How to diagnose and manage basic pediatric fractures in the primary care clinic
Identifying fractures and injuries that require further workup and referral
Initiating early evaluation for benign and malignant bone tumors
Implementing appropriate referrals
This virtual lecture is part of a series provided by CHOC that aims to bring the latest, most relevant news to community providers. You can register here.
CHOC is accredited by the California Medical Association (CMA) to provide continuing medical education for physicians and has designated this live activity for a maximum of one AMA PRA Category 1 Credit™. Continuing Medical Education is also acceptable for meeting RN continuing education requirements, as long as the course is Category 1, and has been taken within the appropriate time frames.
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When 7-year-old Naomi Adrian took a spill on the school playground early this year and a schoolmate fell on top of her left leg, she got up with a slight limp.
After what appeared to be a bruise kept growing, and as she continued to walk awkwardly, her mother, Maria Nino, took her to the doctor.
A subsequent visit to a specialist revealed a tumor — an osteosarcoma, a type of bone cancer — on the Riverside girl’s left distal femur, the area of the leg just above the knee joint.
When a Riverside doctor who was supposed to remove the tumor was unable to see her on the day of the planned surgery, Maria rushed Naomi to CHOC.
Thus began a medical journey that showcases CHOC’s commitment to outside-the-box thinking when it comes to patient care, including investigational therapies, diagnostics, and devices — as well as the benefits of CHOC’s partnership with UCI Health.
In Naomi’s case, her lead physician at CHOC, Dr. Amir Misaghi, an orthopaedic surgeon with specialties in pediatric orthopaedics and musculoskeletal oncology, was able to secure a device that doesn’t have U.S. Food & Drug Administration approval yet for use in pediatric patients to help him successfully remove the tumor and reconstruct Naomi’s leg.
“I’ve used it before,” Dr. Misaghi said of Onkos Surgical cutting guides, “but this was the first time I’ve used it in a pediatric patient.”
Ruling out other surgical options that he deemed less promising and more onerous on young Naomi’s growing body, Dr. Misaghi, who came to CHOC in October 2019 from Children’s Hospital of Philadelphia, used the Onkos device after his one-time compassionate use trial request was approved by the FDA.
In the surgery, in which Dr. Misaghi was assisted by orthopaedic surgeon Dr. Carl Weinert, the Onkos 3D resection guides, which were customized to Naomi’s leg and the growing tumor on it, helped the surgeons make extremely precise cuts as they removed the baseball-sized tumor and surrounding bone while sparing Naomi’s knee joint and the part of her bone that grows through adolescence.
Dr. Raj Vyas, chief of plastic surgery at CHOC and vice chair of plastic surgery at UCI School of Medicine, then began to reconstruct Naomi’s femur. To do this, he dissected free a segment of Naomi’s fibula bone along with the artery and vein that supply that segment of bone.
The fibula bone runs on the outside of the leg from the knee joint to the ankle joint and can be mostly removed without affecting one’s ability to bear weight.
Drs. Misaghi and Vyas then worked together to hollow out a cadaveric arm bone (humerus) and insert Naomi’s fibula bone into its core. The cadaver humerus bone was custom selected to match the size of Naomi’s femur and provide structural support. Dr. Vyas then connected the artery and vein supplying the fibula bone to a nearby artery and vein in the leg using microsurgical techniques. This allowed the vascularized fibula to “bring back to life” the cadaveric humerus bone so that it can continue to grow with Naomi.
“This was pushing the envelope as far as reconstructive surgeries go for this type of thing,” Dr. Misaghi said.
Said Dr. Vyas of the 10 hours he worked on Naomi’s leg: “In kids, it’s especially an advantage to use their own tissue if possible; if we didn’t have the ability to do this miscrosurgery, then we would have just done an inferior operation. Being able to work together and plan to do this at a children’s hospital with Dr. Misaghi’s expertise and our expertise at UCI Health, we were able to provide to Naomi state-of-the-art reconstruction.
“A while ago,” Dr. Vyas added, “maybe at some hospitals they would have just performed an amputation. Because we have Dr. Misaghi, who can do a limb salvage using a cadaver graft, we were able to really perform the best operation possible.”
Alternative treatments that Dr. Misaghi ruled out for Naomi included a rotationplasty, which would have resulted in the loss of her knee joint and a large portion of her leg, thus requiring a prosthesis; and another technique that also would have meant the loss of her knee joint and a prosthesis that would have required several subsequent surgeries as Naomi grew.
A very active child, Naomi loved to participate in ballet and gymnastics before her diagnosis on March 3, 2020.
“Hopefully we can get her back dancing,” Dr. Misaghi said. “That would be the goal.”
