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Summer Safety with William Morris, M.D.

Summer Safety with William Morris, M.D.

by | Jun 12, 2024 | General News

William Z. Morris, M.D., knows pediatric trauma and knows what it’s like to be a parent. As a pediatric orthopedic surgeon, his experience in the operating room has led him to raise awareness about some of the risks associated with lawn mowers and ATVs.
 
“I wouldn’t let my young kids use or be around a lawn mower,” says Morris. “It’s estimated that there are over 9,000 pediatric lawn mower injuries a year. One large study showed that about half of these injuries occur in kids 5 yrs of age or under. Lawn mowers can cause pretty terrible injuries that can result in amputations, most frequently in the lower extremities. In fact, around a quarter of all traumatic amputations in children are attributed to lawnmowers.

The second thing I wouldn’t let my young kids do is ride an ATV or all terrain vehicle. Injuries from ATV accidents are serious with one study showing almost 90% of kids have to get admitted to the hospital, half have some broken bone, and a quarter end up in the intensive care unit. Our general surgeon colleagues at Children’s Medical Center also recently showed that ATV injuries at our trauma center went up 77% during the COVID era, so we have unfortunately been seeing more of these injuries over the past few years.”

At any age, safety is key when using ATVs and lawn mowers. Please be careful as we head into warmer weather and outdoor activities.

The Growing Athlete’s Hip: How to Prevent Problems Today and Tomorrow

The Growing Athlete’s Hip: How to Prevent Problems Today and Tomorrow

by | May 29, 2023 | Sports Medicine

Download a PDF of this summary.

In this program, our pediatric orthopedic and sports medicine experts described how the skeletal development of the hip is affected by repetitive and extreme movements inherent to athletic activity. The changes, in some cases, can be permanent. Keep reading to learn what we know about preventing irreversible changes and treating symptoms of these sport-related hip conditions.

Apophysitis and Apophyseal Fractures in the Hip and Pelvis

Apophysis is a normal bony outgrowth that arises from secondary ossification centers. The bone fragment will ultimately fuse with the primary bone. The apophysis contributes more to the shape of a bone than the longitudinal growth. Until the ossification center fuses, also referred to as the point at which the “growth plate closes,” the tendon or ligament attached to the apophysis can pull and cause pain in the soft cartilage in the apophysis.

Hip and pelvic apophyses that are vulnerable to acute or overuse injuries are located at the ischial tuberosity, the iliac crest, the anterior superior iliac spine (ASIS) and anterior inferior iliac spine (AIIS). An apophyseal avulsion fracture. An anterior-posterior view of the pelvis is helpful when evaluating complaints in the pelvis so contralateral comparison can be made.
Risk factors for injury includes:

  • Tight muscles and muscle groups
  • Early in the sports season
    • Change in activity from sedentary to active
    • Sudden increase in intensity or duration of training or competition
  • Ignoring activity-related pain
  • Minimal recovery from workouts
    • Year-round training
    • Lack of cross-training
    • Overtraining

Treatment for these conditions is most often nonoperative and is centered around protecting the area involved. Rest, protected weight-bearing, gentle passive ROM and gradual return to play are necessary elements of the plan. Healing and symptom resolution may take 12 weeks or more and radiographic healing is not required prior to returning to sports.

Internal and External Snapping Hip

Athletes may report “popping” in the hip.

If you can see it, it’s likely coxa sultans externus, external snapping hip. This is a condition of the iliotibial band popping over the greater trochanter on the lateral side of the femur. Runners may complain of this when running or walking, and they may describe that it “pops in and out.”

If you can hear it, it’s likely coxa sultans internus, internal snapping hip. This occurs when the iliopsoas muscle, deep in the groin, causes painful popping. This condition is often seen in dancers and tumblers. Treatment includes hip flexor stretching and activity modification.

