Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

I lay no claim to being an authority on etymology but it has always intrigued me that the word orthopedics is derived from two Greek words - "ortho" meaning straight, and "pats" meaning child. Apparently the profession of orthopedics had its origin in the "straightening" of deformed children, probably first directed at the correction of club feet. The first institute for the correction of such deformities was opened in Switzerland during the 18th century. Modern orthopedics did not become a real specialty, however, until about 1920.

But even today the specialty of pediatrics is closely associated with the area of orthopedics. We examine each newborn for possible dislocation of the hips and we observe for club feet and other birth defects, many of which involve the bony structure of the body. Later, in the course of our practice, we see many sprains and fractures among our patients. Numerous cases of scoliosis develop in adolescents and much less frequently we are involved with partial limb deficiencies, spinal cord injuries, myelomeningoceles and bleeding or effusions into the joints.

Like most practicing pediatricians I have treated numerous injuries, including many fractures. However, one that I didn't treat stands out in my memory.

It was in my early years of practice that I had a part-time position with the New York City Department of Health. We were studying the possible prophylaxis against tuberculosis in children by the BCG vaccine. The Harlem area of the city was assigned to me and I examined children in their homes as well as in the clinic at Harlem Hospital.

At this time, there was a cult leader in the community known as Father Divine, whom many blacks believed to be the Messiah. They had no faith in or need for physicians. They were certain complete faith in Father Divine could cure any illness or disability.

One afternoon I visited the home of a mother with an infant three weeks of age. While examining the baby, I looked up and to my astonishment saw a little girl about two years of age running around with her left upper arm bent laterally in the middle at a 90° angle, almost like a second elbow. I realized immediately that this was, in all probability, the end result of an untreated severe fracture. The child, by the way, was in no distress.

I momentarily stopped my examination and asked about the child. She was the mother's niece and had apparently fallen out of her crib some months before. Her parents, followers of Father Divine, would permit no treatment. The humerus had healed spontaneously in the position I observed.

I made a point to follow this little girl through succeeding years. The arm gradually straightened out and by the time she was seven years of age it was practically straight. I'm sure Father Divine got the credit. However, I did find a book at that time on fractures of infancy and childhood by Dr. Edward Truesdell which visually demonstrated cases of untreated angulated fractures of the long bones of children that gradually straightened out spontaneously.

In the course of my many years of practice I have seen numerous fractures involving practically all bones of the body, including the skull. Fortunately, practically all of them healed without any complication. Only one hurt me very deeply - a fracture of the spine in one of my lovely, happy, active patients, a 10year-old girl. An auto accident permanently paralyzed the child.

Such serious auto accidents, where children suffer broken necks, spines, and skulls, are less frequent today due in large part to the efforts of pediatricians,…

I lay no claim to being an authority on etymology but it has always intrigued me that the word orthopedics is derived from two Greek words - "ortho" meaning straight, and "pats" meaning child. Apparently the profession of orthopedics had its origin in the "straightening" of deformed children, probably first directed at the correction of club feet. The first institute for the correction of such deformities was opened in Switzerland during the 18th century. Modern orthopedics did not become a real specialty, however, until about 1920.

But even today the specialty of pediatrics is closely associated with the area of orthopedics. We examine each newborn for possible dislocation of the hips and we observe for club feet and other birth defects, many of which involve the bony structure of the body. Later, in the course of our practice, we see many sprains and fractures among our patients. Numerous cases of scoliosis develop in adolescents and much less frequently we are involved with partial limb deficiencies, spinal cord injuries, myelomeningoceles and bleeding or effusions into the joints.

Like most practicing pediatricians I have treated numerous injuries, including many fractures. However, one that I didn't treat stands out in my memory.

It was in my early years of practice that I had a part-time position with the New York City Department of Health. We were studying the possible prophylaxis against tuberculosis in children by the BCG vaccine. The Harlem area of the city was assigned to me and I examined children in their homes as well as in the clinic at Harlem Hospital.

At this time, there was a cult leader in the community known as Father Divine, whom many blacks believed to be the Messiah. They had no faith in or need for physicians. They were certain complete faith in Father Divine could cure any illness or disability.

One afternoon I visited the home of a mother with an infant three weeks of age. While examining the baby, I looked up and to my astonishment saw a little girl about two years of age running around with her left upper arm bent laterally in the middle at a 90° angle, almost like a second elbow. I realized immediately that this was, in all probability, the end result of an untreated severe fracture. The child, by the way, was in no distress.

I momentarily stopped my examination and asked about the child. She was the mother's niece and had apparently fallen out of her crib some months before. Her parents, followers of Father Divine, would permit no treatment. The humerus had healed spontaneously in the position I observed.

I made a point to follow this little girl through succeeding years. The arm gradually straightened out and by the time she was seven years of age it was practically straight. I'm sure Father Divine got the credit. However, I did find a book at that time on fractures of infancy and childhood by Dr. Edward Truesdell which visually demonstrated cases of untreated angulated fractures of the long bones of children that gradually straightened out spontaneously.

In the course of my many years of practice I have seen numerous fractures involving practically all bones of the body, including the skull. Fortunately, practically all of them healed without any complication. Only one hurt me very deeply - a fracture of the spine in one of my lovely, happy, active patients, a 10year-old girl. An auto accident permanently paralyzed the child.

Such serious auto accidents, where children suffer broken necks, spines, and skulls, are less frequent today due in large part to the efforts of pediatricians, and especially the American Academy of Pediatrics, in publicizing the importance of seat belts and restraints for infants and children.

