News Category: Child

What’s the best way to stabilize a bad fracture of the femur (thigh bone) in children while minimizing pain, maximizing comfort, and preventing scarring or complications? That’s the topic of this article on current strategies for the management of children’s femur fractures.

The truth is there is no known “ideal” method. There is no evidence to suggest one surgical treatment technique outshines all the rest. Currently, the types of surgical stabilization available include elastic stable intramedullary nailing, locked intramedullary nails, plate fixation, and external fixation. Each one of these approaches, along with the advantages and disadvantages are discussed in detail.

But before we fill you in on the surgical side of femoral fracture fixation, let’s take a quick look at nonoperative management. Cast immobilization is a possibility for some children. The cast goes from hip to toes and is called a spica or hip spica cast. Conservative care of this type is possible when the patient is a young child or a small child (up to 60 pounds).

The benefits of this type of treatment include no surgery, very short time in the hospital, avoiding scars from surgical incisions, and preventing infection. The downside of cast immobilization includes the child has to wear a hot, bulky cast and the parents have to care for the child who can’t bend at the waist, roll over, use a toilet, or walk.

There is also the possibility that the fracture will heal improperly when only held in place by a cast. The fracture might separate, a process called “loss of reduction.” Or the broken bones could shift the other way, overlapping each other causing shortening of the leg. But, if it doesn’t work, the child could always still have surgery.

Let’s consider the pros and cons of surgical fixation. Elastic, slightly flexible long nails have been in use for the last 20 years. Titanium has replaced stainless steel making it possible to have a narrow, lighter, less rigid rod down the center of the bone. The child does not have to be in a cast or brace and that is a big advantage. The flexibility of the nail(s) makes it possible for the fracture to withstand some load or force without losing stabilization.

There is some debate about whether or not the nails should be removed after the fracture has healed fully. Pulling the nails back out means another set of small incisions. Sometimes the nail doesn’t come out easily or breaks in the process. That can add another dimension of complexity. While the nails are in place, there can be some irritation and pain at the site where the nail was inserted.

The more rigid locked intramedullary nails are used for adults but also work well for older children/teens or heavier children. They are also the best choice when the fracture site is broken into many little pieces of bone or unstable for any other reason. This type of fixation does not have to be removed.

Another option to choose from is plate fixation. This is a long metal plate that attaches along the bone inside the body with screws through the plate crosswise into the bone. This does require open surgery with incisions that leave scars. Surgeons are also finding ways to slip the plate in through the skin under the muscle. This is more of an indirect technique. Once again, the plates used in this type of fixation would be left in place rather than removed after fracture healing.

The last type of fixation is referred to as external fixation. It is a metal cage that fits around the outside of the leg with multiple long pins crosswise through the bone. External fixation is not used much anymore now that flexible nailing is possible. There were just so many complications with this type of fixation. Infections, loss of reduction, delayed union, ugly scars, and refracture are just a few of the problems reported with this type of fixation. External fixation is still used in cases of extreme trauma or severe, open fractures but for the most part it has been replaced with the flexible nails.

In summary, there isn’t enough evidence to support one single fixation technique over others for femoral fractures in children. The surgeon will weigh all of the pros and cons of each approach and evaluate each child individually when deciding what is best. Factors that must be taken into consideration include the child’s age, weight and size, and type and severity of fracture. The surgeon’s own level of experience and expertise will make a difference along with any other injuries (especially soft tissue trauma) affecting the leg.

Falls and throwing injuries are the two most common causes of medial epicondyle (elbow) fractures in children and teens between the ages of seven and 15. In this article, current evidence is presented for the evaluation and treatment of these fractures.

The medial epicondyle is located on the inside of the elbow. It is the place where several muscles and ligaments of the forearm attach (flexor muscles, pronator teres, medial collateral ligament). The mechanism of injury is usually a valgus force on the elbow strong enough to pull these muscles and ligament off the bone taking with it a piece of bone.

A valgus force goes from the lateral or outside edge of the elbow to the medial or inside of the elbow. This type of injury with a bone fragment attached to soft tissue is referred to as an avulsion fracture. The child may feel or hear a popping sensation at the time of the injury. This will be followed by pain. Elbow dislocation is common and nerve damage is seen in up to 15 per cent of all patients with this type of fracture.

The goal of treatment is to heal the fracture, of course, but also to help the child regain normal motion, strength, and function. In the case of an athlete, return-to-sport and play at a preinjury level is ideal. The surgeon will use X-rays to guide the initial treatment decision.

Some children will be able to be treated with a conservative course of care (no surgery required). The selection of nonoperative versus operative care hinges on whether or not the fracture is displaced (separated) and by how much.

Surgery is required for open fractures (through the skin), fracture-dislocations, and unstable fractures (often those that go through the joint surface). Any sign of nerve or blood vessel damage must also be addressed surgically and quickly. One other reason why surgery might be needed is if the bones have separated apart (called displacement). But there’s no cut off point between when surgery is needed and when it’s not. What one surgeon may consider a “significant” amount of displacement may be not the same for another.

Age and size of the bone fracture fragment help guide the surgeon choose the best surgical treatment approach. Younger children are treated with bone fixation using wires. Older children and teens are more likely to be able to handle having a screw put in place to hold the fracture until healing takes place. Pins (rather than screws or wires) are used when there are small bone fragments.

Many studies report the good success of treatment when following these guidelines for both conservative care and operative treatment. Loss of elbow extension (ability to straighten the elbow) is the number one limitation after this surgery. Starting elbow and arm movement right away after the cast comes off is the best way to deal with this problem.

There are some areas where further studies would help clear up a few questions. For example, just how much displacement is an indicator that surgery is needed? Do children get back to their beloved sports activity faster when treated with surgery instead of the immobilization used during nonoperative care. Does the high level of play and intensity of activity suggest fixation should be considered more often than not?

It’s easy to see that a severe fracture and unstable elbow requires surgery. The cases that fall in between are the ones that require individual consideration of all factors. The surgeon’s own experience and expertise certainly fall into that category. Patient age, activity level, X-ray findings, and patient goals are additional factors.

Many cultures have practiced swaddling their babies. Native Americans used a cradleboard or “papoose” carrier. More modern use of this positioning relies on a blanket or diapers. The child is placed in a straight position with arms and legs held to the sides. The effect is to create neutral warmth, which is calming to the nervous system. Babies sleep better and cry less in swaddles. There is a decreased risk of sudden infant child syndrome for babies who are swaddled.

