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Common Orthopaedic Conditions

At Performance Orthopaedics & Sports Medicine in metro Atlanta, Georgia, Dr. Stephanie Martin understands not only the physical issues specific to treating common orthopedic conditions, but the mental and emotional issues as well. Her extensive pediatric experience allows her to examine and treat children in a way that makes them relaxed and cooperative. With her adult patients, she builds relationships that allow for greater patient outcomes.

Orthopedic conditions may be present at birth (congenital or hereditary), or you may acquire one as you age from trauma or degeneration. As a board-certified pediatric and adult orthopedic surgeon, Dr. Martin specializes in diagnosing a broad spectrum of orthopedic concerns.

For an appointment with Dr. Martin at our Atlanta, Lawrenceville or Snellville office, call us at (404) 973-2444 or use our online appointment request form.

To read about a condition simply click on it. When you are finished reading, click again to retract the content and see the full list.

Arthrogryposis

Arthrogryposis multiplex congenita (AMC) 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 orthopedist.

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.

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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 knees. 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 infantile 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 of the disease.

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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 delays and dysfunction. Cognitive involvement varies with the degree of central nervous system involvement. The incidence is 7 per 1,000 live births.

Orthopedists often help care for people with CP when they have problems with being too “rigid” or “floppy.” 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 upon the age at presentation, motor skill development, and cognitive disability, there are typically four types of treatment: physical therapy, orthoses (braces), medication to control spasticity, and surgery.

Treating CP with 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. When used to treat people, botulism toxin is made in a special way so that only tiny amounts are contained in each injection – 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?

Doctors have used Botox to treat children with cerebral palsy for over 20 years. 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 goals of 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 of 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 Botox injections are minimally invasive, they may improve a child’s ability to sit and walk, and they may delay the need for surgery.

What are the risks of 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 to 2 days. The onset of muscle weakness is noted several days after the injection, when the medicine reaches its maximum strength.

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Clubfoot

Talipes equinovarus (clubfoot) is a congenital birth defect affecting the foot and the lower limb. The incidence is 1 to 3 per 1,000 live births, with 65% of those affected being male. The left foot is most commonly affected, although 30-40% of cases involve both feet.

The etiology is multifactorial and many unproven theories exist: 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 cast techniques that are considered “conservative management,” including the Kite and Ponsetti methods. When the child is young, casts are changed at frequent intervals to maximize correction.

It generally takes 6 weeks of cast treatment to correct a foot, which is often followed by a minor surgical procedure called an Achilles tenotomy. Various types of braces may be advised after the foot is corrected with casts to keep the clubfoot from recurring.

If the foot is not corrected and/or is not showing signs of improvement, the child will need surgery, which is typically performed when the child is approximately six to nine months of age. The percentage of children who can be successfully treated with conservative management is very high.

In some infants, the doctor may recognize characteristics of severe clubfeet at birth or shortly thereafter and may recommend surgery early in the course of treatment.

Other considerations:

A clubfoot deformity may be associated with other conditions. When your doctor sees your child, a number of other causes will be considered, including neurological diseases, chromosomal disorders, and abnormal constriction bands on the leg. These other conditions almost always require surgery for successful correction of clubfoot.

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Developmental Dysplasia of the Hip (DDH)

What is DDH?

Dysplasia means abnormal development. Developmental dysplasia of the hip 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 socket (acetabulum). Subluxation is a situation in which 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, hips that 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, which makes diagnosis very difficult in some cases.

Who gets DDH?

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

  • First born
  • A relative with DDH (family history of DDH)
  • Female gender (four times more likely in girls than in 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% of cases, the right in 20% of cases and both hips in 20% of 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. Treatment differs for children whose hips are dislocated for other reasons.

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 utero (breech position). In addition, first born children may be predisposed because the uterus has not been stretched by prior pregnancy, and further pressure is placed on the hip during labor. There are ongoing studies to further understand the interrelationships 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 limited movement in the hip and different limb lengths. Children who are walking may have a limp.

