News Category: Child

Surgeons from Korea offer this report on a rare injury in children. They had six cases of a knee injury called peel-off injury. Trauma from sports injuries or falls resulted in the posterior cruciate ligament (PCL) tearing away from the tibia (lower leg bone), one of the places where it attaches.

The posterior cruciate ligament is one of two ligaments that criss-cross to form an X-shape inside the knee. Together, these ligaments hold the knee stable and keep the bones from shifting too far apart. The posterior cruciate ligament is designed to prevent the tibia from sliding too far back underneath the femur (thigh bone).

Another term for this type of injury is tibial avulsion of the PCL. In all six cases, boys between the ages of 12 and 13 suffered a direct blow to the upper portion of the tibia (just below the knee) while the knee was bent. Some of these injuries occurred during soccer while others happened during basketball, dodge ball, or as a result of a fall.

This report is important, not only because these injuries are relatively rare, but because surgical repair is tricky. In all six cases, the ligament peeled away from the bone cleanly. In other words, the bone was left intact. Sometimes, the ligament pulls away with a piece of bone still attached to it. Reattachment and fixation with a screw is easier when the ligament avulses (ruptures) along with a bit of bone. The surgeon can anchor it back down where it belongs by using a screw through the bone fragment.

With a peel-off injury, it is necessary to use multiple sutures without piercing any of the nearby nerves, blood vessels, or growth plate. Disturbance of the growth plate (called the physis) by drilling holes through it to anchor the sutures can lead to deformity. Drilling tunnels across the physis can also cause the growth plate to close early on that side. The result can be a difference in leg length from one side to the other.

Given the success of their technique, the authors wrote this article to describe the surgical procedure. With drawings and arthroscopic photos taken during the procedure, they show the injury and the proposed surgical repair.

The postoperative program of physical therapy started right after surgery. The children were kept in a hinged, long-leg brace that was kept locked in a fully extended position for four weeks. This approach of immobility is designed to protect the healing ligament.

At the end of the four-week period of time, the brace was unlocked and passive movement was allowed. The child was allowed to put gradual increasing amounts of weight on the leg until the brace was removed eight weeks after surgery. All activities were resumed as the child was able to perform them. Sports activity was allowed when motion and strength were within normal limits.

During the follow-up period, all six children had full knee range of motion without any sign of instability. Function was rated as normal or near normal as measured by the International Knee Documentation Committee (IKDC) evaluation and the Lysholm knee scoring scale. Follow-up was at least two years long. Some children were followed for a full five years.

The authors conclude that children with peel-off injuries of the posterior cruciate ligament can be treated safely and effectively with surgery to repair the damage. Fixation of the ligament stump (ruptured end separated from the bone) can be done arthroscopically using multiple sutures.

In the case of one child where the stump was split, repair was unsuccessful and the ligament had to be reconstructed instead. Everyone in the study will continue to be followed in order to determine long-term results of this treatment.

Supracondylar humerus fractures, fractures of the elbow, are a common injury in children. Despite their frequency, though, there isn’t a lot of agreement on how best to treat this injury, as surgeons use different techniques and have differing opinions as to when surgery is needed. Some of the issues that come up are the different types of significant complications that may occur as a result of the fractures, such as stiffness, nerve injuries (neurologic), and deformities. In particular, doctors are concerned with vascular injuries, injuries to the blood vessels. If blood cannot get down to the tissues in the lower arm and hand, damage begins quickly.

Up to 20 percent of patients with a supracondylar humerus fracture may not have a pulse that can be felt in the lower arm (wrist). If the hand is cool, surgery must be done as soon as possible to prevent permanent damage to the arm and hand. However, there isn’t much research that has been done about the role of surgery if the pulse is absent but the hand is warm, receiving blood. The authors of this article conducted a review of data to understand how often arterial (blood vessel that provides the pulse) damage occurs with this type of fracture among children.

Researchers found 19 usable articles with 331 cases of pulseless supracondylar fractures. Using this information, the researchers surveyed members of the Pediatric Orthopaedic Society of North America (POSNA) to see what their opinions would be regarding the percentage of these types of fractures that had brachial artery injuries (cool pulseless hands and warmer pulseless hands). Two hundred fifty four surgeons returned their surveys.

Of the 331 cases, 157 did not regain a pulse after surgery was performed to correct the fracture. Of these 157, 82 percent were found to have damage of the brachial artery, although members of POSNA had estimated that only 28 percent would have this type of damage. Ninety-eight of the pulseless fractures had pink hands, which means there was adequate blood circulation, Seventy percent of this group had brachial artery injury, while the POSNA estimated that there would only be 17 percent affected.

Only one complication occurred after full open surgery, osteomyelitis (inflammation or infection in the bone). Another patient had surgery delayed because of a Volkmann contracture, contracture of the wrist.

Damage to the brachial artery can result in having to amputate the affected arm later on, so detecting and correcting this type of damage is an important issue. Delayed treatment can also result in Volkmann contractures, cold intolerance, embolisms, and retarded growth of the arm. When the researchers looked for treatment recommendations, they found that more than half the papers recommended immediate surgery for warm pulseless fractures, but only 16 percent of the surveyed surgeons felt the same way. As well, as demonstrated, the surgeons vastly underestimated the percentage of injuries that involved the brachial artery. Thus, it is important for surgeons to both expect to find more patients with brachial injuries, even if the hands are warm and pink.

In this study, orthopedic surgeons compared three ways to treat elbow fractures in children. The specific type of fracture was a lateral condylar fracture of the distal humerus. The distal humerus is at the bottom of the upper arm.

The humerus flares at the bottom on both sides forming a part of the bone called the condyle. The lateral condyle is the bony projection along the outside of the elbow (side farthest away from the body). Fractures of the lateral condyle are fairly common in children. Finding the most effective treatment with the fewest complications is an important goal.

The choices in treatment include: putting the arm in a cast from the hand to the top of the upper arm. That’s called a long arm cast. Casting without surgery is possible when the break is intact and hasn’t separated or displaced.

A second treatment alternative is called closed reduction and internal fixation or CRIF. With CRIF, the break can be lined up (reset) without an incision to cut through the skin and open the arm up. And for fractures that have separated too much and/or shifted so the broken ends no longer line up, the third procedure used is called an open reduction and internal fixation (ORIF). With the open reduction, the surgeon makes an incision down to the bone. The bone is put back together and held in place with wires, plates, and/or screws. The arm is placed in a long arm cast until sufficient healing takes place.

Each of these treatment approaches have their pros and cons. Putting a cast on without wiring or screwing the bones back together has a risk of the bones drifting too far apart. Closed reduction and internal fixation may not bring the bones back as close together as needed. The result can be deformity and change in the carrying angle of the arm. Open reduction with internal fixation (ORIF) is really the most accurate treatment but it is also the most invasive.

A wide range of complications can occur from the treatment of lateral condylar fractures. There can be infections, loss of blood supply to the bone, failure of the bones to knit back together (malunion), or just a very slow process of healing (delayed union).

Sometimes the bones shift even with surgery (CRIF or ORIF). If too much shifting occurs, an elbow deformity can develop that affects the carrying angle of the arm. There are cases where growth is stopped or the opposite (too much bone growth) occurs. Stiffness, loss of motion, weakness, and loss of function are all possible problems that can develop.

