News Category: Child

There has been some mixed opinion about the routine screening of all infants for a condition called developmental dysplasia of the hip (DDH). In this report, orthopedic surgeons from the Texas Scottish Rite Hospital for Children in Dallas, Texas offer an update on screening and treatment for DDH.

DDH actually refers to several similar conditions affecting the hip. A flattening of the acetabulum (hip socket) is the main problem. this is called dysplasia. Subluxation (partial dislocation) or complete dislocation occurs when the socket is so shallow that the head of the femur (thigh bone) slips out of the socket.

Finding this problem early can help prevent more serious problems later. Taking a history and conducting an exam by the doctor are the first screening steps. If there are concerns, further testing with X-rays or ultrasound can be done.

The American Academy of Pediatrics put out guidelines in the year 2000 for routine DDH screening. But the U.S. Preventive Services Task Force concluded there wasn’t enough proof that routine screening for DDH makes a difference.

Other experts from the Pediatric Orthopaedic Society of North America (POSNA) disagreed with the task force. They believe that without screening many more children will suffer hip dislocations that could be prevented with screening. The authors of this article agree with POSNA.

After reviewing all available studies, it appears there is enough evidence to support routine screening. If there are any signs of hip instability at birth, an ultrasound should be done six to eight weeks later.

Precautions can be taken to prevent hip dislocation in the meantime. With intervention, waiting to confirm the diagnosis won’t cause further problems. Delaying the ultrasound by a few months reduces the chances of a false positive report.

A false positive test means there are abnormal findings that show up on the imaging but are not really present. In some cases, the abnormalities are present but go away with time and do not require further treatment or evaluation.

The authors note that some studies show the link between DDH and hip osteoarthritis. And it’s not clear yet how long surgical treatment can be delayed. The timing and upper age limit for reduction of a dislocated hip remains a hotly debated topic.

Finally, a brief summary of the results of important studies is also presented by age (birth to six months, six months to two years, older than two years) and diagnosis (dysplasia, subluxation, dislocation).

Loss of blood to the growth plate in the head of the femur (thigh bone) leads to a problem called Legg-Calvé-Perthes disease. Children between the ages of four and eight are affected most often. The condition can occur earlier or later as well.

In this article, Legg-Calvé-Perthes disease is reviewed. The name of the condition, who is affected, and how it develops are included. How it first appears, the diagnosis, and treatment are discussed. Drawings and X-rays are provided to show the classification scheme (Class I through V). Classification is used to describe severity of the deformity that can develop.

The disease was first identified by three doctors in three separate countries. Using X-rays for the first time in the early 1900s, Dr. Legg in the United States, Dr. Calvé in France, and Dr. Perthes in Germany all independently described this problem.

Treatment is focused on keeping the femoral head smooth and spherical (round-shaped). Preventing pain, loss of motion, and later, arthritis are the goals of management. Understanding the natural history of a condition gives doctors a chance to change what happens.

Natural history refers to what happens from start to finish. The true course of this disease is only known when a child does not receive the treatment he or she needs.

Most studies report on symptoms and hip structure after treatment that may include traction, physical therapy, medications, casting, bracing, or surgery. The natural history is altered on purpose by treatment.

Research shows that the disease lasts longer when it’s more severe. In other words, milder cases heal much faster than severe cases. As might be expected, the more deformity and collapse of the hip, the worse the results.

Younger patients get better faster with fewer problems. Children over the age of 10 when the disease is diagnosed have the most permanent deformity. Arthritis and hip replacement are common in adults who once had Legg-Calvé-Perthes as a child.

Ongoing research is needed to find the best treatment for each child. Altering the natural history and preventing long-term problems in adulthood is an important goal.

As surgery becomes more involved in correcting adolescent idiopathic scoliosis and with improved anesthetic techniques, perioperative (during surgery) monitoring, and after surgery care, researchers are interested in learning how often non-neurological complications occur following surgery for scoliosis correction and what the contributing factors may be.

The authors of this study undertook this study because previous studies had evaluated the treatment but did not focus specifically on the complications themselves.

A database of patients who had undergone surgery between December 2002 and December 2004 to correct adolescent idiopathic scoliosis was consulted. The final study group included 556 females and 146 males, aged between 8 to 18 years at the time of the surgery (mean: 14.25 years), who were followed for about 12.4 months. Among the group, 523 patients had the surgery from the posterior approach, 105 from the anterior approach, and 74 from both the posterior and anterior.

