News Category: Child

When a doctor writes a prescription for a brace, it can be months before the child actually receives it. Type of insurance makes a difference in how long the child must wait. In this study, three types of insurance are compared. Government, health maintenance organizations (HMOs), and preferred provider organizations (PPOs) are included.

Data was recorded by a single orthotic company (brace supplier) providing ankle or trunk braces for 60 children. The number of days between prescription and insurance company approval was recorded. The time between prescription and actually receiving the brace was also tracked. The orthotic company received the prescription the same day it was written. The brace was ready within two weeks of insurance authorization.

The authors report big delays for children covered by government insurance. More expensive (trunk) braces took longer than less expensive (ankle) braces. They had to wait up to four months longer to receive their braces compared to children with PPO coverage. PPOs were faster than HMOs in approving this treatment.

Delays were not all caused by insurance. Once the brace was ready, families with government insurance took three times as long to pick up the braces. Lack of phone service, change in address, and transportation problems may be factors. Language barriers and time off from work may be other problems causing delays.

The authors conclude that access to care and quality of care is based on insurance status. But it’s also true that a lack of cooperation on the part of the family has some impact. Finding a way to streamline this process and increase patient compliance are the next steps in delivering treatment on time.

More and more children and adolescents are experiencing sports injuries only seen in adults up until now. In this report, surgeons from Children’s Hospital in Boston review the treatment of ligament tears in the wrist in children. Results of treatment usually used for adults are measured and reported.

Thirty-two children ages six to 17 were treated for painful ligament tears in the wrist. Most had a sports-related injury while playing football, hockey, or basketball. Some were involved in gymnastics, cheerleading, or rollerblading.

They followed the same treatment protocol as for an adult. Conservative care of cast immobilization followed by physical therapy. Surgery was delayed by at least six months. When pain persisted past that amount of time, then arthroscopic surgery was done.

The surgeon looked inside the wrist to assess the full extent of damage done. The main ligament involved was the scapholunate ligament. This ligament connects two of the wrist bones together (the scaphoid and the lunate). In all but one case, there was more than one ligament damaged. In many cases, two or more ligaments had been torn. In half the cases, bone damage was seen where the ligament(s) had been pulled away from the bone.

The surgeon removed any loose fragments of tissue or bone from the area and scraped away fibrous scar tissue. Tiny holes were drilled in the bone to help speed up healing. In a few cases, open surgery was needed to repair complete tears of the ligaments.

The authors report good results with this step-by-step approach to scapholunate ligament tears in young athletes. Arthroscopic exam for patients with chronic wrist pain helped isolate the problem and treat it appropriately.

More and more complex injuries in adolescents are occurring. This is as a result of increased participation in sports. In this study, 12 cases of torn anterior cruciate ligament (ACL) and medial collateral ligament (MCL) tears are reported. Results of treatment are compared with a control group of 19 children with an isolated ACL tear.

The group with combined ACL-MCL tears was treated with bracing for the MCL tear. The brace was worn for an average of 33 days. Some patients wore it for up to two months. Then the ACL was repaired arthroscopically. In the control group, just an arthroscopic repair of the ACL was done.

Results showed no difference between the two groups. Everyone was able to return to their preinjury level of sports activity. Pain free motion was restored. A few patients had a second surgery either to remove irritating hardware or to loosen scar tissue in the joint.

The authors suggest that bracing MCL tears with delayed ACL repair works well for sports injuries. They advise a mmore aggressive form of treatment for similar injuries from falls or car accidents.

This study shows that slow, gradual correction of Blount’s disease is a more accurate way to treat this condition compared to acute correction after surgery.

Blount’s disease is also known as tibia varum or bowlegs. Bowlegs is a common condition in toddlers and young children. In some cases, abnormal growth of the bone causes the bowing to get worse instead of better over time. Then the condition is called Blount’s disease.

Two groups of children having correction of their tibia vara were compared. All patients had surgery to correct the deformity. After the operation, the correction was held in place using two different types of fixation.

In group one, the legs were held in an external fixator device (external EBI fixator) to correct the deformity. This device is attached to the bone with pins and clamps. It has a series of joints connected together that can be adjusted. This type of treatment may require a second operation to adjust the angle, rotation, and length of the bone.

