Pediatric Orthopaedics

Bone dysplasia is a group of disorders characterized by abnormal bone and cartilage growth, shape, integrity and development. It is a rare condition and occurs in children. Children affected by this condition are very short in stature, have bowlegs or knock-knees, spine curvature (scoliosis), difficulty in breathing during sleep (sleep apnea) and may not have complete joint motion. Bone dysplasia is caused by mutation in a gene. The condition may be inherited or develop spontaneously during conception.

Your physician will diagnose the condition based on your child’s family history and a thorough physical examination. Your consultant may order imaging studies such as X-ray, CT scan, MRI scan and also a prenatal ultrasonography in suspected cases.

Treatment is based on the problems your child is facing with bone dysplasia. Your consultant may perform limb lengthening surgery, where your consultant cuts the shortened bone into two pieces and pulls them apart. Over a period of time, new bone forms in between them, thus lengthening the bone. Curvature of the spine can be corrected by surgery using metal rods or screws to help straighten the spine.

Congenital muscular dystrophy (CMD) is a group of diseases affecting the muscles that occur at birth or during infancy. CMD is characterized by progressive muscle weakness and degeneration, severe joint stiffness (contractures) and delays in achieving motor milestones such as unassisted sitting or standing. Some forms of CMD may be associated with structural brain defects and mental retardation.

Diagnosis of CMD is made based on clinical findings, imaging tests performed on the brain and muscles, molecular genetic testing (DNA is tested for abnormalities), and removal of the affected muscle (biopsy) for analysis in the laboratory.

No definitive treatment is available for congenital muscular dystrophy; however, the condition can be managed with supportive care to improve the patient’s quality of life and longevity. Treatment is designed with regard to the specific symptoms. Orthopaedic complications may require surgical interventions. Physical therapy and assistive devices such as braces, wheelchairs and walkers can help promote mobility and treat contractures. Respiratory therapy and respiratory aids may be recommended for those with respiratory insufficiency. Speech therapy and close attention to oral hygiene may also be indicated.

The elbow is a joint that consists of three bones – the humerus (upper arm bone), radius (forearm bone) and ulna (forearm bone). An elbow fracture most commonly occurs when your child falls on an outstretched arm. It can lead to severe pain in the elbow and numbness in the hand. Fractures are more common in children due to their physical activities as well as their bone properties. Children’s bones have an area of developing cartilage tissue called a growth plate which is present at the end of long bones that will eventually develop into solid bone as the child grows.

Your child’s consultant first evaluates your child’s arm for signs of damage to blood vessels and nerves. An X-ray examination is then ordered to confirm and determine the severity of the fracture. Treatment of elbow fractures depends on the degree of displacement and type of fracture:

• Nonsurgical treatment: If there is little or no displacement from the normal position, nonsurgical treatment is recommended. Your child’s consultant may immobilize the arm using a cast for 3 to 5 weeks. Regular X-rays are ordered to check if the bones are properly aligned.
• Surgical treatment: Surgery may be recommended if the fracture has caused the bones to move out of alignment. Your child’s consultant brings the bones in correct alignment and may use metal pins, screws and wires to hold the bones in place. Your child will have to wear a cast for a few weeks. Exercises to improve the range of motion will be instructed after a month of healing.

The Femoral neck is a part of the thigh bone (femur) which connects the head of the femur to the shaft of the femur. An injury or crack caused in the femoral neck due to repetitive force, overuse of the bone or insufficiency in bone development is termed a femoral neck stress fracture. These fractures are usually caused in athletes and gymnasts because of their excessive training and changes in practice surfaces.

The most common symptom of a femoral neck fracture is deep thigh or groin pain which increases during your activity, spreads to other parts, and increases during the night or while sitting on the chair with your legs down.

Femoral neck stress fracture can be diagnosed with the help of a physical examination and tests such as the fulcrum test or one legged hop test. Your consultant may also recommend imaging tests such as X-rays and MRI to confirm the diagnosis and find the specific location and cause of the fracture.

Femoral neck stress fracture is treated by taking complete rest from your sports activities. Your consultant may also recommend physical therapy to improve your mobilization and stretching abilities. For severe fractures, surgery would be necessary.

Jumper’s knee, also known as “patellar tendinitis” is an inflammation of the patellar tendon that connects your kneecap (patella) to your shinbone. This tendon helps in extension of the lower leg.

