News Category: Child

Surgeons from Shriners Hospital for Children in Erie, Pennsylvania report on
the long-term results of slipped capital femoral epiphysis (SCFE). They compared their results with previous studies.

In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). The children in this study were all treated with a screw to hold the epiphysis in place.

Results were measured an average of seven years later. Some patients were followed for as long as 26 years. Range of motion, strength, and function were compared to age-matched subjects with normal hips. Leg length was also measured and compared from side to side. Symptoms such as pain, tenderness, and limping were recorded.

The authors report good-to-excellent results for most patients. Most hips were stable with only mild loss of strength or motion. X-rays showed an improved, but not perfect, hip angle. Only a small number of patients had signs of hip osteoarthritis.

The authors suggest that the amount of residual (remaining) hip deformity does influence the final results. Early degenerative changes are more likely in
patients with a greater slip of the epiphysis. Slightly less function and more pain was reported in patients with deformity still present later in life.

Infants born with clubfoot often need surgery to correct the problem. Talipes equinovarus is the medical term for clubfoot. It means the foot is twisted in and down. Wound complications is a common problem after this operation. Up to 30 per cent of the patients have poor wound healing, infection, or too much scarring.

In this study, surgeons from the University of California and Shriners Hospital compare the results of two different incisions used to correct clubfoot. the first incision type called the Turco was developed in 1971 by Dr. Turco. This opening is vertical. After correcting the deformity, the foot is put in a cast in a neutral (corrected) position right away.

The second method is the Cincinnati incision. The cut is made along the inside edge of the bottom of the foot. The foot is casted in stages. First it is put in an equinus position. The cast is changed a week later and the foot is moved into the neutral position.

By comparing the results of two groups of children, the surgeons were able to see fewer problems using the Cincinnati method. They weren’t sure if the lower rate of wound problems was because of the incision or the casting method. More studies are needed to find out exactly why there were fewer wound problems with the Cincinnati method.

Finding the cause of back pain in children can be difficult. X-rays and other imaging studies may help. In this study, radiologists at Harvard Medical School compare two advanced imaging techniques. The cost, dose, and results of fluorine-18 sodium fluoride (18F NaF) PET scan were compared with technetium-99m (99mTc) scintigraphy.

Both methods use a radioactive dye called a tracer. The dye is injected into the blood stream through an intravenous (IV) line. A special gamma camera measures the amount of radiation emitted. The amount of dosage needed for both methods is about the same.

Fluoride PET scans have some potential advantages over scintigraphy. It has smaller-sized ions that can pass across the tiny blood vessels easier. The transfer of the ions is also faster. This means the imaging can begin much sooner (after 30 minutes instead of three hours).

The fluoride PET scan was used in a group of 94 young patients with low back pain. High radiotracer uptake was seen in more than half the patients. One-third of those children had a stress-induced injury to the supporting columns of the spine called the pedicles. Others had injury to the spinous process or the growth plate of the bone.

Although the fluoride PET scan costs more, the resolution was better. Improved image quality made it possible to diagnose and treat the patient sooner and save costs in the long-run.

In the past fluoride PET scans have been used successfully to identify bone cancer in the spine. This study shows it has equally effective uses in identifying orthopedic problems as well.

With today’s time management issues, the significantly faster results with fluoride PET scan make it a very good choice. This is especially true with young children who can’t hold still for three or four hours required for the scintigraphy test.

Children who haven’t completed growing can develop a problem called slipped capital femoral epiphysis (SCFE). The growth center of the hip (the capital femoral epiphysis) slips backwards on the top of the femur (the thighbone).

The standard treatment for this problem is to use a screw to hold the epiphysis in place until growth is completed. The screw is usually placed perpendicular (at a right angle) to the physis. This keeps the screw from going into the joint while giving maximum stability of the slipped epiphysis.