Femoroacetabular Impingement (FAI)

An overuse injury seen in adolescent and young adult athletes in the hip can be caused by changes in the shape of the femoral head-neck junction (Cam-type) or the acetabulum (Pincer-type). These changes can cause pinching and tearing of the labrum, the soft tissue surrounding the acetabulum that acts to deepen the socket. Early injury from impingement can cause premature hip arthritis. Therefore, this condition is continuing to get more attention with the goal to prevent deformity and consequences.

How does a Cam-type deformity develop?
The femoral head collides prematurely with the acetabulum. The impact causes a change in the shape of the head from being spherical to being more “cam” shaped, or oblong. These may develop secondary to another medical condition in the developing hip, such as:

  1. Slipped capital femoral epiphysis (SCFE) is seen in approximately one in 10,000 may occur and result in avascular necrosis of the femoral head.
  2. Perthes disease – rare condition affecting blood flow in the hip and causes deformity.
  3. Trauma or fracture

In athletes, there is not a primary condition like those listed above. Therefore, idiopathic Cam deformities have been identified in teenage athletes who participate in soccer and other sports. Younger players studied do not show this condition, so the window of opportunity and the exacerbating activity are being studied more closely. Shearing forces may be occurring at the physis to protect the bone, but ultimately may be causing changes in the growth plate and therefore the shape of the femoral head.

Can this be prevented?

Early conversations are looking at the parallel occurrence in the shoulder and elbow in baseball players. Evaluation of the dosage of activity, such as pitch counts in baseball, have been implemented to preserve the anatomy and improve performance in elite athletes. For now, working on proper mechanics and activity modification in adolescence may be our best tools to prevent this deformity.

Considerations and Components of a Hip Injury Prevention Program

Factors that must be considered to prevent hip injuries in adolescent athletes include:

  • Open growth plates
  • Peak height velocity (PHV)
  • High volume of training particularly with loading in rotational and axial movements
  • Sport-specific end range of motion demands
  • Explosive and eccentric demands

Modifiable factors may include:

  • Muscle imbalances
  • Muscle weakness
  • Inflexibility
  • Poor technique
  • Sport-acquired deficiencies
  • Joint instability
  • Overtraining

Five Domains of Injury Prevention Strategies of the Hip

  1. Training Load Management
    Higher incidence of athletic hip pain found with athletes who specialize in a single sport before high school and participate in regular training at earlier ages and four times per week before the age of 12. Recommendations include sampling a variety of sports rather than specializing, monitoring workload, neuromuscular training programs and taking rest breaks from sport (two to three nonconsecutive months/year).
  2. Hip Mobility During Rapid Growth
    Through stretching, dynamic warm-up and eccentric training, hip tissues can stay flexible. Progression of eccentric training can improve the length-tension curve to improve performance and resist injuries.
  3. Motor Control and Stability
    Hypermobility and poor motor control need to be addressed with strategies that improve core stability and teach foundational movement patterns for sport-related movements, such as jumping and landing.
  4. Strength to Improve Imbalances & Specificity
    Once mobility and control are addressed, strengthening can occur. Eccentric adductor & abductor strength can be improved by combining activities, such as the Copenhagen plank and a Nordic Hamstring exercise. Looking for sport-specific strengthening tasks.
  5. Sport-Specific Movement Mechanics
    The culmination of these strategies is executing the sport-specific movement patterns with all of the fundamental movement competence and technical accuracy to ensure safety. Whether the sport demands jumping and landing on a court, changing direction at high speeds on the ice or holding extreme postures on a balance beam, the steps follow a standard pattern.

Implementing Hip Injury Prevention Programs

With confidence that many of these elements are modifiable due to neural plasticity of youth athletes before and during growth, making an effort to prevent injuries is appropriate. Research will continue to define the right and wrong approaches; however, we have some tips that are generally accepted. To avoid detraining, it is recommended to perform activities two to three times per week, approximately 20 min duration, up to 60 min for at least six weeks. It is important to implement it prior to the beginning of a season. Qualified instructors and supervision for continued implementation of the proper techniques are crucial elements of a safe and successful program.

