News Category: Child

Epidemiology is the study of factors that describe any health event. In this study researchers update the epidemiology of slipped capital femoral epiphysis (SCFE).
SCFE is the most common problem affecting the hips of 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).

Using information from the Kids’ Inpatient Database (KID), demographics on how often SCFE occurs is reported. KID has the inpatient records of all children discharged or released from a hospital in the United States for the years 1997 and 2000. Who is affected is reported. Based on these results, the authors offer some thoughts on the ‘whys’ behind how and when SCFE occurs.

They found that the overall incidence (how often SCFE occurs) is 10.8 cases per every 100,000 children. Boys are affected more often than girls. Blacks and Hispanics have the highest rates of all the races reported.

Other epidemiologic findings from this study included:

Legg-Calvé-Perthes or Perthes disease is a hip condition in growing children with osteonecrosis or death of bone. The femoral head (round top of the thigh bone) is affected when the blood supply to the growth center is disturbed. The blood supply eventually returns, and the bone heals. How the bone heals determines how much problem the condition will cause in later life.

In this study doctors at the duPont Hospital for Children in Delaware looked at changes in the shape of the acetabulum (hip socket) in 243 children with unilateral Perthes (one hip involved). They tracked these changes from the start of Perthes disease until bone maturity (growth stopped). They looked for any link between age, gender, and type of treatment with the final shape of the acetabulum.

The cup-shaped socket of the acetabulum helps hold the femoral head in place and keeps it from sliding out or dislocating. Subluxation (partial dislocation) or complete dislocation can occur when the bone starts to crumble after it loses its blood supply and dies. Without a normal femoral head inside the acetabulum, the shape of the socket starts to change, too.

X-rays were used to group the hips into one of three types according to the shape of the acetabulum. Type I was normal with a curved edge along the top of the acetabulum to hold the femoral head in place. Type II was flat. Type III sloped upwards. With types II and III less of the femoral head was covered.

The results showed there was no link between age when Perthes first started and the shape of the acetabulum at bone maturity. They did find there was less hip motion with Types II and III sockets. Only surgical treatment improved the shape of the acetabulum. Other forms of treatment such as bed rest, traction, or braces didn’t make a difference.

The authors conclude the shape of the acetabulum helps predict the final result of Perthes disease. Keeping the head of the femur centered inside the acetabulum is important to prevent dislocation. The best results were seen in patients who had surgery to rebuild the acetabulum.

Back pain in children can be a serious condition caused by bone deformity, tumors, or scoliosis (curvature of the spine). Doctors want to make an accurate diagnosis without unnecessary X-rays, worry, and expense. In this article, doctors from New York University Hospital for Joint Diseases develop a model for decision-making when examining children with back pain.

Models of this type are called algorithms. In this algorithm the physician begins by taking a history and conducting a physical exam. Blood tests and X-rays are ordered. Blood tests can show if there’s an infection or leukemia. X-rays may show a specific problem or deformity.

If the X-rays are negative, then the doctor takes a closer look at the patient’s symptoms. Constant, intense pain that wakes the patient up at night is a red flag. An MRI is advised. For patients with a negative X-ray and symptoms that come and go or get better or worse, conservative treatment is offered. Sometimes the X-ray is negative but the MRI is positive. In those cases, once the diagnosis is made, then treatment can begin for that problem.

Using an algorithm of this type can help doctors determine which signs, symptoms, or test results can predict a specific diagnosis. The authors used this algorithm on 87 pediatric patients with back pain.

More than one-third (36 percent) had a specific diagnosis either from the X-rays or the MRI. The presence of four symptoms was 100 percent accurate for having a specific problem. The four predictors were: 1) constant pain, 2) night pain, 3) radicular pain (back and leg pain), and 4) an abnormal neurological exam.

Using this algorithm can lead to a diagnosis for back pain in children without exposing them to excess radiation and cost. Having a specific diagnosis helps direct treatment sooner. The authors advise a wait-and-see approach when patients have full spinal motion and no radicular symptoms.

When the tip of the thumb is stuck in a flexed position, it’s called a trigger thumb. In this study researchers from Japan try to find out if children are born with this condition or if it develops as they get older.

The study was done over a four-year period. Over 1,100 babies (boys and girls) were examined during the first two weeks after birth. No one had a locked thumb. Parents were told what to look for and to report any signs of flexion deformity or trigger thumb. The parents agreed to check their children for up to one year.

The authors report two children developed trigger thumb in the first year. Three more children reported a trigger thumb at 15, 21, and 30 months after birth. The incidence of trigger thumb was 3.3 cases per 1,000 live births for this group.

