In this section we will be looking at problems that are unique to children and the growing years. Most of the unique problems that occur in children occur as a result of properties of their bone, cartilage or growth plates. Children are susceptible to injuries of their growth plates and fractures that occur in ways that can only occur when a growth plate is present. These are called epiphyseal fractures and have a whole system of classification into 5 types. The other type of fracture that occurs in children is called a greenstick fracture. This name comes from the similarity of certain long bone fractures to that of a broken tree branch that is young and green. The outer layer of bone is very thick in children and when a fracture occurs the outer layer may not completely crack itself. The attachments may remain in the same fashion as a green stick would retain some attachments if one attempted to crack it in two.
We will focus on injuries that are less often seen than fractures, but about which less is known.
The second major type of problem that occurs is called osteochondroses. This is a particular type of damage to a growth site. It may occur at a joint site in which case it is called an "articular osteochondrosis". At sites at which a joint does not occur this problem is called a "non-articular osteochondroses". It may occur at tendon attachments, ligament attachments or in areas that receive a lot of impact stress. In clinical practise it is most frequently seen at the sites of tendon attachment particularly the tibial tuberosity (Osgood-Schlatter's disease) and at a site of both impact stress and tendon attachment - the calcaneus (Sever's disease). Theory holds that both overuse and tight muscles may contribute to the problem. On x-ray the epiphysis (portion of bone attached to the rest by a growth plate) frequently reveals a fragmentation.
This is seen most often in children aged 9 to 15 years. It is usually self-limited. The usual recommendation is for rest until symptoms abate. Occasionally long leg casting is done for severe cases.
On xray the growth center first appears in girls between the ages of 4 to 6 years and boys aged 7 to 8 years. The centers fuse to the primary ossification center of the calcaneus in girls at appoximately ages 12 to 14 on boys at ages 15 to 17. When Sever's disease is present the x-ray appearance usually shows the apophysis to be divided into two three or more parts. Sometimes a series of small fragments is noted.
Pain is usually related to activity levels. In most cases the posterior aspect of the calcaneus will be tender. Occasionally, the plantar aspect may be tender or both of these locations may be found to be tender. Frequently the achilles tendon is tight and there may have been a recent increase in activity. The factors contributing to this disorder are similar to those causing plantar fasciitis, but a tight achilles tendon appears to be a greater contributor than pronation.
Recommendations for treatment are usually for rest or significant decrease in activity level. Although, it is often stated to be self-limited the period of time in which it becomes limited may be a bit longer than many people would wish. I recommend a decrease inactivity and usually recommend the use of a heel lift. Sometimes I will combine this with high voltage galvanic to decrease symptoms and relax the calf muscles. After symptoms have diminished I start a gentle posterior muscle group stretching program. Occasionally, orthotics are useful to prevent symptoms from returning.
Frieberg's disease is more common in women than in men. It is classified as an osteochondroses and as such afftects the epiphysis or end part of the bone just before and at the joint. On X-ray it appears as a flattening of the metatarsal head. It usually occurs at adolescence, starting between ages 11 and 17. A review of the literature cited by David Katcherian, in an article entitled, "Treatment of Freiberg's Disease", Clinical Orthopedics and Related Research, January 1994, concluded the aggregate average female:male ratio was approximately 5:1. It occurs most often in the second metatarsal head, less often in the third and even less often in the fourth, fifth and first. When it is first noticed there is usually pain and limited motion at the metatarsal-phalangeal joint. The pain is aggravated by moving the affected joint. There may also be swelling and tenderness in this area.
There is no definitive treatment for this condition. A decrease in activity and occasionally casting may be considered to reduce acute pain. Shoe modifications, such as rocker sole or orthotic use to diminish stress at the affected metatarsal join are used as conservative treatment. Surgical treatment varies and is in a state of evolution.
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Copyright © 1995 Stephen M. Pribut