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 ball and socket are mostly held together by ligaments. With normal movement and eventual weight bearing (walking), the socket deepens and the upper femur changes its shape to the adult pattern.

If the hip is not reduced (ball and socket put together), these developmental changes cannot 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 in place on its own.

How is DDH treated?

The treatment of DDH is the subject of whole textbooks. Treatments may vary 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 the hip has developed enough to stay in place on its own.

Pavlik Harness

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 ball must be held in contact with the socket for the hip joint to develop. To take the harness on and off would 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. Newborns generally need to wear a harness for 2 to 3 months. For hips that are simply unstable or subluxated (partially out of the socket), the Pavlik harness is usually all that is necessary.

Closed Reduction and Casting

For the child whose hip is truly dislocated and for children who are older than 6 months, other treatment may be necessary. Closed reduction and casting is the next level of treatment. This treatment is typically recommended for hips that do not become stable and for those that do not reduce (go into the socket).

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 so that the hips can be examined while the baby is fully relaxed. This permits the doctor 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. 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 the doctor determines that the ball can be put back into the joint and that the hip will not immediately dislocate again, a spica cast is applied over the legs and trunk to immobilize the hip. An opening in the bottom is made for hygiene. After the cast is applied and the baby is awake, a CT scan is taken. The CT allows the doctor to look at the hips while the cast is in place.

Surgery

If the child’s hip cannot be placed into the socket or will only partially reduce, surgery is performed to loosen the ligaments that are keeping the hip out of the socket. This is a relatively minor operation. A spica cast is then applied after surgery for 3 to 4 months, depending on the case.

Due to the anticipated growth of the child and the need 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. Some form of brace will typically be used for a variable period of time following cast treatment.

Finally, some children require complex surgery. 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 relating to the treatment of DDH. Treatment can be difficult and some will not work on a given patient. Some patients may experience a loss of blood supply to the femoral head (ball). 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 this: for a hip to develop normally, it must be properly placed in the socket. Babies whose hips are not properly placed can develop premature arthritis, limping, and limb length discrepancy. In order for your child to run and play actively and without limitation, treatment is clearly the best option.

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Flat Feet

There are several types of flatfeet, the most common being the familial flatfoot, which is flexible and generally 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 it does not work and is not necessary.

The average height of the arch is lower in children than in adults. 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 cause 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.

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Idiopathic Toewalking

Toewalking is not an uncommon habit in 2 and 3 year olds. Children who toe walk can usually 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 toewalking 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 toewalking may improve or may cause no functional limitations if left untreated. Treatment options for persistent toewalking 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 may need to be changed every one to two weeks to stretch out the heel cord. Initial success may be tempered by recurrence. Recurring episodes of toe-walking may require additional treatment.

After the foot is level, this position is usually maintained with a temporary ankle-foot orthosis (brace). In severe cases, surgery may be necessary to lengthen the heel cord.

Legg-Perthes Disease

This is a rare condition that results from loss of blood supply to the femoral head, the round upper end of the femur, or the ball that inserts into the hip socket. It is not clear what causes the interruption in blood supply, but it may occur in some patients 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 of the hip. 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?

Symptoms vary with the severity of the abnormality, though all patients initially have loss of hip motion due to inflammation. Your child may limp occasionally with no complaints of pain. In fact, 50% of children do not have pain at the onset of the condition. For others, 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.

What is the treatment for Legg-Perthes Disease?

Although there is some controversy regarding the treatment of Legg-Perthes disease, all doctors 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.

The area of bone that has lost its blood supply will heal and new blood supply will appear over a period of 14-18 months. During this time, it is necessary to restrict a child’s activities to reduce the inflammation. For some patients, this may mean stopping soccer and PE, while for others, it may mean being in a wheelchair for a period of time.

