Experts Share Research at National Conference

Experts Share Research at National Conference

by | Oct 15, 2021 | Research & Innovation

As an institution dedicated to providing the best care to kids, experts from Scottish Rite for Children are involved with various medical organizations that support education and research. Recently, the American Academy of Pediatrics (AAP) held its virtual national conference and exhibition. AAP is an organization with more than 67,000 pediatricians who are committed to the health and wellness of all infants, children, adolescents and young adults. Our team at Scottish Rite has an active role with AAP as they share their expertise on caring for children with orthopedic conditions and regularly serve as a resource to pediatricians and their patients.

The 2021 virtual meeting provided attendees with a well-rounded educational program that included live presentations, a virtual hall of selected poster projects and a library of on-demand sessions. Topics covered all areas of caring for children, and during a session on pediatric orthopedics, several Scottish Rite experts were selected to present their latest research. Below are a few of the presented projects:
Hip

  • Isolated Hip Click and Developmental Dysplasia of the Hip

Sports Medicine

  • An Activity Scale for All Youth Athletes? An Analysis of the HSS Pedi-fABS in 2,274 Pediatric Sports Medicine Patients
  • Are There Differences in Reported Symptoms and Outcomes Between Pediatric Patients With and Without Obsessive Compulsive Disorder After a Concussion?
  • Are there Differences in Concussion-Related Characteristics and Return-to-Play in Soccer Positions?
  • Predictors of Reoperation in Adolescents Undergoing Hip Preservation Surgery for Femoroacetabular Impingement
  • Isolated Hip Click and Developmental Dysplasia of the Hip
  • History of Anxiety Associated with Head CT Following Sport-Related Concussion
  • Single-Sport Athletes Not Experiencing Increase in Secondary Tear Incidence Despite Earlier Clearance

Learn more about our research. 

Infants and Developmental Dysplasia of the Hip

Infants and Developmental Dysplasia of the Hip

by | Oct 7, 2021 | Research & Innovation

This article was originally published in the Pediatric Society of Greater Dallas newsletter. Committed to improving orthopedics care of pediatric patients in all settings, Scottish Rite for Children specialists are regular contributors to this publication for local pediatricians in North Texas.

Developmental dysplasia of the hip (DDH) is the most common orthopedic condition affecting newborns. The overall incidence has been estimated at approximately 1%. Dysplasia is a term that means poorly formed. It describes this condition well because one or both sides of the hip joint do not grow correctly as the child develops. In severe forms of DDH, the hip joint can be completely dislocated, meaning that there is no contact between the ball of the hip joint (femur) and the socket (acetabulum). 

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Screening for DDH
The American Academy of Pediatrics (AAP) published a clinical report on current standards for evaluating and treating DDH. With later recognition of the condition, the treatment becomes more complex and may even require surgery. In order to minimize missed cases of hip dysplasia, the AAP recommends that pediatricians periodically screen for DDH during routine office visits, from infancy until the child is walking. With effective screening, most cases are identified and managed during infancy, leading to complete correction of hip dysplasia and the development of normal hips.

Ann,-Hip.jpg

As a pediatric orthopedic surgeon, Corey S. Gill, M.D., M.A., cares for many children with DDH and has received several questions from referring providers about appropriate care. The most important things for pediatricians and other referring providers to understand about DDH include:

  • Perform a hip examination on every newborn and infant patient. Soft tissue clicks around the hip and knee are very common and do not generally indicate hip dysplasia. Similarly, asymmetric skin creases on the inner thigh do not usually mean there is a problem with the hip. Findings that are clearly abnormal and should lead to orthopedic referral include:
    • An unstable hip that “clunks” into or out of place. Hip stability is evaluated during the exam by performing the Barlow and Ortolani maneuvers. The Barlow test identifies a hip that is in place but can be easily dislocated with gentle pressure. The Ortolani test identifies a hip that is dislocated at rest, but can be placed back into the joint with positioning of the thigh.
    • Significantly decreased or asymmetric range of motion. This is especially important for abduction of the hips, which is moving the hips out to the side when lying down. Differences as small as 10 degrees compared to the normal side may indicate a significant problem.
    • A significant leg length difference, which may indicate a hip dislocation. Leg length difference is best evaluated with a Galeazzi test. This test is performed by flexing the hips to 90 degrees and checking to see if the knees are level.
    • In toddlers and older children, decreased hip abduction and a waddling gait, limp or unilateral toe walking may indicate hip dysplasia or dislocation.
  • Identify the risk factors that make hip dysplasia more likely. The two most important are family history of hip dysplasia and breech presentation (especially frank breech). Providers should have a low threshold for orthopedic referral in these patients. Other risk factors include female sex, first born child and oligohydramnios.
  • Understand the right time to refer a patient for DDH evaluation. In newborns with unstable hips on exam, a referral should be made immediately so treatment can start as soon as possible. In children with a normal exam but risk factors for DDH, an ultrasound should be obtained at approximately six weeks of age. Obtaining an ultrasound in children earlier than this often leads to a false positive diagnosis of DDH secondary to physiologic immaturity of the hip joint in the newborn.

