News Category: Child

This article is a reprint of an article that appeared in 1958, reviewing the effectiveness of different methods of treating scoliosis. Surgery for scoliosis has evolved and been refined over the years since the first spinal fusion was done by Dr. Hibbs in 1911. This study examined the outcomes of 266 patients with idiopathic scoliosis (unknown reason) or paralytic scoliosis (caused by something external). The patients were treated from 1947 to 1956 and most were followed for 2 to 8 years.

Of the 266 patients, 130 had idiopathic scoliosis, 116 were female. The average age at time of fusion was almost 14 years old. The youngest patient was 9, the oldest 40. The outcome of these patients was generally positive. On average, the patients showed an average gain of 40 percent in angle curvature (of the spine). Cosmetically, 78 percent of the patients were found to have good results in their appearance. The patients had undergone 1 of 3 types of spinal fusions: the early type, which was first done in 1948, Cobb method, which was first done in 1952, and articular-facet fusion, which was first done in 1953. The success of the surgeries varied. The early method had a 56 percent rate of defective bone grafts, while the Cobb method only had a 7 percent rate. Originally, the articular-facet fusions had a higher rate at 15 percent, but at one point, doctors began using bone grafts from the patients themselves and then this rate dropped to 7 percent.

The researchers also looked at the incidence and the effect of pseudoarthritis, bones that don’t join properly, among these patients. The findings showed that the patients with idiopathic scoliosis had fewer incidences of pseudoarthritis than did the other group. Among all patients, 135 separate incidences of pseudoarthritis were found, more in some patients than in others.

For the 136 patients with paralytic scoliosis, 81 were female, and the youngest was 3 years old while the oldest was 20. The average gain for this group was 44 percent. Cosmetically, the average gain was 49 percent. Overall, an average of 78 percent of patients reported a “good result.”

Among the patients in the paralytic scoliosis group, the patients who had the early type of fusion showed pseudoarthritis in 65 percent. The Cobb-type fusions showed 36 percent, and the articular-facet fusions showed 14 percent, once the surgeons began using the patients’ own bones for grafting.

The author concluded that the surgeries provided good cosmetic and functional results if the proper fusion is done and a solid fusion results.

Children born with a clubfoot must wear special casts and braces for 23 hours a day for three months, and then every night for three to four years. While this traditional bracing system, called the Ponseti method is effective, many children whose parents are not vigilant about the amount of time the brace is worn do not get a full correction of the clubfoot.

When a patient or family doesn’t participate fully in a treatment, this is called non-compliance. Researchers have found that parents who are non-compliant usually are so because the braces are too awkward to put on, the child gets upset and is uncomfortable, or the child develops blisters on the feet.

The researchers in this study wanted to see if a newer style of bracing would increase parent compliance, increase the chances of preventing clubfoot relapse after it was corrected using the Ponseti method, and decrease any complications. While the Ponseti method uses stiff boots/shoes attached to a wide metal rod, to hold the feet in place, the new dynamic method allows for some movement of the child’s legs, so there can be some muscle movement, and the shoe/boot part is replaced by a softer molded section that is put inside the part that holds the foot.

Twenty-eight patients were studied; they had been treated with the Ponseti method and then the new dynamic method to keep the clubfoot from returning. Eighteen patients had originally used the Ponseti method but the parents had stopped because of blisters or difficulty applying the braces. The rest of the patients had completed their treatment with the Ponseti method.

At the start of treatment with the Ponseti method, all parents were taught how to care for the braces and how to apply them properly. They received support from a special “clubfoot” nurse. The parents were taught how to exercise their child’s legs in order to keep the muscles from wasting. The children received their casts/braces between the ages of one week and 77 weeks, but the usual age was around 16 weeks. Follow-up was about 29 months, but ranged from 24 to 36 months.

