News Category: Child

This is the first published study on the number and type of injuries sustained by children using an inflatable bouncer. The bouncers are enclosed and seem safe, but accidents do occur.

Although some people purchase their own bouncer, most of these inflatable houses are rented for special functions. And as more and more children use these bouncers, the number of injuries is on an upward trend, The Consumer Product Safety Commission (CPSC) reports some, but not all, inflatable bouncer injuries. There are no safety regulations for the use of these devices and no requirements for reporting injuries.

In this study, the medical records were reviewed for all pediatric patients treated for inflatable-associated fractures. Forty-nine (49) children from age one to 15 years were included. Most of the children were between the ages of seven and nine.

Injuries occurred when children of different ages and sizes crashed into each other. Sometimes the force was enough to throw the child out of the bouncer. Smaller children fell out of the bouncer without colliding with someone else. Landing on a hard object caused a bone fracture or other soft tissue injury. Sometimes the inflatable device lost air and collapsed. The sudden loss of support caused injuries as well.

The most common injury was to the elbow. Other injuries to the upper arm, forearm, and wrist made up the bulk of problems. Leg injuries affecting the shin and thigh were the next most likely injury pattern. Slipping and getting the leg trapped in a twisted position was a typical pattern of leg injury. Boys were three times more likely to get hurt than girls.

The authors suggest (based on their findings) that there are ways to prevent these injuries. Adult supervision is important. Almost half of all bouncer-related injuries are attributed to a lack of adult observation and guidance. Too many children of all sizes, shapes, and ages are often in the inflatable device at the same time.

Experts recommend keeping children of similar ages and sizes in groups. Parents and other adults must be on hand to provide guidance and supervision at all times. Only small groups should be allowed inside at one time. Rough-housing and deliberate pushing or bumping into one another must be limited. The bouncer must be inflated to the recommended pounds per square inch at all times.

The authors hope the results of this study will increase public awareness of the dangers associated with inflatable bouncers. Previous warnings against the purchase of home trampolines applies to inflatable bouncers. Injuries are common and often preventable by following these guidelines and providing adult supervision.

You may have heard how the overuse of antibiotics has led to bacteria that is resistant to most antibiotics. In the hospitals, this has been a major concern. Patients admitted are often already at risk for infection. And hospitals are a breeding ground for many infections.

These are referred to as hospital-acquired infections. Methicillin-resistant Staphylococcus aureus (MRSA) is the most important cause of hospital-acquired infections. S. aureus is a bacteria known by its shorter, abbreviated form: staph infection.

MRSA refers to the fact that S. aureus is resistant to most penicillins. For a long time, Methicillin (a penicillin derivative) was the only drug that could combat this infection. Eventually the staph bacteria became resistant to Methicillin.

Methicillin is no longer on the market but the term MRSA is still used. Other similar drugs (e.g., flucloxacillin, dicloxacillin, clindamycin) are now in use instead. If staph becomes resistant to all antibiotics, there may be no way to treat simple infections.

Now it appears that MRSA is becoming a community-acquired infection. This is especially true for skin and soft tissue infections in children, which were rare before. This report investigates the changing pattern of MRSA acute osteomyelitis (bone infection) in children.

Investigators reviewed the records of children at the Children’s Medical Center of Dallas over a five-year period of time. They divided the overall time period into two segments for comparison. They were looking for trends or changes in the clinical pattern of acute osteomyelitis in young children.

Data was collected about a wide range of possible factors (age, gender, results of lab work and bone scans), patient treatment, and patient outcomes. They noted that S. aureus affected the bones of the lower extremity (leg and pelvis) and spine (vertebrae) most often. Staph infection was more likely than other infections to affect multiple sites (not just one bone). This was true in both time periods.

Analysis of the data showed that MRSA increased dramatically between the two time periods (more cases over time). There were other bacterial causes of osteomyelitis (e.g., streptococcus, S. pneumoniae) but most were caused by MRSA. African American and older children were the most susceptible.

And children with MRSA osteomyelitis had worse symptoms, more complications, and longer treatment. They also had more frequent and longer periods of hospitalization. The authors suggest the poor outcome of MRSA osteomyelitis was linked with more significant complications.

Children with MRSA osteomyelitis were more likely to have blood clots, spread of infection, and extensive bone involvement with bone abscesses. Children with anemia at the time of the MRSA osteomyelitis also had a worse prognosis. A smaller number of children developed long-term complications. The most common was delayed bone growth.

And although there was an increase in the number of cases of acute osteomyelitis caused by MRSA, there was no change in the resistance patterns to antibiotics during the five-year period. However, children with MRSA osteomyelitis in the later years had a more severe case with worse outcomes.

Knowing that MRSA osteomyelitis is an increasing problem among children (especially among older African American children), there is a need for more investigation and better treatment. Finding the right antibiotic and providing treatment in the optimal amount of time may help prevent serious complications. The authors suggest multicenter studies to address this problem.

Guidelines are in place for adult males injured on the football field. Cervical spine (neck) injuries are of special importance because of the danger of permanent spinal cord damage. In football, the helmet and shoulder pads are left on the adult injured player. The player is placed on a spine board and transported to the hospital. The face mask can be removed to allow for breathing.