Orthopedic Intervention

When infants do need orthopedic intervention for hip dysplasia, our first line of treatment is a Pavlik harness. This fabric and Velcro harness is generally worn for 23 hours per day for approximately six to eight weeks, but it is removable for bathing. The harness keeps the hips flexed and rotated in the correct position for normal development of the hip joint. After treatment with a Pavlik harness, we use physical exams, ultrasound and X-rays to monitor growth and confirm the hip joint is developing normally. Most infants with DDH require no further orthopedic treatment after wearing a Pavlik harness.

In some infants, especially those with severe hip dysplasia or a dislocation, Pavlik harness treatment may not be successful. Occasionally, a different type of hard plastic brace may be successful in correcting the hip dysplasia in these children. However, most children who do not respond to Pavlik harness treatment will ultimately require surgical intervention to prevent long term problems from hip dysplasia such as cartilage injury, limp, leg length difference and early arthritis. Depending on the severity of the hip dysplasia, surgical treatments may include:

  • Closed reduction – This involves repositioning the ball of the hip joint deeply into the socket when the child is asleep under anesthesia and then applying a body cast called a spica cast for a total of three to four months. During this procedure, we often inject a small amount of medical dye into the hip joint to confirm that the ball of the hip joint is appropriately positioned in the socket. This is called an arthrogram.
  • Open reduction – Sometimes the hip joint will not line up well with repositioning of the leg because there are tight tissues blocking the ball from sitting deeply in the socket. In these cases, an incision is made in front of the hip where the tight tendons, ligaments and soft tissues are moved out of the way. Afterwards, the lining of the hip joint is tightened with a strong suture to help hold the hip in position. This procedure is called a capsulorrhaphy.
  • Osteotomies – In older children (over age 1.5 – 2 years), soft tissue procedures alone are often not enough to ensure the hip joint is lined up well. In these cases, we often supplement the open reduction procedure by cutting the bone in a controlled way to help reorient the hip into the socket. This is called an osteotomy and can be performed on the ball side of the hip (femur osteotomy) or socket side of the hip (pelvic osteotomy). Metal implants are often used to hold the bone in the new position and are removed at a later date.

Conclusion

Hip dysplasia is a common orthopedic condition in newborns that can lead to significant long-term consequences if left untreated. Certain risk factors such as family history of dysplasia and frank breech presentation greatly increase the risk of developing DDH. Pediatricians play a crucial role in examining infants, identifying those with risk factors and referring them to a pediatric orthopedic specialist when appropriate. When diagnosed in the first few months of life, noninvasive treatment with a harness or brace is highly successful and generally leads to the development of a normal hip. In some cases of severe hip dysplasia/dislocation or in cases of delayed diagnosis, surgical intervention is required to improve the long term prognosis of the hip joint.

Referral Tips 

A potential diagnosis of hip dysplasia can lead to significant anxiety for new parents. Understanding the best time to refer patients and initiate treatment helps to maximize treatment success and efficiency while minimizing parental stress and worry.

