for fast pain relief. Medium-term outcomes were reported with follow-up from five to ten-years.

Perthes disease (sometimes referred to as Legg-Calvé-Perthes) is the collapse of the hip joint due to a loss of blood supply. It occurs most often in children between the ages of four and eight.

In this condition, the blood supply to the capital femoral epiphysis (growth center of the hip) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals. How the bone heals determines how much problem the condition will cause. This condition can lead to serious problems in the hip joint later in life.

To help prevent deformity and keep a stable hip, surgery may be needed. The children in this study had severe Perthes with hinged abduction confirmed by X-rays. Hinge abduction is the abnormal movement of the hip that occurs when a femoral head, deformed by Perthes disease does not slide as it should within the acetabulum (hip socket).

In such cases, a large portion of the femoral head is not under the acetabulum. As a result, during hip movement, a portion of the bone and cartilage from the deformed femoral head gets pinched against the acetabular rim. It is a painful condition that can be corrected surgically.

Shelf acetabuloplasty is the use of grafted bone to build a shelf to deepen the socket. Strips of bone are taken from the pelvis. They are inserted into a slot cut into the acetabulum. Enough bone is grafted to cover the front and sides of the uncovered femoral head. This procedure is possible when the femoral head is not flat or too large for the size of the socket.

In this study, 27 children with unilateral (one-sided) Perthes disease were treated with a shelf acetabuloplasty. Ages ranged from three to 14. All had hinge abduction confirmed by a special X-ray called arthrogram. Dye was injected into the joint and a series of X-rays were taken. The joint can be imaged this way from many angles in real time.

Results were reported in terms of pain, limp, and deformity. Pain relief was right away and remained that way for most of the children. In a few children, activity brought on some mild pain from time to time. Limp was improved or eliminated in all but one child. Hip motion also improved in the majority of the patients.

Special care was taken to avoid damage to the acetabular growth plate. The surgeon placed a needle where the cartilage rim met the growth plate. All efforts were made to stay away from this area. As a result, there were no cases of injury to the acetabular growth cartilage.

The authors recommend dynamic arthrograms for any children with Perthes reporting increased pain and loss of motion. If the acetabulum is too vertical (socket if facing outward rather than downward), an osteotomy is advised. A wedge- or pie-shaped piece of bone is removed to change the angle of the femur (thigh bone). This creates a sharper angle and aligns the femoral head more sharply into the acetabulum.

Osteotomy is not appropriate if the arthrogram shows hinge abduction. Instead, treatment may include traction and casting to realign the hip. When surgery is needed, a different type of osteotomy called valgus extension osteotomy has been used.

Now, shelf acetabuloplasty has also been shown effective as a way to treat severe cases of Perthes. In addition to fast pain relief, this procedure has the advantage of fostering acetabular growth. Pressure up through the femur during weight-bearing exerts forces on the growing femoral head and stimulates growth. With the shelf in place, proper formation of a round femoral head (avoiding a flattening effect) is possible. This procedure is not possible unless the femoral head has the potential to remodel.

Fibromyalgia, an autoimmune disease, is one that usually affects adults. However, there is a fibromyalgia syndrome that affects children, called Juvenile Fibromyalgia Syndrome. Like adult fibromyalgia, the syndrome causes general pain and tender points throughout the body, fatigue, difficulty sleeping, irritable bowel syndrome, and other problems. While fibromyalgia affects mostly women, juvenile fibromyalgia also affects mostly girls, although it can affect boys. It usually strikes children in the mid-teen years, from 13 to 15 years old.

Juvenile fibromyalgia is as puzzling to researchers and doctors as is the adult type. As well, doctors don’t know how children with the syndrome will end up, although some research says that the majority of affected teens (80 to 90 percent) continue to have symptoms two to three years after follow-up. Doctors have also found that many teens with fibromyalgia also have emotional or psychological problems that can play a role on how the syndrome progresses.

