News Category: Child

Bracing has been used with some success in the treatment of scoliosis. This is the first long-term study of part-time bracing in children with juvenile idiopathic scoliosis (JIS). JIS occurs before the start of puberty. Most children are affected between the ages of three and 10.

Studies have shown that there are negative effects on teenagers’ personality and self-esteem who are treated full-time with bracing. JIS especially requires a long period of bracing as the child is growing. Finding a part-time bracing program that would work for JIS may help prevent progression of the curve during growth spurts.

The Charleston nighttime bending brace was used with children who had JIS curves greater than 20 degrees. The Charleston brace is molded to the patient while they are bent to the side. This applies pressure to bend the child against the curve to correct it.

The braces in this study were all made and fitted by the same orthotist. Everyone wore the brace for at least eight hours during each 24-hour period. The brace was worn at night while they slept.

Measurements of the curves were taken before, during, and after bracing. Various X-ray views were included. Standing X-rays were taken out of the brace. Best correction in the brace was also done in the supine position (lying on the back).

The children were divided into three groups based on the size of their curve before and after bracing. Group one was labeled the success group. Their curves stayed the same, got better, or progressed five degrees or less.

Group two showed worsening of their major curve. The curve stabilized when their bones stopped growing. Surgery was not needed. Group three had continued worsening of their curves until the curve measured more than 45 degrees. Surgery was indicated for this group.

At the end of the study, slightly more than half the children had a successful result. Children were more likely to succeed who had a single (rather than double) curve with good correction in the brace.

The authors report that the small number of children in this study make it impossible to know if some curves respond better to bracing than others — or to find any consistent factors linked with brace failure. Future larger studies using bracing for JIS are needed.

Scoliosis or curvature of the spine can be severe enough to cause rib rotation as well. Rib cage deformity causes a rib hump to form that can be cosmetically unacceptable. But besides how it looks, the rib hump can also reduce pulmonary (lung) function.

As a result, surgery may be needed. The goal of surgery is to stabilize and balance the spine. If this goal is met, then the curve won’t get worse and the deformity will be corrected. The best way to achieve these goals isn’t clear. New developments in surgical instruments and methods are being reported.

In this study, thoracoplasty and the use of pedicle screws for scoliosis with rib hump is investigated. Thoracoplasty is the removal of ribs, which are then ground up and used as graft material for spine fusion. Pedicle screws are placed through the bridge of bone between the vertebral body and the back half of the vertebral segment. The pedicle forms part of the arch of bone that surrounds and protects the spinal cord.

Patients ages 11 to 19 with idiopathic scoliosis were included in the study. Idiopathic means there is no known cause for the problem. There were three groups based on type of surgical technique used to correct the deformity. Pedicle screw instrumentation was used in all three groups. One surgeon did all of the operations.

The first group had a spinal fusion using iliac crest bone for the graft. No ribs were removed (thoracoplasty was NOT done). Group 2 had a thoracoplasty and fusion but the spinal rotation was not corrected. Group 3 had a thoracoplasty, fusion, and derotation of the rib deformity. Special rods were used to distract the spine, correct the rib rotation, and realign the spine.

Results were measured using X-rays of spinal alignment (including rib hump and angle), pulmonary function, and self-image. The results showed better rib hump correction in the two groups who had the thoracoplasty. They also scored higher on tests for self-image (better self-image).

Two-year outcomes showed that the best way to correct rib hump associated with scoliosis in young patients is a thoracoplasty with direct vertebral rotation. Using the patient’s ribs accomplishes two things. It reduces the unacceptable rib hump. And it eliminates the need for the removal of bone graft material from the pelvic crest. Pulmonary function and self-image are also both improved.

Children who need orthopedic surgery of the lower extremity often end up in a cast for four to eight weeks. Immobilization with a non-weight bearing status can lead to bone loss. As a result of these factors, the risk of bone fracture goes up.

In this study, the amount of bone loss before and after immobilization is measured. Dual-photon dual energy X-ray absorptiometry (DXA) scans were taken just before surgery. The DXA was repeated within a week of cast removal or restarting weight bearing activities.

Children included in the study were between the ages of four and 18 years old. There was a wide range of diagnoses for which surgery was needed. Some children had Legg-Perthes disease, cerebral palsy, or spina bifida. Others had neuromuscular problems such as Charcot-Marie-Tooth disease or neuromuscular flatfoot.