In this study, the researchers found that non-compliance with the new braces only happened in two cases (7.1 percent) of the patients. Of these two, one child’s braces were not being applied properly and caused skin breakdown. With the other child, family scheduling and lack of family support didn’t allow for proper bracing. This rate of 7.1 percent compares with a non-compliance rate of 41 percent reported earlier for the Ponseti method. Only 7 percent of patients developed skin blisters with the new system, compared with 23.5 percent with the older system.

The researchers concluded that the new system was well tolerated by both patients and their parents.

There has been some controversy in the treatment of clubfoot, mostly regarding surgery. Some surgeons prefer to do a technique that involves dividing a ligament in the foot called the talocalcaneal interosseous ligament, while others feel that it shouldn’t be done. The procedure, called the TCIL, can result in an “over” correction of the clubfoot, some researchers say.

The researchers in this study wanted to compare the results of children who have surgery with, and without, TCIL. Forty-one boys and 5 girls (with 66 clubfeet total) were included in the study. They ranged in age from 2 to 24 months, with the average age being 9 months. During the surgery, half of the feet received the TCIL procedure and the other half did not. The researchers used before and after x-rays and magnetic resonance images (MRIs) to assess the changes in the feet. The feet were assigned a score depending on how they looked cosmetically, the range of motion, strength of the calf muscles, and findings on the x-rays and MRIs. The scores were then divided into 4 groups: above 75 was excellent and between 61 and 75 was good. Feet in these categories were considered satisfactory. If the score was between 46 and 60, the outcome was fair, and lower than 45 was considered poor. The feet in these two groups were considered to be unsatisfactory.

In group A, the patients who had the TCIL procedure, the outcome was excellent for 32 feet (96.9 percent); for group B, the patients who did not have the TCIL procedure, the outcome was excellent for 29 feet (87.9 percent). The fear that there would be an over-correction seemed unfounded when looking at the patients’ MRIs 5 months after surgery, although the authors do say that the short duration of follow-up is a weakness of the study, and that other studies have shown over-correction in some patients.

The authors conclude that this procedure is advisable for patients with severe and very severe clubfeet.

A cuboid nutcracker fracture is a break of the shinbone caused by the forefront being forced away from the center, usually because of a force that pushes it away. Left untreated, these fractures could cause disability and severe pain.

The researchers in this study went over the records of children who were admitted to a particular hospital because of fractures of the tibia (shinbone). They found four girls ranging in age from 11 to 15 years who had broken their leg in a horseback riding accident. As they fell, the horse did as well, trapping the girls beneath, causing the fracture.

Two patients underwent surgery and then wore non-weightbearing casts for six weeks followed by walking casts for another six weeks. Both girls recovered well and on follow-up (two years for one girl, three years for the other), there were no complications. The girls were walking normally and both had resumed their previous level activity, including participating in sports. The other two girls did not have surgery because they or their parents refused. Both girls wore non-weightbearing casts for six weeks. One girl then wore a walking cast for six week. Follow-up after three years found that the girl had no pain in the foot but did have stiffness and some arthritis was found in the joint. Although she had returned to her previous level of activity, she could only participate in non-strenuous sports. The fourth girl had a walking cast applied after six weeks of non-weightbearing the cast was only removed after three months. At five-year follow-up, the girl was not able to return to sports and still had pain and stiffness in her foot. This affected her daily activities and she could not participate in any sports activities.

The authors concluded that although these fractures are rare, if they are found, physicians should also look for other injuries in the mid-foot. A computed tomography scan (CT scan) is the best way to detect this. If there are no other injuries mid-foot, surgery may not be needed, but other studies did not have good results (fair to bad) from non-surgical treatment. The authors also point out that physicians should encourage the use of safety equipment, such as strengthened riding boots, to reduce horseback riding injuries.

Researchers are taking steps to improve studies on the subject of scoliosis (curvature of the spine). In order to compare one study to another, similar methods and measurements must be taken. The Scoliosis Research Society (SRS) has set up guidelines for all future studies. The guidelines will make it possible to compare the results of different treatment for children with scoliosis.