The second group wore a circular device around the leg called a Taylor spatial frame. A series of six struts as part of this system are designed to improve bone alignment gradually.

The group with the Taylor frame had the best results. Angular correction of the bone was much more accurate than in the EBI fixator group. The authors conclude that gradual deformity correction is also safer with fewer complications without pins that can damage nerves or blood vessels. Any adjustments can be made without returning to the operating room.

Infants are screened for many illness, diseases, and conditions at birth. About one per cent of the newborns have a condition called developmental dysplasia of the hip (DDH). Babies with DDH are much more likely to have another condition called congenital muscular torticollis (CMT).

With DDH there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). The hip may be partially dislocated or completely dislocated. A partial dislocation is called subluxation.

CMT or wry neck means twisted neck. One of the neck muscles (the sternocleidomastoid muscle or SCM) is in a contracted state. Constant contraction of the SCM tilts the head to one side. The chin rotates or turns to the opposite side.

In this study, pediatric orthopedic surgeons reviewed the medical charts of children with DDH or CMT. If the child was diagnosed with DDH in the first month of life, there was a nine per cent risk of also developing CMT. They found that girls were more likely to have DDH. Boys with DDH were five times more likely to have both DDH and CMT. The authors suggest this link may be due to problems during the birth, genetics, or hormonal factors.

The authors conclude that children with CMT should also be screened for DDH. Ultrasound is the best tool for screening DDH in children up to six months of age. X-rays are used after that. Infants with DDH (especially boys) should be watched for any signs of CMT developing.

Finding the best treatment for some conditions requires working backwards. In this study, 64 babies were treated from birth with a Pavlik harness. The harness is used for hip instability, meaning the hip is dislocated or dislocates easily. All 64 babies were followed for six months.

Results of treatment were compared with ultrasound (US) measurements. The goal was to see if the US tests could predict the results of treatment. They also looked at which measurements were the most accurate and reliable. Finding ways to reliably measure hip instability is important for making treatment decisions.

Ultrasound pictures of the hip can be used to measure hip angles. US can also show how much of the femoral head (top of the thigh bone) is covered by the acetabulum hip socket. This is called femoral head coverage (FHC).

In many cases, hip instability gets better without treatment. But it would be better to know in advance which hips won’t get better. That way treatment can get started right away.

The results of this study show that using the FHC is a good way to predict outcomes. There is both inter- and intra-rater reliability. That means the same person gets the same measurements when repeated more than once. It also means two different people can come up with the same results when measuring separately.

Looking back after six months, FHC at six weeks was able to predict the final outcome. Poor coverage of the femoral head suggests the need for early splinting. It can also give surgeons an idea of which babies will not be treated successfully with splinting, requiring surgery later on.

In this detailed article, a condition called slipped capital femoral epiphysis (SCFE) is reviewed. SCFE is a common hip problem in adolescents. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone).

The condition can be classified in several ways. The traditional method is based on history, symptoms, and the results of examination. Using this method the stages are labeled pre-slip, acute slip, chronic slip, and acute-on-chronic slip.

More modern groupings are based on how stable the growth plate is and whether or not the child can walk. The newer classification describes SCFE as stable or unstable. X-rays are used to describe the severity of SCFE as mild, moderate, or severe.

SCFE occurs most often in overweight boys of Pacific Island or African Ancestry. It does affect Caucasians and Native Americans but not as often. There may also be endocrine and hormonal factors involved. Left untreated, the hip becomes unstable. Symptoms increase and function decreases.

Loss of blood supply and death of the bone called necrosis can occur. As an adult, the affected individual may develop degenerative arthritis. There are many ways to treat this condition to avoid complications now and problems later.

Surgery can include fixation with a single-screw or multiple pins. Bone graft taken from the pelvis can be used inside the femoral neck to hold the femoral head in place. The use of a hip spica cast on both sides is no longer advised. In some cases, more extensive surgery may be needed. Each of these procedures is described in detail. Advantages and disadvantages of each are mentioned.

The authors conclude the best treatment for stable SCFE is single-screw fixation. Afterwards, the child uses crutches and partial weight-bearing. Gradual progression to full weight-bearing without crutches is advised. If the condition only affects one hip, the surgeon must evaluate the need to treat the other side to prevent similar problems from occurring.

