PEDIATRIC ORTHOPAEDICS

Cerebral palsy is a group of conditions that affect movement and postüre. It is a result of non-progressive permanent damage to the brain that has not yet completed its development (<2 years of age). Its effect on the patient is dynamic and orthopaedic pathologies change dramatically as the child grows. As a result of the involvement of the muscles crossing the joints, progressive contractures, dislocations and degenerations may develop in the joints. The incidence is 2.4 - 2.7 per 1000 live births.

Physiologically, it consists of 1) Spastic (Most common 80%) 2) Hypotonic 3) Athetoid 4) Dystonic 5) Ataxic 6) Rigid 7) Mixed types.

Anatomically, it is classified into the following groups: 1) Monoplegia (one extremity is affected), 2) Hemiplegia (both extremities on the same side are affected), 3) Paraplegia (both lower extremities are affected), 4) Diplegia (all four extremities are affected, upper extremities are less affected), 5) Quadriplegia (all four extremities are affected equally), 6) Double hemiplegia (all extremities are affected, lower extremities are less affected), 7) Whole body involvement (all extremities are severely affected and there is no head and neck control).

Orthopedic treatment in spastic type cerebral palsy is aimed at the treatment of spasticity and the contractures and deformities that develop as a result. There are many methods used in the treatment of spasticity. Conservative treatment methods; physiotherapy, medications (oral, intrathecal, neuromuscular blocks, Botulinum toxin A injections), electro-stimulation and splints. Surgical treatment includes muscle/tendon lengthening and/or transfer surgeries, bone surgeries, and selective dorsal rhizotomy.

First and foremost, a secondary disability caused by spasticity must be prevented. In children with cerebral palsy, spasticity-related muscle and tendon shortening and then joint contractures (hardening) occur. The most crucial secondary disability in extreme spasticity is the spasticity in the adductor muscle group on the inner side of the hip, causing hip dislocations. These cases are followed up with hip X-rays taken every 6 months.

BOTILINIUM TOXIN TYPE A INJECTIONS

These injections create a presynaptic effect by reducing the secretion of acetylcholine from nerve endings. Since old synapses are re-formed, muscle tone and spasms recur after a period of time. Therefore, it should be repeated every 3-6 months. Sedation should be done beforehand. Injection under general anesthesia is preferred in young children. Intensive physiotherapy and/or serial casting is applied after the injection. It should be used after 1.5 – 2 years of age in the lower extremity and after 4 years of age in the upper extremity. Weakness, temporary posture changes and pain in the injection area, general weakness and fatigue can be seen as side effects. Side effects are temporary and insignificant. This treatment has no effect other than reducing spasticity in the muscles. The experience of the physician administering the injection significantly affects the success of the treatment. We can perform Botilinium Toxin Type A Injection treatments in our clinic.

SURGICAL TREATMENT

If contractures and deformities limit function and cause pain, surgical treatment is required. It is the only effective treatment method in advanced rigid contractures. Since walking patterns set by the age of seven, surgery is postponed until this age when possible. The recommended surgery is a multi-level surgery in a single session and postoperative physical therapy is very important for the success of the surgery. In cases such as progressive hip subluxation and lower extremity contractures that prevent walking, surgery may not wait until the age of 7. It is important to understand that anesthesia-related risks (such as latex allergies and bleeding risks) are higher in patients with cerebral palsy than in other children.

Selective dorsal rhizotomy is a surgical method that reduces spasticity and balances muscle tone in carefully-selected patients. It can be applied to patients between the ages of 3-8, with complete spasticity, diplegia, voluntary motor control and dynamic contractures. It is important to note that hip dislocation, lumbar hyperlordosis, pes planovalgus are potential complications of this procedure.

Spinal Deformities in Patients with Cerebral Palsy: Scoliosis is seen in 7% of walking patients and 35% of non-walking patients with cerebral palsy. Hyper-kyphosis is the most common sagittal plane deformity. Scoliosis that limits function and accompanying pelvic obliquity require surgery. Segmental instrumentation and fusion surgery to include the pelvis must be performed.

Hip: Soft tissue interventions are often sufficient if diagnosed early. (This is why regular hip X-rays are important.) In young children, lengthening the adductor (intra-groin) muscles alone may be sufficient. However, in some cases, major surgeries to also include the treatment of the hip bones may be necessary. In the vast majority of children, surgical treatment aims to keep the hip in place rather than having to replace it, thus preventing the formation of a painful hip dislocation in the child’s later years.

Knee: By lengthening the hamstring muscles (the muscles at the back of the thigh), it is possible to open the knee and thus improve walking. Sometimes, by moving a part of the tight muscle from the front of the knee to the back, stiffness around the knee can be reduced.

Ankle and foot: This is the body part where orthopaedic surgery is most necessary. The most common problems are as follows:

Equinus Deformity: This deformity can be static or dynamic. The child walks on their tiptoe. Achilles tendon lengthening or gastrocnemius muscle lengthening is performed. Achilles tendon lengthening can be done using both open and closed techniques.

Pes Equinovarus: This condition occurs due to an imbalance between some muscle groups in the foot. Patients’ feet turn inward while walking and they walk by stepping on the outside of their feet. It is more common in spastic hemiplegics. In patients with only equinus contracture, turning inward in the foot can also be observed, so a distinction should be made. The treatment aims to establish a balance between the muscles that rotate the foot inward and downward, which are more dominant due to spasticity, and the weaker muscles that rotate the foot outward and upward. For this purpose, tendon transfers and muscle tendon lengthening operations are performed separately or in combination in non-rigid dynamic deformities. These treatment options generally prove to be successful

Developmental hip dysplasia (DDH) is a dynamic disorder in which the structures forming the hip are normal during their formation in the womb but subsequently show structural deterioration for various reasons.

