News Category: Child

Bone morphogentic protein, called BMP, is a naturally occurring protein that scientists have discovered can be a replacement for bone grafts. A bone graft is a procedure where a surgeon replaces part of a bone to attach to another bone to either replace a missing part or to strengthen it. Usually, the graft is done with part of the patient’s bone, taken from elsewhere in the body, but grafts can be taken from cadavers, people who have donated their body for this purpose.

At issue with BMP is the lack of studied done regarding the safety of using it among children. Currently, there are good safety reports for adult use.
The product, rhBMP, has been used in children on an off-label basis, meaning it has not been given the official go-ahead by the United States FDA. Good reports have come from its use such as with one case where rhBMP was used to correct problems with the tibia in three different children. It was also used successfully for spinal surgery in a 2-year-old girl. On the other hand, one study, done by Lee and colleagues, found that of five cases where they used rhBMP for tibia correction, only one had a satisfactory response. The authors of this article evaluated the use of the product recombinant human bone morphogenetic protein , or rhBMP, in children to see if there were any complications that could be associated with its use.

Researchers found 81 patients (37 male) who had 101 surgical procedures using rhBMP among them. The children ranged in age from 1.6 years to 17.8 years at the time of their surgery or surgeries. The researchers reviewed the patients’ charts for demographic information, surgical records, and follow-up data. Follow-up lasted, on average, about 22 months. In addition, the researchers searched through the medical literature to find mentions of any types of complications and theoretical complications associated with the use of rhBMP.

The researchers were able to find nine operative site problems that included abnormal wound drainage (five patients), swelling (two patients), and dehiscence (wound opening) (two patients). These all resolved with local wound care. Seven problems that could have been related to the use of rhBMP were also noted. This left the group with a complication rate of 17.5 percent. Because of multiple surgeries in some children, some were exposed to rhBMP more than once: eight received it twice and one patient three times. There were three complications noted in this smaller group, leaving a 27 percent rate. No signs of toxicity in the system were found by the researchers, nor was their excessive bone growth at the grafting location.

Other complications included infections, which may occur after any type of surgery. In this study, three patients had deep infections when they were seen at follow-up and this needed care, including irrigating (cleaning out) the wound, debriding (removing dead tissue) and intravenous antibiotics. Another possible post-surgery problem is compartment syndrome, a condition where the nerves, blood vessels, and muscle become compressed. One patient in this study did develop post-surgical compartment syndrome. Another patient developed dural fibrosis, a thickening of tissue, which resulted in weakness.

One concern was the possible carcinogenicity, or cancer causing issues with rhBMP. The researchers did not find any cancers of the soft tissues, called sarcoma, although one patient was diagnosed with cancer in the brain (gliomas).

In conclusion, the authors believe that their study findings show that rhBMP is a relatively safe product to be used in children when it is appropriate. However, because it is still being used off-list, the use of the product should be thoroughly discussed with the parents or guardians before it is used in the children.

Osteochondritis dissecans is a condition where the blood supply to a part of the bone is cut off, denying the bone cells the nutrients from the blood. Some people who develop osteochondritis dissecans don’t experience any symptoms. Others, particularly older children, teens, and young adults who are active in sports, do develop symptoms that can include pain, “locking of the joint,” and swelling. Ultimately, movement could become quite restricted especially if the bone that is affected is the femur, the shin bone, where it meets the knee.

Doctors don’t know what causes osteochondritis dissecans of the knee but they do agree that symptomatic cases need to be treated as soon as possible to avoid any long-term damage and disability. Management, however, is controversial with doctors approaching it in different ways. Some doctors prefer more conservative treatments, while others prefer surgery. The authors of this article wanted to determine if the presence of asclerotic ring (hardened tissue in a ring shape) around the area of the lesion, would be able to tell doctors ahead of time how well the condition will heal.

Researchers looked back at the records of 85 patients (62 boys) who had been diagnosed with osteochondriti dissecans. They were divided by age at time of diagnosis: group 1 was under 12 years old (about 29 percent of the children), group 2 was between 12 and 15 years old (57 percent), and group 3 was 16 years and older (14 percent). By reviewing two different angled x-rays that had been taken when the patients were diagnosed, the researchers determined in which group of three the patients belonged:

– Stage 0: no sign of a sclerotic rim on any angle of x-ray
– Stage 1: signs of a sclerotic rim in one angle of x-ray
– Stage 2: signs of a sclerotic rim on both angles of x-rays

The patients were initially treated conservatively (restriction from sports) for about 10 months. Those patients whose x-rays did not show improvement after conservative treatment went on to have surgery. This surgery involved drilling through the sclerotic ring using arthroscopic surgery, surgery done through tiny incisions that the surgeon uses to insert long instruments and a camera.

Healing in the patients with stage 0 was 100 percent, after 12 months, without surgery. Those with stage 1 healed without surgery in 36.4 percent of cases, with surgery in 63.6 percent. Among patients with stage 2, only 13.5 percent of cases were healed conservatively.

The authors concluded that the presence of the rim on x-ray can help predict if a patient will heal spontaneously, with conservative treatment, or will need surgery.

Slipped capital femoral epiphysis is a condition where the upper part of the femur (thigh bone) slips backwards, out of place. It affects adolescents, usually just after puberty. Because the condition isn’t all that common, the authors of this article reviewed their particular institution’s experience with dealing with valgus (turning outward) slipped capital femoral epiphysis.

Researchers reviewed cases of children who had undergone surgery to correct the disorder. The researchers divided the cases into either classic (varus) or valgus. If it wasn’t clear as to which type the child had, he or she was not included in the study. In all, 12 children with valgus slipped capital femoral epiphysis were identified.

The researchers made note of the patients’ demographic information (age, gender), their x-rays and clinical notes when they first arrived at the institution, treatment, and follow-up. They also measured hip stability (ability to bear weight). In order to compare results, the researchers also looked at 123 x-rays of atients who had been diagnosed with the classic form of the disorder.

What was found was that valgus slipped capital femoral epiphysis occurred in only 4.7 percent of the cases overall (12 out of 258 patients). Fifty-eight percent of the patients were girls and four patients were diagnosed with endocrine abnormalities. The endocrine system is the part of the body that controls growth, development, tissue function, and more. One patient had been diagnosed with Stickler syndrome, a connective tissue disorder. Interestingly, the patients who had the valgus type of disorder had their femoral neck angle that was higher than those who had the varus type.

To manage the problem, surgery was performed on 11 of the patients. Screws were inserted to stabilize the hip. None of the patients experienced any significant complications as a result of the surgery, however the surgical procedure itself was difficult to perform in five patients. During follow-up, two patients experienced complications. one had to have the hardware removed from the hip and the other needed additional hardware inserted.

In conclusion, the authors wrote that valgus displacement may look fairly normal on x-rays taken from the front of the hip (anterior). Patients with the valgus type are often most likely to be obese, have an endocrine imbalance, or have Stickler syndrome. Surgical correction can be difficult, but results are usually successful.

