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Pediatric Musculoskeletal Radiology

Pediatric Musculoskeletal Radiology

by | Sep 20, 2019 | Uncategorized

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.

Watch the lecture
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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.

Laying a Solid Nutrition Foundation for Adolescents and Young Athletes

Laying a Solid Nutrition Foundation for Adolescents and Young Athletes

by | Aug 22, 2019 | Uncategorized

With the start of the new school year upon us, it is important to fuel active children and young athletes’ bodies with the proper food. From healthy snacks to making sure you are drinking enough water, our team has the tips on setting your adolescent up for success. We sat down with the hospital’s sports dietitian Taylor Morrison, M.S., R.D., CSSD, L.D., to learn more about nutrition and the importance of giving your body the right amount of energy.  

Consistent Meals & Snacks

  • Three meals a day
  • One to two or more snacks a day (depending on the athlete, sport and training level)

Variety of Foods From All Food Groups

  • Food groups: protein, fruit, vegetable, grains/starch, dairy, fat
  • At least three different food groups per meal
  • At least two different food groups per snack
    • EXCEPTION = during training or competition

Adequate Fluid Intake

  • Drink with and between meals and snacks
  • Check urine color.  The goal is a lighter color like lemonade.  A dark color, like apple juice, means you may be dehydrated.

Positive/Healthy Food Attitude

  • Food is here to fuel, improve performance and prevent/help heal from injury
  • Notice hunger, satiety and how different foods work with training and competition

Breakfast Ideas

  • Greek yogurt + whole grain granola + blueberries
  • Whole Grain English muffin + nut or seed butter + fruit
  • 2 Eggs + slice of whole grain toast with jelly
  • 1 cup instant oatmeal + nut or seed butter + banana slices and / or a yogurt
  • Pre-made egg muffins + fruit
  • Peanut butter & jelly sandwich
  • Whole grain waffle spread with nut or seed butter & sliced strawberries
  • Granola bar + low-fat yogurt

Snack Ideas

Eating on the Run

General: 2 out of 5 food groups

  • String cheese + whole grain crackers
  • Whole grain crackers + nut butter
  • Fresh fruit + nuts or nut butter
  • Yogurt (plain or Greek)
  • Veggie sticks & hummus
  • Trail mix (nuts/seeds + dried fruit or dark chocolate chips + whole grain cereal)
  • Whole grain crackers or corn chips + avocado and/or salsa
  • Glass of chocolate milk
  • Whole grain granola bar
  • Turkey + grapes 
  • Small bowl of low-sugar cereal w/ milk
  • Oatmeal cup with a drizzle of peanut butter or topped with chopped almonds
  • Oatmeal cup + dried fruit or honey
  • Hard-boiled egg + fruit 
  • PB&J
  • Cottage cheese & cherry tomatoes

Practice/Performance: Carbohydrate

  • Fresh or dried fruit
  • Crackers 
  • Low protein & low fiber granola bars
  • Dry low fiber cereal
  • Sports drink
  • Plain bagel

Rule of Thumb: 3 out of 5 food groups

Homemade Lunchable 1

  • Pulled rotisserie chicken
  • Fresh fruit
  • Whole grain crackers
  • Mashed avocado

Homemade Lunchable 2

  • 2 hard-boiled eggs
  • Veggies + hummus or ranch
  • 1 apple
  • Dark chocolate chips

Peanut Butter Sandwich 

  • On whole wheat
  • With a low-fat yogurt

Turkey & Cheese Sandwich

  • 2 slices whole grain bread
  • Deli turkey
  • 1 to 2 slices of cheese
  • Lettuce, tomato on sandwich
  • Mustard or Dijon
  • + granola bar/pretzels

Homemade Trail Mix (nuts/seeds + dried fruit + whole grain cereal)

  • Piece of fruit
  • Greek yogurt
  • Whole grain granola bar
An Orthopedic Surgeon’s Perspective On Child Obesity

An Orthopedic Surgeon’s Perspective On Child Obesity

by | Apr 17, 2019 | Uncategorized

Originally presented by Corey S. Gill, M.D., at the Sports Medicine for Young Athlete: How Do We Keep Our Kids Safe Conference in Frisco.
Childhood obesity is a significant public health problem and significantly increases the risk of developing a number of debilitating medical conditions, such as diabetes and heart disease. The prevalence of childhood obesity nationwide is approximately 15%, but is often much higher in pediatric orthopedic patients. For example, more than one third of my patients who require surgery for orthopedic problems are obese. Obesity may play a causative role in disorders such as slipped capital femoral epiphysis (SCFE) and Blount’s disease, and often increases the severity and complexity of fractures and other orthopedic injuries.

