News Category: Child

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.

The number of children ages 12 to 18 playing on soccer teams is increasing every year. Along with increased game play come increased injuries. Ankle and knee injuries occur the most often. In this study risk factors for injury are identified. The long-term goal is to reduce risk factors and prevent injuries.

Over 300 players from 21 different soccer teams joined in this study. Boys and girls between the ages of 12 and 18 were included. Preseason testing included balance testing, vertical jump, two-footed jump, and a 20-meter shuttle run.

Information was collected throughout the season about injuries. An injury report form was filled out. Any time lost from play or practice due to injuries was recorded. The cause and type of each injury was examined. Direct contact with another player or contact with equipment was part of almost half of all injuries.

The authors report risk factors for soccer injuries included:

Ways to treat hip disorders in young people are improving and expanding over time. Decisions must be made about who should have which operation. Just such treatment guidelines are offered in this article by doctors at two large children’s hospitals in St. Louis, Missouri.

The authors of this article divide hip patients into five groups based on three factors. The first is the location of the disease (bone, inside joint, outside joint). The second is the presence of any deformity or abnormality of the bone. How much joint destruction is present makes up the third element.

The major goal of patient exam is to match up the problem with the best treatment option. Sometimes there is more than one operation that can be done. Treatment doesn’t always mean surgery. Sometimes nonoperative care is best.

Various hip conditions are reviewed along with questions physicians should ask patients. Clinical exam and tests to carry out are presented for hip snapping, popping, and clicking. How and when to take X-rays for hip problems are included.

Many other hip conditions and general guidelines for their treatment are discussed in detail. The authors make note of the fact that there’s a need for better ways to diagnose problems. Long-term studies are needed to show the true outcomes for the surgical treatment of each condition.

This is the first study to use MRI to measure limb length. Scientists used 12 cadavers (body preserved after death for study). They used four different methods of limb measurement and compared the results. Just the length of the femur (thigh) bone was measured. Standard X-rays were used along with CT scans, MRIs, and electronic calipers.

All three types of imaging gave reliable and accurate results. X-rays were the most accurate but X-ray exposes the person to ionizing radiation. MRIs don’t expose to radiation but take longer and cost more. The electronic caliper is a direct measurement of the bone. It’s the gold standard measurement used to compare the imaging results.

The authors conclude MRI might be a good tool to use when making serial measurements of limb length in children. Children with leg length differences often need new X-rays every six months for many years. Using MRIs, which are both reliable and accurate, can reduce the amount of ionizing radiation.

In the mid-1980s a new method was developed for treating ischemia after hip dysplasia. A special 120-degree angled blade plate was used to restore a normal hip joint position. The operation is called a femoral or valgus osteotomy.

This is a report of the long-term results of this technique used in 94 joints in children ages three to 15. Pain, motion, and function were measured before and after the operation. X-rays taken before and after were also compared. Signs of osteoarthritis were monitored.

The authors report the best results were seen in children ages seven to 12. They had the least loss of motion. They also had the best correction of leg length difference. As adults they had milder arthritic changes. They found that surgery done too early could disrupt the repair due to further bone growth. This could require additional surgery.

Very good long-term results were reported with the use of the 120-degree angled blade plate to perform a rotational osteotomy. This method was not compared with other methods. Since the results were so good the surgeons say they had no reason to try another method.

Sometimes rest really is the best treatment for body aches and pains. In this study doctors show that stopping sports for three months is the best medicine for back pain in young soccer players. Everyone in the study had a condition called lumbar spondylolysis. This is a fracture in the column of the vertebral bone.

Spondylolysis is a common cause of low back pain, especially in young athletes. Many notice the pain started after a high-velocity kick. The goal of this study was to find the best treatment for this problem that would return the athlete to full play again.

All patients were given the same treatment. Each one was given a back brace to wear full-time for three months. They were advised to stop all sports activities for at least three months. They were also instructed in a rehab program of exercises.

The patients were divided into four groups based on how much of the treatment plan they followed. Group one followed all the directions. Group two stopped sports but didn’t wear the brace. Group three wore the brace but didn’t stop playing sports. Group four was completely noncompliant: they didn’t follow any of the doctor’s advice.

Results showed that stopping all sports activity works better than bracing for back pain from spondylolysis. This stress-related injury can be treated without surgery. According to these authors, playing soccer while wearing a brace may not be a good idea.

Obesity has been linked with the most common hip disorder in children ages nine to 17: slipped capital femoral epiphysis (SCFE). In this study scientists report on the specific Body Mass Index (BMI) for age that puts a child at increased risk for SCFE.

In older children and teens, the head of the femur (thigh bone) is still a cap of cartilage called the epiphysis. There is also a growth plate called the physeal plate. These two features allow for continued bone growth. As the child reaches bone maturity the growth plate closes and the cartilage hardens to form one long bone.

With SCFE there is a separation of the ball of the hip joint from the femur. The force of the child’s body weight puts a shear force across the physeal (growth) plate.