I have mentioned fractures of the spine with resultant paraplegia and am reminded again of the influence of pediatricians in reducing the number of paraplegic accidents. The most recent effort was directed at the trampoline. We all remember how popular trampoline jumping and bouncing was a few years ago with children and adolescents. Many professional and public school gyms had trampolines and even contests. Some parents actually purchased trampolines for their children. And then the reports started to come in. The late Dr. Harvey Kravitz, a practicing pediatrician, reported in 1974 on the rise of cases of trampoline paraplegia and urged banning the trampoline in schools. Kravitz reported 34 cases. In 1978 a meeting arranged by the Academy of Pediatrics was held in Kansas City. At that meeting, physicians, coaches and instructors drew up a list of safety precautions in trampoline usage. It was noted that one of America's all-around leading gymnasts had been killed attempting a complicated somersault on a trampoline. Safety suggestions for the use of this potentially dangerous apparatus were presented by Dr. George Rapp in the October 1978 issue of Pediatric Annals.

Another area in which pediatricians have been closely involved is sports medicine. In 1952, Dr. George Wheatley, a former president of the American Academy of Pediatrics, established the Accident Prevention Committee. Through the years that followed, a primary effort was aimed at the prevention of injuries in childhood and adolescent sports activities. There has been, as we all know, a great increase in interest in sports in the past 10 years. Television has popularized, among other sports, football and basketball. The spectacular gymnastic achievements of Olga Korbut in the Olympics of 1 972, and Nadia Comaneci in 1976 stimulated an enthusiasm for gymnastics among our American children - even some as young as three or four years of age.

So we must expect an increase of orthopedic injuries among our patients since so many are now involved in sports. The greatest number of injuries are among our adolescents since they so frequently enter the violent contact sports, especially football, basketball and soccer. A study from the University of Rochester a few years ago showed that sprains and strains, fractures, chondromalacia patellae, contusions and meniscus difficulties of the knee accounted for almost 50% of the injuries.

But what can we as pediatricians do to limit the number and degree of these traumatic injuries? We must become more closely involved with the direction of athletic activities - insisting on adequate training programs, competent care during sports activities, and immediate and accurate medical and surgical treatment at the time of an accident. Some pediatricians are sufficiently interested to become team physicians - but few can afford the time. In such cases they can instruct the athletic director or assure that a paramedic attends the contact sports activities.

A few years ago we devoted an entire issue of Pediatric Annals to Sports Medicine (October 1978). It is worth re-reading. I remember a good deal of that important issue, but two warnings stand out. First, if a child or adolescent has a concussion during athletic activities, do not let that child return to the activity even though he or she acts and feels fine. The second was a warning (emphasized by an article in this present issue on "Cervical Spine Injuries") that when one suspects a cervical injury in a football game - "Do not remove the helmet" - for fear of moving the cervical spine.

All of the facts I have described give some idea of the pediatrician's value in preventing and treating traumatic injuries in children and adolescents.

But there are other orthopedic areas in which the pediatrician has had tremendous influence, among them the prevention of birth defects. Following the European thalidomide experience, pediatricians have insisted that pregnant mothers take no drugs unless absolutely urgent. One can only guess at the great benefit children have derived from these precautions.

Another more recent advance in the potential prevention of an orthopedic deformity is in the prenatal diagnosis of myelomeningoceles by amniocentesis or maternal blood serum (by the finding of an increase in the level of alpha-fetoprotein). This disastrous deformity, if discovered prenatally, can be avoided by termination of the pregnancy, if desired by the parents.

To guest edit this issue of Pediatric Annals we have called on Dr. Albert B. Ferguson, Jr., an international authority on orthopedic conditions in children. Dr. Ferguson is the author of the authoritative text Orthopedic Surgery in Infancy and Childhood which is now in its 5th edition. He is Silver Professor of Orthopaedic Surgery at the University of Pittsburgh School of Medicine, and Senior Staff Member at the Children's Hospital of Pittsburgh. Dr. Ferguson is a Past President of the American Orthopaedic Association as well as the American Board of Orthopaedic Surgery.

Dr. Ferguson has selected for discussion in this symposium a broad range of subjects of interest and importance in the area of pediatric child care. These are limb deficiencies, cervical spinal injuries, congenital dislocation of the hip, adolescent bunions, musculoskeletal bleeding in hemophilia, myelomeningoceles, and elbow fractures.

There is so much of value in the articles included that it is difficult to review all of them adequately within the confines of this introduction. Obviously, the primary pediatrician will have much to do with the early care of the various conditions, referring the child for optimal treatment and care, and also with helping and supporting the parents.

However, after reading the articles, certain facts stand out: the newer treatment of the limb deficient child and the rapidity with which the child adjusts to the prosthesis under trained supervision; the urgency after severe neck injury of preventing flexion, extension or rotation of the neck while handling the child. Also, the early diagnosis of congenital dislocation of the hip is not as easy as generally believed - the "clicking" hip does not necessarily mean dislocation; during adolescence when bunions develop, if operation is deemed necessary, it should be performed only by an orthopedist specialized in such surgical procedures. In the case of hemophiliacs, bleeding into muscles or bony structures should receive immediate factor replacement; in the care of the child with a myelomeningocele it is the duty of the pediatrician to present parents with reasonable expectations and understanding; and in fracture of the elbow, the need for prompt treatment is essential.

It is obvious, from my brief statements concerning certain salient points in the articles, that much thought has been given to present an interesting overview of certain important aspects of orthopedic surgery in infants and children.

The articles are well written and the authors experts in their respective specialties. Pediatricians should gain a great deal of new information when reading the symposium.

10.3928/0090-4481-19820601-04

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