So, which one of these treatments works best? Which one has the fewest complications? How can surgeons optimize motion, strength, and function and help the patients get back to as normal as possible? Let’s see what this study of 175 children revealed. Please note: all 175 children were treated by the same surgeon and given the same follow-up care and rehab.

Fourteen patients of the 39 who were put in a long arm cast without surgery ended up with a gap in the fracture site that required surgical fixation. Almost one-fourth of the children had obvious overgrowth of the lateral condyle. It looked funny but didn’t alter their arm function or require surgery to realign the bones.

Lateral overgrowth and bone spur formation occurred most often in the open reduction and internal fixation (ORIF) group. This was the most common complication of ORIF. An increased carrying angle was the second most common complication. Neither of these problems went away even almost two years after the surgery.

For all three types of treatment, elbow range of motion was normal. Remember the 14 children who were initially put in a cast but had to have surgery later because the break was drifting apart? Once they had surgery (either CRIF or ORIF), union occurred without any further problems.

The authors concluded that there was no significant difference in outcomes between fracture types or treatment method. Good-to-excellent results can be expected when treating lateral condylar fractures in children with conservative (nonoperative) care or surgical management. The two major complications (lateral condyle overgrowth and a change in the carrying angle of the elbow) appear to be permanent changes.

Surgeons face some interesting challenges when dealing with broken bones in children. One of the most common bone fractures in children between the ages of four and 14 is the forearm. There are two bones in there: the radius and the ulna.

In a simple (undisplaced) fracture of both bones, the forearm can be put in a cast and the bones will knit together. But when the fracture separates and no longer lines up properly, surgery is often needed to reduce the fracture (i.e., bring the edges back together and line them up). When it comes to a fracture of both bones in the forearm, reduction can get tricky.

These two bones make it possible for the forearm to rotate. Forearm rotation allows the hand to turn palm up (a movement called supination) or palm down (pronation. Surgery must be done in such a way that the bones are stabilized (held in place) while preserving forearm rotation.

Placing a metal rod down the middle of each broken bone has been a popular fixation method for many years. Maintaining good bone alignment is necessary to save forearm rotation. Then back in 1996, the first orthopedic surgeon tried using a metal rod just down one of the two broken forearm bones (the ulna). This type of fixation is called single intramedullary fixation.

Since that time, other surgeons have tried the new technique and reported on their results. There have been good and not-so-good results. Sometimes single intramedullary fixation yielded excellent outcomes. In other cases, there were problems with failure of the fractured bone to heal, loss of reduction, and increased bend in the bone. The last complication (angulation of the healing bone) can lead to loss of forearm rotation, which is a major concern.

To help answer the question of whether or not single bone fixation is safe and effective, hand surgeons from Children’s Hospital in Boston tried the single bone intramedullary fixation. They used it in 48 cases of fractures of the ulna and radius in children. They hoped to identify possible risk factors for failed cases. In this way, it might be possible to screen children ahead of time and only perform the double rod fixation when absolutely needed or when the patient is at risk for malunion or nonunion.

In all 48 patients, only the ulna was stabilized with the rod. Surgeons with special training in pediatric medicine did the surgeries. Special imaging X-rays called fluoroscopy was done in the operating room to make sure the bones were stable and in place before putting a cast on the arm.

After collecting all the data on each case and analyzing the post-operative results, they found two potential risk factors for complications after single rod fixation for double bone fracture. The first was an open fracture. Open fracture refers to the fact that the two ends of the broken bone have not only moved apart but separated sideways so that they no longer line up. When this happens, the soft tissue structures around the broken ends are also affected, making it more difficult to maintain reduction.

Another potential risk factor is the cast that is applied after surgical reduction and fixation. If the cast is molded around the forearm too tightly, a condition called compartment syndrome can develop. Swelling and pressure on the soft tissue structures from a too-tight cast can cause more problems including death of tissue. Applying a cast that is too loose increases the risk of forearm movement inside the cast. During the early days of healing, movement can cause the fractured bones to distract even more. Either complication leads to a second surgery.

After looking over the results of their own study as well as the results of other studies examining single-rod fixation, the authors also saw that younger patients seem to be the best candidates for this approach. Surgeons can use these newly identified risk factors to carefully select who can be treated with the less invasive single-rod fixation for a double-bone forearm fracture.

The results of this study support the idea that single-rod fixation can be used with double bone fractures in the forearm. Fluoroscopy can be used during the surgery to confirm that the fractures are lined up and stable. Careful patient selection for this surgical technique is advised. Loss of bone reduction can result in a bone angle that limits forearm rotation. Some of this angulation can be prevented with intramedullary fixation and proper cast molding.

More studies are needed to determine long-term results of a single rod to support double forearm fractures. It would be good to have some studies that directly compare patients who are treated with a single rod vs. those who have a rod placed down through both bones. For now, it looks like certain patients can benefit from single-rod intramedullary fixation for fractures of both the radius and ulna.

Department stores with escalators often have a sign posted that the escalator is not to be played on or ridden for fun when shopping. Safety is the store’s first concern. Injuries can and do happen on escalators. These kinds of signs rarely keep children from taking a joy ride. And even when accompanied by an adult, severe fractures, cuts, and even traumatic toe amputations have been reported in children riding escalators.

In a recent report from Singapore, three-fourths of the children suffering severe foot injuries while riding an escalator were wearing rubber clogs on their feet. These colorful foot apparel look perfectly safe but the soft leather and lack of support on the sides can lead to serious foot injuries.

What happens to cause these injuries? The front of the clog is wide and gives the impression that the foot is well-protected. But children who don’t pick the feet up to step off the escalator can get the clog stuck in the gap where the last step slides into the comb plate. The side of the clog can also get caught on to the metal side panel. Often the injury is made worse because the escalator keeps going until a store employee finally turns it off.

After examining the data collected from the 17 cases of escalator-related foot injuries, the authors found that gender (boys versus girls) wasn’t as much of an issue as age. Younger children are at the greatest risk for these types of injuries. They have small feet that can slip into the comb plate. They tend to stand on the escalator right to the top without actually stepping off. And they fall down a lot, increasing the risk of an injury when the fall occurs while on the escalator.

For anyone who has ever walked holding the hand of a toddler or young child, you know that adult supervision can’t always protect and prevent accidents. If the child falls at just the right moment, injuries can occur.

Many things have already been done to reduce these kinds of injuries. The manufacturers of rubber clogs have started a safety campaign called the Escalator Safety Awareness Initiative. Tags are attached to the clogs with safety information about escalators. Efforts are being made to improve the design and maintenance of escalators. Safety side plates are now part of newer escalator installations.

Store managers are advised to ensure safety inspections, routine escalator maintenance, and regular lubrication of moving parts. Parents are reminded to keep children away from the sides of the escalator, face forward, and always be aware of where the escalator emergency stop button is located.

Children should never be allowed to sit on the escalator steps (or stand facing backwards) when it is moving. Trying to walk down the up escalator and vice versa is to be strictly forbidden. Any child wearing clogs must be closely supervised.

