News Category: Child

Children often fall and break their arms. The forearm with its two bones (radius and ulna) is one of the most common childhood fractures. Most of the time these types of breaks are clean and simple. The physician can line the bones back up without surgery.

The child wears a splint or cast for four to six weeks while the bone remodels and heals. And quite honestly, if the child has not yet completed his or her full growth and has not yet reached skeletal maturity, the bone does a remarkable job healing and even restoring normal anatomy.

But there are those cases we call bad actors: problematic forearm fractures that require recognition and special treatment. In the simplest of cases, the bones are displaced (separated). There may be a hidden dislocation along with the fracture that doesn’t show up on a plain X-ray.

Or there could be a fracture with bone rotation so the ends no longer line up as they should. Putting the arm in a cast without realigning the bones could result in permanent loss of wrist and forearm motion. Sometimes one or both of the bones break and leave the bone at an angle. This type of deformity won’t realign on its own. To add to that list, there could be cases where the forearm fracture affects the alignment of the elbow.

To address these “bad actors,” Dr. Dan A. Zlotolow, orthopedic surgeon from Children’s Hospital in Philadelphia, Pennsylvania offers some treatment guidelines. First, he reviews the potential mechanisms of injury stating that the surgeon must make every effort to identify the type of fracture and any other associated soft tissue or joint injury. It is especially important to look for damage to the ligaments, blood vessels, and/or nerves. Complete diagnosis may require additional imaging using computed tomography scans (CTs) or magnetic resonance imaging (MRI).

The child’s age makes a big difference in planning treatment. Children up to age eight will have the capacity to heal, repair, and remodel angular deformities of the bones up to 15 degrees. X-rays will help determine the skeletal age of maturity and show how much more growth is left. If the child is within a year or two of full skeletal maturity, then he or she should be treated as an adult.

Closed reduction (realignment without surgery) is acceptable for many of the younger children. But open reduction with internal fixation (ORIF) is often required when the “bad actor” shows up with any of the complications described. A flexible titanium rod may be placed down through the length of the fractured bone. Metal plates and/or stainless steel pins may be used until union occurs.

And here’s an important tip from Dr. Zlotolow: the surgeon must make sure the child has full forearm rotation before considering the case closed. It’s all too easy for a child with limited forearm movement to make up the loss by compensating with the wrist and shoulder. The loss of forearm rotation (palm up and palm down) may not be evident until years later when they start to participate in sports and can’t move as needed.

Corrective surgery may be needed if the desired range-of-motion has not been achieved within the first year after fracture treatment. Even with surgery, there is a risk that with soft tissue scarring and shortening, full motion won’t be possible with corrective surgery.

In summary, surgeons treating children with forearm fractures must be vigilant in watching for complications that can leave the child with permanent deformities or loss of motion. Careful evaluation at the time of the injury AND close observation during healing, recovery, and follow-up are essential to recognize fractures referred to as “bad actors.” Elbow joint instability (due to ligamentous damage or dislocation), malunion, and excess bone angulation require special surgical management.

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:

In this study, surgeons from Turkey ask the question: is the level of surgeon experience linked to decisions made regarding second surgeries for hip dysplasia in children? In other words, are the more experienced surgeons more (or less) likely to perform a second procedure in children with this problem? Or is it the less experienced surgeons who opt for second surgeries. Let’s see why that question is important and what they found out.

First, a little bit of background information about developmental dysplasia of the hip or DDH. This condition used to be known as congenital hip dysplasia. The change in name reflects the fact that DDH is a developmental process that occurs over time. It develops either in utero (in the uterus) or during the first year of life. It may or may not be present at birth.

In this condition there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). DDH can affect one or both hips. It can be mild to severe. In mild cases called unstable hip dysplasia, the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called a subluxation.

Most of the acetabulum is cartilage at birth. The right amount of pressure and contact between the surfaces of these two parts helps make sure the hip joint develops normally. The head of the femur inside the acetabulum helps shape the joint as it continues to form. In DDH the usual contact between the femoral head and the acetabulum is disrupted. An abnormal position of the femoral head can result in a dysplastic hip. Sometimes the acetabulum is too shallow or sloping rather than a normal cup shape. It cannot hold the femoral head in place.

If the problem is not diagnosed and treated early, the soft tissues around the hip start to stretch out. There can be changes in the blood supply to the hip. Surgery to reshape the hip socket and reposition the head of the femur in the socket is usually done early in the child’s life. For some children, that is all that is needed. They develop normally and achieve skeletal maturity (full bone growth) without further problems.

But for others, avascular necrosis (AVN) (loss of blood to the hip) develops. Other problems that can occur over time include recurrence of the dysplasia, subluxation, or redislocation. These kinds of problems tend to show up when children are between the ages of five and eight. The challenge becomes identifying when a child needs a second surgery to maintain good hip alignment and when it is a watch-and-wait situation because the problem can correct itself over time.

Looking back over cases when the children are grown and skeletally mature and evaluating the results is one way to study this problem. Evaluating individual risk factors (e.g., surgeon experience) in making the decision helps identify ways to improve results.

There were 17 children with DDH in the study with a total of 21 hips surgically corrected before the age of 18 months. None of the children had a second surgery. All reached skeletal maturity with only the first corrective surgery. Twenty independent surgeons (they had nothing to do with treating these children) conducted the evaluation. They reviewed patient records and X-rays including mid-term and final outcomes. They compared the results against the level of the surgeons’ experience who made the mid-term decision whether the child needed a second surgery or not.

They found there was a 12 per cent risk that hips would need a second surgery that in fact turned out to be normal at the end of the growth cycle. If surgery had been done, it would have been unnecessary. Performing a second surgery was not needed in this group — even when it looked like it might be necessary during that five to eight year old age span. There was also a 40 per cent chance that surgery would not be performed on a group who should have a second surgery. This group would go on to develop hip dysplasia by the time the bones matured fully.

Although more experienced surgeons are less likely to perform surgery (and more likely to recommend conservative care), the level of surgeon experience was not linked to the decisions made in these 17 cases (21 hips).

Surgeons do not make decisions about second surgeries for hip dysplasia without specific reasons. X-ray findings of hip angle, slope of the hip socket, and the amount of femoral head covered by the acetabulum (socket) are just some of the factors taken into consideration when making the decision about a second surgery. Knowing that the top of the femur stops growing around age 10 but the acetabulum (socket) continues to develop until the child reaches full skeletal maturity also weighs in on the decision.

Surgeons know that if the head of the femur remains spherical in shape (nice and round) and stays firmly inside the hip socket by age eight, it is likely that the child will have normal hip development when fully grown. But they also know that a child can look good on X-ray at that mid-term check up and still develop hip dysplasia during their teen years. Again, that’s because changes can occur in the growth and shape of the acetabulum right up until skeletal maturity.

The surgeons who conducted this study offer their opinion on this decision dilemma. They say it is better to delay the second surgery when there is no sign of blood loss or hip instability at the mid-term point. There is no way to tell with 100 per cent accuracy from the X-rays whether this is the right decision or not.

The most challenging cases are those that have X-ray changes close to abnormal but still within “normal range.” There is general agreement from studies and from consensus of surgeons based on experience that the acetabular index angle or AIA (as seen on X-rays) is the most reliable guideline at this time.

The authors conclude that this was a study with a small number of hips involved. More study is needed to clearly identify ways to predict the need for a second surgery during the mid-term developmental stage (ages five to eight). Further study may be able to pinpoint predictive factors of prognosis to help guide surgeons’ decisions about second surgeries for children with developmental dysplasia of the hip.