The authors knew there would be bone loss. They were surprised by just how much bone loss occurred. In some cases, up to one-third of the bone mineral density was lost in the operated leg. The average bone loss was around 11.5 per cent.

Healthy children with good bone mineral density might be able to handle this much bone loss. But most of the children who are immobilized after orthopedic surgery have a chronic illness or disease. They are more likely to have decreased bone density from abnormal growth. The risk of bone fracture is much higher in this group.

The authors also report that recovering from bone loss in this population takes much longer than expected. Again, the risk of fracture is much higher during the months it takes to replace the bone loss.

The next step is to find ways to treat this problem. Right now, vitamin D, calcium supplements, and weight-bearing activities are used to support bone mineral density. More research is needed to identify ways to prevent the problem from occurring in the first place.

The electronic medical record is showing up in more and more doctors’ offices. Instead of filling out pages of paperwork, patients are taking surveys and answering questions on a computer.

Using an interactive program that adapts the questions based on previous answers helps save time. It cuts out unnecessary questions. For example, if a child can walk independently, then asking about wheelchair skills or stair climbing abilities isn’t needed.

In this study, parents of children with spine impairments complete the Pediatric Evaluation of Disability Inventory Multidimensional Computerized Adaptive Testing (PEDI-MCAT). The goal was to see if this tool could be used effectively to assess the physical function of children with a wide range of abilities and impairments.

The PEDI-MCAT was given to parents of children with complex spinal impairments. All were patients in a busy pediatric spine clinic. Questions about self-care and mobility were the main focus. A tablet computer was used to complete the parent-report in the clinic waiting room before seeing the doctor. The parents said that it was easy to complete. They preferred it to answering questions on paper.

Data collected showed that children with adolescent idiopathic scoliosis (AIS) tested at a higher level of function compared with children who had early-onset scoliosis. Scoliosis refers to a condition of curvature in the spine. Idiopathic means the cause remains unknown.

This particular tool did not have high enough functional scores for some children. The test needs to be modified for older children to provide a broader range of items to match the children’s abilities. More items need to be added to reflect their skills and abilities.

This study showed that the PEDI-MCAT is a good tool for use in a busy pediatric spine clinic. Speed and accuracy were key ingredients. Test results were reproducible, which helps prove that the test is reliable. Further modifications will be made to the test to include higher-level skills for older children.

In this review article, orthopedic surgeons from Childrens Hospital in Los Angeles, California bring us up-to-date on supracondylar humeral fractures in children. This fracture occurs in the humerus (upper arm bone) just above the elbow.

Most of these fractures are caused by a fall onto the outstretched arm. The elbow is extended at the time of the trauma. Force through the forearm causes the elbow to act as a fulcrum (lever arm) on the lower end of the humerus. The result is a supracondylar humeral fracture.

The break doesn’t go all the way through the bone. Instead, it forms a hinge with the anterior (front part) of the humerus broken open. The posterior (back side) of the humerus remains intact.

These fractures are divided into four types based on how much of the bone is displaced. More severe fractures (Type III and IV) have bone, soft tissue, blood vessel, and nerve damage. Type IV fractures are unstable in all directions.

After a thorough exam, X-rays are taken, and a treatment plan is formed. The child may only need a splint to hold the arm in the correct position for healing. Tight splinting or bandaging should be avoided to prevent loss of blood flow or pressure within the soft tissues.

Traction has been replaced by pin fixation to hold the bones in place until healing can occur. Surgery is required to do this. A special imaging technique called fluoroscopy allows the surgeon to realign the bones without using an incision. This is called a closed reduction. A pin or wires are used to hold the bones in place during the healing phase.

In some cases, open reduction is needed. The authors review in detail treatment by fracture type. They offer an in-depth discussion of special cases and what to do in case of complications. The most common problems that occur include infections along the pin or wire tracks, blood vessel or nerve injury, and deformity.

Less often, compartment syndrome of the forearm develops. Severe swelling inside the fascia (fibrous connective tissue) and within the soft tissues leads to increased pressure. Blood supply can get cut off to the arm. Death of tissue, is a possible consequence of severe compartment syndrome.

The authors also offer surgeons their thoughts on current controversies in the surgical treatment of supracondylar humeral fractures. For example, pins used to hold the bones in place can injure nerves traveling through the area down the arm. The most common pin-fixation errors are described. Ways to prevent nerve damage are offered.

The position of the immobilized arm is also important. Elbow flexion versus extension and forearm supination (palm up) versus pronation (palm down) can make a difference in stabilizing the arm. Treatment decisions are made on a case-by-case basis. Surgery should not be delayed if there is a risk of compartment syndrome or loss of blood supply to the forearm.