Although research has found that depression and anxiety can be found in adults with fibromyalgia, this research hasn’t been done in children. Up 24 to 34 percent of adults with fibromyalgia appear to have these difficulties, although this may be higher as not everyone with fibromyalgia who experiences depression or anxiety seeks medical help.

The authors of this article wanted to find out how many children with juvenile fibromyalgia experienced anxiety and/or depression during their illness and throughout their lifetime. To do this, researchers recruited 76 children, aged from 11 to 18 years, who had juvenile fibromyalgia. To qualify for the study, the children must have had general pain in three or more places for three or more months, with no explained cause. Or, they could have severe pain in at least five tender points and at least three other symptoms, such as irritable bowel, headache, sleep difficulties, and fatigue.

The patients were sent information on how to complete a pain diary one week before their first visit, when they turned in the diary. At the visit, the patients completed an interview using the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). This method is used to assess psychiatric issues. The researchers also obtained information on any medications used and pain intensity ratings on a visual assessment scale (VAS) of 0 to 10, with 0 being no pain and 10 being the worst pain ever. A rheumatologist also assessed the patients were doing. This, too, was on a scale of 0 to 10, ranging from “doing very poorly” to “doing very well.”

When gathering the data, the researchers found that the children’s VAS rating on pain in their pain diary was an average of 5.27 (out of 10). Seventy-three patients completed the K-SADS-PL and 49 had at least one current psychiatric diagnosis at that time and 72 had one over their lifetime. The most common diagnosis was anxiety disorder (phobias, anxiety and panic). Twenty-two patients had two diagnosis at the same time. Sixteen patients were diagnosed with mood disorders at the current time and 30 over their lifetime. Six patients had major depressive disorder. Attention deficit problems were found in 19 patients. Put into percentages, children with fibromyalgia syndrome had a 67.1 percent chance of having a psychiatric diagnosis at least once and a 71.2 percent chance in their lifetime. In the general population, there is a 36.7 percent chance of children and teens having a psychiatric problem.

Many of the children were taking medications most often the older antidepressant medication, amitriptyline and/or pain relievers from the nonsteroidal anti-inflammatory drugs (NSAIDs) group. Some other types of antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and medications for seizures were given to a few children.

The authors wrote that the findings weren’t surprising as they had found earlier that children with juvenile fibromyalgia tended to have more anxiety than children who didn’t have it. They found that teens with the disorder “were perceived as more sensitive and isolated than their peers.” The study outcome is important in helping doctors understand treatment of juvenile fibromyalgia and that anxiety orders are often part and parcel of the problem. The authors also point out that their finding of attention deficit disorder was a new finding so more research is needed along those lines.

As with all studies, this one had limitations. For example, the children in the sample weren’t representative of the general public as they had all been referred for care and the sample size itself was small, making it harder to draw general conclusions. However, despite these drawbacks, the researchers believe that the study findings are a good start in helping understand the psychological issues associated with juvenile fibromyalgia.

Dislocated elbows are not an uncommon injury in children. Between 3 percent to 6 percent arm injuries in children are traumatic elbow dislocations, caused by an injury. Up to 41 percent of the dislocations are also part of other injuries around the elbow and are usually caused by a fall on to an outstretched arm and hand. As with most injuries, complications can happen and one serious one after a dislocated elbow and fractures of the lower arm bones, the ulna and the radius is called compartment syndrome.

Compartment syndrome happens when swelling and pressure within the muscles begin to build. But, the way the body is built, there is no room for the swelling to go and the pressure continues to build on the muscles, blood vessels and nerves. As this pressure increases, the blood can’t flow to the muscles and this causes death to cells in the muscles and nerves.

One type of elbow dislocation and injury is rare but it can result in compartment syndrome. This is the osteochondral fracture and it occurs in between 4 percent and 7 percent of elbow fractures. With this type of fracture, the cartilage that covers the end of a bone in a joint and creates bone or cartilage fragments. It is possible for doctors to miss this diagnosis as it is such a rare injury. Sometimes, when the elbow is dislocated, it can move back into place on its own right away and in these cases, it may be even more difficult for a doctor to see the fractures.