Congenital hip dislocation used to be defined as the femoral head being outside the acetabulum at birth. However, since hip dislocation does not always occur congenitally, the term “developmental hip dysplasia (DDH)” is now used instead of “congenital hip dislocation”. The disease has a dynamic process and can spontaneously improve or, less likely, worsen as the child grows in the presence of various factors. The term DDH includes all known forms of the disease (complete dislocation, incomplete dislocation, dysplasia). Complete dislocation is used to describe the femoral head leaving the acetabulum completely in the hip joint, incomplete dislocation (subluxation) is used to describe the femoral head leaving the acetabulum partially, and dysplasia is used to describe the femoral head being in place but the acetabulum covering it being inadequate.

Diagnosis: Physical examination is very important for diagnosis during the newborn period. The Ortolani and Barlow tests are the most commonly used physical examination and diagnosis methods. In unilateral DDH, restriction in abduction (lateral opening of the hip) compared to the other side and inequality in the groin-thigh skin folds are also important findings in the diagnosis. Since the newborn hip is predominantly cartilage, it is difficult to evaluate with X-ray. During this period, the best way to reveal the presence of DDH is with hip ultrasonography (USG). Hip USG is the gold standard in radiological diagnosis, especially in the first 6 months of life. Pelvic X-ray is extremely important in the diagnosis and follow-up of DDH, and is the benchmark for diagnosis for patients over 6 months. Evaluations made on this X-ray provide very valuable information in the diagnosis.

Treatment: The goal of DDH treatment is to anatomically place the hip joint in its place as soon as possible, to continue this and to ensure the normal development of the hip joint, to provide the patient with a functional hip joint for life by eliminating any permanent damage that may occur. The later the diagnosis is made, the more complex the interventions to be made and the risk of complications increase, while the chance of success decreases. The first 2-3 months of life is the optimal time for DDH treatment. Successful treatment of DDH results in normal anatomical structure and function of the hip. For this, it is necessary to provide complete reduction and maintain it until sufficient stability is achieved. In dislocated and sub-dislocated hips, in the early stages when bone and soft tissue pathologies are not apparent, it is possible to provide complete reduction with non-surgical methods. However, in the later stages when pathological changes become apparent, surgical intervention is required for complete reduction. If complete reduction is achieved in the hip joint by closed or open method before the patient is eighteen months and this position is maintained sufficiently, the problem often resolves spontaneously. Reduction is achieved by simply positioning the hip in the first 6 months of life. The most commonly used method to maintain reduction during this period is the Pavlik bandage. Hips that are not fully reduced with simple positioning are reduced under general anesthesia and the position is maintained with a cast that includes the torso and legs. Between 6-18 months, treatment can be provided with reduction and cast under general anesthesia. However, conservative methods become inadequate as the baby grows and surgical reduction is often required. In the later period, especially after 18 months, extending the reduction position both causes problems due to long-term fixation and does not provide sufficient stimulation on the bony development of the hip. Therefore, after 18 months, bone correction surgeries that ensure the anatomical and physiological integrity of the hip should be applied. During the treatment of DDH, the most important possible complication to note is damage to the vessels feeding the femoral head, especially due to tension caused by exaggerated cast positions or due to surgical trauma. This situation is not rare and avascular necrosis can occur in the femoral head as a result.

Post-Treatment Follow-up: Whether treated with bandages or surgery and plaster, all babies with DDH should have regular follow-up appointments with their physician until the end of their growth period. It is difficult to predict the changes that the child will go through during their growth and development period. In some cases, if the hips do not develop sufficiently, although this does not cause any disruption during childhood and cannot be detected from the outside, further problems can occur after the age of 18-20 when it becomes too late for easier treatment options. In these cases, very major and invasive surgeries may be required. Therefore, children should have follow-up appointments until the end of their childhood growth, even if they have no pain or complaints.

Perthes Disease occurs most frequently in young children after the age of 4. Its cause is unknown. It is a disease that occurs when the area above the growth cartilage in the hip joint does not get the necessary blood supply or when the blood supply to that area is disrupted. The period from the time the blood supply is disrupted, to the recovery, healing and reshaping of the area is a process that usually takes 2 to 4 years to complete. Depending on the size of the affected area and other factors, the results of the process can be both good or bad. The first symptoms of Perthes Disease are usually knee pain, hip pain and limping. Sometimes children who are taken to the doctor with knee pain are evaluated as having no problems even after taking knee X-rays, hence delaying the diagnosis of Perthes Disease. Treatment is decided upon with regular follow-up appointments according to the deterioration in the hip joint, the type of the disease and the age of the patient. In the past, some orthosis (devices attached to the leg) were used. However, in scientific studies conducted over time, it was determined that these treatments were ineffective and did not change the course of the disease and such treatments were abandoned. If a deterioration occurs in the hip joint, surgical treatment is intended to prevent the deterioration developing further. This is achieved by regular 3-month x-ray follow-ups and necessary interventions as required. Possible negative results of Perthes Disease include shortness in the leg, limitation in hip movements and the patient needing prosthesis surgery due to calcification in the hip joint in later ages. The ultimate goal of treatment is to stop the disease from causing further hip joint deterioration, while healing the hip joint and preventing deterioration to arise again in the future.

“Congenital Clubfoot” or “Pes Equinovarus” is a congenital deformity in the foot. It is usually referred to as “clubfoot”. The affected foot or feet are turned inwards from the ankle. If left untreated, the person can only walk on their ankle or on the side of their foot. However, with treatment, the vast majority of patients recover in the early years of childhood.