The researchers found that there was a 15.4 percent prevalence of complications in the study group overall. This included 43 complications during surgery in 41 patients, 44 early complications in 23 patients, and 21 late complications in 17 patients. Five patients required further surgery as a result of the complications: 2 because of infection and 3 because of implant failure. Although there were a number of complications that occurred only once, the most common non-neurological (affecting the nerves) complications were difficulties with respirations (10), excessive bleeding (6), wound infections (5), and wound hematoma (bruising and blood clotting), seroma (fluid under the wound), or dehiscence (wound opening) in 5 cases.

When the researchers analyzed the data, they found that more complications did occur in patients who had the posterior approach, but they appeared to be due to how long the surgery took, how long the patient was under anesthetic, and how much blood was lost during surgery. What did not appear to make any differences in the complication prevalence were patient age, body mass index, previous cardiac or respiratory disease, previous surgeries, pulmonary function, surgical approach, number of levels fused during surgery, materials used for grafting, curve type, or region of the curve. The researchers did note, however, that a history of renal disease did result in an increased prevalence.

Children who are physically abused often suffer orthopedic injuries. Orthopedic surgeons must be able to recognize signs of abuse injuries.
Long-term effects of child abuse include stress, depression, and substance abuse later in life. Violent behavior in teens who were abused as younger children has been documented.

Children who are mistreated are twice as likely to die before the age of 18 compared to those who are not victims of physical abuse. In this article, red flags for possible abuse are described. These include:

In this study, the records of 126 children with scoliosis who had surgery were reviewed. The researchers were looking for any problems that occurred right after the operation. Risk factors for those problems were also identified.

The goal is to develop a course-prediction model. This type of model could help predict outcomes of pediatric scoliosis surgery. Prevention of such problems is the main purpose of such a model.

Results showed that children with neuromuscular types of scoliosis were more likely to develop problems. This was compared with children who had idiopathic scoliosis. Idiopathic means of unknown cause.

Children with scoliosis caused by neuromuscular conditions such as cerebral palsy often have other medical problems as well. This puts them at increased risk for postoperative complications.

The most common immediate problems included bleeding, blood clots, and respiratory distress. Lung puncture and pneumonia were reported in one-third of the children. Oxygen was needed in the case of some lung complications.

There were fewer problems in patients who had a posterior fusion. This was compared with patients who had an anterior fusion or combined anterior-posterior fusion. The number of vertebrae fused did not appear to be a risk factor for problems after surgery.

The authors conclude that scoliosis surgery is a safe procedure. But problems can occur, and steps must be taken to prevent them. Patients with neuromuscular scoliosis must be followed carefully. Posterior spinal fusion is the preferred approach for most pediatric scoliosis surgeries.

Further study is needed to complete the course-prediction model. Other risk factors must be identified. Reducing length of hospitalization, costs, and post-operative problems while providing a safe and effective operation is the final outcome.

Osteoporosis also known as brittle bones is a decrease in bone mass or mineral density (BMD). Aging adults are affected most often, but children can have osteoporosis, too.

In this article, doctors from several research centers around the world discuss osteoporosis in children. Factors that affect bone growth and skeletal development are presented. Ways to identify risks and prevent this problem in young patients is a second focus of the report.

Most fractures in children are caused by trauma. Children with fragile bones from osteoporosis may be fracture-prone. They are at increased risk of fracture from minor injuries. The most common bone break in children occurs in the forearm just above the wrist.

Common factors affecting bone mass include genetics and environment. Genes inherited from both parents is a major factor. Diet and exercise make up the bulk of the environmental factor. For girls and women, hormone levels are also a key factor. Corticosteroid treatment and chemotherapy are two other causes of osteoporosis in children.

Physical activity early in life builds bone mass. This must occur before the growth plates between the bones and the joints finish growing and close up. At the same time, getting enough calcium, vitamin D, and phosphorus is also important to bone growth and development.

Even with good genes, children must have a certain level of calcium. This is needed to reach peak bone mass that is preset by the genetic code. Higher levels of calcium in the diet during childhood and adolescence can build bone mass and prevent fractures.

Not getting enough vitamin D from diet or lack of sunshine can also contribute to the development of osteoporosis in children. Phosphate in soft drinks is a risk factor for low peak bone mass. This is true when soda pop replaces milk on a daily basis.

Prevention is the most important treatment for osteoporosis in children. Once osteoporosis occurs, current treatment for children is limited. Drugs used to boost bone density in adults have not been tested in children. We don’t know if these agents will interfere with bone growth. Long-term effects are also unknown. Further studies in these areas is needed.

