News Category: Child

Hip pain in growing children isn’t always from “growing pains.” Children and young teens active in sports training and competition who have not completed their growth often develop hip pain. They will need some special consideration when being evaluated because the bones are not fully formed yet.

For example, when the hip socket (known as the acetabulum) is still more cartilage than bone, X-rays may falsely show what looks like a rotated angle of the hip. It is easy to mistake the hip pain as coming from a problem known as femoroacetabular impingement when that’s not it at all.

In another example, X-rays and CT scans looking for a fracture of the backside of the acetabulum may not show a torn labrum (fibrous rim of cartilage around the hip socket) or a loose piece of cartilage in the joint. Only an MRI will show that.

So when should an X-ray versus CT scan versus MRI be ordered for a child with hip pain associated with trauma (accident, injury, or sports overuse)? That’s what the orthopedic surgeons from the Hospital for Special Surgery in New York City try to sort out in this article.

They found medical records for 180 patients between the ages of four and 15 with hip pain who were evaluated by X-ray and MRI. They compared the findings and results. In the process of collecting this information, they were able to determine the order, speed, and age(s) at which the backside and rim of the acetabulum (hip socket) develops.

Up until now, no one has really known for sure how and when the bone develops in that particular location. And this piece of information is important because this portion of the hip socket is located at the juncture where three other bones meet (the ilium, the ischium, and the pubis). So the pattern of development of the posterior acetabulum depends on the coordination and timing of development of these three bones as well.

They found that the posterior (back) wall of the hip socket (acetabulum) develops in four distinct phases. At first (in the young child before age eight), the acetabulum is made up of 100 per cent cartilage. Around age eight or nine, the cartilage starts to turn to bone. That process is called ossification. MRI images showed a cobblestone formation with islands of bone ringed by areas of cartilage.

By age 12 or 13, the three bones (ilium, ischium, pubis) that join together to form the acetabulum have met together and fused. At this point, there is still a rim of bone forming (ossification) around the upper back (posterior) portion of the acetabulum. This is referred to as the posterior rim sign. The final step is closure of the cartilage between the three bones called the triradiate cartilage. This last phase occurs in girls by age 12 and in boys by age 14.

As a result of this study, it is clear that the posterior aspect of the acetabulum (hip socket) develops and progresses in an orderly fashion. It goes from cartilage to bone more slowly (and after) the same process takes place in the front (anterior) portion of the socket. But it is a predictable series of four phases. Boys tend to complete this ossification process later than girls (one to one and a half years later).

If a surgeon needs to know the shape and developmental phase of the acetabulum before that final phase (before closure of the triradiate cartilage), then an MRI (not X-rays or CT scans) will be needed. Children younger than eight won’t need an MRI since it is known the socket is all cartilage. Children between nine and 14 must be evaluated on an individual basis keeping their gender in mind (remember, girls complete the fusion process at a younger age than boys).

Using only X-rays during phases two and three (ossification and fusion but before closure of the cartilage) can lead to problems. There can be false positives for femoral anteversion (twist in the angle at the top of the femur or thigh bone) and false negatives for damage to the posterior wall of the acetabulum from acute traumatic injury. Misjudging either of these signs can cause delays in diagnosis and treatment for these children.

In conclusion, the authors suggest surgeons should NOT rely on anything but MRIs when evaluating the hip socket in older children and young teens who do not have a fully closed triradiate cartilage.

Nerve damage in the forearm from crush injuries or cuts by glass, knife, or saw can lead to significant disability. But nerves do heal even if at a very slow rate. In fact, studies show that with nerve repair, improvement can continue up to five years after the surgery. The keys to best outcomes are age at the time of injury and time between injury and surgery. Younger patients who have surgery soon after the injury have the best results.

Now with this new study from Sweden, we find out what happens 30 years after nerve injury and repair in childhood or adolescence. They followed 45 patients who had a complete (nerve cut clear through) nerve injury of the median and/or ulnar nerves in the forearm. They measured outcomes in terms of sensory and motor function, level of pain or discomfort, and impact on the patient’s life (education, work, recreation).

They found that children who were younger at the time of the injury and repair (younger than 12 years old) had significantly better results. Complete recovery occurred in 87 per cent of the younger children compared with only 67 per cent of the teens (12 or older). Which nerve was cut (median or ulnar) didn’t seem to matter; age was the main prognostic factor.

The cut-off age between the two groups (12 years old) wasn’t arbitrary but rather based on the knowledge that this time period is when growth reaches a peak. Maximal growth acceleration in girls is around 11 years and 13 years of age for boys. It was expected that the growth spurt might make a difference in recovery (and it did).

Other factors assessed in the long-term period after surgery included sensitivity to cold, motor function, and difference in size of the two hands (injured versus uninjured). The patients (now adults) were asked if the nerve injury affected their choice of work or career. And they were tested for locognosia, a sign of misdirection.

Locognosia is the ability to tell where on the skin the injured person was touched. This sign is referred to as “misdirection” because when nerve cells regrow (regenerate), they are misdirected at the site of the cut. The nerve ends try to reach across to each other but end up going in all different directions. The end-result is a change in the signal pattern from the nerve to the spinal cord and up to the brain. The brain then remaps the location of sensation from the hand based on these signals.

Surgery was done in all cases to either repair (stitch the two ends of the cut nerve together) or reconstruct (use a grafted nerve to help the two ends meet) the injured nerves. In some cases, reconstruction had to be done right from the start because of the extent of the damage. In other patients, enough time had passed (up to 15 months in some cases) that the two nerve endings had retracted (pulled away) enough that stretching the nerve ends to meet was no longer possible.

When nerve grafting (reconstruction) was done in both age groups, the younger children still had better results. That was true regardless of whether one nerve (either one) or both were injured. Fortunately, motor function was preserved in all the patients no matter what age they were or which nerve was injured. Locognosia was significantly better among those who were injured at an earlier age.

Cold sensitivity wasn’t a big problem. A few patients still had less tolerance to cold. The older group was affected the most and they reported that this problem gradually got better over time. Hand size was not different among any of the participants. The older group also said the injury influenced their leisure activities and choice of career but not how far they went in school (high school versus college).

The authors concluded that children who sustain nerve injuries at a younger age have a better chance for full recovery and function. Which nerve was injured doesn’t seem to make a difference in long-term results. But when both nerves were cut, patients reported a greater impact on education and recreation.

Return of normal sensation is less likely than return of normal motor function. Pain and cold sensitivity were reported but difficulty with locognosia was not a problem. It seems that motor recovery is not dependent on age like sensory function is. Better brain capacity and ability to adapt at a younger age may account for the differences in results based on age.

The authors mention that today’s patients facing similar nerve injuries may have even better long-term results compared with children and teens treated 30 years ago. It is now recognized that associated injuries (e.g., tendons, arteries) must be repaired as well.

Newer surgical techniques and tools may also aid in better outcomes. We also now know that participation and motivation in the rehab process make a difference. And we have better strategies to help patients relearn sensory function based on new information about brain plasticity (ability of the brain to adapt and recover).

Infection of the hip joint that is undiagnosed and therefore untreated can lead to a condition known as septic arthritis. In young children, dislocation of the septic hip can be a challenge.