Clubfoot, a condition where a foot (or both feet) turn inward and downward, is a common orthopedic problem. In New Zealand, where the authors of this article are based, clubfeet are present in almost seven out of every 1,000 people who are of Polynesian descent, an ethnic group that makes up almost one quarter of the New Zealand population. The rate of clubfeet in Polynesian ethnic people is quite high compared with those of white European descent, who have an average of one clubfoot out of every thousand.

Traditionally, treatment of clubfoot in New Zealand has been with surgery, followed by casting below the knee. However, because there are so many clubfeet in New Zealand, researchers wanted to compare traditional surgery with manipulation and casting, called the Ponseti method. The study was supposed to be randomized, a procedure where the parents and the researchers don’t know what type of treatment the children had, but only nine families agreed to the randomization; the others would not participate if they didn’t know what treatment was being done. As a result, this was a study where the researchers looked back at the results, instead.

Researchers recruited 55 patients who had a total of 86 clubfeet. All patients had idiopathic clubfoot, which means that there was no known cause of the deformity. Twenty six patients (with 40 clubfeet) were treated with the Ponseti method and the remaining 29 patients (46 feet) were treated with surgery, followed by below-the-knee casts. The researchers gathered information on the children’s sex, ethnicity, family history, the Pirani score (based on level of deformity), the number of casts used to treat each clubfoot, any complications, and if any revision (repeat) surgery was needed.

The children in the Ponseti group had casts applied to their clubfeet to manipulate their feet into the desired position. After the feet reached a certain angle, a small surgical procedure was performed to release (lengthen) the Achilles tendon, the tendon at the back of the ankle. Finally, the feet were then held in position by a cast for another three weeks, followed by bracing for three months full time and then for at least nine months worn while sleeping, including nap time. The total time for bracing was at least one year.

The children in the surgical group were also casted at first, but the casts were changed every week or two, depending on the child, as the foot moved position. At around six months old, each child had surgery, although the more severe clubfeet were generally operated on before the moderate or milder cases. During the surgery, the joints and muscles were moved and the Achilles tendon lengthened, as with the Ponseti group. In some cases, wires were inserted to hold the feet into place. After the surgery, the cast would be changed a couple of times. No bracing was done after the final cast was removed.

In gathering the data, the researchers found no difference between outcomes when looking at the two groups in regards to the children’s sex, ethnicity, which foot was involved, age at first casting, initial Pirani score, or the number of years the children participated in follow-up. There was a significant difference between the groups with the number of casts used before Ponseti or surgery, with many more being used in the surgical group (5 versus 11) and in total, there were six compared to 13. Twenty four children had difficulties with their casts (poorly fitting, skin irritation) that required recasting.

Looking at the age of the children, those in the Ponseti group had, on average, the Achilles tendon procedure when they were 2.4 months, while the children in the surgical were, on average, 6.7 months when they had this procedure. Thirty eight of the feet in the Ponseti group had this procedure; 43 of the other group did.

Forty three of the children who had below-the-knee casts ended up having surgery, with 42 of them having a more extensive surgery. Eleven had the posterior released and the other 31 had the posteromedial (midline and back) released. Thirteen in this group needed repeat or revision surgeries. In the Ponseti group, 14 of the feet required a total of 15 surgeries (one revision), but 11 were minor procedures. Only four needed posterior (one) or posteromedial (three) releases. Both groups had two complications after surgery. In the surgery group, one child developed a urinary tract infection (UTI) and another developed cellulitis, infection in the skin. In the Ponseti group, one child developed an infection in the incision after having a posteromedial release and the other developed an infection after tendon surgery.

The average follow-up was 3.5 years for the Ponseti group and 3.8 years for the surgery group. Fifteen feet in the Ponseti group had recurrences, as did 14 in the surgery group. Only nine (35%) of the children in the Ponseti group wore their brace for the full year.

The authors pointed out that although the recurrence numbers were similar in both groups, the severity of the recurrence and the need for major surgery was different, with the surgery group requiring more than the Ponseti group. As well, with such a high rate of non-compliance with bracing for a full year in the Ponseti group, it was not possible to tell if the recurrences were due to an issue with the method or with the lack of proper bracing.

In all, the authors concluded that the Ponseti method was cost effective because of the similar results without the major surgery, however compliance was an issue.

Idiopathic scoliosis, curvature of the spine for unknown reasons, may be treated in a few ways. While mild curves may be left untouched but monitored, moderate curves of between 20 to 45 degrees may be treated by bracing, sometimes for up to 23 hours per day. However, not all doctors agree with bracing as treatment and feel that surgery is a more effective and permanent solution for the curved spine. This opinion is often due to factors such as teen patients not being compliant with their bracing treatment, often because the braces result in poor self-image, particularly in boys.

Surgery can be approached in a number of ways. One method involves using staples across the length of the bones, the physes, but earlier attempts at using staples were not very successful, resulting in problems such as breaking or loosening, causing instability in the spine. The authors of this study reviewed the cases of patients who had undergone stapling with a new product. The goal of the study was to see if the new product was feasible and safe, two years after surgery.

Researchers reviewed the cases of 28 patients (24 girls) who had been treated with vertebral body stapling. Among the patients, there were 26 thoracic (mid back) curves and 15 lumbar (lower back) curves. The study began with 29 patients, but one was lost to follow up after one year. The researchers noted the patients’ age at the time of surgery (average 9.4 years), the procedure, when the surgery occurred, if any complications occurred, the patients’ measurements before and after surgery, after one year and again after two, as well as x-rays taken every three months.

All the patients underwent the same type of surgery and the same type of postoperative car. They initially wore a non-corrective brace (corset) that was used to stabilize the staples. After four weeks, the patients were allowed “activity as tolerated,” and after six weeks, the patients had no activity restrictions. To be considered a successful outcome from surgery, the patients’ curves were corrected to within 10 degrees of surgery measurements or had decreased more than 10 degrees.

When reviewing the findings, the researchers noted that in 13 patients, only the thoracic curve was stapled, while 13 patients had both thoracic and lumbar curves stapled. Finally, two patients had only lumbar curves stapled.

The thoracic group curves were divided into two, depending on their curve size: below 35 degrees and 35 degrees or more. Among the 18 curves of less than 35 degrees, three improved, there was no change in 11 and four worsened. There were eight curves in the other group. Only one improved, there was no change in one, and six worsened. Thoracic kyphosis, humpback, improved in seven patients.

The lumbar curves (15) were kept in one group. Three patients with lumbar curves improved, 10 had no change, and two worsened. Lumbar lordosis, swayback, improved in all cases.

Patients who had both curves (13) showed a 61 percent rate of success, but the authors noted that the group was too small to see if there were any significant differences in the changes between the double curves and the single ones in the other patients.

Complications did occur as a result of some of the procedures. In this group, there were two major complications (rupture of a congenital diaphragmatic hernia after surgery, and an overcorrection of the curve, making it necessary for a second surgery to reverse the curve). There were two minor complications and three broken staples but none of them needed to be removed.

