Choosing Wisely: 5 Things Physicians Should Question

Transcription

1 Choosing Wisely: 5 Things Physicians Should Question Dorothy Harris Beauvais, MD Assistant Professor of Orthopedic Surgery Texas Children s Orthopedic Hospital Baylor College of Medicine DEVELOPMENTAL DYSPLASIA OF THE HIP Do I need to order an Ultrasound??? 1

2 DDH Occurs at birth or early infancy: 1-7 per 1000 births Spectrum of disease Unstable Subluxated Dislocated Malformed acetabula DDH: Risk Factors Breech Female First born Family history Fetal anomalies (Oligohydramnios) Incorrect swaddling 2

3 Physical Exam DDH: Diagnosis Asymmetric range of motion Galaezzi Test Asymmetric leg lengths Barlow Maneuver Up to age 3 months Ortolani Maneuver Up to age 3 months Possible Scenarios Scenario 1: Normal physical exam/no risk factors Scenario 2: Abnormal physical exam Referral to Orthopedics Scenario 3: Normal physical exam + risk factors 3

4 Normal Physical Exam + Risk Factors Consider ultrasound Perform after 6 weeks of age High false positive rates of DDH in infants < 6-8 weeks Infants > 4-6 months require X-ray (2-view pelvis) for evaluation What about Universal Screening with Ultrasound? 4

5 Universal Ultrasound Screening For clinically stable/normal hips Negligible positive yield Substantial false positive rate Increased treatment rate Costly Time-intensive Risk of Pavlik treatment 2016 AAP/AAOS Recommendations 1 DO NOT order screening hip ultrasound to rule out DDH if baby has NO risk factors and clinically stable hip exam 5

6 Concerns What if I don t trust my physical exam? What if family is demanding imaging? How quickly should referral be initiated? IN-TOEING 6

7 In-toeing Very common Causes Metatarsus adductus Tibial torsion Femoral anteversion Femoral Anteversion 3-10 years of age Females > Males Worse when running or fatigued Natural History: 99% Resolution Birth: 40 degrees anteversion Adolescent/Adulthood: degrees anteversion 7

8 Femoral Anteversion No Role/Efficacy Special shoes Twister cables Bracing Physical therapy Tibial Torsion In-toeing: 2-4 years of age Often bilateral Natural history Spontaneous resolution by 6 Not changed by bracing/orthotics 8

9 Metatarsus Adductus Convexity of lateral border of foot 1-3/1000 children Most common foot deformity in children Majority are flexible Passively correctable to neutral Natural history: 90-95% spontaneous resolution by age 4 Associated conditions DDH (10-15%) Torticollis 2016 AAP/AAOS Recommendations 2 DO NOT order radiographs or advise bracing or surgery for a child less than 8 years of age with simple in-toeing 9

10 When is In-toeing Not Simple > 8 years of age* Pain Leg length discrepancy Family history: rickets/skeletal dysplasia Rigid metatarsus adductus Neuromuscular disorder PEDIATRIC FLAT FEET 10

11 Flexible Flat Feet Normal physiologic variant Arch develops > 5 years of age Childhood Incidence: unknown Adults: 15-23% Etiology Physiologic ligamentous laxity Orthotics do not alter natural history Usually asymptomatic Foot flat when standing Arch present Flexible Flat Feet Toe walking Great toe dorsiflexion Nonweight bearing 11

12 Flexible Flat Foot: Treatment Asymptomatic/minimally symptomatic No bracing or orthotics Reassurance Painful Assess with imaging Assess for heel cord tightness Consider orthotics Consider referral 2016 AAP/AAOS Recommendations 3 DO NOT order custom orthotics or shoe inserts for a child with minimally symptomatic or asymptomatic flat feet 12

13 ADVANCED IMAGING: MRI OR CT FOR MUSCULOSKELETAL CONDITIONS Advanced Imaging: MRI or CT Scan Costly Frequently require sedation (< 5 years of age) Require clinical correlation Require specific protocols/sequences Can involve radiation USE SPARINGLY if at all 13

14 Musculoskeletal Conditions Common pediatric MSK conditions Injury/pain (back, knees, ankle, legs) Infection Deformity Primary diagnostic modalities History Physical exam Appropriate radiographs Appropriate laboratory assessment 2016 AAP/AAOS Recommendations 4 Do Not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory, and plan radiographic examinations have been completed. 14

15 BUCKLE/TORUS FRACTURES FOLLOW-UP IMAGING? Buckle/Torus Fractures Common fracture pattern Metaphyseal region Only ONE side of bone is compressed and buckles The other side is completely intact 15

16 Buckle/Torus Fractures Inherently stable Metaphyseal region reliably remodels Treat with removable splint or brace for 4 weeks Consider cast Severe pain Unable to comply with brace wear/activity restrictions 16

17 2016 AAP/AAOS Recommendations 5 DO NOT order follow up X-rays for buckle/torus fractures if there is no longer pain or tenderness at 4-week follow-up Pitfalls: Torus/Buckle Fracture Ensure only ONE side compressed Should not see a fracture line If severe pain, swelling, or deformity initially Consider another diagnosis 17

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