Pediatric Annals

EDITORIAL 

A Pediatrician's View

Milton I Levine, MD

Abstract

The orthopedic problems of infancy, childhood, and adolescence vary greatly as a child grows older and differ largely from those of adults. All pediatricians are aware of this fact and realize that they are caring for human beings during the years of bodily growth. We watch the infant increase its bodily activity and develop new abilities, efforts, and interests. Traumatic possibilities also increase.

Orthopedics, as is generally known, was originally a pediatric profession. The name was derived from two Greek words: "ortho" meaning straight and "pais" meaning child- As a matter of fact during the 18th century an institution was opened for the correction of clubfoot. Modern orthopedics, as a medical specialty, developed in the 1920s.

The newborn child presents the pediatrician with two potentially serious orthopedic problems, dislocation of the hips and clubfoot. The latter is easily recognized and corrected; but hip dysplasia, if not detected and treated early, can cripple a child for life - and in today's atmosphere will almost always lead to a malpractice suit.

After this postnatal period most of the orthopedic problems treated by pediatricians are traumatic. We all realize the potential dangers as the child grows older - learning to walk, run, skate, ride a bicycle, skate board; engaging in contact sports, and more recently break dancing with frequent sprains, fractures, and tendonitis. These are but a few of the numerous potentially traumatic situations to which active children are exposed.

It should be noted that fractures of the shaft of the femur are most common in growing bones. Fractures of the ribs during childhood are also seen as a result of child abuse, auto accidents, falling, or such sports as boxing or wrestling.

Many traumatic conditions have been avoided through the efforts of the American Academy of Pediatrics in publicizing the use of seat belts, proper car seats, and restraints for infants and young children. The Academy also presented the dangers of trampoline use by children.

Traumatic injuries can easily be recognized on physical examination combined with the history. But the problems that tax the diagnostic ability of the pediatrician are often subtle in origin. Such conditions include rheumatoid arthritis, rheumatic fever, osteomyelitis, various tumors, Osgood Schlatter's disease, and Legg-Calvé-Perthes disease. And one must not forget the many manifestations of child abuse.

This present issue of Pediatric Annals discusses certain "diagnostic pitfalls" in pediatric orthopedics. It is under the Guest Editorship of Dr. Lynn T. Staheli, Professor of Orthopedics at the University of Washington, and Director of Orthopedics at the Children's Hospital and Medical Center in Seattle.

The first article in this symposium deals with the hip and is contributed by Dr. Vincent S. Mosca, also of the Children's Hospital and Medical Center where he is a Pediatric Orthopedic Surgeon and Head of the Orthopedic Clinical Services. Dr. Mosca first describes the uniqueness of the hip joint, the only true ball and socket joint in the body. The anatomy of the joint, especially the vascular anatomy, is carefully described. He notes that diagnosis of the etiology of hip joint tenderness is often difficult because the hip is located deep in the soft tissue of the body. Deformity is also obscured. He then considers the pitfalls in diagnosis emphasizing "What else could account for the symptoms?" This is followed by a detailed description of the conditions to be considered as well as certain important diagnostic aids.

The second paper is written by Dr. Staheli, the Guest Editor, and deals with the most important hip problem in pediatric care - the management of congenital hip dysplagia. This abnormality is most important to recognize and correct…

The orthopedic problems of infancy, childhood, and adolescence vary greatly as a child grows older and differ largely from those of adults. All pediatricians are aware of this fact and realize that they are caring for human beings during the years of bodily growth. We watch the infant increase its bodily activity and develop new abilities, efforts, and interests. Traumatic possibilities also increase.

Orthopedics, as is generally known, was originally a pediatric profession. The name was derived from two Greek words: "ortho" meaning straight and "pais" meaning child- As a matter of fact during the 18th century an institution was opened for the correction of clubfoot. Modern orthopedics, as a medical specialty, developed in the 1920s.

The newborn child presents the pediatrician with two potentially serious orthopedic problems, dislocation of the hips and clubfoot. The latter is easily recognized and corrected; but hip dysplasia, if not detected and treated early, can cripple a child for life - and in today's atmosphere will almost always lead to a malpractice suit.

After this postnatal period most of the orthopedic problems treated by pediatricians are traumatic. We all realize the potential dangers as the child grows older - learning to walk, run, skate, ride a bicycle, skate board; engaging in contact sports, and more recently break dancing with frequent sprains, fractures, and tendonitis. These are but a few of the numerous potentially traumatic situations to which active children are exposed.

It should be noted that fractures of the shaft of the femur are most common in growing bones. Fractures of the ribs during childhood are also seen as a result of child abuse, auto accidents, falling, or such sports as boxing or wrestling.

