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.5 min read
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
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 manipulation generally has no place in the treatment of pediatric orthopaedic conditions. Manipulation will not stop the 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.