Diagnosing elbow fractures

Diagnosis of elbow fractures can also be more complicated than detection of other childhood fractures. Before a growing child reaches skeletal maturity, the elbow joint is partly composed of cartilage, and an X-ray that clearly shows bone tissue more clearly than cartilage may not provide a clear image of the fractured area.  

Types of elbow fractures and treatment options

The term elbow fracture describes an injury that can occur in numerous locations in the joint. These include:

• Supracondylar fractures
• Lateral condyle fractures
• Medial epicondyle fractures

• Supracondylar fractures

Seen primarily in younger children – ages four to eight years – these are the most common type of elbow fracture seen by pediatric orthopedic surgeons. This break occurs in the humerus bone just above the elbow joint.

Because the brachial artery (the main artery in the upper arm) and the nerves that control movement of the hand sit along this bone, these fractures are also associated with an increased risk of vascular and nerve injury.

In many cases, reducing the bone – putting it back into proper alignment and relieving the pressure on the blood vessels will address the problem, and the patient’s pulse will return to normal. If a tear in a blood vessel is suspected, a vascular surgeon becomes part of the treatment team. Nerve injuries, including bruising or stretching, can take longer to resolve.

When treating a supracondylar fracture, the orthopedic surgeon strives to restore the anatomy as closely as possible to its pre-injury position or alignment.

To repair a supracondylar fracture, the orthopedic surgeon realigns the bone and usually inserts wires – about the diameter of a pencil lead – into the bone and across the fracture site, an approach that helps maintain proper alignment while protecting the growth plate in these young children. The wires extend through the skin and are covered by the cast.

After a period of about four weeks, when the fracture has healed sufficiently, the cast is taken off and the wires are removed. The child is then instructed on a gradual return to daily activities to help prevent stiffness from developing. Physical therapy can be prescribed if the patient has difficulty achieving elbow motion.
 

• Lateral condyle fractures

These breaks occur at the outer part of the elbow, an area that serves as an attachment point for most of the muscles that straighten out the wrist and fingers, and also for the ligaments that stabilize the elbow joint. Lateral condyle fractures usually result from relatively low energy injuries, and the growth plate of the elbow typically resumes normal growth after the fracture heals.

Orthopedic surgeons classify these injuries based on the degree to which they are displaced and determine treatment accordingly. If the fracture is non-displaced, that is, the fracture line can be seen on an image, but the bone has not shifted out of position, the patient may only require immobilization of the arm in a splint or cast.

 

• Medial epicondyle fractures

These are breaks that occur on the inner part of the elbow (the side closest to the body).
Usually seen in somewhat older children in the preteen and teen years, these fractures are often incurred during athletic activities. A violent throwing motion in football or baseball, or a hard landing in gymnastics, may result in this type of fracture. These fractures can be associated with an elbow dislocation. Like the lateral epicondyle, the medial epicondyle is an important attachment point for forearm muscles – in this case, those that flex the wrist and fingers. It is also an attachment point for elbow ligaments.
 

Classification and treatment of medial epicondyle fractures

The precise treatment for medial epicondyle fractures is based on a classification system:

1. Type I fractures, in which the bone has barely moved out of position, can be effectively treated in a cast.
2. Type II fractures, in which the bone has shifted to some intermediate level, treatment often depends on the child’s level of physical activity and commitment to sports. If the child’s activity and interests mean that it will continue to be subjected to repeated overhead stress such as throwing, surgery is usually recommended.
3. Type III fractures, in which the bone has been pulled significantly out of position, are candidates for surgical repair.
    

Because medial epicondyle fractures usually occur in older children in whom the growth plate is almost closed (marking the completion of bone growth), and because surgery requires attachment of a small piece of bone, the orthopedic surgeon may use a slightly different approach, inserting a small screw in the bone to secure the fragment.

Recovery time with this type of fixation is shorter than that needed when wires or pins are used, and the cast can be removed in as little as two weeks. Motion is then started to prevent stiffness.
 