The authors of this article discuss a case of a four-year-old boy who had fallen off a swing set five days before they saw him. He had pain in the right elbow and wasn’t able to extend, or stretch out, his fingers of his right hand. The day he had fallen, he was seen in an emergency room and was diagnosed with having an olecranon fracture. This is a fracture of the very tip of the elbow. He was given a cast that kept his arm bent at 90 degrees. After 48 hours, he was brought back to the emergency room because of unrelieved pain. The cast was removed and reapplied. Three days later, he was brought to the institution where the authors were because the boy still had pain and was having difficulty moving his fingers.

The doctors examined the elbow and found that there was a tense swelling in the forearm and there was ecchymosis, a type of bruising that shows that blood is escaping into the body tissues. The boy could move his elbow a bit, with pain, but stretching his fingers caused excruciating pain. X-rays showed a bit of osteochondrial bone and a computed tomography image (CT scan) confirmed that there was a speck of bone where it shouldn’t be.

Surgeons operated on the arm to remove the pressure that the bone speck was causing, debris was removed as was any part of the muscle that was no longer usable. After the surgery, the boy was casted for five weeks and then he used a hinged brace for another week.

One year after the surgery, the boy had no pain in the elbow and good elbow movement.

The authors concluded with an emphasis of the importance of careful clinical and x-ray examination of children who have elbow injuries. They also wrote that they recommend “more surveillance for all children who revisit the hospital within 48 hours following this sort of injury.”

A trigger finger is a condition where a finger is stuck in a bent position as if pulling a trigger. The tendon in the finger, the tough fibrous tissue that controls the finger’s motion, becomes irritated and may swell up in the opening of the passage through the finger. As it becomes inflamed, the tendon can thicken and then get caught in the opening. When the situation isn’t severe, it is possible to straighten the finger and you may even feel a popping sensation as the tendon is released from the opening. but in severe cases, the finger remains bent.

Although the cause of trigger finger isn’t really known, doctors do know that people who use repetitive motions with their hands and fingers are more prone to developing the problem.

The author of this article wrote about a 13-month old boy who was originally seen because he had a “crooked thumb.” When the parents were questioned, they mentioned that for the past three months, they noticed that the child was having difficulty extending his thumb and that when he did, they could sometimes hear a clicking or popping sound. No treatment has been done and the child is being considered for surgery to correct the problem, diagnosed as trigger finger.

Since doctors don’t know what causes trigger finger, this case is interesting because it puts into question how trigger finger starts. Is it something that someone is born with, perhaps (a congenital condition)? Is a child’s trigger finger different from an adult’s? And how and when can surgeons tell if surgery is the right step? Some studies have shown that there is no congenital trigger thumb and that even a child’s trigger thumb is caused by something. Estimates are that about three out of every 1,000 children born will develop the condition. There isn’t any agreement on the reason why they develop it though. Some researchers feel that the tendon and the sheath around it are mismatched, causing irritation, while others feel that there is a degeneration of tissue because of the way a baby holds his or her thumb in the early years.

Right now, there are many opinions about how to treat trigger finger in a child. Some surgeons prefer not to do surgery and would rather try other options, such as watchful waiting (not doing anything unless the condition gets worse), stretching the finger, or splinting it. Using this approach, it’s felt that the condition will fix itself. Other surgeons, however, feel that the best treatment is surgery, releasing the tendon so that the finger has full range of motion again.

One study, by Dinham and Meggitt, reviewed 131 thumbs with trigger finger on 105 children. Twenty-six thumbs were left as is and observed, rather than treated. Of these 26, 19 cleared up on their own. One hundred five thumbs were treated with surgery and 100 had full recovery. Other studies show different numbers of the thumbs healing on their own, or spontaneous resolution. The numbers range from zero to 66 percent.