But the question has been raised about the potential harm this positioning may have on the hips. A straight position held too long can lead to hip subluxation (partial dislocation) or even full dislocation. Children’s hips need the opportunity to move in all directions, especially hip abduction (away from the body) in order to fully form a deep, stable hip socket.

In order to study the effect of swaddling, researchers from China swaddled baby rats. Studying this problem in humans would not be considered ethical so animal studies are the next best way to investigate potential harm to humans. They used four groups of rats.

One group (control group) was not swaddled at all. The other three groups were swaddled for varying lengths of time using surgical tape to hold the hind legs together against the body. Group two (early swaddling) was held in the swaddling position immediately after birth and for the first five days of life. Group three was swaddled for the second five days. Group four was swaddled early (first five days) and for a prolonged or extended period of time (total of 10 days).

The rats were allowed to return to normal movements for three months and then the hips were X-rayed and examined with dissection. They found that the rats who were swaddled the earliest and longest had more cases of small, deformed femoral heads (round bone at the top of the thigh bone that fits into the hip socket). This group was also most likely to have hip subluxations and/or dislocations. And the cartilage growth that forms the hip socket was deformed or distorted.

At the other end of the continuum, the control group had perfectly formed hips with no problems of any kind. In the two remaining groups, the early swaddling group had the worst results with more hip dysplasia (shallow hip sockets), more subluxations, and more dislocations compared with the late swaddling group. Female rats were more likely to have hip problems in general but especially in the early swaddling group.

The value of this study is to help prevent developmental dysplasia from forming in human babies. The authors suggest that the practice of swaddling should be avoided in humans because of the potential negative effect on hip development. It is important to find other ways to achieve the same benefits of swaddling without binding the hips/legs.

The authors were unable to explain why some hips subluxed or dislocated while others did not. They did observe that one side did not dislocate more than the other. In human infants, left hip dysplasia with subluxation or dislocation is more common that right-sided problems. The reason for this may be the position of the child while in the mother’s uterus. Ultrasound images show a tendency for babies’ left hips to be pressed up against the mother’s sacrum, which could contribute to the greater number of cases of left hip dysplasia in infants.

The causes and effects of tarsal coalition are presented in this article from The Children’s University Hospital in Dublin, Ireland. Some of the information comes from CT scans of patients being treated for this condition. Other insights come from cadaver studies (after death).

What exactly is tarsal coalition? It is the failure of the developing bones in the foot to properly form all the distinct, individual bones in the midfoot (between the ankles and toes). Instead, two or more bones can form a bridge of bone between them or fuse together. Males are affected more often than females though the reason for this remains unknown.

What causes tarsal coalition? This condition is usually congenital (present at birth) and there are inherited factors involved. Tarsal coalition can also develop after birth as a result of trauma, infection, or inflammation (e.g., arthritis). In some cases, tarsal coalition is part of a larger problem with other bony malformations.

How is the problem diagnosed? The most obvious symptom of tarsal coalition is a rigid flatfoot. An X-ray or other imaging study provides a look inside the foot to confirm the diagnosis. CT scans are especially helpful to see exactly what’s going on. This information helps the surgeon know how to best treat the problem.

Symptoms such as pain and stiffness don’t develop in children until the connecting tissue between the bones hardens or ossifies forming a bony bridge. Increased activity (e.g., sports or dance) involving the feet may aggravate the child, teen, or young adult. Sometimes it’s weight gain or repeated ankle sprains that bring on symptoms of pain, foot fatigue, or limping. Muscles in the foot may spasm in an effort to protect the foot adding to the discomfort.

What can be done to treat this problem? If there are no symptoms, treatment may not be necessary. Conservative (nonoperative) care is the first line of treatment. This can include orthotics (molded shoe inserts), nonsteroidal antiinflammatory medications, or steroid injections. Changes in activity can also provide some relief from symptoms.

Surgery is another treatment possibility but this is usually reserved for patients with foot pain that is intolerable and doesn’t go away otherwise. Usually, the bar of bone is removed and body fat or muscle is used to fill in the space. Packing the space left by bone excision (removal) is necessary so the bone doesn’t grow back in.

In some cases fusion of the surrounding bones to the bony bridge is the best approach. This procedure is called an arthrodesis. This type of surgery is recommended when more than half the joint is involved. The fusion procedure may fuse two, three, or more bones together. The goals of all treatment are to reduce (eliminate if possible) pain and other symptoms, to correct ankle and foot alignment, and to restore full function of the foot and ankle complex.

What can the patient expect after treatment? The prognosis for this condition is considered good-to-excellent. Delayed diagnosis or failure to recognize the full extent of the problem may affect final outcomes. Likewise, complications from surgical treatment can compromise outcomes. With multiple bone coalitions (connectors), several surgeries may be needed to complete the treatment process.

It is always distressing when a baby is born with a foot deformity known as “clubfoot.” The clubfoot is unmistakable. The foot is turned under and towards the other foot. The medical terminology for this position is equinus and varus (also known as “equinovarus”). Equinus means that the toes are pointed down and the ankle flexed forward (sort of 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.

A commonly accepted treatment for this problem is the Ponseti Method, a series of sessions involving manipulation and casting of the foot. If the foot does not fully correct, then the surgeon can release the Achilles tendon and recast the foot. The tendon release procedure is called a tenotomy. Without the constant pulling of a tight tendon, the ankle can assume and maintain a correct alignment.

In this study, surgeons from Israel evaluate the results of using the Achilles tenotomy when it was performed as an outpatient procedure without general anesthesia. The children were given a local anesthetic so they didn’t feel anything. It wasn’t necessary to put them to sleep and they went home an hour later. The tenotomy was done percutaneously. This means the needle used to lengthen the tendon was inserted through the skin without a large incision. Afterwards, the foot was put in a cast for three weeks and then the results measured.

Each child was followed closely to watch for any complications, need for hospital readmission, follow-up retenotomy, and to evaluate the foot correction. In the past, bleeding, nerve damage, infections, scarring, and residual equinus (from incomplete tendon release) have been reported complications. For this group, there were none of those (or other) complications.

Not all babies or young children with clubfoot treated with the Ponseti Method will need a tenotomy. In this study, all but one child required this additional procedure due to a lack of cooperation with using the foot brace that is recommended after casting. During the final stages of the Ponseti manipulation and serial casting, if the hind foot remains uncorrected, then a tenotomy to release the Achilles tendon (that is pulling on the hind foot) is considered.