For severe cases and in situations in which a child’s activities cannot be controlled, long leg casts with a bar attaching the two casts together may be advised. In the past, bed rest and traction was used successfully and remains an option today, but for most family situations it is not a good or practical option.

In follow-up visits, your doctor will check the motion of the hip. Your doctor may recommend the use of anti-inflammatory medications for short periods of time to decrease the inflammation and pain in the hip. However, this type of medication does not speed the healing process and may have side effects.

Among orthopedists, 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.

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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 when the child is done growing (versus correcting the difference that is currently present in the child).

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
  • Cosmetic abnormalities

Children tolerate limb inequalities better than adults and will walk on their toes or bend the long leg’s 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 “bone age.” This is an X-ray of the hand that will be used to determine the relative age of a child’s 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 (2.5 cm = 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 the child is having pain or problems walking).
  • If the difference is between 2 and 6 centimeters, then either a shoe lift on the outside of the shoe or a surgical procedure to slow 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, 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 solution.

Fortunately, most people have a discrepancy that is treatable by either a shoe insert 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 with ankle injuries.

Neurofibromatosis

What is neurofibromatosis?

Neurofibromatosis (NF) is a set of inherited disorders that can affect many tissues in the body. NF causes tumors or bumps 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 among patients with NF. Some have severe involvement while others may not be aware that they have the condition.

What are the types of neurofibromatosis?

Type 1, or NF1, occurs in 1 of 4,000 births and is characterized by multiple café 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 20s.

NF1 is the type most likely to be seen in orthopedic offices. Some of the physical signs your doctor will notice are the skin lesions described below. If your doctor suspects NF, he 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?

  1. Café 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 café 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 15 mm in adults. These spots are different than freckles, which are usually very small and increase with sun exposure. However, patients with NF do have abnormal freckling under the arms and in the skin creases of the groin.
  2. Neurofibromas are the most common tumor in NF. These are benign growths that 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.
  3. Iris nevi (Lisch nodules) are areas of pigment accumulation on the iris (the colored part of the eye). An ophthalmologist will need to be involved for this evaluation.
  4. The most common skeletal manifestation of NF is scoliosis and kyphosis. Scoliosis is side-to-side curvature of the spine as viewed from the front or back. Kyphosis is forward curvature of the spine as 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 evaluate 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 orthopedic 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 heal, since they don’t 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 usually necessary to help the bone heal.

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Osteogenesis Imperfecta

Osteogenesis imperfecta (OI), or “brittle bone disease,” is a diverse group of inherited connective tissue disorders. Manifestations of the disorder are variable and include:

  • Osteoporosis
  • Dentinogenesis imperfecta (abnormal enamel formation on the teeth)
  • Blue sclerae (sclerae are the white part of the eye)
  • Hearing loss
  • Short stature
  • Easy bruising
  • Excessive sweating
  • Joint laxity
  • Cardiopulmonary abnormalities

Osteoporosis is present in all patients and is responsible for the hallmark feature of the disease, a tendency for fractures to occur with minimal inciting trauma.

There is no distribution by gender, race or ethnic origin. The disease probably affects 1 in 10,000 people.

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Osteomyelitis and Septic Arthritis

What is osteomyelitis?

Osteomyelitis is an infection of a bone usually caused by bacteria and treatable with antibiotics. If symptoms have been present for some time before treatment is started, an abscess may form and blood supply to the bone may be compromised.

If an abscess forms in the bone prior to or during treatment, surgery will be necessary. Therefore, osteomyelitis can be one of the most difficult conditions for an orthopedic surgeon to 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 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. Symptoms include fever and pain. Pain is usually severe enough 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 in pain is difficult. Your doctor will 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. 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 to get rid of the infection.

If blood supply to the bone has been lost, managing the condition becomes more difficult. Your physician will discuss the pertinent issues with you.

How long does antibiotic treatment last?

There is no set time for treatment with antibiotics. In general, antibiotics are used until the patient’s temperature and the laboratory studies have returned to normal. However, treatment with antibiotics depends on the degree of severity, type of bacteria present, and the condition of the patient.