  • For infants with risk factors for DDH such as family history or breech presentation but a normal physical exam, an ultrasound should be obtained around six weeks of age. Ultrasounds performed earlier than this age result in a large number of false positives and potential unnecessary treatment in a harness.
  • There is no need to obtain an ultrasound prior to referral as we work closely with experienced ultrasound technologists who can perform the diagnostic hip ultrasound on the same day as an infant’s office visit.
  • In children with a clearly abnormal exam (unstable/dislocatable hip or asymmetric hip abduction) in the nursery or in routine office visits, immediate referral should be made so that treatment in a harness can be initiated as soon as possible. In these children, there is no need to wait until the child is 6 weeks of age for referral.
  • If only abnormal exam finding is a “hip click” or asymmetric thigh crease, referral and ultrasound should be deferred until 6 weeks of age given the relatively low prevalence of DDH in these children.
  • In premature infants still in the NICU with risk factors for DDH, it is generally OK to wait for referral until after the child is discharged to go home. If an examiner finds the hip to be unstable while still an inpatient, phone consultation with a pediatric orthopedic surgeon is available to answer questions or discuss the most appropriate time to see the patient.
  • If a family has an infant diagnosed with DDH, all future siblings of the child should be referred for screening, ultrasound at six weeks of age and strong consideration should be given for referral of older siblings for a hip radiograph. First degree relatives have more than a tenfold higher risk of DDH compared to controls.
Sports Medicine Team Presents Latest Studies at National Meeting for Clinical Research Professionals

Sports Medicine Team Presents Latest Studies at National Meeting for Clinical Research Professionals

by | Sep 27, 2021 | Research & Innovation

The Society of Clinical Research Associates (SOCRA) is an organization committed to the education and certification of people involved in clinical research. Scottish Rite for Children has many research coordinators who participate in SOCRA and its activities. “We are fortunate to have individuals who are committed to ethical and meaningful research,” says Henry B. Ellis, M.D., pediatric orthopedic surgeon and associate director of clinical research. “Their membership and active participation in professional organizations like SOCRA bring value to our teams and work products.” While collaborating with others in study development and enrollment, data collection and manuscript preparation, research coordinators at Scottish Rite are encouraged to perform original research, publish and seek opportunities to share with appropriate audiences. This month, two research coordinators from our Sports Medicine team shared their work at the SOCRA annual meeting. Clinical research personnel from across the country participated in virtual continuing education opportunities, including digital poster presentations. “Posters are a traditional way of sharing an overview of a project and stimulating conversations among peers,” explains research coordinator Hannah M. Worrall, M.P.H., CCRP. “Even before the pandemic, we saw a shift to sharing them digitally, in place of or in addition to a traditional poster exhibit in a large hall.” All three posters were selected as finalists for the top clinical trial posters. Soccer-Related Concussions and Position Played The prospective study, “Differences in Concussion-Related Characteristics and Return-to-Play in Soccer Positions,” addresses a question about the influence of position-played on injury-related details and outcomes after a sport-related concussion. The data was prospectively collected from participants enrolled in the North Texas Concussion Registry (ConTex) from August 2015 to April 2021. This data has strong representation from patients seen in the Scottish Rite sports medicine clinic, so it is helpful to our team to continually improve care for this population. “In this study of almost 300 soccer players, goalkeepers showed higher rates of depression, disproportionately suffered more concussions and experienced a different mechanism of injury as well as had the lowest rate of returning-to-play three months after their injury,” says Worrall. This information may aid providers in educating players, their families and their coaches about the risks of concussion with different soccer positions and may play a future role in injury prevention. Investigators of this study include Hannah M. Worrall, M.P.H., CCRP, Claire E. Althoff, BA, Shane M. Miller, M.D., Jane S. Chung, M.D., Mathew A. Stokes, M.D., Stephanie Tow, M.D., C. Munro Cullum, Ph.D., and Jacob C. Jones, M.D.
Early Specialization The prospective study, “Sport Participation and Specialization Characteristics in a Pediatric Sports Medicine Clinic,” evaluated sport-related variables of more than 10,000 patients seen in our sports medicine clinic (2016-2021) with a specific set of questions in mind. The concepts of overuse and overtraining in youth sports have gained a lot of attention over the past decade because they lead to an increased risk of injuries.

SURVEY OF 10,000 PATIENTS MORE hours/week than age in years 15%. A pie chart that says survey of 10,000 patients more hours / week than age in years

A guideline has been proposed to reduce the risk of injury by limiting the number of training hours per week to the athlete’s age in years. For example, a 7 year old should not train more than seven hours/week in organized sports. The study found that 15% of athletes seen in the clinic did participate in more hours per week than their age. These athletes were more likely to report they are single-sport athletes, which is also known to increase their risk of injury. 

“The results support a growing body of evidence describing the risk of early specialization and overuse in youth sports,” says research coordinator Savannah Cooper, M.S., CCRP. “The effort should help guide continued education efforts for coaches, parents, administrators for youth sports and medical professionals.”

