Education Center

Bowlegs Cerebral Palsy Clubfoot Casting for uncomplicated procedures Flatfoot
Fractures Hip Dysplasia Muscle Disorders Perthes Disease Spina Bifida
Scoliosis Adolescent Idiopathic Scoliosis Juvenile Scoliosis Infantile Scoliosis Congenital Scoliosis
Congenital Kyphosis Scheuermann's Kyphosis Spondylolysis/ Spondylolisthesis    

Bowlegs

Bowleggedness is an outward bending of the legs from the knees down that affects most children under the age of 18 months. Most children are born bowlegged because of their folded position in the uterus, and the condition will continue to become more pronounced until the age of 18 months. When this condition continues past this age, it may be a sign of another condition such as Blount's disease.

Children with bowlegs may experience excessive tripping, in-toeing and knock knees as a result of this condition. Your child's doctor may perform an X-ray exam of the legs, but may not be able to distinguish if this is a serious problem until the child is older.

Most cases of bowlegs are corrected on their own as your child ages. More severe cases may require braces, special shoes, casts or surgery. If left untreated, this condition may cause trouble walking.

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Cerebral Palsy

Cerebral palsy is a neurological condition that causes problems with body movement and muscle coordination throughout a child’s life. While most children are born with this condition, signs may not appear until months or years later. If you notice your child having trouble sitting, crawling or walking, he or she may have cerebral palsy.

Cerebral palsy affects the central nervous system and may occur as a result of several different causes. In most cases, the condition develops during the pregnancy, but may also be a result of complications with delivery. Some of the risk factors for cerebral palsy include:

There are four main types of cerebral palsy, which can be diagnosed once the child is about two years old. These types include:

Although there is no cure for cerebral palsy, there are several treatments available to help relieve the symptoms of this condition and improve your child’s physical capabilities. Many children with this condition are able to go on and enjoy functional, independent adult lives. Treatment for cerebral palsy may include physical, occupational and speech therapy, and medications to help control seizures, relax muscle spasms and relieve pain. Surgery may be required to correct structural abnormalities or release tight muscles.

Other treatment options for cerebral palsy include:

Through continued treatment, most children are able to improve their motor skills and communicate to lead a life that is as close to normal as possible.

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Clubfoot

Clubfoot is a common childhood condition that causes the foot to turn inward to the side, resembling the head of a golf club. This condition is present at birth and can affect one or both feet. It is usually an isolated condition that does not cause any other health problems for the child. But if left untreated, clubfoot can cause arthritis and issues with self-confidence as the child continues to grow.

The cause of clubfoot is unclear, but is believed to be a result of congenital abnormalities or a genetic defect. While it may seem like a painful and serious condition, clubfoot does not typically cause any symptoms in patients, until they try to walk on it. It is most effective to treat this condition before the child is able to walk, in order to prevent symptoms and complications from occurring.

Clubfoot treatment often begins with nonsurgical methods such as manipulation and casting. The foot is manipulated into the correct position and then placed in a cast to stay in the corrected position.

When nonsurgical techniques are unsuccessful, surgery may be required to correct clubfoot. Surgery for this condition is usually performed when the child is 9 to 12 months old and involves adjusting the tendons, ligaments and joints in the foot and ankle to keep it in a corrected position.

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Casting for uncomplicated fractures

A fracture is a break or crack in the bone, often caused by extreme force or injury. Fractures are more common in children than adults because of their active lifestyle and pliable bones. Pediatric fractures often involve growth plates, areas of cartilage where the bones can grow.

Although treatment for fractures varies depending on the location and severity of the injury, many can benefit from casting. Casting is usually needed for several weeks and helps hold the affected bone in place so that it can heal naturally. Casts require certain care to keep the area clean and dry, which help promote effective healing with no risk of infection or other complications.

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Flatfoot

Most children are born with flat feet and develop arches as their bodies grow. However, in some children, the arch never develops, leaving the child with inward-turning ankles. While this condition is not usually serious, parents should seek medical attention for flatfoot, as it may cause pain. Some children also experience flexible flatfoot, a condition in which the arch disappears while standing, and then reappears when the child sits or is on tiptoes.