A significant difference in leg length from one leg to the other may require surgical correction. A special device called a circular external fixator is often used to maintain a correct position of the leg as it heals.

Standing full-length X-rays are used to guide the surgeon in recreating normal alignment of the lower extremity. Correcting the deformity and equalizing the leg length are important outcomes of this procedure.

In this study, the accuracy of X-ray assessment of limb alignment is reviewed. All patients included had surgery to realign the leg. Most subjects were children but a few adults were also included.

Everyone had an external fixator applied during the operation. X-rays were taken during the early phase of bone healing with the fixator in place and again after the fixator was removed.

Alignment of the bones, angles, and rotation of the knee were measured and analyzed using special computer technology. The data generated was used to evaluate the effect of the external fixator on the leg length measurements. In fact, the effect of the fixator on both legs was evaluated. Measurements obtained for alignment, rotation, and leg length were compared to values known to be normal.

The authors found that standing full-length X-rays may not be a reliable way to assess limb length. Not only does the fixator affect the leg it’s on, it also changes the alignment of the other leg.

Using the X-rays, surgeons may overestimate the malalignment and discrepancy between the two legs. The result may be undercorrection or overcorrection of limb alignment. The authors describe the various positions of the knee and how these might change the accuracy of measurements taken radiographically.

The most common error was a position of external rotation of the knee in the fixator device when the X-ray was taken. This led to an overestimation of varus (bow-legged) alignment. The difference in angle measurements also increased from before to after the device was removed. The more external rotation occurred in the device, the more the varus angle (and malalignment) increased.

It appears that there is a tendency for a leg in an external fixator to externally rotate at the knee. X-ray measurements taken before and after the fixator is put on and taken off may be affected by this malalignment of the leg. This can be a problem for the surgeon who is depending on the X-rays to guide treatment.

Surgeons using external fixators to correct leg length discrepancy or reconstruct the limb after trauma should be aware of this problem. Full-length standing radiographs to assess (and correct) limb alignment and limb length may be inaccurate. Clinical results may be negatively affected.

Shoulder, arm, and elbow injuries are common among young pitchers. And the number of youth affected is rising every year. This has caught the attention of parents, coaches, and sports medicine experts.

Risk factors for pitching injuries include number of pitches over time, type of pitches, pitching mechanics, and physical condition of the athlete. In this study, three type of pitches are compared: fastballs, curveballs, and change-ups.

It’s generally thought that the kinetics (joint force and torque) of these three pitches are very different. The results of this study helped shed some light on this subject.

Youth baseball pitchers between the ages of nine and 15 were included. Everyone threw five pitches of each type of ball release. The pitches were done in an indoor laboratory so that each arm motion and timing could be video taped, measured, and analyzed. Ball velocity was recorded. Stride length, forearm action, and wrist release were studied.

The results showed very different kinetics among the three pitches. The fastball put the greatest load on the shoulder and elbow. The changeup had the least force, load, and torque. The curveball had the greatest wrist torque but it was low overall and not a major concern. The change-up produced the least amount of impact on trunk motion and position.

In general, curveballs are not more injury-producing than fastballs. The changeup is the least harmful pitch. It appears that the number of pitches is still a bigger risk factor than the type of pitches thrown. Repetitive forces during the pitching motion increase the risk of injury. Total pitch volume throughout the season must be considered (practices and games).

Fractures of the metatarsal (toe) are a common childhood injury – most frequently the first and the fifth ones are affected. Children under five years old appear to break their first toe more often, while children over five were most likely to break their fifth toe, much like adults.

Several studies have been done regarding metatarsal fractures, but few have been done that target the pediatric population. The authors of this study wanted to establish the cause, location, mechanism of injury, and the age of children who were most likely to sustain such a fracture.

Researchers reviewed the cases of 125 children with metatarsal fractures, who made up 0.6 percent of all the patients who presented at their institution’s emergency department, and they made up 3.2 percent of all patients who presented with fractures. Sixty percent of the patients were male. The mean age of the patients was eight and a half years old, with the younger children being mostly girls and the older children being mostly boys. Eighty-five children were over five years old. Those 85 patients had 104 fractures between them.

In reviewing the sites of the fractures, the researchers determined that 38 patients were injured outside (backyard or playground), 31 in the home, 31 while playing sports, and 15 while in school or daycare.