Here in the United States, a club foot deformity (known as congenital talipes equinovarus) in a baby or young child is treated quite successfully. A special treatment technique called the Ponsetti method is used with good to excellent results.

But in Third World or developing countries, such foot deformities may not be treated at all or inadequately treated. The result is a rigid, deformed foot and ankle. Often these children cannot walk, squat, or even wear shoes to protect their feet.

In this report, surgeons from Abu Dhabi capital city of the United Arab Emirates (UAE) on the Persian Gulf describe their attempts to correct this neglected foot deformity in nine children over the age of six. They treated a total of 11 feet using a combination of staged surgeries, traction, and a device called the Taylor spatial frame (TSF). They report that these rigid foot deformities in older children can be safely and successfully corrected with this treatment approach.

Before planning the surgery, a complete assessment of each child was done. The foot was examined carefully to look for flexibility and correctibility. Tendons and ligaments were evaluated for shortening or contractures (fixed and unable to stretch or move). X-rays, CT scans, and MRIs were examined to look for bone or joint fusions.

Each of the children in this study was able to walk but that actually contributed to the problem. By putting weight on the deformed feet, further malformations developed along with callouses and injuries. All of these factors were taken into consideration when planning each step of the corrective surgeries.

Surgical procedures performed included soft tissue releases of contracted ligaments, tendon lengthening, tendon transfers, bone osteotomies, and limb lengthening. The authors provided before and after photos for some of the children to help show the benefits of the treatment with surgery, traction, and the Taylor spatial frame.

For most of the children, it was necessary to make corrections carefully by using slow, gradual, steady traction to provide an additional three-dimensional force. A special computer program calculated exactly how much force could be applied to the foot following surgery. The Taylor spatial frame made it possible to start with just 30 per cent surgical correction of the bones. By providing a slow change rather than a sudden shift in anatomical alignment, damage could be avoided to the nerves and blood vessels in the area.

After surgery and one week of traction, the lower leg was kept in the Taylor spatial frame. That made it possible to avoid using a lower leg cast, thus maintaining good blood circulation and nerve function that was easy to monitor.

Some children could go home with their families and continue the treatment under adult supervision. For other children, a six-week hospital stay was required to complete treatment in the frame. The children were allowed to walk wearing the Taylor frame. When the foot and ankle were fully realigned, the child was transferred from the frame into a lower leg (walking) cast for an additional month. The cast was designed to help maintain the improved alignment.

The surgeons summarize this report by saying that it is possible to salvage rigid foot deformities from untreated or poorly treated (severe) clubfoot. The three-prong approach they shared with staged-surgeries, traction, and the use of the Taylor spatial frame is a safe and effective way to treat fixed foot deformities in children over the age of six. The Taylor frame is an essential key in making the anatomic corrections slowly enough to avoid problems while restoring limb length.

Young children in good health are known to heal quickly. This is generally true for many conditions from bug bites to bone fractures. Some bone fractures can be complicated by infection or joint dislocation. Forearm fractures affecting both bones in the forearm (the radius and the ulna) can present some unique problems. A delay in union is one of those complications presented in this article.

Orthopedic surgeons from the University of Zaragoza in Spain reviewed over 400 cases of both-bone forearm fractures treated in their hospital. About three per cent (14 cases) were associated with delayed bone union. The question is why? Why are there some children who experience a very slow recovery and healing time?

Surgeons explore questions like this in hopes of finding ways to predict (and prevent) such problems. Most children show X-ray evidence of a healing bone formation called a callus at the fracture site four weeks after the injury. Complete healing is often present by the end of eight weeks. Failure to callus formation or healing at the fracture site by 11 weeks is a signal that there is a delay in bone union.

What are the contributing factors to this problem? In particular, why does delay in healing occur when there aren’t other risk factors (e.g., infection, surgery, dislocation, multiple bone fragments) for delayed healing? The authors suspected there were other predictive risk factors but didn’t know for sure what those factors were.

By comparing the children with delayed union to children with the same type of forearm fractures, they were able to isolate some additional contributing risk factors. For example, older children (10 years old or older) were more likely to need more time for healing.

Surgery to correct the problem was also a significant risk factor. In fact, open reduction was the strongest predictor of delays in healing forearm fractures. Open reduction means that an incision is made and the bones are realigned. Then the bones are held in place with hardware such as a metal plate, screws, and/or pins.

Further observation of the nonunion group of children showed that all but one did eventually heal fully. That one case involved a second surgery with eventual healing as well. All children in the delayed union group had unstable fractures requiring open surgery. Children with stable fractures who were treated conservatively with a forearm cast were much less likely to develop delayed bone union.

The question was also raised as to whether or not keeping the hardware in a long time is also a risk factor for delayed union. There is no set time for hardware removal in these cases. Sometimes the plates, screws, or pens are removed within seven weeks of the injury. In other cases, it’s a full year before the hardware is taken out.

After analyzing all the data carefully, the authors concluded that the single biggest predictive factor of delayed fracture healing when both bones in the forearm are involved is open reduction surgery. For this reason, they recommend closed reduction for both-bone forearm fractures in children whenever possible. There is less risk of damage to the periosteum (outer covering of bone) and/or blood vessels in the area. Disruption of either of these anatomic features could contribute to the delayed healing observed with open reduction.

The forceful and repeated actions of sports can strain the immature surface of the knee joint in children and teens. 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. When this condition occurs in this age group, it is called juvenile osteochondritis dissecans (JOCD).

JOCD can also occur in children and adolescents with no known cause. The condition can be stable and without symptoms but more often there is knee pain and/or tenderness around the joint. Mild swelling may be present but more often than not, there is no swelling. With stable lesions, motion is normal. Loss of knee motion is more common with unstable lesions.

An OCD lesion is unstable when a piece of cartilage or cartilage and bone breaks loose and is free to float around inside the joint. How does this happen? The articular (joint surface) cartilage in children is newly formed. It can’t handle the type of forces placed on it with repetitive activity.

The subchondral bone (under the articular cartilage) takes the brunt of the stress. A portion of the bone may eventually weaken, and possibly even crack. When the bone is damaged, the tiny blood supply going to the area is somehow blocked. Without blood supply, the small area of bone dies. This type of cell death is called avascular necrosis. (Avascular means without blood, and necrosis means death).

The crack may begin to separate. Eventually, the small piece of dead bone may break loose. This produces a separation between the articular cartilage and the subchondral bone, which is the condition called OCD. If the dead piece of bone comes completely detached, it becomes a loose body that is free to float around inside the joint. And that is how an OCD lesion becomes unstable.

In the absence of a specific injury, the child may at first feel bothersome knee discomfort only while playing sports or during physical activity. The soreness generally goes away quickly when the leg is rested. Over time, however, the joint pain worsens, is hard to pinpoint, and may linger after using the leg. The knee may feel stiff, and it may not completely straighten out.

In advanced (unstable) cases of OCD, the patient may notice that the joint grinds (called crepitus). The knee may catch, or even lock up occasionally. These sensations may mean that a loose body is floating around inside the joint. The joint may also feel warm and swollen, and the muscles around the knee may appear to have shrunk (atrophied).

Studies show that the best way to get a good look at the condition of the joint surface and cartilage is to do an MRI. X-rays may look normal early in the condition when there is, in fact, a real problem. As the condition worsens, the X-ray image shows changes in the bone and joint.

