Orthopedic

What ethical, regulatory, and security challenges accompany AI implementation in healthcare settings?

2026-01-20T05:28:00.000-08:00

What ethical, regulatory, and security challenges accompany AI implementation in healthcare settings?

The implementation of AI in healthcare is accompanied by a complex array of ethical, regulatory, and security challenges that impact patients, providers, and the global healthcare infrastructure.

Ethical Challenges

Algorithmic Bias and Inequality: AI models often encode system-wide biases because they are frequently trained on datasets from high-income countries, which may lead to recommendations inappropriate for low-income settings. Furthermore, groups such as individuals with disabilities may face discrimination if AI systems are trained on datasets that exclude them or misinterpret their communication styles.
Transparency and "Black Box" Logic: A critical concern is healthcare AI explainability; many AI models, particularly large multi-modal models (LMMs), are so complex that even their developers may not fully understand how they generate specific responses. This lack of transparency can undermine the trust of medical professionals and patients.
De-skilling and Moral De-skilling: There is a long-term risk of skills degradation, where clinicians may become unable to perform routine tasks or make difficult moral judgments independently because they have outsourced these responsibilities to AI.
Human Epistemic Authority: By providing plausible but potentially inaccurate responses, AI may eventually undermine human epistemic authority in medicine and science. Over-reliance on AI could lead to "model collapse," where AI-generated errors pollute public knowledge bases.
Digital Divide: AI may exacerbate the digital divide, where wealthy individuals have access to "real" clinicians while poorer populations are relegated to using lower-cost, AI-driven solutions.

Regulatory Challenges

Inconsistent Frameworks: The regulatory landscape is currently fragmented, with different regions (such as the U.S., Europe, and China) enforcing varying standards for data protection and AI oversight.
Liability and Redress: Determining liability along the value chain is a significant challenge; it is difficult to assign blame among developers, providers, and deployers when an AI system causes harm. Some jurisdictions may lack professional liability rules that account for injuries caused directly by AI.
Compliance Gaps: Existing laws, such as HIPAA and GDPR, were often written before the emergence of modern generative AI, leading to regulatory "gray areas" regarding data scraping, the "right to be forgotten," and the use of sensitive data in chatbots.
Medical Device Classification: There is ongoing debate over which AI applications—particularly chatbots—qualify as medical devices, which determines the level of regulatory scrutiny they must undergo before being deployed to the public.

Security and Privacy Challenges

Connected Device Vulnerabilities: Interconnected medical devices like pacemakers, insulin pumps, and ventilators are susceptible to remote exploitation and hacking, which can turn life-saving equipment into life-threatening weapons.
Ransomware and DoS Attacks: Hospitals are primary targets for ransomware because the urgency of patient care forces quick financial decisions; such attacks have already resulted in documented fatalities when critical systems were disabled.
Data Privacy Breaches: AI systems require vast amounts of data, increasing the risk of unauthorized disclosure of sensitive health information. Unencrypted data transmissions can be intercepted via "Man-in-the-Middle" attacks, allowing hackers to manipulate treatment instructions.
Technical Exploits: AI models are vulnerable to "prompt injection" attacks, where malicious data is fed into a model to force it to behave in ways the developer did not intend, such as deleting or stealing information from a database.
Supply Chain Risks: Vulnerabilities can be introduced through counterfeit components or pre-installed malware in third-party software before a device even reaches a hospital.

How can AI technologies enhance clinical workflows, remote monitoring, and patient-provider communication?

2026-01-20T04:42:00.000-08:00

How can AI technologies enhance clinical workflows, remote monitoring, and patient-provider communication?

AI technologies, particularly large multi-modal models (LMMs) and conversational agents, are reshaping healthcare by streamlining administrative burdens, enabling proactive home-based care, and facilitating more empathetic interactions.

Enhancing Clinical Workflows

AI enhances efficiency and productivity by automating routine administrative and clerical tasks that typically consume a significant portion of a clinician’s time.

Documentation and "Keyboard Liberation": AI can draft clinical notes after patient visits, fill missing information in Electronic Health Records (EHRs), and pre-emptively write automated prescriptions, billing codes, and discharge summaries. This allows providers to be more "present" for their patients rather than focused on screens.
Virtual Triage: Algorithms analyze symptoms and patient data to prioritize cases based on urgency, ensuring that critical conditions receive timely care while optimizing resource allocation for the healthcare workforce.
Clinical Decision Support: Using retrieval-augmented generation (RAG), AI can synthesize historical EHR data and precedent cases to provide context-aware treatment suggestions, aiding in complex scenarios involving polypharmacy or diagnostic uncertainty.
Medical Imaging: AI-driven analysis of X-rays, MRIs, and CT scans accelerates the diagnostic process, enabling radiology departments to serve a larger population more efficiently.

Remote Patient Monitoring

Remote monitoring is one of the most critical applications of AI in telehealth, moving care from the hospital to the patient’s home.

Continuous Data Collection: AI-powered wearables and biosensors collect real-time physiological data, such as heart rate, blood pressure, glucose levels, and ECG signals.
Proactive Interventions: By analyzing data streams, AI can anticipate health deterioration and trigger alerts before a patient’s condition worsens, allowing for early intervention and reducing the need for frequent in-person visits.
Specialized Care: In oncology, AI-driven wearables track digital biomarkers of frailty and predict chemotherapy tolerance, enabling clinicians to tailor treatment plans based on a patient's real-time functional status. In geriatric care, these technologies have shown statistically significant success in helping manage systolic blood pressure and HbA1c levels.

Improving Patient-Provider Communication

AI facilitates more frequent and organic communication, bridging the gap created by medical staff shortages.

Compassionate Message Drafting: Studies show that generative AI can help time-crunched physicians by drafting longer, more empathetic responses to patient inquiries. While this may not always save time due to the need for human editing, it significantly reduces the cognitive burden and "writer’s block" associated with high message volumes.
Conversational Agents and Chatbots: AI-driven bots can handle routine patient inquiries, provide preliminary health examinations, and assist with scheduling, which relieves staff of routine tasks. Advanced 3D simulations and voice-driven bots can even mimic the visual emotions of clinicians, providing comfort and improving the mental well-being of patients.
Accessibility and Translation: AI assists in simplifying medical jargon to make it "patient-friendly" and provides real-time translation services, ensuring that language barriers do not obstruct care.
Patient "Nudges": AI systems can send reminders and motivational messages regarding medication adherence, nutrition, and exercise, acting as a persistent virtual assistant between formal appointments.

Ganglion of the Wrist

2011-03-24T04:57:00.000-07:00

Ganglion (Cyst) of the Wrist

A wrist ganglion can appear on the A, back (dorsum) of the hand or B, on the underside.
Ganglion cysts arise from the capsule of a joint or the sheath of a tendon. They can be found at different places on the wrist. A ganglion cyst that grows on the top of the wrist is called a dorsal ganglion. Others are found on the underside of the wrist between the thumb and your pulse point, at the end joint of a finger, or at the base of a finger. Most of the time, these are harmless and will often disappear in time.

Cause

A ganglion cyst contains a thick, clear, mucus-like fluid similar to the fluid found in the joint. No one knows what triggers the formation of a ganglion. Women are more likely to be affected than men. Ganglia are common among gymnasts, who repeatedly apply stress to the wrist.

Symptoms

Wrist ganglion.

Because the fluid-filled sac puts pressure on the nerves that pass through the joint, some ganglion cysts may be painful. Large ganglia, even if they are not painful, are unattractive. Smaller ganglions that remain hidden under the skin (occult ganglions) may be quite painful.

A ganglion grows out of a joint, like a balloon on a stalk. It rises out of the connective tissues between bones and muscles. Inside the balloon is a thick, slippery fluid similar to the fluid in your joints. Usually, the more active the wrist, the larger the cyst becomes. With rest, the lump generally decreases in size.

Diagnosis

Your doctor may ask you how long you have had the ganglion, whether it changes in size, and whether it is painful. Pressure may be applied to identify any tenderness. A penlight may be held up to the cyst to see whether light shines through. X-rays may be taken to rule out other conditions, such as arthritis or a bone tumor. Sometimes, an MRI or ultrasound is needed to find a ganglion cyst that is not visible.

Treatment

Initial treatment is not surgical.

• Observation.
Because the ganglion is not cancerous and may disappear in time, just
waiting and watching may be enough to make sure that no unusual changes occur.
• Immobilization.
Activity often causes the ganglion to increase in size. This is because
activity increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms, letting the ganglion decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
• Aspiration.
If the ganglion causes a great deal of pain or severely limits activities, the
fluid may be drained from it. This procedure is called "aspiration." The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid drains away.

Nonsurgical treatment leaves the outer shell and the stalk of the ganglion intact, so it may reform and reappear.

The ganglion cyst can be removed through outpatient surgery, but this is no guarantee that the cyst will not grow again. Surgery may also include removing part of the involved joint capsule or tendon sheath. There may be some tenderness, discomfort, and swelling after surgery. Normal activities usually may be resumed two to six weeks after surgery.

Frozen Shoulder

2011-03-24T04:49:00.000-07:00

Frozen shoulder is characterized by pain and loss of motion or stiffness in the shoulder. It affects about two percent of the general population. Frozen shoulder most commonly affects patients between the ages of 40 and 60 years, with no clear predisposition based on sex, arm dominance, or occupation.

Cause

Anatomy of the shoulder, showing the ligaments and bones.

The causes of frozen shoulder are not fully understood. The process involves thickening and contracture of the capsule surrounding the shoulder joint.

Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10 percent to 20 percent of these individuals. Other medical problems associated with increased risk of frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease or surgery.

Frozen shoulder can develop after a shoulder is immobilized for a period of time. Attempts to prevent frozen shoulder include early motion of the shoulder after it has been injured.

Symptoms

Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. The pain is usually located over the outer shoulder area and sometimes the upper arm.

The hallmark of the disorder is restricted motion or stiffness in the shoulder. The affected individual cannot move the shoulder normally. Motion is also limited when someone else attempts to move the shoulder for the patient.

Some physicians have described the normal course of a frozen shoulder as having three stages:

• Stage one: In the "freezing" stage, the patient develops a slow onset of pain. As the pain worsens, the shoulder loses motion. This stage may last from six weeks to nine months.
• Stage two: The "frozen" stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four months to nine months.
• Stage three: The final stage is the "thawing," during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.

Diagnosis

A doctor can diagnose frozen shoulder based on the patient's symptoms and a physical examination.

X-rays or MRI (magnetic resonance imaging) studies are sometimes used to rule out other causes of shoulder stiffness and pain, such as a rotator cuff tear.

Treatment

Frozen shoulder will generally get better on its own. However, this takes some time, occasionally up to two to three years. Treatment is aimed at pain control and restoring motion.

Nonsurgical Treatment

Pain control can be achieved with anti-inflammatory medications. These can include pills taken by mouth, such as ibuprofen, or by injection, such as corticosteroids.

Physical therapy is used to restore motion. This may be under the direct supervision of a physical therapist or via a home program. Therapy includes stretching or range-of-motion exercises for the shoulder. Sometimes, heat is used to help decrease pain. Examples of some of the exercises that might be recommended can be seen in the following figures.

If these methods fail, nerve blocks are sometimes used to limit pain and allow more aggressive physical therapy.

More than 90 percent of patients improve with these relatively simple treatments. Usually, the pain resolves and motion improves. However, in some cases, even after several years the motion does not return completely and a small amount of stiffness remains.

Surgical Treatment

Surgical intervention is considered when there is no improvement in pain or shoulder motion after an appropriate course of physical therapy and anti-inflammatory medications. When more invasive measures are considered, the patient must always consider that most individuals will get better if given sufficient time and that surgery always has risk involved.

Surgical intervention is aimed at stretching or releasing the contracted joint capsule of the shoulder. The most common methods include manipulation under anesthesia and shoulder arthroscopy:

Manipulation under anesthesia involves putting the patient to sleep and forcing the shoulder to move. This process causes the capsule to stretch or tear.