Among all 125 patients, there were 166 fractures – 22 patients had multiple metatarsal fractures. Those children who had fractures other than the first and fifth also had other metatarsal fractures. Seven percent of the patients (nine children) had other traumas, as well.

The authors of this study write that by knowing how, where, and why the fractures occurred, physicians are better equipped to manage the fractures. In a previous study, published in 1995, researchers stated that the most common fracture in childhood was of the fifth metatarsal. The findings of this study confirmed this finding among the children over five years old.

Of note, the authors point out the finding that if there is a fracture of the second, third, or fourth metatarsal, there are frequently other metatarsal fractures as well, while the first and fifth metatarsals were most frequently the only fractures.

Adolescents with idiopathic scoliosis are often treated with bracing to prevent further curvature of the spine. Unfortunately, as with most treatments, non-adherence to the bracing affects the treatment outcome.

Studies done previously to assess patient adherence involved the use of sensor technologies. The findings were that, on average, 65 percent to 75 percent of the adolescents were treatment compliant. Other studies have shown non-adherence rates of 25 percent to 50 percent among diverse patient populations.

Knowing that many patients will be non-adherent means that physicians need to be more able to identify the patients who may fall into that category. The authors of this study wanted to test the findings of a new pretreatment questionnaire, the predictions of physicians and orthotists regarding potential non-adherence, and the ability of patients, parents, doctors, and orthotists in accurately estimating how long the braces were actually worn during the first year of treatment.

The study began with 124 patients (108 girls), aged between 10 and 15 years. All patients were treated with a Boston brace for 16- (49 patients) or 23-hour (75 patients) periods per day.

Before the study, the patients completed the Brace-Beliefs Questionnaire (BBQ) to predict the likelihood of wearing the brace as prescribed. The results were measured on a five-point scale, ranging from “strongly agree” to “strongly disagree.” Before the patients were fitted for their braces, the physicians and orthotists also predicted the adherence of each patient, using a five-point scale of one (not likely) to five (highly likely), when answering if they believe the patient will be compliant with the wear schedule.

During follow-up visits, the patients were asked about how many hours per day they were wearing their brace, while the parents, doctor and orthotist were asked to estimate their idea of how long the patient wore the brace. At the same time, the braces had been fitted with temperature sensors. The patients were not aware of the true purpose of the sensors (to log the amount of time the brace was worn) but were told that the sensors were evaluating comfort. The sensors recorded data every 15 minutes.

When analyzing the results, the researchers found that there was no difference between the 16-hour and 23-hour groups in terms of adherence so the results were combined into one. the results from the BBQ ranged from 47 to 88 and the adherence to bracewear was positive. In respect to the physicians’ and orthotists’ ratings, the correlation between the physicians was very weak, but was slightly stronger with the orthotists.

The results of the follow-up visits showed that family estimates of adherence “significantly exceeded those of the treatment team, as child and parents reported that the brace was worn an average of 74 percent of the time recommended during the first year, whereas physicians and orthotists reported a mean estimate of 65 percent. The actual average percent adherence in the first year was 47 percent.”

One quarter of the non-adherent patients were not identified by the physicians as indicated by the sensors. The average physician overestimated the actual wear of the non-adherent patients by 28 percent.

The authors state that predicting adherence is difficult to accomplish, with many healthcare professionals unable to accurately say who will adhere to the bracewear schedule and who will not. Use of the pretreatment questionnaire, the BBQ, did help improve the odds of being accurate, however. Interestingly, the researchers learned that of the adolescents who were not compliant, many were this way because of mistaken beliefs about the brace and its use or effectiveness. The authors suggest that the patients should be specifically asked about their beliefs and explain the issues before treatment begins.

For on-going treatment follow-ups, the results showed that there was at least 10 percent to 20 percent overestimation by the physicians and orthotists about adherence, with patients and parents overestimating by 25 percent.

In conclusion, the authors suggest that although estimating possible or probable adherence to treatment remains difficult, the use of a pretreatment questionnaire could be beneficial. They point out that healthcare professionals should keep in mind the tendency to overestimate the use of the brace all those involved, not just the patients themselves.

When a child breaks his or her arm, it is most often the radial humeral condyle that is affected. Most often, healing is rapid and uneventful. Delays in healing, when they occur, are most often due to developmental failure of the bone, open or comminuted fractures, or a treatment failure.

