The field of pediatric sports medicine includes operative and nonoperative management of sport-related injuries and consideration of how conditions and treatment affect long-term athletic development during continued physical and mental maturation. The program provides in-depth training for managing common and complex conditions, including ACL injuries, osteochondritis dissecans, patellar instability, meniscus, hip preservation, shoulder instability and more. In the United States, approximately 45 million children between the ages of 5 and 18 participate in organized sports according to a paper published in theInternational Journal of Sport Communication, which makes the need for specially trained pediatric sports medicine physicians and surgeons important for the well-being of today’s youth
Fellows are frontline members of the sports medicine care team at Scottish Rite for Children Orthopedic and Sports Medicine Center in Frisco, Texas. In addition, they rotate with sports medicine surgeons at UT Southwestern and other adult colleagues for the full gamut of operative sports training. Additionally, the fellow assists in the management of pediatric fractures and acute orthopedic conditions at Children’s Medical Center Dallas, one of Texas’ only Level 1 pediatric trauma centers
The one-year fellowship program is available to postgraduate surgeons who have completed an orthopedic residency. The fellowship provides the recipient the opportunity to pursue advanced study, in-depth training, management and research in sports medicine, musculoskeletal, and complex injuries. The fellowship accommodates one fellow and begins on August 1
Learn more on our Fellowship & Graduate programs page
We asked our surgical services manager at the Frisco campus Patty Crabb, B.N., B.S., R.N., ACLS, to tell us all about how the services and the facility make it an ambulatory surgery center just right for kids.
Most importantly Crabb says, “We take care of kids as if they were our own.”
What makes the surgical experience at Scottish Rite for Children unique?
Our ambulatory surgery center in Frisco serves our pediatric and adolescent sports medicine, orthopedic and fracture patients in North Texas. Because our services are all focused around treating kids’ muscles, joints and bones, our staff and our facility is too. In fact, the surgery center was designed with help from our pediatric surgery team with our young patients and families in mind.
What is an ambulatory surgery center?
It’s an outpatient setting for surgeries that do not require an overnight stay for recovery. This is best for patients and families to transition to the comfort of their own home as soon as it is medically safe to do so.
What special training does your staff have?
All Scottish Rite for Children surgeons are fellowship trained in pediatric orthopedics and many also completed a fellowship in another specialty area. Our surgery staff have many years of experience in pediatric surgery, many with years of experience with our pediatric orthopedic surgeons.
What services do you offer families that come to the ambulatory surgery center?
We have a few things that make surgery in a pediatric setting a lot more comfortable for patients and their family.
Child Life specialists are staff members with special training to work with children in health care settings. They are available in clinic to help the child understand the procedure and prepare for surgery day. In some cases, they may provide a tour of the surgery center to help a child feel more at ease.
Pediatric anesthesiologists at Scottish Rite for Children have focused their clinical and academic attention to caring for children. This means that their procedure and pain management planning and bedside conversations before and after surgery are all child-focused.
Comfortable waiting areas including the Ronald McDonald room that is hosted by a volunteer to attend to family needs.
Family Services are available to help families navigate the challenges of having a child going through surgery. For some, this may be help with arranging a stay at a nearby hotel or completing an application for our financial assistance program called Crayon Care.
Check out this tour of our ambulatory surgery center led by pediatric orthopedic surgeon Henry B. Ellis, M.D.
Recently, Assistant Chief of Staff Philip L. Wilson, M.D., and pediatric orthopedic surgeon Henry B. Ellis, M.D., published a novel technique for treating an anterior cruciate ligament (ACL) injury.
Too many young and growing athletes who have an ACL injury and reconstruction reinjure the same leg or have a new injury in the opposite leg within two years of the initial reconstruction. In fact, the rate of re-injury can be as high as one out of every four (25%). “Young children and adolescents are the most challenging to treat after an ACL injury because their growth plates are still open,” says Wilson. “Because of this and their commitment to returning to a high level of activity, they require special techniques to both allow continued growth and give them the best chance of not re-tearing.”
