Orthopedic Issue in Kids? Skip These Tests, Experts Say

Ricki Lewis, PhD

February 13, 2018

The American Academy of Pediatrics and the Pediatric Orthopaedic Society of North America have identified five procedures or tests that may be unnecessary when evaluating young patients with hip, foot, and other musculoskeletal symptoms.

The targeted, evidence-based recommendations are intended to minimize additional testing in response to false-positive findings. Follow-up tests, such as advanced imaging methods, expose children to radiation and may require sedation. Testing too soon also may not provide sufficient time for certain musculoskeletal issues to resolve on their own.

"There should always be a conversation between physician and patient on what procedures and tests are really necessary. We want to provide the best care, and when it comes to testing, sometimes less is more," said Brian Shaw, MD, a member of the American Academy of Pediatrics Section on Orthopaedics, in a news release.

The groups published the list online as part of the American Academy of Pediatrics' ongoing Choosing Wisely campaign.

The "five things physicians and patients should question" are:

  1. Screening hip ultrasounds to rule out developmental hip dysplasia or developmental hip dislocation in a baby who has no risk factors and clinically stable hip examination. Incidence of hip dysplasia/dislocation is rare (7 per 1000 births), and universal screening programs using ultrasound on infants without obvious hip abnormalities identify few cases and have a considerable false-positive rate. Without physical findings or underlying risk factors, "a hip ultrasound is costly, time-intensive and the findings may be misleading to parents and physicians."

  2. Radiographs or advising bracing or surgery for a child younger than 8 years who has a simple in-toeing gait. This condition usually reflects ongoing skeletal maturation. Metatarsus adductus, femoral anteversion, and tibial torsion contribute to in-toeing and typically resolve with growth. It is sufficient to monitor gait at well-child exams until age 7 or 8 years, unless tripping or falling is severe or posture asymmetric. Physical therapy, bracing, or shoe inserts cannot alter skeletal maturation.

  3. Custom orthotics or shoe inserts are not appropriate for a child with mild or asymptomatic flat feet, which are normal physiologic variants. Observation or use of over-the-counter orthotics is sufficient to manage feet that have an arch when the person stands on tiptoe. Custom orthotics do not affect arch development.

  4. Delay advanced imaging studies (magnetic resonance imaging or computed tomography) for most musculoskeletal conditions (injury, pain, deformity, or infection) in a child until all appropriate clinical, laboratory, and plain radiographic studies are completed, including considering family history. Risks include possibility of sedation (magnetic resonance imaging), exposure to radiation (computed tomography), and need for a specialist to repeat the study (magnetic resonance imaging). If testing indicates need for an advanced imaging study, consult with an orthopedic surgeon to confirm interpretation of findings.

  5. Follow-up X-rays for buckle (or torus) fractures of the forearm that are no longer tender or painful are not necessary. Immobilization with a simple wrist brace or removable splint may be sufficient for these stable fractures, instead of casting. Initial deformation tends to remodel with time. If the fracture is no longer tender on palpation 4 weeks after the injury, full activities may be resumed, and follow-up radiograph is unnecessary.

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