The normal shape of the bony knob at the end of the femur (thigh bone) called the femoral condyle may appear irregular. In bad cases of knee juvenile OCD, the condyle might even look like it has flattened out, suggesting that the bone has collapsed. The X-ray could show a crack in the bone or even a loose body.

A magnetic resonance imaging (MRI) scan may show more detail. The MRI can give an idea of the size of the affected area. It can show bone irregularities and also help detect swelling. Doctors may repeat the MRI test at various times to see if the area is healing. MRIs are also very helpful when considering and/or planning surgery. That’s where this study comes in.

The authors examined 132 juvenile OCD lesions using MRIs and then compared the results to their actual findings on arthroscopic examination. In this way, they could judge the accuracy of MRIs when diagnosing and evaluating this condition. This information is important because it provides surgeons with the predictive value of MRI regarding the stability of JOCD lesions.

What they found is that MRIs are “reliably sensitive” to articular (joint) surface lesions associated with juvenile osteochondritis dissecans (JOCD). This is especially true for low-grade, stable lesions. More severe unstable lesions are less likely to show up on MRIs, especially if they are located in unusual areas of the joint (e.g., the nonweight-bearing surface of the lateral femoral condyle). The lateral condyle is the round bottom of the femur that forms the top portion of the knee joint. Lateral means it occurs on the side away from the other leg. The medial femoral condyle is on the side closest to the other knee.

For surgeons who need the statistical specifics on sensitivity, specificity, and predictive values, here is the breakdown:

The lives of children and teens with a condition known as spondylolisthesis can be negatively affected by the consequences of this problem. According to this study from Canada, spondylolisthesis in teens lowers their physical quality of life. They have back pain, tight hamstrings, and neurologic symptoms. The greater the angle of the lumbar vertebra on the sacrum, the higher the grade of spondylolisthesis and the lower the physical quality of life.

Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful.

Any of the vertebrae can slip forward but in young people (under 20 years old), spondylolisthesis usually involves slippage of the fifth lumbar vertebra over the top of the sacrum. There are several reasons for this.

First, the connection of L5 and the sacrum forms an angle that is tilted slightly forward, mainly because the top of the sacrum slopes forward. This angle is referred to as the lumbosacral kyphosis or LSK. Second, the slight inward curve of the lumbar spine creates an additional forward tilt where L5 meets the sacrum. Finally, gravity attempts to pull L5 in a forward direction. All three of these bony alignments can be measured using X-rays.

In this study, 96 adolescents (teens) with spondylolisthesis were X-rayed using a digital radiographic system. Then they were given an opportunity to answer some questions in order to measure their physical quality of life. The slip angle, the lumbosacral angle, and the lumbosacral joint angle were all calculated using the X-rays. All X-rays were taken with the patients standing in a comfortable upright position.

Then scores from the health questionnaires were compared to each radiograph. They found a definite link between lumbosacral angles and quality of life. High-grade slippage (defined as more than 50 per cent of the vertebral body is slipped forward over the vertebra underneath it) was significantly linked with low quality of life.

The results of this study point out clearly (for the first time) how much a lumbosacral kyphosis impacts the lives of affected teens. The less contact there is between the surface of the L5 vertebra and the sacrum (S1), the greater the chances that individual will have changes the body can no longer compensate for.

For example, not only do the bones shift forward but when they shift that far forward, they can start to twist or rotate. This altered alignment can put increased pressure on the spinal nerves as they leave the spinal cord. The end-result can be severe deformity and neurologic impairment.

Physicians treating adolescents with spondylolisthesis are advised to routinely assess each child for the presence (and severity) of lumbosacral kyphosis. The three angles visible on radiographs are an important feature when determining the best plan of treatment for that patient.

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

If untreated this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. Surgery is usually necessary to stabilize the hip and prevent the situation from getting worse.

The earlier the diagnosis is made, the more effective the treatment. Studies have shown that the more severe the slip, the more likely there will be problems later in life. In general, the most common problem later in life is the development of arthritis in the hip joint.

The type of arthritis that develops in the hip is osteoarthritis (also known as wear-and-tear arthritis). This complication can occur even after surgery so surgeons must keep a close eye on these children as they grow into adults. Further surgery may be needed to improve alignment and prevent osteoarthritis.

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

Surgery to correct SCFE changes the shape, position, and angle of the proximal (upper end) femur. With minimal remodeling of the hip, there can be a larger angle called the alpha angle. And the larger the alpha-angle, the greater the chance of impingement occurring.

One way to monitor patients for impingement and the beginnings of osteoarthritis is by imaging studies such as X-rays and CT scans. But there’s another way that doesn’t involve the cost of imaging or exposure to X-rays. A clinical test can be done by an examiner looking for a positive Drehmann Sign. As you might guess, Drehmann sign was named after the physician who first described it back in 1903.

With the patient lying supine (on his or her back), the examiner bends the patient’s leg up toward the belly button. If the leg automatically rotates outward (external rotation) and moves away from the body (abduction), there is a positive Drehmann sign. These are the movements the body makes in order to avoid hip impingement.

In order to confirm the relationship between Drehmann sign and impingement, Japanese surgeons looked at X-rays of 92 hips with SCFE. They compared the number of patients who had femoroacetabular impingement as seen on X-rays with the number who also had a positive Drehmann’s sign.

They found a direct relationship between a larger alpha-angle, Drehmann’s sign, and impingement. Patients with a positive Drehmann’s were also more likely to report hip pain and a limp when walking. Patients with a negative Drehmann’s sign never experienced either one of these symptoms. This is helpful information because femoroacetabular impingement doesn’t show up very well on X-rays. A positive Drehmann’s sign is direct confirmation of impingement.

On the basis of these findings, the authors make the following recommendation. Drehmann’s sign should be tested after surgery to correct slipped capital femoral epiphysis (SCFE). Even a mildly positive sign is an indication of hip impingement that should be treated. Eliminating impingement will help prevent the development of osteoarthritis later.

If you were to ask how many children are experiencing ongoing (chronic) pain on this day (or during a particular period of time) across the country, you would have determined the prevalence rate. That’s what this study does for pain in children and adolescents.

Understanding persistent, recurrent (chronic) pain in children and teens is important. Symptoms of this type can cause them to miss school, become withdrawn and/or depressed, and even develop more symptoms or problems.

If risk factors or causative factors can be identified, it might be possible to either prevent chronic pain from developing or stop acute pain from turning into chronic, lingering pain. And this information might help us better understand what causes chronic pain in adults. Does it begin earlier in childhood or adolescence?

Because of the difficulty of calling up every family in the nation to find out who is in pain and who isn’t, a systematic review was performed instead. A systematic review refers to a search (and analysis) of all published studies on this topic.

Using predetermined criteria for what would qualify as a high-quality, appropriate study, the researchers sorted through 185 published papers from around the world. They ended up with 41 that could be included. The difference in the number of studies available and the number included gives you some idea of how many studies don’t meet quality standards. That’s a problem in itself.

Looking at the studies that are available, here’s what they found. The first thing they noticed was the wide range of prevalence reported. For example, studies of headache in children showed a range from 23 to 51 per cent. That broad of a range was also reported for stomach pain, back pain, musculoskeletal pain, and pain from other sources (including multiple pains).

How do we explain these differences in prevalence? The first factor discussed was the studies themselves. Not every research study defines pain the same way so children may be included in one study in the chronic pain group where they might not be included in other studies. That’s what is called a design feature of studies that makes it difficult to compare one study to another.