For one thing, the hip that is not fully formed can look like it is dislocated when, in fact, it’s not. If the growth center of the hip (called the capital femoral epiphysis) is not fully ossified (turned to bone and connected to the femur or thigh bone to form the round femoral head), it can give the hip the appearance of being dislocated.

Before a treatment plan can be determined, the surgeon must know for sure whether the child’s hip is truly dislocated or just not fully formed yet with an intact capital femoral epiphysis still in place. X-rays are not enough so that MRI, ultrasound, and/or arthrogram are required.

This article was written to aid surgeons in the management of late presenting cases of septic hip dislocation. Mini-summaries of treatment results from small case studies are reviewed. Treatment reported ranged from no reconstructive surgery called closed reduction with full (spica) cast immobilization to open reduction.

The goals of stabilizing the hip versus restoring normal anatomy depend on knowing whether the capital femoral epiphysis is present or the hip is dislocated. Treatment decisions are also influenced by the age of the child. For example, children under the age of two may be successfully treated with closed reduction. Open reduction is recommended for children older than that.

Treatment may include preoperative traction to pull the dislocated hip down to the level of the acetabulum (hip socket). Some surgeons prefer to shorten (or lengthen) the femur to accomplish this same alignment. Soft tissue structures may be needed such as lengthening of the psoas (hip flexor) muscle or tendon.

Sometimes the surgeon must do a bony osteotomy (remove a wedge-shaped piece of bone from the femur) to correct a problem with the angle of the hip. A shelf procedure may be needed to extend the bone and form a cover around the femoral head. This keeps it from migrating upward and dislocating again.

The following treatment recommendations were offered based on results reported in the literature and the authors’ own experience. Relocation of the hip is not always the best idea. It can result in chronic hip stiffness, leg shortening, and a definite lurch in the gait (walking) pattern. Patients with oddly shaped femoral heads and poor (thin) articular cartilage from the infection often end up with degenerative arthritis and chronic pain even with hip relocation.

Patients should be selected carefully for open reduction and surgical restoration of the hip. A nice, round femoral head of good size is important. Healthy cartilage is a good prognostic factor (meaning surgical treatment is more likely to yield good results). Children older than six years old are not likely to benefit from open reduction. And finally, the patient who does NOT have stiffness before surgery has a better chance of good recovery and positive outcomes.

The authors do provide an algorithm (flow chart) to aid surgeons in making treatment decisions for patients with postseptic hip dislocation. Starting with a proper diagnosis based on imaging studies, the chart flows first according to age (under two or over two years of age).

As mentioned, closed reduction with soft tissue releases and hip cast can be followed by open reduction if the conservative care is unsuccessful in the younger child. Surgery (if performed at all) is for selective patients as described.

Research has shown us that Legg-Calvé-Perthes occurs more often in certain geographical areas. For example, children in Northern Europe have the highest rate of occurrence while children around the equator have the lowest incidence. Why is that?

Well, first, what is Legg-Calvé-Perthes disease (also known as Perthes disease)? Perthes is a condition that affects the hip in children between the ages of four and eight. The condition is referred to as Legg-Calvé-Perthes disease in honor of the three physicians who each separately described the disease.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. There is also an imbalance between the bone building cells (bone deposition) and bone breakdown (bone resorption). The blood supply does eventually return and the bone heals.

How the bone heals determines what problems the condition will cause later in life. Understanding the effects on the bone cells during the early days of this disease helps direct treatment. A three-tier surgical approach has been proposed starting with preventive surgery to preserve the round head of the femur (thigh bone).

The surgeon may use one of several techniques to “contain” the head of the femur in the socket in order to help keep the round shape. This approach is meant to prevent deformity of the femoral head and works best for older children (age six and older). Younger children are more likely to respond well to conservative (nonoperative) care and don’t need corrective surgery.

The second surgical approach is called remedial surgery. The goal is damage control after the disease process has already started to change the bone structure. In other words remedial surgery is to minimize the effects of the deformity that has already occurred (e.g., fragmentation and/or collapse of the femoral head). The child must have good bone quality that can hold up under the stress and pressure of weight bearing. Reducing pain and improving function is possible.

The third tier of treatment referred to as salvage surgery is done to reshape the femoral head and reform the acetabulum (hip socket). This more extensive reconstructive (“joint preserving”) surgery is used for patients who have joint deformity. They are usually older and may even be adults for this type of treatment. They often also have damage to the surrounding cartilage and soft tissues.

Children who do not receive treatment early enough or for whom treatment is not effective may eventually develop degenerative arthritis. Structural changes may be too great for reconstructive surgery. That’s when total hip replacement may be indicated. Saving the joint helps put off hip joint replacement for as long as possible. Studies have shown that people with long-term degenerative effects of Perthes who have total hip replacement before age 40 report a reduced quality of life.

Despite this understanding of a three-tiered approach to Perthes disease, there is still much to be discovered to create the best results. For example, the amount of femoral rotation and the angle of the bone as the femoral head fits into the socket may make a difference in outcomes. How much of the femoral head should be covered by the socket is another area that requires further study.

Knowing that excessive bone resorption is part of the early damage associated with Perthes has led scientists to look for ways to prevent this from happening. Medications (by mouth or by injection directly into the hip) such as bisphosphonates to prevent bone loss are being used in animal studies. These drugs may help decrease bone deformity while the body heals itself and restores blood flow to the area. Other biologic therapy to prevent bone loss is also being investigated.

Now back to the original question. Why do more children in northern latitudes develop Perthes (e.g., northern Europe)? Researchers have uncovered two possible environmental factors: second hand smoke from cooking stoves and tobacco as well as lower socioeconomic status. Children in families with lower incomes appear to be at greater risk. Although these variables have been uncovered, the exact way in which these things contribute to Perthes disease remains unknown.

Treating children with Perthes hip disease presents some interesting challenges. Current approaches include non-weight-bearing (not putting any weight on the leg) for long periods of time. This method is not necessary for younger children (before age six) because they tend to have a good prognosis. It is reserved more for older children but who may be less compliant (cooperative) with the idea of never putting any weight on the affected leg.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calve-Perthes disease in honor of the three physicians who each separately described the disease.

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

In this study, researchers used piglets to simulate Perthes disease in order to study whether or not weight-bearing is harmful to the healing process. At the same time, they evaluated the effect of non-weight-bearing compared with weight-bearing. A group of 16 piglets were surgically altered to stop blood flow to the hip. Half the group were allowed to put weight on that leg; the other half were not allowed weight-bearing.

Eight weeks later, the hips were examined closely using X-rays, microscopic analysis, and micro-CT scans. They found much more flattening of the epiphysis in the femoral head (round bone at the top of the thigh bone) in the group allowed to put weight on the hip. The non-weight-bearing group was protected from deformity but the bone wasn’t perfectly preserved.

Due to the lack of blood supply and hip joint loading (both needed to maintain normal bone balance) there were still some changes observed in the femoral head in the non-weight-bearing group. But the important finding of this study was that non-weight-bearing DOES help protect the hip and helps prevent significant deformity. Maintaining as much integrity, shape, form, and structure of the femoral head also reduces the risk of collapse of the bone.