With shoulder arthroscopy, the surgeon makes several small incisions around the shoulder. A small camera and instruments are inserted through the incisions. These instruments are used to cut through the tight portions of the joint capsule.

Often, manipulation and arthroscopy are used together in combination to obtain maximum results. Most patients have very good results with these procedures.

After surgery, physical therapy is important to maintain the motion that was achieved with surgery. Recovery time varies, from six weeks to three months.

Flexible Flatfoot

2011-03-24T04:41:00.000-07:00

Flexible Flatfoot in Children

Flexible flatfoot is a condition in which the arch of the foot shrinks or disappears upon standing. Upon sitting or when the child is on tiptoes, the arch reappears. Parents and other family members often worry needlessly that an abnormally low or absent arch in a child's foot will lead to permanent deformities or disabilities. Most children eventually outgrow flexible flatfoot without any problems. The condition usually is painless and does not interfere with walking or sports participation.

Flexible flatfoot, showing the absence of an arch when standing.

Symptoms

A flexible flatfoot has normal muscle function and good joint mobility and is considered to be a variation of normal. As the child grows and walks on it, the foot's soft tissues tighten, shaping its arch gradually. Flexible flatfoot often continues until the child is at least age 5 years or older. If flexible flatfoot continues into adolescence, the child may experience aching pain along the
bottom of the foot. A doctor should be consulted if the child's flatfeet cause pain.

Diagnosis

To make the diagnosis, the doctor will examine the child to rule out other types of flatfeet that may require treatment. These include flexible flatfoot with a tight heel cord, or rigid flatfoot, which is a more serious condition.

The doctor will look for patterns of wear on the child's everyday shoes. Tell the doctor if anyone else in the family is flatfooted, as this may be an inherited condition. It is important to know about any known neurological or muscular disease in the child.

The arch disappears when standing (left) and reappears when the child is on tiptoes (right).

The doctor may ask the child to sit, stand, raise the toes while standing, and stand on tiptoe. He or she will probably examine the child's heel cord (Achilles tendon) for tightness and may check the bottom of the foot for calluses.

Treatment

Nonsurgical Treatment

Treatment for flexible flatfoot is required only if the child is experiencing symptoms of discomfort from the condition.

If the child has activity-related pain or tiredness in the foot/ankle or leg, the doctor may recommend stretching exercises for the heel cord.

A child at age 3 years (left) with flexible flatfoot. The same child at age 15 years (right) has a normal arch despite having received no treatment.

If discomfort continues, the doctor may recommend shoe inserts. Soft-, firm-, and hard-molded arch supports may relieve the child's foot pain and fatigue in many cases. They can also extend the life of his or her shoes, which may otherwise wear unevenly. Sometimes a doctor may prescribe physical therapy or casting if your child has flexible flatfoot with tight heel cords.

Surgical Treatment

Occasionally, surgical treatment will be necessary for an adolescent with persistent pain. A small number of flexible flatfeet become rigid instead of correcting with growth. These cases may need further medical evaluation.

Femoroacetabular Impingement

2011-03-24T04:38:00.000-07:00

Femoroacetabular impingement (FAI) is a condition where the bones of the hip are abnormally shaped. Because they do not fit together perfectly, the hip bones rub against each other and cause damage to the joint.

Anatomy

The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

A slippery tissue called articular cartilage covers the surface of the ball and the socket. It creates a smooth, low friction surface that helps the bones glide easily across each other.

The acetabulum is ringed by strong fibrocartilage called the labrum. The labrum forms a gasket around the socket, creating a tight seal and helping to provide stability to the joint.

In a healthy hip, the femoral head fits perfectly into the acetabulum.

Description

In FAI, bone spurs develop around the femoral head and/or along the acetabulum. The bone overgrowth causes the hip bones to hit against each other, rather than to move smoothly. Over time, this can result in the tearing of the labrum and breakdown of articular cartilage (osteoarthritis).

Types of FAI

There are three types of FAI: pincer, cam, and combined impingement.

Pincer. This type of impingement occurs because extra bone extends out over the normal rim of the acetabulum. The labrum can be crushed under the prominent rim of the acetabulum.

Cam. In cam impingement the femoral head is not round and cannot rotate smoothly inside the acetabulum. A bump forms on the edge of the femoral head that grinds the cartilage inside the acetabulum.

Combined. Combined impingement just means that both the pincer and cam types are present.
(Left) Pincer impingement. (Right) Cam impingement.

How FAI Progresses

It is not known how many people may have FAI. Some people may live long, active lives with FAI and never have problems. When symptoms develop, however, it usually indicates that there is damage to the cartilage or labrum and the disease is likely to progress. Symptoms may include pain, stiffness, and limping.

Cause

FAI occurs because the hip bones do not form normally during the childhood growing years. It is the deformity of a cam bone spur, pincer bone spur, or both, that leads to joint damage and pain. When the hip bones are shaped abnormally, there is little that can be done to prevent FAI.

Because athletically active people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active. However, exercise does not cause FAI.

Symptoms

People with FAI usually have pain in the groin area, although the pain sometimes may be more toward the outside of the hip. Sharp stabbing pain may occur with turning, twisting, and squatting, but sometimes, it is just a dull ache.

Home Remedies

When symptoms first occur, it is helpful to try and identify an activity or something you may have done that could have caused the pain. Sometimes, you can just back off on your activities, let your hip rest, and see if the pain will settle down. Over-the-counter anti-inflammatory medicines (ibuprofen, naproxen) may help.

If your symptoms persist, you will need to see a doctor to determine the exact cause of your pain and provide treatment options. The longer painful symptoms go untreated, the more damage FAI can cause in the hip.

Doctor Examination

During your first appointment, your doctor will discuss your general health and your hip symptoms. He or she will also examine your hip.

Impingement Test

As part of the physical examination, your doctor will likely conduct the impingement test. For this test, your doctor will bring your knee up towards your chest and then rotate it inward towards your opposite shoulder. If this recreates your hip pain, the test result is positive for impingement.

Imaging Tests

Your doctor may order imaging tests to help determine whether you have FAI.

X-rays. These provide good images of bone, and will show whether your hip has abnormally shaped bones of FAI. X-rays can also show signs of arthritis.

Computed tomography (CT) scans. More detailed than a plain x-ray, CT scans help your doctor see the exact abnormal shape of your hip.

Magnetic resonance imaging (MRI) scans. These studies can create better images of soft tissue. They will help your doctor find damage to the labrum and articular cartilage. Injecting dye into the joint during the MRI may make the damage show up more clearly. Your doctor may also inject a numbing medicine into the joint as a diagnostic test. If the numbing medicine provides temporary pain relief, it confirms that FAI is the problem.

Treatment

Nonsurgical Treatment

Activity changes. Your doctor may first recommend simply changing your daily routine and avoiding activities that cause symptoms.

Non-steroidal anti-inflammatory medications. Drugs like ibuprofen can be provided in a prescription-strength form to help reduce pain and inflammation.

Physical therapy. Specific exercises can improve the range of motion in your hip and strengthen the muscles that support the joint. This can relieve some stress on the injured labrum or cartilage.

Surgical Treatment

If tests show joint damage caused by FAI and your pain is not relieved by nonsurgical treatment, your doctor may recommend surgery.

Many FAI problems can be treated with arthroscopic surgery. Arthroscopic procedures are done with small incisions and thin instruments. The surgeon uses a small camera, called an arthroscope, to view inside the hip.

During arthroscopy, your doctor can repair or clean out any damage to the labrum and articular cartilage. He or she can correct the FAI by trimming the bony rim of the acetabulum and also shaving down the bump on the femoral head. Some severe cases may require an open operation with a larger incision to accomplish this.

(Left) During arthroscopy, your surgeon inserts an arthroscope through a small incision about the size of a buttonhole. (Right) Other instruments are
inserted through separate incisions to treat the problem.

Long-Term Outcomes

Surgery can successfully reduce symptoms caused by impingement. Correcting the impingement can prevent future damage to the hip joint. However, not all of the damage can be completely fixed by surgery, especially if treatment has been put off and the damage is severe. It is possible that more problems may develop in the future.

While there is a small chance that surgery might not help, it is currently the best way to treat painful FAI.

Slipped Capital Femoral Epiphysis

2011-03-24T04:28:00.000-07:00

Slipped capital femoral epiphysis (SCFE) is an unusual disorder of the adolescent hip. It is not rare. For reasons that are not well understood, the ball at the upper end of the femur (thigh bone) slips off in a backward direction. This is due to weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty.

The patient's left hip (arrow) shows that a slight shift of the head of the femur occurred through the growth plate.

The condition is diagnosed based on a careful history, physical examination, observation of the gait/walking pattern, and X-rays of the hip. The X-rays help confirm the diagnosis by demonstrating that the upper end of the thigh bone does not line up with the portion called the femoral neck.

Risk Factors

The cause of SCFE is unknown. It occurs two to three times more often in males than females. A large number of patients are overweight for their height. In most cases, slipping of the epiphysis is a slow and gradual process. However, it may occur suddenly and be associated with a minor fall or trauma. Symptomatic SCFE, treated early and well, allows for good long-term hip function.

Symptoms

The typical patient has a history of several weeks or months of hip or knee pain and an intermittent limp. The appearance of the adolescent is characteristic. He or she walks with a limp. In certain severe cases, the adolescent will be unable to bear any weight on the affected leg. The affected leg is usually turned outward in comparison to the normal leg. The affected leg may also appear to be shorter.

Diagnosis

The physical examination will show that the hip does not have full and normal range of motion. There is often a loss of complete hip flexion and ability to fully rotate the hip inward. Because of inflammation in the hip, there is often pain at the extremes of motion and involuntary muscle guarding and spasm.

Treatment

The goal of treatment, which requires surgery, is to prevent any additional slipping of the femoral head until the growth plate closes. If the head is allowed to slip farther, hip motion could be limited. Premature osteoarthritis could develop. Treatment should be immediate. In most cases, treatment begins within 24 to 48 hours.

Early diagnosis of SCFE provides the best chance to achieve the treatment goal of stabilizing the hip.
A screw is inserted to prevent any further slip of the femoral head through the growth plate.
Fixing the femoral head with pins or screws has been the treatment of choice for decades.
Depending on the severity of he child's condition, the surgeon will recommend one of three surgical options.

• Placing a single screw into the thighbone and femoral epiphysis.
• Reducing the displacement and placing one or two screws into the femoral head.
• Removing the abnormal growth plate and inserting screws to aid in preventing any further displacement.

Complications

There are several potential complications associated with a slipped capital femoral epiphysis. The most common are avascular necrosis (AVN) of the femoral head and chondrolysis.

Avascular necrosis means that the blood supply to the femoral head has been permanently altered by the femoral head slipping. There is no way to identify children at risk for avascular necrosis or to prevent this complication. Evidence of avascular necrosis may not be seen on X-rays for as long as 6 to 24 months following surgery.
Chondrolysis, or loss of articular cartilage of the hip joint, is a major complication of SCFE. It may cause the hip to stiffen with a permanent loss of motion, flexion contracture, and pain. The loss of motion may be a result of an inflammation in the hip joint. This is still not fully understood by surgeons. Aggressive physical therapy and anti-inflammatory medications may be prescribed for this rare complication. There may be some return of motion.

Care After Surgery

Most likely, the child will be admitted to the hospital by a pediatric orthopaedist. Surgery is usually performed within 24 to 48 hours. After surgery, the child will be on crutches for weeks to months. A physical therapist will demonstrate how to use crutches. The doctor will give you specific instruction about your child's weight-bearing status and activity restrictions. Follow the instructions closely.

It is important that your child be followed closely for 18 to 24 months after surgery. After the immediate postoperative period, X-rays every 3 to 4 months are needed to ensure that the abnormal growth plate has fused.