Children play in such a way that arm fractures, particularly forearm fractures are quite common. The two bones in the forearm, the radius and the ulna bear the brunt of force when a child falls and puts his or her hand out to break the fall.

Usually, the treatment is a closed treatment with a cast, meaning that no surgery is needed. These bones heal quickly and usually are just as strong as they were before the fracture. Two earlier studies done in Europe found children had a 5 percent refracture rate of the forearm, particularly if they had a sustained a greenstick fracture, a partial break much like a wet twig breaks partially when bent. In the study, 75 percent of the children with refractures had greenstick fractures in the radius, ulna, or both. As well, 96 percent had a persistent angulation, a remaining angle at the break of the bone.

The authors of this study wanted to discover what were the risk factors for a forearm refracture in children by looking at how severe the initial fracture was, the location of the fracture, how obvious the fracture was on x-rays after healing, and any angulation left by the fracture. To do this, they looked back at patients who were treated between 1998 and 2005 and they found 63 patients who had refractured one or both of the forearm bones. This group was compared to 169 patients who had not refractured a bone.

The average age of the patients was 9 years in both groups, among both boys and girls. Among the refracture group, 46 percent had a refracture of the radius, 5 percent of the ulna, and 49 percent refractured both bones. Among the control group, 53 percent had fractured only the radius, 1 percent the ulna, and 46 percent both bones.

Initial treatment included casting the arm alone for most patients: 57 percent in the refracture group, and 66% in the control group. Some children needed a closed reduction, during which the physician manipulates the bone back into place. This happened in 33 percent of the refracture group and 29 percent of the control group. Finally, 8 percent of the refracture group and 5 percent of the control group required an open reduction, or surgery to align the bones.

When looking at the location of the fracture, the refractured breaks were closest to the elbow in 8 percent, in the middle section of the bone in 30 percent, and closer to the wrist in 62 percent. In the control group, the fracture locations were 3 percent, 12 percent, and 85 percent, respectively. The researchers also looked at how obvious the fracture by x-ray, after it healed. For the refracture group, the fracture lines in the radius were clearly visible by x-ray in 42 percent compared with 24 percent of the controls. In the ulna, the fracture lines were visible in 50 percent versus 21 percent, respectively.

Because the unexpected can happen, particularly when children are involved, 5 of the patients overall experienced a second fracture, but not a refracture of the original break, meaning it was not in the same place.

Earlier studies of similar refractures recommended that doctors apply splints to the fractured arms after the casting period. They found that arms from which casts were removed before 6 weeks were at a higher risk of refracture.

After examining the findings, the researchers concluded that children who have fractures closest to the wrist have a greater risk of refracturing the bone within 18 months of the fracture. The authors acknowledge that although the bones can heal rapidly, there is still an increased risk for fracture and they recommend that one way to reduce the risk is to examine the fracture line on the x-ray after cast removal. At this point, a decision should be made as to whether a splint would be necessary to protect the bones for a longer period. “Distal forearm fractures that are casted are by no means ‘healed.’ Distal fractures that are casted for 4 to 6 weeks of treatment generally benefit from an additional 4 to 6 weeks of treatment in a removable splint,” they write in their article.

The authors go on to recommend that further splinting should be done for another 8 to 12 weeks, as well as maintaining the restriction on high-risk activities.

The trampoline, patented in 1936, was originally designed for circus acts. Over time, it became a training and fitness tool, a gymnastics apparatus, and a new way of having fun. While trampolines were found only in schools or recreational clubs in the 60s and 70s, the industry has soared as parents began to buy trampolines for use in their backyards.

Trampolining has always had its dangers to the point that in 1971, the National Collegiate Athletic Association in the United States pulled the trampoline from its competition. Most recently, in 2006, the American Academy of Pediatrics has issued warnings and recommendations that would restrict trampoline use and removing them from homes, outdoor playgrounds, and schools.

Despite the more than 83,000 injuries seen in emergency rooms across the United States in 1996, the majority of which occurred at home, trampoline ownership has increased from an average of 3 trampolines per family in the US in 1995 to 1.7 trampolines per family now. This increase in trampoline availability in the home environment has added to the number of children who are not abiding by the manufacturers’ recommendations of only one jumper at a time and safety devices (netting, recessed canvas) are only used a bit more than half the time.