The authors suggest that future treatment of Perthes hip disease include two things: non-weight-bearing status AND medications to decrease bone resorption and stimulate the formation of new bone. Non-weight-bearing does help increase return of blood to the epiphysis but it does not encourage new bone growth. Combining drug treatment with conservative care (non-weight-bearing) might reduce the time older children have to remain non-weight-bearing and thus increase compliance.

The results of this study must be evaluated in light of the fact that animals were used. Human reactions are not always exactly the same as animals. Because the blood supply was cut off to the femoral head in the piglets, total femoral head involvement was present. This isn’t always the case with children who may have only a portion of the femoral head affected.

And finally, young piglets were used (the equivalent of a four or five year old child). Results might be different for older piglets representing older children. More study is needed in this area to understand: 1) the process by which Perthes develops, 2) the role of weight-bearing versus non-weight-bearing in the development of deformity, and 3) how medications might help enhance bone growth and speed up the healing process.

It is a tough sell but patients undergoing surgery for any reason must take their pain medications as prescribed. That means the full amount as often as recommended. Many Americans still subscribe to the belief that if there’s “no pain, there’s no gain”. And they feel it is better to “tough it out” rather than take drugs.

But the truth is — research shows that uncontrolled pain turns on systems in the body that result in delayed or impaired healing. In addition, there are more complications in general, breathing problems, and the risk of death is much higher.

All of these concepts also apply to children. In the pediatric post-operative group, pain increases the child’s stress. Stress hormones increase tissue metabolism and that leads to negative effects on healing. The result is besides pain, the child ends up with a longer hospital stay, which adds more stress and keeps the cycle of impaired healing going.

What can be done to prevent the impact pain can have on a child after surgery? In this article, surgeons answer this question as it relates specifically to orthopedic surgery. They tell us that most surgical teams and postoperative hospital staff take the task of pain control among children very seriously. They may even have a team dedicated to this job.

The first step is family and patient education. Everyone involved with the child’s case must understand the importance of pain control and the consequences of inadequate pain management. The surgeon, anesthesiologist, and nursing staff help parents, family members, and care givers of children understand how the pediatric body responds to pain.

From the youngest baby to the oldest child, decisions about medications for pain control are based on several individual factors. Body weight is important because the water content affects how drugs bind with proteins in the blood. Age and size determine the water-to- protein ratio and thus the amount of drug to use (e.g., anesthesia during surgery, narcotics for pain control after surgery).

There are strict guidelines for the use of pain relievers. One important factor that affects the selection of medications is the child’s health. For example, the presence of any other health conditions (e.g., asthma, diabetes, allergies, bleeding disorders) must be considered carefully. The type of orthopedic surgery, extent of the surgery, and length of the procedure (in time) can also make a difference in postoperative selection of pain medications.

The anesthesiologist can choose from a wide variety of drugs for the actual procedure including nonopioid (nonnarcotic) pain relievers, opioid analgesics (narcotic pain relievers), local anesthetic injection, regional analgesia, epidural therapy, and peripheral nerve blocks. Likewise, the surgeon has quite a few choices for pain control after the surgery.

The authors of this article provide surgeons and physicians with detailed information in the use of these many drug categories. Drug type, drug dose (amount of drug given), and drug administration (by mouth, by injection, or intravenous directly to the bloodstream) are discussed in detail. Adverse effects of each drug are also presented. Several helpful tables are provided with guidelines for the use of each type of drug.

Finally and equally important to the details of the drugs given are the specific individual characteristics of each child. It’s clear that pain is different from one child to another even when they have the same surgery for the same problem. That’s why each child is evaluated and monitored separately from all other children. It’s not a one-protocol-fits-all kind of situation.

Pain control and drug usage is serious business and must be approached that way in each and every case. This review article goes a long way in providing a useful review of evidence-based guidelines for pain control during and after orthopedic surgery for children of all ages.

Sometimes it seems like children are made of rubber. They fall or they injure themselves in some way but they get up and bounce back as if nothing ever happened. But in reality, that’s not always the case. And with more children and teens participating in sports activities, there has been a rise in the number of musculoskeletal injuries in this age group.

One of those injuries is a tear of the anterior cruciate ligament (ACL). The ACL is one of two ligaments that criss-cross inside the knee to give it stability. The ACL helps the knee bear the weight or load of our body while we move, twist, jump and turn.

When this type of injury affects an adult, the surgeon automatically looks for other damage as well. It is not uncommon with an ACL partial tear or complete rupture to have a torn meniscus and/or chondral (cartilage) damage.

But what about children? Are they just as prone to have additional injuries when the ACL is torn? And do their great powers of healing make it possible to delay surgery while we “wait-and-see” if they will recover? Those are the kinds of questions surgeons from the Children’s Medical Center in Dallas, Texas investigated in this study.

They reviewed the medical records of 371 pediatric patients who had surgery to reconstruct a torn ACL. Data analyzed from the charts included number of days between the injury and the surgery, age, weight, gender, and way the injury occurred. They were specifically looking for any factors that were linked with meniscal tears or chondral (cartilage) damage. The surgeons also wanted to know if a child had a meniscal tear, would it lead to further chondral injury?

This type of study has been done in adults and found that the longer the patient waits between ACL injury and surgery, the greater the risk of meniscal and chondral damage. And that can mean damage that can’t be repaired and that leads to arthritis and loss of knee function in time. A study like this could potentially save children from the same fate. And this is the first study this large to really help answer some of these questions.

They found three factors that increase the risk of poor outcomes and degenerative changes in the knee. The first was a time delay between when the injury happened and when treatment was received. Children who had surgery in the first 150 days (five months) had fewer meniscal tears compared with children whose surgery took place later.

And as you might expect, obese children putting greater load on the damaged tissue were more likely to experience additional injury to the meniscus and chondral surface of the joint. In all children, the presence of a meniscal tear also increased the risk of further chondral damage. Pediatric patients older than 15 years had a higher rate of meniscal tears.

There was no one particular sport that seemed to result in more ACL injuries than any other. And unlike some studies where males had more meniscal and chondral injuries, there was not a gender factor observed in this group of patients.

The results of this large series are very helpful for surgeons when trying to advise patients and families of those patients about what to do (surgery or not?) and when to do it (now or later?). Older, heavier patients may not want to wait before having the ACL reconstruction. Younger patients who are not obese may have more time to apply the wait-and-see approach to treatment.

The authors point out the need to continue to educate children and their families about the dangers of obesity. This is true not just to help prevent early-onset of diabetes and later problems such as heart disease but also the increased risk for musculoskeletal injuries. Such physical injuries can have a lifelong impact.

Sometimes in life, there are more answers than there are questions. Orthopedic surgeons certainly face their share of unknowns with many different kinds of problems. Take the treatment of femoroacetabular impingement (FAI) for example. Best practice and guidelines for clinical practice based on high-quality evidence just aren’t available for this condition. As this recent review shows, a more consistent approach to research and study of FAI is needed.

Femoroacetabular impingement (FAI) occurs in the hip joint. Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

Once the diagnosis has been made and all the test results are available, a course of action is determined. This may be conservative (nonoperative) care with antiinflammatories and physical therapy. In some cases, surgery is recommended right away. Early diagnosis and surgical correction may be able to restore normal hip motion.