Learn more about hip health in dancers.

This is a summary of a presentation in a monthly series for medical professionals called Coffee, Kids and Sports Medicine. Through events like these, Scottish Rite for Children experts share their experience and knowledge with others to ensure young and growing athletes are getting the best care in every environment.

Diagnosing, Referring and Treating Newborns with DDH

Diagnosing, Referring and Treating Newborns with DDH

by | Aug 18, 2022 | Hip Disorders

Watch the lecture on YouTube or read this summary to catch the highlights.

Download the PDF.

This is a summary of a presentation for medical professionals that focuses on developmental dysplasia of the hip, or DDH. Presented by William Z. Morris, M.D., the seminar dives into everything medical professionals need to know about evaluating and treating DDH in newborns, helping physicians recognize the condition and respond earlier.

DDH is a common condition that occurs in about one in 100 infants. The condition is characterized by a shallow acetabulum and/or under-covered femoral head in the hip. It can occur due to a malformation of anatomic structures that have developed normally during the embryonic period and ranges in severity from physiologic immaturity to subluxation to frank dislocation. The presentation covers the epidemiology of DDH and its risk factors.

Dr. Morris provides updated guidelines for selective ultrasound screening for high-risk infants and includes data from his recent publications and presentations at national conferences. The presentation covered a full DDH screening and physical exam, showing providers exactly how to look for signs of DDH in newborns. He explains that physical findings fall on a spectrum and vary with the severity of the pathology and the age of the child. The presentation includes a detailed video of a newborn physical exam, showing participants hip-specific tests that can be performed to identify even subtle signs of dysplasia.

Email medicalprofessionals@tsrh.org to request access to the full exam video.

Imaging is a valuable tool in helping to diagnose DDH, but Dr. Morris shares why it is best to wait until the patient is 6 to 8 weeks of age in cases of screening ultrasounds for stable hips,  using facts and figures to illustrate this reasoning. He recommends ultrasounds at 6 to 8 weeks of age, which reduces false positive rate, and X-rays after 6 months of age once the hip has undergone sufficient ossification.

The presentation continues with Dr. Morris describing treatment protocols for DDH. For many, primary treatment for DDH begins with a Pavlik harness for six to eight weeks. He shares what to watch for with this treatment and its success rate using granular data in order to arm primary care physicians with data that can be used to reassure families once the diagnosis is made. He then talks about further treatments, including hip abduction brace, closed or open reductions and spica cast, and in which cases each may be used.

Finally, Dr. Morris shares vital information about DDH prevention, such as healthy hip swaddling, the use of proper sleep sacks and the correct use of baby carriers and how each of these can contribute to DDH in newborns.
Dr. Morris encourages physicians to refer patients early and often in cases of suspected DDH, know the risk factors and help parents with prevention techniques. He stresses that in most cases, nonoperative treatment is very successful, especially when the condition is caught early. Pediatric physicians and their patients can greatly benefit from Dr. Morris’ expertise with DDH, learning everything physicians need to know to provide their smallest patients with the best care.