Investigators of this study include Hannah M. Worrall, M.P.H., CCRP, Savannah Cooper, M.S., CCRP, Jacob C. Jones, M.D., Shane M. Miller, M.D., and Jane S. Chung, M.D.

Standardized Postoperative Pain Management Opioid prescriptions following surgery in the adolescent population contribute to the use and abuse of addictive drugs in this age group. The purpose of this prospective study is to evaluate pain and opioid use following standardized surgeries in our patient population. The Scottish Rite for Children pediatric orthopedic surgery teams who care for joint-related injuries collaborated with pediatric anesthesiologists to implement a standardized pain management protocol for common surgical procedures with the goal of decreasing the number of opioid pills prescribed.

Plan Do Act Check. A diagram showing the steps of plan do act and check

“By using questionnaires to monitor pain level and pill usage, we are evaluating the effectiveness of the multidisciplinary and multi-modal protocol and looking at factors such as procedure type to determine areas for future study,” says Cooper. The team expects to continually adjust the study and the model based on the findings. Investigators of this study include Savannah Cooper, M.S., CCRP, Hannah M. Worrall, M.P.H., CCRP, Benjamin L. Johnson, MPAS, P.A-C., Charles Wyatt, M.S., CPNP, Philip L. Wilson, M.D., and Henry B. Ellis, M.D. “Evidence-based sports injury prevention efforts must be grounded in studies like these,” says Ellis. “Our sports medicine team is passionate about contributing to the growing data that help to focus efforts and future controlled trials.” Keeping young athletes safe requires a collaborative effort. This is why all of our Centers for Excellence include clinical research professionals like Worrall and Cooper. Learn more about our sports medicine research.
Common Causes of Adolescent Knee Pain

Common Causes of Adolescent Knee Pain

by | Aug 12, 2021 | Research & Innovation

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon Philip L. Wilson, M.D.
 
You can watch the full lecture and download this summary.
 
Diagnosing common causes of adolescent knee pain can be confusing, but it can be simplified by looking at history and physical findings during the exam systematically. To narrow the list of common causes, symptoms are broken down in three ways:

  1. Acute vs. Chronic presentation
  2. Effusion vs. No Effusion
  3. Primarily a Pain Problem vs. Primarily a Motion Abnormality

Below is a list of common knee conditions:

  • Sprain
  • Contusion
  • Stress Fracture
  • Apophysitis
  • Patellofemoral Dislocation
  • ACL Tear
  • Tibial Spine Fracture
  • Meniscal Pathology
  • Osteochondritis Dissecans

Conditions with an Acute Presentation
If the presentation is acute instead of chronic, the number of potential diagnoses becomes much smaller:

  1. Acute vs. Chronic presentation: Acute
    • Sprain
    • Contusion
    • ACL Tear
    • Tibial Spine Fracture
    • Meniscal Pathology

By determining if there is an effusion, or a collection of fluid within the joint, the list of common diagnoses narrows even further:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: No Effusion
    • Sprain
    • Contusion

Then, the likely diagnosis can be determined by looking at where the patient’s pain is located:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: No Effusion
  3. Primarily a Pain Problem vs. Primarily a Motion Abnormality: Primarily a Pain Problem

If the patient has soft tissue swelling and pain around the joint with nothing focal, no bony tenderness and no effusion, it is most likely a sprain.

  • Treatment
    • Protect, Rest, Ice, Compression, Elevation (PRICE)
      • Sometimes an Ace wrap, a splint or a brace is used to immobilize and protect the joint
    • Early protected range of motion
      • Get the patients up and moving early
    • Restore strength

Patients do not need to be referred to Scottish Rite unless their pain lasts for more than three or four weeks.
 
If the patient has an acute problem with an effusion, different common causes of adolescent knee pain from the list are likely:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: Effusion
    • Patellofemoral Dislocation
    • ACL Tear
    • Tibial Spine Fracture
    • Meniscal Pathology

To determine the cause, consider the motion associated with the injury to further narrow down the list of diagnoses:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: Effusion
  3. Pain vs. Motion Abnormality: Motion Abnormality
  • Patellofemoral Dislocation
    • Twist and valgus
    • “Knee dislocated”
  • ACL Tear
    • Twist and valgus
    • “Gave out” / “shifted”
  • Tibial Spine Fracture
    • Hyperflexion
  • Meniscal Pathology
    • Twisting event

Knee Injury and Effusion
How to tell if the patient has an effusion, not soft tissue swelling:

  • X-ray – side view image of the knee
    • Look at the kneecap as it is related to the thigh bone.
    • Look at the muscle coming off the kneecap
    • Look at the space between the kneecap and the femur
      • If there is a curvilinear density that is not the linear muscle, not the deep muscle or the fat pad, it is most likely an effusion.
  • Physical examination
    • Compare the patient’s knees
      • A knee with an effusion will look bulbous and will not have all the concavities around the patella of a normal knee
    • Push on the tissues around the knee
      • If the fluid can be moved from lateral to medial or if you can see a fluid wave, it is most likely an effusion
        • Soft tissue swelling cannot be moved around
X-ray of a knee

Knee Effusion – Patellar Dislocation
When a patient has a patellar dislocation, they relate an instability event where they knee “popped out of place.” There is also an effusion.

  • Diagnosis
    • Apprehension sign
      • While pushing down on the medial kneecap, the patient becomes apprehensive and will sometimes try to stop the exam because they think that their kneecap will become dislocated.
    • “J” sign
      • As the knee is flexed, the kneecap visibly jumps from out of the groove to back into place.
  • Treatment
    • PRICE
    • Physical therapy (PT)
    • Surgery

Refer patients to Scottish Rite for continued effusion or recurrent instability.

Knee Effusion – ACL Tear
When a patient describes twisting their knee and it giving out on them or shifting and they have an effusion, they most likely have an ACL tear. Their knee is unstable. There are four ligaments in the knee: the medial knee ligament and the lateral collateral ligament on each side, with the anterior cruciate ligament (ACL) on the front and the posterior cruciate ligament on the back. When the ACL is torn, the knee has more motion, so patients say that their knee slipped or gave out. The best way to check for a torn ACL is the Lachman test.

  1. The patient lies on their back with their legs out straight and their muscles relaxed, especially their hips and hamstring muscles.
  2. Bend the patient’s knee slowly and gently to about a 20-degree angle. Physicians may also rotate the patient’s leg so their knee points outward.
  3. Stabilize the patient’s thigh with one hand and gently move the tibia forward with the other hand.
    • If there is a great deal of of motion and instability, it is likely because the ACL is torn

Treatment

  • Surgery may be necessary to repair instability or an associated meniscal injury.

Refer any patients with a suspected ACL tear to Scottish Rite.

Knee Effusion – Tibial Spine Fracture
With a tibial spine fracture, the patent usually has a large effusion called a hemarthrosis, or blood in the joint, because of the fracture. These are usually caused by a flexion event like a fall from a bike or skiing or a twist in sport. This fracture will leave a fragment within the “notch” between the thigh bone and the shin bone. This is because instead of the ACL tearing in the middle of the rope, it pulls that piece of bone.
Treatment

  • Surgery
    • Put the piece of bone back in place
  • Casting
    • Moving the leg and putting it in a cast may work if it can be placed in a good position

Refer patients to Scottish Rite for immobilization or surgery.
Knee Effusion – Meniscal Tear

It the patient’s reports a twist or pop event and their effusion appears small while experiencing pain on the side of their joint, it is most likely a meniscal tear. Other things to look for to make the diagnosis are focal joint line pain, a loss of extension, a negative Lachman exam, no patellar apprehension, and nothing positive on their X-rays. An MRI may be needed to confirm the diagnosis. The effusion usually means that there is an internal derangement that needs to be treated with surgery.

Conditions with a Chronic Presentation
If the athlete’s injury is a chronic injury, a different set of diagnoses becomes likely:

  1. Acute vs. Chronic presentation: Chronic
  • Stress Fracture
    • Has been sore for a while
  • Apophysitis
    • Pain at the growth plate
  • Patellofemoral Dislocation
    • Pain around the kneecap
    • Not a specific injury
  • Osteochondritis Dissecans
    • An idiopathic osteonecrosis below the cartilage surface during development

These conditions generally do not have an effusion, and are all activity-related knee diagnoses.

  1. Acute vs. Chronic presentation: Chronic
  2. Effusion vs. No Effusion: No Effusion
  3. Pain vs. Motion Abnormality: Pain

To determine which condition it is, find out where the pain is located.

