Pediatric orthopaedic surgeons deal with the
problems of bone, joint, spine and limb development in the growing
child. These problems can be congenital (i.e. present at birth),
developmental (occurring spontaneously during growth) or traumatic.
Many orthopaedic conditions can be evaluated and treated by generalists
but others require pediatric orthopaedic expertise. Pediatric
orthopaedists should have one year of additional training beyond the
five year orthopaedic residency. This latter time is spent learning
about the growing skeleton and its difference from the adult.
Congenital problems will be foot deformities such as
clubfeet, hip disorders such as congenital or developmental dislocation
or the orthopaedic manifestations of cerebral palsy or spina bifida.
Clubfeet and dislocated hips require timely identification and referral
for optimal outcome. Clubfeet are casted but most require surgical
intervention. This is generally performed under one year of age. The
child should be able to walk and run without a limp following a
satisfactory surgical result. Dislocated hips may be difficult to
diagnose. A primary care provider must document a hip exam in the
nursery and at subsequent well baby checks. Breech babies are at high
risk. If discovered under age 6 months the hip can be treated in a
brace. After that time casting is needed and after 12 - 18 months of
age surgery is the treatment. A good result can be obtained after
walking age but requires significantly more work, entails greater risk
and after age 5 or so good long term results are much more difficult to
Slipping of the Hip Epiphysis and Scoliosis:
As children enter pre-teen and teenage years
slipping of the hip epiphysis (or growth center) and scoliosis occur.
Slipped epiphyses occur more commonly in overweight individuals but not
exclusively. If caught early the hip can be pinned in place without a
long term problem but if allowed to slip further the result is early hip
arthritis. Many slips present with knee pain rather than hip pain and
are detected late. Pinning should be done soon after diagnosis as the
hip could slip further. The pinning should also be done differently
than a hip fracture with a single, cannulated type screw. Two screws
can be used in rare cases.
Scoliosis, or curvature of the spine, is common
in teenage girls. This should be screened for in a pre-school physical.
Curves progress the most just prior to the onset of menses and should be
followed while the child is growing. The patient should be braced if
the curve is above 25 - 30 degrees and the patient has growth remaining.
Curves should not be allowed to get over about 50 - 55 degrees without
being closely followed as those curves may continue to progress as
adults leading to a slow, gradual worsening with eventual back pain and
higher risk at surgery. Chiropractic mainuplation generally has no
place in the treatment of pediatric orthopaedic conditions.
Manipulation will not stop progression of scoliosis and may waste time.
Slipped epiphyses will also progress if treated with manipulation alone.
Electrical stimulation has been shown to be ineffective in treating
Fractures are common in the pediatric population.
Fortunately most children do extremely well and do not require
"anatomic" or perfect alignment. Over time and with growth the bone
will usually align itself within given parameters. This does not mean
that all degrees of angulation will correct but the younger the patient
the more one can accept. The orthopaedic surgeon must know to what
degree and in what plane remodeling can be expected to occur. Pediatric
fractures are treated non-operatively more frequently than adult
fractures but that does not mean a less than optimal result should be
accepted. When fixing a pediatric fracture the surgeon must be
cognizant of the growth center. This should not be injured during the
surgery and must be aligned well if the fracture traverses the growth
plate. Growth plate injury is more commonly the result of the initial
trauma than of surgical damage to the growth center.
Femur fractures are common and often problematic.
They must be "set" short as growth stimulation accompanies healing. In
the first 18 months following fracture the femur overgrows and the
result should be a leg length within 1 - 2 centimeters of the other
side. This overgrowth is variable and hard to predict. Fractures set
out to length in traction in the 2 - 10 year old age group may overgrow
too much. However, leg length discrepancies under one inch will not
lead to scoliosis or a higher incidence of back pain
Pediatric Problems Associated with Managed Care:
Managed care has impacted orthopaedic care
significantly as most systems are not set up to deal well with trauma or
unusual situations. Trauma in orthopaedics is rarely life threatening
so it is questionable whether it falls under the category of emergency
treatment in most managed care plans. In that regard care is often
denied or deferred when out of area or until a referral can be sent in.
This commonly leads to treatment that is below the standard of care. As
an example fractures that could be treated with simple manipulation
within the first few days subsequently will require open surgical
manipulation. This involves more risk and a scar. Slipped epiphyses
that are not pinned can displace further. Infections that could be
treated with antibiotics will require surgical debridement and tumor
cases can go on to pathologic fracture. Many plans "make do" with a
small number of general orthopaedists who may lack the expertise in
esoteric conditions. Bone cysts are unnecessarily biopsied, congenital
syndromes are missed and fractures are overtreated as adult type
Children with disabilities are seen by pediatric
orthopaedists. These can be cerebral palsy, spina bifida
(myelomenigocele), muscular dystrophy, traumatic brain injury, spinal
cord injury, etc. There are entire journals devoted to these conditions
and it is hard for a generalist to keep up on all. Surgery in these
conditions may have unexpected outcomes if appropriate pre-operative
evaluation is not performed.
Tendon lengthening, osteotomies and spinal
fusions are common surgical procedures but must be considered in light
of the whole patient and whether or not the patient will benefit. Even
when appropriately carried out re-do procedures are not uncommon.
Surgeons should have experience in dealing with these conditions.
Anorther area that differs from adults is total
joints. There is little indication for total joint replacement in
skeletally immature patients or teenagers. Patients with chronic
arthritis (juvenile rheumatoid arthritis or other inflammatory
conditions) are the exception and possibly sickle cell disease although
there is an early failure rate of 50% in this latter group often due to
infection. Other patients with destroyed hip joints are best treated
with hip joint fusion. Joint replacement seems more "space age" but
will not have the longevity or durability of a fusion. Hip joint
fusions can be taken down in 20 years or so and a total joint placed at
* This article is presented and copyrighted by The 'Lectric Law Library
and Dr. Steven E. Lerner & Associates (www.drlerner.com)