View the issue as a PDF: Spring 2022 Minnesota Pediatrician
Todd Milbrandt, MD, MS
Developmental dysplasia of the hip (DDH) encompasses a spectrum of disorders related to abnormalities of the developing hip and includes frankly dislocated hips, instability, and a shallow acetabulum. The current term defined by the American Academy of Orthopedic Surgeons (AAOS) and the Pediatric Orthopaedic Society of North America (POSNA) emphasizes that DDH is not limited to congenital disorders but is an evolving condition that can change with growth and development. DDH is a separate condition from neuromuscular hip dysplasia, which occurs most frequently in patients with spasticity. The cause of DDH is likely a combination of genetic and environmental factors. A strong association between the female gender and DDH has been shown, with 80 percent of those affected being female. In addition, other risk factors include first born, breech position, a family history of DDH, and oligohydramnios.,
Making the diagnosis in the newborn depends primarily on the hip exam, which should be performed routinely at each visit in infants. The baby should be examined while relaxed. The child should be undressed, and the diaper removed. The leg should be gently abducted and adducted. The sensation of the femoral head moving in (Ortolani sign) or out (Barlow sign) of the femoral head with a soft shifting or clunk should be the trigger for treatment or further imaging. Infants with an unstable hip should be seen by a pediatric orthopedic specialist within 1 to 2 weeks for prompt treatment. Limited hip abduction on one or both sides is another physical exam finding which should prompt ultrasound. In addition, ultrasound imaging should also be obtained at 4 to 6 weeks of age when any risk factors are in place, including 1st degree relative with hip dysplasia or history of breech intrauterine positioning. A low threshold for ultrasound is prudent to ensure early diagnosis and treatment, and it is helpful for providers to know that this is an ultrasound study that requires significant skill. Patients at 6 to 8 weeks of age with ultrasound abnormalities should also be referred for pediatric orthopedic evaluation. As the child ages, the hip instability signs are no longer present. Changes in gait such as a limp or shortened limb is most common. Pain is not seen in toddlers with DDH. After 6 months of age, an AP pelvis x-ray is the best study to evaluate for hip dysplasia and provides more reliable images than ultrasound. As the child ages, undiagnosed DDH will begin to cause pain as the forces across the joint become more abnormal.
For clinically unstable or dislocated hips, the optimal initiation of treatment with the Pavlik harness is as early as possible which is successful in over 85 percent of the patients. For the patient with mild US abnormalities, a stable hip, and a normal clinical examination, treatment timing is controversial. If bracing fails, then a closed reduction and spica cast application is performed around 6 months of age. Some dislocated hips require a more invasive surgery to open the hip joint and reduce the hip. This can be coupled with either a cut in the femur or acetabulum (Figure 1). Some complex hips require making a 3-D model, using techniques readily available at Mayo Clinic, to fully understand the anatomy to ensure a successful surgery.
Older children should also be treated if they develop symptoms. Children over age 10-12 can be treated with a periacetabular osteotomy (Figure 2), which is technically demanding but leads to powerful deformity correction. Sometimes this is coupled with a hip arthroscopy to ensure any issues the inside of the joint are also addressed.
This combination of procedures has shown to decrease the rate of degenerative changes and delay hip replacement. This surgery should only be performed by highly trained and experienced surgeons as complications can occur. Finally, if the DDH is not reconstructible, a hip replacement in late adulthood when performed by a high-volume academic center can return function to a painful hip.
In conclusion, DDH is a common condition with reliable nonoperative treatment options if detected early. Surgery is required for older patients with a dislocated or unstable hip. The role of surgery for acetabular dysplasia in childhood is evolving, but primarily driven by symptoms. The treatment options for DDH are expanding and we are learning how to better assess the patient’s anatomy thus leading to the right intervention at the right time.
Mayo Clinic pediatric orthopedic services are available at Mayo Clinic Square in Minneapolis and at Mayo Clinic in Rochester. To refer a patient, please contact the Referring Physician Office or call 800-538-1515.
Christopher Vara, MD
Shriners Children’s Twin Cities
At Shriners Children’s here in the Twin Cities, we are part of a nationwide group of hospitals and clinics that focus on diagnosing and treating musculoskeletal conditions from birth to adulthood. We are, often, one of the earliest specialty providers that parent(s) and children see, even right after birth.
As with any musculoskeletal condition diagnosed in the perinatal period, parents are often in a state of grief regarding the diagnosis. Our mission, as pediatric orthopedists, is to bring a sense of support and clarity to the diagnosis and treatment and to allay their concerns about their child.