BMI in children is measured according to age in percentiles. Weight above the 95th percentile is overweight or obese. Being in the 95th percentile means the child weighs more than 95 percent of all children the same age. Weight between the 85th and 95th percentiles increases the child’s risk of obesity.

In this study the BMIs of two groups of children with hip pain were compared. One group had SCFE. The other group did not have SCFE. They found that most of the children with SCFE were in the obese range. Most of the children without SCFE were normal weights.

According to the results of this study, BMI can be used to assess risk for SCFE. It’s a simple, safe, and inexpensive test of a child’s level of obesity. Using it on a regular basis can show changes early over time. Since obesity is a modifiable and preventable factor, perhaps the number of cases of SCFE can be reduced in time.

Doctors at the Chiba Hospital in Japan have come up with a formula to predict the prognosis for children with Perthes’ disease. This is important because the earlier the treatment, the better the results.

Perthes’ disease (also known as Legg-Perthes’ disease) affects young children. For some unknown reason the blood supply to the hip is cut off. The bone starts to die. The goal of treatment is to avoid severe deformity and arthritis.

By studying children with Perthes’ disease researchers have been able to look back and see what factors predict the final outcome.

In this study age when the disease first occurred was one of several important factors. The other two are changes seen on X-rays. The first is involvement of the epiphysis (growth plate at the top of the femur or thigh bone). The second is hip subluxation (partial dislocation).

The authors say now that they have a predictive formula they will test it out on a new batch of patients.

Little League Shoulder is a common throwing injury among young baseball pitchers. The medical term for this problem is humeral epiphysiolysis. In this study researchers try to find out the forces around the shoulder that lead to this condition.

They filmed 14 youth baseball pitchers throwing fastballs and analyzed the motion. The pitchers were all right-handed 12 year-old boys who could throw a 50 mph fastball. Front and side views were taken during 10 fastballs pitched by each one with maximum effort.

The force and torque on the shoulder joint were calculated. The researchers looked for a link between pitching biomechanics and shoulder injury. They think these forces can twist the humerus (upper arm bone). The torque may deform the still-growing bone in the shoulder joint. The result is humeral epicondylitis.

There are other factors to think about when looking at the cause and effect of Little League Shoulder. The videos showed joint distraction during forward motion of the pitch. This force was much less than the rotation or twisting of the arm-cocking phase of the pitch. There’s also number of years of pitching and frequency or duration of each pitching session to think about.

The authors suggest more study is needed on pitching biomechanics in young adolescent pitchers. It’s important to find out which factors are the most likely ones to cause lesions. Training and practice can be changed to prevent injuries.

The Journal of Pediatric Orthopaedics offers medical opinions on various topics. Ideas, hints, suggestions, and tips are published on an opinion page called On the Other Hand. In the November/December 2005 journal Dr. Carl L. Stanitski reviews the management of hip dysplasia on this page.

Current treatment for hip dysplasia in young children is with a special device called the Pavlik harness. It looks like a diaper-sling that holds the child’s legs far apart. This position puts the head of the femur (thigh bone) deeply and firmly into the hip socket. It helps prevent hip dislocations.

But what happens when the harness or other treatment method such as a body cast are no longer used? Dr. Stanitski points out there are no answers to this question. No guidance exists to tell the doctor what to use (if anything) or for how long (if at all).

The author of this month’s “On the Other Hand” points out the need for a multicenter study to help answer this and other questions. Children should be followed at least five years or until age eight when the hip socket is fully formed.

Doctors at Columbia University in New York City report a rare case of avulsion fracture of the lesser tuberosity in a 15-year-old baseball pitcher. An avulsion fracture occurs when the tendon tears away from the bone with a small piece of bone attached to it.

The lesser tuberosity is a bump on the front of the upper arm bone. The tendon of the
subscapularis muscle attaches to this bump. The subscapularis is the muscle that helps rotate the shoulder inward while pitching the ball forward. The injury occurs when the arm is rotated back to an extreme position for the pitch.

Rare injuries of this type are becoming more common in children’s sports. Repeated throwing in extreme shoulder positions is the most likely cause. In this case the boy reported sudden shoulder pain during a pitch. He was unable to keep pitching. Ten weeks later he still couldn’t pitch.

Exam and X-ray pointed to an avulsion injury. Treatment was rest and then physical therapy (PT). PT was used to restore motion, reduce inflammation, and increase strength. This pitcher returned to full sports participation 19 weeks later. He was still pitching pain free a year later.

The authors of this report compare Little Leaguer’s shoulder to an avulsion injury of this type. They discuss the mechanism of both injuries. Risk factors in young athletes are also reviewed. Surgery may be needed for either injury if healing doesn’t occur in six to 10 weeks.

Nerve damage before birth or during delivery can cause problems with arm and hand function. The group of nerves affected in the neck and arm are called the brachial plexus. This study shows a second nerve problem may be causing additional muscle weakness.