Your child's doctor can diagnose flatfoot by examining the feet and family history, as well as the child's everyday shoes for signs of abnormal wear. This condition should be monitored on a regular basis, and most cases will gradually improve by the time the child is five years old. If the condition persists and begins to cause pain, arch supports, physical therapy or casting may be recommended to relieve pain and correct the condition.

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Fractures

A fracture is a break or crack in a bone that occurs when the bone cannot withstand the amount of force being placed on it, usually as a result of trauma, falls or a direct blow to the body. Fractures in children are different than in adults, as children's bones are softer and tend to bend or buckle rather than break. Healing is also faster in children's bones.

Fractures in children most commonly occur in the wrist, forearm and above the elbow, and can cause:

There are several different types of fractures that may occur, depending on the age of the child, the location of the fracture and the severity of the condition. Your child's doctor will perform an X-ray exam to determine what type of fracture it is. Because children's bones are softer than adults, they most commonly experience buckle or greenstick fractures, which involve a bending of the bone and sometimes a partial fracture on one side. Older children may experience a more severe break.

Treatment for a fracture depends on the type and severity of the condition, but usually involves immobilization with either a splint or a cast to help keep the bone in place for proper healing. More serious breaks may require surgery to help realign the bone and ensure that it stays together during the healing process. Your child's doctor will decide which treatment is best for your child's individual fracture.

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Hip Dysplasia

Hip dysplasia, also known as developmental dysplasia of the hip, refers to problems with the formation of the hip joint in children. These problems can occur within the ball (femoral head), socket (acetabulum) or both components of the joint. The most common form of hip dysplasia involves a socket that is too shallow, forcing the leg to place excessive pressure on it.

Hip dysplasia can affect one or both hips, and may be mild or severe. Mild cases result in a hip that is unstable and prone to dislocation, while severe cases involve a hip joint that is permanently dislocated, either partially or fully.

Children with hip dysplasia are often born with this condition, or develop it within the first few years of life. The exact cause is unknown, but some babies are at a higher risk of having this condition. Some of these risk factors may include:

While children with this condition may not experience any symptoms, hip dysplasia can lead to major problems later in life, which is why thorough treatment is recommended as soon as possible.

Treatment for hip dysplasia can vary depending on the age of the child and the severity of the condition. Nonsurgical treatment is often the first step in correcting this condition, and may involve a Pavlik harness to prevent the hip from moving out of the socket or a spica cast in older children which restricts movement even more. Surgery may be required for older children to move the hip joint back into its proper position. Your doctor will decide which treatment is best for you child to help prevent future problems such as arthritis.

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Muscle Disorders

Muscle disorders, also known as myopathy, are a series of conditions that cause muscle dysfunction resulting in weakness, deterioration and even paralysis. These conditions can be inherited or acquired, and may be present at birth or develop later on.

The cause of muscle disorders is often unknown, although they may develop from:

Muscular dystrophy is one of the most common types of muscle disorder that affects children. This genetic condition is present at birth, although symptoms do not usually begin until the child is a few years old. Muscular dystrophy may cause children to stumble, waddle and have trouble standing up and pushing things. Symptoms may vary depending on the individual type of muscular dystrophy.

Congenital myophathies are present at birth and usually caused by hereditary factors, but are not considered progressive. These conditions often affect the legs and cause a delayed ability to walk or trouble climbing stairs.

Inflammatory myopathies are muscle disorders that are a result of an immune system reaction in the muscles. These autoimmune disorders attack the body cells and causes overall muscle weakness. Drug-induced myopathy is caused from the use of certain medications, such as immunosupressants, and can cause severe weakness in some cases

Although muscle disorders usually cannot be cured, there are several treatment options available to manage the symptoms of the disorders and maximize your child's quality of life. Treatment for muscle disorders may include physical therapy, bracing, anti-inflammatory medication or walking devices. More severe cases may require surgery to release tendons or correct abnormalities of the spine.

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Perthes Disease

Perthes disease, also referred to as Legg-Calve-Perthes disease, is a condition that involves a temporary loss of blood supply to the hip, causing the ball (femoral head) of the ball and socket joint to die. When the blood supply eventually returns, the bone heals, but can lead to serious problems later in life. This condition is most common in boys between the age of four and eight.

Children with this condition experience discomfort as a result of inflammation and irritation. This discomfort is most often experienced in the knees, and may cause an abnormal gait as well. Discomfort is usually worse when the hip is moved.