In this report, surgeons address a problem that can occur in cases of moderate-to-severe SCFE. The problem is called screw impingement. The head of the screw can bump up against the rim of the acetabulum (hip socket). This happens when the leg is flexed or bent.

The patient must rotate the hip outward to avoid impingement. The result is limited hip motion, pain, and an altered gait (walking) pattern. Over time, the cartilage around the joint gets worn away or can tear causing more problems.

Through a series of X-rays and diagrams, the authors show how changing the placement of the screw can make a difference. An imaginary line drawn down along the neck of the femur is called the intertrochanteric line. The screw is still placed perpendicular, but should be advanced past this line on the lateral side. This avoids a prominent screw head that can cause impingement.

The authors use diagrams to show surgeons where the at risk zone is located. They suggest using the alternative fixation with the screwhead resting lateral to the intertrochanteric line to avoid impingement. The screw must still be located in the center of the femoral head. Only moderate-to-severe SCFE requires this kind of change in screw placement.

For many years, exercise has been dismissed as an effective treatment for adolescent scoliosis (curvature of the spine). In this report, more recent findings in support of exercise are presented.

Looking back at previous studies of exercise for scoliosis, the authors report that many of the children didn’t do the exercises. And those who did them, only did so occasionally. Unless the exercise program was designed to prepare for a sports activity, compliance was very low.

Improved technology and the ability to assess muscle function have changed the picture. We now know that there is asymmetry in muscle function for everyone with scoliosis. More specifically, there is an uneven strength in trunk rotation.

The former exercise programs of stretching and general strengthening may have been the wrong approach. Progressive resistive exercises (PREs) are effective for curves less than 45 degrees. This has been shown with the use of exercise equipment that can measure muscle function.

First, a baseline measurement was taken. Then an exercise program was prescribed and supervised. Torso rotation equipment was used. Exercises were done for 15 minutes, twice a week. Measurements were repeated.

EMG studies showed that the muscles along the spine called paraspinal muscles were inhibited at first. After the exercise program, this was corrected, and muscle function was equal on both sides.

The authors conclude that PREs for torso rotation and lumbar extension are safe and simple to do. Resistance should be started at one-fourth of the patient’s body weight.

Resistance can be increased when the child can do 20 repetitions. They should be prescribed and performed using the proper equipment before bracing is used. Adults with scoliosis can be helped by this program, too. It may not change the degree of their curvature, but it can help control back pain.

Doctors from Shriners Hospital for Children in Philadelphia, Pennsylvania present the case of an 11 year-old child with Cobb Syndrome. Because this is such a rare condition, the child was diagnosed with a virus, back strain, and Guillain Barré syndrome before the Cobb syndrome was finally recognized.

The child was born with a large birthmark over his left thoracic spine but there were no other symptoms until he was much older. He eventually developed sharp stomach pain that went into his back. He was an active soccer and basketball player, so at first, the diagnosis was muscle strain.

X-rays and CT scans were negative. With loss of strength and sensation in his legs, he was then diagnosed with Guillain Barré syndrome. Guillain Barré is a viral-caused neurologic condition. MRIs of his spine finally showed the arterovenous malformation (AVM) typical of Cobb syndrome.

AVM is a tangle of arteries and veins with abnormal connections. In the case of this child, there was a large leaking aneurysm. An aneurysm is a thin, weak spot along an artery that can leak or burst. In either case, bleeding and even hemorrhaging can occur.

For this child, the loss of blood supply to his spinal cord resulted in paralysis. By the time it was discovered, he had permanent damage to his spinal cord. Even with treatment, he only regained part of his strength and sensation. He still has weakness, loss of pain or pressure, and no bowel or bladder control.

The authors advise physicians to pay attention to large birthmarks on babies. They may be benign and go away in time. But if any back pain or neurologic symptoms occur, an MRI of the spine must be done right away.

Children with cerebral palsy (CP) often have problems walking. Tight, spastic muscles limit their hip, knee, and ankle motion. Many are pulled down into a crouch position when walking. They can’t straighten up. All these variables affect the way they walk.