Young children should be assisted at the top until they have developed the skills needed to step off safely. All of the unfortunate escalator-related injuries involving clogs have been preventable. Parents can help prevent loss of toes, fractures, and crush injuries by following these simple suggestions.

For 50 years, children born with developmental dysplasia of the hip (DDH) have been treated successfully with the Pavlik harness. Most studies show that the earlier the treatment, the better the results. The Pavlik harness is not usually recommended for older infants (six months of age or older). The results of this study may suggest differently.

What is developmental dysplasia of the hip (DDH)? In this condition there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). The socket is shallow and the femoral head doesn’t stay in the 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 subluxation.

The goal of treatment is to keep the femoral head in good contact with the acetabulum. A stable hip encourages the development of a normally shaped socket and rounded head of the femur. The proper hip position must be maintained for enough time to stabilize the joint. The hip should be flexed to 95 degrees and abducted (apart) at least 90 degrees. This position keeps the ball (the femoral head) in the best position and allows the ligaments and joint capsule to tighten up.

The best way to achieve this is often with the Pavlik harness. The harness keeps the hip in flexion and abduction. It may be worn until the doctor can no longer move the hip in and out of the socket. Usually this takes about six weeks. As mentioned, the harness is not recommended for children older than six months.

But the results of this study may indicate otherwise. Twenty-four children between the ages of nine months and 23 months (almost two years old) were placed in the Pavlik harness despite the late diagnosis.

Almost half (46 per cent) had a successful result and did not need any additional surgery. Results were obtained in the first six weeks if the harness was going to work. The harness was augmented by a dynamic abduction splint in about half of the group. But the results were not any better with the dynamic abduction splint than without.

In one case, the Pavlik procedure worked for one hip but not for the other. For those who had a failed result with the Pavlik harness, surgery was done to reposition the hip in the socket. The children with the most severely dislocated hips had the worst results.

There are different ways to describe or classify hip dysplasia. The authors of this study used the Graf classification, which uses ultrasound studies to look at the shape of the acetabulum. The more flattened the roof of the socket, and the further off center the head of the femur was positioned in the socket, the worse the Graf grade. Children with Graf type 4 (most severe) dysplasia were the most likely to fail late Pavlik harness treatment.

As a result of this study, the following recommendations were made:

Hip dysplasia is a condition where the head of the femur (thigh bone) does not fit properly into the acetabelum (the cup-like area of the pelvis where the femur sits). For several years, a procedure called the Ganz (Bernese) periacetabular osteotomy was used in adults who had hip dysplasia, but recently, surgeons have been using this procedure on teens. However, there is not much research on how effective the procedure is on teens over the short term, nor is there any reliable information regarding the gait and functional outcome in this age group.

Other procedures have been tried to treat hip dysplasia. The Wagner spherical osteotomy corrected the problem, but at a cost. The surgery would put the blood supply in the acetabelum at risk, putting the hip in jeopardy. The Steel triple innominate osteotomy has been fairly successful but not so for the more severe dysplasias.

The Ganz procedure is popular because of its technical advantages. The authors of this article analyzed the short-term outcomes of teens who underwent the Ganz procedure for adolescent hip dysplasia to see how this surgery can help this age group.

Researchers studied 21 patients (18 female) who had a total of 24 hips that required correction. They were, on average, 16.1 years old at the time their hip disorder was diagnosed and 16.2 years when they had their surgery. About 38 percent of the patients had had previous hip surgery. Most of the hips were considered to be moderate-to-severe hip dysplasia. Preoperative assessments of the patients included range of motion of both hips, checking for pain with flexion (bending), adduction (moving away from the body), and internal rotation of the hip. X-rays of the hips were taken before surgery and again at six months after surgery and one year after surgery. The gait of each patient was analyzed in the same time period.

The researchers found that there was a significant improvement in all measurements among the teens who had the surgery. The hip angles and weight-bearing zones improved, as did their strength, flexion power, and gait. Interestingly, the abductor strength actually declined at six months, but was above pre-operative levels by one year. The authors of the article were surprised by this finding, particularly because there were exercises to strengthen these muscles not long after the surgery was completed.

Home physiotherapy plays a large role in post-surgery progress. After hip arthroplasties (replacements), it has been shown that three times daily physiotherapy effectively strengthens the hip muscles. However, compliance when it comes to teens is not always possible. In this study, the patients did have a short course of in-patient physiotherapy to show them how to do exercises. After six weeks, the physiotherapy program increased to full weight-bearing and more intense strengthening exercises. Not all patients complied with the program, which could have resulted in the delays seen by the researchers.

The authors concluded that the Ganz procedure is effective in teens, but work needs to be done on strengthening the muscles after surgery, which may require different strategies than with adults.

One way physicians have to keep up with the rapidly changing discoveries in medicine is by reading journals. Sometimes it’s just a matter of browsing various journals to see what’s happening. In other cases, a specific journal title may catch the physician’s eye as being worth the time to sit-down and read it page-by-page.

One of the services the American Academy of Orthopaedic Surgeons (AAOS) provides is a specialty update on various topics in orthopedics. In the June 2010 issue of The Journal of Bone and Joint Surgery, updates are provided on a wide variety of pediatric orthopedic conditions. The word pediatric tips us off immediately that the focus group is children.

Children don’t suffer from the joint aches and pains experienced by older adults plagued by arthritis. Instead, they have sports injuries (or other traumatic injuries), orthopedic problems they might be born with (e.g., developmental dysplasia of the hip, clubfoot), and tumors. The recent increase in antibiotic resistant bacteria leading to skin and muscle infections has affected children as well as adults.

These and other conditions are discussed in this update/review article. The authors searched all other published journals and materials related to children’s orthopedic problems. Then they put together a summary of what’s new. The areas they focused on included the upper extremity, hip, lower extremity, foot, and spine. They also presented an update on tumors, neuromuscular disease, and trauma seen in a typical pediatric orthopedic practice.

Here are a few key points from each section:

Broken collarbones (fractured clavicles) are fairly common among adolescents. They make up about 15 percent of all fractures in this age group. Most of of these fractures happen in the midshaft region and about half are displaced, or moved out of place. Most often, clavicle fractures are not treated with surgery, usually because doctors used to feel that it wasn’t too much of an issue if the bones didn’t heal exactly in place. However, the doctors did not perform studies to follow patients to see if these malunions (not meeting and healing) actually did cause any long-term problems with shoulder movement and use.

Some studies of adults done recently found that this may not be a good approach because there have been higher rates of malunion and nonunion, as well as problems in shoulder strength and endurance. Unfortunately, not a lot of study has been done on adolescents and tthey are usually grouped with children, a group younger than them.

Overall, most doctors agree that clavicle fractures that are still in place do not necessarily need surgery, but disagreement comes when there is displacement – the bone ends have moved. Studies – again among adults – have shown that surgery does not result in higher complication rates and that the surgery could improve patient outcome. The authors of this article aimed to report how long it took for the bone to heal (time to union), complications, how often the bone didn’t heal or healed incorrectly, residual symptoms from the fracture, and how long it took to return to pre-fracture activities, comparing those who had surgery and those who didn’t.