But what about the growing number of children participating in tackle football? Should the same guidelines be followed? This is an important question because the number of boys in the seven to 17 years old group active in tackle football has almost doubled in the last 10 years. Participation in other collision sports such as ice hockey and lacrosse has also increased. At the same time, the risk of sports-related neck injuries has gone up.

Studies in the past have shown that the head-to-body size in children is different than in adults. Children grow at variable rates. But for the most part, the head during childhood is the size it will be as an adult. The body grows to match it in proportion. Adding sporting equipment might alter the spinal alignment. With an additional neck injury, this head-to-torso ratio could be important.

In this study, 31 male athletes from a local youth football league were examined by X-ray with and without protective equipment. The goal was to see if immobilization of the pediatric trauma patient is needed. Maintaining spinal alignment may be important to prevent further serious injury.

Each child was X-rayed three times. The base of the skull and cervical spine were the main focus areas. The child was placed supine (on his back) and X-rayed without the protective equipment. The second X-ray was taken in the same position with shoulder pads only. The third view was with helmet and shoulder pads.

Two physicians independently measured angles of the cervical spine. They used the standard Cobb measurement for C1 to C7 and the Gore measurement from C2 to C7. The angles were then compared among the three radiographic views. Each child’s height, weight, and age were factored into the analysis.

The results showed excellent reliability between the two physicians using both methods to calculate the spine angles. This tells us that the method of measuring spine angles can be depended on to give a true picture of what’s going on. The angle of cervical lordosis (backward curve of the spine) was greatest when the children wore just the shoulder pads.

Cervical angle did not change between being fully equipped with helmet and shoulder pads versus no equipment at all. Age, height, and weight did not seem to be a factor in spine angulation for the three equipment conditions.

Based on these findings, the authors recommend transporting pediatric patients with a potential neck injury with helmet and shoulder pads in place. The equipment aligns the cervical spine better than just one or the other. These guidelines only apply to football players. Further study is needed to identify the best way to manage and/or transport ice hockey or lacrosse players with cervical spine injuries.

Removing the equipment may result in increased cervical motion. If there is an injury, this increased motion could result in spinal cord damage. It’s best to wait until the protective gear can be removed in a controlled setting. Usually this means after X-rays have been taken at the hospital emergency department.

Bacteria, viruses, and fungi are all capable of infecting a joint. These tiny organisms invade and inflame the synovial membrane of the joint. Joint destruction with arthritis may be a local response to this infection. This condition is referred to as bacterial, infectious or septic arthritis.

Acute septic arthritis in children can be present at birth. Or it can develop in the early weeks-to-months after birth. Treatment is based on X-ray findings. The hips are classified based on radiographic appearance.

The most commonly used classification scheme was published by Dr. Choi and associates in 1990. This method places the hips in one of four types. There are eight subtypes. But the Choi classification doesn’t work well in young children. For this reason, Drs. E. Forlin and C. Milani from Brazil have devised a simpler model of radiographic classification.

The new classification has two groups. Grade 1 means the hip is well-placed in the hip socket. If there is a femoral head present, it is labeled Grade 1A. If the femoral head is absent at birth, it is classified as Grade 1B. Hips in the second group (grade 2) are dislocated. Grade 2A means the femoral head is intact. Grade 2B tells us the femoral head is missing.

With this method, there are only two groups and two subgroups. The classification is first based on whether or not the femoral head or neck was in or out of the acetabulum (hip socket). The subgroups depended on whether or not the femoral head was present or absent.

Using this grading system, the medical records and X-rays were reviewed for all children with septic arthritis of the hip. The children were treated at the hospital between 1985 and 1997. The children were first treated at other medical centers during the acute phase. Treatment at the authors’ hospital was for complications later.

After using the new classification method, results were compared with the Choi classification model. Independent pediatric orthopedic surgeons were asked to use both systems to classify the hips of 37 children with hip septic arthritis (41 hips total). The authors compared their results with results reported by Dr. Choi in another publication.

At the same time, a separate clinicalclassification was made. This was based on 1) whether or not the joint was stable, 2) range of motion, and 3) presence of pain. Unstable meant the hip was dislocated. An unsatisfactory result occurred when there was instability, less than 50 degrees of hip flexion or loss of hip extension, or a painful hip during daily activities.

The results of all comparisons showed no differences between the Choi method and this new method. The advantage of this new classification is that it is simpler and more appropriate for use with children. It relies on the assessment of two factors: instability and the presence of the femoral head.

As might be expected, type 1 hips had a better chance for a satisfactory result. The earlier the treatment, the better the prognosis. Delays of more than four days led to complications and poorer prognosis.

The authors present the procedures they used to correct the changes that occurred within the joint after infection. The shelf procedure and proximal femoral valgus osteotomy were both mentioned.

Reconstruction with osteotomy and acetabuloplasty were also discussed. Osteotomy refers to cutting out a wedge- or pie-shaped piece of bone. The bone is used to extend the shelf over the femoral head. This forms a deeper, more stable socket. Acetabuloplasty accomplishes the same thing using bone graft from some other source such as a bone bank.