The editors of the Journal of Pediatric Orthopaedics report two studies in this month’s journal using these guidelines. The guidelines direct who can be included in the study. These are called inclusion criteria.

The second set of guidelines are for measuring how well nonoperative treatment such as bracing works (effectiveness). These guidelines include how many patients had a curve that got worse and by how many degrees. They also kept track of how many patients were advised to have surgery. And they added up the number of patients who then had the operation.

The inclusion criteria states that all patients in the studies on bracing as a treatment for scoliosis have to be at least 10 years old when the brace was made. The main spinal curve has to be between 25 and 40 degrees. And for girls, they must not be more than one year past the start of their menstrual cycle.

The guidelines further state that all patients are to be followed for at least two years past skeletal maturity. Successful brace treatment means keeping the results until the child has stopped growing.

The editors also comment on the recent decision to stop school screening for scoliosis. This decision was made because it appears that there isn’t enough evidence to show that school screening is cost effective.

Drs. Hensinger and Thompson agree that this decision is wrong. They predict there will be more children diagnosed with scoliosis later when the curve has progressed beyond a mild case. This may mean more complex surgery will be needed to correct the spinal curvature.

This policy may not change unless it can be proven that bracing or other nonoperative treatment can make a difference for children with mild to moderate curves.

In this study, the results of using stainless steel elastic nails to support unstable femoral shaft fractures in children are reported. Nails is a term to refer to a long stainless steel rod that is placed inside the femur (thigh bone).

The nails are elastic meaning they can be bent before inserting them into the bone. Once inside, this type of nail sits flat against the bone without changing shape. The same type of flexible stainless steel nail was used in two groups of children. The first group had a stable fracture. The second group had an unstable fracture.

Stable was defined by the type of fracture. In this study, a transverse (straight across the bone) or oblique (across at an angle) break was stable. Unstable fractures were either spiral (twisted apart) or comminuted (broken into more than two pieces).

The authors report the stainless steel nail worked well in both types of fractures. Patients healed with no difference in leg length from side to side. No one refractured. The was no difference in the rate of complications between the two groups.

The authors conclude flexible fixation of femoral shaft fractures in children is possible with stainless steel nails. They are stiffer and stronger than titanium nails. They work well for older children and teenagers who are too large for closed reduction (align bone without open surgery) and a full hip spica casting. And they can be used for unstable fractures.

Studies are ongoing to compare stainless steel with titanium nails (rods) used to treat broken bones. In this study, surgeons report on the results of titanium elastic nails for fractures of the tibia (shin bone). Sixty children ages five to 17 were included.

Titanium elastic nails can be bent before placing them in the bone to stabilize a fracture. Once inside the bone, they are a solid support while healing takes place. Complications can occur and are the subject of this study.

The authors reviewed the charts and X-rays of children with unstable tibial diaphyseal fractures over a seven year period of time. Diaphysis is the main shaft of the tibia.

All the children were treated with titanium elastic nails. Titanium is the alloy used to make the nails. Elastic refers to the fact that there is some give or bend to the bone. This allows the surgeon to shape the nail before inserting it into the bone.

Nail size selected depended on the child’s age and size of the tibial bone shaft. In all but one case, two nails were used to stabilize the fractures. The nail was taken out when there was a solid fracture union formed. Each child was allowed to go back to his or her regular activities as tolerated.

The authors report a high rate of delayed healing and nonunions in their patients. Older children (ages 11 to 15) were most likely to have this problem. This is known to happen in adults who have tibial fractures. Children are more likely to have an uneventful course of healing. The results of this study were surprising.

Children who were put in a short leg walking cast to give the bone increased stability seemed to do better. Two children needed additional surgery. There was extra bone formation that the authors think was caused by too much motion at the fracture site during healing.

Titanium elastic nails are safe in children with stable or unstable bone fractures. However, there are some problems. Titanium may not give enough stability for tibial diaphyseal fractures. Although some studies report nail migration and infection, in this study lack of stability was the greatest problem.