Many traumatic conditions have been avoided through the efforts of the American Academy of Pediatrics in publicizing the use of seat belts, proper car seats, and restraints for infants and young children. The Academy also presented the dangers of trampoline use by children.

Traumatic injuries can easily be recognized on physical examination combined with the history. But the problems that tax the diagnostic ability of the pediatrician are often subtle in origin. Such conditions include rheumatoid arthritis, rheumatic fever, osteomyelitis, various tumors, Osgood Schlatter's disease, and Legg-Calvé-Perthes disease. And one must not forget the many manifestations of child abuse.

This present issue of Pediatric Annals discusses certain "diagnostic pitfalls" in pediatric orthopedics. It is under the Guest Editorship of Dr. Lynn T. Staheli, Professor of Orthopedics at the University of Washington, and Director of Orthopedics at the Children's Hospital and Medical Center in Seattle.

The first article in this symposium deals with the hip and is contributed by Dr. Vincent S. Mosca, also of the Children's Hospital and Medical Center where he is a Pediatric Orthopedic Surgeon and Head of the Orthopedic Clinical Services. Dr. Mosca first describes the uniqueness of the hip joint, the only true ball and socket joint in the body. The anatomy of the joint, especially the vascular anatomy, is carefully described. He notes that diagnosis of the etiology of hip joint tenderness is often difficult because the hip is located deep in the soft tissue of the body. Deformity is also obscured. He then considers the pitfalls in diagnosis emphasizing "What else could account for the symptoms?" This is followed by a detailed description of the conditions to be considered as well as certain important diagnostic aids.

The second paper is written by Dr. Staheli, the Guest Editor, and deals with the most important hip problem in pediatric care - the management of congenital hip dysplagia. This abnormality is most important to recognize and correct since a delay in recognition and correction may cause permanent disability in the child. Specific instructions for examining every newborn infant, plus the most effective treatment, are presented. Dr. Staheli emphasizes the importance of examining young infants for hip dysplasia at every office visit during the early months. And, of great importance, he relates the various risks for the development of this abnormality.

The next contribution discusses "Bone and Joint Infection in the Neonate. " It is presented by Dr. Raymond P. Morrissy, Medical Director and Chief of Orthopedics at the Scottish Rite Children's Hospital, Atlanta. Dr. Morrissy notes at the outset of his article that acute hematogenous osteomyelitis and septic arthritis are not uncommon problems of the newborn child, and the diagnosis is often difficult. He warns of the severity of these infections and the potential dangers subsequent to the destruction of the epiphysis and the physeal plate. This important article not only presents the clinical findings in these dangerous infections but clearly defines the laboratory x-ray and bone scan findings accompanying these pathologic conditions. The discussion of treatment is of special importance. The author describes the most effective antibiotics, but recommends the aid of an infectious disease expert because of the varied metabolism of small infants. Surgical treatment of the condition is also discussed. Dr. Morrissy notes, however, that even with the best of modern antibiotics and neonatal intensive care, the morbidity is high.

Following this is an article on diagnostic problems when dealing with pediatric musculoskeletal tumors. It has been written by Dr. Ernest U. Conrad, III, Chief of the Bone Tumor Clinic at the Children's Hospital Medical Center, and Assistant Professor, Director of Divisions of Musculoskeletal Oncology and Tissue Banking, Department of Orthopedics, University of Washington, Seattle, and Medical Director of the Northwest Tissue Center. Dr. Conrad introduces his article with a warning that delay in diagnosis may result in pulmonary metastasis, cutting patient survival by 50%. The incidence of these soft tissue and bony sarcomas is relatively high. It is noted that 2,000 new cases of osteosarcoma occur in the United States each year. This is the most common pediatric primary malignancy, and most frequently occurs during adolescence. The clinical features of this condition are carefully presented as are the radiographic studies. It is noted that since the 1970s the five year survival rate has doubled, following improved chemotherapy, combined with modern surgical, radiographic, and pathologic techniques. Dr. Conrad suggests that due to the complexity in treatment it should be undertaken by a center experienced in the treatment of sarcomas.

The final paper discusses the subject of pitfalls in the diagnosis of fractures in children and has been contributed by Dr. Mercer Rang, MD, FRCS, Staff Orthopedic Surgeon at the Hospital for Sick Children, and Professor of Orthopedic Surgery at the University of Toronto, and by Dr. James Wright, Clinical Fellow of the Hospital for Sick Children. The authors start by listing false negatives that may complicate the diagnosis of fractures. They also note that false positives can at times occur, but do not present serious problems. Mistaken diagnoses, especially in cases of child abuse, are also discussed. The treatment of fractures is presented with comments on indications for reduction and plaster immobilization. The article is well illustrated and emphasizes the care needed to arrive at the correct diagnosis when bone fractures in children are considered.

10.3928/0090-4481-19890101-04

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