In summary, the two-group/two subgroup classification scheme is simple and reliable. It helps the surgeon decide the timing and type of treatment needed. It may also be useful for making a long-term prognosis.

There are times when it would be helpful to know how well healed a bone is in a growing child. For example, when the bone is strong enough, hardware used to support the leg during healing can be removed. This situation arises after surgery for bone fracture, limb lengthening, or joint fusion.

In this study, the method of measuring bone stiffness in adults is applied to children. The idea was to see if it is an acceptable way to measure the strength of the healing bone. It would be helpful if a safety baseline could be established. Having a safe value when external fixation could be removed would help surgeons progress treatment of these children.

A small number of children (11) were involved in this study. All were in good health and having surgery to lengthen one leg. Boys and girls between the ages of five to 16 were included. A device called an Orthometer was used to measure bone stiffness.

Measurements were taken while the child was under general anesthesia after pins had been inserted to hold the bone in place. A special tool called a goniometer was used to measure the change in angle of the bone. Stiffness was recorded and bone angulation was measured in the anteroposterior (AP) direction (front to back). The same measurements were taken in the mediolateral (ML) direction (side to side).

All measurements were entered into a microcomputer that calculated the stiffness values. The results showed that all AP measurements were directly linked with ML stiffness of the bone. If the AP stiffness increased, the ML stiffness increased, too. And the triangular-shaped tibia (lower leg bone) was always stronger than the circular-shaped and more flexible femur.

AP stiffness was also correlated with height. In other words, stiffness increased with greater heighth. There was a wide range of differences among the children based on height and weight. Age did not appear to be a factor.

This was the first study to look at leg bone stiffness in children using an Orthometer. The authors point out that different results might be found in arm bones. So the baseline values obtained are to be considered preliminary.

More studies will be needed to validate these Orthometer measurements during the healing phase of children. The goal is to find a minimal value or range of safe Orthometer readings that will guide surgeons in the removal of pins, plates, cages, and other surgical hardware.

This study is part two of research done in France. The researchers measured bone stiffness to find safe levels before removing hardware used in limb-lengthening procedures. Removing an external fixator too soon can result in bone fracture and deformity. All patients were children with limb-length differences.

In the first part of the study, a special device called an Orthometer was used during the limb-lengthening operation. While the child was anesthetized and external fixator pins were in place, stiffness measurements were taken. This was considered the reference value.

In the second part of the study, clamps were applied to the external fixator pins. A goniometer (tool used to measure angles) was attached to the pins. A force was then placed between the two sets of pins. The amount of force and the corresponding bend of the bone were both measured. Bending stiffness was measured in two directions: anteroposterior (AP) and medial-lateral (ML).

Stiffness measurements were taken at three regular intervals between the time of the operation and the removal of the fixator. At the same time, bone mineral density (BMD) was measured using DXA scanning. Results using bone stiffness measurements were compared with findings of bone mineral density on DXA scans. The authors provided all of the mathematical formulas used to calculate bone length, density, stiffness, and strength.

Healing took place in 22 to 61 days. The device remained on the child for 141 to 284 days. After the fixator was removed, four of the 22 bones fractured without trauma. Stiffness progressed faster than the authors were expecting. A value of 75 per cent of normal bone bending stiffness (density) was determined to be the safety zone for fixator removal.

This is the first time an objective guideline to assess bone healing has been provided for children after limb lengthening. The amount of bone stiffness needed for safe removal of the external fixator is similar to adults. And like adults, stiffness increases in children as bone is regenerated.

The authors admit there are some limitations both to their study and to the method used to measure bone stiffness. First, this was a small study over a short period of time. Long-term studies with many more children are needed before the results can be used routinely. It may be possible to create a chart with end-point values for monitoring children and adults. Such a guide could be used during the early healing phase after surgery.

Second, measuring bone stiffness with an orthometer during the healing phase wasn’t easy. Pain, anxiety, and muscle spasm were common. Often the measurements had to be repeated more than once. They suggest that the Orthometer may be a good way to compare other imaging methods such as the DXA used in this study. The goal is still to assess safe levels of bone regeneration. Given the limitations, it may remain a research rather than a clinical tool.

This study presents the first published information using the Ponseti method for treating clubfoot in infants with arthrogryposis.

Clubfoot is a condition affecting the feet and ankles that is present at birth. It’s fairly common and occurs in about one in a 1000 infants. The clubfoot is unmistakable. The foot is turned under and towards the other foot. Arthrogryposis is a condition of joint loss of motion called contracture. The contractures are present in two or more different body parts.

The Ponseti method to treat clubfoot is defined as a series of casts on the foot and ankle. As the deformity is gradually corrected, the old cast is removed and a new cast is put on with the joint in the new, more corrected position. Surgery to release the Achilles’ tendon is done to help align the joint first. Bracing is done for several years after casting to keep the foot in good alignment.

Twelve children with bilateral (both sides) clubfoot associated with arthrogryposis were included in this study. A complex (Diméglio) scoring system was used to classify or grade the severity of each foot. In simple terms, Grade I is a mild deformity that can be almost fully corrected. Grade II describes feet with a moderate deformity. Grade III refers to a severe deformity. Grade IV is a very severe deformity.

