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Toddler's range of motion after growth plate injury

My 1 1/2 year old daughter injured her growth plate 4 weeks ago and had surgery to correct (possibly) the issue using 2 pins to hold the elbow in place and then was casted to immobilize the arm. She had her cast removed today and the pins were removed (Quite traumatically I'd say because no anesthetics were used not even topical) The Dr told me no follow up care is needed and she may have a crooked arm for the rest of her life or things might be just fine. But what worried me most is he said there is no therapy for her. At this time she cannot straighten her arm or bear weight on it O dont want to do anything because I want to make sure she is completely healed before attempting any corrective therapy. BUT Is there ANY pediatric home therapy we can do to help her range of motion or get her arm to straighten out???
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replied June 25th, 2013
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It sounds like your daughter had a supracondylar injury to the distal humerus (in the elbow). If the fracture is displaced, it is usually treated with closed reduction and percutaneous pinning (using smooth K-wires). Since very young children will not keep a splint on, the arm has to be casted while the pins are in place.

I am sorry the removal of the pins was traumatic for you. Unfortunately, that is the way the K-wires are removed. Since they are smooth, they can just be pulled out with a pair of pliers (or stout forceps). There really is no way to numb up the skin or underlying bone (no topical anesthetic will do anything). And, for the few seconds it takes to pull the pins, it is not worth the risk of using a general anesthesia (which is the riskiest part of any surgery - children die from general anesthesia). But, the surgeon could probably have prepared you a little better. Since your daughter is so young, she most likely will not even remember it (unless you keep reminding her).

As to having very young children do physical therapy, most of the time, they do not have enough of an attention span to make participation in therapy worthwhile. Most children will do their own therapy through play. But, it is going to take some time for her to start using the arm again. She is going to have to learn to use the arm all over again. But, she will do it, if you let her. She will favor the arm for a little while, then, as she realized that the cast is off and she can do things again for herself, she will. You usually cannot keep kids down, they are going to play and do things.

And, yes, unfortunately, there is no way to know right now if her arm will be completely straight again. It depends upon how significantly the physis was injured. Most kids do fine, even if they do not regain full extension. The biggest concern is if just part of the physis closes prematurely. When this happens, the child may end up with a cubitus varus deformity (also called a gunstock deformity). This deformity is more noticeable than a cubitus valgus one. In fact, most children with a cubitus valgus deformity elect to have nothing done about it, because it causes them little problems (if any). But, a cubitus varus deformity is cosmetically more noticeable. However, it is usually just a cosmetic deformity, as again, most kids have few problem functionally.

But, you will have to wait and see what happens. If the bone heals and continues to grow just fine, then there is nothing that needs to be done. If a cubitus varus or valgus does occur, and the child does have problems with it, then she may need to have a controlled osteotomy done when she is done growing (during adolescence). Most pediatric orthopedic surgeons will leave it up to the teenager, if he/she wants to have anything done. An osteotomy is where the bone is cut, moved, and then fixed with internal hardware. This is not without risks. So, again, it is usually left up to the teenager.

In some rare cases, surgery might be done at an earlier age, if there is a significant deformity, that is causing significant impairment of function.

Again, as to therapy, right now, all you really need to do is let your daughter play. She will not do anything that hurts. If it does not hurt, you will not be able to keep her from doing things.

She will need to have a lot of lotion applied to the arm (dry skin from being under the cast). You can do some massage of the elbow and arm, when applying the lotion. Be sure to keep the pin tracts clean, until they close up completely. If she is complaining of some aching, a hot bath and some massage will usually do the trick.

Again, I am sorry the pin removal was so traumatic for you. But, in the long run, that is really to best way to remove the pins. It is over quickly and there is no risk of anesthetic complications.

Give your daughter a lot of love and encouragement. Kids actually do very well, it is much harder on the parents.

Good luck. Wishing you and your daughter the best.
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