Unstable SCFE requires surgery right away. Any blood in the joint must be removed and the hip stabilized. The child remains on crutches with no weight put on the leg for six to eight weeks. The goal is to stabilize the hip joint with the fewest problems or complications afterwards.

A review of 15 children with sacroiliac (SI) joint infection shows that early imaging studies don’t confirm the diagnosis. In the first week of symptoms, the physician must rely on clinical and laboratory findings.

Common early symptoms of this condition include fever and tenderness over the SI joint. Most of the children in this study also had a positive Patrick’s or FABER test. This is a painful response to moving the hip into a position of flexion (F), abduction (AB), and external rotation (ER). Other symptoms can include hip, buttock, or abdominal pain.

Early diagnosis is important to prevent serious problems. The diagnosis can be delayed when physical findings are vague and imaging studies are negative. Lab tests for white blood count (WBC), sed rate (ESR) and C-reactive protein (CRP) are needed to identify infection as the cause of the symptoms. The type of infection (staph or strep) is also determined.

Although X-rays are often negative, MRIs and bone scans almost always show some changes after six days. Once identified as an infection, antibiotics are the first step in treatment. Caught early enough, recurrence of SI joint infection and the need for surgery can be avoided.

Researchers from India report on three aspects of clubfoot deformity in children. Their main goal is to find a standard way to measure results after treatment. Testing must be valid, accurate, and reliable. Others using the same test should be able to reproduce the same results.

The authors started by using four scoring systems already available. Fifty children with clubfoot deformity were assessed using these scoring systems. Pain, function, motion, and gait were measured. X-ray results and deformity were also included.

They found the tests from system to system didn’t give the same results. The authors devised their own testing instrument. From their own system of tests and measurements, they report that morphology, function, and tarsal (bones of the foot) do influence each other and the results. Morphology refers to the structure and appearance of the foot.

This study also showed that using X-ray findings alone is not the best way to measure the outcomes. Some X-ray views do not correlate with the structural or functional results and can be omitted. The authors suggest that X-rays don’t take into account muscle power and its ability to improve deformity and function.

They conclude that a common language for evaluating clubfoot is needed. Using morphology, function, and appropriate X-ray studies may be a better solution. A scoring system must be reproducible before it can be adopted as a standard tool to assess results of treatment.

Hip dysplasia is a condition characterized by a shallow hip socket. The hip socket is called the acetabulum. With hip dysplasia, the cup-shaped curve forming a roof over the femoral head is shortened. The femoral head can slip out of the socket and dislocate.

Uneven joint load from hip dysplasia can result in severe osteoarthritis (OA). The joint space narrows. Bone spurs form around the joint. X-rays show places where bone density changes occur around the joint. The patient experiences pain and loss of function.

Surgery to repair the hip socket is called rotational acetabular osteotomy. The surgeon removes a wedge of bone and uses it to re-angle the joint. A small piece of bone is also used to improve the roof angle.

In this study, 43 patients with hip dysplasia and osteoarthritis had the osteotomy. Patients were followed from two up to 16 years. Mid- to long-term results were reported based on decrease in pain and increase in walking ability.

Most of the patients had improved joint angle and increased joint space. Ten patients had X-ray changes showing that their arthritis was worse. A 10-year survival rate was predicted for the surgery in 72 per cent of the patients.

The authors conclude a rotational acetabular osteotomy can benefit some patients with advanced OA caused by hip dysplasia. They do not recommend this surgery for anyone with end-stage OA. With end-stage OA, there is no remaining joint surface. Changing the angle of the hip will not improve the width of the joint surface.

Surgeons at Shriners Hospital in Los Angeles (California) are studying the effects of obesity on children. Specifically, they are looking at the relationship between body mass index (BMI) and Blount disease.

Blount disease is bone deformity of the tibia (lower leg bone or shin). The overweight child or teenager puts so much compression on the bone that it stops growing on one side. With a disturbance of the growth plate on one side, the inner (medial) side of the upper part of the tibia slopes downward. The uneven bone changes the natural alignment and causes curvature or bowing of the tibia.

