Keeping Up With the Latest in Children’s Orthopedics

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:

  • Children hospitalized in intensive care units (ICU) must be watched carefully as most cases of acute compartment syndrome and fracture are caused by hospital procedures.
  • The practice of screening every infant for hip dysplasia has been questioned. Does it really help identify children who have hip dislocations? Studies continue to support this practice along with early treatment using a Pavlik harness.
  • When a dislocated hip from hip dysplasia is forced back into the socket, it can cut off the blood supply to the head of the femur (thigh bone). The final result can be osteonecrosis (death of the bone). Use of imaging studies like ultrasound and MRIs can help monitor hip position and prevent this complication of treatment.
  • Athletes who tear their anterior cruciate ligaments (ACL) can expect full return to sports. But as with adults, there will be some adolescents who do not get full recovery of the quadriceps function even after a year. Additional rehab will be needed.
  • Tourniquets used during knee surgery (like for an ACL repair), can be too tight for too long and end up causing problems. Surgeons are advised to use a special device that automatically sets the amount of tourniquet pressure applied throughout the procedure. This has the effect of limiting the amount of blood in the surgical field without causing injury to the leg.
  • Bone cysts are often seen in children. Evidence to support the best approach to treatment remains lacking. Surgeons may operate to remove the cysts or inject the cyst with a steroid. Surgery always has its own risks but injections can cause blood clots. More study is needed in this area.

    In the area of orthopedics involving the spine, scoliosis (curvature of the spine) is the major problem seen in children and teens. For severe curves, spinal fusion may be necessary. Many studies have been done trying to find the best way to do this procedure.

    Final results after fusion for scoliosis (spinal alignment) have been measured and compared with other factors like pain after surgery, length of time in the operating room (cost), amount of blood lost, and other complications. There are no firm conclusions yet to suggest one method of fusion is better than another. They each have their pros and cons. Decisions are made based on each patient’s individual characteristics and needs.

    And finally, more attention has been drawn to pediatric orthopedic trauma. Emergency departments are reporting more cases of severe, complex fractures, especially of the wrist and elbow. Surgeons must be prepared to evaluate these emergencies thoroughly in order to avoid missing other injuries that are ignored or missed in the frenzy of fixing the more obvious problem.