Multiple injuries

In addition to the most common types of fracture described, up to 5% of children with supracondylar fractures experience another injury, such as wrist fracture. Children with medial epicondyle fractures may also have an elbow dislocation (a combination that may require surgical treatment to both realign the bone and repair damage to the ligaments). Typically, this is best treated surgically.
 

Revision surgeries for elbow fractures

Occasionally, revision surgery is necessary to treat elbow injuries that have resulted in problems related to overall alignment or function. For example, lateral condyle fractures, after cast treatment, may result in some displacement of the bone fragment and incomplete healing, a condition known as a non-union. In many cases, a good result can be achieved even after months – or occasionally years – of non-union.
 

Broken elbow recovery time

Following treatment for an elbow fracture, most children remain in a cast for about three to four weeks. Casting extends above the elbow and down to the wrist, leaving the fingers free and the arm placed in a sling. “Keeping the arm immobilized is a key part of successful recovery,” Dr. Blanco emphasizes. “During this period the child needs to refrain from a number of activities, including gym at school and running and jumping during play time.” Keeping the cast dry is also important when wires or pins extend through the skin, and to protect sutures in the area.

Once the cast is removed, with proper rehabilitation, children can quickly return to their normal activities, including sports. Initial stiffness in the arm can be expected to dissipate with use. If stiffness persists, physical or occupational therapy may be recommended if the range of motion remains limited.

 

Hip dysplasia may develop in a baby around the time of birth or during early childhood. Although it is commonly diagnosed in babies and young children, DDH also affects adolescents and adults. This can usually be attributed, however, to milder cases of DDH that are difficult in diagnose and may be untreated as a child.

In the healthy hip joint, the upper end of the femur (thighbone) meets the acetabulum to fit together like a ball and socket, in which the ball rotates freely in the socket. Cartilage, a smooth protective tissue, lines the bones and reduces friction between the surfaces during movement.

In DDH, however, there is an abnormal relationship between the components of the hip, and often the hip socket is underdeveloped and does not support the femoral head (ball).

The conditions encompassed by the term hip dysplasia include:

• dislocated hip: where there is no contact between the cartilage on the ball and the cartilage on the socket
• dislocatable hip: where the ball easily pops in and out of the socket
• subluxatable hip: where the cartilage of the ball and the socket are touching, but the ball is not properly seated in the socket
• dysplastic hip: where the hip socket or acetabulum is underdeveloped or deficient to support the ball (more common in older adolescents and adults than in pediatrict patients)

In children, hip dysplasia more frequently affects the left hip than the right. About 80% of cases follow this pattern. The condition can, however, be present in both hips.
 

Can hip dysplasia correct itself?

Some mild forms of developmental hip dysplasia in children – particularly those in infants – can correct on their own with time.

Who is at risk for hip dysplasia?

Hip dysplasia is much more common in girls than in boys, and it tends to run in families. Even among children who have no hereditary link, there is a greater risk in all first-born children.
 

What causes hip dysplasia?

Genetics plays a strong role, but other influences during pregnancy and birth – such as congenital conditions caused by the fetus being in a uterus that is too small – and cases of breech birth can also lead to developmental hip dysplasia.
 

Family history

The risk of hip dislocation at birth is approximately one in 1,000. If a parent experienced hip dysplasia during childhood, the risk of his or her own child developing this risk increases by 12% compared to a parent with no history of the condition. A child whose sibling has hip dysplasia will have a 6% higher chance of developing the condition.
 

Molding abnormalities in the uterus

Head tilt (torticollis) and the turning in of the front of the foot (metatarsus adductus) are congenital conditions that often the result of being constrained in a uterus that is too small. These conditions alert medical professionals to be on the lookout for the presence of hip dysplasia, which can also be caused by such constraint.
 