Points are given in the scoring system that help distinguish between the grades. Areas that are scored with points include 1) the ability to reduce (correct) the problem manually (by moving the joint into a better position), 2) condition of the muscles, 3) presence of other foot deformities, and 4) ability to flex the ankle upwards toward the knee. The total number of points determines the grade given the deformity.

Most of the children in this study were graded as very severe (Grade IV). Treatment was started in the first six months of life (the earlier the better). Five to eight sets of casts were used within the group. This is more than usual for clubfoot correction but consistent with the severity of the problem.

There was a relapse in three children (total of six feet). Recurrence of the clubfoot position occurred within the first six months after correction. The cause was failure to wear the braces. This is referred to as noncompliance. But in all cases, there were problems with slippage of the foot and blisters with the braces. Repeat casting and switching to a different bracing system corrected this problem.

In the past, multiple surgeries to release the soft tissues around the contracted foot have been the main treatment for clubfoot associated with Arthrogryposis. Scar tissue often prevents a good outcome and results in repeated surgeries.

The final results showed that the Ponseti method was successful for 11 of the 12 patients. Deformities from Arthrogryposis can be well corrected with this treatment. The authors suggest the Ponseti method may work just as well (if not better) and without as much surgery as with the more traditional treatment.

Surgeons at a children’s hospital in New Zealand present the results of 11 years of treatment for large osteochondral fractures of the lateral femoral condyle. The area affected is the cartilage covering the end of the femur thighbone in the knee.

Instead of removing the torn fragments (standard practice), the surgeons held the detached pieces together with a special implant until healing occurred. They used polyglycolic acid rods for the fixation. The rods or pins are small bioabsorbable implants. During the healing process, the polyglycolic acid is absorbed and replaced by living tissue.

Eight patients were followed from injury through follow-up for at least five years. The initial injury was a twisting knee motion with the foot planted on the ground. The trauma occurred in children between the ages of 12 and 15. All of the patients had generalized ligamentous laxity throughout the body, which may have contributed to the injury.

Although the anterior cruciate ligament (ACL) inside the knee was not torn, several patients had a knee dislocation at the time of the osteochondral fracture. The shearing load of the twisting force may be what caused the patella to dislocate, rather than occurring as a direct result of the osteochondral fracture.

Many times these kinds of injuries are much deeper and broader than appreciated. X-rays and MRIs don’t always show the full extent of the injury. It isn’t until the surgeon performs the operation that the severity is clearly seen.

Taking the piece(s) or fragments out leaves a large hole that fills in with fibrocartilage. Since it’s on a weight-bearing surface, over time, the bone deteriorates and the joint develops early degenerative arthritis. This new procedure has the potential to keep this from happening.

MRIs were used to observe the healing tissue. Normal function of the joint articular cartilage returned and remained present during the follow-up. There were no poor results. Most of the children had normal X-rays, normal function for their age, and only a small amount of cartilage thinning. Everyone was followed for at least five years. The average length of time the patients were followed was more like nine years.

The authors weren’t sure the exact mechanism of healing using this method of repair. It seems that restoring the layer between the cartilage and bone resulted in a normal transition from layer to layer. It’s possible the joint recruits bone marrow cells to produce healthy transition cells between layers.

Normal function of the articular (joint surface) cartilage was the long-term goal. So far, this goal has been met in the short-term and medium-length periods of time. The research will continue to follow this group of patients and perfect the technique with new patients.

Disc herniation is most common in adults. But it can occur in children, specifically adolescents (teenagers). In about one-third of these herniations, there is a fracture of the apophyseal ring. Treatment of the ring apophysis fracture associated with disc herniation is the subject of this study.

The apophyseal ring is a tough, fibrous structure around the outer portion of the vertebral body next to the disc. It is attached to the outer portion of the disc called the anulus fibrosus. The ring apophysis attaches the anulus fibrosus to the vertebra. The ring provides an area of denser, stronger bone for the edge around the vertebral bone.

A fracture of the ring indicates that the fibrous ring (along with a small piece of bone still attached) has pulled away from the vertebra. This can occur along the upper (above) or lower (below) endplate of the affected disc. It appears to be caused more by repetitive stress rather than a single traumatic event. Many of the athletes who have a ring apophysis fracture don’t even know it.

Because of the rarity of this condition, long-term studies of many patients haven’t been possible. Thus, it’s not clear what treatment is best. Should the fractured part of the ring be removed when the disc is taken out? What happens later in life if the ring is or isn’t removed?

To answer these questions, the authors studied 96 adolescents between the ages of nine and 18 years old. All had back and leg pain from a disc protrusion in the lumbar spine. The diagnosis was confirmed with CT scans.

Each case was classified according to the location where the bone was pulled away from the vertebral body. This could be central (or middle) and lateral (or side). It was also categorized by size (large or small). Large was anything that measured more than 50 per cent of the width of the posterior wall of the vertebral body.

An analysis of the cases showed that patients with disc herniation and apophyseal ring fractures were more likely to have surgery. Age didn’t seem to predict who would or would not have a ring fracture. Males were affected twice as often as females. Level of disc herniation and history of injury were not linked with apophyseal fractures either.