  • Stress Fracture
    • Focal distal femur or proximal tibia
    • Tender over a small area around a bone
  • Apophysitis
    • Focal distal patella or tibial tubercle
    • Focally tender
  • Patellofemoral Dislocation
    • Poorly localized / Not focally tender
    • “Horseshoe” sign
  • Osteochondritis Dissecans
    • Cannot localize
    • Deep within

Slipped Capital Femoral Epiphysis (SCFE)

ALWAYS CHECK THE HIP IN ADOLESCENTS WITH KNEE COMPLAINTS

When adolescents have activity related knee pain, often with no inciting event, and display symptoms including a limp, walking with their foot externally rotated and a limited range of motion (especially with internal rotation), it may be SCFE. SCFE is checked with a hip rotational exam. If the patient has equal symmetric range of motion, physicians can rule out SCFE and move on to other diagnoses.

Overuse Conditions – Stress Fracture
Stress fractures are an activity-related pain that often happens after periods of inactivity, like summer. They are associated with high activities like running. Patients are focally tender on their bone, but their knee joints are fine. An X-ray usually shows a stress fracture on their distal femur. The treatment for a stress fracture is forced rest until the patient is pain-free and a gradual return to sports.

Overuse Conditions – Apophysitis
Apophysitis is an activity-related condition with pain focal to only one place. The growth plate is going through a transition with a great deal of stress applied in that area with activities. The two main apophysitis to consider are Osgood-Schlatter Disease in which the patient’s pain is on the tibial tubercle, and Sinding-Larsen Johansson (SLJ) Syndrome in which the pain is on the inferior pole of the patella. The treatments for apophysitis are rest, anti-inflamitories, and quad stretching.

Patellofemoral Pain Syndrome
Unlike Osgood-Schlatter Disease and Sinding-Larsen Johansson (SLJ) Syndrome, the patient cannot pinpoint their pain with Patellofemoral pain syndrome. Patients motion all around the knee in what is called the “Horseshoe” sign. They do not have instability in their knee, but they do have pain around their kneecap. The cause of Patellofemoral pain syndrome is unknown, but it is believed to be related to an abnormal balance of the homeostasis of the muscle strength around the front of the knee. During the exam, physicians determine the “Q” angle, or the quadriceps angle. This is the angle between the quadriceps tendon and the patellar tendon. This angle provides useful information regarding the alignment of the knee joint. “Q” angles greater than 14° are vulnerable to patellar conditions. Physicians also look for poorly developed vastus medialis oblique muscle (VMO), a “J” sign, and pain with patellofemoral compression.

Treatment

  • Physical therapy
    • Quadriceps strengthening
    • Knee balance
    • Knee proprioceptive strengthening
  • 70% improved with physical therapy, regardless of associated interventions.

Osteochondritis Dissecans (OCD)
OCD is an idiopathic osteonecrosis below the cartilage surface during development. This can lead to cartilage surface cracks, instability and lesion on the joint. OCD can happen with or without trauma. In an X-ray, a radiolucent lesion is visible.

  • 2:1 Male to female
  • 33% Bilateral

The younger the patient is and the smaller they are, the more likely they are to heal. The location of lesion and the status of articular surface also play a factor in the patient’s healing potential.

Treatment

  • Forced rest
  • Unloader brace
  • Surgery if the patient is older or if the MRI reveals instability.

Meniscal Pathology
A meniscal pathology has a chronic presentation with no effusion, but a motion abnormality instead of pain.

  1. Acute vs. Chronic presentation: Chronic
  2. Effusion vs. No Effusion: No Effusion
  3. Pain vs. Motion Abnormality: Motion Abnormality

The patient says that their knee pops or snaps. They may also have a loss of extension and a limp. These are signs of a discoid meniscus.

Discoid Meniscus

  • Discoid meniscus is a congenital malformation of the meniscus
    • Affects approximately 1:100 children
  • Mechanical symptoms in childhood with no trauma history
    • Snapping in the knee usually occurs between the ages of 2 to 6.
  • Palpable / audible “snap” at lateral joint line during exam
  • Visible bulge at lateral joint line

As children get older, the discoid meniscus presents like a regular meniscal tear. The treatment for this condition is arthroscopic surgery if the patient is symptomatic.

Refer patients to Scottish Rite for mechanical symptoms or loss of motion.

Therapeutic Camps Improve the Self-Esteem and Confidence of Kids with Hand Differences

Therapeutic Camps Improve the Self-Esteem and Confidence of Kids with Hand Differences

by | Jul 9, 2021 | Research & Innovation

Scottish Rite for Children is world-renowned for its patient-centered care for children with orthopedic conditions. Our Center for Excellence in Hand is committed to caring for children with hand and upper limb conditions. The center is focused on providing innovative treatment to help patients live active and independent lives. Occupational Therapist and Certified Hand Therapist Amy Lake, has recently published The impact of therapeutic camp on children with congenital hand differences in the Cogent Psychology.

