Anterior Cruciate Injuries

A normal knee has three joint areas or compartments, a ligament on the inside of the knee (medial collateral ligament), a ligament on the outside of the knee (lateral collateral ligament), and 2 ligaments in the middle of the knee (anterior and posterior cruciate ligaments). The ligaments keep the knee from bending or twisting further than it should and are even stronger than the growth plates in children. Because of this, children and adolescents who were still growing (skeletally immature) were historically thought to only be capable of sustaining a growth plate fracture and not a ligamentous injury.

Although knee ligament injuries were once thought to be rare in growing children, they are now found with increasing frequency. The reasons for this are multiple: more and more children are participating in sporting events, physicians are becoming much more adept at identifying ligamentous injuries, and there is improved diagnostic equipment available to patients of all ages (such as MRI scanners).

ACL ruptures, in particular, are becoming more common. ACL ruptures can be divided into those that have a bony avulsion and those with a complete intra-substance tear. Bony avulsions can be repaired surgically with a traditional incision or arthroscopically (with a small camera). Treatment for a complete intra-substance rupture depends on the injury to other ligaments in the knee and the skeletal maturity of the patient. If the patient has a repairable meniscal tear, in most circumstances it should be reconstructed at the same time as the ACL. But, if the patient is skeletally immature, reconstruction risks altering the normal longitudinal and angular growth of the femur. Most patients are managed non-operatively with activity modification unless they have a repairable meniscal tear or instability with routine activities; reconstruction is then performed once they are skeletally mature. There is not enough information available to decide how and when to reconstruct a skeletally immature patient. Surgeons are beginning to push the envelope in this respect because many kids have trouble curtailing their physical activities.

More Information:
Johns Hopkins Sports Medicine Information: http://www.hopkinsmedicine.org/orthopedicsurgery/sports/acl/index.html
Arthroscopy.com: http://www.arthroscopy.com/sp05018.htm

Apophysitis

Apophysitis is inflammation of the growing areas of active young children. These problems are annoying, painful, and sometimes activity limiting, but not serious to the overall health of the child.
In the growing child, there are areas in their bones which are the sites of attachment for large muscle groups. These areas are called apophyses. When a child is very active, running and jumping will cause the muscles to contract which then pulls on this specialized growth area. With repetitive activity, the apophysis will become inflamed and painful. Initially, the pain will go away when the activity is stopped.

If the child continues to play through the pain, the pain may continue after the activity is stopped or it may occur with all activities, even those as simple as walking. Apophysitis is diagnosed by history and physical exam. The physical exam will reveal tenderness over the growth area itself without other abnormalities. Sometimes other diagnoses are considered and additional tests like an x-ray may be ordered. Treatment may include anti-inflammatory medications, physical therapy, specialized equipment, ice, and sometimes rest. Fortunately, these maladies will go away once the growth area no longer exists; this happens when the child is done growing.

Arthrogryposis

Arthrogryposis is characterized by multiple joint contractures present at birth, poorly developed and contracted muscles, limb deformities, and intact sensation. The cause is unknown but one common observation is decreased intrauterine movement. The incidence is 1 in 3,000 live births. The initial evaluation and then treatment requires a multi-disciplinary approach including a Pediatrician, Neurologist, Geneticist, physical therapist, occupational therapist, social worker, and an Orthopaedist.
Clinically, there are multiple contractures or joint tightness. The skin is tense and glossy or waxy, with limited subcutaneous tissue. Webbing of the skin may be present at the knees or elbows. Distally the deformities are typically most severe. Some children also have respiratory insufficiency or difficulty eating. Treatment varies according to severity and consists of physical therapy, the use of orthoses (braces), and surgery. These children are cognitively normal.

More Information:
National Support Group: http://sonnet1.sonnet.com/avenues/

Blount's Disease

Blount’s disease is a developmental condition that affects the growth plate around the knee causing progressive bowing. The exact cause is unknown. There are three forms of the disease depending on the age of diagnosis.

Infantile: Age less than 3 years old. Most often affects both sides. Early walking and obesity may be involved.
Juvenile: Age between 3 and 8 years of age.
Adolescent: Age older than 8 years of age. This type often involves only one side and obese children are most commonly affected.

Treatment is determined by the age of the child and the severity of the condition. In the infant form, bracing will sometimes be advocated. Surgery is often recommended for progressive deformity in the infantile form or those patients with juvenile or adolescent forms.

More information:
http://www.med.umich.edu/1libr/child/child68.htm
http://www.orthoseek.com/articles/blount.html
http://orthopedics.about.com/library/glossary/bldef-blounts.htm

Botox

What is Botox?
Botulism toxin is a substance produced by certain kinds of bacteria. Food containing botulism toxin can cause food poisoning (botulism). Botox is a drug made from botulism toxin. Botulism toxin, used to treat people, is made in a special way so that only very tiny amounts are contained in each injection. The amount is much less than the amount that can cause food poisoning.

Botox has been shown to help children with cerebral palsy and other neuromuscular diseases in several ways. It can help children who have problems with increased muscle tone in their arms, legs, and trunk. And, it has been shown to be useful in children who have troubles with daily activities, such as sitting and walking. The use of Botox has also been shown to delay the need for musculoskeletal surgery.

How was Botox developed?
Botox was originally called OCULINUM. Dr. Scott, an ophthalmologist in California, was the first to use these injections to help patients by injecting a small amount of this medicine into the eye muscles of people with crossed-eyes. He noted remarkable improvement. Botox is still used for this purpose.

How is Botox used in children with cerebral palsy?
The use of Botox in children with cerebral palsy has had over 20 years of experience. The drug is injected into spastic muscles (overactive or too tight) causing the muscles to loosen up. Unfortunately, the effect of the medicine usually only lasts 3-6 months. Repeat injections may be given if the muscles become tight again.

What are the risks with using Botox?
The most common problem children have after Botox injections is soreness in their muscles, sometimes associated with some redness near the injection sites. These problems are generally short-term and go away in 1-2 days. The onset of the muscle weakness is noted several days after injection when the medicine is at its maximum effect. There is a low risk of allergic reaction, but when properly diluted, this drug may be safely injected into spastic muscles.

What are the goals with Botox treatment?
The goal of the treatment is to make certain muscles weaker to allow better motor and functional control of these spastic muscles. After the injections, a child may feel generally weak and tired.

What are the outcomes with Botox treatment?
Since its inception, Botox injections have shown marked clinical improvement in the function and motor control of a child with cerebral palsy. Your doctor cannot promise that your child will benefit from these injections, and Botox does not replace other diagnostic and therapeutic procedures that might benefit your child. The advantages are that this is minimally invasive, may allow for improved abilities for the child to sit and walk, while delaying any possible surgery.

