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Common Problems Seen by Pediatric Orthopaedic Surgeons
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 achieve.
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 scoliosis.
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 injuries.
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 that time.
* This article is presented and copyrighted by The 'Lectric Law Library
and Dr. Steven E. Lerner & Associates (www.drlerner.com)