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Pediatric Orthopeadics Treatment

A pediatric orthopedist is the most experienced doctor who specializes and treat all aspects of musculoskeletal (bone, joint or muscle) problems in infants, children and adolescents in a growing phase. A pediatric orthopedist surgeon is trained to treat a wide range of problems such as skeletal deformities, congenital, traumatic conditions and musculoskeletal problem such as:

• Scoliosis – is the condition of curvature of the spine causing the spine to turn so that one shoulder, shoulder blade or hip is higher than the other. Scoliosis generally doesn’t cause pain or problem with daily functioning. Surgery is recommended for curves around 50 degrees or more, once it is diagnosed through X-rays and other tests. The curves can get larger even at adulthood eventually affecting lung function if not treated on time. This procedure requires placing of rods into the spine, holding the spinal bones with hooks and screws to straighten the spine. With the help of bone grafting, spine is fused to avoid anymore curving.

• Clubfoot – is foot deformity present at birth in which the foot is twisted inward and pointed down. If not treated on time, this can cause problem in walking and wearing shoes when the baby grows. Some clubfeet deformities are mild and flexible while others are more severe. Once the problem is diagnosed on time, sometimes in the prenatal ultrasound done before the baby is born. A series of casts are changed once a week gently stretching the foot into a normal position. This is called Ponseti method. Baby needs to wear special shoes attached to a bar for the first few months after the casting is done. In case of severe clubfeet where the deformity reoccurs, surgery might be required which is usually done after age 3 and may involve transferring a tendon to keep the foot in good alignment.

• Limb and spine deformities – Limb deformities can be congenital present at birth or may occur in later age due to fracture, infection, arthritis or tumor. Limb deformity may cause developmental disorders leading to altercation in the shape and appearance. Children may also experience back pain due to a pediatric spinal deformity. There are various types of pediatric spinal deformity that may occur in children such as scoliosis, kyphosis, spondylolisthesis and spinal trauma. Abnormal curvature of the spine occurs in Scoliosis and kyphosis whereas displaced vertebra is known as Spondylolisthesis.

There are some common symptoms of pediatric spinal deformity include lower back pain, wobbling, formation of humpback. Younger children around 6 can also have a displaced vertebra sometimes without pain. Parent should seek medical attention as soon as possible, if the child has spinal deformity. Many pediatric spinal deformities can be treated with help of physical therapy or bracing but in serious cases, surgery may be required by highly experienced pediatric orthopedist.

• Abnormal gait – is irregular walking pattern. It is important to be aware of any possible abnormalities in growing children’s posture and steps. As soon as the problem is diagnosed, it becomes easier to correct the problem with help of therapy. The most common causes of abnormal gait may include arthritis, congenital defects, and bone fractures, infection damaging tissues in the legs, conversion disorder, inner ear infection, cerebral palsy or stroke. There are several types of gait abnormality:

• Antalgic gait – causes pain due to which child may not able to put weight on the affected area.

• Circumduction gait – swinging of leg with each step

• Spastic gait – this usually occurs due to an upper motor neurone neurological disease e.g. cerebral palsy or stroke. In this, child drags their feet inward while walking.

• Ataxic gait – difficulty in maintaining stability when moving.

• Trendelenberg’s gait – occur due to weak hip abductor muscle or pain

• Toe walking gait – it is normal in up to the age of 3 but persistent toe walking can be seen in children with motor neurone neurological disease such as cerebral palsy.

• Stepping gait – may be a result of week ankle dorsiflexors and often seen in diseases like spina bifida.

• Clumsy gait – a result of delayed motor development known as dyspraxia.

Physical therapy is the most common treatment for walking disorders that allows patient to strengthen their weak muscles and rectify their walking patterns. There are also some assistive devices, such as crutches, leg braces, a walker, or a cane that can prove beneficial.

• Broken bones – Bones in the children are more fragile than the adult bones. Thus the treatment of the broken bones in children also differs from the treatment given to adults. In younger children femur bone fracture will heal easily with the help of hip spica (large cast). Children have great healing capacity that requires less time than adults which allows surgeon to treat children differently and more often without surgery. Some of the common fractures in children are forearm fracture, elbow fracture and ankle fracture.

• Tumors or infections in joint bone – infections in bone is known as Osteomyelitis usually caused by bacteria, mycobacteria, or fungi that infect bones by spreading through the bloodstream or often by spreading from nearby infected tissue or open contaminated wound. In infected bone, the soft and inner part often swells and this swollen tissue pushed against the outer wall of the bone compressing the blood vessels in the bone marrow causing inadequate blood supply due to which some parts of the bone become dead. These areas of dead bone are difficult to cure infection as body’s natural infection fighting cells and antibiotics could not reach them. This infection can spread outward from the bone nearby tissues forming abscesses in it.

• Cerebral palsy – cerebral palsy is a complex condition that describes a wide range of physical and development problems caused by injury or abnormal development in the immature brain mostly at the time of the birth. People with cerebral palsy may have problem in controlling the body movement, muscle tone, weakness, reflexes, balance along with some additional cognitive difficulties related to the brain and its symptoms are swallowing disorders, seizures, constipation, excessive drooling, disability in learning. There are different types of cerebral palsy such as quadriplegia, diplegia, triplegia, or hemiplegia that person may have depending on how the body is affected.