In this study, the records of 102 children with Blount disease were reviewed after surgery. This is called a retrospective study. Information taken from X-rays, BMI measurements, and results of surgery were analyzed. The children were grouped according to age. The groups included children who developed Blount disease before age three and after age three.

The authors report that older children (boys and girls) are more likely than younger patients to be listed for surgery. BMI was higher for those having surgery. There was no link between BMI and gender. One quarter of the group had Blount disease on both sides called bilateral. BMI was not linked with bilateral presentation.

If, as this study indicates, being overweight increases the risk of Blount disease in children, then weight loss in some children may prevent this from happening. Likewise, weight loss may reduce the risk for surgery.

More and more schools are cutting out physical education (PE). The goal is to increase students’ academic achievement by offering more academic classes. In this study, researchers test the idea that increased exercise improves school performance.

Children in sixth grade at one school in western Michigan were included in this study. The effect of PE and overall physical activity on grades was measured for one school year. The 214 boys and girls enrolled in the study included whites, Hispanics, Asians, multiracial, African-Americans, and Native Americans.

Students were in a daily PE class for one semester. They also filled out a survey reporting on their daily physical activity. Grades for each student in math, science, social studies, and language arts were used as a measure of academic success.

The authors found that being in a PE class did not influence grades. Only about 19 minutes of the 55-minute PE period was spent in moderate-to-vigorous physical activity.

Students who engaged in vigorous physical activity outside of school did have higher grades compared to those with moderate levels or no activity. Vigorous activity was judged based on standards set by the federal government in its Healthy People 2010 guidelines.

The authors say it is possible that a higher socioeconomic status could be a factor for students with better grades who reported a vigorous level of physical activity. Analysis of the results suggests that at least some of the improved academic performance can be linked with increased activity. Increasing the level of activity in PE classes may be one way to improve grades in middle school students.

Many athletes experiencing aching and tenderness where the patellar tendon inserts at the patella (kneecap) have a condition called “jumper’s knee” or patellar tendinitis. Symptoms can occur above or below the patella. Landing from jumps is the most painful.

In this review article, doctors specializing in orthopedic sports describe this condition and its causes. They discuss the nonoperative management of jumper’s knee. When to consider surgery is also presented.
Patellar tendinitis is classified or graded from Stage I to Stage IV. Stage I is pain only after sports activity. Stage II is pain at the start and end of sports activity. Stage III is constant pain. Stage IV is complete rupture of the tendon.

Microtears of the tendon occur with repeated loads. If the body doesn’t have time to heal between training sessions, then chronic tendinitis and even can rupture occur. Risk factors for this condition include the patient’s anatomy, tight muscles, or leg length difference. Other factors include the hardness of the playing surface and number of training sessions. Direct trauma to the patella or tendon can also cause chronic tendinitis.

Early stages of patellar tendinitis (Stages I and II) are treated conservatively. Rest, strengthening, and medications are used first. The athlete is told to avoid motions that will reinjure the tendon. Sports training should be restricted to every second day. Slow return to full activities is allowed when the athlete is completely without pain when jumping. Reducing tendon load this way allows time for better healing. The player is also advised to use ice after activities to control swelling and inflammation.

When conservative care fails, surgery may be needed. Nonoperative care must be tried consistently for six to 12 months first. Surgery is reserved for more advanced disease that does not respond to all other measures. After surgery, the patient is protected in a splint and started on a rehab program. It may be six months before the athlete can return to full sports play.

Falls and car accidents account for most forearm fractures in children. Treatment is based on the results of X-rays. X-rays show the amount and type of break. If the bones have moved apart the break is displaced. Surgery is usually needed to line the bones back up. This operation is called a reduction. In this study, the results of 26 children who had a percutaneous reduction are reported.

Percutaneous reduction means the surgeon inserts a small tool through the skin to use as a lever. The device is placed between the fracture fragments. The bone is elevated and pushed back in place. This method avoids making a long, open incision in order to do an open reduction.

Special X-rays used right in the operating room help the surgeon test the stability of the reduction. If the reduction is acceptable, then the arm is put in a cast for five or six weeks. X-rays are taken a week later and then at regular intervals.