Since Perthes disease can affect the structure of the hip, it is important to seek medical attention for this condition as early as possible to help treat it properly and prevent complications.

The best treatment for Perthes disease depends on the age and gender of the child, along with the severity of the condition. In many cases, especially in younger children, no treatment is necessary and the condition will correct itself. Anti-inflammatory medication can help relieve symptoms. Other cases are treated with nonsurgical techniques such as traction and immobilization, while the most severe cases may require surgery to restore movement to the hip joint. Physical therapy is beneficial to most Perthes disease patients in order to promote proper healing.

Perthes disease does not usually last more than two years, and most patients will continue to grow with no major physical limitations from this condition.

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Spina Bifida

Spina bifida is a nervous system disorder that involves an incomplete development of the spinal cord. This condition occurs after the first month of pregnancy, which is when the spinal cord typically closes. Babies with this condition have an open area in their spinal cord, which may be caused by a combination of genetic, nutritional and environmental factors.

Many cases of spina bifida can be diagnosed while the child is still in the womb through a fetal ultrasound and other prenatal testing. Mild cases may not be detected until after the child is born, and are often diagnosed during a routine X-ray exam.

The risk of spina bifida can often be reduced by making sure the mother receives enough folic acid during pregnancy. This can often be done with prenatal vitamins and a healthy diet.

Depending on the type of spina bifida your child has, he or she may or may not need treatment. Spina bifida occulta is a mild form of the condition that does not usually cause any other health problems and leaves the spinal cord unaffected. Spina bifida manifesta, which can include a diagnosis of either meningocele or myelomeningocele, is more severe and can cause paralysis and an accumulation of fluid in the brain.

Spina bifida occulta rarely requires treatment and should just be monitored through regular doctor's visits. More severe cases may require surgery, often as soon as a day or two after birth. These surgeries push the spine back into the vertebrae and close the opening to help prevent infection and complications.

Children with spina bifida often need several surgeries throughout their life to manage problems with the feet, hips and spine, and may also need to rely on assistive devices such as braces, crutches and wheelchairs. The best treatment for your child depends on their individual condition, and can be determined by working with an experienced doctor that you trust.

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Spine Education

Scoliosis

Scoliosis is a 3-dimensional deformity consisting of a lateral curvature and rotation of the spine. This can result in spinal imbalance, asymmetric shoulder heights or rib prominence on the side of the curvature. There are many conditions that can be associated with scoliosis including congenital spinal abnormalities, but the majority are idiopathic (without a known cause). Idiopathic scoliosis can be divided into infantile, juvenile and adolescent categories depending on the age at presentation.

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Adolescent idiopathic scoliosis

This is the most common accounting for about 80% of all idiopathic curves. Usually this begins at the age of 10 years. Small curves above 10° can be seen often (in up to 3% of the population) but larger curves about 30° are far less common (0.3%). Greater curve sizes that require treatment are more typically seen in girls than boys. Genetic testing is currently being developed to help assess the risk of progression for each individual patient.

Nonoperative treatment is aimed at minimizing progression of the curvature, defined as an increase of >5°. The patients that we worry about the most for progression are girls, patients with large curves, and young patients. A young, premenarchal girl with a large curve, for instance, is especially worrisome for progression of the curve which seems to increase as patients grow.

MRI is rarely helpful in the adolescent group unless there are abnormal findings on the neurologic examination or an atypical curve pattern.

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Treatment

Management options include observation, bracing and surgery. There is no established benefit from exercise, biofeedback, electrical stimulation or chiropractic therapy in preventing curve progression.

A brace is typically used to prevent curve progression in immature patients with a Risser sign between 0 and 2 with curves between 20-40° in size. The brace is continued until either skeletal maturity is reached or the patient requires surgery. There are many different styles of braces, but in our practice we use the Boston brace and Spine Cor brace systems. The determination of which brace to use will be largely determined by the curve size and flexibility. For the brace to be effective, it needs to be worn >18 hours per day including at night as better results are seen when the brace is worn longer. After the orthotist fits the brace, we evaluate the fit and pad placements and then obtain an X-ray in the brace after 3-4 weeks of use. With the Boston brace, roughly 50% correction of the curve in the brace is desirable, otherwise adjustments will be needed. Less correction is typically seen right away with the Spine Cor brace which gradually corrects over time. Once satisfied with the brace fit and correction, X-rays are then repeated every 5-6 months out of the brace to assess for progression. As long as the curve remains stable or <50° in size, the brace will be stopped near skeletal maturity. This occurs roughly 18-24 months after onset of menses, but can also be defined by X-ray findings or when there is no change in the patient’s height between visits.