Researchers identified 42 patients, average age 15.4 years, who had experienced 43 midshaft clavicle fractures. One patient had two fractures. The fractures were caused by sports injuries (24 patients), motor vehicle collisions (10 patients), and all-terrain vehicle accidents (eight patients). Fifteen patients had other injuries in addition to the fractured clavicle, including fractures of the pelvis, spine, and extremities.

Twenty five patients (16 males) were treated without surgery; the patients wore slings or a brace, while the remaining 17 (16 males), with displacements of more than two centimeters, had surgery for repair. Both groups of patients received similar follow-up visits and restrictions during the healing phase. Visits were at two and six weeks, and then six and 12 months after surgery if the fracture healed. If the fracture had not healed after six week, follow-up visits were every two weeks until healed.

The researchers obtained x-rays and measured shortening of the bone before and after treatment. The patients were measured on both sides – the injured and non-injured – for comparison. The fractures were considered delayed union if there was no union at four months after treatment and nonunion if no union at six months. If union has occurred but without alignment and symmetry, this was classified as malunion. Symptomatic malunion occurred when there was shortening, angulation or asymmetry, compared with the noninjured shoulder, as well as complaints from the patient of pain when lifting the arm for use overhead, weakness, tiring of the arm, or neurologic (nerve) symptoms.

Results showed that the patients in the first group (those who did not have surgery) were injured through sports (44 percent) and 14 patients had displacements. In calculating shortening of the area, excluding patients with displacements, the average shortening was 18.8 millimeters. The patients with displaced fractured had the bones joined at about 9.9 weeks and there were no nonunions. On average, patients returned to their pre-fracture activities at around 16 weeks after the injury.

In the surgical group of 17 patients, there were 18 fractures that were repaired. Again, sports was the most common cause of injury, at 58.8 percent of patients. All patients were about 2 centimeters displaced. Union occurred around 7.5 weeks for most patients, compared with 9.9 weeks in the other group. There were no significant complications during or after surgery. Twelve weeks was the average time to return to activity, four weeks earlier than the group that didn’t have surgery. There were no nonunions or malunions, but three patients elected to have the hardware removed from the area because they were prominent.

Among the patients who did not have surgery, five who had displaced fractures developed malunions and complained of pain, fatigue in the arm, or drooping shoulder on the side that was injured. For all five patients, the affected side was their dominant side. These symptoms developed anywhere from six months to 24 months after the injury. Upon measuring the length, the researchers found that these patients had an average displacement of 26.6 mm and four patients underwent surgery to correct this.

In conclusion, the authors wrote that surgery to correct mishaft clavicle fractures in adolescents often results in good alignment and healing of the fracture, allowing the patients to return to previous levels of activities earlier than patients with displaced fractures who are treated nonoperatively.

Diaphyseal (long bone) arm forearm fractures are common among children – making up between three and six percent of fractures in children. Most often, the fracture can be set by a closed reduction, putting it back into place without surgery, and then casting. Up to 85 percent of arm fractures treated this way heal well. Because of this success rate, surgery is usually only recommended if there are any complications and the arm bone cannot be realigned without surgery. That being said, doing surgery for realigning the bone is controversial even though the surgery rates are rising. One particular procedure, inserting a nail to stabilize (IM nailing) has increased in use from 1.8 percent of cases to 22 percent, over a 10-year period.

Despite the increase in surgery, the IM nailing is considered the lesser invasive of surgeries, compared with inserting a plate, which is how this type of fracture is often treated in adults. The IM nailing has a good success rate, but the authors – as well as other researchers – have found that there are some problems associated with the procedure, such as delayed union of the bone, the need to expose the fracture site to do the procedure, compartment syndrome (pressure of the nerves, blood vessels and tissue), and wound problems. The authors reviewed their own long-term experience with the procedure for risks and complications.

Looking through the records, the researchers found that they had treated 2,297 such fractures. Of these, 155 underwent surgery and six were lost to follow-up, leaving 149 patients total. The patients were an average age of 11.2, ranging from 3 years to 17 years. Follow-up was an average of 5.1 months. IM was done alone in 69.1 percent of the children and about 29.5 percent were given plates. The IM group was on average 10.6 years, about two years younger than the average age of the plate group. A small group, 1.3 percent of the children were treated with both IM nail and plates.

The researchers found that there was a seven-fold increase in the procedure from the first year of the 11-years reviewed to the last year. The most common reason for the surgery was that the bones couldn’t align properly after closed reduction was tried (69.1 percent of cases). When IM nailing was done, 30 fractures needed an incision to insert the nail. Twenty three cases involved open fractures (where the skin was already torn) so this opening was used for the nail insertion.

On average, the time for bone healing – or union – was 8.6 weeks for fractures that had to be opened for nailing, compared to 6.9 weeks for fractures that did not need an incision to be made because of the already present opening. This compares similarly to fractures that were not open to begin with.

In looking at the 4 fractures treated with plate fixation, 26 had singlebone fixation and 16 needed plates on both bones, the radius and ulna. The average bone healing time was 9.2 weeks, with the time being a bit longer in the older patients.

There were complications for some patients. In the IM nail group, there were 15 complications:

– delayed union (six cases – in patients over 10 years old)
– compartment syndrome (two cases)
– infection (two cases)
– tendon laceration during nail insertion (two cases)

Compartment syndrome appeared to be connected to having the procedure done on the day of the injury.

The authors pointed out that they divided the IM nailing group into two: one group over 10 years old and the other 10 years old or younger. The younger children had better outcomes than their older counterparts.

Since surgeons have begun using IM nailing for aggressive management of such types of fractures, calling them less invasive than using plates, this does depend on how the fracture presents itself: closed (no open wound) or open. In this study, the authors found that open wounds, where another incision had to be made, had a slower bone healing time than closed wounds or open wounds where no extra incision needed to be made.

Broken bones are a common calamity among children. But young children seem to have an amazing ability to heal and heal well. Fractures of the femur (thigh bone) become more problematic as children get older, larger in size, and heavier.

Studies have been done in younger children with femoral fractures to determine the best way to surgically restore bone alignment with pins, nails, plates, and screws. But surgeons can’t rely on that data when working with older children and teens.

In order to find the optimal way to hold the broken pieces together in more complex femoral fractures in teens, surgeons from The Hospital for Sick Children in Toronto, Ontario (Canada) conducted this study. They went back into their medical records and pulled the medical records of all children ages 11 to 18 who had traumatic femoral fractures.

They compared the results of treatment based on four different ways to surgically fix (hold in place) the broken bones. The four methods of fixation included: 1) elastic stable intramedullary nail fixation, 2) external fixation, 3) rigid intramedullary nail fixation, and 4) plate fixation.

Results were measured using length of hospital stay, time to heal (bone union), development of complications, and the need for a second operation. X-rays taken at the time of surgery and postoperatively were reviewed. They also looked at the type and number of complications associated with each fixation method.

Complications included things like infection, refracture, delayed union, malunion, shortening or lengthening of the bone, and loss of reduction. Loss of reduction means that the bones shifted apart after the fractured edges were brought back together and held in place with hardware.