Breech birth

This is when the baby emerges from the birth canal buttocks-first instead of headfirst. A breech-birth child is 10 times more likely to develop hip dysplasia than a child born headfirst.
 

What are the signs and symptoms of developmental hip dysplasia in children?

When present at birth, the abnormality may be detected during a routine physical examination of the newborn baby. Other signs include a leg length discrepancy, restricted range of motion in the hip, or a limp or waddle in walking in toddlers.

During a routine examination of a newborn, the physician gently flexes the child's hips in different directions. If the hip is dislocated or can be easily dislocated or subluxated (partially dislocated), the doctor may feel a "clunk" as the hip moves out of alignment. In a smaller percentage of cases, the problem does not become apparent until later in infancy or early childhood. Later diagnosis of hip dysplasia may be detected during routine examinations of hip stability in the pediatrician's office.

Additional signs that may bring undiagnosed developmental hip dysplasia to the attention of parent and physician include:

• a limb length discrepancy (one leg shorter than the other) on the affected side
• a limp
• a waddling gait (indicating both legs are affected)
• restricted range of motion of the hip joint (that initially may be detected by the caregiver when changing a diaper)

To confirm a diagnosis of developmental hip dysplasia in children up to four to six months of age, an orthopedist uses ultrasound imaging. This technology offers a significant advantage over conventional a X-ray because images may be taken while the hip is in motion. "This is a very accurate and safe diagnostic tool since there is no radiation," according to Roger F. Widmann, MD, Chief of Pediatric Orthopaedic Surgery at HSS. In children older than six months, X-rays, which show bone detail better, are used to confirm the diagnosis.
 

How is hip dysplasia treated?

Early intervention is essential to ensure the bones that make up the hip joint develop properly. Incorrect growth in either the ball or socket can cause formation problems in the other. The goal is to achieve and maintain joint congruity.
 

Does hip dysplasia always require surgery?

When treatment is required, the first choice for children under six months old is nonsurgical, using a Pavlik harness. In the minority of cases where this does not work, and in children not diagnosed until after six months of age, surgery may be required.
 

Pavlik harness

The Pavlik harness is a soft brace that gently redirects the head of the femur into the depth of the socket or acetabulum, which stimulates normal development of the joint.

Usually, the harness generally is used for three months. Initially, the child will wear the harness full-time and, as the hip position improves and stability is achieved, this can be reduced to part-time use. Treatment with the Pavlik harness is successful in about 85% of dislocated hips in children under six months of age.

Unfortunately, the Pavlik harness is not a good treatment option for older children because the hip has become more fixed in the dislocated position and is more difficult to realign.
 

Reduction

For the small number of patients in whom treatment with the Pavlik harness is not successful, and for children in whom the diagnosis is not made until after they are six months old, the orthopedist may recommend either a closed reduction or open reduction surgery. Reduction is a procedure in which the bones are realigned or put back into place to optimize hip joint congruity. Reduction procedures are performed by pediatric orthopedists with specialized experience in the treatment of hip dysplasia. There are two types of reduction:

• Closed reduction: Although no incisions are made in this procedure, it does require the child to be placed under general anesthesia. During a closed reduction procedure, the physician uses radiography to observe the hip and then gently manipulates it into proper alignment, without making any incisions. A cast is then applied to hold the hip in place for up to three months.
• Open reduction: In an open reduction, also performed under general anesthesia, a surgical incision is needed to remove any tissue that is keeping the femoral head from proper alignment in the socket. A cast is then applied as well.
   

• Closed reduction and spica cast

Following closed reduction of the hip, the patient is placed into a spica body cast for 12 weeks to maintain proper alignment of the hip ball and socket.
 

• Open reduction surgery for hip dysplasia

Treatment by open reduction is generally reserved for children greater than 10 months of age who have new diagnosis of a dysplastic hip, or in cases in which a prior, closed reduction of the hip was unsuccessful.