Treatment is often focused on managing gait problems. Having a way to measure improvements before and after treatment is helpful. Most therapists don’t have access to a gait laboratory with video and computer analysis of walking patterns. Observational gait assessment (OGA) is the best alternative.

There are several OGAs currently in use. Patients are viewed from the side while walking. Position of the hip, knee, and ankle are recorded at different points in the gait cycle. There aren’t very many studies to test these scales and make sure they are accurate and reliable.

Researchers in England are working on developing a new gait assessment tool. It’s called the Salford Gait Tool (SF-GT). The SF-GT uses a five-point scoring system. Positions of the hip, knee, and ankle are recorded at six points in the gait cycle.

In this report, the authors review the steps they’ve taken so far to develop and test the SF-GT. They tested the tool out on 13 children with CP. A group of 23 physical therapists used the SF-GT to score each child’s gait.

The authors were able to analyze how much agreement there was among the therapists. They could use this information to compare the SF-GT to other OGA tools. It turns out there was good agreement among all the SF-GT scores.

The next question to study is: how much disagreement is acceptable for the SF-GT to still be considered a valid tool? Further work will be done to evaluate this new gait assessment tool.

Fractures of the pelvis are rare in children. Only about one per cent of all fractures seen by orthopedic surgeons who treat children are in the pelvis. The cause is usually high-energy trauma from a car accident or sports injury.

This review article was written to help orthopedic surgeons evaluate and treat pediatric pelvic fractures. The authors compare and contrast adult to pediatric pelvic fractures.

Children are more likely to injure the organs in the abdomen. Adults are more likely to break the bones of the pelvis. In young children, the pelvic bones are still more cartilage than bone and less likely to break. Bleeding is less in children because they don’t have atherosclerosis (hardening of the arteries) yet. And their blood vessels vasoconstrict (close) quickly to shut off excess bleeding.

A step-by-step approach to diagnosis through the history, physical exam, and imaging tests is presented. First the accident patient is stabilized. Once life-threatening injuries have been taken care of, then other injuries such as pelvic fractures can be assessed and treated.

The medical team must look for internal bleeding and damage to the bladder and urethra. Hip motion is checked to see if the hip is dislocated. Nerve and blood vessels can also be damaged in a high-energy trauma. Neurovascular tests of the legs should be done to rule this out.

X-rays and CT scans are most helpful when identifying the presence, location, and type of pelvic fractures. MRIs have less value but may be used later to look for soft tissue and cartilage injury.

Treatment is usually nonoperative. The surgeon takes the child’s age and type of fracture into consideration. The authors present each type of fracture and review specific medical treatment for each one. Close observation and further tests may be needed for the child with an unstable fracture. In a small number of cases, surgery is required.

The prognosis is good for most children with pelvic fractures. Healing occurs quickly and without long-term problems. Complications can include leg length difference, low back pain, and early arthritic changes. Nerve injuries and myositis ossificans (bone forms in the muscle) can cause problems later.

Infants and very young children with developmental dyplasia of the hip (DDH) are usually treated with a Pavlik harness with good results. A Pavlik harness holds the child in a position with the hips bent and apart. This position keeps the hip in the socket until it stabilizes. Surgery may be needed if this treatment fails to keep the hip in place.

Using traction to pull the leg down and position the head of the femur (thighbone) in the socket is called closed reduction. If that fails, an operation called an open reduction to put the hip back in its socket may be done. Parents and doctors want to know when is the best time to do the surgery?

The authors of this article test the idea that early hip reduction is the best way to avoid a condition called avascular necrosis (AVN). AVN is a loss of blood supply to the hip with bone death. It is a serious complication after DDH. It can lead to joint deformity, a difference in leg length, and problems with walking.

All patients in the study were diagnosed within two months of birth with DDH. Treatment by Pavlik harness failed to reduce or stabilize the hip. Most of the children were then treated with closed reduction by the time they were three months old. Two patients had open reduction.