The authors summarized by saying if and when a tenotomy is needed, it is safe to perform the operation as an office procedure. The skin is numbed with a topical agent and the area around the tendon numbed with a local anesthetic. The tendon is released safely and effectively without complications. When the parents follow-up diligently with the home program, the results are excellent. With good parental compliance, the need for a second tenotomy is eliminated.

The clavicle known more commonly as the “collar bone” is the most commonly fractured bone in children. No surprise there since falling on the point of the shoulder is the way the bone gets broken in the first place and falling is what young children do so well! By the very number of children who fracture their clavicle (10 to 15 per cent of all fractures in children), physicians are sure to see this problem in their practice.

Dr. Michelle S. Caird from the Department of Orthopaedic Surgery at the University of Michigan in Ann Arbor presents some helpful guidelines when treating clavicular shaft fractures. First, she says don’t consider them to be the same as fractures in adults.

That’s because children have a very thick outer covering of bone around the clavicle limiting displacement (separation) of the broken bones. They also have excellent ability to heal and remodel bone compared with adults. Surgery is rarely needed. A sling or figure-8 brace may be all that’s needed for a few weeks before easing back into full speed ahead.

Adults are more likely to experience malunion, nonunion, and the need for operative care. Adults are also more likely to be unhappy with the results of treatment — especially if they can no longer move the arm normally or if they have pain and decreased strength.

Sometimes surgery is necessary for children. The indications for operative treatment include multiple trauma to the body (usually signaling a more severe clavicular fracture), other shoulder injuries, shortened fractures (the two ends of the bones telescope onto each other), or comminuted fractures (many bone pieces).

When surgery is needed, there isn’t one operative method that works best for all children. The surgeon must consider the needs of the child and the concerns of the parents or family. The surgeon’s own experience and expertise also play a role in decisions about treatment.

The most commonly used surgical techniques include intramedullary (IM) fixation. IM refers to the use of a metal plate with screws to hold the bones together or a long pin through the length of the bone to hold it together until healing takes place.

Many decisions go into the operative care of children. Age, size, growth status, location and type of clavicular fracture, and activity level are just a few factors. Then type of fixation, type of incision, and potential for complications must be considered.

The most worrisome complications include infection, nerve or blood vessel damage, pin migration, shortening of the bone, and failure to heal to name a few. Then there are the problems that can occur when trying to remove the hardware used for fixation. For example, the bone can break again when trying to pull the pins out.

Dr. Caird uses two case presentations to help illustrate her point that children with clavicular fractures should not be treated in the same way adults with similar fractures would be treated. Both cases were teenagers with high-energy injuries from an all terrain vehicle accident (first case) and collision during ice hockey in the second case. For both of these adolescents, the middle of the clavicle was broken and severely displaced (telescoped and shortened). Surgery was needed for both boys.

In summary, there’s no cookie cutter recipe for the treatment of clavicular fractures in young children and teens. The fact that many of these patients are still growing plays a huge role in the decision about what kind of treatment is best.

Dr. Caird offers some insight into the treatment of clavicular shaft fractures in this population. Physicians do not have a clear set of guidelines to follow when planning treatment. The decision-making process must take into account many factors not present in adults.

You’ve heard it here before: guidelines for treatment of any problem are just that: guidelines. Each and every patient must still be considered individually. Treatment should be customized based on patient factors and surgeon opinion.

In this article on forearm fractures in children, these same principles are applied. The authors provide best-practice ideas for the problem of forearm shaft fractures in children. They offer their opinions as well and point out “operative pearls and pitfalls” when treatment requires surgery.

A forearm shaft fracture is a break in the middle of the two long bones in the forearm (radius and ulna). A simple fracture without displacement (separation of the bones) can be successfully treated with cast immobilization. But displacement and angulation (bones shift and are no longer straight but instead form a V- or angular-shape) may be severe enough to require surgery.

The decision between cast immobilization and surgical reduction and fixation depends on a number of factors. First, there are guidelines for what is acceptable versus unacceptable angulation and displacement. For example, children under the age of nine can still be treated with cast immobilization when there is complete displacement but only up to 15 degrees of angulation and 45 degrees of malrotation.

The guidelines for casting children with forearm shaft fractures who are nine and older are 10 degrees of angulation and 15 degrees of malrotation. The reason children with these changes in alignment can still be treated conservatively (nonoperative care) is that they are still growing and the bones will reform, reshape, and realign on their own.

Surgery to realign (reduce) the bones and hold them together with hardware (fixation) is recommended when it would be difficult to keep the fractured bones lined up and held in place with a simple cast. This is often the case when the bones are in a severe V- or angular position referred to as bayonet apposition. Surgery is also required anytime the fracture site is unstable or an acceptable reduction position cannot be reached.

Making the decision to perform surgery is just the beginning of the process. Now the surgeon must decide whether to use fixation on one or both bones and what type of fixation to use. The two most commonly considered options are a metal plate or a long nail down the shaft of the bone (called intramedullary fixation or IM).

Choice of fixation device goes hand-in-hand with type of procedure: open or closed reduction. As the names suggest, an open reduction means the surgeon makes an incision to open the arm. A closed procedure is done through the skin (percutaneously) or other minimally invasive approach.

Follow-up treatment involves post-operative care selecting either a long or short arm case, length of time in the cast, and if/when to remove the hardware after healing is complete. Removing fixation devices too soon can cause failure to heal and even loss of reduction and reangulation.

Surgeons are encouraged to reduce the bone that is easiest first. If it looks like a toss-up between the two bones, then the straighter bone (the ulna) is reduced first. The authors discuss how and where to insert the nail for best results when intramedullary nailing is the treatment choice.

Failure to gain access down the middle of the bone with the nail is a possibility. Repeated efforts to accomplish the task can result in significant soft tissue damage. At that point, the surgeon should switch to an open reduction procedure.

The authors summarize their comments by saying that using fixation for forearm shaft fractures in children does improve results. Not all children need fixation so the challenge becomes the ability to evaluate each child and make the best decision for that patient. Suggestions and guidelines provided in this article may help when there are complex considerations.

Fractures of the lower leg (tibia) are most often treated with cast immobilization. But when the fracture is unstable and especially if the bone is broken in multiple places, then surgery may be needed. The authors of this article reviewed the published literature looking for information on the surgical treatment of tibial fractures in children. They provide their findings and their own opinions based on clinical experience.

Any bone fracture near a joint in a child raises concerns and issues about growth. Consideration is always given to the effect of the injury and any treatment planned on bone growth. The goal of surgery is to stabilize the bone and maintain good alignment and length.

