Pediatric Orthopaedic Surgeons in New York
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Orthopeadic Care

Common Pediatric Orthopaedic Conditions

Clubfoot (Ponseti casting)
Developmental Dysplasia of the Hip (DDH)
Trauma and Growth Plate Injury
Orthopaedic Pediatric Sports Medicine
Scoliosis
Neuromuscular disorders (cerebral palsy, spina bifida, muscular dystrophy, arthrogryposis, Charcot Marie Tooth Disease, etc.)
Leg Length Discrepancy (LLD)
Infection (osteomyelitis, septic arthritis, Lyme disease)
Benign musculoskeletal tumors
Juvenile arthritis
Brachial plexus birth palsies
Congenital hand, upper extremity, knee and foot deformities

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Clubfoot - Ponseti casting

Clubfoot, (or talipes equinovarus), in which there is a deformity of the foot or feet that affects children at birth. Clubfoot is generally completely painless. The foot has a complex musculoskeletal structure, consisting of many bones, connective tissue and ligaments that attach to each other, and to the lower leg bones. In clubfoot the foot (or feet) is inverted (twisted in) and down. Treatment is necessary or afflicted persons appear to walk on the sides of their feet and their ankles.

Clubfoot is a common birth defect, occurring in approximately 1/1,000 births. Approximately 50% of these clubfeet cases are bilateral (affecting both feet). The occurrence of the condition varies with race, sex, and genetics; however, the exact cause of clubfoot remains unclear. A clubfoot diagnosis is made by physical examination soon after birth. Occasionally, because prenatal ultrasound has become very advanced, the diagnosis of clubfoot can be made before birth.

Clubfoot is treated by manipulation with a trained physician such as an orthopedic surgeon. Manipulation is followed by serial casting using the Ponseti method.

The Ponseti method of clubfoot treatment is becoming the standard in the U.S. and worldwide. Described by Dr. Ignacio Ponseti in the 50's, it reached a wider audience through Dr. John Herzenberg, and by parents of children with clubfeet using the Internet to communicate on a large scale about it's success.

Studies show the Ponseti method is successful in over 95 percent of cases in correcting clubfeet. A typical case of clubfoot will normally require 5 casts over 4 weeks. Complex cases of clubfeet may require a greater number of casts. Manipulations of the foot usually begin within one to two weeks of age.

Ponseti method includes stretching and casting therapy in which the doctor changes the cast multiple times over a few weeks, gradually stretching tendons until the foot is in the correct position of external rotation. The heel cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three weeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at night up to four years of age.

Additional extensive surgery of the tissue or bone is not normally necessary to treat clubfoot. There are two minor surgeries that may be required (depending on the case):

Tenotomy is a release/clipping of the Achilles tendon
Anterior Tibial Tendon Transfer is a less common procedure where the tendon is moved in order to release the inward traction of the foot.

While these require a local or general anesthetic, minor surgery risks are small. They include scar tissue developing inside the child's foot. Scaring can contribute to functional, growth or aesthetic problems in the child's foot if the scaring tissue interferes with the normal development of the foot.

After treatment, maintenance of correction may require the full-time use of a splint (foot abduction brace or FAB) for several weeks. For children under 4 years, additional part-time use of a brace is often prescribed. With unilateral clubfoot it is also possible that even after successful treatment, the foot and calf muscle of the affected side are noticeably smaller than the normal side.

In most cases the long term outlook for children after Ponseti Method treatment for clubfoot is comparable to that of non-affected children.

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Developmental Dysplasia of the Hip (DDH)

A musculoskeletal condition in children in which the bones of the hip joint (a ball-and-socket joint) do not form or grow together properly is Developmental dysplasia of the hip (DDH).

Several factors contribute to hip dysplasia development. Certain symptoms may factor in more or less for different patients. In young infants, Developmental dysplasia of the hip (DDH) is usually diagnosed by physical exam, in which the physician tests the hip joint movements. These exams are routinely performed by pediatricians.