Surgeons from the Leatherman Spine Center in Louisville, Kentucky report on 76 cases ofjuvenile degenerative disc disease (JDD) in young patients. Out of a possible 1,877 patients referred to their spine center, there were 76 who qualified for this study.

All 76 patients had back pain that lasted more than six months despite treatment. They ranged in age from 11 years to 21 years old. MRIs were taken and reviewed. Anyone with scoliosis, tumors, fracture, or other serious cause of back pain were not included.

Based on MRI results, the diagnosis of JDD was confirmed. The levels most commonly involved were L4-5 and L5-S1. The degenerative discs were usually only at one or two levels, not the entire spine.

A smaller group of 13 patients had both JDD and spinal stenosis. Spinal stenosis is a narrowing of the canal where the spinal cord is located or a narrowing of the opening where the spinal nerves exit. These two conditions are most often seen in older adults as a result of the aging process.

This study showed that low back pain in young adults can be caused by either (or both) of these conditions. In the past, chronic low back pain in this age group was assumed to be either a serious condition like tumor or fracture or psychologic. MRI results showed that some of the young people had congenital spinal stenosis. This means they were born with the condition.

Everyone was advised to avoid activities that involve heavy lifting or repeated bending. A treatment program of antiinflammatory drugs, bracing, and weight loss was started. Everyone also saw a physical therapist for a program of back and abdominal muscle strengthening exercises.

Sports activities were not approved until the patients were improved enough to participate safely. Some patients with both JDD and stenosis didn’t get better. They had three epidural injections (once a week for three weeks). Those who still didn’t get better had surgery to take pressure off the nerve tissue.

This is the first report published on the use of two different braces for scoliosis using the new Scoliosis Research Society (SRS) Guidelines.
The guidelines are a list of methods that should be used by all researchers when studying bracing for scoliosis.

If everyone carried out the experiment the same way, then the results could be compared directly. For example, all patients had adolescent idiopathic scoliosis (AIS). AIS means the spine started to curve abnormally in a teenager. There was no known cause.

The age of the patients included was the same (10 years old or older). They all had the same size of spinal curvature (between 25 and 40-degrees). And the way the results were measured after bracing was the same. Other criteria were included as well.

The thoracolumbosacral (TLSO) brace was compared with the Providence. The TLSO is a brace that goes under the arms. It is smaller
and more pleasing cosmetically compared to the full neck-to-sacrum Milwaukee brace. The Milwaukee is worn 22 hours each day. The Providence is worn only at night for eight to 10 hours.

Comparing the outcomes of these two braces (using the same criteria) showed that the Providence brace had better results. Not as many Providence patients’ curves got worse. And far fewer ended up needing surgery. Even so, the results till suggested that bracing for AIS.

As a result of this study, the authors also found out that earlier bracing has
the best results. A separate group who received their braces when the curve was between 25 and 35 degrees had the best results. The authors plan to reevaluate the use of bracing sooner for patients with smaller curves (starting at 25 degrees).

The position of the sacrum and pelvis below the spine is important to maintain an upright, straight spine. Scoliosis or curvature of the spine may be linked to the position of the sacrum and pelvis. Studies have shown that the shape and position of the pelvis does affect the spine in normal children and adults. This study is an effort to see if there is a connection between the sacrum and pelvis and the development of scoliosis.

One measurement of sacral angle is called the pelvic incidence (PI). The PI is the angle formed by a horizontal line drawn across the base of the sacrum and a vertical line drawn through the femur (thigh bone). The angle is measured using X-rays viewing the sacrum, pelvis, and femur from the side. This is called a sagittal view.

In this study, rehab specialists look to see if the pelvic incidence determines the location of spinal curvature in children with scoliosis. Two types of scoliosis were compared. The first was in the thoracic spine. The second was lower in the area of the thoracolumbar spine.

X-rays taken in both groups and compared to normal children showed no difference in PI between the two types of scoliosis. There was an increased PI for all the children with scoliosis compared to the normal subjects.

