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Ask the Orthopedist

April 30, 2019

A Q&A with Ellen Dean Davis, MD

What is the scope of practice of a pediatric orthopedic surgeon?

Pediatric orthopedics encompasses a wide range of congenital and developmental pathologies as well as various injuries. This includes everything from infants with hip dysplasia to adolescents with sports injuries. In an era where most orthopedic surgeons are subspecialty fellowship-trained (e.g., sports, spine, trauma), pediatric orthopedists are unique in the sense that they are not limited to one part of the body or a small subset of procedures.

Although interests of practitioners vary, all pediatric orthopedists are trained to treat the growing child, head to toe. Pediatric orthopedics also varies somewhat from adult orthopedics in that it relies heavily on collaboration with pediatricians and pediatric subspecialists, especially when treating children with medical complexities such as cerebral palsy.

What is the most common benign complaint that is encountered by pediatric orthopedists?

Intoeing, or “pigeon-toed,” is one of the most common reasons that parents bring their children in for evaluation. This is typically an aesthetic concern that does not cause any functional problems. The cause can be divided into three anatomic locations – the femur, tibia and foot. In the femur, it can be due to excessive femoral anteversion (internal rotation of the femur), which improves spontaneously until about eight years of age. Internal tibial torsion is the most common culprit overall because of in utero positioning. This will improve as the child becomes a proficient walker, until about four years of age. The foot is the site of a common foot deformity, which is another result of positioning of the baby’s leg while in the mother’s uterus, which happens in one of 1,000 births. This will usually correct within the first year of life with simple stretching.

Regardless of the cause of intoeing, parents are counseled appropriately. There is no role for physical therapy, orthopedic shoes or braces. With proper explanation, parents are relieved. They are always welcomed to bring the child back in for reevaluation in six to 12 months if they do not see any spontaneous improvement.

What is the most common operative injury encountered in pediatric orthopedic surgery?

Far and away, the most frequent injuries that require surgery in young children are elbow fractures. The fracture of the upper arm bone near the elbow is called a supracondylar humerus fracture which is particularly common in children ages three to nine. This occurs after falling onto an outstretched upper extremity, oftentimes a result from a fall off monkey bars, playground equipment or trampolines. Because of the limited ability of the lower part of the upper arm bone to remodel, this requires surgical fixation in all but the absolutely nondisplaced fractures.

Usually this can be performed in a minimally invasive fashion. Live intraoperative X-rays and manual manipulation are used in the operating room to realign the fracture while two to three wires are inserted to hold the position. A long-arm cast is applied. The cast and wires are removed as an office procedure in three to four weeks. Kids are back on the playground shortly thereafter.

Learn more about Atlantic Health System's pediatric orthopedics >