As with any infant, a musculoskeletal diagnosis may be made prenatally or in the immediate postnatal period. Congenital talipes equinovarus (commonly referred to as a clubfoot or clubfeet) are among the diagnoses we are asked to evaluate frequently.
The history of talipes equinovarus dates to antiquity (Hippocrates, ca. 400 BC) and, with such a longstanding history, treatment methods have, thankfully, evolved over time.
In the not so distant past, as a junior resident, I was taught that the infant with talipes equinovarus should return at approximately 1 year of age, around walking age, for extensive posteromedial releases, pinning of joints, and casting of the foot or feet as a “one and done” approach, with the added caveat that “probably something more will be needed later in life.”
Fortunately, after the turn of the millennia, Ignatio Ponseti, MD (1914-2009) of the University of Iowa presented his treatment method which consisted of successive casts over the course of 5-6 (and sometimes more) casts to manipulate the feet sequentially. Initially met with some skepticism, it was soon thereafter adopted and studied further, revolutionizing how we approach clubfeet in children. The principles of treatment involve corrective manipulation and long leg casting, to “bring the feet out of the CAVE” (cavus, forefoot adductus, heel varus, and finally equinus). Typically, once the first 3 (“the CAV”) are corrected by casting, the last procedure (90% of the time), involves a percutaneous tenotomy (either under a local anesthetic in the office or under light sedation in the procedure room), with the final cast in place for 3 weeks.
I am happy to say this Ponseti method has become the standard of care here in the United States and is known worldwide for its successful outcomes and for its simple yet elegant approach. It can be used for any type of talipes equinovarus (regardless of etiology); however, early institution of treatment, even as early as 2 weeks of age, is the key to success. Understandably, the neglected clubfoot at 2, 12 or 20 years of age (rather than 2 weeks) adds layers of rigidity and complexity not found in the infant’s foot or feet. These feet often require extensive bony and soft tissue procedures that cannot rival the traditional Ponseti method for long term outcomes.
As I explain to parents, the critical orthopaedic components of the examination of the infant include an evaluation of the spine (for scoliosis or signs or spinal dysraphism), the hips (for hip dysplasia), and the feet. These are three areas where early diagnosis, and often immediate, intervention can have a positive, long lasting outcome.
Shriners Children’s has immediate openings for evaluation and treatment of children with talipes equinovarus. To refer please email your referral to firstname.lastname@example.org or fax to 612-596-6102.
With vaccinations and new data, many medical recommendations and best practices surrounding COVID-19 are evolving, including guidance on sports participation and returning to sports post illness. The American Academy of Pediatrics (AAP) recently updated their COVID-19 Interim Guidance: Return to Sports and Physical Activity at the end of January. The American Medical Society for Sports Medicine (AMSSM) and National Federation of State High School Associations (NFHS) also recently released similar updated guidance on cardiopulmonary considerations specifically for high-school athletes. The AAP interim guidance applies to all children and adolescents returning to physical activity like free play, organized sports or physical education in school, and includes information about family considerations, the benefits of physical activity, transmission mitigation strategies, and specific guidelines about returning to sports after a COVID-19 diagnosis.
New cohort research studies in athletes have reported a lower incidence (0.5 percent – 3 percent) of myocarditis than found earlier in the pandemic, however, cardiac involvement remains a concern when returning to sports and physical activity. If a patient is asymptomatic or only mildly symptomatic (< 4 days of fever >100.4, < 1 week of myalgia, chills, and lethargy), the AAP recommends an assessment by a primary care physician either via telemedicine, phone or in person. Along with providing appropriate isolation and illness guidelines, this assessment should include targeted cardiac screening questions including any history of chest pain, shortness of breath, new-onset palpitations, or syncope. Any positive signs or symptoms would warrant an in-office visit and possibly an EKG prior to allowing a return to physical activity. For children with moderate symptoms, an in-office evaluation is recommended along with an EKG. An additional evaluation by a cardiologist is recommended if there are any positive screening questions or the EKG is abnormal. Children and adolescents with severe COVID-19 symptoms including an ICU stay and/or intubation or multisystem inflammatory syndrome in children [MIS-C] should be restricted from exercise for a minimum of 3-6 months and be evaluated by a cardiologist prior to returning to activity.
The AAP does recommend a gradual return to sports progression after COVID-19 infection. All athletes should be a minimum of 1-day symptom free prior to starting physical activity and should follow CDC guidance for isolation and masking, even while active. All families should be given instructions to monitor for signs and symptoms suggesting myocarditis with increased activity that would prompt further cardiac work up. Children under 12 can generally progress back to activities at their own tolerance. Adolescents who are 12 and older, who were asymptomatic or had mild symptoms should gradually increase their activity over 3 days, while those with moderate symptoms should take 5 days to increase activity prior to game participation.