In this procedure, the surgeon makes an incision, removes any obstacles to anatomic realignment of the hip (such as adjusting tight muscles or other soft tissue) and relocates the femoral head into the acetabulum. The surgeon may also need to restore normal anatomy by performing a hip osteotomy, a procedure in which cuts are made to the femur and/or the acetabulum in order to adjust the angles at which the bones meet and optimize joint congruity. The need for a femoral or acetabular osteotomy increases with the age at which diagnosis is made. It is usually required to correct abnormal development of the bones in any child over age three or four.

All reduction procedures, including those that involve an osteotomy, are done on an inpatient basis and require the use of general anesthesia. Children who undergo open reduction wear a cast for a period of six to eight weeks. Once the cast is removed, he or she usually continues to wear a brace at night until the orthopedic surgeon determines that the hip joint is developing normally.

In some patients who have an open or closed reduction and/or a femoral osteotomy, an osteotomy of the pelvis may also be required to adjust the angle of the acetabulum. In younger patients, the procedure often used is the Pemberton or Dega osteotomy, in which the bony and cartilage roof of the hip is reoriented into normal alignment.
 

What are the risks of DDH treatments?

The risks associated with surgery – bleeding, infection and those associated with anesthesia – are minimal. Pediatric orthopedists take special care to avoid a condition called avascular necrosis (also known as AVN or osteonecrosis), in which the bones of the hip joint do not receive enough blood. This can be caused if the femoral head (the ball of the hip joint) is put back into the acetabulum (socket) with unnecessary pressure, and so minimal pressure is used. Avascular necrosis can result in abnormal growth of the bone.

Although the numbers are difficult to define, some members of the medical community believe that up to 50% of adults who eventually require hip replacement due to osteoarthritis, have developed the disease as a result of a pediatric hip problem. The majority of those cases are thought to be hip dysplasia.
 

What kind of outcome can a child with DDH expect?

The earlier the condition is treated, the better the chance of a successful outcome, meaning a hip that appears anatomically normal both during physical examination and on X-ray. Children who are treated for hip dysplasia are examined on regular intervals until they are skeletally mature (when growth is completed), to ensure that normal development continues. In some cases, a dislocated hip that was successfully reduced may still develop dysplasia in later years, requiring additional treatment.

As recently as five years ago, children or adolescents complaining of groin pain were advised to stretch, ice, and take a rest from the activity which aggravated the discomfort. When the pain did not diminish, they would either continue to participate in the activity and play through pain or their career in that sport would be at an end.

Due to advances in diagnostic and clinical medicine, it has been discovered that the source of “groin” pain may not be a muscle strain, but could be possibly a tear of the labrum of the hip due to repetitive stress and microtrauma, or secondary to a structural bony anomaly, creating hip impingement. This bony impingement which may occur from the acetabular or the femoral head side or a combination of the two is referred to as femoroacetabular impingement.
 

How to Identify a Labral Tear?

Children or adolescents who may have labral tears present with complaints of a sharp pain or catching at the front of the hip with walking, running, or pivoting. They often feel achy with prolonged sitting or standing. Their symptoms often limit their ability to perform their sport or activity.

Clinical findings on examination may include pain with hip flexion, adduction, and internal rotation, or pain with pure flexion. An adductor or hip flexor strain or tear may be ruled out with resisted strength testing.

Another entity that may present and be confused with a labral tear is a sports hernia (athletic pubalgia). The differential diagnosis between an intra-articular hip pathology and athletic pubalgia may be a challenge and requires a meticulous clinical exam.

How is adolescent idiopathic scoliosis diagnosed?

Typically, adolescent idiopathic scoliosis is first noticed by the child’s pediatrician, family member or school nurse. As an initial screening method, healthcare professionals use the Adams forward-bending test to look for the presence of any asymmetry of the torso or shoulder blades, or for protrusion of the shoulder blades.