When treating a trigger finger with exercises and splinting, the results vary considerably. In one study of 58 thumbs in 46 children by Watanbe, the results were originally reported as “satisfactory” in 96 percent of the thumbs, but when looking at the data further, it was found that 34 of the thumbs, 59 percent, were not with normal function. Yet another study by Nemoto and colleagues, described nighttime splinting of 40 thumbs for about 10 months. They, too, reported a good success rate (73 percent), but several patients were not accounted for in the final results. Finally, a third study by Lee and colleagues, looked at full-time splinting, not just at night, in 31 locked thumbs. The results of this study of six to 12 weeks found that 71 percent of the thumbs had improved, but full motion was not found in all thumbs.

Surgery, usually recommended if the trigger finger is still present after a year, can vary according to the surgeon. Usually, surgery is quite effective. A study by McAdams and colleagues followed for 15 years children who had the trigger finger released. The surgeons had released 30 thumbs in 21 children. Their findings, after 15 years, was that no-one had a return of the trigger finger and all had good use of the affected thumb or thumbs, although 23 percent did have a bit of trouble straightening out the thumb and 18 percent could hyperextend the finger. Other similar studies had similar findings. However, one study done by van Loveren and van der Biezen has found that the simple surgery done by most surgeons, a release that allows the tendon to move freely, may not be enough. They found that of their review of 16 patients, 69 percent needed a release of the area around the first part that was released. Lastly, some surgeons say that the surgery may not be necessary at all, but that using a needle, they can fix the problem.

The author writes that it’s obvious that there are several limitations to the available studies so it’s not possible to come up with a definitive optimal treatment for trigger finger of a child’s thumb. Further study is needed comparing the types of treatments, the results, and the long-term outcomes.

A common and potentially serious fracture in children is a supracondylar fracture of the humerus (upper arm bone). Humeral fractures are named for the location of the break. A supracondylar fracture tells us the bone is broken at the lower end of the humerus above the elbow. In children, this fracture occurs most often around ages six to seven.

Surgery is needed to reduce and fix the fracture. Reduction refers to the process of putting the two displaced ends of the bone back together. A pin or a special wire called Kirschner (K-wire) is used to hold it in place until healing occurs. The surgeon uses a special X-ray imaging technique called fluoroscopy to see the bone. This can be done without making an incision and opening up the arm.

The surgery is usually done with the child in the supine position (on his or her back). But there are problems using this position. It’s difficult to hold the bone in place while inserting the wire.

The elbow must be fully flexed making it difficult to get the fluoroscope arm around it. The arm must be rotated externally (outward) to get the proper view. Even with two people working together, it’s difficult to keep the fracture reduced. When there’s swelling it’s difficult to see or feel the nerve. It’s very easy to poke the ulnar nerve with the wire and cause nerve damage.

In this study, surgeons from Europe show how using the prone (face down) position can be done easily and safely without complications. The child is placed at the edge of the table with the arm hanging down freely over the edge. Gravity helps pull the bone down and aids in the reduction process.

The elbow position in less than 90-degrees of flexion is an added benefit of this position. Blood supply to the arm is better. And there’s less chance that the ulnar nerve will get pinched or compressed in this position. One surgeon can manipulate, distract, reduce, and fix the arm without an assistant. The wire can be inserted from both sides of the elbow.

The authors showed excellent results with 455 patients treated this way over a period of 17 years. An equal number of right and left arms were reduced using the prone method. Children ranged in age from three to 14 years old.

Everyone was rechecked after 14 days to make sure the arm position was maintained. A second X-ray was taken when the K-wire was removed at the end of six weeks. A recheck was done at three months and again after six months. Only 3.5 per cent of the fractures had moved. The cause of this problem was incorrect wire placement.

Other complications were minimal. One per cent of the group had infection at the pin (wire) site. No one had loosening of the pin. Everyone was wearing a full arm cast, which helped support the arm and the pin.