One-third of the 96 patients had surgery (discectomy with or without removal of the apophysis fragments). Two-thirds were treated nonoperatively. Of the patients with lumbar disc herniation AND apophyseal ring fractures, more than half had surgery. Twenty-five per cent of the patients with disc herniation alone also had surgery. The difference between these two groups may have been severity of pain.

Patients with large apophyseal fragments had the greatest risk for a poor outcome. They were more likely to have chronic back pain years later. Small fractures did not seem to have any negative long-term effects.

The authors conclude that disc herniation with ring apophysis fracture does not require surgery because of the fracture. The surgeon makes the decision to operate based on the patient’s symptoms, not on X-ray or CT findings. It is likely that patients with both a disc herniation and fracture will have more pain than someone with just the disc herniation. Large, central fragments that are not removed pose the greatest risk for future problems.

Basketball, football, and bicycle accidents are still the most common causes of fracture in young children. Less often, monkey bars, skateboarding, jumping on a trampoline, and using heelys leads to fracture injuries.

Heelys are shoes for children that have rolling wheels in the heels. The child lifts the toes up and glides along on the heels. One foot is slightly in front of the other foot. Each shoe may have one or two wheels. The activity is called heeling.

In this study, physicians at a large urban emergency room (Miami, Florida) tally up the number of bone fractures linked to the use of heelys. They report on how often these injuries occur, who is affected the most (boys or girls), and the type of injuries.

Children coming into the emergency department with a bone fracture over a period of 90 days were reviewed. Less than two per cent were caused by heely injuries. Ages ranged from as young as five to eleven.

Girls between eight and nine years old were involved much more often than boys. This may simply be because more girls purchase heelys than boys. It’s possible girls are more prone to injury. No one knows for sure why this difference occurs. Most of the fractures were located in the wrists and forearms. A lack of safety equipment was noted in all cases.

Heeling seems like a fairly simple activity. The child stops by shifting the body weight to the front of the shoe. The wheels stop turning and the child can resume walking. But like all play equipment, problems can occur.

Forward falls outdoors onto an outstretched hand were most common. Rocks stuck under the wheel caused several of the falls. Cracks in the road or sidewalk also tossed the children down. Inexperience (using Heelys less than one week) was a factor. But even kids who had worn Heelys for more than one year had a fall and fracture.

The associated costs can be quite large even with a simple fracture. Total cost of care adds up with the charge for the emergency department visit, X-rays, cast application, follow-up X-rays, and any cast changes needed over time. No surgical costs were incurred by the patients in this study. If surgery were needed, then that could drive the cost up even more.

A survey of the parents and children showed that most would not purchase (or use) heelys in the future. Most of the participants said they weren’t going to continue using (or allow children to use) the current pair of heelys.

The authors note that accidents are going to happen in active children. Heelys don’t really put a child at greater risk of injury than other commonly enjoyed games and sports. However, safety is still a concern.

It is recommended that children using heelys should be supervised and wear protective gear at all times. This includes helmet, forearm and kneepads, and gloves with wrist padding. More effort should be made to alert parents to the safety hazards of these shoes.

There are many questions and concerns about children carrying heavy loads in backpacks. Does it matter if they sling it over just one shoulder? Should they carry it evenly across the upper back? Can they wear it down over the low back and sacrum?

Studies so far have shown that the load when evenly distributed over shoulders and upper back creates pressure. The pressure is high enough to cut off the blood flow to the skin under the straps.

In this study, the focus is on how loads are distributed under the shoulder straps. If researchers can measure the pressures from typical loads, we may be able to come up with some helpful guidelines for wearing backpacks.

The authors looked at four separate carrying patterns: 1) high on the upper back with straps over both shoulders, 2) down low on the back over both shoulders, 3) over the right shoulder only in the high back position, and 4) over the right shoulder in the low back position.

Ten children (boys and girls) were included in the study. All were healthy and between the ages of 12 and 14. Everyone wore backpack on a regular basis. The backpack was loaded at zero, 10, 20, and 30 per cent of the child’s body weight in each of the positions.

Skin sensors were used to measure contact pressures under the shoulder straps. Measurements were taken as the child was putting the backpack on. Pressure was also recorded in the standing position and while walking.

Contact pressure increased in all positions for all loads. And the level of pressure was enough to block blood flow to the skin under the straps. Pressures were highest in the right shoulder even when the pack was placed over both shoulders. This may be related to posture and the fact that children raise the right shoulder. Altering their posture in this way places more pressure in the area.

As might be expected, pressures were higher when the pack was down low over the back. This was compared with pressures with the load supported in the upper back area. Pain was also reported more often and at higher levels of intensity when backpacks were worn in the low-back over one shoulder.

The method by which the child put the pack on did not seem to influence load pattern. But the load increased when wearing the pack over one shoulder and while standing and walking. Loads were not greater for walking than when just standing quietly. And the pressure was highest along the front of the shoulder just above the collarbone when the backpack was worn low over the spine and sacrum.

The authors point out some limitations of their study. The number of children involved was low. The length of time the backpacks were worn before measuring skin pressure contact was short (25 seconds). Most children wear backpacks for much longer than 25 seconds. So over time, the pressures may be even greater than reported here.