Cerebral Palsy

Cerebral palsy (CP) is a non-progressive disorder of the central nervous system (brain) usually due to an injury to the brain around the time of birth. CP results in varying degrees of motor milestone delay and dysfunction. Cognitive involvement varies with the degree of central nervous system involvement. The incidence is 7 per 1,000 live births. Orthopaedists often help care for people with CP when they have problems with being too %u201Crigid%u201D or %u201Cfloppy.%u201D The medical evaluation is coordinated with the primary care physician and/or a pediatric neurologist. The goals of treatment are to maximize their functional abilities and self-care skills as well as to promote functional independence. Depending on the age at presentation, motor skill development, and cognitive disability, four types of treatment are typically used including: physical therapy, orthoses (braces), medication to control spasticity, and surgery. More information: American Cerebral Palsy Information Center: http://www.cerebralpalsy.org American Academic for CP and Developmental Medicine: http://www.aacpdm.org National Institutes of Neurologic Disorders: http://www.ninds.nih.gov/health_and_medical/disorders/cerebral_palsy.htm Medline Information: http://www.nlm.nih.gov/medlineplus/cerebralpalsy.html United Cerebral Palsy of Georgia: http://www.ucpga.org

Clubfoot

Talipes equinovarus (clubfoot) is a congenital birth defect affecting the foot and the lower limb. The incidence is 1-3 per 1,000 live births with 65% of those affected being male. 30-40% of cases involve both feet. The etiology is multifactorial and there are many unproven theories: abnormal intrauterine forces, abnormal amount of amniotic fluid, arrested fetal development, abnormal muscle and tendon insertions, and other pathological conditions.

Clubfoot refers to the position of the foot. A true clubfoot always requires treatment. As with all conditions, clubfeet vary in their severity. The initial treatment may involve casts to gradually correct the foot. There are a variety of casting techniques including the Kite and Ponsetti methods. Casts are changed at frequent intervals when the child is young in order to gain correction. It generally takes 8-12 weeks of cast treatment to correct a foot. Various types of braces may be advised after the foot is corrected with casts to attempt to keep the clubfoot from recurring. If the foot is not corrected and/or is not showing signs of improvement, surgery is advised. Surgery is generally done when the child is approximately six months of age. The percentage of children who can be successfully treated with repeated casting is about 40-50%. There are, however, some feet which your doctor may recognize at birth, or shortly thereafter, as having the characteristics of a severe clubfoot and may recommend surgery early in the treatment course.

Other considerations:
A clubfoot deformity may be seen with other conditions. When your doctor sees your child, a number of other causes will be considered. Neurological diseases, chromosomal disorders, and abnormal constriction bands on the leg are a few of the other conditions which can cause a child’s foot to be in the club position. These other conditions almost always require surgery for successful correction.

More information:

AAOS Information: http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=161&topcategory=Foot

Medline Encyclopedia: http://www.nlm.nih.gov/medlineplus/ency/article/001228.htm

Information and Support:
http://www.clubfoot.co.uk/
http://avoca.vicnet.net.au/~tips/
http://xprss.com/clubfoot/welcome.asp
http://www.orthoseek.com/articles/clubfoot.html

Development Dysplasia of the Hip

What is DDH?
Dysplasia means abnormal development. DDH refers to a spectrum of abnormalities of an otherwise normal child’s hip ranging from frank dislocation to mild instability. This deviation from normal development usually occurs when the child was a fetus but can occur in early childhood as well. Dislocation means that the ball (upper end of the femur or thigh bone) is completely out of the acetabulum (socket). Subluxation is a situation wherein the ball and socket are partially together. The mildest form refers to babies whose ligaments are abnormally loose and whose hips can slip in and out the joint very easily.

Why is DDH a problem?
If left untreated those hips which are partially dislocated may progress to frank dislocation. Patients with dislocated hips will walk with a limp, have a limb length discrepancy and develop premature arthritis of their hips.

Does this cause pain?
Pain is not a factor with DDH and that makes its diagnosis very difficult in some cases.

Who gets DDH?
One of every 100 children born will have mild DDH; 1 in 1,000 will have a frankly dislocated hip. There are several known factors that are associated with a greater risk of DDH.

First born
A relative with DDH (Family history of DDH)
Female gender (Girls have four times greater frequency than boys)
Premature birth (More common in babies born before 37 weeks)
Breech position
Decreased amounts of amniotic fluid
Children with certain foot deformities or a tight muscle in their neck
The left hip is affected in 60%, the right in 20% and both hips in 20% of the cases.
Are there other types of hip dislocation?
Hip dislocation is seen in a number of conditions. The discussion in this section refers to otherwise normal children. The treatment principles for children whose hips are dislocated for other reasons are different.

What causes DDH?
Ligamentous laxity is likely to be the most important factor. The acetabulum (socket) is very shallow at birth. If the ligaments are loose they, may not be able to hold the hip together. Another factor is position in (breech position). First born children may be predisposed because the uterus has not been stretched by prior pregnancy and with labor, further pressures are placed on the hip. There are ongoing studies to further understand the inter-relationships of these factors.

How is the diagnosis made?
In the newborn, physical examination is the basis for the diagnosis. These exams are typically done by your Pediatrician at the time of birth and on subsequent visits to their offices. You may be referred to us for further evaluation if an abnormality is suspected. In addition to physical exam, other diagnostic studies such as an ultrasound may be necessary. The ultrasound study is useful in the young child because so much of the bone tissue in the hip is cartilage and cannot be seen on x-ray. Plain x-rays become useful after a child is one month of age. In older children, other physical signs are present such as limitation of movement in the hip and the observation of different limb lengths. In children who are walking evidence of limp usually is seen.

How does the hip joint normally form?
Hip joint development occurs mainly during fetal life but continues to develop during the first several years of growth. At birth the shallow joint with the femoral head (ball) and acetabulum (socket) are mostly held together by ligaments. With normal movement and eventually weight bearing (walking) the acetabulum deepens and the upper femur changes its shape to the adult pattern. If the hip is not reduced (ball and socket together), these developmental changes can not occur. Therefore, the treatment is directed at putting the ball and socket together and permitting the hip joint to develop. The ball and socket must be held together until the socket deepens enough that the hip stays reduced (in place) on its own.

How is DDH treated?
The treatment of DDH is the subject of whole textbooks. There are varieties of treatments, which are used based on the age of the child at the time of diagnosis. All treatments are directed at placing the hip back into the socket and keeping it there until there has been enough development that the hip will stay in place on its own.

The first treatment option is a Pavlik harness. This is a simple cloth device that keeps the baby’s legs in a position favorable to the development of the hip. The harness needs to be worn full-time because the femoral head (ball) must be held in contact with the acetabulum (socket) in order for the hip joint to develop. To take the harness on and off will also make it more difficult for your baby to adapt to wearing it. Your doctor will advise you as to how long your child will benefit from the harness. Generally 2-3 months is necessary in the newborn. For hips that are simply unstable or subluxated (partially out of the socket) the Pavlik harness is usually all that is necessary.

For the child whose hip is truly dislocated and the children who are older than 6 months, other treatment may be necessary. Closed reduction and cast application is the next level of treatment. For hips that do not become stable and for those that do not reduce (go into the socket) this is often recommended. The term closed reduction means that the bone and joint are put together by manipulation but without surgery. This procedure is done in an operating room with the baby asleep in order that the hips can be examined with the baby fully relaxed. This permits us to judge if the hip can be placed back into the socket and whether it will stay in the socket. At the time of this procedure, water-soluble dye is placed into the hip joint (arthrogram). This dilute solution outlines the ball, which is largely cartilage and not visible on x-ray, and gives us valuable information about the hip joint. If it is judged that the hip can be reduced (ball put back into the joint) and that the reduction is stable (hip will not immediately fall back out again), a spica cast is applied. In order to immobilize the hip, it is necessary to put a cast over the legs and over the trunk. An opening in the perineum (bottom) is made for hygiene. After the cast is applied and the baby is awake, a CT scan is taken. The CT allows us to look at the hips and gives us good information while the cast in place.