The authors concluded that the stapling could be an option to treat scoliosis that could still progress but more follow up, particularly as the patients head towards bone maturity, is needed to be more definite.

A group of Japanese orthopedic surgeons have been studying young athletes who experience low back pain that goes down the leg. The leg pain is referred to as radiculopathy. It means there is pressure on a spinal nerve root in the lumbar spine. This type of presentation is rare in young athletes. After collecting data on 10 such cases, the authors provide a report on what’s going on to cause these symptoms.

Using X-rays and CT scans, the surgeons were able to identify the main problem as lumbar spondylolysis. Lumbar, of course, refers to the vertebrae in the low back or lumbar spine. Spondylolysis is a medical term to describe a stress fracture of a supporting column of bone called the pars interarticularis. The most common place for this type of fracture is at the last lumbar level (L5).

Once the fracture occurs, the body sets up a healing response. Bone fills in around the fracture site forming a bone callus or osteophyte. This lump of bone isn’t always smooth and round. Sometimes it can have jagged edges. And there isn’t a lot of extra room in this area of the spine. If the bone extends over into the area where the nerve root leaves the spine to go down the leg, pressure on the nerve from the osteophyte can case leg pain (radiculopathy). There can be other symptoms such as altered sensation in the leg and/or foot (e.g., numbness, pins and needles).

Most adults who develop back and leg pain associated with lumbar spondylolysis do so because of the osteophyte nerve compression. But in this younger group, there wasn’t any evidence of osteophyte nerve compression, yet radiculopathy still occurred. The authors reasoned that there must be other reasons for this symptom.

Sure enough, when they did further imaging studies with MRIs, they found a cyst in one patient and a herniated disc in two others. The remaining seven patients in the study group had a hematoma (pocket of pooled blood) and edema (swelling) in the area of the fracture site. It appeared that these two responses to the fracture were irritating the nerve root closest to the fracture site.

The patients were treated and followed over time to see what the final results would be. The patient with a cyst ended up having surgery to remove it. The patients with disc problems were treated successfully with conservative (nonoperative) care. And the remaining patients with hematomas and edema were also treated conservatively. Conservative care consisted of wearing a brace for at least a month and stopping all sports and physical activities.

Everyone was followed with repeat MRIs, which showed a gradual healing response at the fracture site. As a result of seeing the various causes of the radiculopathy, the patients were divided into two separate groups. The group with cyst or disc-related problems were labeled as having nonspondylolytic radiculopathies. For the patients with disc problems, stress on the disc between the fractured vertebra and the vertebra above or below it resulted in disc degeneration, protrusion, and eventually herniation. Because the cause of the radiculopathy isn’t the fracture site itself but something else caused by the fracture (cyst or disc), this type of radiculopathy gets the nonspondylolytic radiculopathy designation.

The rest of the patients were labeled as having spondylolytic radiculopathies. Their symptoms were a direct result of changes at the fracture site (edema and hematoma). The changes were not because of jagged bone edges pressing on the nearby nerves as is often seen in adults with this problem.

Instead, these young patients with spondylolytic radiculopathies were in the early stages of spondylolysis when the body was still responding to the acute injury. The natural history (what happens over time) for these patients is that the body heals itself over a period of months. The fracture heals, the swelling goes down, and the body absorbs the hematoma. These changes take place over a period of six to seven months. For the patients in this study, surgery was not required for the problem to resolve itself. We call this a self-limiting condition.

In summary, radiculopathy (leg pain) can occur in young athletes who have been diagnosed with lumbar spondylolysis but the condition is rare. This is the first study to show that radiculopathies can be spondylolytic (those caused directly by the fracture site) or nonspondylolytic. Spondylolytic radiculopathies don’t always occur because of jagged bone edges pressing on the nearby nerve. There can be other causes of nerve impingement such as the hematoma and edema observed in the early stages of healing. Nonspondylolytic causes of radiculopathy occur less often and can be accounted for by cyst formation or disc degeneration — indirect biomechanical effects of the spondylolysis defect.

Imagine a 12-year-old with low back pain from a herniated disc. You might think disc problems only affect adults but it happens even in children. Fortunately, it doesn’t happen very often so we don’t know a lot about it. But thanks to the surgeons at Children’s Hospital in Boston, we now have some data to give us a better idea of what happens to these children.

One surgeon performed 87 lumbar microdiscectomies in children ages 12 to 18 over a 10 year period of time. By going back through the charts and performing a medical review, it was possible to get a composite view of this group. Their symptoms, clinical findings on exam, and MRI results were reviewed. The researchers helping on this project took a look at how the surgery went — amount of blood loss, length of stay in the hospital, and complications.

What does a herniated disc look like in this age group? Well, like adults, the affected children suffer from back and leg pain (sciatica). The majority (60 per cent) were female athletes, which left the surgeons scratching their heads? Is this a sex-based injury or merely a reflection of the increased number of girls participating in sports? This study was unable to answer that question.

One-fourth of this group had muscle weakness and decreased deep tendon reflexes (tested at the knee and ankle). Almost half of the pediatric patients had numbness and/or tingling (sensory changes). Painful symptoms did not resolve with conservative (nonoperative) care. The children were unable to resume their daily activities or participate in sports, so surgery was advised.

The surgery performed was minimally invasive (referred to as microdiscectomy) with a tiny incision that didn’t require cutting through back muscles. Instead of cutting away a large portion of the vertebral bone to get to the damaged disc, a tiny keyhole is made through the bone. Then the surgeon used a special operating microscope to see inside and remove the disc material.

Complications such as infection, neurologic symptoms, and cerebrospinal fluid leakage from this procedure are few and far between in adults. And this study showed the same for children. In fact, only one per cent of the group had any problems of this sort. A few more (six per cent) ended up having a second surgery because not all of the disc material was removed the first time causing further painful symptoms.

The authors conclude that this is the first published record on children having microdiscectomies. Many times children with disc herniation respond well to epidural steroid injections (ESI) and physical therapy. Conservative care of this kind is always recommended first as the standard of care. Children who recovered after conservative care were not included in this study. Only those with leg pain that wouldn’t go away had surgery.

A final note was made for surgeons. The high rate of reoperations to remove residual (leftover) disc material can be avoided. The surgeon must appreciate how different discs are in children compared to adults. Despite herniation, the disc is tough and hasn’t started to deteriorate like adult disc material.

In many cases, there wasn’t a single piece or fragment of disc to remove. The surgeon had to cut away the protruding disc and make sure there was no more compression present at the time of the operation. Children generate new bone quickly and can end up with a hardened shell around the herniated disc as the body tries to repair the damage itself. That requires a chisel to break up the shell before removing the disc.

Despite these unique challenges to microdiscectomy, the procedure is safe and effective in this age group. Almost all of the 87 children in this particular study were pain free and able to return to their regular activities including sports eight to 12 weeks after surgery. The authors predict that these early disc problems will NOT put the children at risk for future back problems but this remains to be seen. The children will be followed into adulthood and long-term results studied.