The researchers still don’t know if the scoliosis is caused by the change in the pelvic and sacral alignment or the other way around. Pelvic incident does not appear to be the factor determining where the scoliosis occurs. More study is needed to answer this question.

The authors suggest the next study should look at what various pelvic sagittal measures that occur with scoliosis. It may be helpful to look at the pelvic incidence in many children without scoliosis and see if it changes for any who later develop scoliosis.

Screening for curvature of the spine called scoliosis is often done in the schools by a trained nurse. Children between the ages of 12 and 13 are checked for any signs of a scoliosis. In Canada, the screening program was stopped. There wasn’t enough proof that the money spent on the program saved money in the end.

In this study, results of school screening are compared with what happens without screening. The researchers reviewed patient charts for all adolescent patients sent to the orthopedic clinic for a spine problem. There were 489 patients included.

They compared the referral patterns for scoliosis from before (when screening was still done) to after screening was stopped. The results showed two main findings. First, after screening was discontinued, half of the patients sent to the clinic were normal and didn’t have scoliosis at all. One-third of the patients were referred too late. Their scoliosis had already gotten so bad, they needed treatment with braces right away.

They compared these results to a study done of 713 patients referred to a children’s clinic from a school screening program. Late referral was very rare in the screened group. About 40 per cent in the screening group did not have scoliosis.

The authors point out that without scoliosis screening in the schools, more children are sent to the doctor without cause. At the same time, those children who really need treatment, don’t get sent to the doctor until it’s too late.

However, re-starting a school screening program may not be the best answer for under-referral and late referral. One solution to the problem might be better training for family doctors about scoliosis. Clinical practice guidelines including when to refer to a specialist might be helpful while still reducing the cost.

Trying to compare the effectiveness of different braces used in treating scoliosis has been difficult. The type of patients and measures of results were often inconsistent from study to study. Making any kind of meaningful comparisons was impossible. As a result, the Scoliosis Research Society (SRS) put together a group of research guidelines.

All studies of bracing from now on will use these new guidelines. Age, size of scoliosis curve, and skeletal maturity are some of the specific criteria put forth in the guidelines. The amount of change measured in degrees after treatment was also broken down into groups. This will make it possible to compare results from study to study. The comparisons will be valid and reliable.

The new SRS guidelines were used in this study to test the SpineCor brace for the treatment of scoliosis. It was developed in 1992. SpineCor provides corrective movement specific for each type of curve. Studies so far show it works best for mild to moderate curves.

In this study, researchers followed patients up to two years after the brace was discontinued. In many cases, bracing helps hold the spine. It usually doesn’t improve the problem but keeps it from getting worse. It does not curescoliosis.

The SpineCor brace has been shown to improve the curve. And as this study shows, the improvements are maintained for up to two years. Almost 60 per cent of the children in this study were stabilized or improved. And the positive outcomes were still present two years later. This is very different from other braces where loss of correction is expected over time.

The authors plan to conduct future studies comparing the SpineCor with other rigid braces.

With more and more children involved in sports at a younger age, anterior cruciate ligament (ACL) injuries are on the rise. Treatment for this injury poses some new problems compared with adult injuries. For one thing, bone growth isn’t complete yet. Surgery to repair the torn ACL involves drilling through the bone.

In this review article, surgeons report on the timing and type of surgery needed for ACL injuries in the skeletally immature patient. Conservative care without repair at some point is not advised.

Surgery is needed to prevent knee instability. The timing of the repair can be delayed until the bone has stopped growing. But this means the child can’t play or compete in athletics. Reconstruction should be done within a month of when the growth plate closes signaling the end of bone growth.

The authors describe four different types of ACL reconstruction for the child or adolescent who is still growing. These include:

The editorial staff of the Journal of Bone and Joint Surgery reviewed over 100 articles published in the last few years on the topic of children’s orthopedic conditions. In this review, they offer a brief summary of these problems.