In a very small number of patients, DDH persisted and a second operation was needed. AVN did not occur in any of the hips treated in the first three months of life with reduction. The results support the authors’ theory that the risk of AVN is decreased after failed Pavlik harness treatment with early hip reduction.

Children in third-world or developing countries often face problems from lack of treatment. In this report, researchers look at the issue of traumatic hip dislocation that goes untreated. What’s the best treatment once the problem is presented?

Options include doing nothing (no treatment) or surgery with a variety of operations to consider. Eighteen children or adolescents in Nepal with neglected, traumatic hip dislocation were treated by open reduction. The results of eight of those children are reported here.

Open reduction is an operation to make an incision and then put the hip back in place. The children ranged in age from two to 16 years old. They came for treatment an average of 12 months after their injuries. All eight patients had signs of avascular necrosis (AVN). AVN is the death of bone cells from a loss of blood supply.

Traction was used at first to try and reduce or reset the hip back in place. This treatment was not successful. Open reduction was the next step. The authors report improved motion and function after the operation. However, normal range of motion was not restored.

AVN did not seem to affect the final outcome. It was more important that the hip was put back in the center of the socket. If the head of the femur (thighbone) wasn’t exactly in the center, other problems developed.

Long-term prognosis for these eight patients remains guarded. If the open reduction doesn’t work, then other (less desirable) surgeries can be considered. For example hip fusion may be needed. Fusion is not the best option in countries where sitting and squatting are part of everyday life.

Detecting hip dislocations early in life caused by developmental dysplasia of the hip (DDH) is important. All newborn babies should be screened in the early months to identify this problem. Early detection and treatment are the key to a good result.

Doctors are taught how to test babies for this condition. But some physicians lack the skill needed to accurately conduct and assess the results of these tests. And the tests can be difficult to do on a screaming, squirming infant.

Some groups have suggested using ultrasound (US) as a screening test for all infants. This is called universal screening. Universal screening is already being done in many other countries.

Others suggest just using US when there are positive risk factors. This type of screening is called selective screening. Risk factors include positive family history of DDH, breech birth, and foot deformity present at birth.

In this report, orthopedic surgeons present the pros and cons of universal versus selective screening. Universal screening helps identify problems and guide treatment early. It costs more to test everyone but it saves money in the long run by avoiding the cost of surgery for many infants.

But routine screening isn’t always a good thing. Many children with unstable hips at birth outgrow the condition without treatment. Family distress is the downside of early detection for everyone. US can also be difficult to carry out and interpret, so results may not always be accurate.

The authors suggest the best time to do an US hip screening program for DDH may be during the first three to six weeks after birth. This gives the hips a chance to stabilize first before testing.

Follow-up with repeat US is advised in children who have additional risk factors. Serial (repeated) US may not be needed for children with normal, stable hips who don’t have any risk factors. More study is needed to evaluate the cost of universal vs. selective screening for DDH.

Legg-Calvé-Perthes disease is a degenerative disease of the hip joint. It primarily affects young children. A loss of blood supply to the head of the femur (thighbone) can cause collapse of the joint.

It’s not clear what causes Legg-Calvé-Perthes disease. Delay in bone maturation is a common feature of this condition. Scientists think there may be a general disorder of skeletal growth. The hip may be just a local expression of the overall bone delay.

In this study, researchers look at the patterns of bone delay in each of the four stages of the disease. Two different methods of X-ray examination were used: the Tanner and Whitehouse 3 (TW3) system and the Greulich and Pyle (G and P) atlas method.

The G and P atlas method is the most commonly used way to estimate bone age. It is based on a single X-ray of the fingers, hand, and wrist. The bones in the X-ray are compared to the bones of a standard atlas. The overall appearance of the X-ray is matched with the closest standard. This method is not as precise as the TW3 rating.