Delaying surgery is possible for other patients but the long-term effect(s) of putting surgery off have not been determined. There is concern for the development of osteoarthritis without treatment or with delayed treatment. The current data related to hip deformity and osteoarthritis is the specific focus of this review study. The authors point out that whether someone with FAI will develop osteoarthritis, how soon, and how severe remain some of the unknowns with this condition.

Taking a look at the studies done so far, they were unable to add much new to the surgeon’s understanding of the diagnosis, treatment, and outcomes for FAI. Why is that? You might think with all the latest developments in technology, it would be possible to document and follow everything that is going on with these patients. And, in theory, that is true. But the key is in data collection.

For studies to generate useful information, it is necessary for everyone to collect and report on the same types of data. This is called standardization of data collection. For example, patients can vary tremendously in the type and severity of hip impingement. Patients can be professional athletes or stay-at-home parents so the goals and hoped for results may be different from one patient to another and one group to another.

The way surgeons measure disease severity isn’t always the same. The type of surgery performed and the way surgery is performed (open versus arthroscopic) can vary. Even the way the surgery is described differs in published studies. Finally, documentation and reporting of complications are not similar enough from study-to-study to combine the results toward any useful conclusions or recommendations.

What can be done to correct this problem? What we need is a universal, consistent, and standard way to collect, process, and analyze data in order to shape treatment and provide successful outcomes. The studies must use reliable tools to measure pain and level of activity as appropriate outcome measures for patients with femoroacetabular impingement (FAI).

With long-term data reporting, it will be possible to see the natural history (what happens over time) with FAI, determine who is getting the best results and why, and thus guide treatment decisions. This type of approach could make it possible for surgeons to predict which patients will do best with conservative (nonoperative) care or surgery. If surgery is deemed best, then the same process can aid in determining what approach is best: an open procedure or an arthroscopic approach?

In summary, based on currently published studies of femoroacetabular impingement (FAI), there is a clear need for long-term data collection that is standardized across all studies. Only then will the goal be met to provide best practice and thus best outcomes for the treatment of all patients with FAI.

Whether you are new to the topic of slipped capital femoral epiphysis (SCFE) or well-acquainted with this condition, the results of this recent study will be of interest to you.

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

If untreated this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. But what is the best treatment for this problem? And what evidence do we have to support treatment as “best”? That is the topic of this literature review from two orthopedic surgeons (one from the University of Iowa and another from the University of Indiana).

The goals of treatment are to 1) keep the problem from getting worse, 2) avoid complications, 3) improve hip motion, and 4) delay or prevent the development of degenerative hip disease. With that many different kinds of goals, you can imagine treatment may be varied (different for each child).

One approach is to provide treatment based on whether the condition is stable or unstable. Stable SCFE means the child can put weight on the leg and walk (with or without crutches). Unstable SCFE is defined by the child’s inability to walk with or without crutches due to severe pain. Surgery is usually necessary to stabilize the hip and prevent the situation from getting worse.

In this study, current best evidence is reported on treatment for stable versus unstable SCFE and treatment involving surgical dislocation. As we find out from the results of this systematic review of the literature, there are easily a half dozen ways to treat a stable SCFE. But the consensus is that the best way to treat stable SCFE is with a single, large screw into the epiphysis to hold it in place.

The best treatment for unstable SCFE isn’t as clear. In fact, the treatment for this type of SCFE is quite controversial. The risk of avascular necrosis (AVN; loss of blood to the hip with death of the bone) must be taken into consideration. This complication is the number one reason why patients with SCFE end up with a total hip replacement.

The timing of surgical treatment for unstable SCFE is also hotly debated among and between surgeons from the U.S. and Europe. The risk of necrosis is one reason why some surgeons insist on early treatment. But others think that surgical stabilization can lead to avascular necrosis. Right now, the best evidence suggests that the need for surgery is “urgent” in children with unstable SCFE. This approach has the lowest rates of necrosis.

Then the final decision is whether or not to dislocate the hip during surgery. Hip dislocation is done in order to better realign the epiphysis and therefore improve hip function. But there is concern that surgical dislocation can also increase the rate of avascular necrosis. Surgeons must also weigh other risks that come with surgical dislocation such as damage to the hip cartilage, labrum, joint surface, and/or bone.

According to this review, there is no evidence to support the more aggressive approach of surgical dislocation and epiphyseal realignment for stable SCFE. The single screw fixation method should remain the treatment of choice for these patients. As for surgical dislocation to treat unstable SCFE — caution is advised. This is a newer treatment method that hasn’t stood the test of time. There aren’t enough studies to report on long-term results. For now (and until better evidence is available), gentle surgical reduction with internal fixation is advised.

As more and more children and teens participate in organized sports at a younger age, it is no surprise that knee injuries are on the rise. In this report, a pediatric orthopedic surgeon from UCLA School of Medicine reviews four specific injuries that may require surgical intervention. These include: 1) anterior cruciate ligament (ACL) injury, 2) symptomatic discoid lateral meniscus, 3) juvenile osteochondritis dissecans, and 4) traumatic patellofemoral instability.

The injuries themselves are unique in that they affect a knee that is not skeletally mature. Prevention of long-term complications such as stiffness and growth arrest must be addressed during treatment. Given these two concerns, the author focuses on what’s new in the surgical treatment of these four conditions.

Let’s take a brief look at each of these four knee injuries in the youth athlete. In youths, anterior cruciate ligament ACL injuries can create knee joint instability, damage to the meniscus (knee cartilage), and chondral injury (damage to the bone). When the ACL is torn during pivoting activities of the leg in this age group, two things can happen.

First, the place where the growth plate and bone meet (called the condroepiphyseal attachment) is damaged. This, in turn, can cause a fracture of the tibial spine (place where the ACL attaches to the bone). And like all fractures, the bone can be separated and displaced (shifted).

Repairing this type of fracture without further injuring the growth plate is a challenge. Many different surgical approaches (e.g., transphyseal soft tissue ACL reconstruction, extraphyseal ACL reconstruction with iliotibial band graft) have been tried and reported on with varying degrees of success. So far, there isn’t one best way to surgically repair this problem. More study is needed as all reports so far are just case series with a small number of patients with a short period of follow-up.

Next, injury to the discoid lateral meniscus is only treated when there are painful symptoms with snapping or clunking of the knee and/or loss of full knee extension. Children affected most often by this type of injury are usually under the age of 10. As with adults, the current thinking on this injury is NOT to remove the torn cartilage. Instead, the tissue is repaired as much as possible in order to prevent arthritic changes later.

Juvenile osteochondritis dissecans (OCD) is our third condition of interest. OCD is a problem that affects the knee at the end of the big bone of the thigh (the femur). The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone is referred to as the osteochondritis lesion.

Treatment of OCD can be nonsurgical with immobilization and change in activity until healing is seen on X-rays. When healing doesn’t occur, the surgeon can drill tiny holes in the joint surface to cause bleeding and stimulate healing. If the joint cartilage is broken off with a bit of bone still attached, it may be necessary to reattach the fragment or remove it and fill in the hole left behind. Treatment really depends on the patient’s age and skeletal maturity, how long the condition has been present, and how stable (or unstable) the lesion is.

And finally, the last of our four knee disorders: traumatic patellofemoral instability. This refers to a chronically dislocating knee cap. Most of the youths who suffer this problem have some type of anatomic abnormality that puts them at risk for this condition. Most of these cases have to be treated conservatively without surgery because a good method of surgical repair has not been discovered yet. Techniques for successful reconstruction of ligaments around the knee cap are being investigated.