World-Renowned Hip Care

World-Renowned Hip Care

by | May 3, 2022 | General News, Hip Disorders

Scottish Rite for Children’s Center for Excellence in Hip has a long tradition of providing the highest-quality medical care to thousands of children, from newborns to adolescents and young adults. Led by director and pediatric orthopedic surgeon Harry Kim, M.D., M.S., the team provides a coordinated and comprehensive approach to care that brings together hip specialists from orthopedics, radiology, physical therapy, psychology and more. This multidisciplinary team approach allows us to offer a broad spectrum of operative and nonoperative care options to preserve, improve and repair the native hip joint. At the Forefront of Innovation  Our experts are committed to advancing clinically important research to provide the best care to our patients. Several of the center’s research projects have led to revolutionary, life-changing results. Patients who had evaluation and treatment at our center have the opportunity to participate in large patient registries to allow for evaluation of treatment outcomes for a variety of conditions. These studies lead to new insight and significant improvement as our team modifies treatment algorithms based on these results. In addition, doctors and researchers are involved in multicenter hip research groups with peers at top-tier institutions around the country. They regularly collaborate to discuss the latest innovations and treatment techniques regarding patients diagnosed with pediatric hip conditions and injuries. Movement Science Laboratory The accredited movement science laboratory is an integral part of the treatment of our patients. The multidisciplinary team of engineers and kinesiologists use leading-edge technology to evaluate and identify joint motion, net joint forces, muscle activity, strength, foot plantar pressures and oxygen consumption. These analyses guide the development of individualized treatment plans for our patients and support research. The clinical research team partners with movement science to study the changes experienced with surgical intervention to ensure each patient continues to maintain improved hip functions. Multidisciplinary Complex Hip Clinic This clinic brings all of our hip experts together in one clinic to review and evaluate each patient in person together. The history, physical examination and images are evaluated, and various options are discussed for treatment. The multidisciplinary approach also includes experts in the fields of physical therapy, psychology, pain management and nursing. A comprehensive diagnostic (if necessary) and treatment plan is then developed specifically for each patient. If surgical treatment is necessary, the full range of procedures are available with the experts in the field to include hip preservation surgery (both open and arthroscopic options) as well as the potential for utilizing total hip arthroplasty (replacement) when appropriate. This clinic occurs every month and only those patients requiring this multidisciplinary approach are included. Patients may request to be seen in this clinic. Hip Team All of our pediatric orthopedic surgeons are board certified in orthopedic surgery and also completed a fellowship in pediatric orthopedics. Several of our medical staff have a particular interest in treating and studying pediatric and adolescent hip conditions. Harry Kim, M.D., M.S. 
  • Special interest in treating patients with Perthes disease, adolescent and young adult avascular necrosis, and developmental dysplasia of the hip (a member of International Hip Dysplasia Institute).
  • Leader and chair of the International Perthes Study Group – multicenter research study focused on advancing the care of children diagnosed with Perthes disease.
  • Extensive basic and clinical research on Perthes disease and avascular necrosis.
Daniel J. Sucato, M.D., M.S. 
  • Special interest in treating adolescent patients with various hip conditions including hip dysplasia, adolescents and young adults with Perthes disease, slipped capital femoral epiphysis and femoroacetabular impingement.
  • A member of the Academic Network of Conservational Hip Outcomes Research (ANCHOR) study. A multi-center project that analyzes hip function and pain, quality of life and other factors on patients who undergo hip preservation surgeries.
Henry B. Ellis, M.D. 
  • Special interest in treating femoral acetabular impingement, labral tears and other sport-related injuries and conditions in the hip.
  • Involved in multi-center research projects with a special interest in hip arthroscopy.
  • A member of the Academic Network of Conservational Hip Outcomes Research (ANCHOR) study.
David A. Podeszwa, M.D. 
  • Special interest in treating patients with hip dysplasia, slipped capital femoral epiphysis and femoroacetabular impingement.
  • A member of the Academic Network of Conservational Hip Outcomes Research (ANCHOR) study.
William Z. Morris, M.D. 
  • Special interest in treating patients with hip dysplasia, slipped capital femoral epiphysis and femoroacetabular impingement.
  • Extensive clinical research in the pediatric and adolescent developing hip with expertise in the pathogenesis of slipped capital femoral epiphysis and femoroacetabular impingement.
Corey S. Gill, M.D. 
  • Special interest in treating infants with hip dysplasia and patients with cerebral palsy with various hip disorders/dysplasia.
  • Other common hip conditions seen include slipped capital femoral epiphysis, Perthes disease, transient synovitis of the hip, osteoid osteoma and proximal femur cysts.
Learn more about the Center for Excellence in Hip.
Adolescent Hip Dysplasia and Other Causes of Hip Pain

Adolescent Hip Dysplasia and Other Causes of Hip Pain

by | Aug 6, 2021 | Hip Disorders

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon William Z. Morris, M.D.