TW3 is a point-scoring method based on the stage of disease present. Each bone gets its own score. The final bone age is based on the sum of all the scores. This may be the first study to use the TW3 system to study Legg-Calvé disease. Hands, wrists, and hips were X-rayed in 83 patients with unilateral (one-sided) hip disease.

Bone age was compared to the child’s chronological (actual) age. Delays in bone age were seen in the wrist bones during the intermediate stages of this disease. There were no differences in bone age delay in early and late disease.

This finding suggests that delays in bone maturation catch up in the healed stage of the disease. This is called bone maturation acceleration. Bone delays in early stages of the disease have a worse prognosis. These children developed more severe disease. The age of the child at the time the disease begins does not seem to be linked with bone age delays.

Children with cerebral palsy often have problems standing up straight and walking normally. The increased muscle tone of the legs causes the knees to bend and move toward each other. The hips are then pulled into a position of internal (inward) rotation. Walking in a crouched position like this uses up energy and leads to a fixed deformity.

Researchers have tried to identify the abnormal activity patterns of muscles causing these changes. Orthopedic surgeons have tried many operations to help with this problem. The results of various studies are often in disagreement.

In this study, surgeons from Vanderbilt University and Shriner’s Hospital measured the effect of hamstring lengthening on hip rotation. The hamstrings muscle along the back of the thigh inserts around the knee. Contraction of the hamstring muscle bends the knee.

The goal was to increase knee extension by lengthening the hamstrings. The hope was that with more normal knee motion, the hip could move out of the internally rotated position that contributes to the crouched gait (walking) pattern.

Thirty-eight children with spastic diplegia cerebral palsy were included in the study. Spastic diplegia means that only the legs are affected by the condition. Before surgery, hip and knee range of motion (ROM) were measured. Full body gait analysis was also performed in a special motion analysis lab.

Surgery was done to release and lengthen the hamstring muscle. In some patients, other soft tissue procedures were also done at the same time. Everyone had rehab for six to 12 weeks afterwards. ROM and gait analysis were assessed again after surgery.

Although knee extension increased, hip rotation (internal and external) decreased when measured while lying still on a table. The authors reported that hamstring lengthening did decrease internal hip rotation when measured while walking. The surgery did help the children stand up out of the crouch position. Standing posture and gait pattern were not normal but improved.

Clubfoot in children is a common deformity that causes the foot to be twisted in and turned down. Sometimes it affects both feet, but in many children it is unilateral (just on one side). Studies of unilateral clubfoot often use the unaffected side as normal for comparison. But is it really normal?

In this study, researchers compare weight-bearing forces through the
unaffected foot of children with unilateral clubfoot to normal feet of
children who don’t have this condition.

The children in both groups were between four and eight years old. A small
group of 16 children with unilateral clubfoot and 110 normal children were
included. Thirteen of the children with clubfoot had surgery by the same surgeon by age one year.

The children in both groups were asked to walk along a surface that could measure forces through the foot with each step. Peak pressure was measured for each of 10 points on the foot from the heel to all five toes.

Analysis of the results showed a major difference between the two groups.
Children with unilateral clubfoot had less ground reaction force on both sides
compared to the normal group.

For example, when the foot was flat or during toe-off while walking, forces in
the midfoot were much less in the unaffected side of the clubfoot group
compared to the normal group. In general, the peak pressures in the unaffected foot of the clubfoot group were lower than in the feet of normal children.

These results suggest a previously undetected change in the motor pattern of the clubfoot group. The nervous system may be trying to adapt and make the gait pattern equal and even from side to side.

This is the first study to show that pressure distribution on the bottom of
the unaffected foot is not the same for children with unilateral clubfoot as
it is for children without clubfoot. Although it means recruiting more people
for studies, the authors advise against using the unaffected foot as a control
or comparison in studies of clubfeet.

The results of treatment for children with clubfeet isn’t always satisfactory to the parents. An inwardly curved foot called forefoot adduction may persist. This is the most common reason parents aren’t happy with how the foot looks.