If the child is hip cannot be reduced (placed into the socket) or will only partially reduce, surgery is done to loosen the ligaments that are keeping the hip out of the socket. This is a relatively small operation. A spica cast is applied after this surgery as above. The cast is usually used for a period of 3-4 months depending on the case. Because of anticipated growth and to evaluate the reduction of the hip, these casts are usually changed every six weeks. Anesthesia is used for all cast changes. Although cast application is not painful, babies will simply not lie still enough to permit application of a good cast. Usually some form of brace will be used following cast treatment for a variable period of time.

Finally, there are children who require complex surgery. It is beyond the scope of this section to outline all of the possibilities and variations of management. If such treatment is necessary, your doctor will discuss the problem and recommended treatments with you.

Are there complications associated with treatment of DDH?
As with all complex problems, there are possible complications that have been identified. Treatment can be difficult and, of the many options, some will not work on a given patient. Loss of blood supply to the femoral head (ball) is seen in the treatment of DDH. This problem has been reported even in the basic treatment with a Pavlik harness and increases in probability if surgery is necessary. Your doctor will discuss these issues with you.

Why should I put my child through treatment?
Treatment for most patients with DDH is completed by the time the child is 6 months of age. For those children who have had a more difficult problem and may require a cast for their treatment, it is usually completed by the time they are walking. In many ways, the difficulty of treatment is largely for the caregiver. The bottom line is: in order for a hip to develop normally, it must be properly placed in the socket. For those whose hips are not properly placed, premature arthritis, limping, and limb length discrepancy are real problems. In order for your child to run and play actively and without limitation, treatment is clearly the best option.

More information:
http://www.aap.org/policy/ac0001.htm
http://www.orthop.washington.edu/faculty/Diab/ddh/03
http://www.drhull.com/EncyMaster/H/hip_dysplasia.html

Flat Feet

There are several types of flatfeet. The most common is the familial flatfoot; it is flexible and generally is not a source of pain. In the past, such painless feet were treated with special shoes, wedges, and cookies, all in an attempt to correct the flatfoot. This type of treatment is no longer recommended, because is does not work and is not necessary. The average height of the arch is lower in the child than in the adult. The height of the longitudinal arch increases spontaneously during the first decade of life in most children, and there is a wide range of normal arch heights at all ages, particularly in young children. The arch in a child’s foot matures over the first 12 years of life. The diagnosis of flatfoot cannot be made until a child is at least 2 years of age. Ligamentous laxity (flexibility) is the primary thought behind the flattening of the arch in a child. Some children with flexible flatfeet have activity-related pain in the leg or foot that is relieved by shoe inserts. If your child’s foot is painful, your doctor will evaluate the foot to determine the cause of the pain. There are several types of foot problems that can be painful and that may be associated with the non-flexible flatfoot.

More information:
http://kidshealth.org/parent/medical/bones/common_ortho_p2.html

Fractures

Fractures in children and adolescents are very common and present in all ages. Many healthy and active children will have fractures in different locations during their childhood years. Broken bones in children differ significantly from adults. First, because of their immense growth potential, they have a wonderful ability to heal and remodel a broken bone. Second, children have growth centers that may be injured and may require more aggressive treatment. If a child complains of pain, there is obvious deformity or an unwillingness of a child to move an extremity or walk, this may indicate a fracture and the child should be evaluated by a medical professional. There are many different types and locations of fractures. The most common being fractures of the collar bone, elbow, forearm, wrist, fingers, ankle and foot. The majority of fractures are related to falls, sports and minor trauma. Once a fracture occurs, it is important to monitor for swelling, skin condition, sensation and blood supply. A thorough physical examination is essential since there may be other associated injuries that may not be recognized. X-rays are essential for evaluation and fracture management. They show the alignment, healing, growth plate and joint architecture. Serial x-rays may be necessary to document final healing. Treatment options include observation, casting with immobilization, and surgery. Observation may be indicated in partially healed fractures, avulsion fractures and minor toe and finger fractures. Casting and splinting are frequently used to immobilize a fracture to allow healing and to mold a deformity. Molding is successful in children because of their immense growth and remodeling potential. Lastly, certain fractures require surgery to improve the fracture and may require metal instrumentation to stabilize the fracture during the healing period.

Ideopathic Toewalking

Toe-walking is not an uncommon habit in two and three year olds. Frequently children that toe walk can be coaxed into normal gait patterns with encouragement. This habit becomes less common as the child grows. A child usually has a normal heel strike by age four. 

The etiology of persistent toe-walking is unknown but may be associated with neurological conditions or short heel cords. Therefore, a thorough physical examination, including gait analysis and neurological examination, is necessary. If contracture of the heel cord exists, the chance for spontaneous improvement without treatment decreases.

Mild variants of toe-walking may improve or may cause no functional limitations if left untreated. Treatment options for persistent toe-walking include serially casting to stretch the tight heel cords, orthotics (inserts in shoes) and surgical intervention. 

Serial casting is initiated by placing a short-leg walking cast (cast from below knee to tips of toes) and this cast may need to be changed every 1-2 weeks to further stretch out the heel cord. Sometimes initial success will be tempered by recurrence. This return of toe-walking sometimes will require additional treatment. After the foot is level, this is usually maintained with an ankle-foot orthosis (brace), temporarily. In a severe case, surgical heel cord lengthening may be necessary.

Legg-Perthes Disease

This is a rare condition which results from loss of blood supply to the femoral head. The femoral head is the upper end of the femur (thigh bone) and is normally round. The cause of the interruption in blood supply is not known but may, in some patients, occur after a common viral infection. When the femoral head does not receive enough blood, it becomes susceptible to collapse or small fractures, which deforms its round shape. 

At what age does Legg-Perthes Disease occur?

Generally, the peak incidence is 5-7 years of age, but children from age 2-12 may be affected. In 10% of cases, the condition occurs on both sides (bilaterally). Some of these cases do not develop problems on the other side for several months or years later.

Who is more likely to get Legg-Perthes Disease?

Males (twice as often as females) 

Short stature 

Delayed growth 

Breech delivery 

Caucasians 

Family history (Legg-Perthes in a first-degree relative) 

What are the symptoms of Legg-Perthes Disease?

Initially your child may limp occasionally with no complaints of pain. 50% of children do not have pain at the onset of the condition. Pain may occur at the hip or knee. In some patients, the entire femoral head (ball) is affected, while in others, only a small portion is affected. Symptoms vary with the severity of the abnormality, though all patients initially have loss of hip motion due to inflammation.

What is the treatment for Legg-Perthes Disease?