In this study, the authors reviewed the accident records from trampoline injuries during a 3-month period in one emergency room. They found 101 children, average age 8.5 years, ranging from 1.4 to 16 years, out of 6636 patients in that 3-month period. This represents about 1.5 percent of the patients. The majority of the patients had fractures (35 arms, 24 legs, 1 sternum) and the remaining had soft tissue injuries (36 patients) or head injuries (5 patients). Broken down, the injuries were:
– arms: 38
– legs: 36
– head: 5, 1 with loss of consciousness
– trunk: 4
– face: 3

Twenty of the patients were admitted to the hospital; 12 of whom had to have surgery, 58 went to a fracture clinic, and one to plastic surgery for stitches to the face. Broken into percentages, almost 20 percent of patients with trampoline injuries were admitted to the hospital.

The injuries occurred from:
– falls off the trampoline: 31 patients
– awkward falls on to the canvas: 23
– patients colliding with another person on the trampoline: 13
– falls into the springs around the canvas: 9
– attempting to do stunts: 12
– jumping from somewhere else onto the trampoline: 1

There was protective netting only around 47 trampolines, and only 52 had a responsible adult supervising the play. The researchers found that 80 percent of the children had sustained trampoline injuries earlier, as well. And, “Despite this and the manufacturer’s guidelines, 58 percent of injuries in this study, occurred when more than one person was on the trampoline,” the authors write.

Despite manufacturers’ recommendations, 58 of the patients were jumping on the trampoline with at least 1 other person:
– 6 people jumping on the trampoline: 1 case
– 5 people jumping on the trampoline: 2
– 4 people jumping on the trampoline: 9
– 3 people jumping on the trampoline: 13
– 2 people jumping on the trampoline: 33

When the injury occurred with more than one person on the trampoline, more than half of the patients were the smallest or lightest in weight.

The authors of this study conclude that when more than one child is jumping on a trampoline, it is the lightest child who has the greatest risk of injury as the larger child can rebound on top of the lighter one. In fact, the lighter child has a 14 times higher chance of injury.

A specific type of fracture, a complete distal femur metaphyseal fracture, a complete break of the thigh bone, is often seen in children who have been abused. Fractures are the third most common type of injury resulting from abuse, after bruising and burns.

The authors of this study investigated this type of fracture and its relationship to abuse of children. The researchers reviewed the database of a trauma center and found 29 children in all, 20 children under the age of 1 year (14 boys), who had sustained the fracture. After reviewing the records for the way the children were injured, x-rays, associated injuries, treatment, and outcome, the researchers noted cases of suspected child abuse or neglect.

The 20 younger children were an average of 6 months at the time of injury, but ranged in age from 5 days to 1 year. Five of the children had another long-bone in addition to the study fracture, and 1 child also had a fracture in a rib.

After screening by a social worker, it was found that 10 of the 20 younger children did sustain the fracture from abuse and 5 were considered to be highly suspicious for abuse. The remaining 5 were accidental injuries. None of the 9 children over 1 year appeared to have any signs of abuse.

The authors comment that these types of fractures are the most common type associated with child abuse. Statistics from previous studies say that between 60 percent to 93 percent of such fractures in children who are not yet walking are the result of abuse. They also write, “Nonaccidental femur fractures are more commonly seen in children younger than 1 year, firstborn, children with preexisting brain damage, and those with bilateral [one on each side] fractures.”

They recommend that children who are not old enough to walk but present with these fractures be examined for abuse.

Osteochondritis dissecans, a disorder that keeps blood from reaching a part of bone beneath a joint, usually affects teens and young adults; because it rarely affects children who are still growing, there is not much information on the best way to treat it. As well, because children who do have OCDT begin to feel better before healing is actually complete, many do not show up for follow-up appointments, so it is difficult to tell when the problem has healed.

The authors of this study reviewed the healing rate of juvenile osteochondritis dissecans of the talus; the talus is the ankle bone. Also called JOCDT, this type is treated very differently from the adult type.

After reviewing records of children diagnosed with OCDT, the researchers found 32 patients (20 boys) who met the requirements for JOCDT and had completed at least 6 months of follow up. Thirty one of the patients were treated without surgery. The researchers noted information including patient age, race, sex, history of the injury, pain, swelling, limp, range of motion of the ankle, and how long the pain lasted. They then classified the injury, or lesion, according to where it was located and the size.