Your child may be restricted from certain sports and activities during this time of recuperation. This helps to minimize the chance of further complications. The fusion must be mature enough to prevent further slippage. Then, vigorous physical activities can begin.

Elbow (Olecranon) Bursitis

2011-03-24T04:23:00.000-07:00

Description

The bursa is a slippery sac between the loose skin and the bones of the elbow. It is located at the tip of the elbow. The bursa allows the skin to move freely over the underlying bone. Normally, the bursa is flat. If it becomes irritated or inflamed, a condition known as bursitis develops.

Cause

Elbow bursitis can occur for a number of reasons.

• Trauma: A hard blow to the tip of the elbow could cause the bursa to produce excess fluid and swell.
• Prolonged Pressure: Leaning on the tip of the elbow for long periods of time on hard surfaces, such as a tabletop, may cause the bursa to swell. Typically, this type of bursitis would develop over several months.
• Infection: If the tip of the elbow has an injury that breaks the skin, such as an insect bite or a scrape, bacteria may get inside the bursa and cause an infection. The infected bursa produces fluid, redness, and swelling. If the infection goes untreated, the fluid may turn to pus.
• Medical Conditions: Certain conditions such as rheumatoid arthritis and gout are
associated with development of elbow bursitis.

Symptoms

Swelling is often the first symptom. The skin on the back of the elbow is loose, which means that a small amount of swelling may not be noticed right away. As the swelling continues, the bursa grows. This causes pain as the bursa is stretched, because the bursa contains nerve endings. The swelling may grow large enough to restrict motion of the elbow.

If the bursitis is infected, the skin becomes red and warm. If the infection is not treated right away, it may spread to other parts of the arm or move into the bloodstream. This can cause serious illness.

Diagnosis

An X-ray may be taken to look for a foreign body or a bone spur. Bone spurs are often found on the tip of the bone of the elbow in patients who repeatedly have elbow bursitis.

Treatment

Nonsurgical Treatment

Elbow bursitis due to infection.

If the doctor suspects that bursitis is due to an infection, he or she may remove fluid (aspirate) from the swollen area. This is commonly performed as an office procedure. Fluid removal helps relieve symptoms and gives the doctor a sample that can be looked at in a laboratory to identify if any bacteria are growing. This also lets the doctor know if a specific antibiotic is needed to fight the infection.

Often, the doctor may prescribe antibiotics before the exact bacterium can be identified. This is done to prevent infection from progressing. The antibiotic that the doctor uses at this point will cover a number of possible infections.

If the bursitis is not from an infection, it is treated through a number of options. The elbow is elevated and ice is applied. An elbow pad may be used to cushion the elbow. Direct pressure to the swollen elbow should be avoided. Oral medications such as ibuprofen or other antiinflammatories may also be used.

If swelling and pain do not respond to these measures, the doctor may recommend removing fluid from the bursa and inject a corticosteroid medication into the bursa. The steroid medication is an anti-inflammatory drug that is stronger than the medication that can be taken without a prescription.

Surgical Treatment

If the bursa is infected and it does not improve with antibiotics or by removing fluid from the elbow, surgery may be needed. This is an inpatient procedure.

If elbow bursitis is not a result of infection, surgery may still be needed if nonsurgical treatments don't work. Surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament, or joint structure.

Rehabilitation

Physical therapy after surgery is not always needed. Postoperative casting or prolonged immobilization is not typically required.

Developmental Dislocation

2011-03-24T04:18:00.000-07:00

Developmental Dislocation (Dysplasia) of the Hip (DDH)

Developmental dysplasia (dislocation) of the hip (DDH) is an abnormal formation of the hip joint in which the ball on top of the thighbone (femur) is not held firmly in the socket. In some instances, the ligaments of the hip joint may be loose and stretched.

The degree of hip looseness, or instability, varies in DDH. In some children, the thighbone is simply loose in the socket at birth. In other children, the bone is completely out of the socket. In still other children, the looseness worsens as the child grows and becomes more active.

In a normal hip, the head of the femur is firmly inside the hip socket. In some cases of DDH, the thighbone is completely out of the hip socket.

Pediatricians screen for DDH at a newborn's first examination and at every well-baby checkup thereafter. When the condition is detected at birth, it can usually be corrected. But if the hip is not dislocated at birth, the condition may not be noticed until the child begins walking. At this time, treatment is more complicated and uncertain.

Left untreated, DDH can lead to pain and osteoarthritis by early adulthood. It may produce a difference in leg length or a "duck-like" gait and decreased agility. If treated successfully (and the earlier the better), children regain normal hip joint function. However, even with appropriate treatment, especially in children 2 years or older, hip deformity and osteoarthritis may develop later in life.

Cause

DDH tends to run in families. It can be present in either hip and in any individual. It usually affects the left hip and is predominant in:

• Girls
• First-born children
• Babies born in the breech position (especially with feet up by the shoulders).

The American Academy of Pediatrics now recommends ultrasound DDH screening of all female breech babies.

Symptoms

Some babies born with a dislocated hip will show no outward signs.

Contact a pediatrician if your baby has:

• Legs of different lengths
• Uneven skin folds on the thigh
• Less mobility or flexibility on one side
• Limping, toe walking, or a waddling, duck-like gait

Doctor Examination

In addition to visual clues, the doctor will use careful physical examination tests to check for DDH, such as listening and feeling for "clunks" as the hip is manipulated. For older infants and children, X-rays of the hip may be taken.

Nonsurgical Treatment

Treatment methods depend on the child's age.

Newborns

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH.

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH. The baby is placed in a soft positioning device, a Pavlik harness, for 1 to 2 months to keep the thighbone in the socket. This will help tighten the ligaments around the hip joint and promote normal hip socket formation.

1 to 6 months

The baby's thighbone is repositioned in the socket using a harness or similar device. The method is usually successful. But if it is not, the doctor may have to anesthetize the baby and move the thighbone into proper position, and then put the baby into a body cast (spica).

Surgical Treatment

6 months to 2 years

The child is placed under anesthesia, and the thigh bone is manipulated into the proper position in the socket. Open surgery is sometimes necessary. Afterwards, the child is placed into a body cast (spica) to maintain the hip position.

Older than 2 years

Deformities may worsen, making open surgery necessary to realign the hip. Afterwards, the child is placed into a body cast (spica) to maintain the hip in the socket.

In many children with DDH, a body cast and/or brace is required to keep the hip bone in the joint during healing. X-rays and other regular follow-up monitoring are needed after DDH treatment until the child's growth is complete.

Complications

Complications of treatment may include a delay in walking if the child was placed in a body cast. The Pavlik harness and other positioning devices may cause skin irritation, and a difference in leg length may remain. Growth disturbances of the upper thigh rarely occur.

Dupuytren's Contracture

2011-03-24T04:11:00.000-07:00

Dupuytren's contracture is a thickening of the fibrous tissue layer underneath the skin of the palm and fingers. Although painless, the thickening and tightening (contracture) of this fibrous tissue can cause the fingers to curl (flex).

Dupuytren's contracture is more common in men than in women.

Cause

Symptoms of Dupuytren's contracture include painful bumps (nodules) under the skin that develop into tight bands of tissue, causing the
fingers to curl.

The cause of Dupuytren's contracture is not known. It is not caused by an injury or heavy hand use.

There are factors that put people at greater risk for developing Dupuytren's contracture.

• It is most common in people of Northern European (English, Irish, Scottish, French, Dutch) or Scandinavian (Swedish, Norwegian, Finnish) ancestry.
• It often runs in families (hereditary).
• It may be associated with drinking alcohol.
• It is associated with certain medical conditions, such as diabetes and seizures.
• It increases in frequency with age.

Symptoms

Dupuytren's contracture symptoms usually occur very gradually.

Nodules. One or more small, tender lumps (nodules) form in the palm. Over time, the tenderness usually goes away.

Bands of tissue. The nodules may thicken and contract, forming tough bands of tissue under the skin.

Curled fingers. One or more fingers bend (flex) toward the palm. The ring and little fingers are most commonly affected, but any or all fingers can be involved. As the bend in the finger increases, it may be hard to straighten your finger. Grasping large objects and putting your hand in a pocket becomes difficult.

Doctor Examination

Your doctor will examine your hand and test the feeling in your thumb and fingers. Your grip and pinch strength may also be tested.

During the examination, your doctor will record the locations of nodules and bands on your palm. Using a special device, he or she will measure the amount of contracture in your fingers.
Your doctor may also measure the range of motion in your fingers to determine whether there is limitation in your flexion.

Your doctor will measure the bend in your finger, and note where the bands of tissue and nodules are.

Your doctor will refer back to these measurements throughout your treatment to determine whether the disease is progressing.

Treatment

There is no way to stop or cure Dupuytren's contracture. However, it is not dangerous.
Dupuytren's contracture usually progresses very slowly and may not become troublesome for years. It may never progress beyond lumps in the palm.

If the condition progresses, nonsurgical treatment may help to slow the disease.

Nonsurgical Treatment

Steroid injection. If a lump is painful, an injection of corticosteroid -a powerful antiinflammatory medication -may help relieve the pain. In some cases, it may prevent the progression of contracture. Several injections may be needed for a lasting effect.

Splints. Splinting does not prevent increased bend in the finger. Forceful stretching of the contracted finger will not help either, and may speed the progression of contracture.

Surgical Treatment

Surgery is recommended when your doctor has confirmed through measurements over time that the disease is progressing. Some patients turn to surgical treatment when hand function is limited; they have trouble grasping objects or putting their hands in their pockets.

Surgical procedure. Surgery for Dupuytren's contracture divides or removes the thickened bands to help restore finger motion. Sometimes the wound is left open and allowed to heal gradually. Skin grafting may be needed.

Complications. Although rare, risks of surgery include injury to nerves and blood vessels, and infection. Permanent stiffness of the fingers may occur, although this is also rare.

Recovery. Some swelling and soreness are expected after surgery, but severe problems are rare.

After surgery, elevating your hand above your heart and gently moving your fingers help to relieve pain, swelling, and stiffness.

Physical therapy may be helpful during recovery after surgery. Specific exercises can help strengthen your hands and help you move your fingers.

Most people will be able to move their fingers better after surgery.

Recurrence. Approximately 20% of patients experience some degree of recurrence. This may require further surgery.

New Developments

Experiments are being performed with enzyme injections that may be able to break down the tough bands and improve motion without surgery. Early results are promising, but these injections are not available for general use at this time.

A new, less invasive procedure called needle aponeurotomy is being performed by some hand surgeons. Recovery is much faster, but long-term outcome is unknown. The procedure requires special technical expertise and has greater risk of nerve and/or vessel damage.

Down Syndrome: Musculoskeletal Effects

2011-03-24T04:03:00.000-07:00

Down syndrome is one of the most common genetic disorders. According to the Centers for Disease Control and Prevention, it affects about 13 babies in every 10,000 births. Its primary effect is mental retardation and a number of physical abnormalities.

The child may have special medical problems of the heart, stomach, eyes and other parts of the body. Some problems in Down syndrome involve the bones and joints (musculoskeletal system).

Symptoms

X-ray of the pelvis shows that the patient's left hip is dislocated.

A child with Down syndrome may have weak muscle tone (hypotonia). He or she may also have ligaments that are too loose (ligament laxity). This leads to excessive joint flexibility.

Associated findings include:

• Developmental delays. A child with Down syndrome will eventually reach the same growth milestones as other children. But, he or she may be slow learning to turn over, sit, stand, walk or do other physical activities.
• Joint instability. Children with Down syndrome may have joints, such as the hip or knee, which slip out of place or become dislocated. Joint laxity in the neck may be excessive. This can lead to compression of the spinal cord.
• Other Problems. Down syndrome may also lead to other problems, such as flat feet and bunions.

Nonsurgical Treatment

Getting early medical care and treatment (intervention) can improve the health of a child with Down syndrome and address some musculoskeletal problems.