There are a variety of treatments available for hip dysplasia, and the most important factor in selecting appropriate treatment is normally the age of the child. There are a variety of treatments available for DDH, and the most important determinant in selection of the appropriate treatment is age of the child.

As children age and the severity of the condition increases, children may require different or additional procedures. These include operations to reposition the femur or pelvic bones. All surgical methods are designed to position and stabilize the hip and the joint into the future. Casting is often necessary following surgery. These operations are common and can help get hip and joint growth back to normal development.

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Growth Plate Injury

At birth and as children, the bones are quite small and need to grow in order for our bodies to grow. A growth plate (also known as a epiphyseal plate) is the portion of our bone that grows as children age. The growth plate generally consists of cartilage that will gradually harden into bone.

Growth plate injury can be caused by trauma, tumors, infection and other diseases, which can lead to arthritis, bone deformities, and even stop bone growth altogether (called "premature closure" of the growth plate).

Treatment for a simple injured growth plate can be rest, protection and immobilization, but orthopaedic surgery may be needed to lengthen/shorten, re-align or otherwise correct abnormal growth plates. Fractured growth plates are treated based on the severity and classification of the fracture.

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Orthopaedic Pediatric Sports Medicine

Often injury in children affects their performance in sports, exercise and other physical activity.

In growing children, injuries and other musculoskeletal conditions in the bones, muscles, ligaments, tendons, and joints are often different from conditions seen in older patients. Experience and specialized training in orthopaedic pediatric sports medicine allows us to appropriately treat unique sports-related medical conditions of children and teenagers.

Orthopaedic doctors specializing in Pediatric sports medicine  diagnose, treat, and manage medical and musculoskeletal problems including:

  • Sprains and strains
  • Dislocations
  • Ligament injuries
  • Minor fractures and avulsions
  • Apophysitis
  • Tendinitis
  • Overuse injuries
  • Cartilage injuries
  • Exercise-induced asthma
  • Concussions
  • Nutrition and supplement issues
  • Diabetes
  • Eating disorders
  • Stress fractures
  • Heat illness
  • Unique conditions of athletes w/ special needs

Orthopaedic pediatric sports medicine specialists know how to examine and treat children and teenagers so that they feel relaxed and cooperative. Orthopaedic pediatric sports medicine specialists are trained to examine, diagnose, and treat injuries, illnesses and conditions in physically active children and teens.

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Scoliosis

The treatment of scoliosis is a pediatric orthopaedic specialty. For poorly understood reasons, curvature develops in the spine of some children, which if left untreated leads to undesirable deformity and may progress to cause chronic pain and breathing problems. The treatment of scoliosis can be complicated and often involves a combination of treatment that may include observation, physical therapy, bracing and surgery (dependant on age and form).

Scoliosis is typically classified as congenital (caused by vertebral anomalies present at birth), idiopathic (sub-classified as infantile, juvenile, adolescent, or adult according to when onset occurred) or as having developed as a secondary symptom of another condition, such as Cerebral Palsy or Spinal Muscular Atrophy.

Dextroscoliosis is a scoliosis with the convexity on the right side.
Levoscoliosis is a scoliosis with the convexity on the left side.

Various causes have been examined, but none has consensus among scientists as a single cause of scoliosis. In some cases, scoliosis exists at birth due to a congenital vertebral anomaly. Occasionally development of scoliosis during adolescence is due to an underlying anomaly such as a tethered spinal cord, but most often the cause is unknown or idiopathic. Scoliosis does not occur due to bad posture or sleeping position. Scoliosis often presents, or worsens, during an adolescent growth spurt.

It is important to continue your Orthopaedic visits into adolescence, because growth may trigger new progression of the curve. Although rare, if progression does re-occur the patient will require additional casting and bracing treatments.