Causes

Jumper’s knee usually results from repetitive trauma or overuse, particularly from sports activities involving jumping such as basketball or volleyball. Therefore, this condition is also known as jumper’s knee. Rarely, this condition may also occur because of an acute injury to the tendon that has not healed properly.

Symptoms

Pain over the patellar tendon is the first symptom of Jumper’s knee. You may also have pain during activities, especially jumping or kneeling. Rarely, swelling around the tendon may be seen.

Diagnosis

Your consultant will evaluate your condition based on your symptoms and physical examination. X-ray of the knee may be taken to make sure there is no problem involving the bones or bone spur around the knee. An MRI scan can reveal degenerative changes in the patellar tendon.

Conservative Treatment Options

Treatment options for Jumper’s knee include:

• Rest the injured knee and avoid activities such as running and jumping that worsen the condition
• Nonsteroidal anti-inflammatory medications (NSAIDs) may be prescribed to provide relief from pain and swelling associated with patellar tendinitis
• Stretching out before exercising is important to prevent recurrence of patellar tendinitis. These exercises can also help strengthen the patellar tendon and nearby muscles such as the quadriceps, hamstrings, and calf muscles

• Application of ice to the affected area helps to control the inflammation and reduce the swelling
• A knee support or strap (called an intrapatellar strap or a Chopat strap) can be worn to relieve pain by directing the force away from your tendon and into the strap
• Iontophoresis: In this technique, a topical corticosteroid medication is applied to the affected area with the help of a small device that uses an electric charge to deliver the medication through your skin
• Corticosteroid injection: With the guidance of an ultrasound, corticosteroid injection may be given directly into the sheath around the affected patellar tendon. This helps to relieve pain and perform strength exercises without any pain

Surgery

In rare cases such as when there is persistent pain despite of the other treatment options, surgery may be considered. Surgery involves removal of severely damaged parts of your tendon and repair of any tears in the tendon.

Little league shoulder is an injury to the growth plate of the upper arm bone in the shoulder joint of children. It is caused due to overuse from pitching or throwing, especially in children between the ages of 10 to 15 years. This condition is mostly seen in baseball pitchers but children in other sports who use improper throwing action are also at risk.

Symptoms associated with this condition include:

• Pain in the shoulders while playing
• Swelling of the shoulder joint
• Reduced speed and control while throwing
• Difficulty in lifting your arm

Little league shoulder is diagnosed with the help of your child’s symptoms, medical history and physical examination of the shoulder. Your consultant may also suggest a shoulder X-ray to confirm the diagnosis.

Little league shoulder is best treated by resting the shoulder until the injury heals. Your consultant may recommend exercises to strengthen your shoulder muscles or physical therapy during this time.

Introduction

The radius (bone on the thumb side) and ulna (bone on the little-finger side) are the two bones of the forearm. Forearm fractures can occur near the wrist, near the elbow or in the middle of the forearm. Apart from this, the bones in children are prone to a unique injury known as a growth plate fracture. The growth plate, which is made of cartilage (flexible tissue) is present at the ends of the bones in children and helps in the determination of length and shape of the mature bone.

The healing of fractures in children is quicker than that in adults. Thus, if a fracture is suspected in a child, it is necessary to seek immediate medical attention for proper alignment of the bones.

Types of fractures

Forearm bones may break in many ways. Fractures may be “open” where the bone protrudes through the skin, or “closed” where the broken bone does not pierce the skin.

The common types of fractures in children include:

• A stable fracture that compresses the bone on one side, forming a buckle on the opposite side of the bone, without breaking the bone (Buckle or torus fracture)
• One side of the bone breaks and bends the bone on the other side (Greenstick fracture)
• Displacement of the radius, and dislocation of the ulna at the wrist where both bones meet (Galeazzi fracture)
• Fracture affecting the upper or lower portion of the bone shaft (Metaphyseal fracture)
• Fractured ulna and dislocated head of the radius (Monteggia fracture)
• Fracture occurring at or across the growth plate (Growth plate fracture)

Causes

Forearm fractures in children are caused due to a fall on an outstretched arm or direct hit on the forearm, which may result in breakage of one or both bones (radius and ulna).

