5 Incredible Hawaii Medical Stories


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Children, Heal Thyselves

A pediatric bone specialist pioneers a minimalist fix for broken wrists.

Dr. Byron Izuka.
Photo: Rae Huo
 

A radical shift in the way doctors treat severe wrist fractures in children began with a 9-year-old Hawaii girl who snapped her wrist when she fell from her mother’s high-heeled shoes.  The standard treatment for such injuries has long been the same for children as it is for adults. Doctors straighten the bones, either manually or surgically.

The new approach can be summed up in two words: Do nothing. Or at least do nothing other than putting a cast on the child’s arm and allowing the bones to straighten themselves as they continue growing.

“It’s a concept that’s completely counter-intuitive, but when the process is done, you can’t even tell that the bones were broken in the first place,” says Dr. Byron Izuka, the pediatric orthopedic surgeon who pioneered the approach and won a prestigious medical award for his efforts.

When Izuka saw the 9-year-old girl in the emergency room of Kapiolani Medical Center, her hand hung alongside her arm. After giving her a powerful sedative, Izuka used his hands to try and manipulate her fractured bones back into place, as orthopedic surgeons are trained to do. But this break was especially bad. No matter how much he squeezed, pushed and kneaded, Izuka could not get the fractured pieces back in place. That meant he would have to take the girl into surgery.

The girl’s father, however, refused. As Izuka recalls: “This was one of those dads who had this unreasonable fear of anesthesia. He said, ‘If you put her to sleep in the operating room, she will never wake up. She will die there.’”

The father was adamant. “He told me he’d rather leave her arm like that than let her go into the O.R.,” Izuka says. “I thought he was nuts.”

Izuka could go no further without the father’s consent. So he made sure the girl’s hand was pointed in the right direction, put a cast on her arm and sent her home. Initially, the arm healed crookedly. But as Izuka followed the girl’s recovery, he witnessed the bones begin to correct themselves. After a year, the arm had completely straightened.

The knowledge that children’s broken bones can straighten as they grow isn’t new. It’s part of a phenomenon called bone remodeling. Izuka found a handful of case studies in which orthopedists had, when conventional measures failed, let bone remodeling do its wonderful work. In every instance, the children healed perfectly. But in none of the cases was bone remodeling the first line of treatment.

Izuka realized that turning to bone remodeling first could have significant benefits. It would mean less pain for the child, it would eliminate the risks of surgery and sedation entirely, and it would consume less of the medical staff’s time. It also would cost significantly less. “I started thinking, If what I’m doing isn’t better than what nature is doing, should I be doing it?” he says.

Izuka decided to continue treating children with wrist fractures the way he treated the girl.

“For the first five or six kids, I was walking on eggshells because I wasn’t sure if maybe the first girl wasn’t just a lucky case,” Izuka says. “Maybe some kids do straighten out and some don’t. But the first five all turned out fine.” As did the next five, and the five after that.

Between 2004 and 2009, Izuka treated 51 children between the ages of 3 and 10 this way. All of them healed perfectly. He published these results in The Journal of Bone and Joint Surgery and won an award from the Pediatric Orthopedic Society of North America for outstanding scientific achievement. Other orthopedic surgeons in Hawaii and across the Mainland have adopted the technique, and three major teaching hospitals now teach it to doctors in training.

Izuka still marvels at how this all came about. “If it wasn’t for that 9-year-old girl, and if that crazy dad didn’t refuse treatment,” he says, “I’d still be straightening these things out.”
 

A NEW BONY YOU: BONE REMODELING

Bone remodeling is the biological process in which the body replaces old bone with new bone. Two different types of cells do the work. Osteoclasts absorb old, mineralized bone. Osteoblasts lay down new bone. Bone remodeling revamps about 10 percent of an adult’s skeleton per year. In children it works much faster. In the first year of life, it’s responsible for replacing almost 100 percent of the skeleton.
 

    

A 9-year-old girl’s fractured wrist, front and side views.

The bones were left unstraightened when the cast was applied.

     

After 42 days, the bones have healed crookedly.
Two years after the injury, the bones have straightened themselves.
X-Rays: Courtesy Dr. Byron Izuka
 
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