You can watch the full lecture and download this summary.

In hip dysplasia, the acetabulum (or hip socket) is shallow and doesn’t adequately cover the femoral head. Developmental dysplasia of the hip (DDH) occurs in approximately 1% of newborn children, and it is associated with four risk factors:

  • Female
  • Firstborn
  • Feet first (breech)
  • Family history

Hip dysplasia is relatively more commonly diagnosed in skeletally mature adolescents, affecting around 3% to 5% of the asymptomatic population. Cross-sectional studies have shown that female sex and a family history of dysplasia remain risk factors in adolescents.

There has been growing attention to the treatment of hip dysplasia as there is an association between hip dysplasia and the development of early osteoarthritis. In 1939, Gunnar Wiberg first described hip dysplasia and objectively measured it using what is now called the lateral center edge angle, to describe how well the socket (acetabulum) covers the ball (femoral head). On an AP (anterior posterior) pelvis X-ray, the angle is created by a vertical line through the center of the femoral head and a line from the center of the femoral head to the lateral border of the acetabular fossa. A larger angle reflects greater hip coverage, and a smaller angle reflects less coverage, commonly seen in a dysplastic hip.

Wiberg followed patients with dysplasia for up to 30 years and found that all of the patients with hip dysplasia eventually developed osteoarthritis. The smaller their center edge angle was (reflecting greater hip dysplasia), the faster they developed osteoarthritis.

Development of Osteoarthritis in Dysplastic Hips
The development of early osteoarthritis is suspected to occur due to a couple mechanical reasons. The most important factor is that:

Pressure = Force / Unit Area
In the hip, pressure on the joint surfaces depends on the total surface area of the femoral head in contact with the socket. A well-covered femoral head distributes weight-bearing forces across a larger surface area, reducing the pressure on each unit of cartilage. In contrast, a dysplastic acetabulum offers less surface area which increases the pressure on the cartilage contributing to earlier hip degeneration. In addition to the smaller weightbearing surface, the acetabulum is also more obliquely oriented. Therefore, compressive forces are less and shearing forces are greatly increased. This increased shear force may also contribute to cartilage degeneration.

Symptoms of Adolescent Hip Dysplasia
There are many different causes of hip pain in an adolescent patient and combining clues from the history and physical exam is essential to determine the underlying problem. The location of a patient’s pain can help determine the underlying etiology. Intra-articular pain of the hip usually presents as anterior groin pain, often due to a cartilage injury, a tear in the labrum (the ring of cartilage at the periphery of the socket) or inflammation of one of the hip flexors called the Iliopsoas tendon. Lateral hip pain that locates over the greater trochanter (the bony prominence on the lateral aspect of the thigh) probably reflects trochanteric bursitis or inflammation of the bursa overlying that region. Pain or soreness after activity above the greater trochanter where hip abductors like the gluteus medius are located may signal hip abductor fatigue, which is common with hip dysplasia. Pain over the iliac crest where the abdominal musculature attaches could reflect some inflammation of that apophysis, of the anterior superior iliac spine (ASIS) where the sartorius attaches, or of the anterior inferior iliac spine (AIIS) where the rectus tendon attaches.

Additional Factors to Consider when Discussing Hip Joint Symptoms

  • Pain
    • Duration
    • Aggravating factors
      • Squatting, stairs, low chairs
    • Alleviating factors
  • Mechanical symptoms
    • Locking, popping, catching, snapping
  • Neurological symptoms (which may suggest spinal pathology)
    • Radiating pain, paresthesias

Physical Exam

  • Pain Assessment
    • Palpation can reproduce symptoms and help to localize the pain.
  • Strength Testing
  • Range of Motion
    • Limited internal rotation (IR) can indicate hip impingement or a more acute concern, slipped capital femoral epiphysis (SCFE)

Special Tests

Straight Leg Raise Test
A straight leg raise is a passive test that helps to distinguish between hip and spine pathology and is performed by flexing the hip with an extended knee in a supine position. If this maneuver reproduces the patient’s pain that radiates distally, the problem may be related to nerve compression in the spine rather than a problem in the hip.