In summary, this article provides orthopedic surgeons and sports physicians an opportunity to review four injuries to the skeletally immature knee. Treatment is focused on surgery, surgical techniques, and the outcomes for each one. Anyone treating young athletes will find this information of interest, especially now with community sports involvement and subsequent knee injuries at a peak.

Young children with a fractured femur (thigh bone) can be treated in a number of different ways. Most involve casting of some sort. To prevent movement and allow the bone to heal, a spica cast is used most often. This type of cast starts at the waist and goes all the way down to the toes.

The spica cast may be single leg or double-leg. The single leg cast ends above the hip on the uninjured side. This type of cast leaves the uninjured leg free to move. The double leg cast immobilizes the injured leg from waist to toes and covers the other hip down to just above the knee. Not being able to bend at the hips (and knee) for four to six weeks presents some difficulties for families caring for young children.

In this study, orthopedic surgeons at The Johns Hopkins Hospital in Baltimore, Maryland compare results between single-leg and double-leg spica casting. The children in the study were all between the ages of two and six with a diaphyseal femoral fracture. The diaphyseal part is the shaft or middle long part of the bone. The hope was to provide an easier way to care for these children using a single-leg cast without compromising the results.

Treatment of diaphyseal femoral fractures with spica casting is considered “best practice” based on recommendations from the American Academy of Orthopaedic Surgeons (AAOS). Cast immobilization avoids surgery with anesthesia, scarring, and the possibility of complications.

Surgeons recognize that even casting has its downside. Skin problems can develop under the cast. Too much pressure can cause swelling causing a compartment syndrome. And, of course, caring for a child in such a bulky cast is no easy task. Transporting the child in the car seat or car, toileting, and lifting and carrying the child are some of the challenges the family members or caretakers face.

But the good news is that the benefits of a single-leg spica cast were very valuable to the families while still resulting in fracture healing. The parents or care givers took fewer days off from work to care for the child.

The single leg cast could be molded with enough hip and knee flexion (bend) to allow the child to sit in a special car seat. And the children with single-leg spica casts could sit in chairs more comfortably. Children in this type of cast could even walk a little bit.

The surgeons conducting this study summarized their recommendations by offering the following opinions:

Thousands of children are being seriously injured in all-terrain vehicle (ATV) accidents every year. In fact, the number of accidents and injuries has doubled in the last 10 years. Children are less likely to be riding ATVs compared with adults but they make up a full one-third of all injuries. And some of those accidents result in death.

Orthopedic surgeons treating these injuries have expressed concern publicly. Even so, the number of ATV sales has continued to rise and along with it the number of children and teens riding these vehicles. Not only that, but the vehicles have become heavier, larger, and faster. Roll-over accidents resulting in spine injuries increased by 476 per cent between 1997 and 2006.

In this study, surgeons from the University of Tennessee compiled information from their records to get an idea of how many and what kind of ATV-related injuries are being treated at their clinic. They divided them up by age (birth to 15 years and 16 to 18 years) and by type of injury (head/skull, trunk/abdomen, nonspinal orthopedic).

Some children had more than one type of injury including spine and nonspinal locations. Most of the spine injuries were single level injuries. In a smaller number of children, multiple spine injuries (fractures, spinal cord injuries, nerve root injuries) were recorded. More than half the children in the study required surgery.

Children are more likely than adults to be injured in an ATV accident for several reasons. Of course, they are usually smaller in size compared with adults. They are no match for a 500 pound (half ton) machine. In this study, only 14 per cent of the group was wearing a helmet. This is typical of what has been reported in other similar studies as well.

Children and younger teens have less muscle strength compared with adults. Other factors include decreased depth perception, level of emotional maturity and cognitive ability, and experience. Females are more likely to experience a spine injury due to a phenomenon referred to as vehicle-rider mismatch. They are simply outweighed by these machines and have more trouble correcting or preventing accidents, especially rollovers.

Older teens were more likely to have spine injuries. This may be explained by the fact that they have reached full growth (skeletal maturity) and have less flexible bone structures. Their spines are more adult-like with less ligamentous laxity (looseness) and more upright (vertical) positioning of the spinal (facet) joints.

The authors conclude that ATV-related injuries are high-energy resulting in multiple (and often very serious) injuries. Almost half of the children involved were younger than 16 and were not wearing a helmet. These facts suggest the need for more education and legislative efforts to change this pattern of behavior.

Surgeons treating children and teens who have been involved in ATV accidents are encouraged to examine them carefully to find all areas of injury and involvement. This includes the entire spine as well.

In this brief document, members of the American Academy of Orthopaedic Surgeons provide a 16-point clinical practice guideline for the treatment of osteochondritis dissecans (OCD). Although OCD can affect several areas of the body (ankle, elbow, knee), this review is strictly limited to the diagnosis and treatment of the knee.

When osteochondritis dissecans (OCD) that affects the knee, it’s mostly at the end of the big bone of the thigh (an area called the femoral condyles. A joint surface damaged by OCD doesn’t heal naturally. Even with surgery, OCD can lead to future joint problems, including degenerative arthritis and osteoarthritis.

That’s why guidelines to the care and management of this problem are important. Informing surgeons of the best practice for this condition can aid them in helping patients obtain the best results possible.

The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

The lesions usually occur in the part of the joint that holds most of the body’s weight. This means that the problem area is under constant stress and doesn’t get time to heal. It also means that the lesions cause pain and problems when walking and putting weight on the knee. It is more common for the lesions to occur on the medial femoral condyle, because the inside of the knee bears more weight.

Nonsurgical treatments help in about half the cases of OCD affecting children (called juvenile OCD or JOCD). The goal is to help the lesions heal before growth stops in the thighbone. Even if imaging tests show that growth has already stopped, it is usually worth trying nonsurgical treatments. When these treatments work, the knee seems as good as new, and the JOCD doesn’t seem to lead to arthritis.

Some patients who are too near the end of bone growth may not benefit with nonsurgical treatment. Surgery may also be advised if and when the lesion becomes totally or partially detached. There are several ways to fix it in place. In some cases, the loose fragment will just have to be removed.

So, what are the new guidelines? Anything really new from the way things have been done? Well, first of all, most of the evidence from studies currently available is weak or inconclusive. For example, the committee was unable to recommend for or against nonoperative care for children with OCD that does not cause pain or other symptoms. Likewise, the committee was unable to recommend for or against surgical drilling in patients with symptoms after nonoperative care but with a stable lesion.

Other areas where the research remains inconclusive include: 1) whether or not to take X-rays of the other knee once OCD has been discovered, 2) which type of cartilage repair works best when surgery is needed, 3) whether to treat patient with or without symptoms who are fully grown (skeletally mature) in a similar fashion, and 4) whether or not patients should have repeat or follow-up MRIs when they are skeletally mature without symptoms.

There are some areas where the committee could offer guidelines based on agreement (referred to as consensus). Consensus means the committee agrees on the recommendation even though there isn’t enough reliable evidence to prove the guideline is accurate. For example, most experts agree that skeletally immature patients should be offered surgical correction when the lesion is unstable or shifted but still salvageable.