Ten children with brachial plexus birth palsy between the ages of nine months and eight years were studied. All had less than 90 degrees of shoulder movement when lifting the arm out to the side. Surgery was done to take pressure off the nerves. Strength, motion, and function of the arm were all measured before and after the operation.

The authors found before surgery the children had less active motion than passive. This suggests a problem separate from the original nerve damage. After surgery all had improved arm strength and motion. Eight of the 10 children could raise their arms past 90 degrees.

The results of this study show that muscle weakness after birth brachial plexus palsy may not be due to the original nerve damage. Scarring and muscle shortening affecting the axillary nerve may be the problem. The surgeons suggest early surgical treatment to prevent this from happening.

Parents of children with orthopedic injuries prompted this study. They told staff at the Columbia University orthopedic clinic that their children were turned away from school. The reason? Safety issues because of their casts, crutches, or wheelchairs.

As a result the next 78 children treated were followed after injury. The goal was to see how many went back to school. About half were able to return right away. Three-fourths of those who were absent were refused entrance by the school. The rest of the children were kept home by their parents.

Using crutches was the biggest problem. Leg injuries, surgery, and splints were also listed as reasons children were refused entrance. The researchers also reported very few children received any home instruction or help keeping up.

Children who miss school after injury are at risk for academic failure. This report points out how often schools refuse to allow injured students in school.

The quadriceps tendon attaches the group of strong muscles in the front of the thigh (the quadriceps) to the shinbone (the tibia). Inflammation of this tendon is known as jumper’s knee. Jumper’s knee is common in athletes who play sports that involve jumping and stop-and-go running. Treatment is fairly simple, and the outcomes are generally good.

In rare cases, the quadriceps tendon actually tears. This is not such a simple injury. When it happens, the injured person feels an intense tearing in front of the knee. Patients generally can’t straighten the knee fully and have problems walking up hills and ramps. Swelling from the injury can make diagnosis a bit tricky. Surgery is most often needed.

These authors detail the anatomy, diagnosis, treatment, and possible complications of a quadriceps tendon tear. This article would be useful to anyone who wants an overview of the current medical thinking and treatment possibilities for this condition. Among the highlights of the authors’ findings:

Sudden weakness in any athlete is cause for concern. When a 15-year old girl developed severe weakness in both arms after swimming, a medical exam was needed. There weren’t any problems at rest, just during swimming or weight-training.

The weakness was bad enough that she was forced to stop swimming. Tenderness was present in both arms when pressure was applied to the back of the elbow on the lateral (outside) surface. X-rays for fractures and nerve testing (called nerve conduction studies) were normal.

Doctors thought the problem was the radial nerve where it passes in a groove in the lower part of the upper arm. When the triceps muscle on the back of the upper arm contracts, it presses on this nerve. A special testing machine was used to prove this was the problem. The test wasn’t for the strength of the muscle, but to see if the weakness occurred when the muscle contracted against the nerve.

A loss of 45 percent power in the swimmer’s arms supported the idea that the radial nerve was getting pinched. This is called nerve entrapment. Since it only happened when the arms were used for heavy and repeated activity, it was further labeled a “functional” entrapment.

The treatment in this case was surgery to release the nerve. This was done in two parts, first on the left and then on the right. When the doctors opened the area up, they were able to see that the muscle did indeed trap the nerve.

This girl was able to return to swimming after 10 weeks of recovery. And six months after surgery she won a silver medal at the Swiss National Championships.

Parents and coaches involved in youth baseball in the United States have asked for help. Arm problems in pitchers are all too common. The athlete’s elbow and shoulder are structurally the same as the nonathlete’s. The difference is the stress of training and the demands of regular and intense competition. Using the same arm over and over can cause damage to the ligaments, tendons, nerves, and muscles.

Repeated requests for information about elbow and shoulder injuries in young pitchers have been received. How many pitches per game are safe? What causes elbow or shoulder pain or injury in pitchers? Does it matter what kind of pitches are thrown?

Answers to many of these are still unknown. Information is limited, as only a few studies have been done. Risk factors for pitching injuries are unknown. For these reasons, researchers spent two baseball seasons interviewing 298 pitchers after each game. Here’s what they found.

Nearly half of the pitchers reported pain after a game. Elbow pain occurred one-fourth of the time, and shoulder pain was present one-third of the time. The causes of elbow and shoulder pain were different, so preventive steps are often different. This is what coaches can do to help prevent problems for their pitchers:

• Certain types of pitches such as the curveball and slider are stressful and should be saved for older ages. These pitches can be used when the arm is more developed.


• Throwing the change-up pitch is safe and has less risk of injury.


• Young pitchers should not throw more than 75 pitches in a game.


• Pitchers should throw at least 300 pitches but not more than 600 pitches during the season.


• Remove pitchers from a game if they show arm fatigue.


• Limit pitching in nonleague games. Limit recreational baseball outside of league activities.


• Any changes made to prevent pain in the elbow should not increase pain in the shoulder. Likewise, any measures to decrease pain in the shoulder should not increase pain in the elbow.