Conditions Often Found in This Population
SCFE is a condition that can develop in the hips of obese children and adolescents. The excess body weight increases the stress across the cartilage growth plate of the femur near the hip joint and can lead to a stress fracture or complete fracture. This condition always requires surgical intervention and may lead to significant long-term damage to the hip joint that necessitates additional surgery or even hip replacements at a young age. This condition is often difficult to diagnose, as the hip pain can be vague or even manifest as knee pain. All obese adolescents with significant hip/knee pain, or a noticeable limp, should be evaluated by a pediatric orthopedic surgeon.

Blount’s disease is another condition correlated with obesity. In this condition, there is severe bowing of the knees that leads to pain, joint damage and a significant visible deformity. Surgical treatment for mild Blount’s disease is called growth modulation. This treatment involves tethering a growth plate near the knee with a metal plate and screws, so that the leg can gradually straighten over approximately one to two years. In more severe cases, larger surgeries are often required to cut and realign the tibia bone, often with an external metal frame attached to the leg for stability.

Fractures or broken bones are relatively common in growing children. Obese children are more likely to sustain arm and leg fractures after a fall compared to normal weight peers. In addition, these fractures are usually more severe and more complicated to fix in obese children. Finally, the excessive soft tissue present in obese limbs makes fractures more difficult to hold in position in a cast. Consequently, many fractures that can be treated nonsurgically in normal weight children require surgical intervention in obese children.

Peri-operative Risks in Obese Children
Overweight and obese children often have medical comorbidities that increase risk of complications during and after surgery, such as anesthesia-related complications, infection and wound problems.  A thorough preoperative evaluation is recommended in obese patients undergoing surgery in order to optimize perioperative care. For example, sleep apnea is found in 85% of patients with Blount’s disease and hypertension is present in 65% of Blount’s and SCFE patients. Oftentimes, these medical comorbidities are undiagnosed at the time of presentation, so orthopedic surgeons play an important role in the recognition and diagnosis of these diseases.

Now What?
Childhood obesity is a difficult problem, and there are no easy solutions to eliminate the epidemic. A multidisciplinary approach with frequent communication between surgeons, pediatricians, nutritionists and other health care providers is mandatory to optimize orthopedic care of the obese patient. The pediatric and orthopedic communities must continue to support initiatives to encourage kids to be active and to eat a healthy balanced diet. Regarding diet, healthy eating habits need to be established at a young age, as studies have shown that obese children as young as 11 are already consuming in excess of 1100 to 1300 extra calories per day. Regarding activity, children and adolescents should be encouraged to participate in at least 60 minutes of physical activity each day. Participation in team sport, or other activities such as walking, running or biking, may decrease obesity rates and promote a lifelong love of a healthy activity.

Learn more about injury prevention and pediatric sports medicine.

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Paving the Way to Bright Futures

Paving the Way to Bright Futures

by | Mar 1, 2019 | Uncategorized

If you are on the grounds of the hospital, take a moment to explore the James F. Chambers, Jr. Youth Fitness Park. The park features a large green lawn surrounded by an inviting walking path, which winds past decorative sculptures and recreational areas.

In this tranquil outdoor setting you will also find a brick pathway. Upon closer inspection, you will discover that these bricks are unique. Many of them are engraved with a name or personalized message to honor a loved one or celebrate a milestone.

But one thing these amber-colored blocks have in common is that each one is a symbol of hope and support for Scottish Rite Hospital patients.

“Participating in our brick program is a meaningful and affordable way for our donors to leave a legacy on the grounds of Scottish Rite Hospital,” says Stephanie Brigger, the hospital’s vice president of Development.

One of the longtime supporters, Dallas-area donor Michael Turner, began creating a legacy when the program started 20 years ago. Since then, he has donated more than 100 bricks to the hospital.

“I give from my heart,” Turner explains. “I give bricks rather than flowers because a brick will last forever.”

Individuals, families, corporations and anyone who wants to create a bright future for the patients of Scottish Rite Hospital can participate in the program. The cost of each brick is $150 and multiple bricks can be purchased, with all funds supporting the hospital.

Remember a loved one, commemorate a milestone or celebrate a special occasion, while benefiting hospital patients. To purchase a brick or receive more information, call 214-559-7618. You may also fill out an engraved brick donation form on our website here.