In the case of tibial shaft fractures (the shaft is the long part of the bone), compartment syndrome is a second very real concern. Compartment syndrome describes a condition in which fluid (swelling or blood) builds up inside one or more of the individual compartments of the leg. Traumatic injuries, especially bone fractures that puncture the soft tissues are a common cause of compartment syndrome.

Surgical treatment usually follows one of two approaches: the use of titanium elastic nails or external circular fixation. Titanium elastic nails are somewhat flexible but sturdy, thin rods that are inserted into the center of the bone to support and align it while healing. The surgeon must be careful when placing the rods not to disrupt the growth plate. The authors provide some details in their recommendations for nail placement that might be of interest to other surgeons using this treatment technique.

External circular fixation is just as the name describes — a metal cage that encircles the lower leg on the outside. Pins placed horizontally from the cage through the leg hold everything together and even allow the child to put weight on the leg. Weight-bearing and walking on the surgical side isn’t advised until X-rays show good alignment and signs of bone healing. This usually takes about three weeks in children and teens.

After surgery, the leg is placed in a splint to help prevent motion at the fracture site and nonunion or malunion. The child is monitored for any postoperative complications, especially compartment syndrome. Pain out of proportion to the injury, pain that isn’t relieved by medications, and increased use of pain medication (e.g., narcotics) are early signs of a potential problem.

Anyone experiencing numbness or partial paralysis must see a physician right away. The surgeon will remove anything from around the leg (cast, splint) and take the pressure off the leg. There isn’t a fool-proof test for compartment syndrome.

Failure to relieve pain by removing external pressure on the leg means surgery is needed. A fasciotomy is done immediately. In this procedure, the surgeon cuts through the fascia or connective tissue around the muscles of the leg forming four distinct compartments. The purpose is to take pressure off the tissues and restore normal circulation to the leg, thus avoiding the need for amputation.

In summary, fractures of the tibial shaft are common injuries among children. Treatment can be straight forward with cast immobilization but the surgeon must evaluate each child and assess for the need to do surgery. Fractures most likely to need surgery are unstable, poorly aligned or separated, open, and/or with many broken pieces.

Nonunion or malunion can still occur even with fixation (hardware such as rods inside the shaft of the bone or an external circular cage). Serial X-rays are needed to see if and how well the fracture(s) is/are healing. Failure to achieve acceptable alignment in an acceptable or reasonable amount of time may result in the child needing serial (multiple) surgeries. The child must be observed carefully throughout the healing time for any signs of compartment syndrome. Failure to treat compartment syndrome immediately can result in loss of circulation to the leg (ischemia with a potential to lose the 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-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. The blood supply eventually returns, and the bone heals.

The primary goal of treatment for Perthes disease is to help the femoral head recover and grow to a normal shape. The closer to normal the femoral head is when growth stops, the better the hip will function in later life. The way that surgeons achieve this goal is using a concept called containment.

Surgery may be needed in some children to realign the hip and achieve containment. Sometimes it is necessary to surgically dislocate the hip during the procedure. Doing so gives the surgeon a better idea of the full extent of hip deformity and the knowledge needed to realign the bones. The question raised in this study was related to the blood supply to the hip after healing took place.

The authors used MRIs of the children’s hips to determine the location and number of blood vessels to the head of the femur (thigh bone). The MRIs were high-resolution contrast-enhanced to show the path of the main artery and artery branches to the femoral neck and head. They compared the results to MRIs of an equal number of very similar children (matched by age and sex) who had developmental hip dysplasia (shallow hip socket causing hip dislocation).

By using MRIs with three-dimensional (3-D) computer reformatting, the surgeons were able to map the blood supply exactly as the blood vessels inserted on the femoral neck. The blood supply to this area of the hip is called the vascular safe zone. Knowing where this vascular safe zone is located allows the surgeon to avoid disrupting it when surgically dislocating the child’s hip.

They found that children with Perthes disease who had surgery to correct the problem had fewer blood vessels compared with children who had a similar surgical procedure for developmental hip dysplasia. Most of the blood vessels in the children with Perthes disease inserted into the femoral neck through a very narrow pathway.

There is a reason this information about number, location, and pathway of blood supply is important in the treatment of children with Legg-Calvé-Perthes disease. The disease is caused by a loss of blood to the weight-bearing portion of the femoral head via the medial femoral circumflex artery and its branches.

How well these children recover depends on the surgeon’s ability to restore the interrupted blood supply to the hip. Operating within the vascular safe zone (and avoiding further disrupting the arteries bringing blood to the femoral head) when performing a surgical dislocation to correct the hip problem is important in preventing additional problems. In conclusion, careful planning is required for this type of reconstructive surgery, including knowing where the vascular safe zone is located.

When it comes to treating hip problems in children, it would be helpful to know what is normal motion and what is not. Other measures of things like grip strength, height, weight, head circumference, and even IQ (intelligence quotient) have normative values. Normative values means you can find a chart with the expected measurements for each of these areas based on age and sex (male and female).

Although we have some general guidelines for range-of-motion measurements in adults, normative values for children of varying ages are not available. Hence this study was done to determine what constitutes normal (versus abnormal) hip motion in normal, healthy children.

The study was done at Children’s Hospital of Philadelphia (CHOP). Hip measurements were taken of children who came to the hospital for treatment of a broken arm. There were no leg injuries or other compromising health conditions. There were 252 children involved in the study (that’s 504 hips to measure).

Measurements were taken in two positions lying down: supine (face up) and prone (face down). Measurements taken in the supine position included flexion, abduction (leg away from the midline), adduction (leg toward the midline), and rotations (internal and external). Extension and rotations were measured from the prone position.

Photos demonstrating the measurement techniques and patient positions were provided. The authors also gave a detailed explanation of the statistical tools used and analysis conducted. A graph showing the range and averages over time for each measured motion was included based on age and sex.

In addition, the authors provided a table with a review of the normative hip motions for adults based on the report of four very well-known researchers in this area (Kendall, Daniels and Worthingham, Hoppenfeld, Mohr).

In general, it appears that hip range-of-motion decreases as children get older. This effect is more obvious in boys than in girls. Differences between boys and girls at different ages are presented but the study was not designed to compare differences based on race (e.g., Whites, Blacks, Hispanics, Asians). That will be something future researchers may address.

The information gathered in this study will help physicians evaluating children for problems such as slipped capital femoral epiphyses (SCFE), synovitis or other inflammatory hip problems, and femoroacetabular impingement. Such diagnoses depend on altered range-of-motion as a primary measure. To really help in the evaluation of all pediatric hip diseases, the additional information about differences based on race will be needed.