Because children grow most rapidly during the first three years of life, it is important that the child have a comprehensive medical examination at birth.

Physical Therapy

The doctor may recommend a special program of physical therapy, exercise, and other activities early on. Early intervention can help a child with Down syndrome achieve developmental skills and build muscle tone and coordination. It can also give extra stimulation and encouragement to help the child achieve his or her full potential in life. Many children with Down syndrome go on to hold jobs and live independently well into middle age and beyond.

Early diagnosis and treatment is also important for managing orthopaedic problems in children with Down syndrome. Some children may need splints or other devices for physical activity. Sometimes your doctor may refer you to a pediatric orthopaedist for specialized help or surgery.

Neck Instability

In some people with Down syndrome, the upper part of the spine (cervical) is abnormal under the base of the skull. Muscles are weak and ligaments may be looser than they should be.
Potentially, this can cause bones (vertebrae) in the neck to press on the spinal cord, leading to an inability to coordinate muscle movement and weakness.

Any progressive changes in a child with Down syndrome should be brought to the doctor's attention. These changes may include:

• Weakness, clumsiness and tripping
• Walking with stiff legs
• Having a stiff neck, neck pain, and headaches
• The doctor may recommend taking X-rays of your child's neck to look for joint laxity. In some cases, a child may be kept out of contact sports or other activities that put stress on the neck, such as high jumping, diving, gymnastics, and using a trampoline.

Staying Active

A child with Down syndrome should be encouraged to be physically active and consume a healthy diet. This will help them avoid excess weight gain and other physical problems. Your doctor can help develop a well-rounded exercise routine that includes aerobic activity, strength training, and stretching exercises.

Surgical Treatment

Occasionally, a child with Down syndrome may need a type of surgery called spinal fusion to hold the bones in the neck together. This will prevent excessive pressure on the spinal cord.

Surgery may also occasionally be needed to manage looseness of the hip and knee joints and looseness of the joints in the feet.

De Quervain's Tendinitis

2011-03-24T03:16:00.000-07:00

De Quervain's tendinitis occurs when the tendons around the base of the thumb are irritated or constricted. The word "tendinitis" refers to a swelling of the tendons. Thickening of the tendons can cause pain and tenderness along the thumb side of the wrist. This is particularly noticeable when forming a fist, grasping or gripping things, or when turning the wrist.

Anatomy
Two of the main tendons to the thumb pass through a tunnel (or series of pulleys) located on the thumb side of the wrist. Tendons are rope-like structures that attach muscle to bone. Tendons are covered by a slippery thin soft-tissue layer, called synovium. This layer allows the tendons to slide easily through the tunnel. Any swelling of the tendons located near these nerves can put pressure on the nerves. This can cause wrist pain or numbness in the fingers. De Quervain tenosynovitis of the first extensor compartment.

Causes
De Quervain's tendinitis is caused when tendons on the thumb side of the wrist are swollen or irritated. The irritation causes the lining (synovium) around the tendon to swell, which changes the shape of the compartment. This makes it difficult for the tendons to move as they should.
Tendinitis may be caused by overuse. It can be seen in association with pregnancy. It may befound in inflammatory arthritis, such as rheumatoid disease. De Quervain's tendinitis is usually most common in middle-aged women.

Symptoms
Signs of De Quervain's tendinitis:
• Pain may be felt over the thumb side of the wrist. This is the main symptom. The pain may appear either gradually or suddenly. Pain is felt in the wrist and can travel up the forearm. The pain is usually worse when the hand and thumb are in use. This is especially true when forcefully grasping objects or twisting the wrist.
• Swelling may be seen over the thumb side of the wrist. This swelling may occur together with a fluid-filled cyst in this region.
• A "catching" or "snapping" sensation may be felt when moving the thumb.
• Pain and swelling may make it difficult to move the thumb and wrist.
• Numbness may be experienced on the back of the thumb and index finger. This is caused as the nerve lying on top of the tendon sheath is irritated.

Diagnosis
The Finkelstein test is conducted by making a fist with the fingers closed over the thumb and the wrist is bent toward the little finger. Finkelstein test. Arrow indicates location of pain when test is positive.

The Finkelstein test can be quite painful for the person with De Quervain's tendinitis. Tenderness directly over the tendons on the thumb side of the wrist is a common finding with this test.

Treatment
The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling.

Nonsurgical Treatment
• Splints. Splints may be used to rest the thumb and wrist.
• Anti-inflammatory medication (NSAIDs). These medications can be taken by
mouth or injected into that tendon compartment. They may help reduce the swelling and relieve the pain.
• Avoiding activities that cause pain and swelling. This may allow the symptoms to
go away on their own.
• Corticosteroids. Injection of corticosteroids into the tendon sheath may help reduce swelling and pain.

Surgical Treatment
Surgery may be recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment (covering) to make more room for the irritated tendons. Normal use of the hand usually can be resumed once comfort and strength have returned. Your orthopaedic surgeon can advise you on the best treatment for your situation.

Corns

2011-03-16T06:01:00.001-07:00

Every day, the average person spends several hours on their feet and takes several thousand steps. Walking puts pressure on your feet that's equivalent to 2-3 times your body weight. No wonder your feet hurt!

Actually, most foot problems can be blamed not on walking but on your walking shoes. Corns, for example, are calluses that form on the toes because the bones push up against the shoe and put pressure on the skin. The surface layer of the skin thickens and builds up, irritating the tissues underneath. Hard corns are usually located on the top of the toe or on the side of the small
toe. Soft corns resemble open sores and develop between the toes as they rub against each other.

Cause

• Shoes that don't fit properly. If shoes are too tight, they squeeze the foot, increasing pressure. If they are too loose, the foot may slide and rub against the shoe, creating friction.
• Toe deformities, such as hammer toe or claw toe.
• High heeled shoes because they increase the pressure on the forefoot.
• Rubbing against a seam or stitch inside the shoe.
• Socks that don't fit properly.

Diagnosis and Treatment

Corns can usually be easily seen. They may have a tender spot in the middle, surrounded by yellowish dead skin. Treating foot problems like corns is a team effort. You will need to work with your physician to ensure that problems don't recur.

During your office visit

• To restore the normal contour of the skin and relieve pain, your doctor may trim the corn by shaving the dead layers of skin off with a scalpel. This procedure should be done by a professional, and not by yourself, particularly if you have poor circulation, poor eyesight, or a lack of feeling in your feet.
• If the doctor discovers an underlying problem, such as a toe deformity, he or she can correct it. Most surgeries can be done on an outpatient basis.
At home
• You can soak your feet regularly and use a pumice stone or callus file to soften and reduce the size of corns and calluses.
• Wearing a donut-shaped foam pad over the corn will also help relieve the pressure. Use non-medicated corn pads; medicated pads may increase irritation and result in infection.
• Use a bit of lamb's wool (not cotton) between your toes to help cushion soft corns.
• Wear shoes that fit properly and have a roomy toe area.

Congenital Scoliosis

2011-03-16T05:59:00.001-07:00

Congenital scoliosis is a sideways curvature of the spine that is caused by a
defect that was present at birth. It occurs in only 1 in 10,000 newborns and is
much less common than the type of scoliosis that begins in adolescence.
Children with congenital scoliosis sometimes have other health issues, such as
kidney or bladder problems.

Even though congenital scoliosis is present at birth, it is sometimes impossible to
see any spine problems until a child reaches adolescence.

Types of Congenital Scoliosis

A single hemivertebra in the lower back shown in a 3-D image from a computed
tomography (CT) scan. Note the four normal rectangular vertebra below the
single triangular-shaped hemivertebra (arrow). This wedged vertebra creates the
deformity that would not have otherwise been there.

Incomplete Formation of Vertebrae

As the spine forms before birth, part of one vertebra (or more) may not form
completely. When this occurs, the abnormality is called a hemivertebra and can
produce a sharp angle in the spine. The angle can get worse as the child grows.
This abnormality can happen in just one vertebra or in many throughout the
spine. When there is more than one hemivertebra, they will sometimes balance
each other out and make the spine more stable.

Failure of Separation of Vertebrae

During fetal development, the spine forms first as a single column of tissue that
later separates into segments that become the bony vertebrae. If this separation
is not complete, the result may be a partial fusion (boney bar) joining two or
more vertebrae together.
Such a bar prevents the spine from growing on one side after a child is born.
This results in a spinal curve that increases as a child grows.

Combination of Bars and Hemivertebrae

The combination of a bar on one side of the spine and a hemivertebra on the
other causes the most severe growth problem. These cases can require surgery
at an early age to stop the increased curvature of the spine.

Compensatory Curves

In addition to scoliosis curves, a child's spine may also develop compensatory
curves in order to maintain an upright posture. This occurs when the spine tries
to make up for a scoliosis curve by creating other curves in the opposite
direction above, or below, the affected area. The vertebrae are shaped normally
in compensatory curves.

Symptoms

This 4-year-old girl's body shifts to the left. One hip looks higher than the other
and her waistline is not the same shape on the two sides.
Congenital scoliosis is often detected during the pediatrician's examination at
birth because of a slight abnormality of the back.
Scoliosis is not painful, so if the curvature is not detected at birth, it can go
undetected until there are obvious signs --which could be as late as
adolescence. A child may suspect that something is wrong when clothes do not
fit properly. Parents can discover the problem in early summer when they see
their child in a bathing suit.

The physical signs of scoliosis include:

• Tilted, uneven shoulders, with one shoulder blade protruding more than the other
• Prominence of the ribs on one side
• Uneven waistline
• One hip higher than the other
• Overall appearance of leaning to the side
• In rare cases there may be a problem with the spinal cord or nerves that
produces weakness, numbness, or a loss of coordination.

Doctor Examination and Investigation

Physical Examination

The standard screening test for scoliosis is the forward bending test. Your child
will bend forward and your doctor will observe your child from the back, looking
for a difference in the shape of the ribs on each side. A spinal deformity will be
most noticeable when your child is in this position.
With your child standing upright, your doctor will check to see if the hips are
level, the shoulders are level, and that the position of the head is centered over
the hips. He or she will check the movement of the spine in all directions.
To rule out the presence of a spinal cord or nerve problem, your doctor may
check the strength in your child's legs and the reflexes in the abdomen and legs.

Tests

This adolescent girl's curve and the hemivertebra causing it show up clearly on
x-ray.
Although the forward bending test can detect scoliosis, it cannot detect the
presence of congenital abnormalities. Imaging tests can provide more
information.

X-rays. Images of your child's spine are taken from the back and the side. The
x-rays will show the abnormal vertebra(e) and how severe the curve is.
Once your doctor makes the diagnosis of congenital scoliosis, your child will be
referred to a pediatric orthopaedic surgeon for specialized care and further
tests.

Computed tomography (CT) scan. A CT scan can provide a detailed image of
your child's spine, showing the size, shape, and position of the vertebrae. To
see the vertebrae better, your doctor may have a 3-D image made from the CT
scan. This looks like a photograph of the bones.
This 3-D image from a CT scan shows hemivertebrae, as well as a fused, boney
block.

Ultrasound. Your doctor will do an ultrasound of your child's kidneys to detect
any problems.
Magnetic resonance imaging (MRI) scan. Because an MRI can evaluate soft tissues
better than a CT scan, an MRI will be done to check for abnormalities of the
spinal cord at least once for every patient.

Treatment
There are several treatment options for congenital scoliosis. In planning your
child's treatment, your doctor will take into account the type of vertebral
abnormality, the severity of the curve, and any other health problems your child
has.

Your doctor will determine how likely it is that your child's curve will get worse,
and then suggest treatment options to meet your child's specific needs.