Since 2012, our team has been studying the results of a unique approach for this surgery. Our experts have combined a surgery intended for younger children (less than 12 years old) with a commonly used procedure for an older child. This approach has resulted in a reduced rate of re-injury to approximately 5% compared to 25%.
While allowing for uninterrupted function of the growth plates, the technique provides additional support when compared to other treatments for this rapidly growing population. The technique adds both additional lateral knee support as well as added ACL graft size, both of which have been demonstrated to reduce the risk of ACL reinjury. The reduced rate of secondary ACL injury in the study are less than half of any other reported results in a similar group. In many cases, ACL injuries take very young athletes out of play for a year. This important step in reducing the risk of secondary injury helps to ensure that athletes can stay active once they are cleared to return.
“This surgical technique is very promising,” says Ellis. “As an institution committed to innovation, we are proud of the work that has gone into this project. It is rewarding to help athletes get them back to doing what they love and know that they have a much lower risk of re-injury.”
This research study was presented at the 2019 annual meetings of two prestigious organizations: Pediatric Orthopedic Society of North America and the American Orthopedic Society of Sports Medicine. The manuscript has also published in a highly rated, peer-reviewed journal American Journal of Sports Medicine. The data include outcomes from this procedure in almost 60 athletes (age 11-16 years) collected over a five-year period. The combined TPH/ITB technique has a low re-injury rate (5.3%) and high return to sport rate (91%) and a low risk of minor growth-related changes (5.5%).
Learn more about the ongoing research in the Center for Excellence in Sports Medicine.
This weekend, at the third invitation-only Dallas Mavericks Youth Combine, the area’s top middle school basketball players and their parents heard one message over and over again –don’t specialize in one sport too soon.
Our team was excited to be there and happy to support this message. The evidence is piling up against early specialization including early burnout, quitting sports at a young age and less career playing time often directly associated with injuries. Pediatric orthopedic surgeon Henry B. Ellis, M.D., was invited to provide an overview of injuries in basketball. He emphasized the importance of rest, at least three months from each organized sport every year. This interactive conversation with parents included these key messages:
Knee overuse injuries(Osgood Schlatter and Sinding Larsen Johansen) are more likely in this age group, particularly with basketball players. Proper knee range of motion and stretching can help.
Hip overuse injuries(femoral acetabular impingement) are progressive and should be evaluated to minimize the damage to soft tissues in the hip joint.
In response to questions about bracing and cryotherapy, Ellis reminded parents that there are no fast cures to something that is caused over time. Rest is necessary and the studies are starting to show that diversity in sports and taking breaks throughout the year, can place athletes at an advantage.
Greg Nared, Senior Vice President of Community Relations for the Dallas Mavericks, echoed this in his message to the players and the parents. Convinced that injuries can be avoided with proper rest and skill development, Nared encouraged parents to expose their children to other sports and non-basketball training. He and Ellis decided several years ago that they needed to work together to get this message and others about health and wellness to kids. Playing sports, including basketball, has many advantages and together they want to figure out how to get more involved to help keep kids playing longer.
In the combine event, Scottish Rite for Children staff participated by taking some measurements and offering feedback to the athletes about opportunities for improvement. Some suggestions included:
Stretch the ankle and heel cord to improve ankle flexibility. Rigidity at the ankle can cause excess demands on the knee.
Stretch the quadriceps (muscles in front of the thigh). Short muscles and repeated jumping and running can cause overuse injuries in the knee.
Learn proper squatting form. Poor movement with squatting will translate into poor movement with jumping and landing, leaving a knee vulnerable to significant injury.
This NBA-like combine experience was designed with the young athlete in mind. These young athletes are in the prime of their development and growth, putting them at risk of certain injuries. However, it also puts them in a perfect position to learn about protecting their bodies.
Learn more about our partnership with the Dallas Mavericks.
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.
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.
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.
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.
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.
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
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.
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