There is controversy regarding the treatment. The area of bone which has lost its blood supply will heal. New blood supply will come into this area over a period of 14-18 months. All agree that the primary focus of treatment is to restore motion of the hip. This can be very difficult in some cases and relatively easy in others. Restriction of activities is necessary to reduce the inflammation. For some patients, it may mean stopping soccer and PE, while for others, it may mean being in wheelchair for a period of time. For very severe cases and in situations where a childís activities cannot be controlled, long leg casts with a bar attaching the two cast together may be advised. Bed-rest and traction was used successfully in the past and remains an option, but for most family situations it is not an option today. In follow-up visits with your doctor, the motion of the hip will be checked and will be the primary concern. Anti-inflammatory medications may be used to decrease the inflammation and pain in the hip. This type of medication does not speed the healing process and may have side effects. Your doctor may recommend its use for short periods of time. There is less agreement on the role of various surgical procedures. For selected patients, surgery may be appropriate and may be advised by your doctor. 

More Information:

Pediatric Orthopaedic Society: http://www.posna.org/InfoParents/Perthes.htm

Medline Information: http://www.nlm.nih.gov/medlineplus/osteonecrosis.html

Medline Encyclopedia: http://www.nlm.nih.gov/medlineplus/ency/article/001264.htm

Limb Length Inequality

Limb length inequality is defined by one leg being longer than the other in a patient of any age. The goal for treating a growing child is to correct the difference as it will exist at maturity (when the child is done growing) and not to correct the difference that is currently present in the child. 

The problems that can be associated with a leg length inequality include: risk of arthritis in the knee, hip, or spine; increased energy expenditure for walking and running; and cosmetic abnormalities. Children tolerate limb inequalities better than adults and will walk on their toes or bend the long legís knee to walk more normally. Unfortunately, this becomes harder and harder to do as one gets older.

The important thing to determine in a growing child is whether this discrepancy is staying the same length as the child becomes older or if the difference is getting larger. Sometimes x-rays made periodically over time are required to determine if this is the case. Also, if a leg length inequality is identified, the patient will need an x-ray called a ìBone Ageî. This is an x-ray of the hand that will be used to determine the relative age of a childís bones (degree of skeletal maturity) compared to other children of the same age.

What are the treatment options?

Treatment is decided based upon how much difference is expected to be present when the child is done growing. All people have some difference in limb length, normally less than 1 centimeter between legs. (There are 2Ω centimeters in one inch). If the predicted difference in limb lengths at skeletal maturity is less than 2 centimeters, treatment is conservative (close observation or shoe inserts if they are having pain or walking problems). If the difference is between 2 and 6 centimeters, then either a shoe lift (on the outside of the shoe) or an epiphyseodesis (slowing the growth on the longer side so that the shorter side can catch up) is appropriate. When the difference is between 6 and 20 centimeters, then combinations of different procedures are typically required, including lengthening the short side and shortening the longer side. If the difference measures more than 20 centimeters when they are done growing, a prosthesis may be the best answer. 

Fortunately, most people have a discrepancy which is treatable by either an insert into the shoe or a lift on the outside of the shoe. Shoe inserts are limited to 2 centimeters to prevent the foot from sitting too high and popping out when walking. A shoe lift works well for differences between 2 and 5 centimeters, but if it is more than that, the patient may have problems ankle injuries.

Little League Elbow

Little League Elbow is a spectrum of disorders which are characterized by pain around the elbow in someone who typically plays baseball, but can also be involved in other throwing motion sports such as tennis and football. At the one end of the spectrum are the youngest kids who present with pain on the inside of their elbow. This is usually from flexor tendonitis or a stress fracture of the medial epicondyle. If ignored, this can lead to an acute fracture of the medial epicondyle which sometimes requires surgical intervention. This usually occurs in the adolescent in association with an injury to the ulnar collateral ligament. As the thrower becomes older, their pain will change and localize to the outside of the elbow. This can be extremely serious. This is usually osteochondritis dissecans (OCD) of the capitellum or the radial head. OCD can lead to loose bodies in the joint, arthritis, and permanent disability. 

Pitchers have a higher incidence of elbow disorders because pitching places the most stress on the elbow during play, but all other positions may also develop elbow problems.

What are the physical exam findings?

Most patients will not be able to fully extend the elbow, they may or may not have swelling, and the location of the pain will be variable.

Will x-rays be taken?

Usually x-rays are taken when either acute or chronic pain exists in someone who throws repetitively. A CT scan or MRI may also be ordered. 

What is the treatment?

The treatment depends on the age of the patient and the cause of the pain. Treatment can be from rest to casting to surgery depending on the nature of the injury. It is extremely important that the physician's instructions are followed regarding both the acute care of the elbow as well as the instructions for return to play. Elbow injuries in the adolescent are serious and can have long-term sequelae if treatment is ignored.

Little League Shoulder

Little League Shoulder is a disorder that is characterized by repetitive microtrauma to the proximal growth plate of the humerus. Failure of the growth plate results in a stress fracture. This is most commonly seen in male pitchers ages 11-13 years. The common finding on x-ray is widening of the growth plate. Fortunately most pitchers respond to rest and then pre-season conditioning the following year.

Besides having chronic repetitive stresses, pitchers with poor pitching technique are more likely to become symptomatic. In the development of young pitchers, the emphasis should initially be on the development of skills and control. Then as they mature, emphasis can change to increasing the speed of pitching. 

Meniscal Tears

A normal knee has three joint areas (compartments) covered by articular cartilage (pearly white stuff seen on the ends of all bones), a ligament on the inside of the knee (medial collateral ligament), a ligament on the outside of the knee (lateral collateral ligament), and 2 ligaments in the middle of the knee (anterior and posterior cruciate ligaments). The ligaments stop the knee from moving in certain directions and give stability to the knee. The knee also has a different type of cartilage, called menisci, one on the inside of the knee (medial meniscus) and one on the outside of the knee (lateral meniscus). The menisci serve several functions in regards to normal knee mechanics. Most importantly they act as shock absorbers to cushion the articular cartilage. They also provide stability to the knee and help with nutrition of the articular cartilage. In the past, they were thought to be extra tissue found in the human body and they were removed at the first sign of problems. We now know that they are extremely important to the knee and meniscal preservation should be the goal of all orthopaedists. What is the incidence of meniscal tears in children and adolescents? The incidence is rising because of increased participation and physicians being better at diagnosing the problem. Football, basketball, and soccer seem to have the highest incidence of tears. In the past, meniscal tears in children less than 12 years of age were thought to be due to a congenitally abnormal meniscus. In fact, meniscal tears do occur in children with normal knees. After age 12, the incidence dramatically increases because of more damaging physical activity and a change in the mechanical properties of the menisci. How is a meniscal tear diagnosed? Taking a history from a child or adolescent is very difficult because of their inability to communicate about the problem. They are usually very vague about how they injured their knee, the symptoms they are feeling, the location of the pain, and whether or not they have any mechanical symptoms like locking, catching, or giving way. The physical examination can be difficult because of the fear that the child has about going to the doctor. Determining where the pain is located is very important to determining the cause. Will x-rays be ordered? Plain x-rays may be ordered depending on the onset of pain and injury. Sometimes a MRI will also be ordered to look at the structures on the inside of the knee which do not show up on regular x-rays. What is the treatment of a meniscal tear? Fortunately for children and adolescents, most meniscus injuries occur in a way than can be fixed. Younger individuals usually tear the back of the meniscus where there is good blood supply. Adults usually tear their menisci after a lot of wear and tear. The goal is always to preserve the meniscus in order to maximize long-term function of the knee. If a meniscal tear is identified, an arthroscopy will usually be performed. This is a surgical procedure where 2 small holes are made in the skin and a camera is placed into the knee. The meniscus can be repaired by using very small instruments and watching through the camera. If the meniscus cannot be repaired, then the torn part is trimmed back to an area that is not loose. How soon can my child return to sports? The answer to this question depends on whether the meniscus was partially resected (trimmed) or repaired. If a partial resection was performed, the patient can usually return to activities in a few weeks after they have progressed through the physical therapy criteria. If a repair was performed, the patient will be on crutches, then start physical therapy, and be out of all activities for 3-4 months. Though a meniscal resection seems easier at the beginning, it is not the best answer for the long-term function of the patient and their knee.