If you are a parent of a school age child, you’ve probably wondered if carrying those heavy backpacks is really such a good idea. But when you suggested trying a rolling backpack, all you got was an eye roll and the message that those just aren’t cool. So your son or daughter continues to struggle under the weight of a backpack that can sometimes equal one-fourth of their body weight.

But what can you do? The results of this study might give you the ammunition you need to make some changes. Parents are increasingly expressing their concerns to teachers, principals, and school board members. These individuals and groups can set school policies to limit size, weight, and usage of backpacks. Children can be given time in the school day to complete assignments and studies that would otherwise require carrying multiple heavy books home.

So, just how dangerous is it to wear these backpacks? Researchers from the University of California (San Diego) teamed up with doctors from Rady Children’s Hospital (also in San Diego) to conduct an experiment. They used standing magnetic resonance imaging (MRIs) to measure the physical effects on children’s spines from wearing backpacks of differing weights. Boys and girls between the ages of nine and 14 were loaded down with 12, 22, and 32 pound backpack loads. That’s about 10, 20, and 30 per cent of their body weight. MRIs were taken with each of these weights.

Two MRI measurements were made: disc height and spine curvature. The researchers were expecting to see narrowing of the lumbar discs as a sign that the vertebral bodies were compressed under increasing loads. And that’s exactly what they saw. They also saw lumbar asymmetry (curvature of the spine in the low back region). And when they had the children report and rate their level of back pain, there was a significant increase in low back pain linked with wearing these heavy loads.

This is the first study using radiographic imaging to provide solid evidence that high contact pressures from heavy backpacks leads to back pain and abnormal compressive forces on the spine. Measurements taken showed that there was increased load throughout the lumbar spine (from T12-L1 all the way down to L5-S1). The greatest load was recorded at the L5-S1 segment. And as the children adjusted their posture to higher loads, the spine started to curve to one side or the other. The children shifted the load to the right shoulder most often in an attempt to balance their center of gravity with the heavier loads.

The results of this study highlight the effects of heavy backpack loads on the lumbar spine. And that was with wearing the pack on both shoulders at the same time. Other studies have used the same two-strap pack configuration but looked at pelvic position. The pelvis also shifts to accommodate loads causing asymmetry (unevenness) and rotation of the pelvis below the lumbar spine. It is assumed that these responses to backpack load would change even more dramatically when the backpack is worn on just one shoulder. That’s the way many children wear their backpacks most often.

The authors point out that in this study, the children wore the backpacks for a total of 30 minutes (about 10 minutes with each load). That’s not an accurate reflection of how it is at school where they are more likely to wear their packs for 30 to 60 minutes every day. They do tend to take the pack off and on during that time, which might help off load the spine with each episode of wear.

More studies are needed to help show the long-term effects of wearing a backpack. Considering that children are in school 10 or more years, the use and effects of backpacks over at least that time period need to be investigated. Comparing children at different ages and body weights who wear backpacks to those who don’t wear them would also provide additional information. With this type of data, school officials and parents would be better equipped to make and enforce policies to protect children.

Scoliosis, curvature of the spine, affects about three out of every 100 people, although the severity ranges from very mild to very severe. A study done in 1995 looked at the use of back braces in helping correct scoliosis or to prevent it from getting it worse. The patients had all be diagnosed with a curve of between 25 degrees and 35 degrees at between 10 and 15 years old. The authors of this study followed up on these patients to see about their quality of life as adults.

Researchers only looked at the patients who had stable curves at the end of the study and did not include those who had to interrupt their participation due to curve progression. This left the researchers with 100 patients with stable curves. Twenty-three were unavailable for follow-up, leaving 77 in the study group. The groups had been divided during the study. One group, which was represented by 40 patients in this follow-up, was only under observation and treatment was done if the curves changed by more than six degrees. The remaining patients represent the braced group. The patients’ charts were reviewed as well as x-rays. The patients were asked to complete the SRS-22 quality of life questionnaire, which was specifically designed for patients with scoliosis.

The results showed that neither group, neither group of patients showed any significant change in curve size and no-one had had to have surgery to correct the curve after they reached physical maturity. The quality-of-life scores also did not show any significant differences between the groups. After reviewing the original study and the findings of the follow-up, the authors wrote that patients with moderate adolescent idiopathic scoliosis who are left untreated because of stable curves, will likely have a good quality-of-life, as related to the scoliosis.

Osteoid osteoma is a frightening sounding term, particularly when parents are told that this is what their child has. However, osteoid osteoma is not usually something to be worried about because it is a benign (not cancerous) tumor produced by bone cells and there is virtually no risk of it developing into a cancerous one. That being said, the small tumors, usually less than a centimeter, can be quite painful so they need to be treated. Most often, it is the longer bones that are affected, but any bone can develop such a tumor. The tumors are also found more often in males than females and most of them occur in patients between five and 24 years old.

Once the tumor has begun to cause pain, it may begin to cause swelling and an inability to use the body part that is affected. Some classic features of this tumor is severe night pain and relief from the pain with nonsteroidal anti-inflammatories, such as ibuprofen.

In this article, the authors describe a case history of a two-year-old boy diagnosed with osteoid osteoma after experiencing five months of left shoulder pain and increasing reluctance to use his arm. The pain was also worse at night, responding for a while to ibuprofen. The boy had not had any trauma to the arm or shoulder.

Upon examining the boy, the doctors saw no obvious injury or masses that could be felt. Although the boy may have been reluctant to use his shoulder, he did have good range of motion and his blood tests all came back within normal limits. X-rays were done and this is when the doctors saw a small suspicious area in the shoulder and a bone scan made the images clearer.

Once the diagnosis was made, treatment could begin, which in this case was surgical removal of the tumor. The boy wore a collar and cuff for two weeks after the surgery and then was allowed to resume his normal activity. When he was seen one year later, there were no lasting effects of the tumor or the surgery.

Young athletes rarely develop rotator cuff tears (RCTs). That’s because most rotator cuff tears occur as a result of chronic, repetitive microtrauma causing a gradual degeneration of the tissue and eventual tear. In this case report, one 16-year-old football player’s rotator cuff injury is presented and discussed.

The rotator cuff refers to four tendons (and their attached muscles) that surround the shoulder. They hold the head of the humerus (upper arm bone) in the shoulder socket. The muscles of the rotator cuff help move the shoulder in all directions while the tendons keep it stable in the joint.

There have only been a handful of cases of traumatic rotator cuff tears reported in the orthopedic and sports literature. All were in contact athletes who were hit while playing football. A direct blow to the shoulder was also the cause of this patient’s rotator cuff tear.

The authors present this case to show other sports specialists the importance of considering a rotator cuff tear in the diagnosis. Even when it looks like something else (e.g.,contusion, burner, stinger), there could be an underlying cuff tear as well.