This treatment requires specialized health care providers that includes developmental pediatricians, neurologist, neuropsychologist, neurosurgeons, occupational therapist, ophthalmologist, orthopedic surgeon, pediatric rehabilitation medicine specialist, physical therapist, speech and language pathologist and clinical nursing team

• Osteochondritis – it develops in joints most often in children and adolescents. This occurs when a small part of bone separates from its surrounding region due to lack of blood supply. Most commonly affects the knee, ankle and elbow than others joints. In Osteochondritis (OCD) in growing children, the affected bone and cartilage heal on their own whereas in grown and young adults, OCD may have more severe effects. Surgery might be needed if the lesion part from the surrounding bone and cartilage detach and floats around inside the joint.

• Hip dysplasia –commonly called developmental dysplasia of the hip (DDH) is a wide range of hip problems in infant or younger children. This happens when the femoral head of the hip joint is not held firmly in the acetabulum (hip pocket). Hip of the baby may not be dislocated but may have some looseness leading it to slip in the joint. Some of the symptoms of the hip dysplasia are uneven thigh folds, one leg shorter than the other, tightness with the hip flexibility, limping, family history of hip dysplasia. Treatment can be recommended depending on the age of the child after the problem is diagnosed. Some of the treatments are pavlik harness, closed reduction, open reduction, hip osteotomies.

• Knee problems – Growing and active children may experience knee pain due to many factors such as overuse of knee especially in active children, imbalance of thigh muscles that support the knee joint, poor flexibility, improper alignment, aggressive sports etc. knee pain in children can also occur due to injuries to ligaments and tendons such as anterior cruciate ligament injury, posterior cruciate ligament injury, lateral collateral ligament injury, medial collateral ligament injury, dislocated kneecap, Osgood – Schlatter’s disease, sinding –larsen Johansson syndrome, juvenile arthritis, osteochondritis dissecans. Doctor may suggest the treatment depending on the problem that may involve physiotherapy, exercises, or medication.

• Myelodysplasia – also known as MDS is a rare disease of the blood in children in which body could not produce enough blood cells properly. It develops in the bone marrow, soft tissue of the bone that produces white blood cells to fight infections, red blood cells that carry oxygen and platelets which helps in blood clotting and stop bleeding. In this disease, the blood cells don’t mature and function properly. The most effective treatment is called allogeneic stem cell/bone marrow transplant.

• Rheumatic disease – pediatric rheumatic disease, also known as juvenile arthritis is used to describe many autoimmune and inflammatory conditions which may develop in young children. The most common symptoms experienced by children with rheumatic disease are pain, joint swelling and redness. Some pediatric rheumatic diseases affect the musculoskeletal system. Other body parts such as the eyes, skin, muscle and gastrointestinal tract can also get affected by this disease.

There are various types of pediatric rheumatic diseases such as:

1. Juvenile idiopathic arthritis – JIA is very common disease categorizes into oligoarthritis, polyarthritis, systemic, enthesitis-related, juvenile psoriatic arthritis.

2. Juvenile dermatomyositis – it is inflammatory disease that causes muscle weakness and rashes on eyelids and knuckles.

3. Juvenile lupus – Its immune system disease that affects the joints, skin, kidneys, blood and other parts of the body.

4. Juvenile scleroderma – scleroderma means hard skin. This causes the skin to tighten and harden.

5. Kawasaki disease – this causes inflammation of the blood vessels that may lead to heart complications.

6. Mixed connective tissue disease – may include features of arthritis, scleroderma and lupus dermatomyositis. It is associated with very high levels of antinuclear antibody (anti-RNP)

7. Fibromyalgia – this condition is related to arthritis and can cause stiffness, aching, fatigue, disturbed sleep and other symptoms. Mostly occur in girls and is rarely diagnosed before puberty.

• Spondylolysis and Spondylolisthesis – spondylosis is a spine defect occurs in the lower back (lumbar). This is more common in adolescents who are active in sports that involves repetitive hyperextension of the spine e.g. gymnastics, football or diving. This affects the vertebra (par interarticularis) which is the ring through which the spine cord passes. The fourth and fifth lumbar vertebrae are the most common parts that get affected by spondylolysis.

Spondylolysis may lead to spondylolisthesis which means spine slippage. This defect weakens the vertebrae due to which it is unable to maintain its proper position and when one of the bones slides off the disk or slip out of the place is called spine slippage. Most of slippage can be treated without surgery but in case the slip is large may require surgery to correct the condition.

Symptoms for both spondylolysis and spondylolisthesis are similar. The most common symptom is pain in the lower back worsen over the time with spine extension and with high impact activities like running and jumping. Sometime a person may experience muscle spasm also which can make the condition more painful and cause awkward posture and gait.

• Brachial plexus palsy – also known as Erb’s palsy, affects the nerves passing from the neck to the arm. These nerves trigger movement from the shoulder down to the fingers. It can result in a lifelong disability if not treated immediately. The brachial plexus is a complex network that controls movement and sensation in the shoulder, arm, hand and fingers. Stretching, compressing or tearing of the nerves is the most common cause of brachial plexus palsy that may result in scar formation. Some of the symptoms of brachial plexus palsy are:

• Loss of sensation

• Loss of muscle control

• Limited or no range of motion

Brachial plexus palsy treatment includes observation, occupational and physical therapy and surgery. A combined medical team of doctors specializes in neurosurgery, hand surgery, orthopaedic surgery, physical medicine and rehabilitation, electrodiagnosis, occupational therapy and nursing is required for the comprehensive evaluation and timely treatment of such problems.

There are surgical and non-surgical (minimally invasive) treatments options to treat these problems that may include:

• Orthopedic surgery • Arthroscopic and less invasive surgery • Spinal deformity correction • Foot deformity correction

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