Nonsurgical Treatment

Observation. A child with a small curve that seems to be unchanging will be
monitored to make sure the curve is not getting worse. Although it does not
happen in every patient, congenital scoliosis curves can get bigger as the spine
grows and the deformity of the back becomes more noticeable. It is likely that a
curve in a young child will get worse because younger children still have a lot of
growing to do.
Your doctor will follow the changes of your child's curve using x-rays taken at
6-to 12-month intervals during the growing years.
Physical activity does not increase the risk for curve progression. Children with
congenital scoliosis can participate in most sports and hobbies.
Bracing or casting. Braces or casts are not effective in treating the curvature
caused by the congenitally abnormal vertebrae, but they are sometimes used to
control compensatory curves where the vertebrae are normally shaped.

Surgical Treatment

Surgical treatment is reserved for patients who:

• have curves that have significantly worsened during the course of x-ray
monitoring
• have severe curves
• have a large deformity of the spine or trunk
• are developing a neurological problem due to an abnormality in the spinal cord
An important goal of surgery is to allow the spine and chest to grow as much as
possible. There are several surgical options.

This x-ray was taken of the same patient after her surgery to remove the
hemivertebra and fuse the curved vertebrae with a metal implant.
Spinal fusion. In this procedure, the abnormal curved vertebrae are fused
together so that they heal into a single, solid bone. This will stop growth
completely in the abnormal segment of the spine and prevent the curve from
getting worse.

Hemivertebra removal. A single hemivertebra can be surgically removed. The
partial correction of the curve that is achieved by doing this can then be
maintained using metal implants. This procedure will only fuse two to three
vertebrae together.

Growing rod. Growing rods do not actually grow but can be lengthened with
minor surgery that is repeated every 6 to 8 months. The goal of a growing rod is
to allow continued growth while correcting the curve. One or two rods are
attached to the spine above and below the curve. Every 6 to 8 months, the child
returns to the doctor and the rod is lengthened to keep up with the child's
growth. When the child is full grown, the rod(s) are replaced and a spinal fusion
is performed.

Rehabilitation. Young children usually recover quickly from surgery and are
discharged from the hospital within 1 week. Depending on the operation, a child
may need to wear a cast or brace for 3 to 4 months.
Once they are healed, children are allowed to participate in most of the activities
that they had previously participated in.

Long-Term Outcomes

Congenital scoliosis detected at an early age is one of the most challenging
types of scoliosis to treat. The curves can be large to begin with and because
children have so much growth ahead of them, the chance of severe curve is
high.

Although fusion of vertebrae at an early age results in the spine and trunk being
shorter than they would have been, children can have outstanding results and
achieve normal, or near-normal, function.

Congenital Muscular Torticollis

2011-03-16T05:55:00.001-07:00

Congenital Muscular Torticollis (Wryneck)

Congenital muscular torticollis, also called wryneck, is usually discovered in the first 6 to 8 weeks of life. The infant keeps his or her head tilted to one side and has difficulty turning the head to the opposite side.

If the infant is examined in the first month, a mass, or "tumor," may be felt in the neck. This is nontender and soft. It is attached to the muscle in the neck on the side to which the head is tilting. The mass gradually regresses so that by 4 to 6 months of age the "tumor" is gone.

A young child with a right-sided congenital muscular torticollis. Notice how the face turns away from the tight muscle. (Courtesy of Texas Scottish Rite Hospital for Children)

Congenital muscular torticollis can be associated with hip dysplasia (10% to 20%) so the hips should be examined in children with torticollis.

If you notice that your child holds the head tilted to one side, consult your physician. Other conditions can cause torticollis, and the physician will check for those during the physical examination. X-rays and/or an ultrasound of the neck and/or hips may be taken.

Ninety percent of children can be treated successfully with a stretching exercise program.

Cause

First-born children are more likely to have torticollis (and hip dislocation). This is likely from intrauterine "packing," resulting in injury to the muscle. The "tumor" is seen with response to the injury. As this resolves, the amount of scar in the muscle determines how tight the muscle is. There is no known prevention.

Symptoms

The head tilts to one side and the chin points to the opposite shoulder. The right side is involved 75% of the time. The lump is found in the muscle and it gradually goes away. There is limited range of motion of the neck. One side of the face and head may flatten as the child always sleeps on one side.

Treatment

The usual treatment consists of stretching exercises to turn the head so that the chin touches each shoulder and also so that the ear touches the shoulder.

There are other options that can help. Position toys where the infant has to turn his head to see them. Carry the child so that they have to look to the involved side. Place the child in bed with the involved side toward the wall so that they have to look the opposite way to see you outside the crib.

In 10% of children, surgery may be needed to correct the torticollis. This is an outpatient surgery to lengthen the short muscle.

Compartment Syndrome

2011-03-16T05:54:00.001-07:00

Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage.

Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion.

Anatomy

Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.

The area between the knee and ankle has four major muscle compartments: anterior, lateral, superficial posterior, deep posterior.

Description

Compartment syndrome develops when swelling or bleeding occurs within a compartment.
Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome.

Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.

Cause

Acute Compartment Syndrome

Acute compartment syndrome usually develops after a severe injury, such as a car accident or a broken bone. Rarely, it develops after a relatively minor injury.

Conditions that may bring on acute compartment syndrome include:

• A fracture.
• A badly bruised muscle. This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player's helmet.
• Reestablished blood flow after blocked circulation. This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. A blood vessel can also be blocked during sleep. Lying for too long in a position that blocks a blood vessel, then moving or waking up can cause this condition. Most healthy people will naturally move when blood flow to a limb is blocked during sleep. The development of compartment syndrome in this manner usually occurs in people who are neurologically compromised. This can happen after severe intoxication with alcohol or other drugs.
• Crush injuries.
• Anabolic steroid use. Taking steroids is a possible factor in compartment syndrome.
• Constricting bandages. Casts and tight bandages may lead to compartment
syndrome. If symptoms of compartment syndrome develop, remove or loosen any constricting bandages. If you have a cast, contact your doctor immediately.

Chronic (Exertional) Compartment Syndrome

The pain and swelling of chronic compartment syndrome is caused by exercise. Athletes who participate in activities with repetitive motions, such as running, biking, or swimming, are more likely to develop chronic compartment syndrome. This is usually relieved by discontinuing the exercise, and is usually not dangerous.

Symptoms

Acute Compartment Syndrome

The classic sign of acute compartment syndrome is pain, especially when the muscle within the compartment is stretched.

• The pain is more intense than what would be expected from the injury itself. Using or stretching the involved muscles increases the pain.
• There may also be tingling or burning sensations (paresthesias) in the skin.
• The muscle may feel tight or full.
• Numbness or paralysis are late signs of compartment syndrome. They usually indicate permanent tissue injury.

Chronic (Exertional) Compartment Syndrome

Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides when activity stops. It most often occurs in the leg.

Symptoms may also include:

• Numbness
• Difficulty moving the foot
• Visible muscle bulging

Doctor Examination

Acute Compartment Syndrome

Go to an emergency room immediately if there is concern about acute compartment syndrome.
This is a medical emergency. Your doctor will measure the compartment pressure to determine whether you have acute compartment syndrome.

Chronic (Exertional) Compartment Syndrome

To diagnose chronic compartment syndrome, your doctor must rule out other conditions that could also cause pain in the lower leg. For example, your doctor may press on your tendons to make sure you do not have tendonitis. He or she may order an X-ray to make sure your shinbone (tibia) does not have a stress fracture.

To confirm chronic compartment syndrome, your doctor will measure the pressures in your compartment before and after exercise. If pressures remain high after exercise, you have chronic compartment syndrome.

Treatment

Acute Compartment Syndrome

Acute compartment syndrome is a surgical emergency. There is no effective nonsurgical treatment.

Your doctor will make an incision and cut open the skin and fascia covering the affected compartment. This procedure is called a fasciotomy.

Sometimes, the swelling can be severe enough that the skin incision cannot be closed immediately. The incision is surgically repaired when swelling subsides. Sometimes a skin graft is used.

Chronic (Exertional) Compartment Syndrome

Nonsurgical treatment. Physical therapy, orthotics (inserts for shoes), and anti-inflammatory medicines are sometimes suggested. They have had questionable results for relieving symptoms.

Your symptoms may subside if you avoid the activity that caused the condition. Cross-training with low-impact activities may be an option. Some athletes have symptoms that are worse on certain surfaces (concrete vs. running track, or artficial turf vs. grass). Symptoms may be relieved by switching surfaces.

Surgical treatment. If conservative measures fail, surgery may be an option. Similar to the surgery for acute compartment syndrome, the operation is designed to open the fascia so that there is more room for the muscles to swell.

Usually, the skin incision for chronic compartment syndrome is shorter than the incision for acute compartment syndrome. Also, this surgery is typically an elective procedure --not an emergency.

Clubfoot

2011-03-16T05:52:00.001-07:00

Parents know immediately if their newborn has a clubfoot. Some will even know before the child is born, if an ultrasound was done during the pregnancy. A clubfoot occurs in approximately one in every 1,000 births, with boys slightly outnumbering girls. One or both feet may be affected.

Cause

Doctors still aren't certain why it happens, though it can occur in some families with previous clubfeet. In fact, your baby's chance of having a clubfoot is twice as likely if you, your spouse or your other children also have it. Less severe infant foot problems are common and are often incorrectly called clubfoot.

Symptoms

The appearance is unmistakable: the foot is turned to the side and it may even appear that the top of the foot is where the bottom should be.

The involved foot, calf, and leg are smaller and shorter than the normal side.

It is not a painful condition. But if it is not treated, clubfoot will lead to significant discomfort and disability by the teenage years.

Treatment

Nonsurgical Treatment

Treatment should begin right away to have the best chance for a successful outcome without the need for surgery. Over the past 10 to 15 years, more and more success has been achieved in correcting clubfeet without the need for surgery. A particular method of stretching and casting, known as the Ponseti method, has been responsible for this. With this method, the doctor
changes the cast every week for several weeks, always stretching the foot toward the correct position. The heel cord is then released followed by one more cast for three weeks.

Once the foot has been corrected, the infant must wear a brace at night for two years to maintain the correction. This has been extremely effective but requires the parents to actively participate in the daily care by applying the braces. Without the parents' participation, the clubfoot will almost certainly recur. That's because the muscles around the foot can pull it back into the abnormal position.

The goal of this, and any treatment program, is to make your newborn's clubfoot (or feet) functional, painless and stable by the time he or she is ready to walk. (Note: Anytime your baby wears a cast, watch for changes in skin color or temperature that may indicate problems with circulation.)

Surgical Treatment

On occasion, stretching, casting and bracing are not enough to correct your baby's clubfoot. Surgery may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to12 months of age, surgery corrects all of your baby's clubfoot deformities at the same time. After surgery, a cast holds the clubfoot still while it heals. It's still possible for the muscles in your child's foot to try to return to the clubfoot position, and special shoes or braces will likely be used for up to a year or more after surgery. Surgery will likely result in a stiffer foot than nonsurgical treatment, particularly as the years pass by.

Without any treatment, your child's clubfoot will result in severe functional disability. With treatment, your child should have a nearly normal foot. He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however. You should expect it to stay 1 to 1 1/2 sizes smaller and somewhat less mobile than the normal foot. The calf muscles in your child's clubfoot leg will also stay smaller.

Claw Toe

2011-03-16T05:51:00.001-07:00

People often blame the common foot deformity claw toe on wearing shoes that squeeze your toes, such as shoes that are too short or high heels. However, claw toe also is often the result of nerve damage caused by diseases like diabetes or alcoholism, which can weaken the muscles in your foot. Having claw toe means your toes "claw," digging down into the soles of your shoes
and creating painful calluses. Claw toe gets worse without treatment and may become a permanent deformity over time.

Symptoms

• Your toes are bent upward (extension) from the joints at the ball of the foot.

• Your toes are bent downward (flexion) at the middle joints toward the sole of your shoe.
• Sometimes your toes also bend downward at the top joints, curling under the foot.
• Corns may develop over the top of the toe or under the ball of the foot.

Evaluation

If you have symptoms of a claw toe, see your doctor for evaluation. You may need certain tests to rule out neurological disorders that can weaken your foot muscles, creating imbalances that bend your toes. Trauma and inflammation can also cause claw toe deformity.