What is 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.

Rotational Abnormalities

Intoeing Gait

Many parents are concerned if their child toes-in when walking, yet an intoeing gait represents a normal variant of walking. However, your doctor will assess a number of factors when a child is brought in for an evaluation of this condition. Various neurological conditions and congenital hip conditions can be associated with an abnormal gait.

If your doctor determines that there are no other problems, your child’s intoeing gait may be related to excessive inward twist of the femur (thigh), tibia (lower leg), or foot segments of the lower limb. As with many physical characteristics, this condition may be inherited.

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 “W.” Sitting on your feet does not cause abnormal inward twist of the bone; children will sit that way because they are more comfortable due to the rotation of their hips. Making them change the way they sit does not affect the rotation of their hips.

Leg Segment

Intoeing may also be associated with an abnormal inward twist 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 bowlegged 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 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.

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 “treatment” that can internally rotate the tibia except surgery. Again, abnormal sitting can aggravate this problem.

Foot

Although rare, children may intoe from a foot condition known as metatarsus adductus, in which the foot is shaped like the letter “C”. While it was more common 20 years ago, this condition still occurs, usually as a 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 “skewfoot,” 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. Your doctor will begin to suspect this condition if the foot does not respond to cast treatment.

Scheurmann’s Kyphosis

What is Scheurmann’s Kyphosis?

Scheurmann’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 Scheurmann’s Kyphosis?

No known cause has been defined, although 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). The condition may be painful during a rapid growth spurt, activities that emphasize forward flexion or lifting, or athletic activities. The pain is usually located at the top of the deformity or in the lumbar region. Patients with Scheurmann’s 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 make the diagnosis.

What are some of the treatment options?

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

Scoliosis

Scoliosis is a side-to-side curvature of the spine when a patient is viewed from either the front or back.

What are some of the signs of scoliosis?

  1. One shoulder may be higher than the other
  2. One shoulder blade may be more prominent than the other
  3. With the arm hanging at the side, there may be more space between the arm and body on one side
  4. One hip may appear higher than the other
  5. The head may not be centered on the pelvis
  6. 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 run in families 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. Children with connective tissue diseases such as Marfan’s syndrome have an increased risk of developing scoliosis. Children with genetic conditions such as Down’s 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, but girls are 5 to 8 times more likely to have progressive deformities requiring treatment.

Approximately 90% of patients who develop scoliosis will have mild curves that do not require treatment. Periodic X-rays are necessary to properly monitor the spine. Mild curves do not necessarily require any modification of activities.

What are the factors used to determine the need for treatment?

  • Age in years
  • Degree of curve
  • Location of the curve in the spine
  • Status of menses (starting of first period) and puberty
  • Gender of patient (females are more likely to have a progressive curve)
  • Worsening of the curve

What is the role for brace treatment?

The purpose of a brace is to attempt to prevent a spinal deformity from increasing. Braces do not correct spine deformity. Your doctor will usually recommend a brace if your child’s curve is approaching or has exceeded 30 degrees and the child is still growing. Long-term studies have shown that most people will tolerate curves of less than 30 degrees as adults.

Curves of 30 degrees or less at skeletal maturity will typically not increase throughout life. If your doctor recommends using a brace, it usually means that she is concerned that, if left untreated, your child’s scoliosis would eventually exceed 30 degrees and need surgery.

To be effective, a brace must be worn 16 to 22 hours per day. This represents a big commitment for both the patient and family. The opportunity to wear a brace exists only while a patient is still growing.

What is the role of surgery?

Minimally invasive spine surgery is an option for those patients whose curves are progressive but not severe. Surgery involves stapling the vertebrae to temporarily hold that side of the spine from growing. This allows the other side to continue growing and gradually straighten the spine.