The authors conclude that treatment for supracondylar fractures can be technically difficult. There can be lots of problems. One way to get around this is with the method described here. There is less risk of blood vessel and/or nerve damage.

Once the arm has been reduced, the arm doesn’t have to be moved again. This makes passing the wires through the arm easier and more accurate. There’s less risk of damage to the surrounding soft tissues. Being able to pass the wires through the arm without flexing the elbow so far reduces the risk of injury to the ulnar nerve.

There are a few problems to consider when using the prone position to reduce a supracondylar fracture. Sometimes getting the patient into a face-down position is difficult. It takes longer, which means the patient is exposed to the anesthesia for a longer period of time.

They may be other injuries to consider. Some injuries could make it difficult or impossible to use the prone position. And if surgery is needed to open the elbow, the patient must be repositioned to expose the area. For patients with a simple supracondylar fracture, the prone position simplifes the reduction process.

Septic arthritis is a type of arthritis that is caused by an infection in a joint. The infection is usually caused by bacteria, but can be caused by a virus or fungus, as well. Septic arthritis can occur in children. In fact, three percent to four percent of all cases of this type of arthritis are in children. Because this type of arthritis can cause quite a bit of damage to the joint, early detection and treatment are vital.

In this article, the authors discuss the case of a six-year-old boy who complained of fever and pain in the right shoulder. The shoulder was painful but there had been no injury or trauma to the area. He was treated initially by doctors at a local hospital, who first gave the patient an antibiotic, amoxicillin, for five days. This was stopped, however, because there was no change in the boy’s fever. The doctors then started treatment with two more antibiotics given by intravenous: teicoplanin, a strong antibiotic usually used for severe infections was given for 15 days and then meropenem followed for another 15 days.

After the 28 days of treatment, although the boy’s fever had gone down a bit, the pain wasn’t relieved and he was still unable to use his shoulder properly. At this point, the doctors did a arthrocentesis, where they removed some of the fluid in the joint to analyze it. Although the fluid was green-yellow, the analysis didn’t find any particular cause for the infection.

By the time the boy was seen by the authors of this article, 35 days had passed from the first day of symptoms. The shoulder x-rays showed that there was fluid in the joint and that there was a thickening of tissue as well. The patient also had a computed tomography scan (CT scan) and magnetic resonance imaging (MRI), with which the doctors could see that the bone in the joint had been damaged. The results of these images and the fluid analysis helped the doctors diagnose septic arthritis.

Treatment for septic arthritis of the knee in children is usually an arthroscopic washout and it is being used more often for treatment of septic arthritis of the hip. However, it has rarely been done for septic arthritis of the shoulder. The procedure involves making a small incision in the joint and then flushing the joint with fluid. The authors of this article performed the washout and debrided the area as well, removing any debris or dead tissue in the joint. Lastly, they did a synoviectomy, which is removing some of the membrane. Drainage tubes were left in so more irrigation to the joint could be done and the arm was placed in a sling.

The drainage tubes were removed four days after the surgery. After receiving more antibiotics by intravenous, teicoplanin again and another antibiotic, ceftriaxone disodium, both for seven days after the surgery, the boy went home on oral antibiotics. He was seen at two months after the surgery and the doctors found that he had recovered completely, although the x-rays did show some irregularity in the bone.

The authors wrote that it isn’t always easy to diagnose septic arthritis in children, which may delay treatment. The prognosis of a child with septic arthritis depends on the age of the child, how far the infection has gone, and how long the treatment has been delayed. Although aspirating the fluid with a needle is simple and inexpensive, this technique doesn’t allow the doctor to see inside the joint nor to remove any debris if needed. Arthroscopic treatment, however, does allow for removing the fluid and performing other techniques as well.

The angle of the femur (thigh bone) as it supports the femoral head in the hip socket is important. If there’s too much (or not enough) angulation in one direction or another, it can cause a problem in the growing child. Coxa vara is one of these problems and the subject of this study.