Neurofibromatosis

What is Neurofibromatosis? Neurofibromatosis (NF) is a set of inherited disorders that can affect many tissues in the body. NF causes tumors to grow along some of the nerves in the body and can affect the development of bone. These tumors can grow anywhere on the body. Patients with NF have a higher incidence of learning disabilities than the general population. As with all genetic conditions, there is great variability between patients with NF. Some have severe involvement while others may not be aware that they carry the condition. What are the types of Neurofibromatosis? Type 1 or NF1 occurs in 1 of 4,000 births and is characterized by multiple caf%uFFFD au lait spots (birth marks) and the presence of neurofibroma (small tumors) under the skin. In some cases, bones may be enlarged or abnormally developed. Spinal deformity is the most common skeletal sign. Tumors may develop in the brain or spinal cord. Learning disability is seen in one half of NF1 patients. Type 2 or NF2 occurs less frequently in about 1 of 40,000 births and is associated with tumors in the brain and spinal cord. Hearing loss is often the first symptom and occurs in the teens or early twenties. NF1 is the type most likely to be seen in Orthopaedic offices. Some of the physical signs we will notice are the skin lesions described below. If we suspect NF, we will refer your child to a Geneticist and a Pediatric Neurologist for further evaluation and diagnosis testing. What are some of the clinical findings in Neurofibromatosis? Caf%uFFFD au lait spots are smooth areas of skin that are darker than the surrounding areas of skin. Ten percent of the general population has up to two caf%uFFFD au lait spots. However, patients with NF will have six or more such lesions. The size of these spots varies from 5 mm in children to 15mm in adults. These spots are different than freckles in that they are usually very small and increase with sun exposure. Patients with NF do have abnormal freckling under the arms and in the skin creases of the groin. Neurofibromas are the most common tumor in NF. These are benign growths, which develop under the skin at the time of puberty. They may increase in size and number throughout life. While a single neurofibroma may occur in the normal population, patients with NF typically have numerous lesions. Iris nevi (Lisch nodules) are areas of pigment accumulation on the iris (the colored part of the eye). An Ophthalmologist may be involved for this evaluation. The most common skeletal manifestation of NF is scoliosis and kyphosis. Scoliosis is side-to-side curvature of the spine as you look at a person from the front or back. Kyphosis is forward curvature of the spine as the patient is viewed from the side. These types of spine deformities can be quite severe and require close monitoring. There are specific characteristics of spine deformities associated with NF, though patients with NF may have scoliosis like that found in the general population. Special studies such as an MRI are often done in conjunction with plain x-rays to evaluation the spine and spinal cord. If the spinal curve is increasing, surgery may be required. The goal is to prevent the development of a more severe deformity. In addition, patients may have an enlarged limb or part of a limb such as a toe. Treatment varies widely with this type of problem and is based on the severity and whether the condition is interfering with normal function. Congenital Pseudarthrosis of bones is also associated with NF. The condition may affect the tibia (shin bone) or the bones of the forearm. This is an unsolved problem in Orthopaedic Surgery. The fundamental problem is that the bone does not develop or grow normally. The most difficult aspect of its management is helping these bones to heal, since they don%uFFFDt grow normally. When this problem is identified in the tibia (leg), a brace is advised to protect the bone from fracture. Unfortunately, even braces do not prevent some patients from breaking their bones. When a fracture occurs, surgery is usally necessary to help the bone to heal. More information: The National NF Foundation: http://www.nf.org Neurofibromatosis Inc: http://www.nfinc.org Medline Health Information: http://www.nlm.nih.gov/medlineplus/neurofibromatosis.html

Nursemaid's Elbow

Nursemaid's elbow is also known as a 'pulled elbow' or 'partial dislocation of the radial head'. It is the most common traumatic elbow injury of children accounting for 15-27% of all elbow injuries in children younger than 10 years of age. The average age of incidence is 2-4 years old. Usually this occurs when the parent, walking with the child, pulls on the childís arm to help them up onto a curb or pulls them from a sitting position. The radial head pops out of joint or the annular ligament becomes entrapped in the joint. The x-rays are usually normal. The child will hold the arm in a protected position and not use the upper extremity. They hold the elbow flexed (bent) with the palm turned downward. The initial pain usually subsides and they will return to play. Younger children may hold the arm limp. The child needs to have the radial head popped back into place. This is usually done at the doctorís office or emergency room. Afterwards, the child should begin using the arm fairly quickly. Casts are not routinely used in order to allow the bones to resume normal function, but casts may be necessary to relieve pain if there have been multiple episodes.

Osteochondritis Dissecans

Osteochondritis dissecans (OCD) is a pathologic change seen in many joints but most commonly seen in the knee. The cause is thought to be due to trauma and a reduction in the blood supply to the bone. The pathophysiology involves the loss of blood supply in an area of bone underlying cartilage. Without blood supply, the bone dies and the cartilage breaks loose and arthritis develops. OCD is the most common cause of loose bodies in the knee. There are two distinct subgroups of patients: the skeletally mature and the skeletally immature. What are some of the symptoms seen in OCD? The patient will complain of pain, catching, locking, swelling, giving way. They may feel something moving inside their knee. Will x-rays be taken? X-rays will usually show an OCD lesion. This is typically seen on the medial femoral condyle (inside bump on the femur). A MRI is used to determine if the lesion is attached or not attached to the underlying bone. What is the treatment for an OCD? The treatment of OCD depends entirely on the skeletal maturity of the patient and if the piece of cartilage is loose or not loose. If the lesion is loose in any age, an arthroscopy needs to be performed to evaluate the cartilage and either fix or remove the loose piece. If the patient is skeletally immature (still growing) and the OCD is attached, then activity modification for 3 months will usually allow the lesion to heal. If a patient is skeletally mature, arthroscopy is necessary because healing cannot occur without medical intervention.

