Sever’s Disease

Sever’s disease is a common cause of heel pain in children between the ages of 9 and 12 years. The pain is due to calcaneal apophysitis occurring due to repetitive and continuous traction on the calcaneus from the Achilles tendon. The apophysis is not part of a joint and has muscle or tendon attachments. This traction apophysitis may lead to stress fractures, pain and tenderness over the heel.

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Sever’s disease is similar to Osgood-schlatter disease of the tibial tubercle.

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Patients are usually young athletes presenting with heel pain that increases with activities. Upon examination there could be swelling, tenderness, warmth and/or redness on the back of the heel where the Achilles tendon inserts.

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Plain lateral X-rays may show sclerosis or fragmentation of the calcaneal tuberosity. Sclerosis is not specific for this condition.

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Fragmentation of the calcaneal tuberosity on the other hand, is more common in patients with Sever’s disease relative to the general population.

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Remember that Sever’s disease is a clinical diagnosis. X-rays may show other causes of pain such as tumors, fractures, infections or cysts. MRI is not commonly used, but can help rule out calcaneal stress fractures or osteomyelitis.

Sever’s disease is a self-limiting condition that usually resolves with time. Treatment usually consists of NSAID, Achilles tendon stretching exercises, and activity modifications and in severe condition a short leg walking cast can be used.

Pediatric Cervical Spine Injuries

Cervical spine injuries are generally not common in children. Blow 8 years of age, cervical spine injuries usually occur in the upper cervical region. Above 8 years of age, cervical spine injuries occur in the lower cervical region. The prevertebral soft tissue shadow may appear widened on lateral x-ray of a crying child with no injury. Cervical spine injuries should be suspected in multiple trauma patients. Rule out cervical injuries in all patients with head or facial trauma.

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Spinal cord injury without radiological abnormality (SCIWORA) is due to ligamentous elasticity and flexibility of the pediatric vertebral column which can withstand injuries without the evidence of deformity, however the spinal cord will be damaged. It should be suspected in a child with neck injury and neurological symptoms with no radiological bony abnormalities. Common in spinal cord injuries below 8 years of age and usually occurs in the cervical or thoracic spine. SCIWORA usually resolves with no neurological deficiencies but there is high risk of reoccurrence. Investigation of choice is MRI and treatment is cervical immobilization.

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Atlanto-occipital dislocation

It is a fatal injury due to major trauma. It is more common in children than adults due to:

Increased head-body ratio in children.

The occipital condyles of children are smaller than those of adults.

There are three classifications for Atlanto-occipital injuries:

  1. Anterior displacement of the occiput
  2. Longitudinal distraction of the occiput from the atlas ( avoid traction)
  3. Posterior displacement of the occiput.

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Diagnosis is by x-ray. CT scan and MRI that shows ligamentous injury.

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Treatment: reduction should be urgently done with early immobilization by halo vest. Avoid traction in type II. Post reduction radiograph should be obtained to ensure adequate reduction. Cervical spine x-ray should be done daily to ensure maintained reduction.  Atlanto-occipital dislocation is a ligamentous injury that is usually unstable and may need atlanto-occipital fusion.

Os odontoid

Os odontoid is due to congenital or unrecognized fracture of the odontoid. It is accidently discovered on radiological investigation. It should be differentiated from acute odontoid fractures.

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Treatment is conservative if no pain, no neurological deficiency and no cervical spine instability. Surgical treatment is done in patients with progressive symptoms as neck pain, neurological deficiency or cervical spine instability. In young children without progressive deficits, it is better to delay surgical treatment until six to seven years of age. By that time the child will have sufficient bony development of the cervical spine.

Odontoid fracture

Odontoid fractures occur in young children usually around 4 years of age. Treatment includes reduction and immobilization in extension. Complete reduction is usually obtained but it is not necessary, 50% reduction is satisfactory. Growth disturbances are rare.

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Persistence of the basilar odontoid synchondrosis is seen in one half of children up to age eleven and may mimic an odontoid fracture. This line appears sclerotic unlike acute fractures and is located well below the base of the odontoid where most adult fractures occur.

Atlanto- Axial rotatory subluxation

Child with rotatory subluxation of C1 on C2 is marked by the direction of head tilt and rotation of the neck.

Atlanto- Axial rotatory subluxation is classified as following:

Type I: unilateral rotatory subluxation with intact transverse ligament.

Type II: unilateral rotatory subluxation with torn transverse ligament

Type III: bilateral rotatory subluxation

Type VI: posterior rotatory subluxation.

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Most common causes of Atlanto-Axial Rotatory Subluxation are:

  • Neck trauma
  • Inflammatory condition as upper respiratory tract infection.
  • Children with congenital anomalies and ligamentous laxity such as Down syndrome.

This injury may be missed due to mild symptoms and signs. The child usually presents with neck pain and torticollis (cock-robin sign). Physician must rule out any neurological deficiencies.