An early diagnosis and treatment can save the athlete’s arm and career. A delayed diagnosis and waiting too long to repair the damage could result in further damage to the soft tissues. Worst case scenario is that too long of a delay in treatment could mean the soft tissues can’t be repaired. A loss of motion, strength, and function could leave the athlete out of the game.

The excellent tendon quality in young (adolescent) athletes is what makes a complete recovery possible. Before inflammation and excessive swelling fill the area, the surgeon can clean up the damage, repair the tear(s), and send the athlete along to rehab.

Making the correct diagnosis requires a careful patient interview. The surgeon must consider all aspects of what happened to avoid missing important details. In this case, the high school quarterback was tackled from behind. At the time of the injury, he had his arm raised overhead. The force of the contact from the other player against the back of his shoulder was enough to dislocate the shoulder and tear four tendons (three of the rotator cuff tendons, plus the biceps tendon along the front of the arm).

Several days after the game, the player was in pain and unable to raise his arm. X-rays, MRIs, and a clinical exam all pointed to a shoulder dislocation that had partially reduced (the head of the humerus slipped back in to the joint). Partial reduction means the shoulder was not completely back in the joint — there was too much swelling and blood from hemorrhaging to make room for the bone just yet.

Surgery was scheduled immediately and the surgeons repaired the damage. At first, an arthroscope was used to examine the extent of the damage. As suspected, there were major tears of tendons and of the posterior joint capsule. Fortunately, the labrum (a fibrous rim of cartilage around the shoulder joint) was not damaged. The labrum helps form a deeper socket for the shoulder joint. Labral tears can be difficult to treat successfully.

After surgery, the swelling gradually went down enough for the head of the humerus to slip back into the joint fully. The patient started on a rehab program under the direction and supervision of a physical therapist. The therapist guided the player through four to five months of movement and exercise to restore joint motion, muscle strength, and joint stability. The therapist helped the athlete prepare to return to full sports participation, which was possible by the sixth month postop.

This case demonstrates the need for careful examination in any athlete who suffers a direct blow to the shoulder. Imaging studies can be followed by arthroscopic exam whenever athletes present with shoulder pain, weakness, and loss of motion that doesn’t go away quickly after the injury. With early intervention, young athletes have an excellent chance of recovery and return to sports.

Overuse injuries used to be seen mainly in adults, in injuries such as carpal tunnel syndrome, but as more children are participating in organized sports activities, doctors are starting to see overuse injuries in them as well. One such injury, osteochondritis dissecans a condition that used to be seen most often in active boys, is affecting more girls now as they join the sports participation ranks. Osteochondritis dissecans is a disorder where there is a disruption in blood supply to the end of a bone, causing bone cells to die from malnutrition. In some cases, nothing happens, but in others, parts of the bone and cartilage come away from the end of the bone, causing pain and making the joint unstable. The injury is being seen more often now in the elbow because of the forces of throwing a ball, for example.

Usually treatment is based on what the doctors find in x-rays and arthroscopic surgery, looking inside the joint with a tiny camera. Different findings result in different classifications. One system described by Bradley and colleagues is described as:

– Type 1A lesions: intact/stable, intact cartilage, no loss of stability
– Type 1B lesions: intact/unstable, intact cartilage but some instability in the bone and imminent collapse
– Type II lesions: open/unstable, clear fracture (break) of the cartilage and collapse or partial displacement of the bone
– Type III lesions: detached, loose cartilage in the joint
– Type IV lesions: two areas where the head of the bone are changing, seen by x-ray

Treatment can be with surgery or non-surgical, although study findings as to non-surgical effectiveness contradict each other. Surgery involves a few different options, from arthroscopically removing the fragments or loose bits with or without drilling, reattaching tissue, etc. The authors of this article are in the midst of studying arthroscopic management of the injury and are presenting their mid-term findings.

The study involves 21 patients – 22 elbows, 10 treated by athroscopic debridement (removing debris) and drilling, and 10 with additional mini-arthortomies (bone removal) for bone grafting or the removal of larger loose bodies after arthroscopy.

Before the surgeries, the researchers obtained information about each patient’s sex, age (average 13.1 years), which arm was to be operated on (16 right elbows), if it was their dominant hand (yes, in 18 patients) the type of injury, sport played, symptoms, duration of symptoms before surgery (average 10.2 months), any treatment tried before surgery and range of motion. After the surgery, the researchers assessed range of motion, as well as follow up, how long it took to return to their sport, and any complications after surgery. Before the surgery, the most common complaint was pain in the elbow (72 percent), followed by catching or locking of the elbow (48 percent) and decreased range of motion (21 percent).

The patients were able to bend their elbows an average of 127.7 degrees and extend it -18.7 degrees before the surgery. After the surgery, they gained an average of 9.7 degrees for bending and 17.2 degrees for extension. All patients were able to move their elbows properly after surgery after a follow up of about 48 months, although five patients complained of limited range of motion after the surgery and four reported pain after activities. Two of those patients did not return to their previous sports activity.

The patients were asked to rate their elbow function on a scale of zero percent to 100 percent after the surgery. The average rating was 87 percent and 18 of the 21 patients did return to their previous sport.

Some children develop a hip dislocation called a stable slipped capital femoral epiphysis. In cases like this, when a hip is dislocated, femoroacetabular inpingement, or too much friction in the hip joint, can cause damage, which can lead to degeneration. If a surgeon operates on this type of dislocation to pin the hip back into place, the surgery gives him or her the chance to see the joint clearly, to check for an friction or problems within the joint. The study described in this article describes and classifies the damage that may occur to the labrum (a ring of cartilage along the edge of the joint) and the acetabulum, the cup-shaped part of the joint that holds the head of the femur, or thigh bone.

Researchers looked at 39 hips from 36 patients (14 girls) that were operated on for stable slipped capital femoral epiphysis. On average, there was a 20-month period between when the patients dislocated the hip or hips and the surgery, ranging from six months to 28 months. The researchers graded the cartilage and labral injury acccording to their severity: mild (zero to 30 degrees); moderate (60 to 90 degrees), and severe (60 to 90 degrees). Eight were classified as mild, 20 as moderate, and 11 as severe.

The surgeons found that there was labral injury in 34 of the 39 hips and cartilage injury in 33 of the hips. The authors of this article describe some of the injuries that had completely eroded the tissue away as “a bucket handle tear.” This damage was seen mostly at the rim of the acetabulum in the front and upper parts. Only one patient had neither type of injury. In patients who had previous surgery and already had pins in the joint, there was damage to the labrum from the head of the screw.When the researchers looked at how long the patients had their symptoms and how severe the injury was, they found no connection between this and the type labral or cartilage injury.

For the most part, the patients experienced at least partial relief after surgery, with many of them experiencing complete relief. The symptoms had included chronic anterior (front) pain that limited their activities, persistent <i.external rotational gait (leg rotating outwards while walking), limited bending of the hip, and poor internal rotation (difficulty turning the leg inwards).