Curves that have progressed beyond 45 to 50 degrees are best treated surgically, as these curves will continue to progress throughout life unless stopped with surgery. The purpose of surgery is to prevent increasing spine deformity. At the time of surgery, the amount of curvature or deformity can be reduced somewhat. But the spine is never “straightened,” as this could cause spinal cord injury.

The degree of correction obtained at the time of surgery depends on the flexibility of the curve. There are many different techniques of spine surgery. The most common is called a posterior spine fusion, in which the incision is made from the patient’s back.

Spine fusion defines a technique of bone preparation that causes the spine to grow vertebra together in the same way that a broken bone heals. Metal pieces are used at the time of surgery to keep the spine from moving during the healing process (much like a cast). This instrumentation eliminates the need to wear a brace after surgery.

What are the factors that influence the recommendation for surgery?

  • Area of spine involved with the curvature
  • Severity of the curve
  • Presence of other spine deformities (increased or decreased curvature of the spine as a patient is viewed from the side – kyphosis or lordosis)
  • Pain (rare in adolescents and usually prompts other studies such as bone scans and MRIs)
  • Remaining growth (time to skeletal maturity)
  • Personal factors

What are the operative considerations?

The goal of surgery is to prevent further progression of the curve and to obtain some correction of the curve. There are risks to this surgery, just as there are with any surgery. These risks should be discussed with your doctor in a pre-operative conference with all involved people in attendance (patient, parents or other caregivers, and physician).

This problem requires substantial parental involvement and it is difficult to adequately explain this type of surgery verbally without X-rays.

Your child may become anemic after the surgery, and if your child weighs more than 100 pounds they will be given the opportunity to donate blood for themselves. During surgery, a machine called a cell saver is used to conserve blood by recycling the patient’s own blood.

What are some frequent concerns regarding scoliosis?

  • Lack of calcium does not cause scoliosis.
  • Poor posture does not cause scoliosis.
  • Heavy book bags do not cause scoliosis.
  • Braces do not straighten a spine.
  • Smoking (even secondhand) does interfere with bone healing after spinal surgery.
  • The instrumentation used does not set off metal detectors at airports, does not rust, and is not rejected by the body.
  • Surgery does not interfere with child bearing.
  • Scoliosis is not usually painful in adolescence, but can become painful in the adult.
  • At present, there is no known prevention of spinal deformities.

More information:

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. It occurs around 14 years of age for boys and 12 years of age for girls. It most commonly occurs in obese children and may involve both legs in up to 30% of cases.

The onset of symptoms may be abrupt or may occur gradually over many months. Symptoms may include:

  • A dull groin ache
  • Knee pain
  • Walking with the foot on the affected side turned out excessively
  • Limited ability to pull the knee up to the 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:

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 the neural tube (spinal cord) to close during development in utero. Neural tube defects are thought to be caused by many factors including:

  • Environmental factors
  • Maternal hyperthermia
  • Administration of valproic acid
  • Maternal insulin-dependent diabetes
  • Folate (iron) deficiency

The incidence is 1 in 1,000 live births in the US. 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 who do not receive treatment have a less than 10% chance of surviving to school age. But with non-selective closure of the defect and shunting of the hydrocephalus (water on the brain), the survival rate at 25 years of age increases to 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 orthopedist, 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 spina bifida are advised to strictly avoid all contact with products containing latex.

More Information:

Spondylolysis and Spondylolisthesis

 What are spondylolysis and spondylolisthesis?

Spondylolysis comes from the Greek words “spondylo” (spine) and “lysis” (breakdown). This condition is a stress fracture of a vertebra. Spondylolysis usually involves both sides of the vertebra while involvement of only one side usually occurs with trauma.

Spondylolisthesis comes from the Greek words “spondylo” (spine) and “olisthanerin” (to slip). This condition occurs when one vertebra slips forward on the next vertebra. 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 do not respond to conservative therapy and require spine surgery.

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 assess joint motion 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 an 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 such as foot orthotics (shoe inserts), casting and anti-inflammatory medications. Patients who 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
  • 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.

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