Trendelenburg Test
The hip abductors (e.g. gluteus medius) are typically weaker when patients come in with pain, so it can be targeted in physical therapy. The Trendelenburg sign is a quick physical examination used to assess for hip abductor weakness.
The patient stands on one leg (stance leg) and bends the other knee about 90°. Observe for evidence of hip abductor (i.e. gluteus medius) weakness which includes:

  • Pelvis drop contralateral to the stance leg.
  • Trunk lean/shift toward the stance leg.

Apprehension Test
Another test to further evaluate for dysplasia is the apprehension test:

  1. The patient lays in a lateral position
  2. Abduct the patient’s leg 30° away from midline
  3. Flex the patient’s knee 90°
  4. Gradually extend the hip

Patients who have an anterior uncovering of the socket from dysplasia will feel pain or a sensation of apprehension, which suggests that there may be some instability or dysplasia.

Femoroacetabular Impingement Test
Hip impingement should also be tested:

  1. Flex the hip to 90°
  2. Abduct the hip, bringing it towards midline
  3. Internally rotate the hip

This test attempts to reproduce hip impingement where the femoral head or neck collides against the socket. If this causes pain, there may be a cartilage injury such as a labral tear. An MRI is recommended to evaluate intra-articular soft tissues.

Slipped Capital Femoral Epiphysis – A condition not to be missed
Slipped capital femoral epiphysis (SCFE) is an adolescent disorder in which the growth plate is damaged and the femoral head epiphysis moves, or slips, with respect to the rest of the femur. Diagnosis in a timely manner is essential to prevent further injury to the hip.

Consider SCFE if these signs are present:

  • limp
  • walk with their foot externally rotated
  • have limited range of motion, especially with internal rotation

Obligate external rotation is nearly pathognomonic for slipped capital femoral epiphysis, so if the patient can’t flex their hip straight up without turning their leg into an externally rotated position to accommodate further flexion, an anterior-posterior and frog pelvis film is recommended to ensure slipped capital femoral epiphysis hasn’t been missed. Immediate non-weight bearing with a wheelchair and urgent referral to pediatric orthopedics or an emergency room is recommended for this condition.

Radiographic Evaluation
A radiographic evaluation is important for a definitive dysplasia diagnosis. The AP pelvis film is a workhorse tool for the evaluation of hip coverage. It is taken standing to allow assessment of the patient’s hip coverage in their functional position using the lateral center edge angle (LCEA). A hip with an LCEA less than 25° is considered dysplastic.
Imaging also allows an assessment of the inclination of the socket. By drawing a line between the medial and lateral edges of the roof of the socket and measuring the angle between that line and a horizontal line, physicians can determine the acetabular inclination. The more inclined the socket is, the more dysplastic.

Treatments
Treatment for dysplasia begins with nonoperative options, which include:

  • Physical therapy
  • Activity modifications
  • Non-steroidal anti-inflammatory drugs (NSAID)

When nonoperative treatments don’t work, and patients continue to have radiographic dysplasia and pain, including abductor fatigue pain above the greater trochanter or anterior intra-articular groin pain, they are treated surgically with a periacetabular osteotomy (PAO). This specialized procedure is done in patients who are approaching skeletal maturity or are already skeletally mature. Several cuts are made around the socket of the acetabulum to mobilize the socket. The socket is then reoriented to better cover the femoral head.

Outcomes
For patients with symptomatic hip dysplasia, the PAO has been shown to be successful in improving patients’ function, getting them back to their activities/sports, and preventing early hip replacement. In patients with hip pain and clinical or radiographic evidence of acetabular dysplasia, please consider a referral to Scottish Rite for Children for discussion of the condition and shared decision-making in the plan for management.

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