Choice of fixation method is always left up to the surgeon. There isn’t a protocol or set of rules to say, Use this one or that one based on specific patient factors. Each surgeon evaluates the individual patient and takes into consideration the type of fracture, severity of fracture, age, and weight. Surgeon experience and expertise is also a factor as is parent/family preferences.

We will cut to the chase and tell you that in the end, the study did not yield enough information to make specific recommendations of when and how to use fixation for femoral fractures. But don’t go away — there are a few conclusions offered by the authors.

First, all four types of fixation methods did yield equally satisfactory results. The one method that seemed to have the highest number of complications was external fixation. With external fixation, there are pins through the skin and muscle into the bone. Pins are placed above and below the fracture site with a rigid bar outside the body holding the bone in place.

Fractures treated with external fixation took much longer to heal. That finding doesn’t necessarily mean surgeons shouldn’t use external fixation in adolescents with femoral fractures. This particular complication could be the result of the treatment method, but it could also reflect the fact that this type of fixation is used for the more severe (open) fractures. And we know that open fractures (bone broken and protruding through the muscle and skin) take longer to heal than closed fractures (bone broken but not displaced through the skin).

Another finding from this study was that titanium elastic nails worked just as well as more rigid methods of fixation. This was true even for the heavier teens who weighed as much as 225 pounds. The types of complications that occurred with elastic nails (e.g., loss of reduction, delayed union, refracture) were considered preventable.

In conclusion, the authors suggest that there just isn’t one way to hold femoral fractures together for every adolescent with this problem. Each method has its own advantages and disadvantages.

It’s good to know that external fixation had the highest rate of complications and rigid intramedullary nails (placed down inside the shaft of the bone) had the fewest problems. Surgeons can take this information into consideration when making their decisions about what type of fixation to use on a case-by-case basis.

This report from the Shriners Hospitals for Children in Salt Lake City is the first to discuss the orthopedic problems shared by children with a condition called Navajo familial neurogenic arthropathy.

It’s a rare problem but one that can have serious consequences for the affected child. Obviously, it is found among people of the Navajo Native American group. This tribe lives in the southwest area of the United States in Arizona, New Mexico, and Utah. The term familial tells us the problem is inherited but the exact gene or genetic problem is still unknown.

The symptoms are similar from case to case. That’s what the name neurogenic arthropathy is all about — the classic symptoms seen in each of these cases. Neurogenic refers to the loss of sensation to deep pain. Without that protective response, the child can develop joint deformities and problems with limb alignment (especially in the legs). Arthropathy is another term to mean joint disease.

In this report, the authors use two cases of children affected by Navajo familial neurogenic arthropathy to show us what happens to patients with this condition. Although the focus is on the orthopedic (bone and joint) problems faced by these children, there are other problems. Anhidrosis (inability to sweat) is one of those problems. These children can’t tolerate high temperatures. And this heat intolerance is made worse by the fact that they live in a hot, dry desert climate.

Both children in the study appeared normal at birth and during the early years of life. There have never been any issues with cognition or mental capacity. But an accident at age five for one patient and symptoms of suffering in the heat for the second patient brought them into the hospital for examination. A closer look at the child’s problems led to a more thorough examination and tests resulting in a final diagnosis of Navajo familial neurogenic arthropathy.

Each child was treated according to his injuries or deformities but the results were disappointing. The first child fell out of a truck and broke his leg and went on to develop a severe knee deformity, joint infection, and almost died from a blood infection. He ended up having many operations and was in intensive care for a long time before going home. The second child also developed knee problems that resulted in severe destruction of the joint called Charcot arthropathy.

Both children have been treated conservatively without any further surgeries. They have developed deformities of the spine and arms in addition to the problems already present in the legs. Both use a wheelchair now with a slow decline in function as time goes by. The results in both cases mirror what has been reported for other children with Navajo familial neurogenic arthropathy.

The authors recommend the following for anyone with this disorder:

Idiopathic clubfoot, a foot deformity from birth, does not alway need surgery for correction. For many years, doctors have been using a the Ponseti method of casting to manipulate the foot into a normal position, reducing the need for drastic surgery in many cases. This method was introduced in the 1950s. In the 1970s, surgery was a more popular option to treat clubfoot as surgeons felt that too many children relapsed when treated with the Ponseti method. Surgery was effective in the short-term, but many patients developed long-term foot pain, disability, stiffness and weakness. In the 1990s, surgeons began looking at the Ponseti method again and found encouraging results, particularly after the treatment was refined. The authors of this article reviewed the effectiveness and outcomes of the Ponseti method and if surgery decreased as a result.

Researchers reviewed the annual number of live births for the duration of the study (from 1996 to 2006). Of the live births, the researchers obtained annual statistics of clubfoot. The number of infants with clubfoot varied from 0.60 per 1,000 births in 1996 to 0.46 per 1,000 births in 2006. There was no gradual decline or increase by year.

In 1996, there were 2,281 diagnosis of clubfoot, 1,641 were repaired by surgery, for a 0.72 rate of procedure. In 1997, that raised slightly to 0.72, but then dropped to 0.56 in 1998. This was followed by a jump for two years, and then drops down to 0.12 in 2006 – 230 surgical procedures on 1,974 clubfeet.

The authors concluded that the rate of surgery for clubfoot was definitely decreasing over time and, in their opinion, this decline will continue as doctors work on less invasive treatments, such as the Ponseti method, with more refining over time.

Surgeons from the Cincinnati Children’s Hospital Medical Center in Ohio have taken the time to conduct a meta-analysis of supracondylar humeral fractures and offer us the results of their findings. In the medical world, a meta-analysis is a big deal. Because most surgeons don’t see 100s or 1000s of the same type of fracture, they depend on reports like this to guide their treatment. By combining the results from many patients, it’s possible to analyze what works best and what treatment to avoid because it causes significant problems.

For example, nerve injuries are the biggest complication with supracondylar humeral fractures. You may be wondering what’s a supracondylar humeral fracture? This is a break in the upper arm bone just above the elbow. It’s the most common type of elbow fracture in children but is relatively rare in adults. In fact, at least half and as many as 70 per cent of elbow fractures in children are supracondylar humeral fractures.

The fracture is caused most often by a fall on an outstretched hand. As the hand hits the ground, the elbow is hyperextended or hyperflexed resulting in fracture above the condyles. The condyles are the bumps you feel on either side of your elbow. Supracondylar means the break is just above those bumps (condyles).

Nerve injuries called neuropraxia associated with supracondylar humeral fractures occur for one of two reasons. The first is from damage done to the nerve by the jagged edges of the displaced (separated) broken bones. The second is from pins used to hold the bone together while it heals.

The authors’ intention with this meta-analysis was to find out: 1) how often do nerve injuries occur with displaced flexion versus extension supracondylar fractures, 2) how often do pins placed through the bone contribute to nerve damage, and 3) does it matter which side of the elbow the pins are placed through in relation to the neuropraxia?

A little bit of information about neuropraxia here might help explain what happens to the patients with this type of fracture-induced or pin-induced injury. Neuropraxia describes nerve damage without disruption of the nerve or its sheath (covering). There is enough damage done that the messages sent along the nerve are interrupted. This causes a temporary loss of sensation and motor function that can last hours to weeks to months. Recovery does occur but can take six to eight weeks or longer.