The researchers also used magnetic resonance imaging, or MRI, to confirm the diagnosis. They used a classification scale (the Berndt and Harty); if the lesions were classified as stage 1, 2, or 3, the patients were treated without surgery. Weight-bearing (walking) casts were applied and kept on for 6 to 8 weeks, followed by a removable brace and activity restrictions for a total of 6 months treatment. They were to return for follow-up at that point. On follow-up, the lesion was checked for new bone formation. If this didn’t appear to happen, MRIs were repeated.

In many children, the pain and symptoms of JOCDT disappear before the healing is complete. If this was found (evidence of no healing by MRI, but no reports of pain), it is recommended that surgery be done to graft bone or remove dead bone. However, surgery could be held off for up to a year if the patient agreed to continued restriction to activities.

For those patients with stage 4 lesions, surgery is likely required, followed by casting and non-weight bearing until given the go-ahead by the treating physician.

Among the 31 patients who did not have surgery, 2 patients (6 percent) complained of severe pain and they underwent surgery after the casts were removed, 5 patients (16 percent) were found to have healed both clinically (symptomatically) and on x-ray, and 24 patients (77 percent) still had signs of lesions on the x-rays. Ten had surgery, 11 felt no symptoms – 4 had successful healing after another 6 months of non-surgical treatment, 7 did not but did not go on for any more treatment – and 3 patients were lost to follow-up.

The authors write that the cause of OCD isn’t yet understood, with many doctors suggesting that it is caused by trauma. During treatment, pain seems to decrease before the lesion is healed, so clinical (symptomatic) results have always had a better rate than x-ray results, after treatment. They point out that 24 of the patients continued to have signs of lesions seen on x-ray, even after 6 months of treatment, and 7 continued after another 6 months. This gives a failure rate from treatment of 54 percent.

The study subjects were all patients who did not have adult bones, something that has not yet been noted in the medical literature. The authors conclude that many patients with JOCDT do not respond to conservative treatment within 6 months and that parents and children should be warned that the treatment could take longer. However, if the pain continues, despite the treatment, surgery should be considered.

Identifying fractures that are the result of child abuse is not easy, therefore it is vital that physicians be more comfortable in finding these types of fractures. Fractures, of any type, have been found in between 11 percent and 55 percent of children who were abused; most often, these children were under 3 years old. In an effort to find if one particular fracture is more common among abused children, researchers have found that they occur equally in the femur (thigh bone), tibia (lower leg), and humerus (upper arm). Although spiral fractures are only one of the most types of fractures seen in this group of children, researchers have suggested that children with this injury be watched for signs of abuse, especially if there was a delay in treatment.

Given the difficulties in determining if child abuse is present when children with this type of fracture come to the emergency room, the authors of this study wanted to identify the fracture patterns that result when a bone is twisted in different directions and is broken. The research was done using rabbit femurs because they are similar in structure and properties to human bones. The authors felt that this would help identify the effectiveness of standard x-rays in detecting spiral fractures.

Using 20 rabbit femurs, previously removed from the animal carcasses, the researchers applied twisting forces to break the bones. Seventeen of the fractures were spirals and 3 had several fragments (multi-fragmented). Following the fractures, the researchers glued the bones back together to mimic a minimally displaced fracture. X-rays were taken of the bones and 10 pediatric, orthopedic, surgical, emergency department, and radiology residents were asked to examine them.

Slightly more than half of the residents were able to make the identification:
Seven pediatric residents, 6 orthopedic, 6 radiology, and 5 emergency room residents were able to say how the bones were broken and in what direction they were twisted. Once they were given more information, they were all able to see how the break occurred.

The authors write that the doctors who can identify if a break has been caused by a twisting motion would be able to use this information in assessing the possibility of abuse.

In conclusion, the authors say that this study “was able to show the direction of the torsional force that produces a spiral fracture can be determined from the characteristic fracture pattern” on the x-rays.

Although many patients with adolescent idiopathic scoliosis (curvature of the spine), or AIS, can be treated without surgery, those who have a severe curvature or curvatures will need surgical correction. The goal of the surgery is not just to straighten out the curve, but to make sure the back is strong, and the patient has a balanced posture and can move well.

In deciding how to fuse the spine, surgeons have to decide how much of it to fuse; they would like to keep it as short as possible, but this may not provide enough stability to the spine. However, the longer the spinal fusion, the lower the mobility of the spine. To help make these decisions, the surgeons use the King and the Lenke classifications. The authors of this study investigated how the classifications were used by the surgeons in deciding on the surgery.