The results of this study suggest that trigger thumb is not congenital. It develops as the child grows. Trigger thumb is likely present at an early age but parents don’t recognize or report it.

A delay in diagnosis often means surgery is needed to release the thumb. It’s possible that screening for trigger thumb and early treatment could solve the problem without surgery.

Surgeons in Korea present the treatment and results for angular deformity in the thumbs of six children under the age of five. Photos of the children showed the tip of the thumb tilted toward the index finger.

All cases were caused by a triangular-shaped ossification (growth) center. Instead of an evenly square-shaped bone, a triangular corner piece of the growth plate is missing. The condition is called abnormal triangular epiphysis of the thumb. Treatment to correct the deformity is with an operation called a closing-wedge osteotomy.

A small pie-shaped piece of bone is wedged into the bone at the tip of the thumb. This bone is called the distal phalanx. The surgeon is careful to avoid the growth plate, cartilage, and tendons.

All children were followed for up to two years. Patients and parents were happy with the results. No one lost thumb motion and no damage was done to the growth plate. Only one patient still had a mild deformity. The surgeons say this was caused by under correction at the time of the original surgery.

The authors also describe three types of angled thumbs based on where the problem begins. Treatment for each type is reviewed based on the patient’s age and X-ray results. Surgery is advised sooner than later for the best results.

Low back pain in children raises a red flag. There have been reports that back pain in children is rare and usually serious. More recent studies show this isn’t true. Children and adolescents often have mechanical back pain similar to adults. But screening is still important.

In this study researchers look at the reliability of Technetium bone scan to diagnose back pain in children up to age 18. A group of 142 children and adolescents were included in this study. They were divided into groups based on age and location of pain (neck, upper back, lower back).

All patients had an X-ray and a bone scan. Some had blood tests and others had an MRI. A known diagnosis was made in about half the cases. Bone scan was positive one-third of the time but more than half the children had pathologic findings. This means that bone scan sensitivity was low.

Signs and symptoms reported by young patients with back pain are unreliable when trying to detect the presence of serious disease. Doctors would like to find one simple test to sort out the cause and avoid unnecessary and costly testing. The authors say the Technetium bone scan has its place as a study tool in diagnosis. It doesn’t always show infection or malignant tumors and that’s a concern.

When the long bones of the arms and legs break in children, a simple cast won’t take care of the problem. In the old days, weeks and weeks of traction were required to pull the bones apart to reset them. Today curved, flexible rods are inserted down the middle of the long bone. This article reviews the use of these rods called Nancy nails.

In the past after traction for femur (thigh bone) fractures, children were put in a large (spica) cast from waist to toe. The spica cast was worn for two more months. Care for the child was difficult. Then surgical methods changed. It became possible to operate and fix the fracture with metal plates and screws. This method is still used in some places in the U.S.

With more single parent and two working-parent families, less cumbersome, less care-intensive treatment was needed. A surgeon in Nancy, France designed the new rods called elastic stable intramedullary nailing (ESIN). Intramedullary refers to the open canal inside the long bones. The nails or rods are pounded down into that space.

Although hospital time is shorter with ESIN, costs can be higher, especially if the nails are taken out in a second operation later. Surgeons agree that ESIN should be the new standard of care for femur and forearm fractures.

There are still large disagreements about whether or not the nails should come out later or stay in permanently. The author presents both sides of this argument. A perfect solution to the problem would be bioabsorbable rods that could stay in and dissolve over time when healing was complete. Our grandchildren may benefit from this type of implant.

More and more children are participating in sports programs. This means more children than ever before will have sports injuries. In fact studies show one-third of these children will have an injury that requires treatment. The ankle and knee seem to be the areas injured most often. Girls have four to eight times more knee ligament injuries compared to boys.

In this study researchers look at strength differences in male and female athletes ages nine to 17. The goal was to see if age and gender have an effect on muscle strength and control during jumping and landing.

A sports injury test made up of three specific tests was given to 1,140 young athletes. The three tests included 1) flexion (hamstring) and extension (quadriceps) strength of the leg, 2) drop-jump test, and 3) single leg hop test.

The drop-jump test was videotaped to show hip, knee, and ankle alignment. Each athlete jumped off a box and landed with both feet on the floor. The box was 30 cm (about eight inches) high. The hop test was made up of two types of hopping skills based on time and distance.