Trips to the park
These days, as Naomi continues to undergo chemotherapy, the now-8-year-old enjoys trips to the park where her sister, Itzel, or other relatives push her in her wheelchair.
Naomi, whose family since has relocated to the Fresno area, also loves arts and crafts, her dolls, and playing with her twin sister, Natalie.
“I felt sad (when diagnosed), but I knew that someone was always with me,” Naomi says of her cancer journey. “Thanks to Dr. Misaghi (and others), they saved my leg and I’m feeling happier now.”
So far, Naomi is progressing very well, said Dr. Misaghi, who keeps regular tabs on her. A year out from surgery, Naomi will be back at CHOC for a second surgery to remove screws that were placed near her growth plate.
“It remains to be seen how her growth plate responds,” Dr. Misaghi said. “But the survival part of her prognosis is very good since she had clear margins and she’s gotten back on the chemo, and so the function of her leg prognosis is very good. She has a normal knee joint. And hopefully when everything heals, she’ll have some metal plates remaining but be able to grow normally with her own growth plate.”
In a Zoom call, Naomi, wearing a white bow on her head, was asked how her leg felt.
“Good,” she said.
Can you walk and do normal things?
“Not yet. Maybe in a year.”
Naomi’s oldest sibling, Itzel, 20, said Naomi has been a champ through the entire process.
“She never complained about pain even after the surgery,” Itzel said.
Itzel and her mother are grateful for the excellent care Naomi received at CHOC.
“We knew that it would be very hard for her to accept losing her leg,” Itzel said. “We were happy that there was a way that that could save not only her life, but her leg.”
Said Maria: “We are extremely grateful to God for listening to our prayers and with the amazing doctors, nurses, and staff at CHOC. I want to especially thank Dr. Misaghi and Dr. Vyas as they made sure Naomi got the care she needed. They are a great team. May God continue giving them the intelligence and determination to continue to save other kids’ lives.”
Naomi already knows what she wants to be when she grows up.
“I want to be a surgeon so I can save other people’s hands and legs,” she said.
For more information about the Hyundai Cancer Institute at CHOC, click here.
Earlier this year, orthopaedic surgeon Dr. Amir Misaghi joined the CHOC Orthopaedics Institute. A member of CHOC’s sarcoma team, his special clinical interests range from bone and soft tissue tumors to limb deformities. He shared with us why he decided to become a doctor, new developments in his field, his hobbies outside of work and more.
What is your education and training?
I completed my undergraduate, medical school and orthopaedic surgery residency all at the University of California, San Diego, followed by a pediatric orthopaedic fellowship at Children’s Hospital of Philadelphia and an orthopaedic oncology fellowship at Mayo Clinic in Rochester, Minn.
What are your special clinical interests?
My clinical interests are bone and soft tissue tumors, trauma, hip disorders, limb deformities and other standard pediatric orthopaedic conditions. The vast majority of tumors in kids are benign but can still be complicated. Tumors can be found in difficult-to-operate areas, or be benign but hard to eradicate, so having both a pediatric orthopaedic and an orthopaedic oncology background helps me manage these complexities.
Why did you decide to become a doctor?
I love working with and helping others, and I was drawn to orthopaedics because I’ve always enjoyed using my hands to build and repair things. I also like working in pediatrics because I find kids fun and fascinating to be around. Oftentimes, especially when working with pediatric cancer patients, some very difficult situations and decisions arise, but I feel privileged to partner with families and navigate these challenges alongside them. Kids tend to do remarkably well and have incredible resilience, and I have encountered very powerful moments working in this field. It is an amazing feeling to witness my patients growing up and thriving.
What are some new programs or developments within your specialty?
CHOC is an amazing place with a fantastic pediatric orthopaedic department and cancer center.
Pediatric orthopaedics and pediatric orthopaedic oncology have changed with advances in growing type prosthesis for limb salvage surgery, as well as advances in lengthening limbs and restoring function after major trauma or cancer treatment. We have access to many exciting new pediatric-focused technologies at CHOC.
CHOC also has a great sarcoma team, and it is incredibly rewarding to be part of this multidisciplinary group. We take care of complex patients with the shared goal of providing the best care and getting them back to living happy, healthy lives. I love being able to work closely with Dr. Elyssa Rubin, medical oncologist, and Dr. Raj Vyas, plastic surgeon, to grow our limb salvage and musculoskeletal oncology/sarcoma program. We also have fantastic pediatric interventional radiology with Dr. Tamman Beydoun, and an amazing pathology department with Dr. Aaron Sassoon and Dr. Ali Nael.
What would you most like referring providers to know about you or your division at CHOC?