The meta-analysis provided 5154 cases of displaced supracondylar humeral fractures to study and compare. Children involved ranged in age from three months to 16 years old. About 11 per cent of the group had traumatic neuropraxia affecting one or more of the nerves (median, anterior interosseous, posterior interosseous, radial, ulnar).

Flexion-type supracondylar humeral fractures were slightly more common than extension type (16.6 per cent for flexion compared with 12.7 per cent for extension). The ulnar nerve was affected most often with flexion-type fractures. The anterior interosseous nerve was at risk most often with the extension injuries.

And damage to the nerves from pin fixation showed up in about four per cent of patients included in a subgroup analysis. Nerve damage from pins used to hold the bones together is referred to as iatrogenic neuropraxia (as opposed to traumatic neuropraxia from the injury itself). Iatrogenic means the problem developed as a result of the treatment. Placing the pin through the lateral side of the bone (side away from the body) was more likely to cause median nerve injury. Pin placement through the medial side (inside of the elbow) increased the risk of ulnar nerve damage.

Knowing the details of traumatic and iatrogenic neuropraxia associated with displaced supracondylar humeral fractures can help guide surgeons when treating children with these common elbow fractures. Anything surgeons can do to avoid or prevent neuropraxia makes for an easier recovery for these children. With the information gleaned from this meta-analysis, surgeons can watch carefully for nerve injuries based on type of fracture and placement of pins when fixation is required.

It’s clear now that a torn meniscus (cartilage) in the knee should be repaired whenever possible. The previous practice of surgically removing the meniscus resulted in early osteoarthritis. So that practice has been abandoned unless it’s completely unavoidable for some reason. Now, the next debate is whether the meniscus should be repaired at the same time as an anterior cruciate ligament (ACL) tear when these two injuries occur at the same time.

Studies have shown that complex knee injuries that damage more than one structure have the best results when everything that’s torn loose is repaired or reconstructed. But surgeons are still studying the effects of doing one repair at a time versus completing all repairs during the same procedure. Toward that end, this study was designed to evaluate the results of surgery for an isolated meniscal repair versus complex repair (meniscus and anterior cruciate ligament).

The main feature of this study that separates it from others is the fact that the patients were all children or teenagers. All 99 subjects included were 18 years old or younger. This is the largest series published for this problem in this age group. Everyone in the group was treated for a complex injury by arthroscopic surgery. Everything that needed fixing was taken care of in one fell swoop. Specific surgical techniques and methods of fixation are reported by the authors in a table for surgeons who might be interested in this information.

The results were compared with a second group (48 patients) in another study by the same authors of this study. In that previous study, only the meniscus was damaged and then repaired. There were patients treated by these surgeons who had a staged procedure (first a meniscus repair and later reconstruction of the torn ligament) but these patients were excluded from this study.

Just what were the results compared? Lots of things — knee range of motion, stability of the joint, pre- and post-op X-rays, and function. Function was assessed by looking at the activity level before injury, just before surgery, and after surgery. Everyone was in a rehab program after surgery and treated with the same protocol. Since this was a young group of patients who injured their knees, a high level of sports and recreational activity was reported prior to the injury.

Return-to-sports involving sudden changes in direction (pivoting and cutting) was allowed six to nine months after surgery for those with complex injuries before surgery who demonstrated good knee stability after surgery. Patients with just a meniscal tear were able to return to their pre-injury level of sports participation much sooner (four to six months after surgery) if the meniscal repair was successful. And success was defined as no pain (or only mild pain) and no locking, catching, or swelling of the knee. Long-term success is measured by the re-tear rate.

In the group of 99 patients, 90 per cent were tear free after two years. Persistent pain and other symptoms were still present in one-fourth of the group, so the overall clinical success rate was 74 per cent. Five years after surgery, the freedom-from-failure rate dropped to around 77 per cent (down from 90 per cent after two years). One-fourth of the group ended up with a failed meniscal repair and required a second operation.

Risk factors for poor results included participation in a high-demand sport after surgery, the original injury being a complex tear (meniscus and ligament), and a particular type of meniscal tear called bucket-handle tear. Type of surgical repair technique used in the first surgery was not a factor in the failures. For those who had to have a repeat surgery for failed meniscal repair, the majority (two-thirds) had to have part of the meniscus removed. Only one-third of the group could have a re-repair.

Now how did the group of 99 patients with complex tears compare with the 48 who only had an isolated meniscal repair? The complex repairs had a better success rate. That was true no matter what type of meniscal tear was present in the complex injuries. When the only damage done by the injury was to the meniscus, the type of tear (simple versus bucket-handle) didn’t result in differences in outcomes — only when the meniscus was part of a more complex injury.

The authors conclude that they met their own objectives in carrying out this study. They found out the success and failure rates of meniscal tears compared with complex tears in adolescents. They discovered some risk factors that help predict outcomes. And they saw the differences in results when menisci were repaired by themselves versus when the repair is done as part of a meniscus plus ligament repair.

They offer some significant buts at the end of the article that strongly suggest further study in this area is needed. For example, there were five different surgeons involved and the procedures were done over a period of 15 years. A lot can change in that time as surgeons gain experience and as surgical techniques change over time. Some of the 99 patients were skeletally mature (had stopped growing) at the time of the injury, while others had open physes (were still growing).

Not everyone had an X-ray taken during the follow-up visits. It was assumed that anyone who was pain free and had no other symptoms to suggest a problem had a successful result. But it is possible that undiagnosed retears were present in those patients. And finally, healing rates can be highly variable in this age group.

Any of these factors could affect the results as measured in this study. The authors consider this project a springboard for future investigations to further identify other prognostic factors predictive of success/failure. With additional research, they also hope to clear up any other issues around when and how to repair complex knee injuries involving meniscus and ligaments in active teens.

You may have heard the statistic that 80 per cent of all adult experience low back pain at some point in their lives. Well, adults aren’t the only ones with back pain. Studies are now showing that the number of children and teens reporting back pain is on the rise. In this study from Japan, the relationship between sports participation and low back pain is the focus.

Researchers from several different universities in Japan (University of Tsukuba, Kyoto University, Waseda University) participated in this study. They surveyed 4667 incoming freshman at the University of Tsukuba about their sports participation and incidence of back pain. Because every freshman was given the questionnaire to fill out as part of the medical screening process, there was a very high response rate (67.4 per cent).

They showed that students involved in a high level of sports activities were much more likely to have back pain compared with those who either didn’t participate at all or students with low sports involvement. Let’s take a closer look at what questions were asked and how the data was analyzed.

First of all, sports participation was defined as more than three times each week from grade school through high school. Factors investigated included whether the student missed school due to low back pain, presence of leg pain and/or numbness, and whether the student had to quit playing competitively due to low back pain. Additionally, they were asked if anyone had low back pain in the four weeks before filling out the survey.

The authors also collected information on type of sports and length of time the students were involved in each. The most common sports activities were soccer, baseball, basketball, track and field, tennis, kendo, swimming, and volleyball. Kendo is a modern Japanese martial art of sword-fighting. Students who participated in more than one sport or who played five years or more in one type of sport were evaluated a little more closely.