For those curves that do progress above 50°, surgery is typically recommended. This is because most of these (65%) will continue to progress even after skeletal maturity. Most smaller curves, in contrast, do not progress after the patient is done growing. With surgical management, we are trying to achieve spinal balance with the head centered over the pelvis and even shoulder heights and 50% or greater curve correction. Surgical approaches include anterior, posterior or combined dependent on the curve pattern, size and flexibility. Most curves are treated with a posterior only approach, but certain lumbar curves may benefit from anterior treatment. Combined procedures are reserved for very young patients or stiff curves in order to improve flexibility.

The surgery involves fusing a portion of the spine using hooks, wires or screws to hold the vertebrae to metal rods which allow straightening of the curvature. In our practice, we use primarily multi-level pedicle screws which provide fixation into the front and back portion of the vertebra thereby permitting rotation of each vertebra in addition to correction of the curve. This rotation allows us to flatten the rib and muscle prominences created by the rotational component of the deformity without performing thoracoplasty where the ribs are actually cut to do this. During surgery, we monitor the neurological function of the spinal cord continusouly to minimize any potential spinal cord or nerve root injury.

After surgery, patients will typically spend 1-2 nights in the Intensive Care Unit. Beginning the day after the procedure, our physical therapists begin working on sitting patients at the bedside and progressively advancing to regular walking without support as quickly as possible. Most patients will be ready to go home 5-7 days after surgery but will need about a month at home before returning to school. During the first 6 weeks, they need to avoid any bending, lifting or twisting movements to avoid excess stress on the spine and metal implants. After 6 weeks, they can slowly advance to swimming and light jogging. Most patients can return to sports by 6 months, except for football, wrestling or gymnastics.

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Juvenile Scoliosis

Juvenile scoliosis represents 15% of idiopathic curves with onset between 3-10 years of age. Girls are more typically affected. MRI is indicated for most patients in the juvenile group as a fair number of them may have abnormal findings. Management is similar to the adolescent group, but there is much greater likelihood of needing surgery in the future despite bracing. Bracing is generally used to minimize progression or at least postpone the need for surgery until the child is older at which time a fusion procedure can be performed. As in the infantile group, growing rods can allow the spine to be gradually stretched as the child grows but multiple procedures are needed before ultimately proceeding to a fusion procedure.

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Infantile Scoliosis

Seen in children under 3 years of age, infantile scoliosis represent about 5% of idiopathic curves. Most are diagnosed by 6 months of age and typically left thoracic curve patterns. MRI is indicated as roughly 20% of patients will have abnormal findings. Many infantile curves will resolve spontaneously without requiring treatment. The x-ray can help to predict whether the curve will increase or decrease with time. With smaller curves, almost 80% of them will resolve spontaneously. The larger curves, however, show 80% of children progressing to larger curves. For these patients, treatment options include bracing, casting or surgery. Bracing and casting can be successful in many patients with infantile curves and are tried before considering surgical treatment. When surgery is required, implants such as growing rods or the VEPTR (vertically expandable titanium rib) are used to gradually elongate the spine to allow growth until the child is older.

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Congenital Scoliosis

In young children, many curves are created by abnormally formed or incompletely separated vertebrae. The vertebrae develop between 5-8 weeks of gestation. This is a critical time in development with multiple organ systems also forming. As a result, many congenital spinal abnormalities are associated with cardiac, genitourinary and brain/spinal cord abnormalities, which should be screened for once the child is diagnosed.

Congenital scoliosis patterns arise from defects of segmentation where the vertebrae do not separate or defects of formation. Segmentation problems include block vertebra, unilateral bar (or fusion) and unilateral bar with a hemivertebra. Vertebral formation problems include wedge vertebra and hemivertebra, which can be fully or partially segmented or incarcerated. Combinations of these patterns are also frequently seen.