A scoliometer is used to measure the amount of trunk inclination (the curve) or rotation (twisting of the spine). Adolescents with a measurement of 7 degrees or greater are referred to an orthopedist for further evaluation. Adolescent idiopathic scoliosis rarely causes pain. For this reason, back pain symptoms in a young person with scoliosis may be a sign of an additional condition.

 

Radiological imaging

To assess the curve further, X-ray images or low-dose radiation EOS images are taken from the front and side views. Side-bending X-rays may also be taken to assess the flexibility of the curve or curves. Sometimes these images reveal two curves: the first curve to appear in the spine (the primary curve) and the compensatory curve that the patient develops through his or her effort to maintain an erect posture.
 

How is adolescent idiopathic scoliosis treated?

Treatment for adolescent idiopathic scoliosis determined by the degree of the spinal curve at the time of diagnosis and by the anticipated progression of that curve. Mild cases may not require any treatment at all. More significant cases of this type of scoliosis may be treated nonsurgically, using braces, or with spine surgery, depending on the individual patient.
 

Non-operative treatment

For curves measuring less than 25 degrees, the orthopedist may recommend frequent monitoring to see if additional intervention becomes necessary.
Young people with curves between 25 and 45 degrees may be candidates for treatment with bracing. While bracing does not correct the curve, it has been shown to stop progression in up to 75% of patients. Bracing is considered a success when progression is halted and maintained within 6 degrees of the original measurement of the curve.
Candidates for bracing are generally younger patients – prepubescent and skeletally immature as measured on the Risser test (a staging system that measures maturation of the hip bone). A measurement of 0 to 2 indicates that the growth is expected to continue. Skeletal maturity is achieved in female patients who reach a level of 4 and in male patients who have reached a level of 5. The absence of any change in height over a period of 6 to 12 months is another indicator of skeletal maturity.
In most cases, patients wear a brace for 22 to 23 hours a day, removing it only for hygiene and sports activities. However, some patients may only require the use of a brace at night.
A variety of braces are available and selection is based on how many curves are present and where on the spine the curve or curves are. Some models provide support at the pelvis, front, back, and neck, where others provide support throughout the torso and underarms.
While many braces are rigid, flexible braces have been developed in recent years. This type of brace, which is only appropriate in patients with single curves, is worn as a vest and allows the patient to participate in some sports activities.
Patients continue to wear the brace until skeletal maturity is reached. A weaning process follows in which the number of hours the brace is worn per day is gradually reduced over a period of six months to a year. This allows the supportive muscles in the back and trunk to become stronger after a period of inactivity. Physical therapy is also recommended, both during bracing and weaning.

 

Surgical treatment

Patients with curves that continue to progress beyond 50 degrees, either with or without bracing, generally require surgical intervention.

How does surgery for adolescent idiopathic scoliosis work?

There are different surgical methods, but the most common type of surgery is a posterior spinal fusion with instrumentation (artificial implants). In this procedure, the orthopedic surgeon makes an incision from the back and essentially "welds" the vertebrae together using bone chips.

These bone chips may be:

• Autografts: taken from elsewhere in the patient's own body
• Allografts: sourced from donors through a bone bank

During the healing process, which takes 6 to 12 months in an adolescent, the spine is held in alignment by hooks, screws or other instrumentation. Once the fusion is complete, the implants no longer serve a function but are left in place to avoid the need for additional surgery.
 

Posterior, anterior and thorascopic surgical approaches

Depending on the nature of the curve and its location, the orthopedic surgeon may need to perform a fusion from the front (anterior), the back (posterior) or both. When both approaches are needed, the procedure may be performed either as a single operation or in stages. Currently, however, this surgery is most commonly performed using a posterior-only procedure.
 

