Pediatric orthopedics
Pediatric orthopedics is a specialized branch of medicine focused on the diagnosis, treatment, and management of musculoskeletal conditions in infants and children. This field addresses a variety of congenital deformities, such as clubfoot and congenital hip dislocation, as well as conditions resulting from neuromuscular disorders like cerebral palsy. Pediatric orthopedic surgeons undergo extensive training, including medical school, general surgery or primary care internship, orthopedic residency, and a fellowship in pediatric orthopedics.
The approach to treating children's musculoskeletal issues often involves a combination of non-invasive methods, such as splints, braces, and physical therapy, alongside surgical interventions when necessary. Given that children's bones are still growing, treatment must be carefully tailored to avoid complications that could affect future growth. Furthermore, pediatric orthopedic specialists balance their time between clinical evaluations and surgical procedures, emphasizing the importance of involving families in decision-making processes regarding their child's care. With advancements in medical technology and techniques, the future of pediatric orthopedics looks promising, ensuring continued support for children facing orthopedic challenges.
Pediatric orthopedics
Anatomy or system affected: Bones, feet, hands, joints, knees, legs, ligaments, muscles, musculoskeletal system, nerves, nervous system, tendons
Definition: The evaluation and treatment of diseases and injuries of the musculoskeletal system and related nerves in infants and children
Science and Profession
The pediatric orthopedic surgeon has received additional training in the management of the orthopedic problems of infants and children. Four years of medical school are followed by one year of internship in either general surgery or primary care. Next comes four years of orthopedic residency, then an additional year of fellowship in pediatric orthopedics. After completing training, this specialist usually works in a community with a large referral hospital or in a children’s hospital.
The word “orthopedics” comes from two Greek root words, orthos (“correct” or “straight”) and pais (“child”). Childhood musculoskeletal diseases were the original reason for which orthopedic surgery was developed early in the twentieth century. As polio, tuberculosis, and dietary deficiencies came under control, however, the practice of orthopedics grew to encompass adult bone and joint diseases and injuries as well. Nevertheless, many orthopedic surgeons continued to work primarily with children.
Infants and children may suffer from any of a number of congenital musculoskeletal deformities, such as clubfoot, hand deformities, congenital dislocation of the hip, and deformities of the spine. Treatment for these disorders may include splints, braces, casts, and surgery. The goal of therapy is to achieve function that is as near normal as possible in the affected part of the skeletal system. Normal appearance, while secondary to function in importance, is also a goal. Some defects require a combination of therapies or repeated operations over several years. As the child’s musculoskeletal system grows and develops, the mechanics of normal movement change. The pediatric orthopedic surgeon must be aware of these dynamic changes to adjust the therapy.
Cerebral palsy, a neuromuscular disorder of infancy and childhood, requires considerable orthopedic evaluation and therapy. As a result of damage to the nerves in the brain that control muscle use, the affected muscles develop abnormal tone (spasticity) and weakness (paralysis). The child cannot control these muscles normally. The asymmetric pull of muscles leads to deformities of the bones and joints and to increasing difficulty in movement as the child grows. Using a combination of splints, braces, and physical and occupational therapy, the pediatric orthopedic surgeon works to keep function as normal as possible in the affected extremities. At times, surgery is necessary to release especially tight muscles. Unfortunately, very little can be done to correct the underlying neurologic defect.
The pediatric orthopedic surgeon also deals with spinal deformities. These conditions may be congenital or may be the result of illness or some types of surgery, such as removal of a portion of a lung. Scoliosis, the lateral curvature of the spine, may be attributable to factors outside the spine, such as cerebral palsy, or to intrinsic factors in the spine itself. Spinal deformity requires regular observation and the initiation of therapy if the curvature becomes too great. Treatment may involve different types of back braces or, in severe cases, back surgery.
A worry to parents, although often not a significant problem, is the in-toeing and out-toeing that may often be noticed in infants and young children. The pediatric orthopedic surgeon can usually reassure the family that there is no serious problem. Severe toeing problems, however, may require special shoes, splints, or casts.
Childhood fractures must be treated differently from those of adulthood. Children’s bones grow at their ends, and growth continues into young adulthood. A fracture at or near the end of a bone may damage the growth area, leading to the loss of normal growth after the injury. Pediatric fractures may be difficult to diagnose since the growing parts of the bones are cartilage and are not visible on X-rays. The pediatric orthopedic surgeon looks for subtle signs of fracture when the growth areas may be involved and follows the patient closely.
Diagnostic and Treatment Techniques
The pediatric orthopedic surgeon’s practice is divided between the operating room and the clinic. The pediatric specialist spends relatively more time in the clinic than his or her adult practice counterpart because a large percentage of pediatric practice in orthopedics involves chronic deformities.
While taking the patient’s history is important, the pediatric orthopedic surgeon relies heavily on a careful and thorough examination of the child’s bones, joints, and nervous system. Radiographic studies, especially routine X-rays and computed tomography (CT) scans, are often helpful in the evaluation.
Pediatric orthopedic operations must often be carefully planned. It is important for the parents to be involved, so that they can be educated about the child’s disorder and can help make appropriate decisions regarding therapy.
Perspective and Prospects
Childhood illnesses and deformities were the original impetus for the development of orthopedic surgery as a specialty early in the twentieth century. Despite the conquest of polio and tuberculosis in the developed world in the mid-twentieth century, the need for pediatric orthopedic surgeons continues into the twenty-first century. Improved techniques and innovative procedures, such as bone transplantation and metal implants, allow the correction of more musculoskeletal deformities and suggest a bright future for the specialty.
Bibliography
Kliegman, Robert M., and Waldo E. Nelson, eds. Nelson Textbook of Pediatrics. 21st ed., Saunders/Elsevier, 2020.
Leet, Arabella I., and David L. Skaggs. “Evaluation of the Acutely Limping Child.” American Family Physician, vol. 61, no. 4, Feb. 2000, pp. 1011–1018.
Moore, Keith L., and T. V. N. Persaud. The Developing Human. 11th ed., Saunders/Elsevier, 2020.
Patel, Hema, and Victor Bialik. “Hip Dysplasia in Infants.” Pediatrics, vol. 104, no. 6, Dec. 1999, p. 1418.
Pediatric Orthopaedic Society of North America. www.posna.org. Accessed 25 July 2023.
Rose, Rene, Andy Fuentes, Brenda J. Hamel, and Cynthia J. Dzialo. “Pediatric Leg Length Discrepancy: Causes and Treatments.” Orthopedic Nursing, vol. 18, no. 2, 1999, pp. 21–31.
Shapiro, Frederic. Pediatric Orthopedic Deformities: Basic Science, Diagnosis, and Treatment. Academic Press, 2001.
Staheli, Lynn. Fundamentals of Pediatric Orthopedics. 5th ed., Wolters Kluwer/Lippincott Williams & Wilkins, 2016.
Wenger, Dennis R., and Mercer Rang. The Art and Practice of Children’s Orthopaedics. Raven Press, 1993.