What factors are linked with chronic pain? The data was analyzed to see if age, sex (male versus female), socioeconomic or psychosocial factors made a difference. In fact, they found that pain was more often reported in girls (in all countries) and in older children/teens. Children in families with lower socioeconomic circumstances were also more likely to report chronic pain. Headache pain was the top of the list for this group.

Let’s take a closer look at the data on headache. Tension headaches were reported much more often than migraines with an obvious increase starting in second grade. Children in families with low levels of education and children who attend daycare are more likely to develop headaches. There is a worldwide trend of increasing prevalence of headache over a long period of time. The reason(s) for this trend remain a mystery at the present time. Future research is needed to further explore this finding.

Abdominal pain studies involving a combined total of more than 27,500 children showed inconsistent patterns. In some studies, repeated stomach pain was reportedly higher in older age groups while some showed a trend toward more abdominal pain in younger children. Other studies found no relationship between age and recurrent abdominal pain.

Once again, girls were more likely to suffer chronic stomach or abdominal pain compared with boys. This was true for all age groups. Likewise, the role of socioeconomic and psychosocial factors in relation to stomach/abdominal pain varied from study to study with no clear pattern identified.

Back pain seems to have a more predictable pattern. Pain present at least once a week was observed in older children in rural areas with less difference between boys and girls than with headache and stomach pain. Anxiety and depression may have a role in back pain but social class did not appear to be related.

General musculoskeletal and/or limb pain studies of multiple pain were difficult to really analyze. There were just too many symptoms reported in each study. In this category, the role of sports participation was a key factor that wasn’t always present in the other pain areas. As with other bodily pain, general musculoskeletal pain increased with age and was more common in girls compared with boys.

Other discoveries from this systematic review on the prevalence of chronic, persistent, or recurring pain in children and teens included: lower quality of life and greater use of medications among the pain groups. Marital status of the children’s’ parents was only reported in one (Spanish) study but it did not appear to be a factor.

What was the final conclusion from this study? The authors say we should realize that persistent (chronic) pain in children and teens is a major health concern. Studies of health must shift focus to include children in this area and look for ways to reduce risks. Treatment to intervene as early as possible should be established and results studied to look for evidence-based success.

And finally, studies across the developmental life cycles (children to adults) may help reduce the numbers of adults who end up with chronic pain problems. Better designed, higher-quality studies are needed to make this research relevant and accurate. The authors also suggest that understanding why girls suffer more pain than boys across the years should be a focus of future studies as well.

Surgeons in China proudly report their early experiences using titanium elastic nails (TENs) in children. Fractures of the proximal humerus (upper arm near the shoulder) are the main focus. Treatment of severe, displaced (separated), or irreducible (bone cannot be lined up) fractures at this site so close to the growth plate can be very challenging. The excellent results in the 25 children presented in this study are very encouraging.

Fortunately, bone fractures in children repair quickly. The already rapidly growing bone aids in this process. But a complete fracture that splinters into pieces or separates and then buttonholes (one end of the bone pops through the muscle) cannot be easily put back into place and held there until healing takes place.

That’s where these titanium elastic nails come into the picture. First used in the early 1970s by a French surgeon, the technique was brought to China in 2004. At least one of the authors of this study went to France to study the Metaizeau TEN technique under Dr. Djamel Louahem.

The first case of severely displaced proximal humeral fracture in a child was treated with the TEN approach in 2006. The authors present a step-by-step description of the surgical procedures with X-rays to show the final nail placement. Holes are drilled at the bottom of the humerus and two thin nails threaded up through the bone. A special X-ray table is used to guide the surgeon.

Performing the surgery like this without a long incision is called a closed reduction. In seven of the patients, open reduction with a long incision was necessary. But the use of the titanium elastic nails was used in all 25 cases. The nails are prebent in a slight C-shape to help prevent rotation of the bone and displacement of the healing fracture.

Since that first case in 2006, 25 children ages six to 15 have been treated this way. Tumbling and traffic accidents accounted for the majority of cases. Many children now ride their bicycles to school resulting in more injuries due to car accidents than ever before.

They were all followed for up to three years. Results were reported using X-rays, presence of limb deformity, patient/family satisfaction, and shoulder range-of-motion. The X-rays could show the placement of the nails and premature (too early) closure of the growth plate. X-rays also gave the surgeons a visual picture of the fracture itself and an opportunity to measure for shortening of the bone.

How did things turn out for these children using this new treatment approach? The good news is that all fractures were completely healed in two months’ time. There were no major problems or complications. Skin irritation where the end of the nail was located was reported in three children. All children achieved full shoulder range-of-motion and returned to unrestricted participation in sports.

The authors conclude the minimally invasive Metaizeau TEN approach to these upper arm fractures in growing children and teens has changed the way these injuries are treated around the world. There is no need to make repeated attempts to reduce the fracture without surgery and no need for open incision fracture reduction.

Functional results are improved because there is less risk of nerve and blood vessel injury. Being able to stabilize severe fractures also reduces the number of arm deformities and limb shortening. And finally, when compared with conservative (nonoperative) care with immobilization, this operative treatment was preferred by families. Children experienced less pain, a shorter healing time, and faster time getting back to their daily activities including recreation and sports.

Many people of all ages suffer from a condition known as recurrent patellar dislocation or patellar instability. In this condition, the patella or kneecap as it is more commonly referred to pops off to the side (usually to the lateral side away from the other knee). It may or may not pop back in place, a movement called reduction.

Early on in the acute phase, treatment is likely to be conservative care with taping or bracing, and exercises. But with repeated episodes causing pain and loss of knee function, surgery may be necessary. Children and teens with this problem must be treated carefully to avoid damaging the growth plate when full growth has not been reached yet.

In this study, the results of two surgical techniques for recurrent patellar dislocation in adolescents are compared. One method (medial retinaculum plication) or MRP is minimally invasive using an arthroscopic approach.

The second surgery (vastus medialis plasty) or VMP is done with an open incision. Both of these treatment approaches are physis-sparing (don’t affect the growth plate) so don’t cause leg length differences after surgery.

Medial retinaculum plication refers to a procedure in which the medial (side closest to the other knee) retinaculum (connective tissue that holds the knee cap in the middle) is tied back using three sutures. At the same time, the lateral retinaculum on the other side of the knee (outer edge) is cut or “released” so that it can no longer pull the knee cap off center.

The vastus medialis plasty is a more complex procedure. The surgeon still releases the lateral retinaculum. But instead of tying the medial retinaculum back and holding it firmly in place, the medial portion of the hamstrings and connecting joint capsule (also on the medial side) are cut, released, and moved over to the opposite side of the knee. The idea is to suture these structures in place so that they continue to exert a pull on the kneecap to keep it in the midline (middle of the knee joint).

The question these surgeons wanted an answer to was this: which one of these two surgical techniques work better? They usually use the open medial vastus medialis plasty (VMP) but if the less invasive medial retinaculum plication (MRP) would work just as well, then the cosmetic appeal (no scars) might tip the scales in favor of the arthroscopic MRP approach.

To compare results of these two procedures, one surgeon performed all 60 surgeries (30 teens in each treatment group). Then they followed each patient for two years at regular intervals. This type of multiple series of evaluations helps show any hidden factors that might help determine the best treatment approach for these children.

CT scans were used to look at the position of the patella. The International Knee Documentation Committee (IKDC) tool was used to measure knee function. Results showed that the more invasive open surgery (vastus medialis plasty or VMP) had the better results.