Treatment

Claw toe deformities are usually flexible at first, but they harden into place over time. If you have claw toe in early stages, your doctor may recommend a splint or tape to hold your toes in correct position. Additional advice:

• Wear shoes with soft, roomy toe boxes and avoid tight shoes and high-heels.
• Use your hands to stretch your toes and toe joints toward their normal positions.
• Exercise your toes by using them to pick up marbles or crumple a towel laid flat on the floor.

If you have claw toe in later stages and your toes are fixed in position:

• A special pad can redistribute your weight and relieve pressure on the ball of your foot.
• Try special "in depth" shoes that have an extra 3/8" depth in the toe box.
• Ask a shoe repair shop to stretch a small pocket in the toe box to accommodate the deformity.

If these treatments do not help, you may need surgery to correct the problem.

Chordoma

2011-03-16T05:49:00.001-07:00

Chordoma is a rare tumor that usually occurs in the spine and base of the skull. It is a malignant tumor that grows fairly slowly. It can spread to other organs, usually the lungs. It represents only about 1 percent of all malignant bone tumors.

Description

Chordomas develop in a structure called the notochord. The notochord forms the early spine in the beginning stages of fetal development. Most of the notochord is replaced by the spine during the first six months of development. Small areas can remain, and chordomas can form in these areas.

Most chordomas occur at the base of the spine (sacrum), in the tailbone (coccyx) or at the base of the skull (40 percent), but they can occur other places in the spine.

Most patients with chordomas are between 40 and 70 years of age. Occasionally this tumor can occur in younger patients, even children. The average age of people affected is about 55 years.

Chordomas are life-threatening. They can cause death by direct growth or by spreading to other organs. They spread to the lungs about 20 to 30 percent of the time.

Cause

Chordomas occur spontaneously. They are not known to be caused by trauma, environmental factors, or diet. Chordomas are not inherited. Chordomas are not associated with any medical conditions or use of any medications or supplements.

Symptoms

Chordomas grow slowly. Patients often have symptoms for a long time (more than a year) before they seek medical attention.

Symptoms depend on the location of the tumor:

• Tumors in the skull can cause headache or problems with vision.
• Tumors in the spine can cause pain in the area of tumor (neck, back, or tailbone). A tumor pressing on nearby nerves can cause symptoms similar to a "slipped" (herniated) disk. These symptoms include arm or leg pain, weakness, or numbness.
• Tumors in the tailbone area can cause a noticeable mass, numbness in the crotch area, and problems with the bowel and bladder.

Tests

Several imaging tests may be required to identify a chordoma, including x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans.

Chordomas themselves do not show up well, but the bone damage may be seen on the x-rays. X-rays of the sacrum are often difficult for doctors to interpret.

Typical sacral chordomas.

Computed tomography (CT) scans of the same sacral chordomas.

Corresponding magnetic resonance (MRI) scans.

Treatment

Treatment of chordomas is very difficult. This is mainly because these tumors are near the brain and spinal cord.

Traditional chemotherapy has not been very effective, and radiation alone rarely cures the tumor.

Surgery is the preferred treatment option, where possible. Surgery in combination with radiation is often used to treat chordomas. When tumors cannot be surgically removed, sometimes radiation therapy can stop the growth of the tumor.

Although it is the best treatment for chordomas, in many cases surgery can be difficult to perform because of important structures near the tumor. The surgeon must remove the tumor and a margin of normal tissue around it. This often results in a loss of neurologic function. For example, surgical removal of tumors in the sacrum can result in loss of control of bowel and bladder function (incontinence).

Fifty to 75% of patients treated with surgery will be alive after 5 years.

Research on the Horizon

Advances in radiation therapy are allowing higher doses of radiation to be applied with less damage to surrounding normal tissues, such as the brain and spinal cord. Different types of radiation therapy (including proton beam therapy, intraoperative radiation, and brachytherapy) may offer better treatment of these tumors. These therapies may be combined with more limited surgery in the future.

New drug treatments, including use of a drug called imatinib mseylate are being investigated which may help slow the growth of tumors that cannot be removed.

Cervical Spondylotic Myelopathy

2011-03-16T02:53:00.000-07:00

Cervical Spondylotic Myelopathy (Spinal Cord Compression)

One of the most common neck conditions that occurs with age is cervical spondylotic myelopathy (CSM). Over time, the normal wear-and-tear effects of aging can lead to a narrowing of the spinal canal. This compresses — or squeezes — the spinal cord. CSM can cause a variety of symptoms, including pain, numbness, and weakness.

Understanding your spine and how it works can help you better understand CSM.

Description

The vertebral column.

Spinal cord compression is a very common neck condition affecting older people in the United States. Symptoms usually begin after the age of 50, but can occur earlier if there was an injury to the spine at a younger age.

Many people with CSM will have steady progression of their disease. Once symptoms start, they tend to continue. Typically, the disease progresses slowly over several years. In about 5% to 20% of people, CSM worsens more rapidly.

Cause

Neck pain may result from abnormalities in the soft tissues—the muscles, ligaments, and nerves—as well as in bones and joints of the spine. The most common causes of neck pain are soft-tissue abnormalities due to injury or prolonged wear and tear. In rare instances, infection or tumors may cause neck pain. In some people, neck problems may be the source of pain in the
upper back, shoulders, or arms.

Inflammatory Diseases

Rheumatoid arthritis can destroy joints in the neck and cause severe stiffness and pain. Rheumatoid arthritis typically occurs in the upper neck area.

Cervical Disk Degeneration

The disk acts as a shock absorber between the bones in the neck. In cervical disk degeneration (which typically occurs in people age 40 years and older), the normal gelatin-like center of the disk degenerates and the space between the vertebrae narrows. As the disk space narrows, added stress is applied to the joints of the spine causing further wear and degenerative disease.

The cervical disk may also protrude and put pressure on the spinal cord or nerve roots when the rim of the disk weakens. This is known as a herniated cervical disk.

(Left) Side view of a healthy cervical vertebra and disk. (Right) A disk that has degenerated and collapsed.

Injury

Because the neck is so flexible and because it supports the head, it is extremely vulnerable to injury. Motor vehicle or diving accidents, contact sports, and falls may result in neck injury.

The regular use of safety belts in motor vehicles can help to prevent or minimize neck injury. A "rear end" automobile collision may result in hyperextension, a backward motion of the neck beyond normal limits, or hyperflexion, a forward motion of the neck beyond normal limits.

The most common neck injuries involve the soft tissues: the muscles and ligaments. Severe neck injuries with a fracture or dislocation of the neck may damage the spinal cord and cause paralysis.

Other Causes

Less common causes of neck pain include tumors, infections, or congenital abnormalities of the vertebrae.

Symptoms

The spinal cord is the cable of nerves that send and receive signals from the body. When the spinal cord is slowly compressed, people may develop symptoms such as:

• Tingling and numbness
• Weakness: trouble lifting objects, dropping things
• Difficulty walking (loss of balance), wide-based gait
• Coordination problems/clumsiness: handwriting, buttoning clothes, and feeding oneself can become difficult
• Neck pain and stiffness

Doctor Examination

After discussing your symptoms and medical history, your doctor will examine your neck. He or she will look for:

• Abnormal reflexes: usually overactive (hyper-reflexia)
• Weakness: usually in the arms more than in the legs
• Numbness: mostly in the arms and hands
• Atrophy: muscles deteriorate and shrink

Tests

This MRI image shows bulging disks pressing on the spinal cord.

Other tests which may help your doctor confirm your diagnosis include:

X-rays

These studies are useful to look at the alignment of your neck.

Magnetic resonance imaging (MRI).

These studies can create better images of soft tissues. They can be used to look for compression of the spinal cord.

Myelogram

Your doctor may order this special type of computed tomography (CT) scan. CT scans allow better detailed cross-section images showing bone spurs and the size of the spinal canal. In a myelogram, color dye is injected before the scan to better outline the spinal cord.

Treatment

Nonsurgical Treatment

Some people get relief from symptoms without surgery. The most common nonsurgical treatment options include:

Soft Collars. Soft collars allow the muscles of the neck to rest and limit neck motion. This can help decrease pinching of nerve roots with movement. Soft collars should only be worn for short periods of time, because long-term wear can decrease the strength of neck muscles.

Exercise. Improving neck strength and flexibility with simple exercises may lessen discomfort.

Nonsteroidal anti-inflammatory medications (NSAIDs). Drugs like aspirin and ibuprofen can reduce swelling and painful symptoms.

Epidural steroid injections. Cortisone is a powerful anti-inflammatory. Cortisone injections in the "epidural space" can decrease swelling as well as pain, although they are not often used in CSM.

Chiropractic manipulation. Manipulation is never used if a patient has spinal cord
compression.

Surgical Treatment

Whether to have surgery or not is a complex decision made between you and your doctor.

Cervical Spondylosis

2011-03-16T02:49:00.000-07:00

Cervical Spondylosis (Arthritis of the Neck)

Neck pain is extremely common. It can be caused by many things, and is most often related to getting older.

Like the rest of the body, the bones in the neck (cervical spine) slowly degenerate as we age. This frequently results in arthritis. Arthritis of the neck is called cervical spondylosis.

Cervical spondylosis is the degeneration of the joints in the neck. It becomes increasingly more common as people age. More than 85% of people over age 60 are affected.

Although it is a form of arthritis, cervical spondylosis rarely becomes a crippling or disabling type.
Understanding your spine and how it works can help you better understand cervical spondylosis.

Cause

Disk Degeneration and Bone Spurs

In the spine, arthritis can result as the disk degenerates and loses water content. In children and young adults, disks have high water content. As we get older, our disks begin to dry out and weaken. This problem causes settling, or collapse, of the disk spaces and loss of disk space height.

As the facet joints experience increased pressure, they also begin to degenerate and develop arthritis, similar to the hip or knee joint. The cartilage that covers and protects the joints wears away.

If the cartilage wears away completely, it can result in bone rubbing on bone. To make up for the lost cartilage, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth — called spurs — may narrow the space for the nerves to pass through (stenosis).

(Left) Side view of a healthy cervical vertebra and disk. (Right) A disk that has degenerated and collapsed.

Risk Factors

There are several factors that increase your risk for cervical spondylosis. The following have all been linked to higher risks of neck pain and spondylosis:

• Genetics -if your family has a history of neck pain
• Smoking -clearly linked to increased neck pain
• Occupation -jobs with lots of neck motion and overhead work
• Mental health issues -depression/anxiety
• Injuries/trauma -car wreck or on-the-job injury

Symptoms

Pain from cervical spondylosis can be mild to severe. It is sometimes worsened by looking up or down for a long time, or with activities such as driving or reading a book. It also feels better with rest or lying down.

Additional symptoms include:

• Neck pain and stiffness (may be worse with activity)
• Numbness and weakness in arms, hands, and fingers
• Trouble walking, loss of balance, or weakness in hands or legs
• Muscle spasms in neck and shoulders
• Headaches
• Grinding and popping sound/feeling in neck with movement

Doctor Examination

Determining the source of the pain is essential to recommend the appropriate treatment and rehabilitation. Therefore, a comprehensive examination is required to determine the cause of neck pain.

Your doctor will take a complete history of the difficulties you are having with your neck. He or she may ask you about other illnesses or injuries that occurred to your neck. Questions may include: When did your neck begin to hurt? Has it ever hurt like this before? When your neck hurts, how often and for how long does it hurt? Does anything make it better or worse? Were you ever involved in an accident or had an injury to your neck? Have you ever been treated for your
neck pain?

A thorough physical exam will include your neck, shoulders, arms, and frequently your legs, as well. Your strength, touch sensation, reflexes, blood flow, flexibility of your neck and arms as well as your walking may be tested. The doctor may press on your neck and shoulders, and feel for trigger (tender) points or swollen glands.