Treatment depends on the pattern of abnormalities present as these determine the risk of progression. A unilateral bar with a contralateral hemivertebra has the highest risk of progression and is typically treated shortly after diagnosis. This pattern is followed by unilateral bar formation, multiple fully segmented hemivertebra, and single fully segmented hemivertebra in terms of progression risk. Bracing is rarely indicated for treatment of congenital scoliosis and observation or surgery are the mainstays of treatment. These curves require close monitoring during significant growth seen in the first three years of life and adolescence. Surgical treatment options include growing rods, VEPTR or hemivertebra excision. Partial fusions are less commonly performed now due to secondary deformities that may develop or limitations in trunk and lung growth that may occur.

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Congenital Kyphosis

Congenital kyphosis often requires early surgical management as the sharp angular deformities that develop can lead to a much higher risk of paralysis than seen in congenital scoliosis patients. The kyphosis can arise from defects of formation, segmentation or both as seen in congenital scoliosis. Bracing is not effective for most patients and surgery is usually indicated. For curves <45-50°, an isolated posterior fusion can be performed with or without instrumentation. Larger and less flexible curves require both anterior and posterior fusion to minimize the risk of neurologic and achieve correction.

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Scheuermann’s Kyphosis

Scheuermann’s kyphosis develops during puberty and is caused the anterior wedging of the vertebral bodies, typically in the thoracic spine, which leads to a fixed, angular kyphosis. There is a possibly higher likelihood of degenerative disc disease and spondylolysis in adulthood due to the compensatory increase in the lumbar lordosis that develops. Patients may experience pain near the apex of the kyphosis, but this does not necessarily match up with the degree of deformity.

Treatment includes exercise to strengthen the back extensor and abdominal musculature while improving hamstring flexibility. Bracing may be used for skeletally immature patients with progression. However, this usually requires use of a Milwaukee brace (a brace for the back that includes the head), which is often poorly tolerated. Surgery may be considered for progressive or painful kyphoses >75°. This may entail a posterior only fusion for a flexible kyphosis, based on extension X-rays of the spine, or combined anterior releases and posterior fusion for larger, stiffer deformities.

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Spondylolysis/Spondylolisthesis

Spondylolysis is defined by fracture through an area in the back of the vertebrae call the pars interarticularis. This is a weak area of the bone that sees very high stress with extension maneuvers of the spine, such as in gymnastics, cheerleading or football. These “stress fractures” occur commonly and may be seen in 6% of people by the age of 18. The L5 vertebra is most commonly affected followed by L4. Spondylolysis can be difficult to assess by X-ray and additional imaging studies such as bone scan and CT scan are often diagnostic in cases of persistent back pain reproduced by extension maneuvers but previously negative X-rays.

Spondylolisthesis involves a slippage of one vertebra relative to another. This may be due to dysplastic, isthmic, traumatic or degenerative causes. Dysplastic spondylolisthesis that are present since birth, results in abnormal development of the facet joints, usually at L5-S1, which allows the slip to develop. These patients have the greatest risk of progression to high-grade spondylolisthesis or neurologic problems and often require surgical management. Isthmic and traumatic spondylolisthesis are both due to fractures through the pars interarticularis as seen in spondylolysis. Acute, traumatic spondylolysis may be associated with disc herniations and a greater degree of instability.

Treatment for both spondylolysis and spondylolisthesis is dependent on symptoms and the risk of slip progression. For acute back pain, nonsurgical treatment such as rest, bracing and therapy is beneficial. Surgery is usually reserved for those patients who have failed nonoperative treatment or have a greater risk of slip progression or high-grade spondylolisthesis at presentation. Symptomatic spondylolysis may be treated with either a direct pars interarticularis repair or posterior fusion. Low-grade spondylolisthesis without neurologic symptoms may be managed with posterior or anterior fusion. High-grade spondylolisthesis or patients with neurologic problems require decompression of the nerves in addition to posterior fusion or combined anterior/posterior fusion with or without reduction of the slippage. While reduction of the slip restores a more normal alignment to the spine, there is a higher likelihood of nerve injury when performed, so these procedures require close neurologic monitoring intraoperatively. Recovery is similar to that seen in patients treated for adolescent idiopathic scoliosis.

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