There were fewer re-dislocations in the group of patients who had the VMP procedure. The VMP group also had better clinical outcomes. And in the end, the VMP group had better overall results despite the fact that patients in both groups experienced deterioration of knee stability over time.

In conclusion, the more invasive procedure (VMP) is also a more reliable way to treat chronically recurrent patellar (knee cap) dislocations. The medial soft tissue structures just weren’t strong enough to counteract the lateral pull on the knee cap. Even so, there was a high rate of recurrence in both groups.

The authors suggest future studies are needed to take a closer look at this finding. It’s possible that with activity restriction after surgery, repeated episodes of patellar dislocation can be prevented. There may be other patient factors that could predict which surgical approach would work best for each individual patient. Number of previous dislocations, bony alignment or other anatomic differences from normal, and even the post-op rehab program may influence results and should be studied more closely.

Young athletes with anterior cruciate ligament (ACL) tears face a unique problem. Surgery to repair or reconstruct the damage can disturb bone growth. But delaying surgery until bone growth is completed can put the joint at risk of further damage without a stable ligament.

What’s the answer to this dilemma? This study from Children’s Hospital of Philadelphia (CHOP) may shed some light on the problem and the solution. Orthopedic surgeons treating children at this hospital went back and looked at the records of 70 children treated for complete ACL tears.

All patients included in the study were 10 to 14 years old. They all had surgery to reconstruct the knee. The key feature reviewed was the timing of the surgery (early or late after injury). Results were analyzed and compared for timing between injury and surgery.

All kinds of other information was gathered and evaluated as well. For example, data collected included the usual demographic information (age, gender, history of injury, side of injury). It was also noted if the child had episodes of the knee “giving way” or “shifting” (a sense of knee instability). And, of course, observations of other knee injuries (e.g., meniscus, articular cartilage) from X-rays or surgeon visual inspection during surgery were also noted.

After sorting through all the data and making many calculations, it was determined that delaying surgery more than 12 weeks from the time of injury may create many more problems than it solves. There is a greater risk of damage to other areas of the knee (e.g., the meniscus). In fact, the number of massive meniscal tears that cannot be repaired increased dramatically in the children who had delayed knee reconstructive surgery.

The cut-off time seemed to be 12 weeks. In other words, children who had knee reconstructive surgery within 12 weeks of their ACL tears had less risk of other injuries, less severe damage, and better overall results.

One other observation made during this study had to do with return-to-sports before surgery. Children treated for ACL tears at this hospital were routinely told not to engage in any activities that could put their already injured knee at risk for further damage. They were advised to avoid running, jumping, or any activities that involved pivoting or cutting motions of the knee.

Despite these guidelines, significant additional injuries were reported. It’s not clear if this is because the children ignored the counsel of their surgeons or if the everyday activities of children this age are enough to cause ongoing damage.

There is a tendency for children this age to have more ligamentous laxity (looseness) anyway, so it’s possible that without an intact ACL, just normal movement increased the risk of other soft tissue injury. And, of course, the surgeons are aware that children find interesting and creative ways to do what they want to without exactly violating the surgeon’s warnings and perhaps without realizing the full effect of their actions.

The authors note that more and more children are showing up with ACL tears. There are more children participating in sports, in more demanding contact sports, and in year-round sports activity. With better diagnostic imaging, earlier diagnosis is now possible. That means the decision whether to carry out early reconstruction versus delay treatment until skeletal maturity is more important than ever.

The medial meniscus plays an important role in stabilizing the knee, especially the knee without an intact ACL. Without a fully functioning ACL, the meniscus is at risk for injury and that leads to damage of the articular (surface) joint cartilage. The potential for early osteoarthritis is there, too.

Weighing the potential risk of disturbing growth centers against further injury and more severe damage to the knee, the authors concluded that delaying treatment until skeletal maturity is not advised in all cases. The risk of further meniscal damage creating an unstable knee with delays past 12 weeks must be considered on a case-by-case basis.

Managing complete ACL tears in children who have not reached full bone growth remains a challenging affair. More study is needed to further identify the odds of associated knee injuries if the ACL reconstruction is delayed. If possible, determining the exact best timing for surgical treatment would be helpful. Every surgeon does things slightly differently even when seemingly performing the exact same surgery. Therefore, assessing surgical technique may be an important factor as well.

More and more children around the world are reporting low back pain. In this study, public health officials from China report on this problem among their children. It turns out that one-fourth of all boys (ages 10 to 18) and one-third of all girls (the same ages) have low back pain.

How does this high prevalence of low back pain in Chinese schoolchildren compare to children in other countries? Studies show a 22 per cent prevalence rate in British children, 30 per cent in American children, and 50 per cent in Danish children. Japanese children had a much lower point prevalence of 10 per cent but a 29 per cent lifetime prevalence.

Prevalence refers to the number of people who report low back pain at one specific point (day) in time or over a short period of time (e.g., three weeks or three months). The prevalance rate in Chinese children was determined using a questionnaire filled out by 2100 school children.

The children were all from one large city (population of more than 10 million). Information collected from the children included age, sex (male versus female), height, weight, and report of low back pain at least once in the last three months.

Other questions about pain included pain intensity, frequency (how often the child experienced pain), duration (how long the pain lasted), description (e.g., sharp, dull), and the impact of pain on daily life. The presence of leg pain, pain with sports activity, and pain after sitting or getting up were also recorded.

After analyzing the data, they found that girls are affected twice as often as boys. Low back pain is more common as children get older. And children with low back pain are likely to have the same painful symptoms in their adult years. In fact, in this study, between ages 10 and 17 the number of children reporting low back pain doubled from 20 to 43 per cent.

You might think that sitting for long periods of time in school, in front of a television, or while using a computer would increase the prevalence of low back pain. But, in fact, there were just as many students with low back pain who were engaged in sports activities (probably due to injury but this was not reported). With so many children around the world affected by low back pain, the question comes up: Why?

This study did not analyze the why but the authors suggested a few possibilities. Heavier backpacks, longer study time, and greater numbers of children affected by anxiety and/or depression might be contributing factors.

With over one billion people in China and 17 per cent being school-aged children, the high prevalence of low back pain could become a costly problem. The authors of this study suggest additional research is needed to identify possible cause and effect. This information could aid efforts to reduce the number of school-aged children affected by low back pain.

Back pain in children that doesn’t go away is a red flag symptom. Although rare, serious causes of back pain such as tumors, infection, and disc herniations must be considered. In this article, pediatric orthopedic surgeons review back pain in children from disc herniations.

Risk factors, pathophysiology, and clinical presentation (signs and symptoms) are discussed. Evaluation including physical exam and imaging studies guide the physician in making the diagnosis and determining the plan of care.

Most of the time, conservative (nonsurgical) care is the primary focus of treatment. This approach begins with antiinflammatory medications and physical therapy. If the painful back and/or leg symptoms don’t resolve, then a steroid injection may be considered. In a small number of cases, surgery is required.

But let’s back track a bit and take a closer look at each of the details presented in the sections mentioned. First, all the patients in the literature analyzed were 19 years old or younger. Girls younger than 16 years old were more likely than boys of any age to develop disc herniations. This may have to do with sudden growth spurts in girls that occur earlier than in boys.

Risk factors include heavy lifting, previous back injuries, and repetitive motions. Falls associated with athletic and sports activities are additional risk factors. For other patients, sudden increases in training, poor conditioning, or decreased spine range-of-motion increase the risk of disc herniation. It’s possible that congenital defects (present at birth) contribute to disc herniations but this hasn’t been proven directly.