Children born with a clubfoot (medical term: equinovarus deformity) often have corrective treatment called the Ponseti Method. The foot is twisted (turned under and towards the other foot). The Ponseti Method involves manipulating (moving) the bones of the foot and ankle toward a neutral position of alignment. The bones are then held in place by a cast.

Each week the cast is removed, the bones are moved again as close to normal as possible and another cast wrapped around the leg to hold everything in place. This weekly treatment continues for about five to six weeks (or until maximum correction possible is achieved).

The reason this approach works is that manipulation stretches the still very flexible joint capsule ligaments, tendons, and muscles in infants and young children. The Ponseti method also corrects the abnormal relationships of the bones in the foot. By aligning the bones where they belong, this treatment even has the potential to reshape the bones so that they fit together as they should.

A corrective brace is worn after the Ponseti treatment is completed. Failure to wear the brace as directed can result in relapse of this condition. In this study, surgeons at the Ponseti Center for Clubfoot Treatment at the University of Iowa focused on what happens to children after age four if and when the child loses correction of the clubfoot deformity.

Thirty-nine (39) children with relapsing clubfoot were included in the study. Some children had both feet affected so the total number of clubfeet was 60. All the children had been treated at this Ponseti center from early on (some as early as three days after birth, others later but before age two). Everyone was prescribed the required abduction brace, which was supposed to be used up until age four.

There were differences in the timing of relapse among the children. Some lost the initial correction early on while others didn’t relapse until much later after treatment. By studying what happened to the children with later relapses, the authors were able to identify some trends that might help guide prevention and treatment for other children affected by this problem in the future.

Treatment for late-relapses also varied and ranged from 1) observation only to 2) bracing, or 3) casting followed by bracing, 4) casting to prepare the feet for surgery followed by surgery then bracing, and 5) surgery. Most of the children (no matter how they were treated for the relapse) ended up having surgery to correct the deformity. The most common surgical procedure was a tendon transfer called TATT for tibialis anterior tendon transfer.

Continued follow-up of these children showed that almost all of them could wear normal shoes. Some of the children were limited in what they could do as they got older because of their feet. Complaints of pain with activity or aching at the end of the day were reported by 44 per cent of the group.

Different patients reported a variety of problems (e.g., inability to walk a full golf course, difficulty jumping or going up and down stairs, being “clumsy,” unable to stand for an eight-hour shift at work). Half of the group still had mild foot deformities that contributed to their functional limitations. A few individuals had further corrective surgery with extended periods of time in braces.

The authors present these findings to help identify the prevalence of late relapse after successful treatment of clubfoot deformities in children using the Ponseti method. Although the Ponseti method seems to be successful early on, children should be followed routinely to recognize early signs of relapse.

We know that relapses don’t recover on their own without intervention. Research is needed to determine the best treatment for late relapses and to identify risk factors for relapse. Currently, poor compliance with abduction bracing is the only known risk factor. Changes in the brace angle and wearing schedule have already been implemented, which may account for th

Occasionally, a child will learn to walk up on toes rather than the more typical heel-toe pattern we are used to seeing. It’s not really something to be concerned about unless it continues as the child gets older. Children who are still toe walking after age two should be evaluated more closely by their pediatrician or perhaps even referred to a specialist such as an orthopedic surgeon.

There are many possible causes for this type of persistent gait (walking) pattern. The list includes muscular dystrophy, cerebral palsy, autism, spina bifida, and even schizophrenia. Other possible causes have been reported such as a general (“global”) developmental delay, leg length difference, or a neurologic disorder known as Charcot-Marie-Tooth disease.

Most of the time, the condition is referred to as idiopathic, in other words: cause unknown. The diagnosis may take some time as the physician examines the child, considers the history, and conducts some specific tests. The calf muscle will be tested for tightness called a contracture. A neurologic exam will be performed.

More advanced testing such as EMGs (electromyography) of the muscles and computerized gait analysis may help identify unusual patterns of muscle activation. In the case of true idiopathic toe walking where there is no neuromuscular or neurologic problem, treatment depends on the age of the child. For example, children who have not reached their second birthday may just be observed carefully. It is possible that over time, the child will start to walk more normally.

After age two, then the condition of the muscles is rechecked. If there is no contracture, the child may be helped by stretching exercises. Casting the leg or wearing a special brace may help as well. When the muscle is contracted and the ankle cannot move past neutral, then surgery to lengthen the muscle may be advised. Surgery may also be required when conservative care with stretching and bracing or casting hasn’t worked.

In summary, although toe walking in young children can be a sign of a true developmental problem, most of the time, it is not. That’s when it’s referred to as idiopathic toe walking. Idiopathic toe walking is just one of those things adults can’t explain and kids outgrow. In cases where it persists past age two, efforts should be made to lengthen the calf muscle. This can be attempted first with a conservative approach with surgery as the backup plan. Children with an underlying neuromuscular or neurologic cause for their toe walking may be treated differently.

Children have remarkable healing abilities but sometimes their fast growth just isn’t enough. That’s the case with large gaps in bone caused by tumor removal or traumatic fractures. To help bridge the gap, surgeons from Spain have developed a special technique called vascularized fibular periosteal graft. This report gives the results of a dozen children who received this treatment.

A fibular periosteal flap is a piece of bone taken from the fibula the smaller bone in the lower leg. A special tool called a periosteal elevator is used to lift the top layer of bone, which is then transferred to the site where it is needed.

The way in which the bone graft is placed in the defect depends on the underlying problem. For example, if a fracture hasn’t healed (called a nonunion), then the periosteal flap is wrapped around the two ends of the bone in a “J” pattern. If the gap is from bone (tumor) removal, then the flap is used to bridge the gap by attaching it from one side to the other.

If the bone is used in the same leg, then blood vessels to the bone can be taken at the same time. This is called a pedicled graft. If the bone graft is used anywhere else, the donor bone is taken without attached blood vessels (called a free flap). With a free flap, the surgeon must perform microsurgery to connect the bone graft to local blood vessels (at the site of placement).

Once the procedure has been completed, the wait begins. In places where the bone is close enough to the surface, it may be possible to palpate or feel the new bone growing. New bone forms a callus (bony knob) that will eventually be remodeled by the body’s own healing processes and become smooth once again.

The callus can often be felt two to three weeks after the bone graft procedure. Otherwise, serial (repeated) X-rays and CT scans can be used to assess results. Special ultrasound Doppler tests were used to monitor blood flow.

Using this new technique, the authors report success in all but one case. In the one case where it didn’t work, the blood vessel attached to the bone graft was twisted so blood was not getting to the graft site. A second surgery to repeat this technique was successful.