Lateral X-ray shows anterior displacement of C1 over C2. Open mouth view X-ray shows asymmetrical lateral masses of C1. Dynamic CT scan is diagnostic.

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Treatment depends on the duration of injury. For injuries less than 1 week, immobilization by neck collar should be attempted. Halter traction is used in injuries of more than 1 week in duration. Surgical reduction in C1-C2 fusion is used to treat fixed deformities or used in patients with neurological deficits.

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Sub-axial injuries are rare in children and usually occur in adults. These include:

Posterior ligamentous disruption

It is due to flexion or distraction injuries. It may be missed on radiological evaluation due to normal loss of cervical lordosis in children. MRI is diagnostic for the ligamentous injury and treatment by immobilization in extension or posterior arthrodesis if signs of instability are present.

Compression fractures

They occur due to flexion and axial loading injuries. It leads to loss of the vertebral height and usually diagnosed on lateral view x-ray. In children under 8 years of age vertebral height will be regained during growth and kyphosis will be corrected but if kyphosis is more than 20 degrees it might not be corrected with growth.

Burst fractures

It is due to axial loading injuries. Treatment is by traction followed by halo immobilization if there is no neurological deficiency. Surgical fusion is done when neurological deficiencies are present. Anterior fusion leads to kyphotic deformity due to suppression of the anterior growth potential.

Unilateral or bilateral facet dislocation

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Scoliosis in children

Scoliosis is lateral curving of the spine. Pediatric spinal cord trauma will almost always result in scoliosis.

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What is a Growth Plate and Growth Plate Fracture?

During childhood and adolescence, our bones grow through a process called ossification. During ossification, calcium and phosphate salts are laid down to replace cartilage or membrane.

Near the ends of each bone are areas of developing tissue that regulate and help determine the length and shape of the bone. These areas of developing tissue near the ends of the bones are known as growth plates or more technically, physis (Figure 1).

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Figure 1

The widened part of the shaft of the bone is known as the metaphysis, while the end of the bone is known at the epiphysis.

Because growth occurs at the end of the bone, growth plates are the last portion of the body to ossify or harden. This leaves them susceptible to fractures. Injuries to the growth plates may result in limbs that are crooked or of unequal length. Therefore, immediate attention is required.

When growth is complete, growth plates close and are replaced by solid bone. However, until growth is complete, children are at significant risk for growth plate injuries. Typically, girls and boys near the end of their growth period are especially vulnerable.

Statistically, boys are twice as often as girls to suffer growth-plate injuries. This can be attributed to the female body maturing at an earlier age than boys. In addition, one-third of all growth-plate injuries occur in competitive sports such as football or basketball.

Moreover, about 20 percent of growth-plate fractures occur as a result of recreational activities such as biking, skiing, skateboarding or sledding, according to the American Academy of Orthopaedic Surgeons (AAOS). Growth-plate fractures account for 15-30 percent of all childhood fractures. They most occur most often in the long bones of the fingers, followed by the outer bone of the forearm at the wrist; tibia and fibula growth plate fractures are also common.

Growth-plate fractures are characterized by visible deformities, persistent pain, and an inability to move or put pressure on the limb. If a child or teen experiences any of these signs, they should seek medical attention.

Growth-plate injuries heal without any lasting effects in 85 percent of instances. However, there are certain factors that affect the outcome and management such as severity of injury, age, growth plate affected, and the type of fracture. If injury causes the blood supply to the epiphysis to be cut off, growth can be stunted. In addition, an open injury carries the risk of infection which could destroy growth plates. A child can also affect outcome and management. If a child is younger, growth arrest can be more serious. In addition, some growth plates are more involved in extensive bone growth.

The type of growth-plate fracture are usually categorized in six types (Figure 2).

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Figure 2

A Type I fracture describes a break in the bone through the growth plate, but no shift of bone occurs. This fracture usually heals well and requires immobilization.

A Type II fracture is a break through part of the bone at the growth plate and a crack through the bone shaft. This type of fracture is the most common. It is usually treated with cast immobilization, although surgery may sometimes be required.

A Type III fracture is a break through the bone at the growth plate, separating the bone end from the bone shaft and completely disrupting the growth plate. This type of fracture requires surgical treatment in the form of internal fixation to ensure alignment.

A Type IV fracture crosses through a portion of the growth plate and breaks off a piece of the bone end. This kind of fracture is treated with surgery and internal fixation.

A Type V fixation is a break through the bone shaft, the growth plate, and the end of the bone. Fractures like this result in arrested growth and are usually treated with surgery and internal fixation.

A Type VI fracture is similar to a Type V, but the broken pieces of the bone are missing. This fracture occurs only in the case of an open or comminuted fracture. They require surgical repair and possible reconstructive/corrective surgery.