It is one of the most common congenital deformities in the foot and is seen in an average of 1 in every 1000 live births. Half of the cases are seen in both feet and the other half in one foot only. The risk of occurrence is higher in male babies than in female babies. In single-foot deformity, the foot in question may remain smaller than the other foot.

It can sometimes be confused with Postural-positional clubfoot, which is a temporary positional deformity caused by the baby’s position in the womb, which is much simpler to treat and can also be corrected spontaneously with medical follow-up.

Although there is no known cause for clubfoot, if it is present in the family, the incidence is higher than in those where it is not.

The deformity in the foot is noticed with the naked eye immediately after birth. Although it can also be diagnosed with ultrasound in the womb after the 20th week of pregnancy, the definitive diagnosis is made after birth.

TREATMENT

Even if the deformity is detected in the womb, there is no intervention method that can be done before the baby is born. Treatment should be started as soon as possible after the baby is born. Currently, there are two main treatment methods, but the most common of these methods and the first method to be applied by the American Academy of Orthopedic Surgeons is the Ponseti Method casting. All of the treatments for clubfoot should be performed by orthopedic doctors who are trained and experienced in this specific casting method. In addition, the success of the treatment is directly related to the family’s strict adherence to this treatment and its timeline.

Surgical Treatment: Surgical treatment was a very common treatment method before the 2000s. Later, after techniques such as the Ponseti Method, which still provide higher success rates, the option of being the first treatment method has decreased considerably. Surgery is still considered in cases where the deformity is not fully corrected (also called resistant clubfoot) or in cases where this deformity is accompanied by other deformities.

Ponseti Method: This method was developed by Dr. Ignacio V. Ponseti during his time as a doctor, as an alternative treatment option due to the long-term failures of old surgical methods. It was only after his retirement in 1996, when he published the book “Congenital Clubfoot: Fundamentals of Treatment” that his method gained worldwide acceptance.

Treatment generally begins 1 or 2 weeks after the baby is born and continues with manipulation of the foot for 5 to 7 weeks, changing the cast every week. The casts are applied up to the kneecap, leaving the toe exposed. If the heel has not descended to the level of the sole of the foot by the end of the maximum 9 weeks, the Achilles tendon, which prevents the heel from descending to its normal position, is cut with a small surgical procedure (percutaneous achillotomy) under general anesthesia. This procedure is necessary in the vast majority of cases, approximately 85-90%. After this operation, the foot is placed in a cast for 3 weeks. After this cast is removed, special shoes called orthosis (where the two shoes are connected in the middle with an iron bar) is used. The shoes are put on at a certain angle and usually left on the baby’s foot for 23 hours a day for the first 3 months. At the end of the 3-month period, the shoes are worn during the baby’s daytime naps and throughout the night while the baby is sleeping. Afterwards, the shoes are worn only at night until the age of 3-4. If this device is not used according to these recommendations, relapses begin and treatment failures occur. The treatment of relapses seen within the first year of life starts with casting again. The success rate of the Ponseti method is 95% if the casting is performed by trained physicians and there are no other additional problems. The feet of children treated with the Ponseti method have a completely normal appearance and can function normally. They do not need special shoes, have no pain in their feet and can live a normally functioning life.

INTOEING (PIGEON-TOES)

A normal foot is flat or slightly turned outward while walking. Sometimes we see that the tip of the foot turns inward while walking in children. This is a very common condition called intoeing, also known as pigeon-toes. It becomes more obvious especially when children walk and run. This condition mostly improves when children reach the age of 2. This condition can be very worrisome for families with newly walking children. Families usually consult a doctor as soon as the child first starts to walk. In children where intoeing does not improve by the age of two, this condition generally improves on its own by the age of 7-8 and does not require any treatment. There is no orthosis cast or specially made shoes to improve this condition faster.

The conditions that cause intoeing are as follows:

1) Tibia (shinbone) inversion: This condition is caused by the absence of a slight outward rotation that should be present in the tibia bone. It usually improves on its own by the age of 4. It is the most common cause of intoeing in children between the ages of 1-3. If this condition continues over the age of 8, there are some cases where the condition may need to be corrected with surgery.

2) Increased femoral neck angle in the hip: This is the most common cause of inward turning in children between the ages of 3-6. This condition usually improves after the age of 8. If there is excessive inward turning and excessive limitation in outward rotation in hip movements over the age of 8, special methods such as computerized tomography can be used to measure and plan surgical treatment.

3) Flat feet: Children with flat feet can achieve better balance by turning their feet inward while walking. Insoles can be used in children with balance problems and complaints of pain. However, it should be kept in mind that insoles can only temporary alleviate the pain as they do not treat flat feet.

4) Metatarsus adductus: This is a condition where the tip of the foot is turned inward. It is related to the baby’s position in the womb. Most cases correct themselves. In cases that do not improve within 2-3 months after the baby is born, the family usually notices this condition and consults a doctor. Stretching exercises are usually recommended for these patients. In resistant or rigid cases, they are treated with plaster or special shoes. Surgical treatment is rarely necessary in patients with metatarsus adductus.

5) Bow Leg (Genu Varum):strong> This is a condition where one or both of the child’s legs curve outward at the knees. This creates a wider space than normal between the knees. This condition is rarely serious and children usually grow out of the condition by age 6. Appropriate treatments, including splints, casts, braces or surgery, can be planned in some cases that do not improve or have additional reasons for the condition.