Healing time with progressive bone formation ranged between two and nine months. The length of time for bone to fill in the gap depended on the location of the problem (e.g., middle of the bone versus near the growth plate). The final bone union occurred in two stages: first along the outside (periosteal layer) and then the layers underneath forming the cortical (inside) layers.

The authors conclude that this new technique using periosteal bone (with or without blood vessels attached) is an effective way to stimulate fast bone growth in children. It’s not a method that is needed routinely but saved for children with complex bone loss too large to heal completely without some help.

Vascularized fibular periosteal graft is a new reconstructive strategy that works for children because of their unique ability to grow fast. This type of tissue transfer is successful because the bone has strong osteogenic (bone growth) properties and angiogenic (formation of blood vessels) abilities. Both the donor site and the graft site heal quickly and without problems.

Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to an odd and troubling elbow condition. The forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. This condition is called osteochondritis dissecans (OCD).

In the past, this condition was called Little Leaguer’s elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, including gymnastics, weight lifting, and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes.

Elbow OCD affects the articular cartilage in the capitellum. The capitellum is a knob on the end of the humerus (your upper arm bone). The capitellum fits into the cup-shaped end of the radius (one of the two bones in the forearm that connects to the humerus).

The capitellum transmits two-thirds of all compressive forces across the elbow. Throwing athletes with an increased angle at the elbow (called valgus) put even more force and load through the capitellum. Overworked, poorly conditioned, and skeletally immature elbows are at increased risk for this condition.

OCD also affects the layer of bone just below the cartilage, which is called the subchondral bone. In advanced stages of OCD, the upper end of the radius, particularly the head of the radius, is also involved.

When the head of the radius spins on the capitellum, the forearm rotates so that the palm faces up toward the ceiling (supination) or down toward the floor (pronation). The joint also hinges as the elbow bends and straightens. The lesion caused by OCD can cause elbow pain, loss of motion, and even lock the joint and keep it from moving if a loose fragment gets lodged in the joint.

For small defects that don’t involve loose fragments, conservative (nonoperative) care may be successful. The child or teen is advised to modify his or her activity and avoid putting strain and load on the joint. Activity reduction and modification may be required for several months or more.

If this treatment approach isn’t successful or if there is a large lesion with loose fragments, then surgery may be required. The goals of surgery are usually to decrease pain, increase motion, and return the athlete to a preinjury level of activity.

Surgeons have at their disposal several techniques that can be used. The simplest method is called debridement. The surgeon gently shaves away any jagged edges and smooths down the bone. If there are any loose pieces of cartilage or bone, these can be removed during the procedure. Large pieces of bone can be reattached with pins, wires, or screws. The surgeon can also drill tiny holes into the affected area to help stimulate a healing response.

The best surgical approach for this condition has not been identified. That’s where this study comes in. The 13 elbows treated in this study were surgically repaired arthroscopically. Half the group were involved in baseball, one third in gymnastics, and the rest in football. The patients ranged in age from 10 to 15 years old. Each one was evaluated before and after surgery by measuring elbow motion and function.

Imaging studies using X-rays, CT scans, and MRIs helped document the location and severity of the lesion. Not all lesions were the same so treatment varied. There were nine elbows that required drilling and five that needed removal of loose fragments. Only two cases were sufficiently treated with debridement.

Results showed favorable outcomes. The children all experienced pain relief and decreased joint swelling. Elbow motion was improved and locking or catching of the elbow was eliminated for 83 per cent of the group. The remainder reported only occasional locking or catching. Half the group returned to their full preinjury level of activity. Everyone was able to return to their sporting activity at some level. In one case, the child switched to throwing with the other arm.

The authors were satisfied that their treatment was safe and effective with no complications. They agree with other experts who suggest that the best results come with early treatment for this condition. Without some intervention, it will only get worse and can become a chronic degenerative problem. Athletes with osteochondritis dissecans of the elbow may not be able to return to the sport or activity that caused the problem in the first place. They should be warned that this might be the case to avoid any surprises after surgery.

In a small number of children, two bones in the ankle are formed as one without the normal separation between them. The child is born this way but may not know it until later in life when the foot looks flat and ankle pain and deformity interfere with standing and walking.

This condition is referred to as a coalition. The two most common bony coalitions in the ankle are formed by the talus and calcaneus bones (talocalcaneal coalition) and the calcaneus and navicular bones (calcaneonavicular coalition). The condition has been treated in the past with conservative (nonoperative) care (e.g., leg cast) or with surgery to fuse the ankle.

But more modern surgical approaches are now available. And the surgeons who wrote this article offer their insights, expertise, and results performing one of the newer techniques. The specific approach they took was to treat a talocalcaneal coalition in 32 patients (49 total feet).

They describe the surgery designed to remove the bridge of bone between the talus and the calcaneus. Then a piece of fat (taken from the patient’s buttocks or abdomen) was placed in the space left by the resected bone. Fat implantation of this type is referred to as a fat graft interposition.

After the surgical procedure, the children were put immediately into a short leg cast for three weeks. They were allowed to walk on the foot right away as much as they could tolerate. When the cast came off, they used a supportive athletic shoe and began physical therapy right away. The therapist helped them regain motion, strength, and alignment.

Overall results were measured using a test called the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score (AOFAS). The AOFAS provides a way to measure three areas: pain, function, and alignment. Each child was followed for at least one full year. Before and after X-rays and CT scans were also compared.

Only one of the 49 feet was rated “poor” on the AOFAS. The majority (85 per cent) had good-to-excellent results. Ankle range-of-motion and mobility were much better for 92 per cent of the group. One fourth of the group did require additional surgery to further correct ankle alignment. In a small number of cases (two patients), the first surgery was considered a failure and a second (revision) surgery was needed to repeat the procedure.

Comparing these results to other studies where patients’ ankles were fused, the authors point out that this bone resection and fat graft implantation is just as successful (if not more so) than the fusion. The hope is that long-term studies will show less arthritis from this condition (a typical response to the ankle fusion). These patients will continue to be followed to see if results hold or if there is a gradual but steady decline in function and alignment over time.

The authors make note of one final consideration. They suggest that the group of patients who required additional surgery to further correct hindfoot deformities may have two separate conditions: the talocalcaneal coalition discussed and the hindfoot deformity referred to as hindfoot valgus.

Children and their families (as well as older patients who have this surgery later in life) should be advised that the bone resection and fat implantation may be just part one of a two-stage procedure. Further study is also needed to determine whether or not fat implantation is even necessary. At least one study has been done without this step and patients had equally good mid-term results after five years. Long-term studies are needed to compare this bone resection procedure with and without fat implantation.