Signs and Symptoms

A fractured forearm causes severe pain and numbness. Other signs and symptoms include:

• Swelling
• Tenderness
• Inability to turn or rotate the forearm
• Deformed forearm, wrist or elbow
• Bruising or discoloration of the skin
• Popping or snapping sound during the injury

Diagnosis

Forearm fractures in children can be diagnosed by analyzing X-ray images of the wrist, elbow or the forearm.

Treatment

The treatment of forearm fractures in children is based on the location, type of fracture, degree of bone displacement and its severity.

Non-surgical therapy

Your child’s consultant will advise you to apply an ice pack over a thin towel on the affected area for 15-20 minutes 3-4 times a day, to relieve pain and swelling. For severe angled fractures, in which the bones have not broken through the skin, your consultant will align the bones properly without the need for surgery (closed reduction). A splint or cast may be required for 3 to 4 weeks for a stable buckle fracture. Immobilization for 6 to 10 weeks is recommended for more serious fractures.

Surgical Treatment

Surgery may be necessary for severe fractures such as fractures of the growth plate or the joint. Other conditions, such as broken skin, bone displacement, unstable fractures, misaligned bones, and bones healing in an improper position may also require surgical repair. Your surgeon will first align the bones through an incision and use fixation devices like pins or a metal implants to hold the bones in place while the wound heals. A cast or a splint may be placed to hold the bones in place.

Conclusion

In the long run, the forearm of your child may have a slightly different or crooked look than before the fracture, which is normal. It may take around 1-2 years for the bones of the forearm to straighten while the bones undergo the process of remodeling (reshaping). For growth plate fractures, your child’s consultant will carefully monitor the hand for many years to ensure that growth occurs normally.

The number of children participating in sports activities has been increasing over the recent years resulting in a substantial rise in the incidences of sports injuries.  Even though there are several benefits of active participation in sports, including building up of self-confidence, physical fitness, and learning to work in a team, there is also a risk of sports-related injuries. The risk of having an injury increases by a lack of protective gear especially during sports activities such as boxing, wrestling and hockey.

Childhood sports injuries are injuries may either be accidental injuries or develop as a result of inadequate training or practice. The most common sports injuries in children are soft-tissue injuries and head injury.

Some of the common sports injuries in children include:

• Sprains and Strains: A strain refers to the stretching or tear of a muscle or tendon (tissue that connects muscles to bone) while a sprain refers to the stretching or tear of a ligament (tissue that connect adjacent bones).
• Growth plate injuries: Growth plate injuries result from a damage to the area at the end of the long bones (growth plate), of a growing child.
• Repetitive Motion Injuries: Repetitive motion injuries are caused by overuse of the tendons and muscles. It includes stress fractures and tendinitis (inflammation of the tendon). These injuries cause severe pain and discomfort.
• Heat-Related Illnesses: Heat-related illnesses include dehydration (loss of body fluids), heat exhaustion and heat stroke (characterized by hot dry skin, headache, and dizziness leading to vascular collapse, coma, and death).

Causes of sports injuries

The causes of sports injuries in children include:

• Slow reaction time: The slower reaction time in growing children makes them susceptible to sports related injuries
• Poor training or practice
• Lack of adequate protection gear such as mouth guards, headgears for respective sports
• Insufficient stretching or warm-up exercises before playing

Types

The sports injuries in children can be acute injuries or overuse injuries.

Acute injuries: Young children may develop minor bruises, sprains and strains. Teenagers are likely to sustain more severe injuries such as broken bones and ligament tear. Acute injuries most commonly occur due to a lack of proper protective equipment during sports activities.

Overuse injuries: These injuries occur because of continuous stress on the bones and muscles from repetitive movements of a particular joint. The most common types of overuse injuries are:

• Anterior knee pain: It refers to pain in the front of the knee, below the kneecap associated with swelling because of inflammation of the tendon or cartilage.
• Little League elbow: It causes pain in the elbow because of repeated throwing action and may be associated with a difficulty in extending the arm.
• Swimmer’s shoulder: It causes pain and swelling of the shoulder because of stress from repetitive movements of the shoulder during activities such as swimming or throw ball.
• Shin splints: It leads to pain and discomfort in the front of the legs due to continuous running or overtraining.
• Spondylolysis: This condition is characterized by chronic low back pain due to repeated stretching of the back muscles and is common in children who engage in sports such as football, weightlifting, gymnastics and wrestling.