Currently, the treatment of choice for displaced fractures in the forearm is to use elastic stable intramedullary [within the bone marrow] nailing (ESIN). This treatment provides rapid healing with minimal complications in most patients. The authors of this study evaluated how often this treatment was not successful or caused delayed healing.

Researchers studied records of 532 children who presented to any of five pediatric trauma units with a forearm shaft fracture treated with ESIN. Among those treated, they found 10 children (five boys, five girls), or 1.9 percent of the group, had delayed healing of the fracture. Among the fractures, one was a repeat fracture, three were type 1 open fractures. Six patients were treated with open procedure. One patient experienced an infection after surgery.

The researchers could not determine any visible reason for the delay in healing. Five children had their nails extracted, two were casted, two had surgical revisions and one received no further treatments. Full healing in all patients happened within 10 to 13 months following the initial injury.

The authors conclude treatment with ESIN for unstable and displaced forearm shaft fractures results in adequate healing and function in most patients. Delayed healing does occur rarely, however, healing completes by the 13th month.

Children who do not have cerebral palsy but who walk on their toes are often diagnosed with idiopathic toe walking (no known cause), or ITW, by excluding all other possible diagnosis. Toe walking occurs in the early years of childhood in many children, but if it persists beyond the age of five years, this should be investigated for the root cause.

The traditional suspected diagnosis for toe walking is cerebral palsy and other neurological (nerve) disorders, all of which should be ruled out before diagnosing ITW. While some children with ITW do have some tightening of the heel cords, some also just prefer to walk on the balls of their feet or their toes.

Earlier research has found, through quantitative gait analysis, that children with ITW tended to have increased ankle plantar flexion while standing and walking, and the knees showed some differences by hyperextending while standing. On the other hand, children with cerebral palsy had their knees partially bend while standing.

The authors of this study wanted to determine if children with ITW could normalize their gait on demand and how to use quantitative gait analysis to make an accurate diagnosis of ITW.

Researchers studied 51 children (33 boys) and compared their findings with 102 trials. The mean age of the children was 9.3 years (ranging from 6 to 18), most children were born at full term, ranging from 27 weeks to 42 weeks. The children were treated previously with serial stretch casting (15 patients), ankle foot orthosis (two patients), and botulinum injections (seven patients). None of the patients had undergone surgery for the toe walking.

In all children, the diagnosis of IWT was confirmed. Their gaits were analyzed and measurements of flexion and extension were taken. The most common finding among the children was that there was a disruption of all three ankle rockers, as found in previous studies, and most children preferred a plantar flexion of the ankle while making their steps. Also, 17 percent of the children were able to correct or normalize their gait on request. Seventy percent were able to make some changes to their gait, although they were not able to correct their gait completely.

The researchers were not able to find any differences in the range of motion between the children who could normalize their gaits and those who could not.

The authors conclude by suggesting children who are able to normalize their gait can be confirmed as having ITW.

Low back pain, very common among adults in industrialized countries, was never thought to be a common issue for children. According to early studies, it was estimated that about two percent of the pediatric population experienced low back pain.

These numbers are changing, however. Recent studies have shown that almost one-quarter of adolescents have seen a doctor with complaints of low back pain and the incidence may be as high as 36 percent by the time in adolescents up to age 15 years. This percentage rises to 37.1 percent among adolescents who are competitive athletes.

Because of the implied low number of children who complained of back pain, the medical community often considered child lower back pain as having a very serious cause. However, recent studies have shown that the children’s complaints may have causes that are not all that different from adult low back pain.

The authors of this study wanted to evaluate the diagnosis of children with low back pain. To do so, they enrolled 73 children who complained of back pain that lasted more than three months and they had not had spinal surgery. They underwent physical examination, x-rays, bone scans and blood tests. If the patients’ bone scans were positive but their x-rays were negative (nothing was seen), they were followed up with a computed tomography imaging scan (CT scan). Patients with neurological (nervous system) symptoms or who seemed to get worse also had magnetic resonance imaging, or MRI, performed.

The test results showed that 57 patients had no definitive diagnosis following testing and follow up. Of the remaining 16 patients, nine were diagnosed with spondylosis, two with Scheuermann disease, and three with blood tests that were not normal but no diagnosis were made.

Ten of the 13 children with definitive diagnosis were diagnosed by x-rays. Two had negative x-rays but had positive bone scans. Three patients eventually had surgery.

In total, of the 73 children, all had x-rays, 62 had CT scans, 10 had MRIs, and 62 had blood tests.