Likewise, the committee agreed that symptomatic patients who are skeletally mature should be offered surgery when the lesion is unstable or displaced. After surgery, all patients should be provided with physical therapy. X-rays and/or MRIs should be taken to assess healing after treatment, especially for those who are still experiencing painful symptoms.

The committee made it clear that this document is just a quick summary of current guidelines. No explanation is given as to the ‘whys’ or ‘wherefores’ of the recommendations. The full guideline with evidence cited is available for anyone interested in reading it. And as always, each patient must be evaluated and treated on an individual basis. Decisions made about management and treatment techniques to use are determined by the patient in consultation with the physician.

Clubfoot also known as Congenital Talipes Equinovarus describes a position of the foot a baby is born with. The foot is turned under and towards the other foot. When broken down into its parts, equinovarus means that the toes are pointed down (equinus) with the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

This twisted position of the foot causes problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight, stiff foot that cannot be placed flat on the ground for walking. To walk, the child must walk on the outside edge of the foot rather than on the sole of the foot.

Clubfoot is not a rare or new condition. This condition has been described in medical literature since the ancient Egyptians. Congenital means that the condition is present at birth and occurred during fetal development. The condition affects both feet in about half of the infants born with clubfoot. Clubfoot affects twice as many males as females.

For a long time, treatment was with surgical correction. But according to the results of a recent survey, there has been a shift toward less invasive, nonsurgical treatment. Specifically, surgeons are using an approach referred to as the Ponsetti method. This method involves manipulation and casting.

This type of treatment is started as soon as possible. The foot is manipulated (moved) to stretch and loosen the tight structures. The foot is then placed in a cast to hold it in a corrected position. This is repeated every one or two weeks until the deformity is corrected or surgery is performed.

According to the Pediatric Orthopaedic Society of North America (POSNA), the majority of pediatric orthopedic surgeons use the Ponseti method with good results. They say it takes about seven weeks on average to correct the foot position. About one-fourth of their cases relapse (go back to the clubfoot position). In cases of relapse, minor surgery (release a tendon) might be needed. Only about seven per cent of the children ever need extensive reconstructive surgery.

Ten years ago, the Pediatric Orthopaedic Society of North America (POSNA) surveyed their members about their treatment of clubfoot. This same survey was repeated recently showing some changes in treatment over the last 10 years. For example, some surgeons have given the task of casting the children to their staff and they use synthetic (fiberglass) materials instead of the old, heavy plaster casts.

The casts are placed on the entire leg (not just the lower leg and foot) and changed about every seven days. Bracing is used by 99 per cent of the surgeons after cast treatment. Different types of braces are available with no consensus on which one is the best. The length of time bracing is used varies from one year to more than four years. This is a change from 10 years ago when bracing was used for less than one year.

The results of this survey show a trend in the treatment of clubfoot toward almost exclusive use of the Ponseti method. There are several reasons for this shift. First, studies have reported excellent long-term results to support the use of this treatment approach.

Second, parents are using the Internet to search for information on clubfoot and asking about less invasive ways to treat it. And third, the method is being taught in medical school so surgeons have a better understanding of the treatment and use it routinely.

One other shift in philosophy has been reported and that has to do with the tendon releases being done. More surgeons are performing this procedure with the child under general anesthesia rather than local anesthesia. The reason(s) for this were not reported.

There’s more than one way to approach the treatment of pediatric radial neck fractures. In this report, Dr. M. E. Pring from the University of California’s Department of Pediatric Orthopedic Surgery brings us up to date on what techniques can be used to treat this problem in children. Problems that can arise and what to do about them are also presented.

The radial head is a round, disc-shaped top to the radius bone (the smaller of two bones in the forearm). The radial head sits next to and articulates (moves) with the lower portion of the humerus (upper arm bone). The position of the radius is on the outside of the elbow (side away from the body).

The mechanism of injury is usually a fall on an outstretched arm. The force of the impact can be enough to snap the top of the radius right off. If the broken piece shifts away from the main bone, it is considered a displaced fracture. If the radial head moves off to the side and away from the shaft of the bone, it is a translation of the head in relation to the shaft.

If the radial head tips over and forms an angle with the radial shaft, it is considered both displaced and angulated. The amount of angulation will be an indication of severity of the fracture and also direct treatment. Angulation is easier to treat than translation. In younger children (up to age six), angulated radial neck fractures correct by themselves during the healing process.

General guidelines are: 1) less than 30 degrees of angulation can correct in children of all ages. 2) Displacement less than two millimeters does not require surgery. 3) More than 60 degrees of angulation must be treated surgically no matter how young the child is. 4) Angulation between 30 and 60 degrees is a gray area. There are no clear guidelines. In general, the younger the child, the greater the chances for healing and correction.

When selecting treatment options for radial neck fractures, there are other factors to consider. In one-third up to one-half of all children, there are other injuries that occur at the same time. For example, there can be other fractures in and around the elbow, torn ligaments, and damage to the joint surface. Sometimes the broken and displaced radial head flips over on itself and appears to be in the correct place but isn’t. This situation must be identified and corrected or the joint will be destroyed.

In young children (up to age five), the radial head isn’t even made of bone yet — it is still mostly cartilage. X-rays won’t always show damage to this area. With the possibility of additional soft tissue injuries, CT scans or MRIs may be needed to identify all potential problems make a complete diagnosis.

That’s when the surgeon rolls up his or sleeves so-to-speak and gets to work on a treatment plan. The first question is always: conservative (nonoperative) care or surgery? For radial neck fractures with less than 30 degrees of angulation and less than two millimeters of separation, a cast for two to three weeks works just fine.

As a final test in this decision-making process, the surgeon will check forearm motion. If the child has full supination (palm up) and full pronation (palm down) motions, simple immobilization in a cast is acceptable. Any limitations or blocks to these rotational movements is a sign that reduction (correcting alignment) is needed.

The surgeon can attempt to perform what’s called a closed reduction. There are several hands-on techniques to accomplish this type of manipulation. But if the radial head doesn’t reduce (go back into place) with the first (or possibly second) attempt, the surgeon is advised not to keep trying. The risk of further damage is just too great.

Now the next set of decisions pop up. Should the surgeon use an open incision or percutaneous (through the skin) approach? What’s the best way to line up the bones and hold them together? Fixation of the bones with pins or wires is most common.

The author provides drawings, X-rays, and written descriptions to explain various techniques for surgical reduction and fixation of these types of elbow fractures. Three case presentations are provided to illustrate what can happen and how treatment decisions are made. The author concludes these are not uncommon fractures and surgeons who understand the principles and pitfalls described in this article will better aid the patients in regaining elbow motion and function.

Children can experience finger fractures for a variety of reasons including crush injuries (finger slammed in car door), sports trauma, and even fights. Fractures in skeletally immature children can lead to some complex and challenging problems — especially if the extent of the injury is not recognized right away. For example, separation of the bone from the joint can result in a finger dislocation if not treated properly at the start.

In this article, a pediatric orthopedic surgeon from Cincinnati Children’s Hospital in Ohio uses two patient examples to discuss the types of fractures that can “go south” or “get ugly.” For example, the growth plate can be damaged affecting finger growth. The bones may twist or rotate after breaking and shifting apart. The fracture itself might be unstable and the bones easily bent or angled.

