The American Academy of Pediatrics and the Pediatric Orthopedic Society of North America just published 5 recommendations that are sure to benefit the health of our babies and children with musculoskeletal disorders. Certainly, this article should prompt questions and a discussion with your primary care provider should any of these conditions be present in your children.
*And I have translated some of the medical language so this is crystal clear.
Published: February 12, 2018
Do not order a screening hip ultrasound to rule out developmental hip dysplasia or developmental hip dislocation if the baby has no risk factors and has a clinically stable hip examination.
Hip dysplasia/dislocation is relatively rare, with incidence of approximately 7 per 1,000 births. Studies have shown that universal screening programs for developmental hip instability using ultrasounds to assess otherwise normal appearing hips have a nearly negligible positive yield. There is a substantial false positive rate*, with an associated increase in treatment rate, suggesting that babies without hip pathology are being treated. When there are no physical findings or underlying risk factors for hip dysplasia/dislocation in a newborn, a hip ultrasound is costly, time-intensive and the findings may be misleading to parents and physicians. This recommendation is in accordance with the 2016 AAP clinical report regarding the use of ultrasound in early detection of developmental dysplasia of the hip (see reference: “Evaluation and Referral for Developmental Dysplasia of the Hips in Infants”). *Dr. JJ note: false positive means that a test done may show a result that looks like the condition is there, but it's not. This is the risk taken when screening ALL babies vs. those who have physical findings that increase the liklihood that the POSITIVE is really POSITIVE.
Do not order radiographs(xrays) or advise bracing or surgery for a child less than 8 years of age with simple in-toeing gait*.
Mild in-toeing is usually a physiologic phenomenon reflecting ongoing maturation of the skeleton. Metatarsus adductus, femoral anteversion, and tibial torsion all contribute to in-toeing and tend to improve with growth. Simply monitoring gait for continued improvement at normal well child examination intervals is adequate until the age of 7-8 unless there is severe tripping and falling or asymmetry. It is not possible to alter the natural evolution using physical therapy, bracing or shoe inserts. *Dr. JJ note: intoeing is also known as pigeon-toes. So unless your little ones are tripping or falling, or one side is way worse than the other, wait until eight. Once your little ones bones and muscles are older, this self corrects without unnecessary xrays or painful, expensive braces. Metatarsus adductus-the front half of the foot turns in. Femoral anteversion - occurs with the muscles that rotate in the upper leg are stronger than those rotating them out - so there is inward rotation from the upper leg, to the knee and all the way down to the foot. Tibial torsion - when one or both of the shin bones are slightly rotated inward, so the upper leg is straight, and there is inward turning from below the knee.
Do not order custom orthotics or shoe inserts for a child with minimally symptomatic or asymptomatic flat feet.
Flexible flat feet are normal physiologic variants commonly found in children and adults. Unlike a painful or rigid flatfoot that requires further workup, if an arch is present when standing on tiptoe, the foot can be managed with observation or over-the-counter orthotics. The use of custom orthotic devices to provide support for the foot does not aid in the development of the arch. Dr. JJ note: children are naturally flat-footed for the first few years of life. So important to remember, if NO PAIN, and the foot can bend and stretch, no treatment is needed. If your child has an arch when sitting with the feet suspended in the air or on tippy-toes, no need to worry.
Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory and plain radiographic examinations have been completed.
History, physical examination, and appropriate radiographs (xrays) remain the primary diagnostic modalities in pediatric orthopaedics, as they are both diagnostic and prognostic for the great majority of pediatric musculoskeletal conditions. Examples of such conditions would include, but not be limited to, the work up of injury or pain (spine, knees and ankles), possible infection, and deformity. MRI examinations and other advanced imaging studies are costly, frequently require sedation in the young child (5 years old or less), and may not result in appropriate interpretation if clinical correlations cannot be made. Many conditions require specific MRI sequences or protocols best ordered by the specialist who will be treating the patient. Inappropriately obtained MRIs may need to be repeated in those circumstances. Additionally, a significant dose of radiation is delivered to the patient during a CT (CAT) scan, so their utility in a specific case would be best confirmed prior to ordering. Therefore, in those conditions where advanced imaging is indicated, it has greater value when it is used to answer a specific question that arises from a thorough clinical and appropriate radiographic evaluation. Additionally, if you believe findings warrant additional advanced imaging, discuss with the consulting orthopaedic surgeon to make sure the optimal studies are ordered. Dr. JJ note: very often, well meaning parents want to have sophisticated imaging tests before they are warranted. Under some circumstances they will be needed, but many many questions and answers can be found with a really good history, physical exam and some carefully chosen xrays, if needed. We take an oath to "do no harm" - not only to the patient, but also your pocketbook!
Do not order follow-up X-rays for buckle (or torus) fractures if they are no longer tender or painful.
Buckle (torus) fractures are very common injuries in young children, especially in the distal radius. The fracture is one of compression, where the metaphyseal bone impacts on itself, and actually becomes denser. These fractures are inherently stable and do not necessarily require a formal cast, unless severe pain or fracture instability necessitates a cast for 4 weeks. Instead immobilization with a simple wrist brace or removable splint is often preferable. The mild cortical angular deformity reliably remodels over time and requires no intervention or monitoring. If the fracture is non-tender to palpation at 4 weeks post-injury, no follow-up radiograph is required, and full activities may be resumed. Dr. JJ note: so if your child falls on the wrist, and the radius (the bigger of the two bones in the forearm) has crunched in on itself or twisted enough to fray on the outside of the bone, but hasn't separated, management is much easier with a splint, unless there is lots of pain or worries of that bone becoming unstable. Not every child with a fracture needs a cast, and that's a big relief for the kiddo, as well as the family.