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Neuromuscular disorders (cerebral palsy, spina bifida, muscular dystrophy, arthrogryposis, Charcot Marie Tooth Disease, etc)

Cerebral Palsy (CP)

Cerebral Palsy (CP) is a disorder that results when the brain has problems controlling muscles. There are three major types of cerebral palsy:

  • Spastic cerebral palsy is characterized by stiffness of the body and muscles and decreased mobility.
  • Athetoid cerebral palsy involves uncontrolled, involuntary muscle movements.
  • Ataxic cerebral palsy includes primary symptoms of decreased balance and depth perception.

There are a number of different causes, but in most children, the exact cause of cerebral palsy is not identified. Asphyxia, or vascular insufficiency, in which the brain does not receive enough oxygen or blood for a period of time, is the most common known cause of cerebral palsy (CP). This is sometimes related to obstetrical problems around the child's birth.

Depending on the type, cerebral palsy (CP) may be diagnosed at different ages in different children. Children with all types of cerebral palsy (CP) can benefit from orthopaedic treatment, as well as educational, psychological, physical, occupational, and speech therapy. An Orthopaedic surgeon plays a prominent role in managing cerebral palsy (CP) patients, and assists in determining the types and treatments of the musculoskeletal problems or deformities.

Spina Bifida (Myelodysplasia)

Spina bifida (Myelodysplasia) is a neonatal condition in which a portion of the spinal column undergoes abnormal growth during fetal development. This growth creates a defect in the bony encasement that normally surrounds and protects the spinal cord. Today, diagnosis of spina bifida is usually made with the use of ultrasound and sophisticated imaging technologies. Less severe cases are usually diagnosed around the time of birth.

There are many classifications of spina bifida, all derived from problems during the development of the spine.

  • Spina bifida Occulta: The mildest form of spina bifida. A single vertebra (or segment of the spinal column) has a defect. The spinal cord otherwise develops normally and keeps its normal place within the spine.
  • Spina bifida Meningocele: The tissues surrounding the spinal cord protrude out creating a larger defect and increasing the chance of damage to the nervous tissue of the spinal cord.
  • Spina bifida Myelomeningocele: The protrusion of the spinal cord itself is the most common and most severe defect. Myelomeningocele carries the greatest risk of motor and sensory deficiencies.
  • Spina bifida Hydrocephalus: Includes excess accumulation of cerebrospinal fluid (CSF) in the brain. This defect occurs in up to 80% of children with spina bifida. Hydrocephalus is often treated by a surgeon to allow the excess fluid to be drained and prevent increased pressure on the brain tissue.

Because many patients have some paralysis, which causes regions of their legs to lack sensation, skin sores and ulcers can appear due to undetected pressure on the skin. Prevention involves educating children and parents about causes, hygiene, and daily skin inspection routines.

Because the bones become weak from inactivity in spina bifida patients, fractures are more common. Fractures are more common following surgery, however post-operative weight-bearing activity and the use of braces, when possible, can be beneficial for fracture prevention.

In addition to the availability of newer and more effective operations for treating different clinical features of spina bifida, orthopaedic surgeons have also decreased the number surgeries performed for spina bifida by managing the musculoskeletal conditions.

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Leg Length Discrepancy (LLD)

Leg length discrepancy (LLD) normally appears in childhood and occurs when a child's two legs are unequal in length.

The causes of Leg length discrepancy (LLD) may be a cause that shortens a limb vs those that lengthen a limb. Cause may be classified as affecting length vs the growth rate in a limb.

Leg length discrepancy (LLD) may be diagnosed as an infant, or as an child or adolescent, depending on the cause. Conditions are often diagnosed following standard newborn examination by a pediatrician, or parents may notice a child's leg asymmetries.

The treatment of leg length discrepancy (LLD) depends on the cause and severity of the condition and the patient's age. The first step in management is usually non-operative treatment, and in many cases the deformity is mild or can lessen with future growth. This is also dependant on the cause and severity of the condition and the patient's age, as well as growth rate estimates in both legs. However, in many cases, a surgical operation is the best treatment for leg length discrepancy (LLD).

Leg length discrepancy (LLD) surgery is sometimes desirable to shorten the longer leg, stop or slow growth of the longer or faster growing leg, or to lengthen the shorter leg.

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