Risk factors

The factors associated with an increased risk of sustaining a sports injury, in children, include:

• Growth spurt phase (period of rapid growth during adolescence): During this period, the elasticity of the bone is reduced due to rapid bone growth, which predisposes the bone to injury
• Improper use or lack of protective equipment’s and unfavorable environmental conditions increase the risk of injury
• Poor nutrition: Lack of a healthy diet predisposes a child to injury

Treatment

Treatment for sports injuries depends on the nature of injury. The most common treatment recommended for sports-related injury is rest, ice, compression and elevation (RICE). H

• Rest: Avoid activities that may cause injury.
• Ice: Ice packs can be applied to the injured area which will help to diminish swelling and pain.  Ice should be applied over a towel to the affected area for 15-20 minutes four times a day for several days.  Never place ice directly over the skin.
• Compression: Compression of the injured area helps to reduce swelling. Elastic wraps, air casts, and splints can accomplish this.
• Elevation: Elevate the injured part above heart level to reduce swelling and pain.

Prevention

Some of the measures that are to be followed to prevent sports related injuries include:

• Follow an exercise program to strengthen the muscles
• Gradually increase your exercise level and avoid overdoing the exercise
• Ensure that you wear properly-fitted protective gear such as elbow guards, eye gear, facemasks, mouth guards, and pads, comfortable clothes, and athletic shoes before playing any sports activity which will help to reduce the chances of injury
• Make sure that you follow warm up and cool down exercises before and after sports activity. Exercises will help to stretch the muscles, increase flexibility, and reduce soft tissue injuries
• Avoid exercising immediately after eating a large meal
• Maintain a healthy diet which will nourish the muscles
• Avoid playing when you are injured or tired. Take a break for sometime after playing.
• Learn all the rules of the game you are participating in
• Ensure that you are physically fit to play the sport

The femur or thighbone is the largest and strongest bone in the human body. Pediatric thighbone fractures can occur when your child falls hard on the ground and gets hit during sports, automobile accidents, and child abuse. In a thighbone fracture, the broken bones may be aligned or displaced. The fracture can either be closed (with skin intact) or open (with the bone piercing out through the skin). Your child may experience severe pain, swelling, inability to stand and walk, and limited range of motion of hip or knee.

Your child’s consultant will conduct a physical examination. An X-ray or CT-scan may be recommended to locate the position and number of fractures, and determine if the growth plate is damaged. Femur fractures may be treated with non-surgical or surgical methods.

Non-surgical treatment involves stabilizing the bones so they can heal and fuse together. Braces, spica casting (cast applied from the chest, down the fractured leg) or traction (placing the leg in a weight system) may be used to ensure that the bones are properly set in their normal position.

Surgery is recommended for complicated injuries. Your child’s surgeon aligns the broken bones and uses metal plates and screws to hold the fractured bones together in proper alignment. Your child may have to wear a cast for a few weeks until complete healing. An external fixator may be used in case of open injury to the skin and muscles.

The scapulothoracic joint is located where the shoulder blade or scapula joins the rib cage. The scapula moves easily due to the presence of bursa (fluid filled sacs) which helps in the smooth movement of the joint. Inflammation of the bursa is termed scapulothoracic bursitis. This inflammation may be caused due to over usage, consistent motion and repetitive movements of the joint.

The various symptoms of scapulothoracic bursitis include:

• Grinding, grating and snapping noises during movement of the shoulders
• Pain during movement of the shoulders
• Pain in the scapula (shoulder blade) or ribcage.

Scapulothoracic bursitis is diagnosed based on your child’s medical history and conducting a physical examination to check for the symptoms. Your consultant may also perform imaging tests like X-rays or MRI scans to get a clear picture of the inner aspects of the shoulder blade and confirm diagnosis.

Based on the severity of the condition, scapulothoracic bursitis can be treated both surgically and non-surgically.

• Non-surgical treatment: these treatments include anti-inflammatory medications, strengthening the muscles around the shoulder blade and giving corticosteroid injections to reduce inflammation of the bursa.
• Surgical treatment: this treatment is used when the non-surgical treatment fails to provide relief. Surgical procedures are mostly performed arthroscopically and involve removal of the inflamed bursa along with any bony extensions on the shoulder which are rubbing against the ribcage.