The exact cause of FFA isn’t clear. It may be because the navicular bone is moved too much medially (shifted toward the other foot). The navicular bone is the bump you may feel along the top of your foot between the ankle and your forefoot.

In this study, ultrasound is used to view the position of the navicular in children three years old and older who have had surgery to correct clubfeet. Hand drawn imprints of the foot are also made with the child standing. The foot drawings can be used to measure the severity of the FFA. The researchers suspect the more displaced the navicular, the worse the FFA.

What they found was no relation between the navicular and FFA. They did find that the worse the FFA, the more dissatisfied parents were with the results. And they report that ultrasound is a good way to measure the position of the navicular.

Another study is needed to look at other bone displacement as a possible cause of FFA. Once the exact mechanism for FFA is discovered, then treatment to correct the problem may result in a better looking foot after clubfoot correction.

In this study, researchers at the Cleveland Clinic Foundation (Ohio) report on which reconstructive osteotomy restores normal muscle length in patients with slipped capital femoral epiphysis (SCFE). They also try to answer the question of how muscle length differs in hips with mild versus severe SCFE deformity.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip in teenagers between the ages of 12 and 16. In this condition, the growth center of the hip (the capital femoral epiphysis) slips backwards on the top of the femur (the thighbone). If untreated, this can lead to serious problems in the hip joint later in life.

Surgery is usually done right away. A single long screw is used to stop the epiphysis from slipping further. If this doesn’t work, then another operation may be needed to restore normal hip alignment and keep the situation from getting worse. In such cases, the most commonly performed operation is the reconstructive or wedge osteotomy.

One of the drawbacks of this operation is a compensatory deformity that alters hip function. The position of the hip abductor muscles changes resulting in decreased hip strength and motion. By using a life-sized synthetic model of the pelvis and hip, two methods of wedge osteotomy were evaluated.

The length of the abductor muscle was measured after subtrochanteric and femoral neck base osteotomies. All of the changes in muscle position and length were observed when the hip was bent or flexed. The model explains this by seeing how much hip rotation is needed to bend the hip when there is a severe SCFE deformity.

The results of this study confirmed that the osteotomy done at the femoral neck base was better able to align the hip in a normal position. Osteotomies done higher on the femur can cause greater deformity. A detailed description of the anatomy and changes in muscle length was provided for each procedure.

The authors admit their use of a plastic model may not mimic normal human anatomy exactly. Muscles and tendons tend to adapt over time in response to bony deformity. Such changes were not figured into the mechanical model in this study. Further study of this problem is needed.

Infants seen at birth and for early well-child checks are screened for hip problems. Developmental dysplasia of the hip (DDH) is the most common problem. DDH is a shallow hip socket. It can be mild with flattening of the hip joint, or it can be severe enough to cause hip dislocation.

Until recently, children who developed DDH later in childhood were assumed to have DDH at birth that was missed in screening (or not screened at all). In this study five cases of late developing DDH point to the possibility that something else is going on.

All five cases were born with normal hip anatomy. X-rays were taken with no sign of instability or dislocation. Three of the children had a positive family history for DDH. Only one patient had a positive sign of hip dislocation early (three months). The rest were not diagnosed until the child started to walk with a limp.

Other studies have also reported similar findings. The authors conclude that missed cases of DDH may not be missed at all but late in developing. They advise that all newborns have repeated exams during the first year of life for hip instability. Any child with a family history of DDH should be followed until they walk. Ultrasound can be used to confirm the diagnosis when DDH is suspected.

More and more young adults are showing up in doctors’ offices with hip pain. Increased activity and sports participation may be part of the reason for this problem. On the other side of things, inactivity and obesity may be at fault. In either case, increased wear on the hip joint results in hip pain.

In this review, the key elements of patient exam and workup are presented for diagnosing the problem. The doctor must consider hip-related and nonhip-related disorders when looking for the cause of the problem.