The authors concluded that injury to the tissue does occur when a patient has a slipped capital femoral epiphysis and this could contribute to joint degeneration later on.

When a baby is born with all of his or her fingers and toes and looks healthy, everyone gives a big sigh of relief. But babies can be born with unseen conditions like developmental dysplasia of the hip (DDH). All newborns and infants should be screened as early as possible for hip dysplasia to avoid problems later. That’s why doctors usually test for it at birth or at the first follow-up appointment with the pediatrician.

In this condition there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). Sometimes the acetabulum is too shallow or sloping rather than a normal cup shape. It cannot hold the femoral head in place. Hip dysplasia 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.

Early diagnosis in the newborn and young infant is important. 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. Sometimes the hip joint tries to form another hip socket called a false acetabulum. Without the proper ligaments, soft tissues, and joint capsule to hold the femoral head in place, the false acetabulum creates even more problems.

The physical examination performed by the pediatrician is the most important early diagnostic tool. One of the special tests used most often to look for signs of an unstable hip is the Ortolani maneuver. This test is designed to detect if the hip is sliding in and out of the acetabulum.

To perform the test, the doctor places the infant on a table in a supine position (on his or her back). The doctor then abducts the hips by moving the bent hips and knees apart. If the hip feels like it can be pushed out the back of the socket, this is considered abnormal. This is a sign of instability in the hip. As the hip is abducted further, the doctor might feel the ball portion (the femoral head) slide forward as it slips back into the socket. This is a positive Ortolani Maneuver and is also a sign of hip instability.

If the test is positive, the child will be watched closely or immediately placed in a special brace called a Pavlik harness. Treatment isn’t always required as some children seem to grow out of it. The hip socket is a soft, rubbery cartilage at birth and some children have greater laxity or looseness naturally. This laxity means the hip moves in and out of the socket fairly easily — just like in the child who has the anatomic changes associated hip dysplasia–but without any actual changes in the bone structure.

The Ortolani test doesn’t differentiate between children with true hip dysplasia and those who just have loose hips. Recently, the use of ultrasonography as an imaging tool has come into play with hip dysplasia. Ultrasound testing might also help doctors recognize who has a true case of hip dysplasia and is a good candidate for the harness treatment.

Doctors are also concerned because the harness doesn’t always work to put the hip back in place. In fact, it’s estimated that four out of every 10 infants aren’t helped by the harness. That leads researchers to wonder: is there a way to tell ahead of time which children will benefit from the harness and when it is likely to fail? Are there certain signs or anatomical changes that can be seen early with an ultrasound to help guide treatment?

The results of this study suggest yes and show that babies who test positive for Ortolani sign but fail treatment with the harness actually had a visible reason for that failure. They tested a large number of infants (total of 1,566 hips) and found 228 hips that tested positive using the Ortolani’s test. Only those children who had an ultrasound study done within the first four weeks of treatment with a Pavlik harness were included in this particular study. That amounted to a total of 115 hips.

They divided the children in two groups based on treatment results: those who failed the harness treatment and those who were successful. Failure meant the hip did not go back into the socket and further treatment (usually surgery) was required. Going back and looking at the ultrasound studies and comparing the two groups, they found that the failure group had an inverted labrum. The labrum is a rim of fibrous cartilage around the hip socket. It is designed to give the socket a little bit more depth to hold the head of the femur in place and prevent subluxation or dislocation.

Instead of acting as a buttress or barrier to movement, the labrum in the failure group was inverted (turned inward) and blunted (short) and was therefore at an angle that didn’t help stabilize the femoral head in the socket. Without this added support, the harness treatment only keeps the hip in its socket while the harness is in place. Once the harness is removed, the hip slides out of the socket.

The authors provided photos of their ultrasound pictures with lines drawn in to show other surgeons how they measured the angles and determined that the abnormal labrum was the problem. Two angles in particular were predictive of Pavlik harness failure: femoral head displacement relative to the labrum (FHD-L) and total femoral head displacement (FHD-T).

Children with an FHD-L of zero degrees (normal relationship of femoral head to the labrum) had successful results with the Pavlik harness. These children probably just had loose cartilage and the head of the femur could slip into the socket easily. They may not have even needed the harness. By the time the harness was removed, the cartilage had tightened up and the hip remained in the socket without the harness.

Children with FHD-T angles less than -30 to -40 all failed treatment with the Pavlik harness. This angle indicates that the femoral head was displaced out and up away from the socket too far to be reduced by positioning with the harness. Additional treatment was needed — either with a wider hip angle using an abduction brace or with corrective surgery.

In summary, early imaging for all children with a positive Ortolani test might help sort out those who don’t really need treatment with the Pavlik harness from those who won’t benefit from it and need a different treatment approach. The authors have modified their own treatment of hip dysplasia in several ways as a result of the findings from this study.

First, if an ultrasound study shows an inverted and blunted labrum, they use a greater amount of hip abduction and flexion with the harness right from the beginning. Second if the Pavlik harness doesn’t work in the first four weeks, they don’t keep using it. They switch right away to an abduction brace, which puts the hips into an even wider position to put the femoral head deeply and firmly into the socket. If the abduction brace isn’t successful, then surgery is done to reduce the hip (relocate the hip in the socket).

The authors hope that with additional testing to confirm their findings using the two ultrasound angles will help guide orthopedic surgeons in identifying which children are likely to fail harness treatment and need a more aggressive approach right from the start. If there is a normal relationship between the head of the femur and the labrum (FHD-L angle is zero), the harness has a high probability of success. If the hip is located too far out of the socket (FHD-T is -30 to -40 or more), treatment with the harness is more likely to fail.

Doctors who chose to specialize in pediatric orthopedics may now find themselves dealing less with what they had been taught and more with the results of traumas and accidents, say researchers. While the work may not be all that different in basics (working with bones and muscles, as well as other soft body tissues), the overall approach is different.

When a doctor works in orthopedics and is dealing mostly with children who have been born with certain types of problems, such as clubfeet (feet turned inwards), scoliosis (curved back) and other congenital disabilities, the approach and atmosphere is different than if he or she is working with trauma victims, children who have been hurt through some sort of accident. Because this type of work environment is different, the authors of this article looked into the changing world of pediatric orthopedics, perhaps allowing newer doctors a better understanding of what the specialty is like in the 21st century.

Researchers gathered information from an operating-room database to identify orthopedic surgeries performed on children in 1998 and 1999 and compared this information for similar data gathered from 2006 and 2007 records. By comparing them, the researchers would be able to identify any differences in the number and types of surgeries that were performed. The number of surgeries increased in the second group of records (1605 in the 06-07 period, only 931 in the 98-99 period), particularly among trauma surgeries and surgeries from sports injuries. While in the first period, there were around 370 surgical trauma cases, in the second period, there were 700. In the first period, there were 16 sports surgeries but there were 112 in the second period.