All these organization recommend revising the pre-participation physical exam and history forms to include questions regarding COVID-19 vaccine status and illness history, including severity and any new cardiac symptoms. For the Minnesota State High School League, athletes are required to have a PPE every 3 years and submit an annual health questionnaire that now includes COVID-19 specific questions.
AAP COVID-19 Interim Guidance: Return to Sports and Physical Activity https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/ (Last updated 2/18/2022)
Cardiopulmonary Considerations for High School Student-Athletes During the COVID-19 Pandemic: Update to the NFHS-AMSSM Guidance Statement by Jonathan A. Drezner, William M. Heinz, Irfan M. Asif et. al. https://www.nfhs.org/sports-resource-content/nfhs-sports-medicine-position-statements-and-guidelines/ (Last updated January 2022)
About the Author:
Sarah Kinsella, MD, CAQ, FAAP, was recently elected to a three-year term on the AAP Council on Sports Medicine and Fitness Executive Committee. Dr. Kinsella currently practice at M Health Fairview Orthopedics in Blaine.
“Punishment is a widely misunderstood, chronically misused, and wildly overused method for changing behavior, but when properly employed it can be effective…within limits.”
-Alan Kazdin, Ph.D., founder of the Yale Child Conduct Clinic
Not long ago, a parent of a young child I was working with provided me with an unsolicited synopsis of a parenting book they recently read. The author of this book reportedly recommended that timeouts for children should start at one hour in duration and increase in 30-minute increments each time the behavioral infraction occurs. I wish I could write how shocked I was to learn that such misinformed parenting advice was in circulation. Sadly, however, I have become inured to examples such as this. Timeouts have become a first line tactic for parents eager to address their child’s behavioral problems. Pediatricians are often tasked with teaching parents healthy and effective strategies for addressing childhood behavioral issues. While timeouts certainly have their place in generating healthy behavioral changes in children, they are not without limits. In this article, I discuss what we know about timeouts, when parents should use them, and more importantly how parents should implement them.
Grow Grass in Place of the Weed
Despite the popularization of timeouts, they account for a relatively small portion of a behavioral program. The most critical factor in changing a negative behavior is rewarding that behavior’s positive counterpart; or “growing the grass.” For example, say a parent gives their 4-year-old a timeout in response to episodes of physical aggression. Sure, the parent is punishing this negative behavior (i.e., getting rid of the weeds), but if the parent does not grow grass in place of these weeds, the negative behavior will inevitably reappear. In other words, punishment, when used alone, leads to a mere temporary suppression of an undesirable behavior. In the example above, if the parent issues a timeout for physical aggression, they should simultaneously “grow the grass” with praise and reinforcement for behaviors that reflect the positive opposite of physical aggression (e.g., keeping hands to self, using words when upset, etc.)
Success is in the Details
While various parenting books may suggest otherwise, there is no such thing as a magical, one-size-fits-all timeout length. In general, time-outs work best when brief, lasting 2-3 minutes, and never exceeding 10 minutes. Timeouts are more effective for younger children (i.e., ages 2-7) and should take place in an area with little to no stimulation (e.g., TV, electronics, etc.). Parents are advised to remain calm when implementing a timeout. The angrier parents are, the less effective the timeout becomes. I am often asked, “what if my child refuses to go in a timeout?” This is not uncommon, and I always advise parents to practice timeouts with their child and praise their child for complying with a timeout (sounds ridiculous, I know, but it’s important). Nonetheless, if a child does not comply, parents should calmly add an extra minute. Parents are advised to only do this one more time before pivoting away from timeout and removing a privilege instead.
Parents should use timeouts sparingly. As discussed above, parents are advised to focus far more on reinforcing and rewarding positive behaviors. I typically advise parents to choose a range of 1-3 behaviors that will warrant a timeout. Parents should ensure the behavior is defined clearly. For example, hitting a family member is a clearly defined behavior, whereas “acting up” is vague and imprecise. Lastly, parents are better off choosing a behavior that occurs no more than once or twice a day. If parents are punishing a negative behavior multiple times per day, they are wise to shift their focus to rewarding and reinforcing that behavior’s positive opposite.
About the Author
Sam Marzouk, Ph.D., L.P. is a pediatric psychologist and owner of Promethean Psychology in Edina, Minnesota. In addition to his routine clinical work, Dr. Marzouk also enjoys providing trainings on pediatric mental health to pediatricians and other pediatric medical providers.