All the patients in this study healed with good alignment. Three patients needed K-wires to hold the fracture in place. Two patients had slight loss of forearm motion but were unaware of it. Grip strength after healing was normal.

Closed reduction is still the preferred treatment method for all pediatric forearm fractures. This study showed that when necessary, percutaneous reduction can be used instead of an open reduction. Full recovery of forearm motion with a normal appearance is possible after fracture. This method of fracture reduction works well when only one bone in the forearm is broken or when they are both fractured.

Spondylolysis is a common cause of low back pain in children. This is a defect or tiny fracture in the supporting column of the vertebra. If the fracture line separates and the bone moves forward, then the condition is called spondylolisthesis. Back pain and tight hamstrings are typical symptoms with either condition.

In this article, orthopedic surgeons from several well-known clinics and hospitals give a review of spondylolysis and spondylolisthesis. It’s rarely reported in children under the age of six. The lumbar spine at L5 is affected most often. The person is more likely to have symptoms when the problem is at L4. In young children and teenagers, spondylolisthesis occurs most often at the L5-S1 segment.

Sports activities increase the risk of developing spondylolysis. Extending the spine too far and too often (hyperextension) combined with rotation such as occur in diving and gymnastics can lead to spondylolysis. Sometimes it’s congenital with changes in bone formation present at birth.

Spondylolisthesis can be grouped or classified as one of five types based on cause as determined by X-ray findings. A second classification system divides cases into two broad groups. The first is developmental (occurs as a result of trauma or fatigue failure) from repetitive use. The second is acquired at birth from an inherited deformity.

The authors report that conservative care is the gold standard for spondylotic stress fractures. The tiny fracture has a chance of healing. A back brace, activity restriction, and physical therapy are advised until CT scan shows bone healing. Return to full activities is possible.

Surgery may be needed if the painful symptoms don’t go away after six months of conservative care. Neurologic changes can become permanent if not taken care of surgically. When pain persists, spinal fusion to stabilize the displaced vertebra may be the best treatment.

Disc herniation in young patients is rare, but it can happen. When it does, discectomy (removal of the disc) may be required. In this study the long-term results of 26 patients ages 12 to 17 years old who had a simple discectomy are reported. The patients were followed for at least three years. Some had surgery as much as 21 years earlier.

Telephone interviews were done to gather data from the patients. Patients from three spine centers were included. All were treated conservatively at first with medications, physical therapy, and activity modification such as avoiding sports activities. Surgery was done after at least three to four months of nonoperative care.

Results were based on current symptoms and level of function. Half the patients reported excellent results. A total of 65 per cent were considered ‘excellent’ to ‘good’. The rest of the group reported ‘moderate’ to ‘poor’ results. About 15 per cent of the patients had to have a second operation. Most of the patients had minimal disability and held sedentary jobs.

The authors say that diagnosing disc problems in children and teens can be difficult. Symptoms often come and go and don’t always look like a disc herniation. CT scans or MRIs may be needed to show if there is a slipped portion of the growth area around the bone in children called slipped apophysis.

Long-term results of discectomy in this group are similar to outcomes in adults. Discectomy for young patients can be managed in the same way it’s done for adults with the same problem.

Surgeons at Mayo Clinic in Minnesota and St. Christopher’s Hospital for Children in Philadelphia team up together to offer a review of the surgical treatment of spondylolysis and spondylolisthesis in children. These two conditions affect the lumbar spine. Each one is either repaired or fused depending on the status of the condition.

In spondylolysis there is a small fracture in the pars interarticularis of the vertebra referred to as a pars defect. At this point the bone is still intact. The child may or may not have any painful symptoms. Treatment is usually with activity modification, physical therapy, and bracing.

If the bone separates at the fracture site, it’s called spondylolisthesis. A small forward movement of the bone is referred to as a “slip” or low-grade spondylolisthesis. Children aren’t as likely to respond well to conservative (nonoperative) treatment for this condition. Spinal fusion is the usual treatment for this problem.

The authors advise repair of the pars defect is best whenever possible. This can be done when there is either no slippage or low-grade spondylolisthesis. With a pars repair, movement can be preserved. Loss of spinal motion, which occurs with fusion, is avoided. Several methods of pars defect repair are described. Screws, wires, or hooks can be used.