Results showed maximum strength for extension in girls at age 13 and both flexion and extension in boys at 14. Only slight increases in flexion strength were noted for girls ages nine to 11. This may suggest a need for hamstring strengthening in young female athletes. As boys got older (ages 14 to 17) their strength increased more than girls.

There was no difference in limb alignment between the boys and girls with the drop-jump test. The authors say this suggests some factor other than alignment for knee ligament injuries in girls. And for the third test, increased strength with older age didn’t improve results of the hop test.

The authors say this is one of the largest studies ever done on strength differences by age and gender in young athletes. Information on the development of muscle strength and control of the lower leg during jumping and landing may help prevent future knee ligament injuries. They propose a longer study is needed before any final conclusions can be made.

In this study doctors report the results of five cases of Legg-Calve-Perthes disease treated with cheilectomy. Cheilectomy is the partial removal of the femoral head. The femoral head is the round ball of bone at the top of the femur (thighbone) that normally fits into the hip socket.

Loss of blood supply to the hip from Perthes disease causes the femoral head to flatten and collapse. A flat, instead of round, femoral head can slip out of the hip socket causing partial dislocation called subluxation. Complete dislocation is also possible.

Cheilectomy used on five patients had good short-term results. Everyone had less pain and improved motion. Three of the five patients stopped limping completely. The other two limped much less.

But the good results didn’t last. When the patients were in their early 30s osteoarthritis (OA) developed. X-rays showed a narrowed joint space and bone spurs. Hip pain and leg length differences caused four of the five to start limping again. Range of motion was better than before surgery but much worse than during the early years after the operation.

Cheilectomy isn’t a common way to treat Perthes disease. Reports of results are rare. The results of this study show that cheilectomy doesn’t prevent hip OA in patients with Perthes disease.

Many theories have been proposed for the cause of Legg-Calve-Perthes disease in children. Scientists have explored thyroid function, blood conditions, and passive smoking among many other topics. In this study, researchers look at the role of protein C deficiency as a possible cause.

Legg-Calve-Perthes disease affects the hip in young children. Blood supply to the growth center of the hip (the capital femoral epiphysis) is cut off, causing the bone in this area to die. In time the blood supply comes back and the bone heals. Delayed or poor bone healing can lead to serious problems in the hip joint later in life.

Protein C levels were measured in three groups and compared to normal values. Protein C was studied because it is a common factor in blood clotting. The loss of blood supply in Perthes may be linked to too much clotting of the blood.

Two groups of patients were divided by active versus inactive disease. Adults with completed skeletal growth who did not have active disease were in the first group. Children with immature bone development and active disease were in the second group. The third group included children and young adults who didn’t have Perthes disease at all.

The results showed no protein C deficiency in any of the groups. Patients with Perthes had low levels but these were still in the normal range. Levels were compared in subjects exposed to passive smoke to those whose parents did not smoke. There was no difference between these two groups.

The authors conclude that there isn’t a true protein C deficiency in Perthes disease. Low values suggest a possible problem but not the root cause. Exposure to passive smoke was present in three-fourths of the Perthes groups. Altered protein C levels don’t appear to be the result of passive smoke.

Slipped capital femoral epiphysis (SCFE) is a problem for today’s overweight teenagers. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). Predicting which children will have this problem in both hips is the subject of this study.

Fifty-four (54) children with SCFE were measured for height and weight. Body mass index (BMI) was calculated from these two measures. The children were followed until bone growth and closure of the growth plates was completed.

The authors report a much greater BMI in children who progressed from having SCFE in one hip to both hips. Half of the children who had bilateral SCFE by the end of the study showed involvement of both hips to start. All children with a BMI more than 35 kg/m2 went on to develop bilateral SCFE. Normal BMI ranges from 20 to 24.9. Overweight is considered 25 to 29.9. Obese is 30 to 40. Anything over 40 is severely obese.

The authors conclude that obese and especially severely obese children are at risk for SCFE affecting both hips.

In this study researchers at the University of Utah compared children who had spinal surgery for two types of scoliosis (curvature of the spine). The first type of scoliosis is called neuromuscular scoliosis (NMS). NMS often accompanies other conditions such as muscular dystrophy, cerebral palsy, and spina bifida. The second type is idiopathic scoliosis (IS). Idiopathic scoliosis occurs in otherwise able-bodied children, especially girls. The cause is unknown.

Treatment with surgery to keep the curves from getting worse is more common with NMS but may be needed with IS as well. A special database of information collected from hospitals in 2000 was used in this study. It’s called the Healthcare Cost and Utilization Project Kids Inpatient Database or HUCP KID.