Based on these results, children are advised to avoid wearing heavy backpacks. It’s best to keep the weight in the backpack no more than 10 per cent of the child’s total body weight. The pack should be worn close to the body as high up on the back as possible. Both shoulder straps should be adjusted evenly and used together.

Developmental dysplasia of the hip (DDH), previously known as congenital hip dysplasia is a common disorder affecting infants and young children. In this condition, there is a disruption in the normal relationship between the head of the femur and the acetabulum (hip socket). In mild cases called unstable hip dysplasia, the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called subluxation.

Early identification and treatment of this problem is important. Treatment allows normal growth to occur. With normal growth of the hip socket, dysplasia is improved. It may even be possible to avoid surgery to correct the problem.

The earlier surgery is done to correct the problem, the better the final results. The trick is to accurately predict which children are going to need surgery. It’s best to avoid surgery in children with DDH who don’t really need it.

Surgeons from Saudi Arabia think they may have found a new way to predict how things will go. They are using an angle of measurement from X-rays called the acetabular cartilaginous angle (ACA). Results of research using this new measurement are presented in this study.

All children involved had successful closed reduction surgery to correct the problem. Closed reduction means the dislocated hip was realigned in the socket and held in place with a cast. An open incision wasn’t needed to accomplish this realignment. The cast called a hip spica goes from waist to toes on the operated side and from waist to above the knee on the uninvolved leg.

After casting for three to four months, each child was placed in a special abduction splint. The splint was worn full-time for six weeks, then only at night for another six to 12 weeks.

Success was measured using X-rays to see if the head of the femur was fully underneath the bony shelf formed by the hip socket. The acetabular cartilaginous angle was used to guide further treatment. This angle is a system of lines drawn on an x-ray to judge the formation of the cartilaginous portion of the acetabulum.

It includes a horizontal line along the bottom of the acetabulum. This is the Hilgenreiner line. Where the Hilgenreiner line intersects a second line determines the angle. The location of the second line differs according to the type of hip deformity that’s present.

The authors found that if the acetabular cartilaginous angle was less than 20 degrees, then the hip was very likely to develop fully. There was no further need for surgical repair. Patients with an angle greater than 24 degrees always needed surgical correction. The procedure is called an acetabuloplasty. In this operation, the surgeon uses a bone graft (a piece of bone taken from the child or from a bone bank) to build out the edge of the hip socket. This helps enlarge the hip socket and keeps the head of the femur firmly in the socket.

Of the 234 hips corrected, 100 per cent with an ACA angle 24 degrees or more needed acetabuloplasty. Almost all hips (99.5 per cent) with ACA of 20 degrees or less did not require further surgery. The authors also report that age and acetabular index (AI) are two other important factors or indicators in predicting the need for surgical treatment.

The acetabular index is formed by drawing a horizontal line at the bottom of the pelvis and an angled line from the bottom of the pelvis to the outer edge of the socket. A normal child will have an index of 30 degrees or less. The index decreases until it reaches 20 degrees or less. This usually occurs by age four months in a normal child. An acetabular index above 30 degrees is a sign to begin treatment. The higher the index, the more aggressive the treatment.

In summary, it’s difficult to predict whether or not the hip socket will form properly after closed reduction. Early acetabuloplasty has the best results but it’s better not to do surgery if it’s not really needed. By the time it becomes clear who needs further surgery, the results may be less than optimal.

That’s where the three predictive factors (age, acetabular index, and acetabular cartilaginous angle) can help. Using these measures, the surgeon can reliably predict (early on) hips with DDH that will need acetabuloplasty after closed reduction. Results are best if the procedure is done before age four.

In this study, researchers at The Children’s Hospital of Philadelphia look at the natural progression of acetabular retroversion in children with Perthes disease. The acetabulum is the hip socket. Retroversion refers to the angle and position of the hip socket.

Perthes disease is a condition that affects the hip in children.
In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed. Loss of blood to this area causing the head of the femur (upper leg bone) to die.

The blood supply eventually returns, and the femoral head heals. How the bone heals determines how much problem the condition will cause in later life. A more deformed femoral head may result in greater acetabular retroversion. This condition can lead to serious problems in the hip joint later in life.

Radiologists rely on the presence of the crossover sign to diagnose acetabular retroversion. The crossover sign is seen as a change in the position of a line drawn on the X-ray. Normally, the edges of the anterior (front) and posterior (back) walls of the acetabulum appear to intersect at the top and along the side. In cases of acetabular retroversion, this crossover of the anterior and posterior acetabular wall outlines is down farther than normal.

But acetabular retroversion doesn’t show up on X-rays in children. So CT scans were used to measure this angle. X-rays were used to see when children reached skeletal maturity. Everyone in the study was followed until after skeletal maturation.

The results showed that acetabular retroversion was rare in children with Perthes disease. Retroversion was more likely to be seen in severe cases of Perthes. After skeletal maturity, the rate of retroversion was much higher (31 per cent).