They found that low back pain was just as likely in males as in females, so it didn’t look like sex was a risk factor. Since the students who didn’t play had the fewest cases of low back pain, sports participation itself is a risk factor. And those who played the longest had the highest rates of low back pain so duration of play was also a risk factor.

As for the type of sport most closely linked with low back pain: that was volleyball! Soccer had the lowest association with back pain with baseball, track and field, basketball, swimming, kendo, and tennis in between (in that order).

The authors say it would be easy to conclude from their study that high levels of participation in sports activities is linked with an increased risk of low back pain. But there are some important variables to consider.

First, the freshmen weren’t required to fill out the survey. It was done on a voluntary basis. It’s possible that students who had back pain in the past were more likely to participate in this type of study. Second, it’s well known that sitting for long periods (studying or watching television) is also a risk factor for low back pain. And students (even active sports types) sit as much (if not more) than they play.

The fact that low back pain was greater in those who participated in sports compared with those who don’t may be the most significant finding. It’s likely that the non-sports students sit even more than those who play — but the study didn’t ask for information on number of hours sitting so further study is needed to check this out.

The authors suggest that future studies pay attention to the types of postures and motions and compare these with number and types of injuries for each of the eight sports listed. Based on the results of other studies done, it looks like some injuries (e.g., disc degeneration) are more common in some sports athletes (e.g., swimmers and baseball players in this example).

Why all the fuss about which sport causes the most back pain? Prevention. If it were possible to prevent low back pain in any age group, it would be worth it. Finding the key risk factors might make it easier to keep it from happening in the first place. Setting up guidelines for youth sports that might limit the number of cases and severity of low back pain is the goal.

This study helps move us in that direction by investigating duration of sports activities and type of sports to target. Pointing out areas for future study to further identify preventive and management techniques is an extra benefit of this particular project.

How do you find out about problems that are so rare only 300 cases have ever been reported around the world in the last 25 years? Articles like this one might help. Three cases of a particular elbow problem called congenital proximal radioulnar synostosis are reported and discussed.

Congenital means the child was born with this problem. It isn’t always obvious at first. In these three cases, the children were between the ages of seven and 13 before trauma and sudden, severe elbow pain brought them to the orthopedic surgeon’s office.

Radioulnar refers to the two bones in your forearm: the radius and the ulna. Proximal tells us the elbow is involved — specifically where the ulna and the radius meet at the elbow. These two bones also meet at the wrist. Synostosis just means there’s an abnormality in the joint. Let’s find out what kind of deformity was present with this diagnosis for these three children.

All put together, the term congenital proximal radioulnar synostosis is a failure of the two bones to separate and form a true joint at the elbow. There can be different reasons why this happens. The joint may be dislocated. In other words, the bones aren’t in the right place to allow for normal joint motion. In some cases, the top of the radial bone (called the radial head) doesn’t form properly.

Instead of being a firm, round bone that moves smoothly to allow elbow motion, it’s made up of a stiff fibrous piece of cartilage. Sometimes the shape of the radial head is all wrong — instead of looking like a miniature drum, it looks like a fat mushroom. An overgrown radial head pushes the annular ligament up and over itself resulting in a rubberband-like effect preventing full elbow extension. Any change in the size or shape of the radial head is going to mean problems with normal elbow motion.

And that’s exactly what happened with these three children: they couldn’t straighten their elbows all the way. The elbow was stuck in a flexed or bent position. How can this problem be solved? Just separating the two bones doesn’t usually do the trick. And treatment may depend on what the underlying cause is — dislocations can be relocated. Surgery is required to distract the joint and then move the elbow through its full range-of-motion, a procedure called reduction and manipulation.

For one of the children in this case series, the radial head had gotten trapped underneath an elbow ligament called the annular ligament. The surgeon was able to release the radial head by cutting the ligament and removing the radial head. This same procedure was done on another patient when the surgeon found that a layer of soft tissue was covering part of the radial head preventing normal elbow extension.

Removing the top of the radial bone is advised because it prevents future elbow problems like pinching against the capitellum, another bony part of the elbow. An open procedure is advised rather than an arthroscopic approach because of the way the soft tissues all blend together around the elbow. It can be very difficult for the surgeon to separate the tissues in order to release the annular ligament. An open incision makes it possible to see how the tissue is formed all the way around the elbow and do a thorough job removing the problem tissue.

In all three cases, there was a history of trauma (soccer injury, lifting, sleeping with the elbow in a fully flexed position) that contributed to the symptoms. But the congenital condition had been present since birth, so it wasn’t just the incident that caused the acute problem. It was more that the trauma triggered an underlying condition to be made known.

The authors intend to follow-up with each child long-term and report later on the results of the selected surgical treatment. Since this is such a rare condition, reports like this can be very helpful for surgeons who might only see one case in a lifetime.

Developmental dysplasia of the hip is a dislocation of the hip that affects one or both hips from birth. It can range from mild and not noticeable until the child walks to severe and immediately identified. While in most cases the condition can be treated successfully, it has been found that later on in life, patients are prone to hip problems that can be related back to the dysplasia. Although doctors don’t know exactly why there could be later life problems with the hip, such as osteoarthritis, one theory is that the pressing of part of the femur (thigh bone) against the pelvic wall could result in tissue damage over the years.

The authors of this article examined how often there was this type of pressure caused by acetabular retroversion (part of the femur tilting back or turning onto the pelvic bone) and how it could relate to patients with developmental dysplasia of the hip. To do this, researchers recruited 59 patients (52 females) who had been diagnosed with developmental dysplasia of the hip as a child. Combined, they had a total of 96 hips with developmental dysplasia. Their age at the time of the study was an average of 40.1 years, ranging from 15 to 60 years. Eleven patients had received treatment for congenital dislocation of the hip. Of 48 patients, 69 hips were symptomatic, which means they were causing pain and discomfort. The hip dysplasia group was compared with a control group of 44 subjects (40 females), who ranged in age from 52 to 83 years, with an average of 75.1 years. No-one in the control group had any hip abnormalities or degeneration.

The researchers took x-rays of all subjects, looking at the joint and at movement, measuring angles that the hips could bend comfortably. Computed tomography scans (CT scans) were also performed on the patients with developmental dysplasia. Upon examination for the study, 69 hips were reported as painful in the study group.

The results showed that 18 percent, or 17 of the 96 hips, in the study group had developed acetabular retroversion and the angle at which they could bend was smaller than those who did not have the problem. In the control group, who did not have hip problems, there this affected only 4 percent, or two of 50 hips. There were also signs of acetabular anteversion, where the top of the bone tilted forward, but this occurred in far fewer hips and at smaller angles.

The onset of pain in adulthood began, on average at 27.9 years of age in those patients with the positive acetabular retroversion because of damage within the joint. Among the hips without this, the average age of pain onset was 40.5 years. Patients with acetabular retroversion had almost a four times higher risk of pain onset than those with acetabular anteversion. And, body mass index also played a role in the onset of hip pain.

The authors concluded that there was a connection between earlier developmental dysplasia of the hip and later onset of hip pain, caused by acetabular retroversion.