By studying the discharge records of children with both types of scoliosis the authors report the following findings:

What happens to teenagers who have adolescent idiopathic scoliosis (AIS) who don’t have surgery to correct the problem? Patients and families must think about the long-term effects of nonoperative care for this condition. The results of this study will help physicians counsel those patients making this treatment decision.

AIS refers to curvature of the spine in children from ages 12 to 19. The cause of the problem is unknown or idiopathic. Data was collected from two groups. Group 1 had been diagnosed with AIS between ages 10 and 20. Group 2 (control group) were matched by age and gender. The control group didn’t have AIS.

Questions were asked about psychologic, physical, and social well-being. Other questions looked at daily activity level. Physical, neurologic, and X-ray exams were done on everyone.

The goal was to see what the health-related quality of life (HRQOL) is for adults who had AIS and didn’t have surgery. Follow-up was from 10 to 60 years. Most of group 1 was early middle-age when this study started.

After analyzing all the data the authors report the following findings:

Scoliosis or curvature of the spine affects about two percent of the adolescent population. One subgroup called Adolescent Idiopathic Scoliosis (AIS) is usually a cosmetic problem more than a serious problem. This study gives a picture of the long-term results of bracing or surgery for the condition.

Bracing is used when the spinal curve is 30 degrees or more and the child is still growing. The goal is to stop the curve from getting worse and avoid spinal fusion. Surgery to fuse the spine is done with bone graft and metal rods alongside the spine. A brace is worn after surgery for at least three months.

Results are reported based on back pain, activity level, and general health status 10 years after brace or surgical treatment. Questions related to wearing the brace were also asked.

The authors report low levels of back pain in both groups. General health was the same for both groups but lower in all areas compared to adults without scoliosis. Patients were much more sports-active before treatment.

Bracing was a problem for many of the patients. They felt harassed by their peers and reserved in their interactions with members of the opposite sex. Two-thirds of the bracing group didn’t wear the brace as prescribed because of skin pain or ulcers. About 10 percent quit wearing the brace for various reasons.

Doctors are concerned that children with AIS are affected by the treatment as much as by the disease. The impact of both is apparent in their early 20s. A 10-year study isn’t enough to predict what will happen when these patients are in their 50s. Longer studies are needed to assess the impact in later life.

Scoliosis or curvature of the spine can affect young children under the age of five. In this article doctors from the Naval Medical Center in San Diego review what causes this condition and how to treat it. Newer surgical methods of treatment are highlighted. Details of the exam are also included.

Although some cases of early onset scoliosis occur for no apparent reason, most are caused by some other problem. This could be deformity of the vertebra, muscular dystrophy, cerebral palsy, or some other neurologic condition.

MRIs should be done with all young patients whose curves measure 20 degrees or more. The authors suggest this because many of the young children with scoliosis also have hidden spinal cord or brain abnormalities.

Treatment depends on the size of the curve. Curves less than 20 degrees are followed with X-rays every four to six months. If the curve stabilizes, then an exam every one to two years is enough. For curves greater than 20 degrees casting, bracing, or both is advised for at least two years.

If a curve continues to get worse, then surgery to fuse the spine may be needed. The spine does stop growing when fused so this is not the best solution. Another option is the use of “growing rods.” Rods are placed on both sides of the spine. The rods are lengthened every six months as the child grows. fusion can be delayed until much later.

What’s ahead in the treatment of this problem? The authors say the search is on for better ways to correct the curve and keep it from getting worse. Less invasive and fewer operations is a goal. Remote control implants have been tried on dogs. Preserving spinal growth and lung function is important in this age group.

A shallow hip socket in infants and young children is called developmental dysplasia of the hip or DDH. DDH is a risk factor for dislocation. It is treatable with a special harness during the first year of life. The device is called a Pavlik harness named after Dr. A. Pavlik.

In this study doctors report how ultrasound can be used to predict hips that won’t respond well to the harness. Knowing this ahead of time helps doctors make a better treatment plan for the child. Until now researchers have tried to link other factors such as age, gender, and breech birth with increased risk for failure. None of these were helpful.

Serial ultrasound pictures are useful because they allow several measures. The doctor can see how much of the head of the femur is covered by the hip socket. This is called the dynamic coverage index or DCI. It also shows important hip angles and the type of cartilage that forms the hip socket covering.

Full success using the Pavlik harness is possible unless the DCI is less than 22 percent, the angle is less than 43 degrees, and the joint cartilage shows up as fibrocartilage. When any of these three factors are present, the harness is not likely to work. A more rigid splint may be needed.