Vertebral body tethering

A newer approach to treat adolescent idiopathic scoliosis is a non-fusion procedure termed the "tethering" procedure. In Vertebral body tethering (sometimes also called "spinal tethering"), a thoracoscopic approach as described above is performed, and screws are placed within the specific vertebrae. Then, instead of using rods, a thick cord is placed to connect the screws, functioning as a tether. Tension is applied to help a growing child's spine develop with a straighter orientation. Not all patients are candidates for this procedure. Usually, candidacy is dependent on a patient's curve magnitude, age, skeletal maturity and curve type. The results of this procedure have not been researched as extensively as fusion procedures, however, short-term studies demonstrate that it can be successful in selective cases.
 

What are the results of spinal fusion surgery?

The surgery provides significant spine curvature correction, cosmetic and posture benefits, but does cause some inflexibility in the spine.
Curvature correction

Fusion surgery generally yields very good results, with a correction rate of between 60% to 100%, depending on curve flexibility and location. 
The extent of that varies depending on the section of spine corrected and the number of vertebrae fused.
 

Cosmetic results

• A balanced spine
• Leveled shoulders
• reduction or elimination of any rib hump
   

Complications

Rare complications can include infection and spinal cord abnormalities or injury. 
 

What is the expected scoliosis surgery recovery time?

Following surgery, most patients remain in the hospital for 3 to 5 days (slightly longer for those who undergo combined anterior/posterior procedures) and are on their feet in two days. Pain medication is continued for a few weeks and the majority of young people are back in school within 4 to 6 weeks. Some exercise, such as swimming and low-impact aerobic exercise, may be resumed within three months and patients may return to full activity within six months. Different Surgeons have different specified approaches to post-operative management.
 

Diagnosing Kyphosis

The origin of the Kyphosis can be idiopathic (of unknown origin), congenital (present at birth) or neuromuscular (related to the nerves and muscles). Abnormal development of the spinal column in the womb characterizes congenital kyphosis. The vertebrae may be formed abnormally or may be fused together. Surgical intervention is frequently required in order to prevent progressive deformity as well as to prevent injury to the spinal cord.

Kyphosis is diagnosed in children with a forward curve of greater than 45 degrees.

Children with kyphosis who are able to straighten up to normal posture are considered to have flexible round back deformity. In such cases the pediatric orthopedist may recommend physical therapy to strengthen the back muscles.

In cases where the x-ray shows specific vertebral body changes, the child may be diagnosed with Scheuermann’s kyphosis. This condition usually appears in adolescence. Scheuermann’s kyphosis is marked by the presence of vertebral wedging in three or more vertebrae in a row, which can be seen on a lateral (side-view) x-ray.

 

Treating Kyphosis

In a growing child, treatment of Scheuermann’s kyphosis with a spine brace may be effective. However, if the deformity continues to progress—reaching 70 degrees or greater—and the child has finished growing, surgical intervention is an option. In such cases, instrumentation is used to bring the spine into alignment, and bone grafts are made to maintain the correction of the spine.
 

A number of factors may contribute to the need for revision surgery, including:

• Pseudarthrosis, or a non-union of the bone, following a spinal fusion
• Crankshaft phenomenon: in which the posterior column of the spine is fused, and the anterior column continues to grow and “rotate” around the fused area
• Junctional degeneration: damage to the spine (discs and vertebrae) that develops above or below the area that has been fused
• Deformity progression (also known as “adding on”) in the sagittal and/or coronal planes of the spine
• Infection in the bone or around instrumentation
• Fixed sagittal imbalance (also called flatback): a condition in which too much of the natural sway in the lumbar spine has been eliminated
• Pain associated with instrumentation, either due to prominence of the implanted instrumentation and tenderness, or related to infection
• Broken implants requiring replacement
   

Imaging and Diagnosis

Imaging techniques used to assess patients with these symptoms include:

• Standing X-rays as well as dynamic views (the patient is asked to bend side-to-side or forward and back) and oblique X-rays (with the view angled 45 degrees) that can help determine the presence of bone spurs or uncommon fractures
• CT scans, which show more detail, helping to determine the position of instrumentation in the bone and status of the fusion
• CT myelogram; a CT scan combined with a myelogram in which dye is injected into the spinal canal, highlighting soft tissues such as the spinal cord and nerve roots. A CT myelogram is used to show pressure on the spinal cord or nerve roots as well as swelling or inflammation
   