Other types of surgeries were done for the following reasons: congenital, born with the disability (109 first period versus 204 second period), developmental (153 versus 262), infection (45 versus 78), neuromuscular (185 versus 176), and tumors (53 versus 73). The results mean that trauma surgeries made up 43.6 percent of the total in 06-07, up 3.8 percent from 98-99.

The types of surgery were also broken down to spinal surgeries and surgical fractures. The differences were significant in number here as well, but not as a result of trauma. Out of a total of 175 spinal surgeries in 06-07, compared with 83 in 98-99, both only had three trauma surgeries. The largest increase came from congenital, developmental and neuromuscular surgeries.

The surgical fractures were measured by the increase in percentage from the first period to the second. There was a 105 percent increase in fractures of the humerus (upper arm) above the elbow joint. There was a 150 percent increase in fractures elsewhere on the humerus. There was a 52 percent increase in forearm fractures, 211 percent increase in wrist fractures, 55 percent in femur (thigh bone) fractures, 28 percent increase in tibia (shin bone) fractures and a 220 percent increase in ankle fractures.

This type of information for both currently practicing surgeons and for medical students who may be considering what field they may want to pursue. If they have no interest in trauma surgery, then pediatric orthopedics is likely not the best choice. On the other hand, there will continue to be a need for pediatric orthopedists, so it is vital that the medical schools and internships reflect the new reality of orthopedic surgery – that which includes trauma surgeries.

A carpal boss is an area that protrudes (sticks out) at the junction between the first finger bones and the small wrist bones. The condition causes swelling and pain in the wrist and occurs most often in adults, but has been found in children as young as 11 years old. The authors of this article discuss an adolescent, 15 years old, who had a seven-month history of pain in dorsal (back) of the right hand and the wrist. She was since diagnosed with carpal boss.

The patient had not experienced any trauma to the had or wrist nor did she do any heavy lifting with the hand. The pain was worsened when her wrist was extended (stretched out) and if the tendons going to her fingers were pressed upon. X-rays of her hand showed that there was a bony prominence around the metaphyseal area (long part) of the bone at the bottom of the third finger, which led to a diagnosis of carpal boss and wrist extensor tendinitis, inflammation of the wrist tendons.

Treatment for the patient began with anti-inflammatories, medications to reduce the inflammation and a wrist splint. Unfortunately, this treatment didn’t provide full relief for more than two weeks and the pain was now affecting her ability to do everyday activities. More testing was done with a computed tomography scan (CT scan), where the doctors saw the bony mass that extended from the third finger. Surgery was done to remove the bony protrusion. After the surgery, the patient wore a resting splint during the day (part-time) and full time at night, for four weeks, while she participated in a therapy program for her hand. One year later, the patient no longer had pain and was no longer limited in using her hand.

The authors of this article discuss the issue of carpal boss, which is often mistaken for a ganglion, a small, hard bump usually above a tendon and surrounding or enclosing a joint. Doctors often say that a carpal boss is caused by bone spurs that have formed around the joint, either due to degeneration or trauma. Because adolescents rarely have degeneration of their bones and joints, if they develop a carpal boss, it’s most likely due to the bone not fusing properly when they were developing as a fetus.

One study, done by S. Fusi and colleagues, looked at 116 patients who ranged in age from 11 to 75 years. The majority of the patients (94 percent) were relieved of pain after treatment, with seven patients having recurrent symptoms or pain. Similar findings came from a study done by Cuono and colleagues, whose patients ranged in age from 11 to 62 years. The problem with these studies is neither described the effectiveness of treatment for the pediatric population as opposed to the adult population. Because of this, it isn’t possible to tell if surgery is effective for a child’s still growing bones.

Pedicle screws are commonly used in spinal surgery to connect the vertebrae, the bones of the spine. Their use in adults and older children as been studied, but in young children, who have smaller diameter spines and need smaller screws, there isn’t much research or understanding or possible risks. The authors of this study wanted to determine the feasibility and accuracy of pedicle screw placement in children who were younger than eight years old. This age was chosen because the spinal canal generally reaches adults size between the ages of six and eight years.

Researchers looked at the files of 16 children, ranging in age from two years, three months to seven years, eleven months. These 16 children had undergone computed tomography scans of their spines after having pedicle screws inserted during surgery. Altogether, the 16 patients had 88 screws, 30 in the thoracic spine (mid to upper back) and 58 in the lumbar spine (lower back).

As the researchers examined the CT scans, they were looking to see the position of the screws and if there were any complications after surgery from the screws. They found that none of the 16 patients had any complications from the screws and none required a revision surgery to correct the screw placement. There were breaches but no patient had any problems or symptoms.

In assessing accuracy of screw placement, the overall accuracy was 93.2 percent, while the breach rate was 6.8 percent or six screws. The breaches were more common in the thoracic spine (four screws) than the lumbar spine (two screws).

The authors concluded that this study showed that younger children can benefit from the use of pedicle screws in correcting spinal deformities, however, based on findings from another study by Senaran and colleagues, smaller screws would likely be a better choice for children between five years and eight years old.

Chance fractures are fractures of the lumbar (lower) and thoracic (mid-upper) spine and are most often seen in adults who have been in a motor vehicle accident and who were wearing only lap belts as restraints. Chance fractures in children are not common because of the safety restraints used in cars these days, but they do happen. When children do sustain Chance fractures, there is a slight risk of neurological (nerve) issues that result but, usually, doctors find it more common for the children to sustain serious injuries in the abdomen instead, intra-abdominal injuries.

Children who sustain Chance fractures do so usually because they were using lap belts in cars rather than the three-point restraints that hold the chest back, preventing them from bending forward at the waist. The authors of this article write about a family who was in a motor vehicle accident at a high speed. Three of the four siblings (aged 15, 13 and 12 years) were not wearing their three-point restraints properly because they had removed the chest strap during the drive. The children had been reclined in their seats, sleeping in their minivan at the time of the accident. The three sustained Chance fractures and two of the three also developed serious intra-abdominal injuries.

The 15-year-old, a girl, had severe face and head injuries, although she was conscious when she arrived in the emergency room. She also complained of abdominal pain, where there was an obvious seatbelt mark. Her neurological tests were normal but a computed tomography scan (CT scan) of her abdomen and pelvis showed that her colon had been perforated and there was a Chance fracture at the L3 level of her lower back.

Her surgery included repairing the intestine, removing food and fluid from the abdominal cavity and repairing any other internal tears. Two days later, she underwent surgery again to repair facial fractures and when she was physically ready, she was placed in a Risser castto stabilize her back. She has since healed from the spinal fracture and abdominal injuries, but she continues to need several procedures to repair the damage to her face, jaws and teeth.

The 13-year-old sibling, a boy, was also conscious on arrival at the emergency room and also complained of facial pain, back pain and mild abdominal pain. He, too, had a visible seatbelt mark on his abdomen. The boy’s neurological examination was normal and, for the most part, his CT scan was normal, except for some fluid in his pelvis. The spine had sustained a Chance fracture at the L2 and L3 level of the lower back.

