OUTPATIENT PEDIATRIC ORTHOPEDICS: Common and Important Conditions
Section snippets
CONDITIONS REQUIRING URGENT ORTHOPEDIC REFERRAL
Urgent referral is usually necessary for these conditions since there can be significant consequences if the diagnosis is missed. Among these, slipped capital femoral epiphysis and septic hip arthritis are the most common. Other problems to refer immediately include suspected malignancies, deep infections, and displaced intra-articular or physeal fractures.
Slipped Capital Femoral Epiphysis
Slipped capital femoral epiphysis (SCFE) is a relatively common hip problem, usually seen in the adolescent near the time of peak growth velocity. Displacement of the femoral epiphysis, either gradually or suddenly, from the femoral neck through the growth plate, occurs. A slipped epiphysis can later develop in the opposite hip in 36% of cases36 and it does so more frequently in children presenting at a younger age.52, 80 Since obesity is present in at least one half of children with SCFE,
CONDITIONS THAT DO NOT REQUIRE IMMEDIATE SURGERY
These conditions (developmental dysplasia of the hip, cerebral palsy, adolescent idiopathic scoliosis, and back pain) may require more involved diagnostic studies, therapy, bracing, or surgery depending on the severity and natural history. Before a treatment decision can be made, an understanding of the natural history of the untreated condition, of the condition treated conservatively, and the natural history of surgical intervention must be understood.31 Referral is not usually urgent and
Developmental Dysplasia of the Hip in the Infant
Developmental or congenital dysplasia of the hip (DDH) is a spectrum of conditions ranging from laxity to dislocation in the newborn, to end stage arthritis in the elderly. Most infants at risk for developmental dysplasia do not require treatment. However, for those infants who need to be treated, diagnosis should be accurate. The complications of avascular necrosis and inadequate reduction must be avoided, and the patient must be followed to maturity. Developmental hip dysplasia is the most
Cerebral Palsy
Cerebral palsy (CP) is a static disease of the central nervous system that involves the upper motor neurons and has its clinical manifestations in the periphery. Primary, secondary, and tertiary manifestations of cerebral palsy are evident.25 The primary problems are balance, loss of selective motor control, strength, persistence of primitive reflexes, and spasticity. The secondary manifestations are the coping maneuvers the child uses to compensate for primary problems. Tertiary problems are
Adolescent Idiopathic Scoliosis
Adolescent idiopathic scoliosis (AIS) is defined as a lateral curvature of the spine with rotation, occurring in the child over 11 years of age, for which no obvious cause is found. If a child is noted to have an underlying neurologic condition such as syringomyelia, then the scoliosis is a result of that condition and is not idiopathic. The frequency of scoliosis varies from 1.9% to 3%, although for curves larger than 30 degrees the prevalence is only 0.3%. Girls are affected more often than
Back Pain
Back pain was the second most common spine complaint in this series. Like scoliosis, back pain is not a diagnosis, but a symptom. In a referral population, a specific diagnosis is more likely to be found than in the primary care setting. Hensinger reported his experience in a university orthopedic referral clinic of 100 children with back pain lasting for more than 2 years.33 Eighty-four percent of the children had an underlying pathology. These conditions included spondylolysis,
CONDITIONS RARELY REQUIRING REFERRAL OR TREATMENT
These common conditions include: transient hip synovitis, idiopathic toe walking, rotational problems, and Osgood-Schlatter disease. Parents are often worried, prompting unnecessary orthopedic referral for these conditions. It is important to accurately diagnose these conditions in order to reassure the family and avoid overutilization of resources.
CONCLUSION
It is important to make a precise diagnosis and to understand the natural history of pediatric orthopedic conditions. This allows the pediatrician to provide reassurance, treatment, or appropriate and timely referral. The most important requirement in making the correct diagnosis is to have a clear understanding of the diagnostic possibilities. Some conditions such as SCFE, septic hip arthritis, or orthopedic malignancies require surgery and should be referred immediately. Nonsurgical
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Associations of self-reported allergic diseases and musculoskeletal problems in children: A US population–based study
2017, Annals of Allergy, Asthma and ImmunologyCitation Excerpt :Prevalence rates were not significantly different by sex, race/ethnicity, or household income levels; however, affected children aged 0 to 5 years were more likely to have required medical attention during the past year. Prior studies reported that greater than 6% of all visits to outpatient pediatric clinics are attributable to musculoskeletal pain24 and approximately one-third of pediatric medical problems are associated with the musculoskeletal system.25 Data from the 2012 National Health Interview Survey indicated that for patients aged 0 to 17 years 10.9% of reported health conditions affected the musculoskeletal system; prevalence increased to 22.6% in children aged 13 to 17 years.26
Pediatric Orthopedics for the Primary Care Provider
2014, Pediatric Clinics of North AmericaOrthopedic examination
2009, Anales de Pediatria ContinuadaEmergency department evaluation and treatment of pediatric orthopedic injuries
1999, Emergency Medicine Clinics of North AmericaOrthopedic Coordinated Registry Network (Ortho-CRN): advanced infrastructure for real-world evidence generation
2022, BMJ Surgery, Interventions, and Health TechnologiesReferral patterns to a pediatric orthopedic clinic: Pediatric orthopedic surgeons are primary care musculoskeletal medicine physicians
2022, Journal of Pediatric Orthopaedics Part B
Address reprint requests to:Richard M. Schwend, MD, Department of Orthopedic Surgery, Children's Hospital, 219 Bryant Street, Buffalo, NY 14222