Starting from the arm and working down, each body part is included. For the arm and shoulder, brachial plexus palsy and shoulder instability are discussed. Surgery to release or transfer tendons for brachial plexus injury is presented. Immobilization in a sling with physical therapy is advised for the early treatment of shoulder instability.

The hip is next with coverage of slipped capital femoral epiphysis (SCFE), Legg-Calvé-Perthes disease, and deformities of the hip socket. Age, height, and weight remain important factors in SCFE. Children older than 12 years of age with symptoms for more than two months have the worst slips.

Preserving the hip is the key focus of treatment for all these problems. Some surgical procedures work better than others. In all cases, treatment is needed to prevent joint damage from the abnormal mechanics of the hip joint.

In the knee, congenital (present at birth) problems can affect ligaments and bones. There are also traumatic injuries in athletes. Ligament damage is common, especially affecting girls. So far, studies are focusing on exercise to prevent injuries. Surgery is often needed for the congenital problems.

One child out of every 1,000 live births will have a clubfoot deformity. The goal of treatment is to correct alignment and keep it corrected. Most children will need more than one operation to meet this goal. The results aren’t always good. Many children end up with arthritis in the feet.

Other topics covered included hip infection, bone tumors, cerebral palsy, and bone fractures. The rest of the review was taken up with problems in the spine. Delayed growth, scoliosis (curvature of the spine), and spinal muscular atrophy top the list. Surgery for each condition and the complications of each procedure are discussed in detail.

All studies reviewed were in the Level I (highest) Evidence. Level I indicates the studies were high quality. Only those studies that were related to children were included.

Blount disease looks like bowlegs. Bow legs is also known as tibia varum (singular) or tibia vara (plural) Most toddlers and young children with bow legs grow out of it. Those who don’t may have pathologic tibia varum or Blount disease.

In this study, children who developed Blount disease early (by age two) were compared to children with late onset (around age 10). X-rays were used to measure the angles of the lower leg bones from the front and from the side. This is called multiplanar analysis.

The curve of the bone viewed from the front of the tibia(lower leg bone) is called varum. The curve of the bone viewed from the side is called procurvatum. And any rotation or twist of the bone is called tibial torsion. All three of these changes were measured and compared between a group of children with early-onset versus late-onset Blount disease.

They found that patients with early-onset Blount disease had greater severity and worse deformity. The older patients were more likely to have changes in the lower part of the femur (upper leg bone). Deformity in younger children was mostly caused by changes in the tibia.

The authors suggest measuring all angles of both the lower femur and upper tibia is important in Blount disease. The goal of treatment is to line the bones up as normally as possible. It’s important to keep equal leg lengths until the child has stopped growing.

Having multiplanar analysis of deformities can help the surgeon avoid overcorrecting or undercorrecting the problem. The right amount of correction prevents other deformities from occurring.

What happens to children with scoliosis (curvature of the spine) if they aren’t treated? Do they stay the same, get better, or get worse? Bracing is the standard treatment for curves that measure more than 45 degrees.

But what would happen to these children if they didn’t wear a brace? Can a study be done to compare children with braces to children without bracing? So far this hasn’t been done because it isn’t ethical. Not bracing a child with scoliosis is the same as denying that child treatment.

In this study, researchers survey more than 50 pediatric orthopedic surgeons on this topic. Case examples of possible patients were presented. The surgeons were given choices about different ways to treat each one. They were asked to guess (estimate) how many patients could be treated successfully with and without bracing.

The number of surgeons who responded to the survey was very low. The authors decided to put together an expert panel from those who did reply. Again, the surgeons were asked to give estimates on the success of treating scoliosis with and without bracing. They were given 12 different patient profiles to judge.

There was general agreement that bracing works much better for girls before they start their first menstrual cycle (premenarchal). This opinion was the same for both small and large curves. The group agreed that large single or double major curves in postmenarchal girls aren’t as likely to respond to bracing.

There was a wide range of opinion over the success of bracing. Only about one-third of the group agreed about the benefits of bracing. The authors suggest that studies to compare results with and without bracing can be justified.