Osteomyelitis and Septic Arthritis

What is osteomyelitis? Osteomyelitis is an infection of a bone usually caused by bacteria and treatable with antibiotics. However, if an abscess has formed in the bone prior to or during treatment, surgery will be necessary. If the symptoms have been present for some time before treatment is started, an abscess may form and blood supply to the bone may be compromised. Therefore, osteomyelitis can be one the most difficult conditions an orthopaedic surgeon will manage. How does osteomyelitis develop? There are a number of factors that contribute to the development of osteomyelitis. Bacteria may spread to the bloodstream after simple events like brushing our teeth or through other sites such as infected bug bites; sinus, tonsil, or ear infections; or urinary tract infections. There is also some evidence that minor trauma may contribute to the localization of bacteria to certain places. The status of the immune system and the nutritional status of the child are other important factors that may contribute to a predisposition to infection. What are some of the clinical findings associated with osteomyelitis? The onset of the disease may be gradual or relatively sudden. Fever and pain are prominent symptoms that osteomyelitis has developed. Pain is usually sufficiently severe that a child will stop walking or stop using an arm or hand. How is a child evaluated for osteomyelitis? Evaluation of a child who is ill and having pain is difficult. We try to find the area of the body that is causing the pain. Plain x-rays will not show an abnormality for 10-14 days. The x-rays that are made in evaluating a child for possible infection are often made to look for other problems such as fractures. Blood tests are done to look for evidence of inflammation and to culture the blood to look for any identifiable bacteria. Bone scans are tests done to identify abnormal areas of bone early in the infection. Aspiration of the bone is done to obtain specimens for bacterial culture and to determine if an abscess has formed. What is the treatment for osteomyelitis? If the evidence suggests that the child has osteomyelitis and does not have an abscess in the bone, antibiotics will be started. If the pain and fever decrease and the laboratory tests begin to return to normal, the antibiotics will be continued. If there is persistent fever and pain or if the lab tests are not returning to normal, then an abscess may have formed. Abscesses require surgical drainage in order for the infection to resolve. If the blood supply to the bone has been lost, the difficulty in management is compounded. Your physician will discuss the pertinent issues with you. How long will my child be on antibiotics? There is no set time for treatment with antibiotics. As one would imagine there are different degrees of severity, different bacteria, and different conditions of the patient that affect this judgment. In general, antibiotics are used until the patient%uFFFDs temperature and the laboratory studies have returned to normal. What is a septic arthritis? Septic arthritis is an infection in the joint itself. Any joint can be affected, but the most commonly involved joints are the large joints such as the hip and knee. The causes of septic arthritis and the predisposing conditions are similar to those causing osteomyelitis. The difference is that most joint infections require surgery to prevent the joint from being damaged by the infection. This is considered a surgical emergency because the infection in the joint will cause the cartilage to die if it is not treated rapidly. The joint will usually be aspirated with a needle before any surgery. If the removed fluid has bacteria in it, then the joint will need to be opened surgically.

Patella Dislocation

The initial dislocation of a patella (kneecap) is usually a dramatic acute event that occurs during a knee twisting event. The patella will jump laterally (to the outside of the knee) and either stay there or pop back into place. The knee will swell a great deal immediately and the patient may or may not be able to bear weight on that leg. How is a patellar dislocation diagnosed? The diagnosis is based on the history given by the patient and by the physical examination. Will x-rays be taken? If this is the first time that the patella has dislocated, then x-rays will usually be taken. Sometimes, a MRI will also be ordered to look for any other problems in the knee or if a piece of bone has broken loose with the patellar dislocation. What is the treatment for an initial patellar dislocation? This is a controversial area of sports medicine. Depending on the age, physical examination, x-rays, and the athletic level of the patient, a treatment protocol will be initiated. Fortunately for adolescents, the treatment does not usually involve surgery. They will be maintained in a knee immobilizer or a cylinder cast. At a certain point in their rehabilitation, they will be sent to physical therapy to work on a stretching and strengthening program. Some patients will need to have surgery. This is sometimes performed arthroscopically (through a small camera), but also may require a regular surgical incision. Does the patella ever dislocate again in these patients? Yes, the incidence of having another dislocation is dependent on the age at which the first dislocation occurred. Younger children are more likely to have a recurrence. Some patients will have one or two more dislocations and others will begin having dislocations all of the time (or chronically). A patient that has had more than 6 dislocations may be a candidate for a surgical procedure to help keep the patella in place. What are the long-term problems associated with a patellar dislocation? A great deal of force is required to pop the patella out of joint. This force is transferred into the joint where the articular cartilage (pearly white stuff on the ends of all bones) may be damaged. This may lead to arthritis and other persistent problems. Having multiple episodes of dislocations increases the damage to the articular cartilage and puts the patient at increased risk for arthritis in the future.

Patelloformal Pain Syndrome

Patellofemoral pain syndrome (PFPS) is anterior knee pain seen most commonly in two age groups, teenagers and 30-40%uFFFDs. In the adolescent, there are two distinct groups which get PFPS: active athletes especially those involved in jumping and kneeling activities, and non-athletic, inactive, often overweight adolescents, most commonly girls. The cause of this non-traumatic knee pain is unknown, but appears to be multifactorial. What are some of the symptoms that go along with PFPS? During the history, the patient will complain of poorly localized anterior knee pain that moves around the patella (kneecap). They will complain of increased pain with sitting (theater sign), going up and down stairs, and with increased activity. They will sometimes complain of giving way and swelling which is more %uFFFDpuffiness%uFFFD than really being very swollen. The pain can be waxing and waning, and as such, this pain has usually been present for a long time before the patient seeks medical care. What is the physical examination like? The physical examination may involve the entire limb of the patient from the hip to the ankle. It is necessary that the patient be appropriately clothed in shorts, not pants with the leg rolled up, so that the physician can accurately assess the entire lower extremity. Will x-rays be taken? Depending on the history and the physical examination, x-rays may be taken. Other tests like a CT scan or MRI are usually not necessary. What is the treatment? The treatment for PFPS involves a course of non-steroidal anti-inflammatory medicine and physical therapy specifically geared toward PFPS. This means that the patient has to go to physical therapy and do the exercises very reliably. The patient must be an active participant in the treatment program. In order to successfully treat PFPS an aggressive daily home exercise program in addition to outpatient physical therapy 1-2 times a week is required. The longer that the pain has been present, the longer it will take to get rid of the pain. Sometimes your doctor will prescribe a brace that may make physical therapy and some activities easier. Also, specific orthotics may be necessary in some patients. Continuing to be active in sports and physical education is encouraged but coaches and PE instructors must be aware of the ongoing therapy program and the patient%uFFFDs limits.

