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Pediatric Musculoskeletal Radiology

Pediatric Musculoskeletal Radiology

by | Sep 20, 2019 | General News

Key messages from Joseph (I-Yuan) Chang, M.D., and a panel discussion by pediatric orthopedic and sports medicine surgeon Henry B. Ellis, M.D., and Gerad Montgomery, B.S.N., FNP-C, at Coffee, Kids and Sports Medicine.

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How Advances in Radiographic Imaging Can Protect Patients

Though digital X-rays are the gold standard for many musculoskeletal evaluations, EOS is a relatively new technology designed to achieve results with less radiation. These devices are well-suited for pediatric orthopedics because many treatments, like lower extremity and spine straightening procedures, require periodic imaging to monitor growth and success over time.

Here are several features of how EOS is the best option for some evaluations:

  • Uses very low-dose radiation – uses 1/7 the amount of radiation, compared to traditional X-rays
  • Facilitates accurate assessment of standing alignment – evaluating alignment while a patient is weight-bearing posture provides a more accurate picture of the interaction between the joints of the spine, hips and legs.
  • Creates a single image immediately – with a traditional X-ray, separate films in supine or standing are “stitched” together. This process can be negatively affected by human error (this is done relatively quickly by using computer software at a work station, but may be done incorrectly due to inexperience or carelessness).

IMPORTANT NOTE: It does require a child to stand still for a short period of time, so can only be used when the patient is able to bear weight and can stand still for approximately 10 seconds.

Scottish Rite Hospital has been using the EOS Imaging System since 2016 and had a second system installed with the opening of the Frisco campus in 2018. As pediatric providers, we are committed to using the lowest dosage of radiation possible for studies. EOS has been a useful tool in caring for patients with spinal deformities, lower extremity limb differences and malalignment.

Ordering and Reading Pediatric or Adolescent Elbow X-rays

These tips can be helpful with other X-rays. Watch the full lecture to see how they are applied to ordering and reading an elbow X-ray.

Tips for Ordering X-rays:

  • Always order two perpendicular views – X-rays are 2-dimensional. To evaluate a 3-dimensional object, a bone or joint, two views are necessary. In most cases, the anteroposterior (AP) view and the lateral (LAT) view will suffice.
  • When reading a radiology report, remember that the radiologist does not have the advantage of the complementary physical exam. This is critical to pair with the reading of the imaging. When placing an order, include a note about the clinical exam in the order to provide context for the radiologist.

Tips for Reviewing X-rays:
Joseph Chang, M.D., pediatric musculoskeletal radiologist offered “five easy steps” to reading an X-ray.

  1. Is there a positive ‘fat pad sign’? A fat pad sign, also known as a sail sign, is a sign of a joint effusion. A joint effusion is an imaging finding that is highly predictive of radiographically occult injury in the joint. A pediatric elbow has so much more cartilage than an adult, making certain injuries invisible on radiographs.
  2. Is the alignment normal? In the elbow, assess the anterior humeral line (lateral view) and radiocapitellar line (AP and lateral view). Disruptions to these lines are signs of a fracture or dislocation and need to be treated.
  3. Are the ossification centers normal? Ossification centers have a strict order of appearance and disappearance – if one is missing or out of place, an injury may have occurred. The acronym “CRITOE” can be used to help recall the growth plates in the elbow but knowing to look for them is a good first step. Because growth disturbances can be prevented with proper management, refer to a pediatric orthopedic specialist when you are unsure.
  4. Is there a subtle fracture? Evaluate the metaphysis of the bone. The bony cortex should have a nice, smooth slope. Children have soft and more flexible bone, therefore the bone sometimes buckles instead of breaking. These injuries may appear as a blip on the X-rays.
    • CLINICAL TIP: Be careful not to miss a buckle fracture (also known as torus fracture or incomplete fracture) in your imaging review when a patient has these symptoms.
      • Wrist AND elbow pain
      • Loss of terminal extension and pronation/supination
      • Pain over the radial neck
  5. Did you consider the normal variants? Before you finalize your diagnosis, take a step back and see if what looks abnormal is a normal, developmental appearance in a growing child. Skeletally immature patients may have radiolucent growth centers composed of cartridge and sometimes bone. Secondary ossification centers (i.e. trochlea, lateral epicondyle) can have irregular margins or appear as separate ossicles, mimicking traction stress injury or fractures.