If the growth plate at the end of the bone is broken and the nail plate is avulsed (pulled away from the skin fold), the broken bone can be left open to infection-causing bacteria. This type of break is called a Seymour fracture.

Additional problems develop when a Seymour fracture is not recognized and the finger is splinted or immobilized. Healing will not occur, infections are common, and the fracture remains unstable. Surgery is necessary to pull the nail plate off and get the area cleaned out (a procedure referred to as irrigation and debridement). Only then will the fracture heal and nail bed repair itself. The recovery time is usually three to four weeks.

Certain types of finger fractures in children will require surgery to avoid malunion. These include phalangeal neck and condyle fractures. A phalangeal neck fracture occurs in the bone just outside the finger joint. A condyle fracture refers to a similar break but one that does affect the joint. Undetected, either one of these fractures will result in malunion and joint dysfunction if not treated surgically (reduction and fixation procedure).

The author suggests that many of these problems can be avoided with proper evaluation and examination. X-rays of each individual finger must be done. Relying on a hand X-ray where the finger bones overlap when viewed from the side is not advised. Early detection of the full extent of finger fractures and soft tissue damage in children is the key to disrupting finger growth and restoring full joint and finger function.

If you are a parent, nanny, grandparent, or caretaker of any kind for children, you know the moment of panic when the child comes running in crying, holding the arm, often in hysterics. Or worse — someone else comes running in to report that the child in your care is down and something is “wrong.” Is it just a minor “owie” that needs a kiss and a hug? Or could it be something more serious like a broken bone at the elbow?

Swelling, bruising, and pain or tenderness that persist are all signs that a medical examination is needed. The physician will take a history to find out what happened (usually a fall or trauma of some kind) and examine the arm. X-rays quickly tell the rest-of-the-story. If there are no obvious broken bones, a CT scan or MRI may be needed to look for soft tissue damage. Sometimes more complex fractures also require this type of more advanced imaging.

Bone fractures in children near a joint (the elbow in this case) raise additional concerns because of the potential to affect the growth plate and thereby stunt growth. If the joint surface is disrupted (no longer lined up properly), treatment is directed toward realigning the bones and joint (called reduction). At the same time, the surgeon will stabilize the bone fracture (i.e., hold the bones together) while healing takes place. Fixation of the fracture is usually done with hardware such as a metal plate, screws, or wires.

In the case of a simple lateral condylarfracture, nonoperative care may be enough. The lateral condyle is the round end of the humerus (upper arm bone) that forms the upper part of the elbow joint. The arm is put in a cast or splint to immobilize it during healing. Close follow-up is important in order to make sure the bones keep their good alignment without displacement (separation), malunion, or malrotation.

Surgery is advised any time there is a disruption in the joint surface, altering the normal elbow anatomy. Exactly what type of surgical procedure is done depends on the severity of the fracture. Surgeons use a special tool called the Jakob classification to determine what type of surgery is needed. This classification scheme defines joint alignment (displaced vs. nondisplaced, malrotated, and whether or not the growth plate was affected).

There are three basic groups in this classification. Jakob I means the fracture is not displaced or separated and can be treated with conservative (nonoperative) care. Jakob II fractures are displaced by more than two millimeters but without any rotation. Jakob III describes a fracture that is separated completely AND rotated. Jakob II and III elbow fractures of the lateral condyle will require surgery to reduce and stabilize them.

As with other bone fractures, these kinds of elbow injuries can be treated with open or closed reduction. The type of fixation device used (plate, screw, pin, wire) depends on the location of the fracture, severity, and whether or not the growth plate has been disrupted. Open reduction is typically required when there is significant malalignment and malrotation. While the patient is still under anesthesia, the surgeon makes sure the joint surfaces are lined up properly and the joint moves fully and freely.

This sounds all so very simple and straightforward but, in fact, the surgery can be very complex and challenging. There may be multiple bone fragments to deal with. The sharp edges of the bone can come in contact with nerve tissue or blood vessels causing further damage. Loss of blood supply to the area will further compromise healing.

Another tool surgeons use to evaluate lateral condylar humeral fractures is an arthrogram. A special contrast dye is injected into the joint that shows the joint surface and any places where the joint doesn’t line up. When everything in the joint is where it should be, it’s referred to as articular congruity. The arthrogram shows how well the joint surfaces conform to each other (i.e., match up).

In summary, the three most important bits of information about lateral condylar (elbow) fractures in children for surgeons to keep in mind are: 1) Treat Jakob I fractures conservatively with cast immobilization but keep an eye one these for any signs of problems. 2) The goal of all treatment is to restore joint alignment as close to normal as possible. 3) Use hardware to hold fractures together until X-rays show they are stable without malunion or malrotation.

One of the biggest concerns for children with ankle fractures is the risk of damage to the growth plate called physeal arrest. Surgeons evaluating children with physeal fractures of the lower leg bones (tibia and fibula) must be very careful to identify the specific type of fracture and all other areas that might also be injured (e.g., soft tissues such as cartilage, tendons, ligaments).

Successful treatment depends on an accurate diagnosis. Placing a child in a leg cast when there is a large gap in the bone can result in pain and failure to heal. A swollen muscle trapped between the bone and another anatomic part or a piece of flap of bone jammed in the fracture space must be surgically removed before fracture healing can occur.

The clinical exam begins with an understanding of the injury mechanism (e.g., twisting, blunt force). Inspection and palpation are important ways to assess the damage. Not all fractures show up on X-rays so the exam can be the most valuable tool in diagnosing the problem. Swelling may put pressure on the local blood vessels and nerves causing additional symptoms. A special tool called a Doppler can be used to test arteries for adequate blood flow.

X-rays and CT scans will be ordered. Joint spaces, bone alignment, damage to the physeal plate, and bone gapping may be revealed. Any young child with what seems like an “ankle sprain” must be checked for fractures. In young children, the skeletally immature ankle is more cartilage, soft tissue, and ligament than bone. The physeal plate is more likely to fracture before any of the soft tissues are ruptured or damaged. Obvious swelling and bruising are signs of a possible fracture, especially in children younger than 13.

The surgeon is looking for the type of fracture present, especially if there is a Salter-Harris fracture that involves the epiphyseal plate or “growth plate” of a bone. It is a common injury the long bones of children. Any fracture that interferes with the growth plate can cause growth to stop and local fusion of the involved bone. Therefore, these injuries can cause deformity of the joint.

Since Salter-Harris fractures are fractures through a growth plate they are unique to children and skeletally immature teens. These fractures are classified according to the involvement of three levels of growing bone (the physis, metaphysis, and epiphysis). The classification of the injuries is important, because it directs the plan of care and provides clues to possible long-term complications.

There are different types of Salter-Harris ankle fractures named for the location of the fracture. For example, a Salter-Harris Type I fracture goes horizontally through the growth plate. In this injury, the width of the physis is increased. The growing zone of the physis is not usually injured so growth disturbance is uncommon. A Type II Salter-Harris ankle fracture goes through the physis and metaphysis; the epiphysis is not involved in the injury. It is the most common type of Salter-Harris fracture,

A type III fracture goes through the physis and epiphysis. This type of fracture crosses the physis and extends into the articular surface of the bone. Type IV goes through all three levels of bone (the metaphysis, physis, and epiphysis). Once the type of Salter-Harris fracture has been identified, the surgeon pays attention to whether or not the fracture is displaced (separated) or nondisplaced. This is a factor in treatment decisions as well.