The goal of this study was to evaluate the efficacy of hand camp by investigating camp participation and outcomes on self-esteem, physical function, activity participation, and peer relationships. Forty patients with a congenital hand difference seen in hand clinic between the ages of 10 and 13 were eligible to attend hand camp. Following hand camp, Peer relationships, upper extremity function, and self-esteem improved immediately. Upper extremity function and self-esteem scores continued to improve significantly throughout the 6-month follow-up period. The authors of the study believe that research related to therapeutic camping experiences is integral when identifying best-practice interventions to increase the quality-of-life outcomes for children with congenital hand differences.

To date, no research has been conducted on the effects of camp participation in the pediatric congenital hand difference (anomaly) population. Another goal of this study was to evaluate the efficacy of a therapeutic hand camp for children with a congenital hand difference. Attendees of the 2015 Tween Camp (ages 10–13 years) completed self-report assessments of self-esteem, function, participation in activities, and relationships with peers. Attendees also completed an assessment to determine if they believed camp objectives were met. This specific camp was chosen for the initial study due to the camp attendees’ ability to complete assessments independently.

Some of the key takeaways from this study are:

  • Participants reported that their upper extremity function had significantly improved from pre-camp to immediate follow-up
  • Participants expressed a significant improvement in their self-esteem from pre-camp to immediate follow-up
  • Following camp, participants indicated improved skills in peer interaction, daily physical activities, willingness to try new things and confidence in explaining their hand difference.

This suggests that following camp, a child is: more apt to participate in extracurricular activities; have higher self-esteem with regard to their hand difference; be more independent in activities of daily living; and manage negative reactions from others regarding the appearance of their hand. This supports the hypothesis of the study, that camp can indeed make a positive impact on children with congenital hand differences.

Because of the success of our hand camps, Scottish Rite for Children has helped start-up hand camps around the globe based on our Hand Camp Model including camps in Florida, Missouri, California, Italy, and England. Coming soon to Australia.

Learn more about hand research.

Sports Medicine and Psychology Experts Work Together – Caring for the Whole Child

Sports Medicine and Psychology Experts Work Together – Caring for the Whole Child

by | Oct 6, 2020 | Research & Innovation

Our Sports Medicine team noticed that a commonly used outpatient depression screening questionnaire was identifying more patients than were actually at risk for concerns for suicide. This created an excessive number of alerts to the clinical team to assess patients that were not at risk, which is called a high false positive rate. The team implemented changes to reduce that rate without missing those patients that were truly at risk and needed further evaluation.

Jane S. Chung, M.D., sports medicine physician, says, “Suicide is now the second leading cause of death among young people 10-24 years of age, and is a serious public health problem in our youth. Often, in the sports medicine setting, these kids who are hurting and struggling internally are the ones coming in to see you for sports-related injuries and other musculoskeletal ailments,” says Chung. “Our team felt it was important to look into this trend in our own outpatient clinics to come up with a strategy to best identify those patients at risk so we can provide early intervention, as early identification and intervention is key in helping these youth at risk.” Success with the effort would allow resources to be properly allocated to the right patients.

Partnering with the Psychology and Research teams, the group developed a new strategy to decrease the high false positive rate in screening questionnaires utilizing a staged process in the electronic medical record. Additionally, patients were given the opportunity to review their responses before submitting, as often young patients can misread or answer a question too quickly on the iPad questionnaires. The clinical staff was then notified of those patients who provided responses that were concerning for suicide risk.

Recently, in March 2020, the team implemented a more pointed suicide screening questionnaire with hopes that future analysis will show continued improvement in identifying those youth at risk. The staged approach effectively identified patients in need of intervention and the false positive rate drastically improved. Researcher, Connor Carpenter says, “Quality improvement projects like this one have a real impact on our patients and our system. When patients get treatment they need and not the treatment they do not, everyone wins.”

This study, “Effective Administration of Mental Health Screening Tools Affects Appropriate Allocation of Resources and Improves Clinician Ability to Identify Those at Risk for Suicide,” was shared as a medical poster at the 2020 virtual annual meeting of the American Academy of Pediatrics.

Learn more about mental health in young athletes in a previous article.