Rite Up Cover Story: The Sky is the Limit

Rite Up Cover Story: The Sky is the Limit

by | Oct 3, 2018 | Uncategorized

IF YOU ARE READING THESE WORDS WITH EASE, you likely acquired the skill shortly after mastering the alphabet. But what if you lacked the ability to match the proper sounds to the corresponding letters? What if that didn’t come to you naturally? Imagine, sitting at a desk in silent dread as your peers are called upon to read aloud. You stare at the page before you, trying desperately to decode it. Then, it’s your turn. You struggle to voice the words and suddenly, all eyes are on you.

That feeling was all too familiar for McKinleigh, age 12, of Arlington. The difficulty she faced didn’t catch her entirely by surprise, however. Her older brothers, Garrison and Garrett, had undergone testing for the same challenges. At age 5, she couldn’t read words but she could read the signs that told her, like them, she had dyslexia.

“It felt like everybody else could read and I just couldn’t,” McKinleigh explains.
“I was scared of what people would think of me.”

In 1965, pioneering neurologist Lucius “Luke” Waites, Jr., M.D., came to Scottish Rite Hospital to improve the lives of children like McKinleigh. At the time, the field of dyslexia was often misunderstood and discredited. Undaunted, Waites hosted a meeting of the World Federation of Neurology in 1968. At that meeting, the first consensus definition of dyslexia was formed, recognizing it as a medical condition.

This year, the Luke Waites Center for Dyslexia and Learning Disorders marks the 50th anniversary of hosting that momentous meeting. Scottish Rite Hospital continues to be an internationally recognized leader in the field, advancing teaching methods and conducting leading-edge research. We want the world of reading to be an open book for children because from there — the sky is the limit

“Children with this condition go to school expecting to be successful, just like they have been when learning to speak, play and interact with others,” explains Gladys Kolenovsky, administrative director of the Luke Waites Center. “When reading comes easily to other kids but not to them, it often leads to a sense of anxiety and failure.”
Dyslexia, which affects roughly 10 percent of children in the U.S., is characterized as a language-based problem connecting speech sounds to the letters of the alphabet. Children with the condition have difficulty learning to read and spell. As a result, comprehension of written material can also be challenging.

“It is not a vision or intellect problem,” Kolenovsky says. “Children who have
this condition are bright, talented and often gifted.”

In some cases, like McKinleigh’s, genetics can play a role. A child with a parent or sibling who has the learning disorder has a 30 to 50 percent chance of being born with it. “Our nieces and nephews started getting diagnosed with dyslexia,” McKinleigh’s mom, Deborah, recalls. Concerned about her own children, she received a referral to the hospital’s Luke Waites Center. Ultimately, all three children were found to have the condition as well.

Fortunately, their family was at the place where dyslexia was originally defined, a place that has remained at the forefront of dyslexia care and management at a national and international level —Scottish Rite Hospital.

“We are the experts and we share our knowledge,” Kolenovsky explains,
“whether it’s through training educators to employ our techniques,
developing specialized curriculum programs or advancing research.”

One of the most influential ways that knowledge is imparted is through the center’s two-year therapist training program, which focuses on the application of a specialized curriculum. Jeffrey Black, M.D., who has been the medical director of the Luke Waites Center since 1990, has expanded the center’s research program. This led to the production of Take Flight: A Comprehensive Intervention for Students with Dyslexia, the hospital’s award-winning curriculum.

The enormous success of this program is reflected in the use of Take Flight at educator training centers throughout the U.S., each of which has at least one instructor trained at the hospital’s Luke Waiter Center. (See the graphic below.)

“We continue to be leaders in dyslexia intervention, helping improve the quality of services children receive in their schools,” says Black. “Through our training in dyslexia identification and the application of our curriculum, our center has had a broad influence across the country and on a global scale.”

The team is also pioneering approaches to identify the condition in children as young as kindergarten and first grade. In addition, the staff has partnered with The University of Texas at Dallas to develop an innovative technology that will reduce teacher training-time.

Fifty years later, the center continues to lead the dyslexia field with the pioneering spirit upon which it was founded.

“Once the barrier of not being able to read is removed, a child’s gifts and abilities can be revealed and then, the sky truly is the limit,” Kolenovsky says.

McKinleigh’s mother agrees. “To have children who didn’t think they could ever read, who felt like they didn’t fit in and now have great plans for their future, it’s priceless,” says Deborah of her family’s hospital experience.

Like her brothers before her, McKinleigh recently graduated from Scottish Rite Hospital’s Take Flight program. Her future plans are to be a marine and a doctor. She loves God, her family, horses and now, reading — especially in class.