Rotational Abnormalities

Intoeing Gait Many parents are concerned if their child toes-in when walking. Generally, this represents a normal variant. However, your doctor will be assessing a number of factors when a child is brought in for an evaluation of this question. Various neurological conditions and congenital hip conditions can be associated with an abnormal gait (walking pattern). Once your child has been evaluated and it is determined that there are no other problems, an intoeing gait may be related to excessive inward twist of the femur (thigh), tibia (leg) , or foot segments of the lower limb. As with many physical characteristics, inheritance plays a role. Thigh Segment The most common cause of an intoeing gait, in an otherwise normal child, is excessive inward twist (torsion) of the femur, called femoral anteversion. Children with this form of intoeing will intoe more when they are tired. There is potential for the degree of torsion to diminish with time; the proximal femur will remodel up to age 6-7 years old and sometimes even into teenage years. There are no long term problems with excessive femoral anteversion. In young children, they may trip over their feet when walking or running. Special shoes have no effect on the femoral bone. There are no exercises for bone and no orthoses (braces) that can untwist the bone. Surgery can theoretically change the rotational alignment of the femur, though the risks often outweigh the benefits and this surgery is rarely recommended. Children who toe-in often sit on their feet with their legs in the shape of a %uFFFDW%uFFFD. While sitting on your feet does not cause abnormal inward twist of the bone, it may impair the normal process of derotation which occurs with age. Therefore, your child should be discouraged from sitting on their feet. A table and chair set may be helpful. The use of a chair while watching TV is also recommended. A booster chair for the dinner table is another suggestion which may be helpful. Leg Segment Intoeing may also be associated with abnormal inward twist (torsion) of the tibia. This is generally seen in very young children and represents a variant of normal. Children with internal tibial torsion will appear to be bow-legged when they walk. As with the femoral segment of the limb, the natural history of internal tibial torsion is resolution with time. Babies may sleep on their abdomen (stomach) with their feet tucked under them. This sleeping pattern generally does not persist as they become older. Most toddlers will remodel their tibias up to the age of 2-3 years. The same recommendations are made for the management of this segment of the limb as for the thigh and avoid an abnormal sitting posture. Out-toeing may be seen when the tibia is externally rotated more than average. This pattern is also a variant of normal. As with the thigh segment of the limb, there is no %uFFFDtreatment%uFFFD which can internally rotate the tibia except surgery. Again abnormal sitting can aggravate this problem. Foot Children may rarely intoe from a condition in the foot. Although more common 20 years ago, metatarsus adductus still occurs. The foot is shaped like the letter %uFFFDC%uFFFD. Generally, this is the result of position while in the uterus. If the foot is flexible, no treatment is necessary as the foot will straighten itself with normal muscle function. Occasionally, the foot will have a rigid deformity present. This type of problem may require the use of several casts to correct the abnormal curvature. There is a condition called %uFFFDskewfoot%uFFFD which has abnormal configuration of the bones in the foot. This may present with what appears to be a rigid metatarsus adductus deformity. Unfortunately, the diagnosis of this must await maturation of the foot as x-rays do not demonstrate this abnormality until the child is 3-4 years of age. We begin to suspect this condition if the foot does not respond to cast treatment.

Scheurmann's Kyphosis

What is Scheurmann's Kyphosis?

Scheuermann's Kyphosis (increased roundback) is a disorder that affects the development of the vertebra (back bones) causing them to become slightly wedge-shaped. The result is an increase in the normal thoracic kyphosis (roundback). 

What causes Scheurmannís Kyphosis?

There is no known cause that has been defined. There does seem to be a tendency for it to run in families.

What are some of the clinical findings?

Adolescents are usually evaluated because of excessive rounding of the back (poor posture). Pain sometimes can exist and sometimes be associated with a rapid growth spurt, activities that emphasize forward flexion or lifting, or athletic activities. The pain is usually at the top of the deformity or in the lumbar region. Patients with Scheuermannís kyphosis lack normal flexibility that can be detected with various physical tests.

How is the diagnosis made?

In addition to a physical exam, x-rays of the spine can help to make the diagnosis.

What are some of the treatment options? 

For patients will mild increase in their roundback (kyphosis), an exercise program will be advised. When the problem is more advanced either an orthosis (brace) program or surgery may be advised.

Scoliosis

Scoliosis is a curvature of the spine in the lateral or sideways plane when a patient is viewed from either the front or back.

What are some of the signs of scoliosis?

One shoulder may be higher than the other 

One scapula (shoulder blade) may be more prominent than the other 

With the arm hanging at the side, there may be more space between the arm and body on one side. 

One hip may appear higher than the other. 

The head may not be centered on the pelvis 

When viewed from behind with the patient bending forward until the spine is horizontal with the floor, one side of the back appears to be higher than the other. 

What are the causes of scoliosis?

Most patients with scoliosis (70-85%) have Idiopathic Scoliosis, meaning the cause is unknown. This type of curve tends to be familial and has a genetic component. Another type of scoliosis, called Congenital scoliosis, is the result of abnormal formation of the vertebra (back bones). This abnormal formation occurs 4-6 weeks after conception and may be associated with other congenital anomalies or abnormalities. Other specialists are often involved in the care of this problem. Children with various neurological diseases such as cerebral palsy, muscular dystrophy, and spina bifida may develop Neuromuscular scoliosis as a result of muscle weakness. Connective tissue diseases such as Marfanís Syndrome have an increased risk of scoliosis. A number of genetic conditions, like Downís Syndrome, may develop scoliosis as well.

What is the prevalence of Idiopathic Scoliosis in the population?

Based on various population studies, approximately 20 out of 1,000 children have this type of scoliosis. Boys and girls are equally likely to develop scoliosis.

Shin Splints

Shin splints are exercise-related pain found along the posteromedial border (inside) of the distal tibia (shin bone). It is most often caused by a stress reaction of the bone and the attached muscles in response to repetitive overuse. Shin splints accounts for 13% of all injuries in runners. 

Patients typically present with pain, initially upon exertion that may be relieved by continued activity. The pain may recur toward the end of the workout or after running. Over time the pain goes from being dull or sore to sharp, penetrating, and severe. With time, the pain may be present with activities of daily living. Shin splints usually occur when there has been a significant change in activity. It is not restricted to the unconditioned or ill-prepared athlete. Changes in footwear, running surface, terrain, or intensity may precipitate shin splints. 

Will x-rays be taken?

Many times, x-rays will be taken to rule out a stress fracture. Sometimes a bone scan or an MRI is advised to aid in the evaluation of this problem.

What are the treatment options?

The patients are usually sent to physical therapy to work on a stretching and strengthening program. Orthotics may be ordered and the running shoes may need to be evaluated. A non-steroidal anti-inflammatory medicine is a reasonable addition to the treatment regimen. 

How long will it take for the problem to go away?

Usually it takes about 7-10 days for the pain to decrease enough that the patient can resume some training. If it is important to maintain cardiovascular fitness, then cross-training with an exercise bicycle or water running have been found to be excellent alternatives. Relative rest means that the patient is allowed to do activities which can be performed comfortably. Once the patient is comfortable, then the activity level can be gradually increased in response to the patientís symptoms.

Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis is a disorder in which the top part (epiphysis) of the thigh bone (femur) slips out of place across the growth plate. This disorder may cause early arthritis in the adolescent or adult. The incidence is twice as common in boys as in girls, occurring around 14 years of age for boys and 12 years for girls. It most commonly occurs in obese children, and may involve both sides in up to 30% of cases.