The authors conclude that most of the diagnosis were made by x-ray and that there was a lower rate of diagnosable pathology in this group than had been reported in earlier studies. They wrote, “Exhaustive diagnostic protocols may not be necessary for [lower back pain in children].”

Approximately one to two children out of 1000 are born with development dysplasia of the hip (DDH), where the hip joint – most commonly the left hip – is not properly formed. Doctors have noticed that many children with DDH also have a subtle dysplasia on the contralateral (other) hip, often not diagnosed right away and as late as the teen-age years. The question, however, is if the dysplasia in the other hip was there since birth and simply not noticed or that the hip developed that way as the child matured.

The authors of this study sought to find out how common contralateral hip dysplasia is and to see if it was a developmental issue or if the children were born with it.

Researchers reviewed the files of 43 children: 18 with bilateral (both) hip dysplasia, eight of whom were diagnosed at initial evaluation and 10 after repeat evaluations. Therefore, only 19 percent were diagnosed initially. The remaining 25 patients were not found to have bilateral hip dysplasia at any point during the examinations.

Follow-up examinations were done from early childhood to adolescence. X-rays were taken, as were measurements of hip angles. The authors wrote, “of those patients who had no evidence of contralateral hip dysplasia even after careful repeated examination, we identified 10 patients who had mild, or borderline, dysplasia at maturity.” They also noted that these findings indicate physicians should be prudent in evaluating contralateral hip dysplasia because of the unknown consequences of mild hip dysplasia.

They conclude that the results of their small study find the incidence of contralateral hip dysplasia is not as rare as once thought but is not being recognized.

It’s clear that smoking is bad for your health. And studies have shown a direct link between tobacco use and low back pain in adults. In this study, researchers explore the possibility of an increased rate of low back pain (LBP) in teens who smoke.

An earlier study in Canada reported smoking increased the risk for LBP in adolescents. A closer look at how much smoking is linked with back pain is needed. Children in the northern Finland Birth Cohort born between 1985 and 1986 were followed to age 18 and included in this study.

At age 16, each child was asked questions about weight, height, smoking habits, LBP, physical activity, workload, and personality. Information was collected until the children turned 18 years of age. The group included occasional smokers, regular smokers, and exsmokers.

The number of pack-years was calculated. One pack-year is equal to 15 cigarettes (one pack) smoked every day for one year. A 1.5 pack year history of smoking means the child smoked one-and-a-half packs of cigarettes every day each year.

The results of this study may be slightly biased. Surveys were more likely to be filled out and returned by girls who didn’t smoke and who were living in a two-parent family. Boys and girls who didn’t smoke returned the survey more often than those who smoked. The nonsmokers reported better overall health status. The authors suggest their results may underestimate the true association between smoking and LBP.

Regular (daily) smoking of more than nine cigarettes at age 16 was predictive of LBP in girls. Girls who had a history of 1.5 pack-years were even more likely to report LBP. This exposure relationship was not present among the boys.

It’s not clear why there was a difference between boys and girls. It could be that boys underreport their smoking habits. Or girls may be more likely to smoke when upset or distressed. There aren’t enough studies of smoking in children to know for sure yet. And the studies already published don’t always separate out findings for boys versus girls.

The authors suggest future studies to look at the effect of quitting smoking on LBP. Animal studies are currently underway to understand how nicotine and tobacco affect low back structures resulting in painful symptoms.

When a patient presents with Legg-Calve-Perthes disease, the main objective is to minimize damage to the hip joint. However, some patients present with hinge abduction (abnormal hip movement) that can occur when the femoral head (ball part of the hip joint) is deformed. When this happens, the goal is to reduce this and minimize pain.

The authors of this study researched earlier trials to evaluate if surgery, called valgus osteotomy, is appropriate for patents in their late teens.

Fifteen patients, 13 males, who had undergone surgery were identified for this study. The patients were a mean age of 17 years and 9 months at the time of their surgery (ages ranging from 11 to 32 years and 6 months). Assessment before surgery included x-rays, including some while the patients were under anesthesia, an arthrogram (air or dye injected into the joints for x-ray), the Harris Hip Score, and assessment of range of motion and leg length differences.

After surgery, all patients were followed in the clinic for at least six months to ensure that the surgery was successful, and further follow-up was done by telephone.

The researchers found that the HHS score, which was initially a mean of 48 out of 100 (100 being the best possible score) before surgery was now reported at a mean of 89. In range of motion, there was a mean improvement from before surgery of 15 degrees. Fourteen of the 15 patients had improvements in the leg length difference. All x-rays showed union of the bones, and up to two years of follow-up did not show any significant changes in the hip.