Treatment

• Extension of a previous fusion to address degenerative changes above or below the original fusion site
• Additional fusions using a combined surgical approach from the front (anterior) and back (posterior) of the spine
• Osteotomies, a cut across a deformed segment of the spine to restore proper alignment
• Removal and/or replacement of instrumentation
• Debridement - removal of scar and devitalized tissue; often used along with antibiotic therapy to treat an infection
   

Spondylolysis in youth athletes and active children

Spondylolysis is diagnosed when a stress fracture develops in the pars interarticularis (or "pars" for short) of the lumbar spine. This portion of the spine is vulnerable to injury from the repetitive flexion, extension and rotation common in many sports activities.

The injury to the pars, sometimes called a "pars defect" or "pars fracture") may occur at one or both sides of vertebrae in any section of the spine. It is most common, however, in vertebrae L4 and L5 – the lowest two segments of the lumbar portion of the spine.
 

Spondylolysis in children: Causes, symptoms and diagnosis

Traditionally, spondylolysis has been associated with gymnastics, rowing and football. But HSS is seeing greater numbers of patients with spondylolysis in almost every major sport, including skating, fencing, basketball, football, baseball and cheerleading. This is likely because childhood and adolescent athletics have become more competitive and intense over the years. Today, teenage athletes approach their sports more vigorously and often play multiple sports year-round. In addition to these young athletes, spondylolysis is also seen with greater-than-average frequency in young people who work on family farms and who regularly lift heavy loads.

Back pain is the main complaint, but symptoms of spondylolysis can include leg pain (which is commonly due to hamstring tightness) and muscle spasms. Patients or their parents sometimes mistake this pain to be sciatica, which has similar symptoms. The patient’s posture and gait (manner of walking) may also be affected.

A doctor's assessment begins with a physical examination and X-rays.
 

Nonsurgical treatments and recovery

Most young athletes with spondylolysis can be treated with conservative management. This begins first with a period of rest – ceasing all vigorous sports and heavy weightlifting. In younger patients with acute symptoms of spondylolysis, a back brace is often recommended. Second, once the pain subsides, doctors usually have the patient begin a physical therapy program focused on increasing flexibility in the legs and gentle strengthening of the core muscle groups of the trunk. Third, the patient often prepares to return to sports activity with some more aggressive conditioning, such as running. In the fourth or final phase of treatment, the patient is allowed to return to sports.

However, the parents are asked to modify the child’s activities during his or her first season back in sports. Treatment and recovery may be as short as three months or take as long as a year, he notes. The long-term goal is a full return to sports without restriction.

Although the outlook is good, the diagnosis can come as a shock to young patients.
 

Orthopedic surgery for a child with spondylolysis

A small minority of patients with a pars fracture (sponsylolysis) may continue to experience pain after six months of bracing and rest. In these cases, surgery may be recommended.

Surgical treatment consists of either an arthrodesis (in which the affected vertebra is fused to the adjacent vertebra, thereby restricting motion) or direct repair of the pars fracture. This second approach preserves more motion in the spine. However, fusion has a higher healing rates and fewer incidents in which reoperation (additional surgery) is required.
 

Orthopedic surgery for a child with spondylolysis

A small minority of patients with a pars fracture (sponsylolysis) may continue to experience pain after six months of bracing and rest. In these cases, surgery may be recommended.

Surgical treatment consists of either an arthrodesis (in which the affected vertebra is fused to the adjacent vertebra, thereby restricting motion) or direct repair of the pars fracture. This second approach preserves more motion in the spine. However, fusion has a higher healing rates and fewer incidents in which reoperation (additional surgery) is required.