The authors advise doctors to do long-term follow-up studies with all children at risk for problems later on. The single most predictive factor of problems is the presence of fibrocartilage instead of hyaline cartilage forming the roof of the hip socket.

Is there a link between endocrine problems and slipped capital femoral epiphysis (SCFE)? Since low bone density is connected with endocrine problems and SCFE occurs in children with endocrine disorders, maybe the two problems are connected. That’s the focus of this article from the University of New Mexico Carrie Tingley Hospital.

SCFE is a condition seen most often in obese children in early adolescence. In SCFE the growth center (epiphysis) of the femur (thigh bone) slips backwards. The blood vessels to the epiphysis can get pinched off or even torn. Without a blood supply the bone starts to die.

Finding out what causes SCFE and preventing it is a goal of scientists. The authors of this study proposed that children with SCFE have decreased bone density. That’s why they get SCFE. But comparing obese children without SCFE to obese children with SCFE they found out they were wrong.

DXA scans of the spine and hip were done on both groups of children. Boys and girls ages 11 years to 15 years old were included. All were either overweight or obese according to their measurement of body mass index (BMI). They found out the children with SCFE had better bone density than age- and gender-matched children without SCFE.

This study was small (12 children with SCFE, five without) and normal bone density levels aren’t known for obese versus normal-sized children. They say there’s no way to tell if the control group might end up with SCFE later. The authors conclude that more study is needed. For now it doesn’t appear there’s a link between low bone mineral density and SCFE.

Trigger finger is a well-known condition in adults. More rarely infants present with a trigger thumb. The thumb is locked in a flexed position. It can’t be pulled straight out by the parents or the doctor. It’s not clear what treatment is best. This study explores the benefit of surgery in children over the age of three.

Most doctors advise splinting or physical therapy for a child 12 months or less who has a trigger thumb. Surgical release is an option when they’re older. But surgery always has risks and possible problems. In this study, surgeons use a percutaneous release of the A1 pulley mechanism instead of an open incision and release. Percutaneous means a needle is inserted into the skin and used to cut the pulley.

The benefits of percutaneous release are that it can be done in the office. Children recover right away and there’s no scar. There can be nerve damage if the surgeon inserts the needle in too far. The results of this study show it works well with very few problems even after several years follow-up.

The authors say there are two key ingredients to a successful percutaneous trigger thumb release. The first is surgeon experience. Only surgeons who have treated many adults with trigger finger should try doing this operation on children. The second is parental cooperation. Parents must move the thumb often every day for good results. The problem can come back if there isn’t enough movement in the early healing phase.

Sometimes a piece of cartilage along with a thin layer of the bone pulls away from the joint. This condition is called osteochondritis dissecans or OCD. The knee in children and young adults is affected most often. The Japanese population seems to have a higher number of cases of lateral OCD compared to other groups. In this study researchers explore the reasons for this increase.

The authors used MRIs and arthroscopy to report on the location and type of OCD in 38 knees. Most OCD occurs on the medial or inner side of the femur (thigh bone) where it meets the lower leg bone (tibia) to form the knee joint. In the Japanese groups there were more cases of lateral OCD (outside edge of the knee).

They also examined the type of cartilage or menisci present. A link between the type of OCD and the state of the lateral meniscus was found. In these Japanese patients the meniscus was described as discoid. This means that instead of a full, crescent moon shape (normal) the meniscus was a narrower but thicker crescent shape.

It appears from the results of this study that Japanese patients have lateral OCD because of the shape of the meniscus. This is different from the general European population.

In this study doctors report how ultrasound can be used to predict hips that won’t respond well to the harness. Knowing this ahead of time helps doctors make a better treatment plan for the child. Until now researchers have tried to link other factors such as age, gender, and breech birth with increased risk for failure. None of these were helpful.

Serial ultrasound pictures are useful because they allow several measures. The doctor can see how much of the head of the femur is covered by the hip socket. This is called the dynamic coverage index or DCI. It also shows important hip angles and the type of cartilage that forms the hip socket covering.

Full success using the Pavlik harness is possible unless the DCI is less than 22 percent, the angle is less than 43 degrees, and the joint cartilage shows up as fibrocartilage. When any of these three factors are present, the harness is not likely to work. A more rigid splint may be needed.

The authors advise doctors to do long-term follow-up studies with all children at risk for problems later on. The single most predictive factor of problems is the presence of fibrocartilage instead of hyaline cartilage forming the roof of the hip socket.