In summary, current views on talocalcaneal coalitions suggest the need for early surgery to relieve pain, improve alignment, and restore full function of the foot and ankle. Surgical fusion may be replaced by this new technique of bone resection and fat graft implantation. With this approach, patients with talocalcaneal coalitions may be spared early arthritic changes in the ankle. More studies are needed in this area to provide surgeons with evidence-based guidelines for the condition of ankle bone coalition.

One of the most common elbow fractures in children occurs at the bottom of the humerus (upper arm bone). It is called a supracondylar humerus fracture. Efforts to find the best way to treat this type of fracture are underway. The best evidence from current studies was used to write 14 recommendations referred to as clinical practice guidelines (CPGs). This article is a summary of those guidelines.

The idea behind forming clinical practice guidelines for any condition is to improve treatment and give physicians a way to identify the best treatment for each patient. Sometimes that means taking into consideration the child/family’s needs and desires. In other cases, individual factors such as the child’s general health, type of fracture, and severity of injury must be taken into consideration when making a treatment decision.

The various treatment options include conservative (nonoperative) care or surgery. Conservative care consists of immobilization of the arm in a cast or splint. This is called a closed reduction. Surgery is more complex and may involve fixation hardware such as metal plates, pins, screws, or wires. These fixation devices are used to hold everything together until healing takes place. When surgery includes an open incision and fixation, the procedure is referred to as an open reduction and internal fixation (ORIF).

The first clinical decision becomes whether to recommend conservative care or surgery. The clinical practice guidelines provide criteria for selecting one treatment approach over another. When surgery is the necessary choice, research is being done to determine what type of surgery should be done, what type of fixation, and the direction of the fixation.

Then the decision must be made whether and when to remove the hardware after fracture healing. Should the child have physical therapy? When can the child return to full activities (especially sports activities)? Timing of each step in the rehab progress may be as important as the type of treatment provided. Here’s a brief summary of the main points of the 14 clinical practice guidelines:

Trigger finger and trigger thumb are conditions affecting the movement of the tendons as they bend the fingers or thumb toward the palm of the hand. This movement is called flexion. Trigger thumb is much more common than trigger finger among babies and young children.

There are some similarities in this condition as it presents in children versus adults. But for the most part pediatric trigger thumb and/or trigger finger are not the same as adults and should not be treated the same. An understanding of the basic problem may help explain these differences.

In both children and adults, the tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone.

To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects.

Triggering is usually the result of a thickening in the tendon that forms a nodule, or knob. The pulley ligament may thicken as well. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule.

In children, trigger thumb or finger is an acquired (not congenital or present at birth) condition. In other words, the child isn’t born this way but instead, develops the condition early on. A common anatomic cause of trigger thumb is a mismatch in the size of the flexor tendon and the pulley.

Trigger thumb or finger in children is not from overuse, trauma, or injury (those are more common causes in adults). And in children, the thumb is more likely to be fixed or stuck in what is referred to as a flexion contracture rather than a true triggering mechanism. Flexion contracture means the child cannot actively (or sometimes cannot even passively) straighten the thumb.

No one really knows the reason why some children develop these triggering digits. There are plenty of theories but no actual scientific evidence to explain it. Likewise, little is known about the natural history of trigger thumbs/fingers.

Natural history refers to what happens over time without treatment. As with many other orthopedic problems in children, there are a significant number of children who experience a gradual healing or resolution of the condition. This type of spontaneous recovery takes up to two years and is unpredictable. In other words, there’s no way to tell which children will “grow out of it.”

The majority of children do not grow out of it and require surgery to remove the nodule holding the tendon back, to release the stuck pulley mechanism, or to cut the tendon or lining around the tendon. This last treatment technique is used when the tendon isn’t gliding inside the tendon sheath like it should. Most of these surgeries are done with an open incision.

Surgery isn’t always successful. There can be serious complications such as infection or failure of the wound to heal. The triggering can even come back. There may be no apparent reason for the recurrence of this condition but sometimes it’s because the surgeon has failed to release enough of the flexor tendon sheath. Sometimes there is a failure to recognize the need for more than one procedure (release pulley AND divide the tendon) and that’s why the problem comes back.

Overall treatment recommendations are as follows:

One hundred years ago, three physicians (Drs. Legg, Calvé, and Perthes) reported on a bone condition in children’s hips they named after themselves: Legg-Calvé-Perthes disease (Pethes for short). Perthes is caused by a spontaneous loss of blood to the femoral head (round ball of bone at the top of the thigh bone). Necrosis (bone death), then collapse of the hip, and early arthritis are the natural results of this condition.

Since that time, there have been ongoing efforts to understand the cause(s) of this disease and find ways to treat it successfully. In the last few years, there has been some breakthrough in research on animals that might help humans.

In this article, Dr. Harry K. W. Kim, a well-known orthopedic surgeon and expert in the treatment of this condition, brings us up-to-date on current concepts and treatment of Legg-Calvé-Perthes disease. An important feature of this new information is the results of treatment for different age groups.

Until recently, all treatment (operative and nonoperative) was focused on a concept called hip modeling. The goal of treatment has been to mold the femoral head back into a round (spherical) shape and keep it in the hip socket (acetabulum). According to several large studies, the results of this approach have been only “modestly successful.”

Less than half the children treated for Pethes disease end up with a spherical, well-contained femoral head. And no one has been able to identify why some children respond to treatment while others do not. Some experts think there is a need to work more with the cause of the problem (loss of blood to the hip, impaired healing, altered biology) rather than just the effects of the disease (femoral head necrosis, deformity, and collapse).

Dr. Kim reviews current theories regarding the pathogenesis of Perthes disease. Most of the newer information comes from experimental studies on pigs and dogs. It’s looking more and more like a complex problem with multiple causal factors — not just one effect.

The new theories include ischemic injury leading to changes in the mechanical properties of the articular (joint) cartilage, change in mineral content of the bone, disruption of the growth plate, and an impaired repair process.

And with this new understanding comes an effort to rethink our current treatment approaches. For example, it is believed that putting load on the deformed hip will make the problem worse. So sometimes are restricted from weight-bearing activities in order to reduce the load on the hip. But whether or not this treatment strategy really makes a difference is unknown.