The researchers sent a survey to 50 surgeons in North America, France, Korea, and Japan, who were members of the Spinal Deformity Study Group (SDSG). The questionnaire asked the surgeons to rank their goals in treating scoliosis for the best outcome after surgery. The scoring ranged from 1 to 20, with the most important being 1, the least was 20. The surgeons were also asked to weight the correction of the spine: the coronal (front to back), sagittal (left and right), or transverse (top and bottom).

When the responses were received, the surgeons were sent a second survey that looked for more specific objectives. The surgeons were asked to weigh the importance of corrections in the 6 curves identified with the Lenke classification, using a scale of 1 to 5, where 5 was the most important and 1 the least.

Twenty-five surgeons returned the first survey and 10 responded to the second. The results of the first survey showed that the surgeons felt that the sagittal and coronal balance were the most important factors in their surgical decisions. All the other parameters varied across the board. The results from the second survey showed that certain curves were more important in their decision-making than were others.

The authors write this is the first time such a study was undertaken. The decision-making process lies greatly with the surgeons’ training and experience. The authors point out that the study’s drawbacks include the lack of x-rays in the ranking questionnaires, which could affect a surgeon’s decision about fusion. The authors also state that the surgeons were all spinal surgeons with a specific interest in this area.

In conclusion, the researchers state that further research is needed as there is still a big variety in the way spinal fusion decisions are made by the surgeons.

Osgood-Schlatter disease (OSD) is a disease that affects the knee of a child or adolescent. The muscles appear to pull and cause the tendons to pull away from the tibia, or shin bone. It happens most often in very active children and those who are athletes.

While most cases of OSD heal on their own with time and rest, occasionally, the bump that can occur on the knee will not go away and will continue to cause pain. In the institution used for this study, of 3600 patients with OSD, between 1989 and 2003, only 51 patients (about 2 percent) had undergone surgery. In this study, the authors wanted to see what the outcome of this surgery would be for patients who did not respond to traditional treatment.

The researchers looked at 51 patients, 53 knees, of children who were on average 17 years old when they had their surgery. The ages ranged from 13 to 25 years. Because of patient dropping out of the study, only 15 patients (16 knees) remained for follow-up of about 7 years, ranging from 8 months to 15 years.

At the end of the study, the patients were asked about resumption of activity. They were assessed, before and after surgery, with the International Knee Documentation Committee (IKDC), which assesses the pain in terms of frequency and severity on a scale of 1 to 10 (10 being the worst),the Lysholm Knee Scale, which scores pain from 25 to 0 (0 being the worst pain), and the Tegner Activity Score, which measures pain from 0 to 10 (10 being the worst). All patients had complained of a painful bump before surgery.

After surgery, 11 patients were found to have a smaller bump than before surgery, 4 had no change in size but only 1 complained of symptoms from the bump, the other 3 had no complaints. The last patient had an increase in the size of her bump and chose to have another surgery to reduce it.

When assessing pain after surgery, the patients had an average of 3.5 on the IKDC scale, 18.3 on the Lysholm Knee Scale, and 3.2 on the Tegner Activity Scale. When asked about returning to activities, 12 patients had resumed their pre-injury activities, 2 partially, and 1 did not. The patient who had a second surgery did return to her previous level of activity.

The authors conclude that although OSD can be managed without surgery most of the time, there are situations where surgery is required and, when done after skeletal maturity, had a good success rate. The authors do point out that this was not a randomized nor a comparison study.

There has been some debate about the need for routine screening of all babies for a condition called developmental dysplasia of the hip (DDH). DDH describes a wide range of hip problems. The hip socket may be too shallow to hold the head of the femur (thighbone) in place. Or the femoral head may be be lined up properly with the hip socket.

After reviewing the current studies available, the U.S. Preventive Services Task Force (USPSTF) said routine screening for DDH wasn’t needed. The authors of this article took a second look at the findings and disagreed. They offer their reasons for advising doctors to continue screening infants for DDH.

The USPSTF issued a statement saying that routine screening does not result in less surgery or better outcomes. The USPSTF also said that since many babies with DDH get better on their own without treatment, early identification isn’t needed.

The authors point out that no true quality study has been done on this topic. For ethical reasons, it’s not possible to compare a group of infants screened with a group who have not been screened. Withholding screening that could protect a child is not acceptable in our culture.

Three points were made in this article. First, many cases of DDH do resolve without treatment. But they don’t all get better. Some children do need further treatment to avoid a bad outcome. Without screening, this can’t happen.

Second, it is possible to detect an unstable hip early. The examiner must be trained and skilled in carrying out a special test for DDH called Ortolani’s maneuver. Early referral and treatment can make an important difference.