Most nondisplaced fractures can be treated conservatively without surgery. A cast is placed around the lower leg and foot. The child is not allowed to put weight on that leg for four to six weeks. A displaced fracture is reduced (set back in place) whenever possible without surgery. Sometimes surgery is required in which case the bones are reduced and held together with hardware (e.g., wires, metal plates, screws).

If the fracture cannot be reduced quickly and easily there is a risk of premature growth arrest. Surgeons tend to err on the side of caution and opt for surgery under general anesthesia to reduce the risk of this and other complications. The larger the gap between the bones, the more likely displacement cannot be reduced easily, thus requiring operative care.

In summary, physeal (ankle) fractures of the lower portion of the tibia and/or fibula are fairly common in children and must be evaluated and treated carefully to avoid disturbing growth of the bone. Terrible complications can be avoided by recognizing which type of Salter-Harris fracture is present and providing appropriate treatment. Closed reduction (without anesthesia and surgery), open reduction (with anesthesia and surgery), with or without fixation, the use of a long or short leg cast, and follow-up will all be determined by the surgeon in accordance with the classification of the ankle fracture.

Triplane fractures of the ankle affect three sections of the lower part of the tibia (lower leg bone). That’s why they are called “triplane.” The force of injury is strong enough to split the joint surface, fracture the epiphysis (round end of the tibia), move through the growth plate, and go out the metaphysis (area between the main part of the bone and the epiphysis at the end of the bone). The growth plate is contained within the metaphysis.

The location and severity of triplane fractures cannot be fully assessed from plain X-rays. CT scans must be taken in order to show the fracture line through multiple planes and angles of the tibia. Different fracture lines will be seen when viewed from the front/back (coronal view), side (sagittal view), and above (axial or transverse view). This is what is meant by a fracture that is triplanar.

A major complication in treating triplanar ankle fractures is the gap or step-off that occurs when the bones shift. When this happens, the bones no longer line up, which means the two sides of the ankle joint are no longer evenly matched. Such a situation has to be treated or the uneven weight-bearing surface will be painful. Down the road, arthritis will develop causing further problems.

The question addressed in this article relates to that gap. How much of a gap is acceptable? When does the gap have to be reduced (brought back together)? And what’s the best way to accomplish this type of treatment? Dr. Alvin H. Crawford from the Cincinnati Children’s Hospital Department of Orthopedic Surgery offers his recommended approach.

Using X-rays, CT scans, and arthrograms, he demonstrates treatment of several individual cases with a closed reduction under real-time image intensifier (arthrogram or fluoroscopy). Pins and screws are placed through the skin (called percutaneous) to hold the bones together during healing. He suggests on the basis of current evidence that a gap of more than 2 millimeters must be treated and reduced. This is advised in order to avoid complications and the potential for arthritis.

A second type of ankle fracture that affects the growth plate is also discussed. This is the Tillaux fracture. The front (anterior) and outside (lateral) portion of the lower tibia is broken off (called avulsion) while still attached to the anterior inferior tibial-fibula ligament.

Both the triplanar and Tillaux fractures occur most often during the teen years, the growth plate can be affected in a unique way. It’s during this time period that the growth plate starts to fuse with the bone. But it does so in a rather uneven, asymmetric fashion. First the middle portion hardens and stops growing, and then the medial or inside edge completes its growth phase. The lateral (outside) edge is the last to solidify. The area that is still open is usually where the fractures occur.

These fractures can be treated with closed reduction if the patient makes it to the surgeon within the first 72 hours. Open surgery is only required when efforts to traction and place the bones in correct position fail. Any of these fractures that are not stable will need some type of fixation (metal plate, screws, pins, wires). Hardware is removed within a year’s time to avoid screws breaking or stripping.

Studies show that arthritic changes can be seen on X-rays in Tillaux or triplane ankle fractures within six years. Anytime a gap is left untreated after these fractures, there are going to be problems. That’s why the author wrote this article and strongly encourages surgeons to surgically restore the joint as close to its anatomic position as possible. He concludes by saying that a gap of less than two millimeters is acceptable; a gap greater than two millimeters is not.

Any fracture affecting the growth plate of bones in children can result in stopping growth. Disturbance of growth after fracture of the distal femur (bottom end of the thigh bone just above the knee) is a particularly vexing problem. That’s because this is where the fastest growth plate in the body is located. Young children can experience as much as a three-inch difference in leg length from a fracture of this type.

In addition to creating a difference in leg length from one side to the other, growth arrest affecting the distal femur can cause a change in the angle of the knee. Later, posttraumatic arthritis can occur because of the affect of the fracture on the joint itself. In this article, pediatric orthopedic surgeons from Cincinnati Children’s Hospital and Texas Children’s Hospital join together to explore treatment for fractures of the distal femur that affect the growth plate.

Growth plate fractures are diagnosed and classified using a standard model called the Salter-Harris (SH) classification. Fractures in this area are divided into four groups (SH I, II, III, and IV) depending on severity. Severity is determined by the number of bone fragments, presence of displacement (separation), and size of displacement.

As you might imagine, more severe fractures (SH III and IV) are the most likely to develop growth arrest, arthritis, and other complications. Assessment isn’t always easy. There can be more damage present than is visible with standard X-rays. As a precaution, any suspicion of growth plate disruption is treated with a full leg cast (up to the groin) for four weeks. Obese or young patients may need a full hip-to-foot (spica) cast to hold the leg still during the healing phase.

Surgery is advised whenever the fracture is displaced (even for SH I fractures). The pieces of bone are put back in place and held stable with wires, pins, or screws until healing has occurred. Wires are used for small fragments. Pins and screws are used for large bone fragments. The surgeon can place the hardware through the growth plate but must try and avoid going through the knee joint itself. The child is always put in a cast for at least a month (up to six weeks).

Besides growth arrest, infection is the next biggest concern with these fractures. Bacteria entering through the pin sites can travel along the pin tract to the joint. Every effort is made to avoid this nasty complication. When it occurs, the surgeon may have to perform another procedure (irrigation and debridement) to clean out the area.

One other potential complication to watch out for is vascular injury. Damage to the blood vessels supplying oxygen and nutrients to the growth plate can also arrest or disturb growth. The surgeon can check pulses and blood pressure of the foot and ankle to detect or monitor arterial injury. There are other more specific tests that can be done to assess blood flow such as a Doppler ultrasound or arteriogram.

The authors of this article advise monitoring for complications and especially for growth arrest for up to 12 months following a distal femur fracture in children who have not reached their full growth yet. Fracture position is also monitored with serial X-rays (taken weekly) during the first eight to 10 weeks.
Any sign that the fracture is not healing or healing in a misaligned position is an indication that surgery is needed.

In summary, every effort should be made to line up the joint surface during treatment for fractures of the distal femur. This will reduce the risk of growth arrest and/or the development of posttraumatic arthritis in young children who have not yet reached full skeletal maturity (i.e., they are still growing). Patients must be closely monitored for any potential complications including infection, loss of reduction (the fracture opens up again), loss of blood supply, and of course, growth arrest.