FLAT FEET (PES PLANUS)

Flat feet, medically known as ”pes planus”, means the collapse of the long arch of the foot. When a normal foot steps on the ground, the inner edge of the foot does not touch the ground, but in the case of flat feet, this inner edge begins to touch the ground. This collapse can occur at different degrees, as well as at advanced degrees with a complete inversion of the arch. Flat feet is the second most common reason for Pediatric patients consulting orthopaedics doctors and clinics, second after trauma cases, and it can be a worrisome situation for parents. Concerns about whether their newborn or toddler children have flat feet are common among many parents. They worry when they cannot see their child’s inner arch that should be seen in a normal foot. Most often, when the child reaches walking age, families consult with an orthopaedic doctor with complaints of inward stepping. Flat feet are diagnosed with an examination by an orthopaedic doctor. The feet of children who have recently started walking are usually chubby-looking due to the fat pad present from birth, and no arch is seen on the sole of the foot. Feet that transfer body weight to the ground are very important in children. Generally, 70-80% of children initially have flat feet. The most important reason for this is the presence of a fat pad on the sole of the foot, which continues to decrease until the age of 3 due to the fact that the ligaments holding the ankle are not yet fully developed. As the fat pad starts to disappear after the age of 3 and the ligaments of the foot begin to strengthen, the arch of the foot usually takes its normal shape in children and assumes its expected shape by age 8.

There are 2 types of flat feet. The first of these is flexible flat feet, where the arch of the foot is seen when the foot is in the air, and the sole flattens when the foot touches the ground. This condition of flat feet is harmless. If there is no genetic predisposition and it can be corrected after the age of 7 when the ligaments of the foot reach a sufficient strength. If there is a genetic predisposition, that is, if one of the mother, father or close relatives has flat feet, then flat feet may continue permanently after the age of 7. The other type is rigid flat feet. In this type, it can be seen that the patient’s foot does not have an inner arch both when it touches the ground and when it isn’t touching the ground. This is the more significant type of flat feet. It occurs as a result of the disruption of the unity between the ankle bones and early treatment can prevent permanent disabilities. The examination determines whether the flat feet are flexible or rigid. The family is informed that flexible type of flat feet is not a serious condition and that it will be most likely corrected by the age of 8, if there is no genetic transmission. If it is rigid, radiological examinations (such as X-ray and computerized tomography) should be used to investigate the cause. If a condition called “vertical talus” is detected among the causes of the rigid type flat feet in the patient, the family is informed that surgical treatment may be required immediately. Failure to treat this condition can lead to serious foot deformities in later ages and can impair the ability to walk.

For the treatment of flat feet, it is harmful for children to wear shoes constantly and indoors. Shoes should not be worn so that the feet develop properly. Shoes prevent the development of the foot and the strengthening of the bones and muscles. It is best for children to walk around the house with socks, house booties or bare feet. Orthopedic shoes and insoles worn by babies and children to correct flat feet are useless. It is dangerous to put on shoes with the wrong or improper insoles. The ideal shoes for children as they start their walking period are hard-soled, internally supported including cushioned heels, and hard-edged shoes. These are called walking shoes.

It should be emphasized that it is usually unnecessary for families to visit doctors with concerns about their child’s flat feet until the child has reached the age of 3 or 4.

SCOLIOSIS

Scoliosis is the general name given to the curvature of the spine to the right or left. When a healthy spine is viewed from behind, all vertebrae can be seen facing in the same direction. The disruption of this alignment for any reason and the presence or development of an abnormal curvature is called “scoliosis”.

Causes: Scoliosis can occur for a variety of reasons. For example, it can also be seen in spastic children or those who have suffered a stroke during childhood. However, the scoliosis cases we encounter most frequently are (1) those that develop around the age of 10 and whose cause is still not fully known (idiopathic) and (2) those that occur due to various factors in the womb and show symptoms from birth. The exact cause of idiopathic scoliosis is not known. However, recent studies have shown that some genetic factors do play a role. Congenital scoliosis is thought to be caused by infections during pregnancy, diabetes, and certain vitamin deficiencies.

The most common causes and types of scoliosis are:

1) Idiopathic Scoliosis (cause unknown): It occurs in a previously straight spine for an unknown reason. It is the most common cause.

Subclasses of idiopathic scoliosis: Idiopathic scoliosis is defined according to the age at which scoliosis begins to develop. Each age group has its own characteristics and difficulties regarding treatment.

– Infantile onset idiopathic scoliosis: 0-3 years
– Juvenile onset idiopathic scoliosis: 4-9 years
– Adolescent onset idiopathic scoliosis: 10-18 years

2) Congenital Scoliosis: This condition is usually due to a defect in the spine or fused ribs that develops before the baby is born.

3) Neuromuscular scoliosis: It can occur as a result of paralysis of the muscles due to conditions such as polio, cerebral palsy or muscular dystrophy.

4) Neurofibromatosis: A disease that affects bones and soft tissues. Scoliosis often accompanies this disease.

5) Rheumatic diseases

6) Connective tissue diseases: Osteogenesis imperfacta, Ehlers Danlos, Marfan syndrome, etc.

7) Scoliosis developing after spinal fractures

8) Scoliosis developing after spinal infections

9) Metabolic diseases: Morquio, Gaucher disease, etc.

10) Syndromic diseases: Scoliosis can also occur after many genetic syndromic diseases. Individuals with syndromic diseases should be closely monitored for scoliosis.

It can be seen that there are many conditions that can cause scoliosis. Patient follow-ups and treatments may also vary depending on the underlying disease that causes scoliosis.

In Turkiye, it has been determined that spinal curvatures are seen at a rate of 2-3% in screenings performed on children aged 12-14.