The valgus osteotomy, used for hinge abduction, appears to be an effective treatment in this age group, the authors of this study concluded.

As children participate more often in sports and athletic competitions, more children are developing anterior cruciate ligament (ACL) injuries, a knee injury that used to be thought of as only occurring in children if their bones were not mature. Now, surgeons are performing more ACL repairs on children as before, yet they only have the adult guide to use for their landmarks in doing the intricate repair.

It has become known that if a surgeon is more familiar with the anatomy of the femoral intercondylar notch, a notch in the femur, or thigh bone, that they would be able to reduce the incidence of technical errors and increase the incidence of successful surgeries. The authors of this study used a collection of preserved skeletons to examine and characterize surgical landmarks, such as the notch and the resident’s ridge, raised bony landmark just in front of where the femur is attached to the ACL. The ACL begins between these two landmarks.

The researchers obtained 103 femurs of skeletons that were between three and 20 years old at death. One hundred and one were used for the final results. The researchers divided the group into subgroups of ages three to six, seven to nine, 10 to 12, 13 to 15, and 16 to 20 years of age.

Following the tests and measurements, the researchers found that of the 101 bones, “75 had a well-defined resident’s ridge and 26 had a subtle resident’s ridge.” They found that the older bones were more likely to have a more prominent ridge than the younger ones, those under the age of 12. The researchers also looked at the amount of space that would be available to drill in order to do the ACL repair. They found the average space between the “over-the-top” position, which is right behind the notch, and the resident’s ridge became longer as the skeletons were older; they also changed position slightly.

These are important findings because of the increasing number of ACL repairs being performed on children of all ages. Previous studies had looked at the skeletal make up of children but they were either performed on bones that had already been sectioned or cut, or they used imaging techniques. The magnetic resonance imaging (MRI) was useful, but still not hands on. The authors of this study note that their findings of the space available for drilling (the distance) allows surgeons to understand the importance of where to drill so as not to cause damage.

When studying the skeletons, the authors also looked at the female and male aspects of the structure because of the reported higher incidence of girls sustaining ACL injuries over boys. Their findings were that there was a difference in skeletal distance between the boys and girls.

The authors point out the limitations of their study, which include the limited number of bones from the seven to 15 years age group and that the bones were from the early twentieth century, when children may have been shorter than now and may also have had some metabolic disorders that children today don’t have.

In conclusion, the authors state that the study provides valuable information for surgeons to locate where they should drill if performing ACL repair on a child or adolescent, as well as the differences between boys and girls.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip in teenagers between the ages of 12 and 16. In this condition, the capital femoral epiphysis (growth center of the hip) slips backwards on the top of the femur (thighbone).

SCFE can occur in one or both hips. Sometimes it shows up on one side and later develops on the other side. Surgeons debate whether or not the second side should be pinned to prevent it from slipping as soon as the first hip develops SCFE.

Others argue this step isn’t needed. The child can be watched carefully. That way an early slip will be recognized and treated right away. On the other hand, if there is a risk of a severe slip occurring, then preventive pinning may be a good idea.

In this study, surgeons at Children’s Hospital of Philadelphia review the records of all children operated on for SCFE over a 10-year period. They made a note of the severity of the slips. Anyone with a unilateral (one-sided) slip was followed and observed for the development of another slip on the other side.

They found that more than one-third (36 per cent) of the children with unilateral SCFE developed bilateral (both sides) slips. The more severe the first slip, the greater the chance that a second slip would occur. Most second slips occurred within the first six months after the first slip.

And in moderate-to-severe cases, there was an increased risk of osteonecrosis (death of bone) and chondrolysis (degeneration of cartilage). Osteonecrosis resulted in collapse of the femoral head. Chondrolysis caused a narrowing of the joint space and a stiff joint.

Based on the results of this study, the authors advise prophylactic (preventive) pinning of the opposite hip in cases of unilateral SCFE. The unslipped hip can be pinned at the same time as the operation on the first hip.

This step is both safer and preferable to just observing and treating symptoms. The long-term risk of osteoarthritis may be prevented with early treatment and prophylaxis. It also reduces the number of X-rays needed to follow the patient. And the child can be more active without worrying about a second slip.

Treatment of clubfoot requires several casting or bracing changes throughout the process. Manipulation to correct the clubfoot has been done for centuries, reportedly as early as 400 BC. In the early 1800s, use of a plaster cast was introduced and this type of cast is still in use, albeit with modifications.