They say it’s not right for patients to suffer the cost or the discomfort for a treatment that hasn’t really been proven beneficial. Two-thirds of the expert panel agreed with this conclusion.

This is the first report on the use of hip arthroscopy to diagnose and then treat hip dysplasia in children. In the past, hip arthroscopy was difficult to do and its use was very limited in children. Newer methods and better equipment have changed the picture.

Three young children with hip dysplasia were included in the study. All had failed conservative care with a Pavlik harness. The Pavlik harness is a soft brace that holds the child’s hip in a flexed and abducted position (out to the side away from the body).

Closed reduction surgery also failed. In this operation, while under the relaxing effects of anesthesia, the dislocated hip is put back into its correct position. But the hips did not stay in the socket and dislocated again.

With arthroscopic surgery, while the arthroscope was in place, traction was applied manually to the leg. The amount of force needed to reduce the hip was minimal with this technique. The children were put in a spica (hip to foot) cast to hold the hip in place.

The surgeries were done on an outpatient basis. After the cast was removed, the hips were stable and no further dislocations occurred. The authors conclude that arthroscopy can be used in children to treat hip dysplasia and to avoid a more invasive operation.

More studies are needed before this method can be recommended for all children with hip dysplasia. Short-term complications and long-term problems need to be assessed. The risk of avascular necrosis (loss of blood supply to the hip) and the need for further surgeries must be determined.

Spondylolysis, generally thought to be caused by fatigue or stress fracture in the pars interarticularis of the neural arch, is the single most common cause of back pain among adolescent, or teen-age, athletes. The pars interarticularis is a small thin bone on the vertebra. Spondylolysis is particularly aggravated by sports requiring repetitive motion such as gymnastics, weight lifting, track and field, and soccer. This type of lower back pain, which gets worse with activity and improves with rest, can be acute or it can develop over time

Physicians don’t agree on how best to diagnosis spondylolysis. Standing anteroposterior and lateral view X-rays are the most common choice of test, but this defect can be found in approximately 6% of the general population under 18 years old and between 8% and 15% of elite athletes under 18.

If, after using X-rays, spondylolysis is suspected, nuclear tests such as planar bone scans and single photon emission (SPECT), computed tomography (CT) scan, or magnetic resonance imaging (MRI) may be performed. It’s important to keep in mind that few studies have been done regarding how accurate these tests may be for diagnosing spondylolysis.

As with the actual diagnosis, there isn’t complete agreement on how best to treat spondylolysis. What is known is that a good many of the affected athletes do end up returning to their sport. Although there have been no controlled studies on patient management, the mainstay of all the treatment approaches is that of rest from the activities that contribute to the injury. This rest varies from bracing of the back to restriction from anything but movement needed for daily activities.

Bracing restricts the gross body motion, which is felt is what contributes to recover. A recent study didn’t find signs of the fractures healing as a result of the brace. However, the authors do point out that the study was quite small.

It’s suggested that the treatment be tailored to each athlete individually, taking in to consideration the teen’s characteristics and personality, the spinal pathology, and the type of sport involved.

Rehabilitation is an important aspect of treatment in order to prevent re-injury. After sufficient rest, rehabilitation should begin with a focus of cardiovascular training (low-impact), early core stability and a broader kinetic chain assessment. As the teen progresses through the rehabilitation, work-outs can become more aggressive and sport-specific. The time frame for returning to the sports activity can be anywhere from five to seven months, based on a two to four month rehabilitation time line.

Unless the teen was quite young when the injury first occurred or had a spondylothisthesis, bilateral pars defects, or both, follow-up is generally not needed. The authors conclude that more research is needed in order to establish more stringent evidence-based guidelines for treatment of spondylolysis.

Early-onset scoliosis is usually managed through the use of back braces or orthotics. However, if the bracing isn’t successful or if the child’s physical condition doesn’t allow for that approach, surgery might be necessary.