Symptoms: Scoliosis is a disease that affects children during their growing years and puts their lifelong spine health in jeopardy. When the disease is detected early, a high rate of success can be achieved with various treatment options. However, if spinal curvatures that are not diagnosed and progress over time, this prevents the normal development of children. During adulthood, waist and back pain, heart and lung disfunctions can be observed. Scoliosis can be noticed with a careful evaluation. There are usually no complaints of pain in the early stages of scoliosis. Therefore, the diagnosis is often made by chance. Usually, the first finding is visual disturbance. Poor posture, one shoulder being higher than the other, a prominent scapula protrusion on one side, clothes not fitting the body properly (asymmetrical skirt or dress lines in girls) are often noticed by family members or teachers. One of the easiest ways to detect scoliosis is the forward bending examination. Scoliosis can be detected during the forward bending examination where the child is bending forward and trying to touch the ground with both hands without bending his knees. If there is visible rib protrusion or asymmetry in the hips or waist, it could suggest possible scoliosis. Scoliosis is usually detected in patients who consult their doctor with these complaints.

Çocuklarda Omurga Deformitelerinin Tedavisinde Genel Prensipler

Omurga deformitelerinin tedavisinde amaç kozmetik olarak düzgün, dengeli ve ağrısız bir omurga sağlamak ve oluşabilecek ek sorunları önlemektir. Erken tanı, eğriliğin daha küçükken saptanması ve gerekli önlemlerin alınması ile ilerlemenin önüne geçilmesini sağlar. Tanı ve tedavide her hasta bireysel olarak değerlendirilmelidir. Yani her hastanın tedavisi kendine özgüdür. Skolyozun seyri hastadan hastaya değişkenlik göstermektedir. Skolyoz ilerleyebilir, aynı derecede kalabilir veya düzelebilir. Tedaviyi belirleyen ana faktörlerden biri, bu sürecin öngörülmesidir. Genel olarak skolyozun küçük yaşta ortaya çıkması, iskelet olgunlaşmasının derecesi, çift eğrilikler, eğrilik açısının fazla olması, hastalığın ilerleyebileceği konusunda uyarıcı olabilir. Bu hastalar daha yakın izlenip, daha yoğun tedavi alırlar. Dolayısı ile skolyozlu bir çocuk düzenli aralıklarla konunun uzmanı bir hekim tarafından kontrol edilmelidir.

Skolyozda tedavi skolyozun tipine ve büyüklüğüne göre değişiklik gösterebilmekle beraber en sık uygulanan tedavi seçenekleri şunlardır:

What is kyphosis: When viewed from the side, the increase in the curvature of the spine is called kyphosis (humpback). Kyphosis can be a posture disorder. This condition is usually corrected with posture exercises and changing posture habits. The most common subtype of kyphosis is ”Scheuermann Kyphosis”, which progresses with wedging in the spine. This is a more severe deformity. Scheuermann kyphosis requires a more detailed evaluation than regular kyphosis and its treatment is decided upon according to these evaluation results. Although there are some theories, the cause of Scheuermann kyphosis is unknown. When you ask patients with Scheuermann kyphosis to correct their posture, they physically cannot. In kyphosis due to posture disorder, patients can correct their posture whenever they want. In addition to radiological criteria, this finding is an important finding in distinguishing the two types of kyphosis clinically. Another type of kyphosis is ”Congenital”, or birth-related kyphosis. It occurs due to the separation of the spine or formation defect of the spine in the womb. Although it is less common, it causes more serious deformities and symptoms. Congenital kyphosis requires frequent follow-up appointments. When necessary, surgical treatment should be performed without delay.

GENERAL PRINCIPLES IN THE TREATMENT OF SPINAL DEFORMITIES IN CHILDREN

The goal of treating spinal deformities is to provide a cosmetically smooth, balanced and painless spine and to prevent additional problems that may occur over time. Early diagnosis allows the curvature to be detected at a young age and the necessary precautions to be taken to prevent progression. Each patient should be evaluated individually in both diagnosis and treatment. In other words, the treatment of each patient is unique. The course of scoliosis varies from patient to patient. Scoliosis may progress, remain at the same level or improve. One of the main factors of determining the treatment option is the predicting its progression. In general, the emergence of scoliosis at a young age, the degree of skeletal maturation, double curvatures, and a large curvature angle may be warning signs that the scoliosis may progress. These patients are monitored more closely and receive more intensive treatment. Therefore, a child with scoliosis should go in for regular checkups to a specialist physician.

While treatment for scoliosis may vary depending on the type and extent of the scoliosis, the most commonly applied treatment methods are as follows:

1) Observation: In patients with a curve below 20 degrees and nearing completion of skeletal development, observation and periodic checks alone are sufficient. Observation continues until the patient completes skeletal development.

2) Corset (Lumbar Brace) Treatment: The purpose of the corset (also known as a lumbar brace) is to prevent the increase in the curve. The corset is especially effective in children whose curve is over 25 degrees and who are still growing. The effect of the corset begins to decrease in children with curves over 40 degrees and in children whose skeletal development completion is still many years away.

3) Surgical Treatment: If the curve is over 40-45 degrees and the child is still growing, surgery is inevitable. Curves over 50 degrees continue to increase even after growth has ended. For this reason, surgery is performed to prevent future health-related complications as well as for cosmetic results. In some early-onset and congenital scoliosis, surgical treatment can be performed before the curve reaches 50 degrees. Early-Onset Scoliosis in Children: Early-onset scoliosis requires a different evaluation and treatment algorithm than the types of scoliosis seen in older children. Scoliosis that begins under the age of 10 is called early-onset scoliosis. Early-onset scoliosis is usually progressive because the more growth potential the child has, the higher the chance of the scoliosis progressing. This type of scoliosis is very difficult to control with a brace, so surgical treatment is more frequently recommended.