Plaster casts do have drawbacks, including weight and the care that must be taken to maintain their integrity. For that reason, semi-rigid fiberglass has become increasingly popular when bracing clubfeet with the Ponsetti method. The authors of this study sought to compare the effectiveness of plaster and fiberglass casts using the Ponsetti technique.

Thirty one children with 39 clubfeet total completed the study, which originally enrolled 34 children. The average age at start of treatment was two weeks of age. The children were randomized to be casted with either Plaster of Paris or a semirigid fiberglass cast. If a child had two clubfeet, the same cast material was used on both. Sixteen feet ended up with fiberglass and 23 with plaster.

Each foot was assessed before treatment began and follow-up was on a weekly basis. Parents completed questionnaires at each visit regarding any complications and their satisfaction with the cast material. The children had, on average, 6.1 fiberglass casts throughout the course of the treatment or 5.2 plaster casts. Of all patients, 37 feet were considered clinically corrected; three feet did not require further surgery. Of the 37 feet, 34 required surgery to lengthen the Achilles tendon, while one patient in the fiberglass group needed further surgeries. All of the children in the fiberglass group did require surgery.

Complications were minor and occurred in 10 patients total from both groups: cast slippage in six patients, and minor irritation in five.

The parents reported better satisfaction (cast convenience, weight, and durability, as well as willingness to recommend the cast material to a friend) with the fiberglass cast, but the differences were not statistically significant.

The authors report that their study confirmed the efficacy of the Ponsetti method. Eight percent of the feet were corrected just by casting, 87% only needed surgery for the Achilles tendon, and only 5 percent needed further intervention. Importantly, the researchers found that the plaster casts did perform better than did the fiberglass casts, despite the parent preference for the fiberglass.

This type of treatment relies greatly on parental compliance with treatment and as shown in a previous study, fiberglass casts are easier for parents and may increase compliance. However, as the authors of this study point out, the patients who were treated with the plaster casts had statistically better outcomes without having to have surgery. The authors do point out, however, that the long-term effectiveness of cast material was not evaluated in this study.

Research shows a family link between parents and children for various health problems. Heart and lung diseases, metabolic disorders, and cancer have familial links. What about back pain? Could there be a parental back pain link between the adult care giver and the adolescent?

To find out more about this possibility, a large number of teens and parents in western Australia were surveyed and examined. All children involved were 14 years old. Questionnaires with over 100 questions were completed. Information was collected about physical, medical, nutritional, psychosocial, and developmental issues. The physical exam included body, strength, and fitness measurements.

The data was analyzed with the following results:

In the 1970s, Dr. D. S. Weiner, a pediatric orthopedic surgeon, developed a surgical technique to manage rigid pes cavus deformity of the foot. In lay terms, the rigid cavus foot has a very high arch. It is not flexible, so most of the foot doesn’t touch the floor when standing.

Over the years, Dr. Weiner reported on the results of this operation. This is the third published study of results of patients treated with the Akron dome midfoot osteotomy. This procedure addresses the deformity from more than one plane. It corrects the longitudinal (lengthwise) arch and the transverse (crosswise arch.

All children in the study had complex cases with rigid bone position. Dr. Weiner and his associates present details of other procedures used to treat this deformity. The major drawback of other operations was their failure to correct all planes. Step-by-step details of the Akron technique were also provided.

In this study, each patient was evaluated individually. Modifications to the Akron approach were made based on the presence of muscle balances and age of the child. Age is important because it reflects the skeletal maturity of the child. Children with neurologic conditions such as cerebral palsy or Charcot-Marie-Tooth syndrome were also treated with the Akron procedure. For the neurologic patients, the surgery included releasing some of the soft tissues along the bottom of the foot.

Results were satisfactory in three-fourths of the cases. Satisfactory was defined as pain free and at least 75 per cent of the foot was touching the floor. There were no abnormal areas of pressure on the foot.

Older children (eight years old and older) were more likely to have a good result without recurrence of the problem. The authors suggest that when the child’s age is closer to skeletal maturity, there is less room for change with growth. But surgery can’t always be delayed when pain or pressure ulcers are present.

The results of the studies of the Akron dome midfoot osteotomy over the past 40 years show that it is a valuable salvage procedure for a rigid pes cavus foot. Salvage refers to the fact that other treatment has been tried and failed. This approach provides a more functional foot position and reduces the risk of ulcers from too much pressure.