The normal femoral neck angle is about 150 degrees at birth. As the bones grow and develop, the shape changes. By the time we are adults, this angle is about 125 degrees. Less than 110-degrees creates this condition of coxa vara.

Congenital (present at birth) coxa vara is often seen in children who have other deformities or congenital conditions. In this study, children with osteochondrodysplasia (including coxa vara) were treated surgically. Osteochondrodysplasia is a general term for a disorder in the development (dysplasia) of bone (osteo) and cartilage (chondro).

The purpose of the study was to see what kind of results are possible after surgery to correct the hip deformity. Children from age four to 13 were followed for up to 24 years. At first, the authors used arthrography under general anesthesia to assess the hip, especially the cartilaginous structures.

An arthrogram is a series of X-rays of a joint after injection of a dye. A special X-ray called fluoroscopy is used to guide the needle into the correct place in the joint. The joint can be seen from many angles in real time using this method. Early in the study, they realized that arthrograms were not necessary. Only plain X-rays were needed to measure femoral neck angles.

There were two groups of patients based on the condition of the bone and cartilage. Group one had coxa vara with a nonintact epiphysis (round femoral head). The femoral head was fragmented in pieces and had not ossified or solidified into one smooth, round bony structure.

This condition was referred to as coxa vara with fragmented or nonossifying epiphysis. It is the result of a genetic mutation affecting collagen. Collagen is the basic building block of soft tissue and bone structures. The children with this type of disorder often have severe deformities of the spine and limbs. Their growth is delayed or stunted.

Group two had coxa vara but with a normally shaped and developed femoral head. Group two (hips with a regular epiphysis or femoral head) was further classified into two separate subgroups (IIa and IIb) based on the exact location of the angular deformity.

The actual surgical procedure done varied depending on the deformity present. The goal of surgery was to stop slippage of the growth plate, improve hip motion, and reduce pain. Limping or other abnormalities when standing and walking were also addressed.

The most common surgical procedure was an osteotomy. A wedge- or pie-shaped piece of bone was removed. It may be reinserted on the other side to further change the angulation. In a few cases, the osteotomy was accompanied by a derotation procedure.

In those patients, the femur was actually twisted or turned during surgery to further improve angulation and hip stability. There were patients with other osteochondrodysplasia deformities requiring additional surgeries.

Everyone was placed in a spica cast for six to eight weeks. This type of cast goes from the waist down to the toes on the involved side and from the waist down to just above the knee on the uninvolved side. Sometimes, bilateral coxa vara is present requiring surgery on both hips and a full spica cast on both sides.

The results of surgery for group one with fragmented or nonossifying femoral head were very poor. This was especially true for children operated on early (age four). The patients in this group ended up with hip pain and stiffness. Despite improved femoral head and neck angles, joint motion throughout the entire range was not improved. Degenerative arthritis requiring joint replacement was common in the early adult years for this group.

Group two (subgroup IIa) had quite a few cases (60 per cent) of recurrence. The authors suggest this might be caused by the young age of the children at the time of surgery. With so much growth still remaining, the hip could not be kept stable. Over time, some children in this group also developed a leg-length difference.

Children in subgroup IIb had better results because the deformity was mild-to-moderate and didn’t require surgery. When surgery was done in this group, the results were good with lasting benefits.

Overall, recurrence of hip instability after reconstructive surgery for coxa vara linked with osteochondrodysplasia was common. In this study, the prognosis for most patients did not change with treatment. This was especially true when surgery was performed at a young age (before growth is complete).

Surgeons are encouraged to delay surgery until an HEA is greater than 60 degrees. HEA refers to a measurement made on X-rays called the Hilgenreiner epiphyseal angle. The authors also suggested that bracing to hold the hips in place may be helpful until surgery is done. This type of treatment was not done in their patients.

Bracing may make it possible to change mechanical and anatomic factors affecting the hip. Placing stress and strain on the skeleton with special immobilizers and/or braces may help stabilize the femoral head before surgery. More studies are needed to clarify this.