I want providers to feel confident referring patients to us. We are set up to take care of all benign and malignant bone and soft tissue tumors with a comprehensive team. The oncology program at CHOC is a dedicated group of multidisciplinary providers, including oncology, pediatric surgery, radiation oncology, interventional radiology, radiology and pathology. We meet weekly at our oncology tumor board meeting to discuss complex cases, ensuring we can provide up-to-date, cutting-edge treatment. We are fully equipped as a sarcoma team to manage all malignant bone and soft tissue tumors, and we all focus specifically on pediatrics.
What inspires you most about the care being delivered here at CHOC?
The various providers and patients inspire me. I am constantly impressed by the dedication of the nurses, physicians, child life specialists and countless other staff who work so hard. Taking care of pediatric patients, seeing their strength and witnessing them overcome their challenges is incredible.
If you weren’t a physician, what would you be and why?
I would open a small restaurant – I have always loved cooking, especially outdoors. One of the things I love most about my current job is talking to and getting to know my patients and their families. I think that the restaurant world might offer similar rewarding interactions with people, like chatting with regulars over the years, all while making delicious food.
What are your hobbies and interests outside of work?
I enjoy outdoor activities like camping and fishing, and have recently been trying to interest my kids, ages 3 and 7, in these hobbies as well. We’ve also taken up gardening as a family, and we are always ready for a good barbecue or soccer match.
What have you learned from your patients?
I’ve learned that life is a marathon, not a sprint. It is a joy to watch kids heal after surgery, and to then see them months or years later recovered and back to life. They have also taught me some practical things to keep me plugged in to what is cool and trendy. Recently I was educated about TikTok and some of its popular personalities – one patient suggested I even make a TikTok profile and start showing off some of my dance moves.
CHOC wants its referring physicians to get to know its specialists. Today, meet Dr. Francois Lalonde, a board certified pediatric orthopaedic surgeon.
Q: What is your education and training?
A: I attended medical school at University of Toronto School of Medicine. I completed my orthopaedic surgery residency at the University of Ottowa, and a pediatric internship at Montreal Children’s Hospital/McGill University. I completed a pediatric orthopaedic surgery fellowship at both Children’s Hospital of Eastern Ontario/University of Ottawa, and San Diego Children’s Hospital and Health Center/University of California San Diego.
Q: What are your current administrative appointments?
A: I am president of the CHOC Orange medical staff; medical director of the hip program, CHOC Orthopaedic Institute, member of the CHOC board; and president of Adult & Pediatric Orthopaedic Surgery medical group.
Q: How long have you been on staff at CHOC?
A: 11 years.
Q: What are your special clinical interests?
A: My clinical interests include infant, child, adolescent and young adult hip conditions (DDH, Perthes, SCFE, impingement); pediatric fractures and musculoskeletal injuries; pediatric foot conditions and reconstructive surgery; general pediatric orthopaedic conditions; limb lengthening; surgical treatment of bone deformity in osteogenesis imperfecta; and cerebral palsy.
Q: What are your most common diagnoses?
A: We see a variety of conditions, including forearm and elbow fractures; developmental dislocation of the hip in infants; Perthes disease; slipped capital femoral epiphysis (SCFE) condition of the hip; joint, extremity pain in children, adolescents (overuse, growth related); idiopathic adolescent scoliosis; among others.
Q: Are you working on any current research?
A: Yes, on Legg-Calve-Perthes research. We are looking at our five year experience with patients treated with open hip adductor lengthening, range of motion, nighttime orthosis and limited weight bearing protocol. Our patients have maintained femoral head sphericity and containment with congruent hip joint with very limited surgery. Many patients have been back to sports without any symptoms.
Q: What are some new programs or developments within your specialty?
A: Orthopaedic surgeons are better able to diagnose hip impingement based on radiographic and imaging assessment and depending on severity of underlying findings or condition, treat this condition with arthroscopy or surgical hip dislocation with femoral head/neck osteochondroplasty and/or acetabular rim trimming. In doing so, we are better able to differ the onset of premature degenerative changes (arthritis) of the hip.
Advanced hip joint preservation surgical techniques such as the Ganz periacetabular ostetomy and relative femoral neck lengthening have emerged to treat the sequelae of developmental dysplasia of the hip and other childhood conditions. In the appropriate setting, these surgical techniques are able to relieve hip pain and significantly delay or prevent the onset of premature degenerative changes (arthritis) of the hip.
A modular magnetic intramedullary nail (Precise nail) is now available to allow orthopaedic surgeons to lengthen the femur or tibia by up to 8 cm in patients with moderate or large limb length inequality. This internal device is being better tolerated by patients with less soft tissue irritation.
In addition, for several years now, the Fassier-Duval telescoping intramedullary nail has been used at CHOC to correct severe deformities of the femur and/or tibia in patients with osteogenesis imperfecta. This modular implant which is anchored at the top and bottom telescopes as the bone grows and has helped avoid multiple revision surgeries in childhood due to migration of the implant and refracture.