Motions that put stress on the disc and increase pressure within the disc itself are more likely to lead to injury of the disc. For example, repeated flexion (bending) of the lumbar spine (low back), compression down through the spine, and spinal rotation or twisting can tear the outer covering of the disc. This area is called the annulus fibrosis. The gel-like substance of the center can then push out of the disc space ( a disc protrusion) and even break through the outer covering (a disc herniation).

How can the physician tell if the child has a disc (or other serious) problem? Leg pain and numbness down the leg (without back pain) is actually the most common symptom reported by children who have disc herniations. Stiffness and loss of motion are common. A history of trauma or injury associated with sports is an important clue.

Movements that aggravate the pain and the location of that pain provide clues to the differential diagnosis. The physician’s exam takes into consideration the child’s posture and the presence of reactive scoliosis or a lateral shift. A reactive scoliosis or lateral shift occurs as the spine and trunk instinctively move away from the protruding disc. This shift takes pressure off the spinal nerve and may decrease symptoms for the patient.

The examiner relies on other clinical tests (e.g., straight leg raise, pinprick, and muscle testing) to determine when imaging studies (e.g., X-rays, MRIs, CT scans) are needed. Sometimes treatment with antiinflammatories is started first and imaging is held off for a short time. If the child’s symptoms don’t decrease or don’t go away, then further evaluation may be required.

Primary care physicians, orthopedic surgeons, or physical therapists who evaluate children with back pain will find the details of this article of interest. The pediatric orthopedic surgeons who wrote it provide a review of reliable clinical test procedures. Ways to recognize and differentiate between tumors, infection, and injuries to the soft tissues around the disc are also presented.

And finally, treatment options! Rest from all repetitive, sports, and recreational activities is advised. Patients should not strain, bend, extend, or sit for long periods of time. These positions and activities increase pressure on the discs.

A physical therapist will help guide the children through exercises designed to gently nudge the protruding disc back into its normal anatomic space. Core training to stabilize the spine is another important program the therapist will provide and supervise.

For patients who do not have neurologic symptoms (e.g., numbness, tingling, loss of bowel or bladder control, muscle weakness, foot drop), conservative care is usually very successful. Anytime a conservative approach fails to produce the desired results, more aggressive treatment may be needed.

Surgery to remove the bulging disc or disc fragments may be advised. This procedure called a discectomy must be done carefully in the pediatric population. The growing spine must be protected to preserve spinal stability. For this reason, open incision discectomy is the standard technique used to give the surgeon better visual access and control of the surgical area.

How well do children respond to treatment for disc herniations? Prognosis is excellent. More than 90 per cent of the children receiving conservative care recover fully. Pain relief is immediate and long-lasting.

Only a small portion of children with disc herniations actually end up needing surgery. And only a few of the surgical cases (estimated at approximately one per cent of all children with disc herniations) need further surgery in the short-term (first 12 months). Over the next 20 years, additional surgery is required in up to one-third of all children who have disc herniations.

There are several different types of fractures that affect the wrist. This article is focused on fractures of the joint between the two bones of the forearm (the radius and the ulna). Those two bones meet at the elbow and at the wrist. That particular joint at the wrist is called the distal radioulnar joint or DRUJ. A fracture that disrupts the DRUJ is called a Galeazzi fracture.

In this article, orthopedic hand surgeons present a review of Galeazzi fractures from top to bottom. They begin with a description of the fracture, then review the anatomy, and describe the mechanism of injury that causes these fractures. From there, they cover diagnosis and treatment with a follow-up on complications and prognosis. If you have this type of fracture (or know someone else who does), then this article will help you understand all the complexities of this injury.

Let’s start with a quick description of the fracture. The main area affected is the shaft of the radius (forearm bone) down at the end closest to the wrist. Some experts who have studied this problem say Galeazzi fractures occur when the distal one-third of the radial shaft is broken.

But it’s more than just the bone because the fracture causes a disruption of the joint where the radius and ulna are connected together. The interosseous membrane — ligaments that hold the two bones together along the length of the bones can be torn when the force of the injury is forceful enough.

Most of the damage is done when the person falls with an outstretched arm and lands on the wrist with the hand bent back into full extension. The force of the impact causes the break. Other events such as car accidents, electric shock, and blunt trauma can also result in a Galeazzi wrist fracture.

Dislocation of the radius and ulna is a key feature of the Galeazzi fracture. Along with dislocation of the two bones comes a rupture of the fibrous cartilage where the two bones meet the carpal (wrist) bones. The soft tissue at that junction is called the triangular fibrocartilage or TFCC.

If that’s not bad enough, without this important soft tissue structure, the fractured radial bone jams up on itself causing a shortening of the bone. Muscles in the forearm add their own forces on the broken bone causing further deformities.

Combined together, the result of a Galeazzi fracture can be very disabling causing significant functional limitations. Turning door knobs, picking up groceries, even toileting can be difficult if not impossible. Children and adults can both have this type of fracture. Treatment is similar but has some differences depending on age and severity of the damage done. For children, involvement of the growth plate creates some additional potential problems.

What can be done to manage this problem? First, an accurate diagnosis and discovery of the full impact of the damage is important. Some of the worst results occur because of a failure to identify (and treat) all of the soft tissue injuries.

After hearing the history of what happened and examining the injury, the surgeon will order X-rays. Studies show that 20 per cent of true distal radioulnar joint (DRUJ) injuries won’t show up on an X-ray. CT scans aren’t routinely ordered but may be necessary.

Treatment for children is usually with closed reduction and immobilization in a cast that goes up above the elbow. Closed reduction refers to setting the break without cutting the wrist open surgically. Anesthesia is still required to put the child to sleep while performing this procedure. Special real-time X-rays (called fluoroscopy) are used to confirm correct placement of the bones.

If all goes well and the fracture heals, then no further treatment is needed. But in some children, the fracture doesn’t heal or the bones shift apart and there is a loss of the reduction. That requires surgery to pin the bones together, recast, and try again.

For the adult with a Galeazzi fracture, a procedure called open reduction and internal fixation or ORIF is almost always required. These fractures are very unstable in adults and don’t respond well at all to conservative (nonoperative) care. In adults, the weight of the hand and the strength of the muscles pulling on the broken bones are just too much to allow for a good result using the same treatment approach as with children.

During surgery, the surgeon will check each patient carefully for any other soft tissue injuries and repair these as well. Metal plates may be used to hold the broken bone together. The surgeon carefully bends the plate to match the curve of the bone. Aligning the plate as closely as possible to the bone surface will help avoid further deforming forces from affecting the fracture. The use of locking plates is not advised. Nonlocking plating systems seem to provide better stability due to the rotational forces in the wrist and forearm when turning the hand palm up or down.

Other soft tissue injuries may require the use of pins and/or special wires called K-wires to reposition and hold everything together until healing occurs. In some cases, the situation is much worse because cartilage, bone, or ligament fragments can get caught between the pieces of broken bone or jammed inside the joint. That’s when the surgeon has to perform some very complex surgical repairs.

As you can probably tell, final results or outcomes (prognosis) depend on severity of the injury and any complications that may arise during or after surgery. Nerve damage, failure of the bone to heal, deformities, and chronic pain are just some of the problems that can develop.

Sometimes more than one surgery is required to stabilize the joint. The goal is always to reduce pain, improve motion, and restore function. Cosmetics may have to take a back seat if the surgeon has to choose between form and function. As the authors of this review article conclude, this is a complex surgical problem that requires full understanding of all its features. Accurate, early diagnosis with appropriate treatment helps provide the best possible long-term results.