Spinal fusion is more clearly needed for children and teens with high-grade spondylolisthesis. High-grade means that 50 per cent or more of the bone has slipped forward. Fusion is recommended even if the child doesn’t have any symptoms. The nerve roots can be stretched or compressed when the vertebra slips forward this much. Permanent neurologic damage can occur.

The authors suggest a careful and detailed physical exam before doing surgery on these patients. X-ray analysis is also important. The surgeon must look at the degree and angle of slippage and pelvic position.

Types of fusion such as in situ, fusion with reduction, and partial reduction and fusion and when to use each one are discussed. Some methods have higher complication rates. Ways to avoid nerve damage include proper positioning and wake up test during surgery. Proper surgical technique is also important. A second operation may be needed for children who have a complete loss of nerve function when they wake up from the operation.

Repetitive stress at the elbow from pitching can cause a problem called osteochondritis dissecans in teenage baseball players. In this condition the cartilage protecting the elbow joint separates or pulls away from the bone. It can take the first thin layer of bone called subchondral bone with it.

In this study, doctors review the method and results of a new treatment called mosaicplasty for this problem. Small plugs of bone graft were taken from the bottom of players’ femurs (thigh bone). These were transplanted to the elbow and inserted into holes drilled where the defect or damage had occurred.

Bone used from the patient is called a autologous. The entire procedure is called an autologous osteochondral grafting or mosaicplasty. The results of the mosaicplasty are reported for eight teenagers baseball pitchers.

Follow-up two years after the mosaicplasty showed seven patients with a good to excellent results. All seven were free of pain and had increased elbow motion. Based on symptoms, motion, and function, all players could have returned to baseball. Six did go back to playing baseball (including three who were pitchers) but two others went on to play rugby and football instead.

The authors say that mosaicplasty is a good treatment for severe articular tears in teenaged baseball players. Even displaced and detached fragments can be successfully treated this way.

Athletes were able to return to full sports participation. This is not usually possible with other methods of treatment such as removing or smoothing the torn cartilage. Mosaicplasty has the added benefit of protecting against arthritis later.

In response to an increased number of pitching-related injuries, the authors of this study surveyed two groups of baseball pitchers. The goal was to find risk factors for shoulder and elbow injuries. Ideas for prevention were a natural outcome of the results.

Two groups of male adolescent pitchers ages 14 to 20 years were included. The first group (95) had shoulder or elbow surgery at least once. The second group (45) never had a significant pitching-related injury. Each pitcher was given a survey of questions to answer about pitching, playing, and injury.

They found big differences between these two groups. First of all, the injured players were more likely to be taller and heavier. Pitching practices were also very different. The injured players pitched more all the way around.

They pitched more innings per game, games per year, and months per year. They also pitched more often with arm pain or while taking anti-inflammatory drugs. The velocity of their pitches was higher than in the uninjured group.

Based on the results of this study, the author made some safety recommendations for this age group:

Doctors must be able to diagnose septic hip arthritis in children quickly. Septic arthritis is a painful joint condition caused by a bacterial infection. Without early treatment, permanent damage can occur to the hip. The condition is easily confused with synovitis. Synovitis is an inflammation of the lining of the joint.

Doctors at the Children’s Hospital of Philadelphia (CHOP) collected data on 53 children seen at their hospital for hip pain. Septic arthritis was ruled out by doing a hip aspiration. Fluid was removed from the joint and tested for bacteria.

Other tests were done and the results compared once the final diagnosis was made by aspiration. In this way, the doctors could look back and see if other less invasive tests might give an accurate diagnosis. For example, they found that fever was still the best predictor of septic arthritis. No one with synovitis had a fever. Everyone with septic hip arthritis had a fever of at least 99 degrees.

Several blood tests were also helpful. These included C-reactive protein and sedimentation (sed) rate, which are measures of inflammation. Elevated while blood cell count is also a yellow (warning) flag. The study showed that a child with fever, positive blood tests, and unable to put weight on the leg had a 98 percent chance of having septic hip arthritis.

Using statistical analysis, the researchers found that after fever, C-reactive protein was the single best test to use to predict septic hip arthritis. The doctor must combine clinical judgment with test results to make a final decision.