This was the first study to show a cause and effect relationship between the deformed femoral head in Perthes disease and changes in the acetabulum. Surgeons address the changes observed in the femoral head. But they may not be as aware of the changes in the hip socket. More studies are needed to find ways to prevent this extra deformity from occurring.

One of the most common fractures among children is the radial fracture, that of the forearm. Luckily, the arms usually heal well and rarely cause problems, unlike adult fractures of the same bone. However, sometimes, conservative treatment, casting, isn’t always enough to heal the fracture, resulting in displacement, healing that isn’t straight or uniform.

The reasons for this problem include the fracture not being placed properly before casting, a complete break of the bone, break of the nearby bone, the ulna, the cast not being effective, surgeon inexperience, and even the type of anesthetic used during surgery.

The authors of this study investigated their new index for measuring if treatment would be successful or not, using a three-point system.

Researchers enrolled 74 children with radial fractures, three did not complete the study. They were all under 15 years old and were treated with a cast within 24 hours of the break. Initially, all children had a closed reduction of the break, meaning that the physician in the emergency room set the break without surgery, and the arms were then casted. The patients were given some sedatives to make the procedure more tolerable.

The thickness of the padding in the cast, the molding and the positioning of the wrist were all noted. The patients were then followed every week for four weeks to check for any movement in the fracture. As a result, five patients had their arm recasted twice and one had it done three times. The follow-ups included checking for blood circulation in the arm and hand 24 hours after the casts were applied. Three patients had their casts split because of circulation problems and then recasted.

For this study, the three-point index resulted from a calculation of fracture gap, angle and contact between the fracture fragments. At the end of the study, there were 19 fracture displacement in 17 patients and only six needed to be remanipulated. Of the 19, 17 were found within the first week after the break. When using this index, the researchers were able to predict quite well which patients were likely to have problems. The authors do point out however, that their study had limitations: they were not able to use different types of sedation and the long-arm versus short-arm casts weren’t compared, for example.

The authors conclude that their three-point index is a reliable method of predicting how a radial fracture will react, with the complete break and the increased angle of the break being the most important of the three indicators.

Loss of blood supply to the growth center of the femoral head (top of the thigh bone) is a common problem in children. The condition is called Legg-Calvé-Perthes Disease (LCPD). The reason for the blood loss remains unknown.

In this study, bone from the hip of children with LCPD was compared with bone from the hip of children having surgery for hip dysplasia (the control group). The pieces of bone were split into three groups. Each group was tested and analyzed looking for changes from the normal bone in the control group to bone in children with LCPD.

The major difference they found was an increase in the number of lipids (fats) and fatty acids in the resting chondrocytes (cartilage cells). Accumulation of lipids in chondrocytes may be what starts the process of bone degeneration. It’s possible the lipids have some kind of role in the metabolism of cartilage cells.

The authors suggest that some change occurs in the microenvironment of the cell. Perhaps there is a loss of oxygen that takes place. Then the cell responds with some metabolic changes. The result is an increase in the lipids in the cartilage.

How the lipids change cartilage function and metabolism will be the subject of future research. There is a suspected role for hereditary factors but the exact link there is still unknown.

In this study, mechanical factors affecting slipped capital femoral epiphysis (SCFE) are investigated. SCFE is a condition that affects the hip in teenagers between the ages of 12 and 16 most often. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone).

What causes this and why it only affects some children is unknown. It’s likely that there are endocrine, genetic, and mechanical factors. The effect of shear stress on SCFE is the subject of this study. The authors used X-rays of normal hips (control group) and compared them to hips with SCFE. They also looked at the opposite (uninvolved) hip in patients with SCFE.

A mathematical model was used to measure hip stress and force. The formula took into consideration the muscle attachment points around the hip and the interhip distance. The peak shear stress in the epiphyseal (growth) plate of the femoral neck was also measured. Body weight was taken into consideration.

They found that children with SCFE were much heavier in body weight than those in the control group. Hip shear stress was higher in both hips of children with SCFE compared with normal hips. The epiphyseal growth plate of the femoral neck in children with SCFE was more vertical in orientation than in the control group. This position was decidedly a risk factor for SCFE.

The shape of the pelvis and femoral heads helped normalize the hip stress at peak contact. But the added body weight negated the benefit of those anatomic differences. It appears that slipped hips and uninvolved hips in the same child have the same geometry. Based on anatomy and mechanics involved, if one hip slipped, the risk of the second one slipping is much greater than if the uninvolved hip had a more normal shape. The elevated shear stress is a risk factor for SCFE.

Stapholococcus (staph) infection of the sacroiliac joint can cause septic sacroiliitis. The condition can affect children but is rare. Symptoms are nonspecific with frequent reports of back, buttock, or hip pain that can’t be pinpointed.

In this study, surgeons from Japan report ways to diagnose this problem sooner than later. Delays in treatment can result in a worse outcome. X-rays do not show changes that would direct the physician to consider septic sacroiliitis. MRIs may be needed to make an accurate diagnosis.

Eight cases of septic sacroiliitis in children ages four to fifteen were included in the study. All eight patients had pain on one side that was misdiagnosed as a lumbar disc herniation. In some cases, the pain was reported in the knee, back, or buttock. In one patient, the painful symptoms presented in the abdomen.