Spinal fractures from the improper use of seatbelts are associated with car accidents. Children are at risk for Chance spinal fractures when they are not properly restrained or only partially restrained with seatbelts. This report is the largest one of its kind examining Chance fractures in children.

Chance fractures are described as flexion-distraction fractures. They occur in the thoracic (mid) spine most often in children. The same type of fracture can occur in adults but usually affects the lumbar spine (low back).

Chance fractures are also referred to as a traumatic horizontal splitting of the spine. The force of the impact throws the child’s weight forward against the seatbelt. The vertebral bone splits in half from side-to-side. The split goes through the main body of the vertebral bone and extends all the way back through the spinouts process (that’s the bump you feel along the back of your spine).

There are usually other injuries that occur along with the Chance fracture. These associated injuries include abdominal injury (the “seat belt sign”) and neurologic (nerve) damage. In accidents like these, there can also be other fractures and head injuries. According to this study of 35 children from three pediatric trauma centers, neurologic complications can be permanent.

Let’s take a closer look at what they found with these 35 children. They ranged in ages from one year old to 17 years old. Almost half (43 per cent) had a neurologic problem at the time of examination following the accident. Some of those children recovered fully but many did not. Ten per cent of the children who were restrained recovered while 42 per cent of those who were not seat belted in at all reported continued pain and neurologic problems.

Type of treatment given may make a difference in the final results called outcomes. Yet, right now there doesn’t appear to be a standard way to approach treatment for Chance fractures. Sometimes surgeons try placing the child in a cast or brace that holds the spine straight or in slight extension.

In other cases (usually in the case of more severe fractures and more forward flexion of the spine), surgery is done to fuse the spine. Rods, hooks, screws, and/or wires are used to hold the spine in good alignment during healing and recovery. According to the results of this study, children with a forward-flexed spine (called kyphosis) of more than 20 degrees are more likely to need surgery in order to have a good final outcome.

Thirty-five patients aren’t really enough to create a study that can provide specific guidelines. The authors say based on their observations that these rare injuries can be treated conservatively (nonoperatively). But in the presence of severe fractures accompanied by other serious injuries, surgery is advised as soon as the patient is stable.

Further studies are needed to compare the results of different treatment approaches. For example, it’s possible that even one variable (e.g., location of the fracture(s), severity of fracture(s), age of the child, severity of kyphosis, presence of other injuries) could make a difference in selecting the most successful treatment.

In the meantime, education is a key factor in reducing Chance fractures. This is especially important for younger children who tend to be top heavy (their head and chest have greater volume and weight than the lower part of the body). The force of a sudden stop or collision in a car accident throwing the upper body forward puts them at greater risk of injury. Not using a shoulder strap or having difficulty placing the shoulder strap in the right position contributes to the risk of Chance spinal fractures.

At the same time, parents and guardians need to know that small or young children without enough muscle bulk or large enough pelvic and spinal bones are prone to this type of flexion-distraction injury. The risk of damaging the spinal cord (creating significant neurologic problems) is very real. This is because the underdeveloped bones and spinal ligaments stretch easily but the spinal cord does not.

The authors conclude that properly restraining our young children is the key to reducing the risk of Chance fractures. Once this type of injury does occur, surgery may be the best treatment of choice. All factors must be evaluated and considered when making the final decision about surgery.

You might not know it to look at them but teenagers are suffering more chronic pain than we ever realized before. Thanks to this study of over 7,000 participants, we know that 44 per cent of adolescents between the ages of 13 and 18 report chronic idiopathic pain. At least that’s the case in Norway where the study was conducted,

Chronic idiopathic pain was defined as pain anywhere in the body of unknown cause that was present at least once a week for the last three months. Idiopathic means there’s been no known injury, disease, or other cause of the pain. The authors of the study point out that not all experts agree this is the most accurate or best way to define chronic pain. But it was a starting point in gathering information for the study.

A study like this helps identify how prevalent (common) is a problem like pain. By asking questions about difficulties sleeping, sitting, walking, exercising, and completing daily tasks, the investigators were also able to get an idea of how much pain impacts the lives of these young people.

Let’s see what they found. We already mentioned there was a high percentage of teens who reported chronic pain. One-fourth of those children had pain in at least two places (e.g., headaches, neck and/or shoulder pain, stomach pain, other muscle or joint pain). More than half the children (58.5 per cent) judged themselves to have trouble completing daily tasks.

Ten per cent of the group said they have pain every single day. Girls had more pain than boys and the number of girls affected increased as they got older. The location of the pain reported by girls was most often the head (migraines) and abdomen (stomach ache). Younger children of either sex were more likely to say they had leg pain. Headaches combined with neck and shoulder pain was the most common pain pattern reported by everyone no matter what age or sex they were.

This isn’t the first study to take a look at pain reported by children. Others have studied this problem and found that chronic pain in teens has a negative social, financial, and psychologic impact on this group. Many go on into adulthood still affected by their pain problem.

Now that the high prevalence of chronic pain in youngsters has been confirmed, research is needed to identify the cause and find ways to prevent or eliminate the problem and the pain. The authors do point out that compared with studies conducted in Europe, Norway seems to have more people experiencing chronic pain.

There may be lifestyle risk factors or psychosocial factors present but as yet undetermined. These risk factors could be just typical of Norwegians or they could represent teens of all ages in all countries. More study is needed to look for differences geographically and based on economy, culture, availability of health services, or some other risk factors. The identification of any risk factors will help guide us all in protecting our children from a distressing problem like chronic pain.

There’s an old saying in medicine, “If you hear hoof beats, think horses not zebras.” It means to look for the obvious not search for strange, unusual causes of symptoms. But in the case of hip pain in children, it may be a zebra like Lyme disease. Most of the time, joint pain caused by Lyme disease affects the knee. But in a small number of cases, Lyme arthritis presents only in the hip.

That’s the conclusion of a group of pediatric orthopedic surgeons who studied their records of Lyme disease in children. Located in the northeastern region of the United States at the Children’s Hospital, this hospital is in an area where Lyme disease is very high.

Yet out of all the children treated at the hospital, only 73 cases of Lyme disease were reported between 1995 and 2009. And only eight of those cases were hip pain caused by Lyme arthritis. The children in the study ranged in ages from three to 20 years old. The symptoms presented included hip pain (all eight children reported this), refusal to put weight on that leg (five children), and limp (three children).

Fever was not a key feature for most of the children. None of the families were aware of any tick bites or unusual skin rashes. But lab values were suspicious with elevated white blood cell count and sed rate (both indicators of infection and/or inflammation).

As a review of the records showed, special tests such as examining the joint (synovial) fluid gave a wide range of results even in known cases of Lyme disease. The test is still important to help rule out (or rule in) bacterial arthritis. All eight children also had a positive blood test for Lyme disease to help make the final diagnosis. In rare cases, a positive Lyme ELISA test can be a false positive.

Symptoms resolved in all eight children with treatment using antibiotics. The resolution of symptoms with antibiotics doesn’t always confirm the diagnosis of Lyme disease. But given the symptoms and other clues (e.g., lab values), it is a telltale sign that Lyme disease was the cause of the hip pain.

The authors reviewed results from other studies and found that as many as 13 per cent of children with Lyme arthritis have hip pain. But in those other cases, the hip pain was part of several different joints that were affected at the same time. This type of Lyme arthritis is called polyarthritis. Hip pain as the only joint involved just isn’t a typical early presentation of Lyme disease in children.