Early-onset scoliosis can occur idiopathic and congenital scoliosis as well as scoliosis as a result of certain syndromes, neuromuscular (due to diseases involving the muscle and nervous system), metabolic and connective tissue diseases.

Another problem in early-onset scoliosis is the negative effects of the fusion, or freezing of the spine, that can be performed in the surgical treatment of advanced scoliosis in young children at the beginning of their growth period. The fusion procedure performed at a young age stops the growth of the spine. This causes the spinal canal to remain narrow, lung development to be impaired and the development of the rib cage to be impaired. This results in lung-related problems and a short torso. During adolescence, height growth is largely completed, the lungs and rib cage are largely developed, therefore, if fusion surgery is performed during this period, the potential complications mentioned above can be avoided. If early-onset scoliosis is not treated correctly, these children may develop serious deformities and advanced scoliosis and scoliosis-related lung, respiratory and heart problems, serious cosmetic challenges, spinal cord compression and possible paralysis in the future.

Treatment in Early-Onset Scoliosis: The treatment principles for scoliosis at this age are similar to scoliosis in adolescence, but more difficult. Although it varies depending on the cause of the scoliosis, the general approach consists of observation, corset-cast treatment and surgical treatment. Scoliosis patients under 20 degrees are monitored with observation. As in scoliosis during adolescence, cast or brace treatment is recommended for curvatures exceeding 20 degrees. Since corset treatment is difficult in younger children (0-6 years old), trunk correction casts (Risser casts) applied under anesthesia are a preferred method of treatment. The aim of early-onset scoliosis treatment is to allow the spine to grow as much as possible and then apply surgical treatment if necessary. Therefore, early-onset scoliosis patients can be monitored with a brace until the curvature reaches 60 degrees. Surgical treatment options are the preferred method of treatment in curvatures that exceed this degree. The final option for treatment, when other options have been exhausted or proven to be unsuccessful is fusion, or freezing the spine. Other surgical treatment methods can be performed prior to fusion surgery to win some time when for a child who is still growing. The common feature of these procedures is that they allow the spine to lengthen until growth is completed. These methods can be examined under two main headings as ”growing rod system” and ”growth guidance”. When growing rod systems are applied, the spine will continue to grow, so the curvature will continue to progress, therefore, the curvature must be corrected again with periodic surgery and lengthening procedures performed every 6 months. These procedures are continued until the end of puberty, and when growth stops, the final fusion procedure is applied to the spine.

A new technology has recently been developed to avoid a surgical procedure to be performed every six months. In this system called ”Magnetic Rod”, rods can be lengthened without the need for surgery thanks to a magnetic field applied to the rods from outside of the body. This way, instead of repeated surgeries, the progression of the curvature can be controlled with a magnetic field created outside the patient’s skin after placing the specially-made magnetic rods during the initial surgery. The lengthening procedure is applied in an outpatient clinic without anesthesia. This system is available in Turkiye and we are able to do this procedure in our clinic.

The growth guidance system (Shilla Growth Guidance): This system is the application of a short fusion using rods and screws only in the middle part of the curve called the apex, where the curvature is the most prominent. The rods are placed on the spine and connected to screws at the highest and lowest points of the curvature, but the screws are not fully tightened and the rods are left longer to account for growth by calculating the growth margin. This procedure allows for the curvature in the spine is largely corrected, while the spine can continue to grow over these rods because the screws are left loose and rods placed longer than the current length of the spine. There are also many modifications of this system. Studies report successful results of this system, much like other surgical treatment options. Other methods described in the treatment of early-onset scoliosis are thoracoscopic staple (which is applied from the chest with the help of a camera and small incisions) and tension band methods. These methods are only applied in scoliosis cases involving the back spine and are relatively lower degrees. Although they are promising methods and provide new ideas in the treatment of scoliosis in a growing spine, there are still not enough studies on these methods that document long-term results. In short, the treatment of early-onset scoliosis is a bit more difficult than adolescent scoliosis and requires detailed planning. If diagnosed early and intervened without delay, it is a condition that can be treated.

CONGENITAL SCOLIOSIS

In cases such as congenital scoliosis (where the patient has scoliosis from birth), there may be various abnormalities in the spine and rib adhesions may accompany spinal abnormalities. There are many different treatment methods to treat congenital scoliosis. The treatment method to be used should be determined according to the patient and the abnormalities of each patient specific to their case. Brace treatment is ineffective in congenital scoliosis. There are cases that can be treated with fusion to a very short spine section without preventing the development of the spine and rib cage, with the removal of the abnormal vertebra in the spine (hemivertebrectomy), or with a combination of various treatment methods mentioned above. Issues with other organs are also frequently seen in congenital scoliosis. If abnormalities are detected in other organs, their treatment should also be planned separately. In particular, abnormalities in the spinal cord should be detected and, if necessary, there should be a treatment plan for those abnormalities as well. If surgical treatment is necessary for the additional abnormalities, they can often be treated in the same session as or just before the curvature correction.

Treatment options for congenital scoliosis can be summarized as follows:

1) Monitoring at certain intervals: If there is no increase in the curvature, the physician can continue monitoring using X-rays.

2) Short segment fusion: It may or may not be combined with removal of the abnormal vertebra (hemivertebrectomy).

3) Growing rod method: It can be combined with short segment fusion when necessary (hybrid methods).