“I always wanted to read but once people heard me struggle, they would just tell me to stop and call on somebody else,” McKinleigh says. “And now, I read out loud and they won’t stop me, because I can.”

Interested in reading this issue of Rite Up? Click here!

#SRHaccess Facebook LIVE Recap: Inpatient Unit Tour

#SRHaccess Facebook LIVE Recap: Inpatient Unit Tour

by | Jan 17, 2018 | Uncategorized

On this week’s Facebook live, Katy Jones, R.N. joined us to take a tour of our inpatient unit where she explained the various amenities and activities offered to our patients after surgery. Below is a recap of the conversation.

The inpatient unit has 33 rooms and 52 beds. Most of the rooms are singles, however several rooms have double beds when the surgery schedule is busy.

Daily responsibilities of our inpatient nurses:

  • 12 hour shifts, day and night.
  • Taking care of patients coming in for surgery or those staying at the hospital long term waiting to receive surgery.
  • Nurses wake patients up to get the day going and take care of them throughout the day and night.

Some amenities available in an inpatient room:

  • Patient bed with side controls to put bed at a comfortable height and position.
  • Chair that extends to mini bed for one family member to stay overnight with patient.
  • Television with remote control.
  • Phone that connects to dietary to order meals for patients. All meal orders are based on doctor’s orders.
  • Bathroom including a toilet, shower and sink. Towels and soap provided, if needed.

Visiting hours on the inpatient unit:

  • 8 a.m. – 8 p.m.
  • Typically, there is no limit on how many family members and friends who can visit.
  • One family member can stay with the patient in the inpatient room.

Dietary:

  • Only patients can order from the room.
  • Family members can get food from the Cafeteria. Our Cafeteria provides options for breakfast, lunch and dinner.
  • As part of the admission process, nurses will go through a patient’s health history, medications and allergies to make sure dietary is prepared for their needs.
  • After surgery, the patient will begin eating ice chips to make sure their stomach can handle it. From there, the nurse will provide water, juice, crackers, etc. hours after surgery.

What is the average time for an inpatient to stay at the hospital?

  • Same day surgery – patient is admitted in the morning and discharged by the end of the day.
  • Some patients may stay for months at a time.
  • A few nights is the most typical length of stay in our inpatient unit.

What staff members visit the patients while in the room?

  • Nurse
  • Doctor
  • Patient care tech: the patient will see him or her most often to check vital signs and provide assistance to the bathroom, if needed.
  • Charge nurse
  • Respiratory therapy: breathing treatments, if needed.
  • Child life specialists
  • Physical Therapy or Occupational Therapy, if needed.

Nursing station:

  • Nurses are stationed at these areas within the unit to stay close to their patient’s room.
  • All the nurses have mobile phones and patients can press the call button on the remote control if they need anything.

Room 306:

  • Also known as the spine unit.
  • Patients who need to be closely monitored after surgery come to this area.
  • Average time in Room 306: 1-2 days after surgery, however it depends on the patient.
  • This area includes five rooms with two to three nurses working at all times.
  • This part of the inpatient unit allows our nurses to have closer access to the patients who are needing more monitoring.

School room:

  • Patients who plan to stay at the hospital longer than two weeks can be enrolled into the school program.
  • A Dallas Independent School District (DISD) certified teacher is at the hospital to help patients from kindergarten to 12th grade.
  • Classes are based off the DISD schedule. Monday through Friday, four hours a day – two in the morning and two in the afternoon.
  • The inpatient unit coordinator sets up the transition from regular school to school at the hospital.

Family waiting area:

  • Multiple waiting areas throughout the hospital for families.
  • Family members can wait in the patient’s room, waiting area on the third or fourth floor or in the cafeteria.
  • Family members are given a buzzer to keep with them once their child goes into surgery. It is used to notify them when the surgery is complete and the patient is being moved to the inpatient unit.

Activities and therapies offered to the inpatients:

  • Physical Therapy/Occupational Therapy
  • Therapeutic Recreation
  • Child Life provides fun activities for the patients during their time at the hospital Monday through Friday.
    • Arts and crafts
    • Games
    • Movies
    • Every Wednesday, PAWS Across Texas and Pet Partners come to the hospital to provide pet therapy to our patients.
    • If patients are unable to leave their room, Child Life will come to them.

What activities are available for inpatients in the evening?
Each night, volunteers will take the inpatients up the fourth-floor for activities before bedtime.
Patients can rent movies to watch in their room as well.

Learn more about Becoming a Patient at our hospital.