And finally, about one out of every 5,000 babies actually develops DDH later. It’s not present at birth. This is called a late onset hip instability.

Such cases cannot be avoided with early, routine screening. But discontinuing screening can make a difference in other children. It should not be abandoned without clearer evidence. More study is needed before a final screening guideline can be developed fully.

This is the first report of spinal fusion in children with congenital scoliosis using freeze-dried allograft bone chips. The results were very favorable using allograft bone as a substitute for graft material usually taken from the iliac crest.

Scoliosis is a curvature of the spine. It can occur for unknown reasons, or it may be hereditary. Children who are born with scoliosis have the congenital type. Congenital scoliosis is often severe enough to require surgery to fuse the spine in place.

Metal rods and screws are used to hold the spine upright until the fusion occurs. Bone chips are also used to complete the fusion. Allograft material comes from a bone bank. It is used as a substitute for bone that is usually taken from the patient.

Bone harvested from the patient is called an autograft. Autografts can be painful and leave a scar. With allografts, the operation is shorter. There’s a larger supply of allograft bone available. And there’s no pain or scar to deal with.

But there are some potential risks using allografts. There has been some fear that viruses such as HIV could be transferred through the graft. Infection is another possible problem. And sometimes the bone doesn’t generate new bone growth as it’s supposed to. Instead the fusion is unsuccessful.

In this study, the authors report a very successful outcome. They used freeze-dried bone allograft in a series of children who had congenital spinal deformities. There was a very low rate of fusion failure. Almost all of the children had a successful outcome.

The authors believe that careful surgical technique in a young population make the use of allograft bone a good option. Surgeons should consider allograft when fusing the spine in children with congenital scoliosis.

Clubfoot is a condition that some children are born with. The foot is turned under and towards the other foot. The toes are pointed down and the ankle is bent forward. Three bones of the heel and midfoot are involved: the calcaneus, talus, and navicular.

Treatment today for clubfoot follows the Ponseti method developed by Dr. Ignacio Ponseti in the 1980s. This method has been studied and tested. It is effective in more than 90 per cent of all cases.

The Ponseti method uses serial casting to hold the foot in a normal position. Once the foot is corrected, a foot abduction brace is applied for 23 hours each day. The brace is worn full-time for three months. Then the time can be reduced to 14 hours/day (nap and night time).

There has been some question about whether holding the foot in a neutral position causes a change in the rotation of the leg. Rotation of the tibia (lower leg) is called tibial torsion. Rotation of the femur (thigh bone) is called femoral anteversion.

In this study, the effect of using the Ponseti method on leg rotation was measured. Twenty children used the Ponseti method for clubfoot. They were tested for tibial torsion and femoral anteversion and followed for an average of 33 months.

Results showed no effect of foot abduction bracing on leg rotation. Rotations remained within the normal range even after 33 months. For the 19 patients who followed the method, the results were excellent. One family did not use the brace as instructed. Their child had a recurrence of severe clubfoot.

The authors conclude that the Ponseti brace method works well for clubfoot without changing leg rotations.

Femoral head osteonecrosis is the death of bone at the top of the femur (thighbone). It can occur after trauma in children and has a poor outcome. In this study, doctors at the Children’s Hospital at Westmead in Australia try a new treatment to prevent this from happening.

This is the first study in children to use bisphosphonates to prevent osteonecrosis. Bisphosphonates are a class of anti-resorption drugs used for bone cancer patients or for osteoporosis in older adults. Anti-resorptive means they keep the bone from breaking down. They also can improve bone density. So far, only animal and human adult studies have been done.

Children who had surgery for slipped capital femoral ephiphysis (SCFE), femoral neck fractures, or hip dislocation were included. Bone scans were done to detect osteonecrosis. Bisphosphonate therapy was started in any child who had a positive bone scan.

The drug was given intravenously (IV). This method of delivery helps improve absorption. More of the drug is available for use in the body compared with taking an oral dose in pill form. IV administration also made sure the child got the medication.

The children were monitored every three months for at least two years. X-rays and an exam were done to watch for complications. There were no major adverse effects of the drug. No negative effects on growth were seen in the children. The use of bisphosphonates was successful in all children included in the study.

The authors saw signs of bone resorption for up to 18 months after the initial injury. They suggested a higher dose of drug may have been needed. Right now the best dose and duration of bisphosphonate to use is unknown. Further study is needed to find the right balance to protect bone without increasing the risk of adverse side effects.