Tests

Your doctor may supplement your evaluation with blood tests, and, if necessary, consult with other medical specialists. Other tests which may help your doctor confirm your diagnosis include:

X-rays

These pictures are traditionally ordered as a first step in imaging the spine. X-rays will show aging changes, like loss of disk height or bone spurs.

Magnetic resonance imaging (MRI)

This study can create better images of soft tissues, such as muscles, disks, nerves, and the spinal cord.

Computed tomography (CT) scans

This specialized x-ray study allows careful evaluation of the bone and spinal canal.

Myelography

This specific x-ray study involves injecting dye or contrast material into the spinal canal. It allows for careful evaluation of the spinal canal and nerve roots.

Electromyography (EMG)

Nerve conduction studies and electromyography may be performed by another doctor to look for nerve damage or pinching.

Treatment

Nonsurgical Treatment

Physical therapy. Strengthening and stretching weakened or strained muscles is usually the first treatment that is advised. Your physical therapist may also use cervical (neck) traction and posture therapy. Physical therapy programs vary, but they generally last from 6 to 8 weeks.
Sessions are scheduled 2 to 3 times a week.

Medications. Several medications may be used together during the first phase of treatment to address both pain and inflammation.

• Acetaminophen. Mild pain is often relieved with acetaminophen.
• Non-steroidal anti-inflammatory drugs (NSAIDs). Often prescribed with
acetaminophen, drugs like ibuprofen and and naproxen are considered first-line
medicines for neck pain. They address both pain and swelling, and may be prescribed for a number of weeks, depending on the specific problem. Other types of pain medicines can be considered if you have serious contraindications to NSAIDs, or your pain is not well controlled.
• Muscle relaxants. Medications such as cyclobenzaprine or carisoprodol can also be used in the case of painful muscle spasms.

Soft Collars. These collars limit neck motion and allow the muscles of the neck to rest. Soft collars should only be worn for short periods of time because long-term wear can decrease the strength of neck muscles.

Ice, heat, other modalities. Careful use of ice, heat, massage, and other local therapies can help relieve symptoms.

Steroid-Based Injections. Many patients find short-term pain relief from steroid injections. Various types of these injections are routinely performed. The most common procedures for neck pain include:

Cervical epidural block. In this procedure, steroid and anesthetic medicine is injected into the space next to the covering of the spinal cord ("epidural" space). This procedure is typically used for neck and/ or arm pain that may be due to a cervical disk herniation, also known as radiculopathy or a "pinched nerve."

Epidural injection in the cervical spine.

Cervical facet joint block. Steroid and anesthetic medicine is injected into the capsule of the facet joint in this procedure. The facet joints are located in the back of the neck and provide stability and movement. These joints can develop arthritic changes that may contribute to neck pain.

Cervical facet joint.

Medial branch block and radiofrequency ablation. This procedure is used in some cases of chronic neck pain. It can be used for both diagnosis and treatment of a potentially painful joint.

Facet joint injection in the cervical spine.

During the diagnosis portion of the procedure, the nerve that supplies the facet joint is blocked with a local anesthetic (like the medicine used by your dentist). Your doctor will ask if your neck pain is completely gone. If so, then your doctor has pin-pointed the source of your neck pain.
The next step is to block the pain more permanently. This is done by damaging the nerve with radiofrequency, a procedure called radiofrequency ablation.

Although less invasive than surgery, steroid-based injections are prescribed only after a complete evaluation by your doctor. Before considering these injections, discuss with your doctor the risks and benefits of these procedures for your specific condition.

Surgical Treatment

It is uncommon for people with only cervical spondylosis and neck pain to be treated with surgery. Surgery is reserved for patients who have severe pain that has not been relieved by other treatment. Some patients with severe pain will unfortunately not be candidates for surgery. This is due to the widespread nature of their arthritis, other medical problems, or other causes for their
pain, such as fibromyalgia.

People who have progressive neurologic symptoms, such as weakness, numbness, or falling, are more likely to be helped by surgery.

Cervical Radiculopathy

2011-03-16T02:44:00.000-07:00

Cervical Radiculopathy (Pinched Nerve)

Some people have neck pain that may radiate into the shoulder and arm. This type of pain is often caused by an injury near the root of a spinal nerve. A nerve root injury is sometimes referred to as a "pinched" nerve. The medical term for this condition is cervical radiculopathy.

Understanding your spine and how it works can help you better understand cervical radiculopathy. Learn more about your spine: Spine Basics

Cause

As disks age, they lose height and begin to bulge. They also lose water content and become stiffer.

(Left) Side view of a healthy cervical vertebra and disk. (Right) A disk that has degenerated and collapsed.

As the disks lose height, the vertebrae move closer together. The body sees the collapsed disk as a possible weak area and responds by forming more bone — called spurs — around the disk to strengthen it. The bone spurs that form also contribute to the stiffening of the spine. Bone spurs may also narrow the area of the foramen and pinch the nerve root.

The disk changes that occur with age are often called arthritis or spondylosis. It is important to keep in mind that all these changes are "normal" and they occur in everyone. In fact, if MRI scans were performed on all people aged 50 or older, nearly half of the scans would show worn disks and pinched nerves that do not cause painful symptoms. It is not known why some patients have symptoms and others do not.

Symptoms

Cervical radiculopathy pain travels down the arm in the area of the involved nerve. Pain is usually described as sharp. There can also be a "pins and needles" sensation or even complete numbness. In addition, there may be a feeling of weakness with certain actvities.

Symptoms can be worsened with certain movements, like extending or straining the neck or turning the head. These symptoms are often made better by placing the hand on the head and stretching the shoulder.

Doctor Examination

After discussing your medical history and symptoms, your doctor will examine your neck. This will include testing your strength and sensation as well as reflexes. Your doctor may also have you do certain neck and arm movements to try to recreate or relieve your symptoms.

Tests

X-rays

X-rays can show the alignment of bones along the neck. They can also show any narrowing of the foramen and disks.

Computed tomography (CT)

CT scans show the bones of the neck in finer detail. Bone spurs can be seen with CT, especially spurs near the foramen.

Magnetic resonance images (MRI)

An MRI of the neck can show if nerve compression is caused by soft tissue, such as a bulging disk and herniations. MRI can also show the appearance of the spinal cord and nerve roots.

Electromyelography

Electromyography and nerve conduction studies may be able to help show the difference between symptoms caused by pressure on spinal nerve roots and nerve damage caused by other ailments, such as diabetes.

Treatment

It is most important to note that the majority of patients with cervical radiculopathy get better with time and never need surgery, or even any treatment at all.

Some patients will have the pain go away quickly over days to weeks, while others take longer. It is also not uncommon for cervical radiculopathy to come back at some time in the future, but again, this problem usually gets better without any specific treatment. Some patients do develop persistant symptoms and require evaluation and treatment for the arm pain or weakness.

Nonsurgical Treatment

If you are not getting better, your surgeon will recommend a course of treatment. Treatment for radiculopathy starts with nonsurgical options.

Soft Collars. Soft collars allow the muscles of the neck to rest and limit neck motion. This can help decrease pinching of nerve roots with movement. Soft collars should only be worn for short periods of time, because long-term wear can decrease the strength of neck muscles.

Physical Therapy. Physical therapy can help with neck muscle stretching and strengthening. Sometimes, traction is also used.

Medications.

• Nonsteroidal anti-inflammatories (NSAIDS). These include drugs like aspirin and
ibuprofen, and may be helpful if the arm symptoms are from nerve swelling.
• Oral corticosteroids. A short course of oral corticosteroids may also help reduce swelling, as well as pain.
• Narcotics. These medications are reserved for patients with severe pain that is not relieved by other options. Narcotics are usually prescribed for a limited time only.
• Spinal injections. Sometimes, an injection of steroids can be placed near where the nerve is being pinched. This takes advantage of the anti-inflammatory effects similar to oral steroids. The injection may be placed between the laminae (epidural steroid injection), in the foramen (selective nerve injection), or into the facet joint. While steroid injections do not take the pressure caused by a narrow foramen or herniated disk off the nerve, they may lessen the swelling and relieve the pain enough to allow the nerve to recover with more time.

Surgical Treatment

There are several surgical procedures for radiculopathy. The procedure that is right for you will depend on many factors, most importantly the type of problem you have.

Cerebral Palsy

2011-03-16T02:24:00.000-07:00

If your baby has trouble learning to roll over, sit, crawl or walk, see your pediatrician. Delays in development and problems controlling movement or posture may be early signs of cerebral palsy (CP), a group of chronic disorders that stem from abnormalities or damage to the brain.

Cerebral palsy begins before, during, or after birth in the first years of life. Premature babies and others with low birth weight are at greater risk for it. Infection, head injury and other factors can cause CP, but most of the time no one knows why it happens.

Diagnosis

Doctors may use physical examination, medical history and diagnostic imaging tools to determine if your child has cerebral palsy.

Physical Examination

The doctor evaluates your child's muscle tone and reflexes and may want to watch him or her walk, crawl, sit and lie down. Sometimes if the child is less than one year old, the doctor may want to wait a few months and see if specific problems with movement start to happen. The doctor may also check for other conditions linked to CP (i.e., mental impairment, seizures, vision problems, etc.)

Medical History

Give the doctor your child's complete medical history. This helps rule out other disorders that can cause movement problems (i.e., genetic or muscle diseases, metabolism disorders and tumors of the nervous system).

Diagnostic Imaging Tools

The doctor may want to use a specialized test know as magnetic resonance imaging (MRI), to see a picture of your child's brain. There is no specific blood test or imaging study that can make the diagnosis of cerebral palsy.

Symptoms

Cerebral palsy affects the central nervous system and changes the tone of muscles. It takes mild, moderate and severe forms and generally does not get progressively worse. Symptoms vary and may include:

• Tight muscles (increased tone), causing spasms and rigidity.
• Loose muscles (low tone), making limbs weak and floppy.
• Impaired reflexes, coordination and balance.

Some people with CP also have mental impairment (i.e., retardation or learning disabilities); seizures; vision difficulties; shortened limbs; curvature of the spine (scoliosis); dental problems; complete or partial hearing loss; or problems with joints (i.e., contracture). There is no cure for CP, but with early treatment, most children improve their capabilities significantly.

When a child is about 2 years old, the doctor may be able to diagnose the type of CP he or she has. There are four main types:

• Spastic:
In spastic CP, the most common form, there is increased muscle tone/tightness. Legs, arms and back are stiff and contracted, making movement difficult. If both legs are affected (spastic diplegia), tight muscles in the hips and legs cause legs to turn inward and cross at the knees when walking. If only one side of the body is affected (spastic hemiplegia), the arm is often more severely affected than the leg. If all four limbs and the trunk are affected (spastic quadriplegia or total body involved), the muscles of the mouth and tongue may also be affected.

• Athetoid:
(dyskinetic): In athetoid CP there is low muscle tone/looseness, leading to uncontrolled movements of the entire body. It may be difficult to sit straight or walk.

• Ataxic:
A rare form, ataxic CP affects balance and depth perception. There is poor coordination, unsteady walking and difficulty with precise movements such as using a pen or buttoning a shirt.

• Mixed:
In mixed CP, there are symptoms of both spastic and athetoid CP. Some muscles are tight and others are loose. There is both stiffness and involuntary movements.

Treatment

Sometimes people with cerebral palsy need help from their families throughout their lives. If your child has CP, you may want to work with a treatment team of health care professionals to identify and meet the child's individual needs. The goal is to help your child reach his or her potential and maximize independence. Treatment teams often include:

• Orthopaedic surgeons to treat problems with bones, muscles, tendons, nerves or joints.
• Physical therapists to improve movement and strength.
• Occupational therapists to teach skills required for daily living (i.e., eating and dressing).
• Speech and language specialists to treat communication problems.
• Social workers to help locate community assistance and education programs.
• Psychologists to help patients and families cope with stress and/or behavioral therapists to foster social and emotional development.
• Other medical specialists such as eye doctors, neurologists and nutritionists.