In this article, authors report on studies that looked at different techniques aimed at straightening the spine. In the first study, researchers followed children who were placed into one of three groups: Five patients (group 1) had a single growing rod with short anterior and posterior apical fusion; 16 patients (Group 2) had only a single growing rod; and seven patients (group 3) had growing rods and no apical fusion. Almost all children were girls.

The patients were all about the same age: Group 1: 7.0 years (+/- 2.9); group 2: 8.7 years (+/-1.0); and group 3: 7.0 years (+/-3.9). The children in group 3 had their growing rods lengthened every six months, regardless of the curve progression.

Before surgery, the scoliosis curves were: 85 degrees (+/-23 degrees) in group 1; 61 degrees (+/-13) in group 2; and 92 degrees (+/-21) in group 3. After surgery, they were 65 degrees (+/-22), 39 degrees (+/-15), and 26 degrees (+/-18), respectively. The children in group 2 had the lowest complication rate (P=.04). Not all of the children had undergone pulmonary testing before surgery, but all were asymptomatic and were stable on room air pre- and post-operatively.

Another surgery, the vertical expandable prosthetic titanium rib (VEPTR) has also been used in to straighten the spine and increase respiratory ability, most often in patients with extensive thoracic congenital scoliosis and fused ribs. A small study of nine girls and seven boys, mean age 4.5 years (range 1.4-9.5 years), found that curve correction was about 34 degrees at follow-up following surgery in children with scoliosis without rib anomalies, and a mean of 25 degrees in children with congenital scoliosis. This surgery appears to be able to correct curves, or at least stabilize them, adding to the potential of increasing respiratory function.

Thirteen of the children were stable on room air both pre- and post-operatively, but three developed respiratory difficulties, resulting in ventilator support. Ten children experienced complications from the surgery and the authors add that the complication rate may rise in this group as the children grow.

The value of the different available rods are being questioned in many studies. One study of 11 children reported that the subcutaneous Harrington rod produced satisfactory results, but needed several procedures to obtain results. And, several of the patients experienced complications, although none were neurological. In a larger study of 29 children, in which patients were treated with a single growing rod, the researchers felt that they were successful in managing the severe early-onset scoliosis, but only nine children demonstrated definitive spinal fusion.

Another study followed 23 children, who received dual growing rods with periodic lengthening; 16 of the children are still in active treatment. The findings are showing that this is a safe and effective surgery, with a lower complication rate.

After reviewing various study findings, the authors conclude that use of either rod (single or dual) can be effective in controlling scoliosis curves, but that dual growing rods, with frequent lengthening may be superior to the single growing rods. They do, however, caution against anterior and posterior apical fusion because of the number of associated complications.

Children who haven’t completed growing can develop a problem called slipped capital femoral epiphysis (SCFE). The growth center of the hip (the capital femoral epiphysis) slips backwards on the top of the femur (the thighbone).

The standard treatment for this problem is to use a screw to hold the epiphysis in place until growth is completed. The screw is usually placed perpendicular (at a right angle) to the physis. This keeps the screw from going into the joint while giving maximum stability of the slipped epiphysis.

In this report, surgeons address a problem that can occur in cases of moderate-to-severe SCFE. The problem is called screw impingement. The head of the screw can bump up against the rim of the acetabulum (hip socket). This happens when the leg is flexed or bent.

The patient must rotate the hip outward to avoid impingement. The result is limited hip motion, pain, and an altered gait (walking) pattern. Over time, the cartilage around the joint gets worn away or can tear causing more problems.

Through a series of X-rays and diagrams, the authors show how changing the placement of the screw can make a difference. An imaginary line drawn down along the neck of the femur is called the intertrochanteric line. The screw is still placed perpendicular, but should be advanced past this line on the lateral side. This avoids a prominent screw head that can cause impingement.

The authors use diagrams to show surgeons where the at risk zone is located. They suggest using the alternative fixation with the screwhead resting lateral to the intertrochanteric line to avoid impingement. The screw must still be located in the center of the femoral head. Only moderate-to-severe SCFE requires this kind of change in screw placement.