Legg-Calvé-Perthes Disease is a loss of blood and subsequent death of bone tissue. Children are affected (boys more than girls). It affects the head of the femur (thigh bone) where the growth plate is located. This condition can result in hip deformity.

The author of this review article, reminds us that treatment early in the process gives the best results. But sometimes knowing what stage the disease is in can be difficult. By the time X-rays show a collapse of the lateral pillar, it may be too late for optimal treatment.

The lateral pillar refers to the outer one-third of the femoral head. Loss of height and a change in bone density cause the bone to collapse. Collapse of the lateral pillar is never seen on X-ray early in this disease.

Using the lateral pillar as a way to determine treatment and predict the results can only be done after the fact. And by then, it may be too late to save the shape of the hip.

The author concludes that the lateral pillar classification of Legg-Calvé-Perthes Disease cannot be relied upon to help direct treatment.

We still need some kind of scanning technique to identify the problem early and influence treatment choices. This may not be possible until imaging technology advances beyond what it is now.

In this study, an independent spine surgeon reviewed the records of patients who had a spinal fusion using pedicle screws for scoliosis. Patient charts and imaging studies (X-rays and/or CT scans) were used. All 115 patients were treated at the same spine surgery clinic in Italy.

Everyone had a diagnosis of thoracic scoliosis. This is a curvature of the mid-spine. Over 1,000 screws were used by three surgeons over a period of three years. Complications such as fever, screw misplacement, and fractures were recorded. Wound infection, neurologic problems, and loosening of the screws were other problems that developed in some patients.

The authors describe the surgical technique used to place the screws in the spine. A mini-laminotomy was performed. Only part of the lamina was removed. The lamina is part of the curved arch of bone in the vertebra that forms the spinal canal. A special surgical tool called a spatula was used to feel inside the spinal canal and find the right place for the screw.

Patients were followed for up to five years. Any screw-related complications were reported during that time. Screw misplacement was the biggest problem. Patients with the most severe curves were more likely to have this complication. Only one out of the 13 patients with this problem had any symptoms.

Misplaced screws were only removed if they presented a potential risk for the patient. The patients at greatest risk were those whose screws were closest to the aorta. The aorta is the main blood vessel leaving the heart. It takes blood to the brain and rest of the body. Most malpositioned screws can be left where they are without problems.

The authors conclude that the mini-laminotomy method of screw placement for thoracic scoliosis increased the safety of the procedure. Despite some complications, there were fewer problems than with the open-laminotomy procedure. The mini-laminotomy approach does require extra care and caution by the surgeon but has good results.

Elbow injuries are on the rise. This has been linked with the fact that 4.5 million children between the ages of five and fourteen are playing baseball and softball. It’s estimated that up to half of these children will have overuse or traumatic elbow injuries.

In this review, Dr. Tashjian from the University of Utah gives an update on the latest treatment for these two types of elbow disorders. Prevention of elbow injuries is also described.

Athletes involved in overhead sports such as baseball are at risk for elbow injuries. Gymnasts are also at increased risk due to repetitive loading on the elbow joint. Repetitive trauma may reduce the blood supply to the cartilage cells. Normally, these cells will eventually turn into bone. The process is called ossification. Without a good blood supply, ossification is disrupted.

The most common conditions described in this article include osteochondritis dissecans (OCD), injury to the ulnar collateral ligament, and elbow fractures. Treatment varies depending on the athlete’s age, activity level, and severity of the problem.

OCD is a condition in which fragments of cartilage or bone have become loose inside the elbow joint. Pain and inflammation occur and reduce elbow motion and function. For athletes with OCD, changing the activities and decreasing the activity level are advised.

If these conservative measures don’t work, then surgery may be needed. The loose pieces are either removed or reattached. Children who have surgery for large fragments have the worst results. Healing is delayed when there isn’t enough healthy cartilage to protect the area. Return to sports is unlikely when open surgery is done to remove large, unstable fragments.

Surgery to repair a torn ligament is usually able to get the athlete back to their sport in an average of three months. Elbow fractures and dislocations can be treated with or without surgery. The decision about which type of treatment is best can be difficult to make. The goal is to stabilize the elbow without causing nerve damage or a deformity.

And finally, elbow injury prevention is an ongoing topic of discussion. The authors report the USA Baseball Medical and Safety Advisory Committee have made some recommendations for young pitchers. Parents and coaches must monitor athletes for signs of fatigue. Athletes should not play when they are in pain. And the number of pitches per game, per month, and per season should be carefully watched.