4) Expansion operation of the rib cage with prosthetic ribs. (VEPTR: Vertical Expandable Prosthetic Titanium Rib): It is applied if there are rib abnormalities and attached ribs together with congenital scoliosis. The vision cage is opened and expanded with titanium rods placed in the rib cage and curvature is corrected simultaneously without fusion. It can be combined with growing rod systems and the system can be extended and modified either up to the spine or up to the pelvic bone as necessary. Extension operations are also required evey 6 months when implementing this system.

5) Instrumentation and fusion operations performed from behind with osteotomies: This is the only treatment option for neglected advanced curvatures. It can be applied either by removing a segment of the spine or not. It is applied with new surgical techniques using the latest technology. However, it should be performed by experienced surgeons only.

To summarize briefly, congenital scoliosis occurs due to spinal abnormalities present at birth. If appropriate interventions are not performed in a timely manner, the curvatures can worsen significantly. If curvature progression is not noticed during the follow-ups, the necessary surgical intervention should be performed without delay. The idea that surgery should be performed after the child has fully grown is extremely wrong. Early intervention directly affects the patient’s future health.

Skeletal dysplasias are a complex group of diseases that affect bone, cartilage or both tissues and can present with different clinical and radiological findings. Although rare when examined as separate diseases, skeletal dysplasias are seen at a frequency of 1/3000-5000 in the population. Various congenital disorders, spinal abnormalities, short limbs and disproportionate short stature are seen in skeletal dysplasias, which can be divided into 40 main groups according to clinical, laboratory, radiological and molecular evaluations. In addition to bone abnormalities, many hormonal system conditions can also occur in these diseases, most of which have genetic causes. A detailed history and examination, skeletal system radiographs, genetic examination, some advanced laboratory testing, and a joint evaluation of different medical departments are required for the differential diagnoses of skeletal dysplasia. The most common skeletal system dysplasias, which were published in 2010 and divided into 40 subgroups, are: Achondroplasia, Spondyloepiphyseal Dysplasia, Multiple Epiphyseal Dysplasia, Osteogenesis Imperfecta (Grit bone disease), Mucopolysaccharidoses, Marfan Syndrome and Arthrogryposis.

The nerves coming out of the neck of the spinal cord go through the cervical vertebrae and come together under the collarbone in different directions to form a nerve network called the brachial plexus. The nerve branches coming out of the brachial plexus provide both movement and sensation of the parts of the back and chest, shoulder area, arm, forearm and hand. The clinical condition that occurs when the brachial plexus is damaged during a difficult birth is called congenital arm paralysis. The condition’s severity varies according to which nerves are damaged and the extent of the damage.

Cause: The cause of congenital arm paralysis is the result of the nerves being stretched and damaged. The most common risk factors of this condition is the baby being born with high birth weight, undergoing a difficult birth with shoulder compression (shoulder dystocia), breech presentation and the use of forceps during delivery.

Symptoms: Congenital arm paralysis is mostly unilateral. Symptoms may vary depending on the degree of nerve damage. Symptoms include the baby moving one arm less than the other or not being able to move it at all, the baby not being able to make a fist with the affected hand, color difference between both arms, one arm being softer than the other, the baby always grasping objects with the same hand, and the baby not being able to bring their hand to their mouth.

Classification: Brachial plexus injuries are divided into three groups as Upper, Lower and Total depending on the affected area:

Upper brachial plexus injury: In upper brachial plexus injury, the nerves coming out of the C5 and C6 nerve roots are damaged. Sometimes the C4 nerve root is also included in the injury. Upper brachial plexus injury is the most common congenital arm paralysis injury type. It is seen 4 times more than the other types combined. It is also known as Erb’s Palsy. The area damaged by stretching is usually very near where the C5 and C6 nerve roots meet. Since the nerves going to the muscles of the back and torso leave the nerve trunk before this level (C5-C6), these muscles are usually not affected by the incident. The muscles in the shoulder, elbow and wrist are the muscles that are primarily affected by the damage. If no improvement is seen at the end of the first 3 months, it is a sign of poor prognosis. If the baby cannot bring his hand to his mouth while sitting by 6-9 months, surgical intervention should be planned.

Lower brachial plexus injury: In lower brachial plexus injury, the nerves coming out of the C8 and T1 nerve roots are damaged. It is also known as Klumpke Palsy. The muscles that are primarily affected by the event are the shoulder, wrist, fingers and the inner muscles of the hand. The hand feels colder than normal to the touch. In this type of injury, hand movement and sensation are inadequate. The child does not react when painful stimuli are given to his hand. A slight drooping of the eyelid on the same side as the child’s problematic arm and a smaller pupil compared to the other side may also be observed. Surgery may be considered by the 3rd month in patients who not show positive development until then.

Total brachial plexus injury (Total Palsy): This is the congenital arm paralysis type with the worst prognosis. The entire brachial plexus is affected. The arm is completely immobile. The forearm is in supination, which means that the patient’s palm faces forward.

Treatment: Surgery may be required in approximately 10% of babies who have brachial plexus injuries and have the above indications. Babies born with arm paralysis should see a physician who specifically treats brachial plexus injuries as soon as possible, whether or not surgical treatment is required. It is important to distinguish how many nerve roots are injured and at which levels in the early period after birth. Nerves that we use less in daily life may need to be transplanted to the region for injured nerve roots located right outside of the spinal cord. In injuries farther from the spinal cord, nerves taken from the legs can be placed in appropriate gaps in the area to be used for repair purposes. If nerve surgeries are planned for children, they should be performed before the child is one year old. Nerves taken from the leg are sensory nerves that do not cause any movement disorders and their removal does not cause any injury or harm to the child.