The low back and sacroiliac joints can refer pain to the hip. So can some intestinal, kidney, and gynecologic problems. Hip and groin pain in men can be caused by prostate or testicular problems.

When hip pain is really coming from the hip, there can be many different underlying problems. Degenerative joint disease, impingement, cartilage tears, and bursitis are just a few of the more common conditions causing hip pain.

More serious problems such as fracture and dislocation must be considered. In rare cases, tumors or infection may be the cause of hip pain. In all cases, the surgeon relies on the patient’s history and a physical exam to make the initial diagnosis. Tests for motion, soft tissue tightness, and cartilage tears are carried out in the office.

Depending on the results of the initial exam, further testing such as X-rays, CT scans, or MRIs may be needed. Specifics in diagnosing osteoarthritis, impingement, osteonecrosis (bone death), and labral tears are offered. Bursitis, stress fractures, snapping hip syndrome, and inflammatory arthritis are also included.

Risk factors, symptoms, and specific tests for each of these problems are discussed. A brief mention of treatment for each diagnosis is included. The authors promise a second article in a later issue of this journal to expand on the treatment of these various hip problems.

For the last 70 years, physicians have used the Ortolani test or maneuver to check infants for hip dislocation. With Ortolani’s test if the hip is dislocated, it can be put back into the hip socket.

The examiner abducts or moves the infant’s legs apart. If the hip is dislocated, during this motion, the head of the femur slides over the rim of cartilage that is around the hip socket. There is a click or clunking sensation as the head of the femur slips back into the socket. This is called a positive Ortolani’s Maneuver.

In this study, the results of an Ortolani test are compared to findings seen on ultrasound (US). US is an imaging study that has been shown effective in detecting hip dislocations from hip dysplasia.

Four hundred (400) infants were included in this study. All of the babies had been diagnosed with developmental dislocation of the hip. Forty-five (45) patients were in Group 1 (Ortolani positive). Twenty-four (24) patients in group 2 were Ortolani negative but had a positive US for hip dislocation.

After careful study and comparison, the researchers found that age was the main difference between these two groups. The Ortolani test appears to be more reliable with younger children (less than one month old).

In older children, the cartilage around the hip is deformed. The expected clunk may not be present on testing despite the fact that the hip is really dislocated (Ortolani negative). Or the cartilage forms a second false socket trying to stabilize itself. The physician may feel a click or clunk as the hip slips into the false socket.

The authors conclude that the clunk is always a sign of a dislocated hip (positive Ortolani’s test). However, a positive Ortolani’s does not necessarily mean the hip has relocated back into the socket. Imaging studies must be done to know for sure. This second step is important to prevent treating a hip that can’t be fixed without surgery.

When a doctor writes a prescription for a brace, it can be months before the child actually receives it. Type of insurance makes a difference in how long the child must wait. In this study, three types of insurance are compared. Government, health maintenance organizations (HMOs), and preferred provider organizations (PPOs) are included.

Data was recorded by a single orthotic company (brace supplier) providing ankle or trunk braces for 60 children. The number of days between prescription and insurance company approval was recorded. The time between prescription and actually receiving the brace was also tracked. The orthotic company received the prescription the same day it was written. The brace was ready within two weeks of insurance authorization.

The authors report big delays for children covered by government insurance. More expensive (trunk) braces took longer than less expensive (ankle) braces. They had to wait up to four months longer to receive their braces compared to children with PPO coverage. PPOs were faster than HMOs in approving this treatment.

Delays were not all caused by insurance. Once the brace was ready, families with government insurance took three times as long to pick up the braces. Lack of phone service, change in address, and transportation problems may be factors. Language barriers and time off from work may be other problems causing delays.

The authors conclude that access to care and quality of care is based on insurance status. But it’s also true that a lack of cooperation on the part of the family has some impact. Finding a way to streamline this process and increase patient compliance are the next steps in delivering treatment on time.