“I think that a practitioner correlating a good clinical exam with the first three steps above will help you identify 90% of elbow injuries and fractures in this population” says Henry B. Ellis, M.D., pediatric orthopedic surgeon.

Joseph (I-Yuan) Chang, M.D., is a radiologist with specialty experience in pediatric musculoskeletal radiology practicing at Scottish Rite for Children Orthopedic and Sports Medicine Center. He completed his training at the University of Cincinnati College of Medicine followed by a residency at Cleveland Clinic Foundation.

The radiology staff at Scottish Rite Hospital participates in interactive, preoperative and postoperative conferences with the pediatric orthopedic specialists. Imaging services include X-ray, EOS, musculoskeletal ultrasound, CT and state-of-the-art MRI capabilities on both campuses. They offer on-demand consultations for our team to support high quality and efficient care.

An Injury Not to Ignore: Hand & Finger Fractures in Young Athletes

An Injury Not to Ignore: Hand & Finger Fractures in Young Athletes

by | Jan 29, 2019 | Fractures

Believe it or not, hand and finger injuries in kids, especially young athletes are very common. In fact, almost 20 percent of the injuries we see in the Fracture Clinic are hand related injuries. For children, these injuries can occur in a number of ways. For athletes, some of the more common mechanisms we see are from a finger getting struck by a ball, a hand getting stepped on or a finger getting caught in a jersey. While most injuries to the hand or fingers will get better with some time, rest and immobilization, others may require more extensive care or even a surgery to correct alignment or restore function. As the parent of a young athlete, it is important to know when to seek medical treatment.

Recognizing a hand injury in a child is not always easy and may require the attention from an expert who specializes in caring for patients whose bones are still developing. Sometimes, X-rays can appear normal and exam findings can be subtle making it easy to miss or ignore injuries to the hand. If rest is not healing the injury, it is important to know the signs and symptoms where being evaluated by a pediatric specialist is necessary.

Some general “redflags” with finger injuries include:

  • Hearing or feeling a “pop” or “crack” at the time of the injury.
  • Seeing significant swelling immediately after the injury occurs.
  • Noticing differences compared to the same finger on the other hand. Seeing bleeding or drainage at or around the nailbed.
  • Inability to move, straighten or bend the finger or a joint more than two days after the injury.

Gerad Montgomery, M.S.N., FNP-C, tells us that most pediatric hand and finger injuries can be managed with immobilization in a cast or splint. However, when there is significant displacement of fracture, injuries to ligaments and tendons or damage to the nailbed, surgery may be needed.

Advice for parents of young athletes

  • Teach proper techniques with catching, hitting or throwing a ball.
  • Discourage grabbing a shirt or jersey in fast-moving games like football or tag.
  • Encourage athletes to be aware of surroundings during team sports.

  • Insist that athletes wear proper protective sports equipment when appropriate.
  • Never ignore an injury to the hand or fingers. Though it may be tempting to “push through the pain” and keep playing, these injuries can have serious consequences if they are overlooked. Don’t wait to have it evaluated by a medical professional.

Learn more about fracture care at Scottish Rite for Children in Frisco.