Nonsurgical Treatment

• Physical therapy.
Physical therapy (PT) may begin immediately after diagnosis to help your child learn skills like sitting, walking or using a wheelchair. It may also help improve muscle strength, balance and coordination; and prevent muscles from shortening. Stretching muscles may help prevent contracture. Sometimes PT may involve activities like swimming and horseback riding to tone muscles.

• Braces, splints, and casts.
Using braces, splints or casts may improve joint mobility and stability, prevent
contracture and improve hand or leg function. Braces can compensate for muscle imbalance.

• Botox.
This drug can be injected into spastic muscles to loosen them up. It is especially
helpful in children younger than 5 and when used together with casting.

• Medications.
Medications may control or prevent seizures or muscle spasms, ease muscle stiffness or reduce abnormal movements.

• Mechanical aids.
Special machines like computerized communication devices or simple aids like
velcro-fastened shoes or crutches may help a child overcome impairments.

Coping Strategies

Parents of children with cerebral palsy or other disabilities often feel guilt and/or grief about the
child's condition. Some tips to help parents cope:

• Learn all you can about CP. You may want to join a family support group or get help from professionals. Stay informed about new treatments and technologies.
• Work with professionals at your child's school to develop an individualized plan that meets his or her needs and abilities.
• Love and encourage your child. Family support and personal determination are
important factors in achieving long term goals. Treat your child like a normal kid. Go places and have fun. Be patient, and keep hoping for improvement.
• Get help from family and friends. Caring for a child with CP is hard work. Teach
others how to do it so you can take breaks.

Surgical Treatment

If contractures are severe, a child with CP may need surgery to lengthen affected muscles.
Surgery may also help if tightly contracted muscles cause stress to joints and lead to deformities or dislocations. Some children with CP need surgery to correctly position their arms or legs, or to correct curvature of the spine. Other surgical options for spasticity management include selective dorsal rhizotomy and intrathecal baclofen pumps. These procedures are usually done by neurosurgeons.

Carpal Tunnel Syndrome

2011-03-16T02:18:00.003-07:00

Carpal tunnel syndrome is a common source of hand numbness and pain.

Although it is often associated with repetitive hand movements, such as typing,
carpal tunnel syndrome can be caused by many things.

Carpal tunnel syndrome is more common in women than men.

Anatomy

The carpal tunnel is a narrow, tunnel-like structure in the wrist. The bottom and
sides of this tunnel are formed by wrist (carpal) bones. The top of the tunnel is
covered by a strong band of connective tissue called the transverse carpal
ligament.

The median nerve travels from the forearm into the hand through this tunnel in
the wrist. The median nerve controls feeling in the palm side of the thumb, index
finger, and long fingers. The nerve also controls the muscles around the base of
the thumb. The tendons that bend the fingers and thumb also travel through the
carpal tunnel. These tendons are called flexor tendons.

The carpal tunnel protects the median nerve and flexor tendons that bend the
fingers and thumb.

Cause

Carpal tunnel syndrome occurs when the tissues surrounding the flexor
tendons in the wrist swell and put pressure on the median nerve. These tissues
are called the synovium. The synovium lubricates the tendons and makes it
easier to move the fingers.

This swelling of the synovium narrows the confined space of the carpal tunnel,
and over time, crowds the nerve.

Carpal tunnel syndrome is caused by pressure on the median nerve traveling
through the carpal tunnel.

Many things contribute to the development of carpal tunnel syndrome:

• Heredity is the most important factor -carpal tunnels are smaller in some
   people, and this trait can run in families.
• Hand use over time can play a role.
• Hormonal changes related to pregnancy can play a role.
• Age — the disease occurs more frequently in older people.
• Medical conditions, including diabetes, rheumatoid arthritis, and thyroid gland imbalance can play a role.

In most cases of carpal tunnel syndrome, there is no single cause.

Symptoms

The most common symptoms of carpal tunnel syndrome include:

• Numbness, tingling, and pain in the hand
• An electric shock-like feeling mostly in the thumb, index, and long fingers
• Strange sensations and pain traveling up the arm toward the shoulder

Symptoms usually begin gradually, without a specific injury. In most people, symptoms are more severe on the thumb side of the hand.
Symptoms may occur at any time. Because many people sleep with their wrists curled, symptoms at night are common and may awaken you from sleep. During the day, symptoms frequently occur when holding something, like a phone, or when reading or driving. Moving or shaking the hands often helps decrease
symptoms.

Symptoms initially come and go, but over time they may become constant. A
feeling of clumsiness or weakness can make delicate motions, like buttoning
your shirt, difficult. These feelings may cause you to drop things. If the condition
is very severe, muscles at the base of the thumb may become visibly wasted.

Doctor Examination
To determine whether you have carpal tunnel syndrome, your doctor will discuss your symptoms and medical history. He or she will also examine your hand and
perform a number of physical tests, such as:

• Checking for weakness in the muscles around the base of your thumb
• Bending and holding your wrists in positions to test for numbness or tingling in
   your hands
• Pressing down on the median nerve in the wrist to see if it causes any
   numbness or tingling
• Tapping along the median nerve in the wrist to see whether tingling is
   produced in any of the fingers
• Testing the feeling in your fingers by lightly touching them when your eyes are
   closed

Tests

Electrophysiological tests. Electrical testing of median nerve function is often
done to help confirm the diagnosis and clarify the best treatment option in your
case.

X-rays. If you have limited wrist motion, your doctor may order x-rays of your wrist.

Treatment

For most people, carpal tunnel syndrome will progressively worsen without
some form of treatment. It may, however, be modified or stopped in the early
stages. For example, if symptoms are clearly related to an activity or occupation,
the condition may not progress if the occupation or activity is stopped or
modified.

Nonsurgical Treatment

If diagnosed and treated early, carpal tunnel syndrome can be relieved without
surgery. In cases where the diagnosis is uncertain or the condition is mild to
moderate, your doctor will always try simple treatment measures first.

Bracing or splinting. A brace or splint worn at night keeps the wrist in a neutral
position. This prevents the nightly irritation to the median nerve that occurs
when wrists are curled during sleep. Splints can also be worn during activities
that aggravate symptoms.

Medications. Simple medications can help relieve pain. These medications include
antiinflammatory drugs (NSAIDs), such as ibuprofen.

Activity changes. Changing patterns of hand use to avoid positions and activities
that aggravate the symptoms may be helpful. If work requirements cause
symptoms, changing or modifying jobs may slow or stop progression of the
disease.

Steroid injections. A corticosteroid injection will often provide relief, but
symptoms may come back.

Surgical Treatment

Surgery may be considered if you do not gain relief from nonsurgical treatments.
The decision whether to have surgery is based mostly on the severity of your symptoms.

• In more severe cases, surgery is considered sooner because other nonsurgical
  treatment options are unlikely to help.
• In very severe, long-standing cases with constant numbness and wasting of
   your thumb muscles, surgery may be recommended to prevent irreversible damage.

The ligament is cut during surgery. When it heals, there is more room for the nerve and tendons.

Surgical technique. In most cases, carpal tunnel surgery is done on an outpatient basis under local anesthesia.

During surgery, a cut is made in your palm. The roof (transverse carpal ligament) of the carpal tunnel is divided. This increases the size of the tunnel and decreases pressure on the nerve.

Once the skin is closed, the ligament begins to heal and grow across the
division. The new growth heals the ligament, and allows more space for the
nerve and flexor tendons.

Endoscopic method. Some surgeons make a smaller skin incision and use a small
camera, called an endoscope, to cut the ligament from the inside of the carpal
tunnel. This may speed up recovery.

The end results of traditional and endoscopic procedures are the same. Your
doctor will discuss the surgical procedure that best meets your needs.

Recovery. Right after surgery, you will be instructed to frequently elevate your
hand above your heart and move your fingers. This reduces swelling and
prevents stiffness.

Some pain, swelling, and stiffness can be expected after surgery. You may be
required to wear a wrist brace for up to 3 weeks. You may use your hand
normally, taking care to avoid significant discomfort.

Minor soreness in the palm is common for several months after surgery.
Weakness of pinch and grip may persist for up to 6 months.

Driving, self-care activities, and light lifting and gripping may be permitted soon
after surgery.

Your doctor will determine when you should return to work and whether there
should be any restrictions on your work activities.

Complications. The most common risks from surgery for carpal tunnel syndrome include:

• Bleeding
• Infection
• Nerve injury

Long-term outcomes. Most patients' symptoms improve after surgery, but
recovery may be gradual. On average, grip and pinch strength return by about 2
months after surgery.

Complete recovery may take up to a year. If significant pain and weakness
continue for more than 2 months, your physician may instruct you to work with
a hand therapist.

In long-standing carpal tunnel syndrome, with severe loss of feeling and/or
muscle wasting around the base of your thumb, recovery is slower and might
not be complete.

Carpal tunnel syndrome can occasionally recur and may require additional surgery.

Bunions

2011-03-16T02:18:00.001-07:00

If the joint that connects your big toe to your foot has a swollen, sore bump, you may have a bunion.

More than half the women in America have bunions, a common deformity often blamed on wearing tight, narrow shoes, and high heels. Bunions may occur in families, but many are from wearing tight shoes. Nine out of ten bunions happen to women. Nine out of ten women wear shoes that are too small.

Too-tight shoes can also cause other disabling foot problems like corns, calluses and hammertoes.

With a bunion, the base of your big toe (metatarsophalangeal joint) gets larger and sticks out. The skin over it may be red and tender. Wearing any type of shoe may be painful. This joint flexes with every step you take. The bigger your bunion gets, the more it hurts to walk. Bursitis may set in. Your big toe may angle toward your second toe, or even move all the way under it.
The skin on the bottom of your foot may become thicker and painful. Pressure from your big toe may force your second toe out of alignment, sometimes overlapping your third toe. An advanced bunion may make your foot look grotesque. If your bunion gets too severe, it may be difficult to walk. Your pain may become chronic and you may develop arthritis.

Relief from Bunions

Most bunions are treatable without surgery. Prevention is always best. To minimize your chances of developing a bunion, never force your foot into a shoe that doesn't fit. Choose shoes that conform to the shape of your feet. Go for shoes with wide insteps, broad toes and soft soles. Avoid shoes that are short, tight or sharply pointed, and those with heels higher than 2 1/4
inches. If you already have a bunion, wear shoes that are roomy enough to not put pressure on it.

This should relieve most of your pain. You may want to have your shoes stretched out professionally. You may also try protective pads to cushion the painful area.

If your bunion has progressed to the point where you have difficulty walking, or experience pain despite accomodative shoes, you may need surgery. Bunion surgery realigns bone, ligaments, tendons and nerves so your big toe can be brought back to its correct position. Orthopaedic surgeons have several techniques to ease your pain. Many bunion surgeries are done on a same-
day basis (no hospital stay) using an ankle-block anesthesia. A long recovery is common and may include persistent swelling and stiffness.

Adolescent Bunion

Your young teenager (especially girls aged 10-15) may develop an adolescent bunion at the base of his or her big toe. Unlike adults with bunions, a young person can normally move the affected joint. Your teenager may have pain and trouble wearing shoes. Try having your child's shoes stretched and/or getting wider shoes. Surgery to remove an adolescent bunion is not recommended unless your child is in extreme pain and the problem does not get better with
changes in shoe wear. If your adolescent has bunion surgery, particularly before they are fully grown, there is a strong chance his or her problem will return.

Bunionette

If you have a painful swollen lump on the outside of your foot near the base of your little toe, it may be a bunionette (tailor's bunion). You may also have a hard corn and painful bursitis in the same spot. A bunionette is very much like a bunion. Wearing shoes that are too tight may cause it. Get shoes that fit comfortably with a soft upper and a roomy toe box. In cases of persistent
pain or severe deformity, surgical correction is possible.