MRIs can be used to assess the progress of treatment. But as these researchers found out, abnormal findings persisted on MRI even when the patients felt back to normal. Doctors are advised to remember that clinical improvement will be seen with this problem before the MRI shows resolution of the problem. Abnormal bone marrow changes were reported in this study for two to three months after treatment with antibiotics.

In this study, sports physicians conducted a search of current medical literature. The subject was pediatric sports injuries. Bone fractures were the main focus. They analyzed all the data available to find the typical profile of children who have sports injuries resulting in fractures in the United States.

Competitive and recreational sports most often linked with pediatric fractures included bicycle riding, basketball, football, and roller sports. There were some trends noted based on age and sex. For example, younger children (ages one to four) were more likely to break a bone from falls on the playground. And fractures were less common in older teens once the bone growth plates had fused.

Males were more likely to injure themselves. Injuries among girls have increased dramatically in the last 10 years. It is assumed that this is because more girls are participating in sports now than ever before. Injuries to the spine such as spondylolysis (stress fracture) are more common among female dancers, gymnasts, and figure skaters.

One-fourth of all pediatric sports injuries are fractures. The arm is broken most often. Knowing this may help coaches and parents plan prevention strategies. For example, the importance of proper coaching, equipment, and playing conditions can’t be over emphasized. Equipment should include protective gear designed for the specific sport

Preseason physical exams to screen for medical conditions or psychosocial issues must be included. Other prevention strategies include medical coverage at sporting events and proper officiating and coaching. Getting enough and the right kinds of fluids to maintain hydration should be encouraged.

Each sport should have its own model for injury prevention. For example, prohibiting body checking in youth ice hockey can reduce the risk of fracture. This is especially true for head and neck injuries in older age groups where size and strength vary significantly. And requiring wrist guards in skating sports may reduce the risk of wrist fractures.

In all sports, fostering an atmosphere of fun, fair play, and team development may help reduce violent injuries. Coaches and players who abide by the rules and officials who enforce the rules can also contribute to the decline of serious injuries.

More studies are needed to find ways to prevent sports injuries. An overview study such as this one is helpful in identifying common ages, sports, and types of injuries. Safety guidelines are more likely to be followed when they are based on actual statistics of injuries and evidence that prevention makes a difference.

Sometimes infants are born with radial nerve palsy. Palsy is another word for paralysis. The cause is usually positional. The child was lying in a position in the uterus that put too much pressure on the nerve. Prolonged labor is another common cause of this problem

The symptoms include loss of finger and wrist extension. Sometimes there is bruising under the skin. Dimpling over the area occurs when there is a loss of protective fat. Radial nerve palsy is a rare problem. Not much is known about the prognosis.

In this report, four cases of radial nerve palsy in the newborn are presented. In each case, the nerve palsy was limited to the radial nerve. And there was a history of prolonged labor of more than 18 hours.

There were no other problems present. There were no changes in the upper arm. The lack of upper arm involvement and the presence of skin changes near the elbow suggest compression occurred at or near the elbow.

All four children were followed for at least two years. They each received hand therapy with splinting and exercises. Each child had a complete recovery sometime during the first five months after birth.

When a child is born with nerve palsy, the physician must consider a number of different possible causes. Infection, tumor, bone fracture, and the presence of some other syndrome or condition must be ruled out. Complete recovery is expected if there are no bands of tight fascia around the nerve.

Sometimes fusion surgery is needed to correct scoliosis (curvature of the spine) in adolescents. The goals are to correct deformity and balance the curves of the spine. Another goal is to derotate the segments that have gotten twisted around. The surgeon tries to do all this with the least number of vertebrae fused together as possible. Motion is preserved above and below the fusion sites.

Previous studies have helped surgeons identify which patients can benefit from a selective thoracic fusion. This procedure is for the child who has two curves: one in the thoracic spine and one in the lumbar spine. Only the thoracic curve is fused. The lumbar curve often corrects itself after the thoracic segment is fused.

The question posed in this study by surgeons at Duke University was: does it matter what kind of fusion is done? Are patients more likely to experience spontaneous lumbar curve correction with an anterior or with a posterior fusion?

Two groups of patients were compared. One group had an anterior fusion with instrumentation (hooks, wires, screws). The second group had a posterior fusion with similar instrumentation methods. Patients in both groups were matched as carefully as possible. For example, they were the same ages and having surgery at the same thoracic levels.

X-rays were used to measure before and after results. The authors report no significant difference in spontaneous lumbar correction after anterior or posterior fusion. The main determining factor was the lowest instrumented vertebra(LIV). The greatest amount of spontaneous correction of the lumbar curve occurred in patients with the lowest instrumented vertebra.

Analysis of the results also showed two other important factors. First, the more flexible the lumbar curve is before thoracic fusion, the more likely the lumbar curve will spontaneously correct itself. And second, the amount of correction that can be achieved in the thoracic spine makes a difference. The more the thoracic curve can be safely corrected, the more spontaneous correction occurs in the lumbar spine.

This study does not answer the question: how far down should the spine be fused? At what point does the thoracic fusion prevent correction of the lumbar curve? Future studies are needed to add this piece of information to the puzzle.