Q: What would you most like community providers to know about your division at CHOC?
A: Our division covers the entire spectrum of subspecialties in pediatric orthopaedics (fractures, upper extremity, spine, hip, lower extremity, sports medicine, foot/ankle, bone tumours, neurosmuscular conditions – cerebral palsy, spina bifida, muscle disease, osteogenesis imperfecta, brachial plexus injury, concussion. We have three offices in Orange, Irvine and Mission Viejo, in addition to the CHOC Clinic. We try to see our referral patients promptly, and are accessible by phone for questions from physicians.
Q: What inspires you most about the care being delivered at CHOC?
A: I’m inspired by the expertise, drive and dedication of our physicians, nurses and support staff, as well as our state-of-the-art facility, the wide range of subspecialists within pediatrics, the emphasis on patient safety and experience, and the emphasis on delivering high level quality care to our patients.
Q: Why did you decide to become an orthopaedic surgeon?
A: I decided to become a doctor as a teenager. I had a part-time job as a lifeguard at local pools and beaches in Ottawa, Canada, in which I was required to take first aid courses, and that piqued my interest. Later, while attending university, I worked as a children’s swim instructor and gained interest in pediatrics and pediatric orthopaedics. I became interested in orthopaedic surgery as a medical student during a pediatric orthopaedic surgery rotation when I was exposed to a great role model.
In addition, my uncle, who is an obstetrician and gynecologist, was an early role model. I often listened to him talk about his work and schedule during the summer. I used to spend the entire summer at my parents cottage in the Laurentians in Quebec, Canada. My uncle’s cottage was right next door. I liked the diversity of his daily routine. His days were busy either seeing patients in his office for initial consultation or follow-up, or performing surgeries/delivering babies.
Q: If you weren’t a physician, what would you be and why?
A: I would have become a marine biologist. I became interested in this field by watching documentaries, taking biology classes, and by scuba diving.
Q: What are your hobbies/interests outside of work?
A: I enjoy playing ice hockey, as well as watching or attending all sports events.
Q: What have you learned from your patients?
A: I have learned that making funny noises when I examine babies’ hips really distracts them and elicits a smile and lets me conduct my exam more effectively and reliably. With older kids, I have learned how challenging it is to treat great athletes, who present with joint or extremity pain often from overuse, and they can find it difficult to commit to a period of rest, which is often necessary to allow for recovery.
Q: What was the funniest thing a patient told you?
A: One of my patients keeps asking me, “Where is your gold tie?” The first time he met me I was wearing a gold tie. Every time he sees me now, he asks me about my gold tie. I keep asking him to call me the day before so that I can wear it on the day he comes but he keeps forgetting to call.
A new orthopaedic surgeon with special training in orthopaedic trauma has joined the CHOC Orthopaedic Institute team. Dr. Jessica McMichael specializes in the care and treatment of fractures and a variety of pediatric musculoskeletal disorders, including limb and foot deformities, and cerebral palsy.
“There is incredible talent here,” Dr. McMichael says proudly of her team. “Several of my colleagues have been amazing mentors.”
Dr. McMichael is working with the CHOC team to develop a multidisciplinary comprehensive bone health program, which would serve children with osteogenesis imperfecta, muscular dystrophy and other conditions that impact bone health.
After completing medical school and her residency at Saint Louis University School of Medicine, Dr. McMichael served as an orthopaedic surgeon in the U.S. Air Force in Korea. Later, she provided trauma care training to military personnel as an adjunct faculty at the Center for Sustainment of Trauma and Readiness Skills in St. Louis, Missouri. Dr. McMichael completed her pediatric orthopaedic surgery fellowship at Shriners Hospitals for Children Northern California/UC Davis Medical Center.
It was during her fellowship at Shriners that Dr. McMichael became captivated by her young patients’ resilience.
“It was so invigorating to take care of someone who just wanted to play and get better,” she says. “It’s like kids are programmed to do well. That helps in their care and recovery.”
A fierce advocate for families, Dr. McMichael strongly believes in treating her patients and their parents exactly how she would want herself and her family to be treated.
“I like to take the time to listen to their questions,” she explains. “I know that if they’re at the clinic or hospital, they have probably taken time from work, school or other duties, and I want to show them that their time is valuable to me.”
This dedicated physician is a board-certified orthopaedic surgeon with the American Board of Orthopaedic Surgeons. She is a member of the Pediatric Orthopaedic Society of North America, the Orthopaedic Trauma Association, and the American Academy of Orthopaedic Surgeons, among other professional organizations.
In her spare time, Dr. McMichael enjoys spending time with her husband and daughter, reading, camping, and any Disney-related activities.
To contact Dr. McMichael, please call 714-633-2111.