Another new approach is the use of antiresorptive therapy to combat the excess bone resorption. Medications known as bisphosphonates are being used in investigational (animal) studies. These drugs inhibit or prevent bone cells from being broken down. The optimal type of drug (local injection versus systemic application), amount of drug (dosage), timing of drug use (based on child’s age), and duration of drug therapy remain to be determined.

A third therapeutic option is called bone anabolic therapy. With this type of treatment, bone stimulating proteins called bone morphogenetic protein (BMP2) are used to speed up bone growth. The substance is injected into the hip to improve bone healing and preserve the round shape of the femoral head.

Studies using BMP2 for Perthes have all been done on animals with no studies on children yet. Long-term results and safety issues must be explored first before children could receive these new, as yet still experimental treatments.

But as Dr. Kim points out, improved understanding of the pathogenesis of this condition is starting to open doors. New avenues for research centered on pathologic-based rather than symptom-based treatment are being explored. The hope is to find some way to prevent Perthes from developing in the first place. A second goal is to treat the condition quickly and successfully when it does occur, thus preventing some of the long-term effects today’s generation with Perthes will suffer later in life.

It’s likely that you have heard of “staph infections” referring to infections caused by the bacteria known as staphylococcus aurous. In recent years, this bacterium has become resistant to antibiotics traditionally used to treat the problem. And the number of cases in children has risen at the same time. This study is an attempt to identify how often and why this is happening among children and young teens with hand infections.

The term Methicillin-resistant Staphylococcus aureus (MRSA) has been adopted to indicate the bacteria is resistant to a number of antibiotics including penicillin, methicillin, and cephalosporins. The bacteria have mutated (changed) so they are no longer able to be damaged or disabled by these previously effective medications.

MRSA is very powerful and can cause a large number of serious illnesses that do not respond well to current medical treatment. MRSA was initially hospital-acquired — in other words patients developed MRSA infections when they went to the hospital to be treated for something else. But over time, community-acquired MRSA (known as CA-MRSA) developed. CA-MRSA is defined as MRSA that occurs outside the hospital setting.

How many children are affected by CA-MRSA and why? This study attempts to get to the bottom of those questions. The researchers reviewed their records for 10 years (2001-2010) and pulled the medical charts of any patient 0 to 14 years old who presented with hand infections at their hospital.

By studying the information about each case, they were able to see some patterns that might be helpful in better understanding CA-MRSA in children. Overall incidence of CA-MRSA in the group was 25 per cent. That means one in every four children admitted to the hospital for a skin infection already had CA-MRSA before even coming to the hospital. This is much higher than the recommended rate of no higher than 10 to 15 per cent set by the Centers for Disease Control and Prevention (CDC).

Data collected from hospital charts included patient age, medical problems, treatment for the hand infection, and number of days in the hospital. Of course the infection was cultured (sent to the lab) to identify the specific type of bacteria present. The lab tests are able to test the microorganisms and determine which antibiotics will work.

By analyzing the children’s charts, they were able to identify risk factors — variables that put the children at increased risk for developing CA-MRSA. Instead of the typical risk factors reported for adults (e.g., older age, poor health, abscess drainage in a surgical setting, history of trauma, previous history or MRSA), they found children had a different set of risk factors.

For the children in this study, low income living conditions, poor personal hygiene, and crowded settings with close personal contact were the main risk factors. The presence of an abscess that needed surgical draining was an additional risk factor. The deeper the abscess, the greater the chances the child had a positive case of CA-MRSA.

Of course, the question comes up: what can be done about this alarming rise in CA-MRSA among children and young teens? The authors outline their recommendations as follows:

Orthopedic Surgeons from Children’s Hospital in Boston (associated with Harvard Medical School) offer some important modifications to a classification system used to rate the seriousness of pelvic fractures in children. They say their proposed changes can potentially save children’s lives, reduce blood loss, and reduce the number of days children with these types of injuries are in the hospital.

Pelvic fractures are serious business because they often come with major trauma from either a car or pedestrian accident. In many cases, there are other injuries as well affecting the head, face, arms, legs, and/or spine. And when the bones of the pelvis are broken, the soft tissues and organs in the belly and pelvis are left unprotected. In up to five per cent of these injuries, the child dies.

So you can see there is a need to quickly identify anyone at risk for blood loss or mortality (death). These surgeons took the traditionally used Torode classification scheme and tweaked it just a bit. This classification method uses X-rays to identify the specific area(s) of the pelvic bones that are broken, the type of fracture, and the severity of the injury.

Torode fractures are placed in one of four groups labeled I, II, III, or IV. As you might guess, Type I are the least serious injuries and Type IV the most serious. Type IV fractures are considered unstable and include disruption of the pelvic anatomy, hip dislocations, and/or more than one fracture affecting the pelvis and hip.

The modified groups break down Type III into Type IIIA and Type IIIB. This separation helps to identify fractures that are more like Type II (labeled Type IIIA) or more like Type IV (labeled Type IIIB). This distinction is helpful because it tells the surgeon that children with Type IIIB are more serious, more likely to need a blood transfusion, and more likely to need a longer hospital stay.

The authors include a drawing to help us understand the classification categories. Torode I and II pelvic fractures are avulsion (piece of bone breaks off) somewhere along the pelvic crest. With a Type I fracture, a separation occurs in the growth plate, which is still cartilaginous. Type I is much smaller in size than Type II.

Type III fractures affect the lower portion of the pelvis that bear our weight when we sit down. The symphysis pubis (where the two pelvic bones meet in the front of the body) may be involved. This part of the pelvis helps form a bony ring and pelvic “bowl” that support the bladder. The new Type III A/B designation gives an A if just the front or anterior portion of the ring is broken. Type IIIB indicates both the front (anterior) and back (posterior) portions of the ring are fractured.

The drawing of a Type IV fracture shows multiple different locations for pelvic bone fractures. All involve complete disruption of the bone, nearby joints, and/or the hip (dislocation).

To elaborate just a bit more on the modifications made to the traditional Torode classifications, Type III pelvic fractures are stable but the B subgroup are more involved injuries. They require more attention early on after the accident.

For example, children with Type IIIB pelvic fractures are two and a half times more likely to hemorrhage internally and need a blood transfusion. They are also much more likely to have additional injuries. They are twice as likely to need hospitalization compared with the Type IIIA group.

The authors conclude by pointing out that high-energy traumatic injuries to the pelvis resulting in pelvic fractures are potentially very serious and require careful evaluation. The modified Torode classification system they developed and tested can help predict children who will need close management and early intervention. Often, the nature of the other injuries (e.g., head trauma) leaves the pelvis for later treatment but the risk of internal bleeding that can lead to death must be recognized and treated immediately.