One of the most important points that parents of the patient should not forget in brachial plexus surgery is the fact that recovery will take a long period of time. The nerve starts to heal from the area it is repaired and moves approximately 1 mm per day towards the fingertip. Therefore, it takes an average of 6 months to 2 years for the nerve fibers heading outwards from the repaired area to the target muscle to heal completely. It is an integral part of the treatment that patients undergo physiotherapy for a considerable period before and after the surgery. After nerve healing is complete, correction surgeries can be planned for muscle transfers from the back and arm to replace the muscles that do not properly function in the arm, along with bone correction surgeries, if necessary. If these surgeries are necessary, they should be performed preferably at the age of 3-5 before the child reaches school-age. This laborious treatment protocol that could potentially take years aims to achieve the maximum function possible in the arm and hand. However, a 100% recovery and full restoration of all functions should not be expected in these patients. The goal of these procedures is to create a functioning auxiliary arm for the other healthy arm. Achieving this goal is only possible with surgeries at appropriate periods, a strong working relationship and understanding between the patient, family and doctor, and an extensive physiotherapy process.

General Factors: Children’s bones are more flexible than adult bones and the membrane surrounding the bone called the “periosteum” is much thicker than it is in adults. Therefore, accidents that can cause a complete fracture in adults cause bending type fractures in children. The speed of bone healing depends on the child’s age and the location of the fracture. Ligaments are stronger than bones in children. Therefore, a sprain that causes a ligament tear in adults can cause a fracture in children.

The most common fractures in children are wrist and elbow fractures. In children, there is abundant blood supply to the bones and their cellular activity is high. Therefore, children heal faster than adults. The younger the child, the faster a fracture heals. For example, a femur fracture that cannot heal in less than 4-5 months in an adult can heal in 2-3 weeks in a newborn baby. In addition, the closer the fracture is to the growth plate, the higher the rate of healing. Even if the fractures of young children appear to have a severe deformity on X-ray, the bone reshapes itself over time and assumes its natural shape. This is called the remodeling ability of the bone. However, there is a limit to the remodeling ability of the bone. Therefore, it is necessary to know well which bone can correct itself at which age and to what extent so as not to avoid surgical treatment if the deformity in the bone is at a level that cannot be remodeled and needs surgical intervention. Fractures close to the growth plate, fractures close to the shoulder in the arm, fractures in the part of the femur close to the knee, fractures close to the wrist, and fractures that show an angle parallel to the joint movement axis are more easily remodeled than other fractures. Shortening without angular deformity in the fracture or the fracture ends not coming together completely may not cause problems in children, and these fractures can heal without leaving any scars.

Bone bending (Plastic deformation): It usually occurs after fractures in the forearm bones. The bone should be straight but bends after trauma. This is a condition that can only be noticed by an orthopedic specialist and can be revealed more clearly when an X-ray of the healthy limb is taken.

Green Stick Fracture: Fractures in children’s bones resemble underdeveloped tree branches. When one side of the bone is broken, the opposite side remains intact and bends. During treatment, the intact side should also be broken and the shape of the bone should be corrected. If this correction is not performed, curvatures and deformities may occur in the bone.

Torus fracture: Children’s bones are soft and flexible. A torus fracture occurs when force is applied along the axis of the bone cause the bone to fold into itself in an accordion-like manner. This occurs most frequently in the wrist and second most frequently in the ankle.

Complete fracture: A complete fracture usually occurs with high-energy traumas. This is where the bone is completely separated.

Growth Plate Fractures: Fractures in the growth plate can cause growth defects in children’s bones. The growth plate is a cartilage structure located at the end of the bone and functions as the longitudinal growth of the bone. Although these structures vary depending on the bone they are located in and the gender of the child, they are generally active until the ages of 16-21. Since growth plates are located next to the joints, they are easily affected by trauma. Due to their soft structure, they are much more easily damaged than bones. Damages can easily be missed on X-rays, so they should be evaluated by an orthopedic specialist who is experienced in this field, and if necessary, X-rays of the healthy side should be taken to compare. Anatomical (complete reduction) is absolutely necessary in these fractures. If closed reduction is not successful, surgical treatment should be applied. If damage occurs to the growth plate despite all of these treatments, shortening or angulation may occur in the affected bone. Parents should be informed about this and children should be monitored at regular intervals until the end of their growth period. If angulation or shortening is encountered, the necessary interventions should be planned without delay.

Dislocations in Children: Since ligaments are stronger than bones in children, dislocations are rare. The most common dislocation is the dislocation in the elbow region. This occurrence is also known as “nanny elbow”. It occurs in children especially between the ages of 1-4 when the child is pulled hard by the arm or lifted up from their arms. The child cannot move his/her hand and is in pain. In these cases, parents usually urgently consult a doctor. With a simple intervention, this dislocation is put back into place and the child begins to be able to use their hand. Adults caring for young children should be advised not to pull a child’s arm or lift them up in the air by the hand.

Post-Fracture Cast Follow-up: Timely follow-up after cast application after a fracture is extremely important in children. On the first day, parents should watch for signs of impaired circulation including swelling and bruising in the fingers of the casted limb. Parents should be informed about these issues and elevation of the casted limb is strongly recommended. Bleeding and swelling in the cast can disrupt circulation in that area. In this case, the cast should be loosened immediately. Whether the fracture is set to heal in the appropriate position is also monitored with X-rays taken at regular intervals. When union of the fracture is detected in the X-rays, the cast is removed and the child is able to move their limb. Limited movement after the cast is very rare in children. In such cases, physical therapy may be required.