So when physicians are faced with hip pain, a limp, or refusal to put weight on the leg in children, it is better to look for horses (e.g., bacterial arthritis or synovitis) first before searching for zebras (Lyme disease). Either condition must be treated quickly and appropriately in order to get the best results. Whereas septic (bacterial) arthritis may need surgery quickly to save the joint, children with Lyme disease can be spared surgery and treated with antibiotics if and when properly (and quickly) diagnosed.

Over 100 years have passed now since Drs. Legg, Calvé, and Perthes first described a hip condition in children now referred to as Legg-Calvé-Perthes (LCP) disease. In those 10 decades, three things have become much clearer: what causes the problem, who is affected, and which treatment approaches work best.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals.

How the bone heals determines what problems the condition will cause in later life. Perthes disease may affect both hips. In fact, 10 to 12 percent of the time the condition is bilateral (meaning that it affects both hips). This condition can lead to serious problems in the hip joint later in life.

Clearly the problem is one of blood loss called ischemia. The area affected most is the head of the femur (thigh bone). This has been confirmed with today’s modern imaging studies. As a result of this blood loss, the bone dies and starts to collapse. Soon the smooth, round head of the femur starts to flatten and deform.

X-rays helped in the early days of discover to rule out tuberculosis as a possible cause of the hip pain, limp, and loss of motion that accompany Legg-Calvé-Perthes (LCP) disease. It was quickly realized that faulty delivery of blood to the hip was the cause of LCP.

But even with today’s modern imaging tools, the exact vascular (blood supply) problem is unknown. Two theories are currently being investigated: arterial infarction and venous congestion. Arterial infarction refers to blockage of the blood vessels bringing oxygenated blood to the hip. Venous congestion describes a condition in which blood reaches the area but doesn’t return quickly to the heart. Instead, blood pools in the area.

X-rays have also made it possible to classify or “stage” the disease based on severity. But agreement is lacking on the best way to classify LCP. Currently, surgeons are working backwards to identify early stages of the condition and find ways to predict outcomes.

By working backwards, we mean they are looking at the medical records and results of treatment for adults who had this condition as a child. Then they take a look back over the years at X-rays, MRIs, and clinical reports. By seeing the end results, reviewing treatment given and early findings, scientists are able to make better plans for early treatment of children today with Legg-Calvé-Perthes disease.

For example, in this study, X-rays and MRIs of the femoral head deformities seen in adults were compared to the same findings reported in childhood. This type of study technique is called end-result radiographic analysis.

Using this method, they developed a more reliable classification system called the lateral pillar classification. The lateral pillar is seen on X-rays as changes on the outside edge of the femoral head. The classification scheme labels changes in four categories (A, B, B/C, and C) to represent severity from A (mild) to C (severe).

Changes along this side of the femoral head seem to be able to predict final outcomes. Comparing imaging results with treatment applied for each category allowed orthopedic surgeons to see that there was no difference in results based on the treatment applied. So for example, no changes were observed in the lateral pillar after bracing, range-of-motion exercises, or even after no treatment.

The older children (over eight years old) who had surgery to correct the problem were the most likely to have better restoration of the lateral pillar deformity as seen later in adulthood. This was true for mild-to-moderately severe femoral head deformities. Severe lateral pillar changed did not respond better to one type of surgery over another.

The authors came to several conclusions based on the results of this comparative study. First, some children can be spared the discomfort of bracing and even the risks of surgery. Who are these children? Can they be identified ahead of time? They are the patients who have mild changes of the lateral pillar diagnosed before age eight.

Second, something more must be done to successfully treat the severe lateral pillar deformities. Surgery doesn’t really seem to help, so why put these children through that step?

And finally, it is suggested that when the exact vascular problem causing Legg-Calvé-Perthes (LCP) is discovered, then perhaps a more effective treatment can be found. There is plenty of room in the future for research around this problem.

In this expert opinion, two pediatric orthopedic surgeons from Children’s Hospital in Boston discuss femoroacetabular impingement caused by Perthes disease. Perthes disease of the hip (also known as Legg-Calvé-Perthes) occurs when there is a loss of blood supply to the growth center at the top of the femoral head. Without enough blood, the bone dies, degenerates, and collapses.

Children with Perthes disease of the hip may recover fully without further hip problems later. But those patients with growth disturbance of the femoral head and altered shape of the normally round femoral head (top of the thigh bone) may end up with femoroacetabular impingement (FAI) (pinching of soft tissue and bone).

The body is capable of limiting this disease and growing new bone. But in the meantime, the weight of the body on the unstable bone can cause the head of the femur to become more oval-shaped.

That’s a problem because the hip socket is designed to hold the round head of the femur. In fact, the fit is specific and quite tight. That’s what’s needed to provide a stable but moveable hip joint. Without the perfect match-up of femoral head and hip socket, the danger of hip dislocation increases with Perthes disease.

And with the change in shape of the femoral head, there is also a risk of impingement . As the femoral head is pressed down, the femoral neck (between the shaft of the thigh bone and the femoral head) is shortened. There can be a rotation of the bone as well. All these features add to the likelihood of an impingement problem.

How do we know when a child with Perthes hip disease is also experiencing hip impingement? Symptoms of groin pain that is worse with activity or prolonged sitting are the first clues. There could be just stiffness and loss of hip motion without pain. The real tip off is the position of the hip when the symptoms are the worst: internal rotation and flexion.

X-rays will help show what’s going on. The radiologist and orthopedic surgeon look for something referred to as acetabular coverage. This is a view of how much of the femoral head is inside the socket (called the acetabulum). With impingement from Perthes, it is common to see overcoverage (shelf of the socket hangs down over too much of the femoral head).

Other deformities can be seen on X-ray and the physicians use several ways to look for these (e.g., Shenton’s line, cross-over sign, acetabular index). Depth of the socket and presence of rotation of the bones are also assessed. In some cases, it may be necessary to order additional imaging studies such as CT scans or MRIs.

The authors of this article emphasize the need to identify all changes and deformities within the hip complex associated with Perthes disease. They say that successful treatment (especially surgery) depends on understanding all the components that contribute to Perthes hip deformities.

What can be done about femoroacetabular impingement in a child with Perthes hip disease? The surgeon must look at both sides of the hip: the femoral head and the acetabulum (socket). It may be necessary to make surgical corrections of both areas.

On the femoral side, the surgeon may change the length or angle of the femoral neck. The misshapen and enlarged head may have to be corrected, a procedure called osteochondroplasty. This requires surgically dislocating the hip. That sounds pretty dramatic but the authors assure us it can be done safely and is quite effective.

While correcting the deformity that causes impingement, the surgeon will also look for any other areas of soft tissue damage. There may be a tear in the labrum that needs attention. The labrum is a rim of cartilage around the hip socket designed to give the socket a little bit more depth and the hip greater stability inside the acetabulum.

The ultimate goal of surgery for femoroacetabular impingement in the Perthes hip is to improve hip joint motion. Reducing pain and improving joint stability are also important. The surgery can become quite complex when there are numerous changes in the hip to be addressed.

The surgeon must also pay attention to alignment of the involved leg. No sense in making all these corrections to the deformities only to create a leg length difference, loss of joint stability, or abnormal arc of motion.

In summary, children with Perthes hip disease can develop a type of hip impingement as they get older. The effects of the disease in changing the shape of the femoral head contribute to this problem. Surgery to correct the impingement is a possible treatment option. Careful assessment of all deformities and damage present in the hip complex can be done best with surgical dislocation.