What You Need to Know About Getting a Cast Removed

What You Need to Know About Getting a Cast Removed

by | Dec 5, 2018 | Fractures

The experts in our Fracture Clinic specialize in caring for broken bones. Depending on the child and the nature of the injury, a cast may be needed to treat the break. Learn more about our Fracture Clinic, located at our Frisco campus, and what it is like to have a cast removed. Watch the video. When you arrive:
  • Check in at the Fracture Clinic desk and complete a health history questionnaire.
  • A Child Life specialist can be available to talk with you, to make sure the experience is smooth and enjoyable, plus they can prepare you for what to expect.
  • The cast technician will let you look at the tools beforehand and will explain what is going to happen.
During the removal:
  • You can wear head phones, if you are sensitive to loud sounds.
  • Some people even think it tickles.
After the cast comes off:
  • Try not to scratch the skin.
  • Blot warm water on the area if the skin itches.
  • You can use lotion on the skin, but not right away. Speak with your provider before using lotion.
  • A follow up X-ray may be needed.
  • Your provider will then examine you, to confirm the bones are properly healing.
Learn more about our Fracture Clinic and walk-in hours or call 469-515-7200 to schedule an appointment.
Our Fracture Clinic Is Here to Help

Our Fracture Clinic Is Here to Help

by | Sep 30, 2016 | Fractures

A young gymnast’s experience with our Fracture Clinic

When Riley broke her arm during a front handspring at the gym, she and her mom were both afraid that she would need surgery. Thankfully, a friend at her gym told them exactly where to go for expert fracture care. On their first visit to Scottish Rite Hospital, they met with Gerad Montgomery, a certified pediatric nurse practitioner who specializes in nonoperative fracture care. He explained to them that surgery was not the only option for Riley’s injury. After discussing the pros and cons of each treatment option and getting answers to all of their questions, Riley and her mother decided to continue care without surgery. Fractures like Riley’s can be challenging to manage and often require a series of several specialized casts to keep the bones aligned correctly and allow them to heal.

Riley tells us she has gotten lots of questions about her cast, which was specially molded to help align her bone. “I tell people my bones are sticking out,” Riley said with a smile as she talked about the bulges from spacers in the cast. Then, she laughed saying she assures them that her bones are fine.

“When I called to ask about some feelings Riley was describing, Gerad asked to speak directly with her about what she was feeling,” her mom explained. She and Riley thought this was a great example of the outstanding service they received from the moment they met the Fracture Clinic team.

Riley is now back in the gym and able to participate in some activities. She is still wearing a cast, since the healing process takes time. “She’s happy this doesn’t keep her out of her training,” her mom and former coach tells us. “In pediatrics and sports medicine, we look for ways to keep kids engaged in their activities; we know this is good for them physically and psychologically,” Gerad says.

Bumps and bruises are sometimes a normal part of kids being kids. However, if your child breaks a bone, you can call our Fracture Clinic directly at 469-515-7200.

To learn more about our Fracture Clinic on our North Campus, visit our Fractures page.

Little Fingers, Big Problems: Tips From Our Fracture Clinic

Little Fingers, Big Problems: Tips From Our Fracture Clinic

by | Jul 18, 2016 | Fractures

Did you know that some of the more common injuries we see in young children occur inside the home from normal everyday objects like doors, cabinets and drawers? Young children don’t recognize the dangers associated with these and love to play with them. Since children have naturally slow reactions, fingers or toes often get caught when they slam closed.

We call these crush injuries, and they can range from minor to severe. Gerad Montgomery, Lead Clinical Provider for our Fracture Clinic, says, “Many people don’t realize that crush injuries of the fingers and toes can result in cuts in the skin, nail bed injuries, broken bones and, in severe cases, partial amputation.”

Prompt evaluation by a pediatric specialist is important if any of the following signs are present:

  • Swelling or deformity
  • Skin that is split open around the nail
  • Bleeding from around or under the nail
  • Persistent pain or inability to move
  • Concern for a serious injury or the feeling that your young child just needs to be seen

Accidents happen and we can’t protect our young and curious children from everything, but we have some suggestions to help avoid injuries:

  • Teach young children early that doors and cabinets are not toys.
  • Child-proof cabinet doors and drawers with latches.
  • Be aware of doors and drawers in your child’s environment.

Bumps and bruises are a normal part of kids being kids! However, if your child has a crush injury or breaks a bone, you may call our Fracture Clinic directly at 469-515-7200. Learn more about our Fracture Clinic.