Surgery was done immediately to repair his complex facial injuries and surgeons also took a look inside the boy’s abdomen, but did not find any injuries. He was also placed in a Risser cast, but earlier than his sister, only six days after the accident. The boy has since healed and returned to his normal pre-accident activities.

The third sibling was a 12-year-old boy. He was also conscious on arrival at the emergency room, complaining of significant back pain and severe abdominal pain. He, too, had a large seatbelt mark on his abdomen. His neurological signs were normal, despite the complaints of back pain. His abdominal injuries, as seen by CT scan, showed a right-sided pneumothorax, air in the chest that has collapsed the lung. He also had internal bruising and there was fluid in the pelvis. When surgery was performed that night, the surgeons found a tear in the common bile duct (part that exits the liver) and they repaired this and they also inserted a chest tube to treat the pneumothorax. No other abdominal injuries were found. It was only the next day, with another CT scan, that the doctors found that this sibling had also sustained a Chance fracture, this time in the lower level of the mid-upper spine. He was also placed in a Risser cast after this chest tube was removed.

The authors used these cases to show the importance of proper restraints in a motor vehicle. The incidence of Chance fractures have gone down with the wider spread use of three-point restraints, but as shown by this case, they still do happen, usually when the three-point restraints are not being used properly. The authors also pointed out that “up to two-thirds of Chance fractures have associated intra-abdominal injuries, with 25 percent to 58 percent of these injuries requiring surgical treatment.”

Parents try everything they can to protect their children from injury, but sometimes injuries occur when and where we least expect them. A medical problem called toe tourniquet syndrome is one such situation. Sometimes, babies are brought to the emergency room or urgent care clinics with a thin thread that has somehow wrapped itself around the baby’s toe or finger, cutting into the skin and blocking blood circulation to the toe. If the threads are visible, the emergency room personnel remove them and then work to save the digit from further damage. However, there have been cases of babies with the appearance of a thread cutting off the circulation to the toe, but no thread could be seen. The authors of this article describe two such cases.

The first case involves an 18-month-old girl whose parents found that her third toe of her right foot looked like it was being strangulated. It was red and swollen and there was a thin groove along the base of the toe. This groove, however, wasn’t new and they had brought it to their pediatrician’s attention almost three weeks earlier. At that time, the parents were told that it was due to a skin infection for which he then prescribed antibiotics. Despite the antibiotics, the toe worsened. She was then diagnosed with mycosis, a fungal infection. Not long after, the parents brought their daughter to emergency for more investigation.

In the emergency department, the doctors couldn’t find any threads but they did suspect that a hair strand may have been the cause. The girl was taken to surgery where two hair strands were removed from around the toe, a light-colored hair, looking like it was from the child and one dark one, which could have come from either parent. Later on, while the wound was being cleaned, a third, light hair strand was removed as well.

After three days of treatment, the toe regained its usual color, good blood circulation and normal appearance.

The second case involved a five-month-old boy who also had a problem with his third toe of his right foot. Over five weeks, his toe became red and swollen. Originally, the doctor had examined the toe for strangulation but was unable to find anything, even with a magnifying glass. The child’s pediatrician then prescribed a corticoid ointment, which seemed to help reduce the swelling and redness. The strangulation line on the toe did not go away, however, and when the child was put under anesthetic, the doctors did find two fine strands of hair in the groove on the toe. The mother had been losing a lot of hair since the child’s birth, she said but the doctors reported that the hair was more likely that of the baby because of it’s blond color and fineness. After one month, the toe had returned to normal.

The authors wrote that this type of problem can happen to infants and babies and go undetected because of their inability to explain what is hurting them. Therefore, if symptoms like this appear, it is important to take into consideration that hair may be the cause, which would then be difficult to see. Interestingly, the problem happens more often in the warmer summer months, when hair may be in wading or swimming pools.

Toe strangulation from hair seems to occur most often in babies around four months of age, but may be as young as three months or as old as 11 months. This problem may also happen to a finger and the average age is about three months and is often associated with using mittens in the colder months.

It may be a good idea to warn new parents of this type of injury, particularly if either parent has long hair or the father has a lot of body hair. In warm weather months, children’s toes should be checked after spending time in a pool or tub. In the colder months, mittens and gloves should be inspected by turning them inside out to check for loose threads.

Methicillin-resistant Staphylococcus aureus, otherwise known as MRSA, has been making the news for the past few years because of its seemingly sudden presence everywhere. MRSA was once an infection that was only contracted within a hospital or institutional setting, but more people in the community have been diagnosed with it – so many so that there is a new name, community-acquired S. aureus, or CA-MRSA, while the original MRSA is often referred to now as HA-MRSA, or hospital-acquired MRSA.

As CA-MRSA becomes more common, it is found to be the major cause of infections in the skin, soft tissue, and necrotizing fasciitis, the so-called flesh-eating disease. At this point, CA-MRSA is the most common cause of musculoskeletal infections in children and its resistance to typical antibiotics makes it particularly difficult to treat.

There are certain factors that increase your risk of developing CA-MRSA. They include:

– using antibiotics within the previous year
– living in crowded living conditions
– broken skin or problems with skin
– participating in team sports

The authors of this article looked at children who had been diagnosed with CA-MRSA infections to evaluate their symptoms, treatment, progress, and outcomes. To do this, researchers reviewed the records of 27 children (nine girls), 23 of whom had infections in an arm or leg. All children had been healthy before sustaining a minor trauma or sports injury that led to the infection. The children came with complaints of chest wall pain (one child), neck pain (one child), pain in various parts (2 children), temperature of over 38.5 degrees Celsius (17 children), with six being over 40 degrees. Twelve of the children ended up being admitted to intensive care units.

Through the test results, the researchers found that three children had osteomyelitis (infection in the bone), one of whom had a fracture. Eleven children had pyomyositis(infection in the muscle), and six had subperiosteal abscesses (abscess in the bone). Medical complications in seven children included septic pulmonary emboli (infected clots in the lungs) and deep vein thrombosis (blood clots in the veins). One child had DVT but without the signs that the others had. Six of the patients were treated for three to six months with the blood thinner warfarin and two had to have surgery to implant a special filter near the heart to prevent clots from traveling to and entering it.

The majority of the patients (16) were treated with the antibiotic vancomycin alone, nine received clindamycin, and two were given vancomycin along with linezolid. All the children had to undergo surgery to help clean out the wounds and the average hospital stay was a month long.

Complications included four patients having chronic (repeat) osteomyelitis, one child’s elbow contracted, limiting the use of the arm. Another patients developed stiffness in the hip and another had to have a hip replacement because of the damage the infection did to his own joint. Finally, one other patient ended up with an amputation of the lower leg because of complications in the tibial bone.

The authors of this article wrote, “Given its rapid emergence, the orthopaedic surgeon needs to have a high level of suspicion for CA-MRSA infection.” This is crucial to prevent such complications from occurring among those who are infected.