Most people think of arthritis as something older adults often suffer from. But juvenile idiopathic arthritis (JIA) affecting children is not uncommon. This condition used to be called juvenile rheumatoid arthritis (JRA) but new findings have shifted the name to reflect numerous subtypes of the disease.

Two pediatric rheumatologists from Children’s Hospital of Philadelphia wrote this article on juvenile idiopathic arthritis (JIA) to give us a better understanding of the condition. The information is also intended to help physicians treating children and teens with JIA make informed decisions about treatment.

First of all, who is affected by this potentially disabling disease? It first appears in children at a very young age (between one and three years old). It can develop later but rarely presents in babies before age six months. Early diagnosis and treatment can help prevent long-term complications but there is no cure. In some children, it disappears as mysteriously as it came. In others, active disease accompanies them right into adulthood.

What causes juvenile idiopathic arthritis (JIA)? No one knows for sure. There are probably multiple factors including genetics, confusion within the immune system, environmental agents, bacteria or viruses, trauma, and irregular hormone function. JIA is considered an autoimmune because the immune system fails to recognize self from nonself, identifies the joint as a foreign substance, and attacks itself.

How is it diagnosed? There isn’t one single individual lab test that can be relied upon to identify JIA as the underlying problem for all affected patients. That’s why doctors have to depend on the child’s symptoms, history (including family history), X-rays, and other imaging studies to make the diagnosis. There are a couple of blood tests that can help (e.g., presence of antinuclear antibodies or ANAs and rheumatoid factor (RF), but they aren’t positive in everyone.

How can you tell if your child has juvenile idiopathic arthritis? The first symptom is morning stiffness or joint stiffness after any prolonged period of rest or inactivity. Getting out of bed in the morning is a real chore. Te child may walk funny or with an odd gait. Getting the child moving or ready for daycare, school, or daily activities can be difficult. Young children don’t always complain of pain or say they feel stiff but they clearly feel better as the day goes on.

Since any joint can be affected, some odd symptoms might pop up — like difficulty chewing when the jaw is involved, an inability to turn the head when the neck is inflamed, or problems lying flat or leaning the chest against something when the sternum (breastbone) is affected.

Juvenile idiopathic arthritis is a systemic disease meaning it can affect the whole body and not just the joints. Besides joint swelling, pain, and loss of motion, the physician may notice changes in the eyes, swollen glands, an enlarged spleen or liver, and changes in heart and lung sounds.

The authors provide a detailed explanation of the seven subtypes of JIA. These include oligoarticular JIA, polyarticular RF-positive JIA, polyarticular RF-negative JIA, systemic JIA, psoriatic JIA, enthesitis-related or ERA arthritis, and finally, undifferentiated arthritis. These are listed in descending order of frequency. Oligoarticular JIA (affecting more than one joint) is the most common subtype. ERA and undifferentiated arthritis are much more rare.

The physician must know the various components and characteristics of each of these subtypes. This knowledge aids the physician in recognizing, diagnosing, and then treating the problem. For example, polyarticular arthritis affects girls more often than boys — usually in the teen years. It may be easy to think the multiple joints that hurt are linked with her menstrual cycle because that’s a new and different event in their lives. But a blood test will show whether this is an RF-positive or RF-negative form of JIA.

Enthesitis-related arthritis creates inflammation where the tendons attach to the bones. Boys are affected most often and present with back or sacroiliac pain and stiffness. This subtype is often accompanied by inflammatory bowel disease so there can be nausea, abdominal pain and/or bloating, and diarrhea. It’s important that these symptoms aren’t attributed to growing pains or stress. Again a blood test often reveals the presence of HLA-B27, a marker that helps make the diagnosis.

As the name suggests, systemic JIA comes with symptoms that affect the whole body: fever, skin rash, swollen glands. The children (boys and girls equally) are very sick but it can look so much like the flu or a virus that nothing is said or done until months go by and the symptoms keep coming back. Eventually the diagnosis is made but by that time, damage can be done to the joints.

The physician does have a few tools in the medical bag that can help figure out what’s going on. We’ve mentioned blood tests and X-rays. These aren’t always good screening tests but they do provide a place to start and sometimes reveal significant findings. When X-rays are negative, ultrasound, bone scans, and MRIs may be more helpful. Each one contributes something different, so the physician orders them based on the clinical presentation and history.

For children with swollen joints, a small bit of the fluid within the joint called synovial fluid can be withdrawn and tested. Signs of infection or inflammation can be seen when the fluid is examined under a microscope.

Throughout the search to find out what’s wrong, the goal is to treat early and quickly in order to reduce pain, minimize joint damage, and help the child maintain a normal lifestyle. Adequate management over the course of the disease process is important in order to improve quality of life measures as well.

In summary, this was the first of a two-part series reviewing the condition known as juvenile idiopathic arthritis. The focus of this first article was the recognition and diagnosis of the problem with an understanding of the causes and subtypes of JIA. The second article will be coming out with an update on the treatment and management of JIA for all seven subtypes.

Elbow dislocations can happen easily to children and sometimes, the elbow “pops” back into place on its own before the child is seen by a doctor. While this spontaneous reduction of the dislocation may be less traumatic for the child than having to have a doctor reduce the dislocation (put it back), there is a rare complication called intra-articular incarceration of the median nerve. This means that the median nerve that passes through the elbow, down the arm, becomes trapped. Unfortunately, this can’t be seen while the child is being examined just after the injury occurred. The authors of this article describe a case study of a four-year-old boy who had a spontaneous reduction and an incarceration of the medial nerve.

The child had fallen out of a wheel barrow and landed on his outstretched hand. When his parents brought him to the emergency, x-rays did not show any dislocation or fracture, but there was some joint effusion, fluid on the joint. The boy had significant burning pain around the right elbow and he refused to move it. The elbow was tender to touch and there was restricted passive range of motion, meaning that when the doctor tried to move the arm, the motions were not a wide as they are normally.

The final diagnosis was a small fracture of the upper part of the humerus (forearm bone) and a half-splint was applied. On follow up visits, the boy showed signs of nerve damage, including the inability to bend his second and third fingers (pointing and middle fingers). His wrist was weak to bend and turn. X-rays did not show anything out of the ordinary. At this point, the doctors felt that the nerves would recover on their own so the splint was left on for additional time.

Six months after the initial fall, there were still problems with the nerve conduction to the wrist and fingers. After eight months, the doctors found that the nerve had been trapped and they had to do a osteotomy (bone had to be cut) to free the nerve. A cast was applied for two weeks and after six weeks, the boy was able to move his elbow completely. Fourteen months after surgery, his fingers and wrists have improved but there is still some muscle atrophy, wasting.

The authors note that anyone who presents with a nerve problem after they dislocated a joint should be followed closely to avoid longer than necessary diagnosis of nerve entrapment. Once the diagnosis has been made, surgery is usually needed to free the nerve and prevent further damage. The surgery may be difficult, given the scar tissue, limited space, and flattened nerve.

Rehabilitation after this type of surgery should involve splinting the joint for a short period to allow for wound healing, followed by physiotherapy (at home or at a clinic or hospital) to encourage new movement and regaining of range of motion.