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AAP releases Choosing Wisely list for pediatric orthopedics patients

The AAP, along with the Pediatric Orthopaedic Society of North America, has released a list of procedures and orthopedic tests that are often ordered but not always necessary for treating children with hip, foot and musculoskeletal conditions.

“There should always be a conversation between physician and patient on what procedures and tests are really necessary,” Brian Shaw, MD, FAAP, FAAOS, a member of the AAP Section on Orthopaedics, said in a press release.

The list is part of the Choosing Wisely campaign, an initiative of the ABIM Foundation. The Pediatric Othopaedic Society of North America (POSNA) Evidence Based Medicine Committee and the AAP Section of Orthopaedics, which includes more than 150 orthopedic surgeons and sports medicine physicians, worked between 2014 and 2015 to develop five items of tests or procedures that should not be done routinely. There were approximately 20 members between the two committees.

The five recommendations include:

1. When a baby exhibits no risk factors or physical findings, a screening hip ultrasound to rule out developmental hip dysplasia or developmental hip location should not be ordered.
2. For children aged younger than 8 years who have a mild in-toeing gait radiographs should not be ordered and bracing or surgery should not be recommended, because the condition usually reflects an ongoing maturation of the skeleton. Instead, physicians should monitor the child’s gait at well-child examinations until age 7 or 8 years.
3. If a child has mild flat feet, custom orthotics or shoe inserts should not be ordered. Observation or over-the-counter orthotics can be used if an arch is present when standing on tiptoe.
4. Advanced imaging studies (MRI or CT) should not be ordered for most musculoskeletal conditions in a child until all clinical laboratory and radiographic examinations are completed.
5. If an injury is no longer tender or painful, follow-up X-ray studies for buckle (torus) fractures are unnecessary. The fractures are stable and do not usually require a formal cast, unless the patient is in severe pain or fracture instability makes a cast necessary for 4 weeks. Often, a wrist brace or removable sprint is preferred.

Some advanced imaging methods are costly and also easily misinterpreted and could require sedation of young patients, according to the release.

“We know that some conditions require simple monitoring and can be resolved over time,” Harold van Bosse, MD, chairperson for the POSNA Committee on Advocacy, said in the release.  “For instance, custom shoe inserts and braces are not always necessary and may even be ineffective.”

The Choosing Wisely campaign is an initiative to encourage conversations between clinicians and patients to help determine care that is supported by evidence but does not duplicate other procedures already received, and is truly necessary, according to the release.