The onset of symptoms may be abrupt or may occur gradually over many months. Some patients will experience a dull groin ache, knee pain, walk with the foot on the affected side turned out excessively, and be limited in how far they can pull their knee up to their chin. Rarely some patients will have a severe, sudden onset of pain and spasm and be unable to walk at all. Urgent evaluation and referral is needed in order to prevent further slippage and minimize the complications that might ensue. Treatment usually involves the placement of a screw to hold the bone in place until it can heal. This may take 12-18 months. Crutches are often used after surgery to keep the weight off the broken leg until the bone heals. 

More information:

AAOS Information: http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=160&topcategory=Hip

Medline Encyclopedia: http://www.nlm.nih.gov/medlineplus/ency/article/000972.htm

Spina Bifida

Spina bifida or myelomeningocele is a general term used to describe a broad spectrum of defects that occur during pregnancy relating to the formation of the spinal cord and the bony spine (vertebral bodies). Spina bifida results from a failure of closure of the neural tube (spinal cord). Neural tube defects are thought to be caused by many factors including environmental factors. Maternal hyperthermia, administration of valproic acid, maternal insulin-dependent diabetes, and folate deficiency have been associated with myelomeningocele. The incidence is 1 in 1000 live births in the U.S. Screening programs using maternal alpha-fetoprotein (AFP in triple screen), ultrasound, and amniocentesis can now detect almost all fetuses with open spina bifida by 18 weeks gestation.

Children who are born with spina bifida and do not receive treatment have a less than 10% survival rate to school age. But with non-selective closure of the defect and shunting of the hydrocephalus (water on the brain), survival at 25 years is 52%. Adults with spina bifida can lead very full lives. Some will walk, marry, have children, and be able to hold productive jobs. The ability to walk is directly related to the level at which the defect in the spinal column occurred. Some patients have no ability to move their legs while others can walk with braces. This is a multi-discipline disorder; one that requires a team approach including an Orthopaedist, Urologist, and a Neurosurgeon. Problems can arise with latex allergies, malignant hyperthermia, hip and foot deformities, scoliosis, and kidney failure. All children with spina bifida are considered to be at risk for latex allergy. For this reason all patients with spinal bifida are advised to strictly avoid all contact with latex containing products.

Spondylolysis and Spondylolisthesis

What are Spondylolysis and Spondylolisthesis?

Spondylolysis comes from the Greek words ìspondyloî (spine), ìlysisî (breakdown), and 'Olisthanerin' (to slip). Spondylolysis is a stress fracture of part of the vertebral body (spine). Spondylolysis usually involves both sides of the vertebra (bilateral) while involvement of only one side usually occurs with trauma.

Spondylolisthesis occurs when the vertebral body (spine) slips forward on the next vertebral body. This happens after a spondylolysis has occurred. The most common site for spondylolisthesis in the child is where the lumbar spine meets the sacrum (at L5 on S1). 

What is the incidence of spondylolysis and spondylolisthesis?

Spondylolysis and spondylolisthesis may be incorrectly considered as congenital abnormalities. They are rarely diagnosed before 5 years of age. The incidence rises at 7-8 years and stabilizes at age 20. The overall incidence is 4-6%.

What are the causes?

Genetic, traumatic, and developmental causes have been theorized. Repetitive trauma is the most widely considered cause with an 11% incidence in adolescent athletes including female gymnasts, weight lifters and football players. Unfortunately, girls are more prone to severe displacement which usually happens around puberty, during their rapid growth spurt. 

What are the physical findings?

Clinical findings include back pain, postural deformity, and abnormal gait from tight hamstrings. The physical findings typically correlate with the degree of slippage. There may be a palpable step-off, restricted motion of the lumbar spine, increased lordosis (swayback), loss of buttock contour, torso shortening, and a pelvic waddle. 

Will any x-rays be taken?

Probably, though other radiologic studies may also be taken, including SPECT scan (bone scan), CT or MRI.

What is the treatment?

Treatment includes rest, activity modifications, non-steroidal anti-inflammatory medicines, exercises, traction, bracing, and casting. All children or adolescents with bilateral spondylolysis should be followed closely for development of spondylolisthesis. Unfortunately some children fail conservative therapy and require spine surgery.

Stress Fractures

A stress fracture is most commonly seen in the tibia but can occur in many other bones. The majority of stress fractures are seen in runners, with females being 12 times more likely to develop stress fractures. This is thought to be secondary to the smaller size of the bone, their menstrual irregularities, and the higher incidence of eating disorders. The development of a stress fracture is multifactorial. They can occur in the highly trained athlete or a recreational novice. The cause is typically a change in training whether it is an increase in intensity or duration, change in footwear or surface, or an anatomical abnormality. Prior to puberty, stress fractures are thought to be uncommon, but after puberty, the incidence is the same as in the adult population.

Will x-rays be taken?

Usually x-rays are taken to identify a stress fracture. Not all stress fractures will show up on plain x-rays. Sometimes a bone scan or an MRI will be ordered.

How are stress fractures treated?

Relative rest is the treatment of choice, meaning any activity that causes pain should be avoided. Walking with crutches helps to reduce stress on the bone. When the patient can walk comfortably, they can come off of the crutches. When they can run, they can begin weight-bearing training. Until they are able to go back to regular activities, they may perform non-weightbearing exercises like bicycling and swimming. 

What are the complications of a stress fracture?

A stress fracture that does not heal may become a true fracture that requires casting or surgery to heal. It is very important to allow a stress fracture to heal appropriately so additional time away from the patientís sport is not required.

Tarsal Coalition

What is a tarsal coalition?

Tarsal coalitions are abnormal connections between the bones of the foot which may cause loss of motion and pain.

What is the incidence of tarsal coalition?

The incidence is reported between 0.03% and 1.0% of the population.

Where are these connections found?

These abnormal connections are most common between the tarsal bones (bones in the middle of the foot) such as the talocalcaneal and talonavicular joints. 

What causes a tarsal coalition? 

The etiology of tarsal coalitions is probably associated with failure of the tarsal bones to fully divide during their development. Subsequently, these abnormally formed joints limit motion or cause complete loss of motion which then interferes with the function of the nearby joints in the foot and ankle.

What are the symptoms of a tarsal coalition?

The symptoms of a tarsal coalition usually occur in early adolescence. Recurrent ankle sprains may be the only complaint, but pain at the site of the coalition does occur and may significantly limit activities. It is important to recognize that not all coalitions cause pain and disability; therefore, a thorough physical examination is necessary to access joint motion (movement) and to localize pain.

Will x-rays be taken?

Plain x-rays are very helpful in identifying a tarsal coalition but other studies may be necessary to localize and quantitate the size of the abnormal development of these bones. Radiographs may reveal the bony bridge between the tarsal bones (bones in the middle of the foot) or show changes in the nearby joints. A CT scan and/or a MRI may useful in the evaluation of a tarsal coalition.

How are tarsal coalitions treated?

Initial treatment includes conservative (non-operative) measures to relieve pain. These may include foot orthotics (shoe inserts), casting and anti-inflammatory medications. Patients that continue to have pain despite these treatments may be candidates for surgical intervention. Surgery for tarsal coalitions include: removal/excision of the attachment between the bones or fusion of the joint (taking away the joint between 2 bones). Treatment depends on the size, location and character of the coalition (bridge of bone). With the above treatment, most patients show improvement in their symptoms and may fully return to their activities.