key: cord-032363-86ovid90
authors: Gerson, William T.
title: “WHO ARE WE?” Common pediatric orthopedic disorders and the primary care clinician
date: 2020-09-20
journal: Curr Probl Pediatr Adolesc Health Care
DOI: 10.1016/j.cppeds.2020.100885
sha: 
doc_id: 32363
cord_uid: 86ovid90

nan

"WHO ARE WE?" Common pediatric orthopedic disorders and the primary care clinician William T. Gerson, MD* I have no name I am but two days old.-What shall I call thee? I happy am Joy is my name,-Sweet joy befall thee! Pretty joy! Sweet joy but two days old, Sweet joy I call thee; Thou dost smile. I sing the while Sweet joy befall thee.

-William Blake "Infant Joy" 1789

Once there was a way to get back homeward

Once there was a way to get back home Sleep pretty darling do not cry And I will sing a lullaby.

-The Beatles (Paul McCartney), "Golden Slumbers," 1969 Bent, Stork, and Nemeth speak to the soul of children's healthcare in their superb summary on common childhood orthopedic disorders. 1 Theirs is an understated goal: to provide a framework to the approach to some of the most common orthopedic conditions in children. However, the result speaks not only to what we do or strive to do as primary care clinicians but to why. The exposure of the murky underbelly of our healthcare system during the current COVID-19 pandemic gives us a unique opportunity for reflection. A call-out from our specialty colleagues unexpectedly prodding us for self-definition is most welcome À "Who are we?"

We find the soul of children's healthcare in our exam rooms in our consultations with patients and families. That soul is grounded in our expertise over a body of knowledge whose roots travel through developmental biologic turf. Our professional soul's origin lies in the notion of childhood; its poems and lullabies; in our children's hospitals whose own origins derive, in part, from the treatment of orthopedic conditions; and in the breadth of our training and experience in the principles and practice of children's healthcare.

The first encounter with a child and her/his family is often in the newborn nursery À and that evaluation sets the standard for all that follow. Families most remember our touch and our words during those moments À and much of our exam is orthopedic. Some may wonder why parents are so concerned about the curve of the lower legs or feet when the medical focus is on the heart and lungs' transition. The reason, of course, is not difficult to understand. The true meaning of infancy and childhood underpins this critical encounter. In the newborn exam, the juxtaposition of the promised joy of childhood, often perceived as that of play -the walking, running, jumping, climbing of innocent times, is never far from a feared image of difference or even of crippling disorders.

Every primary care clinician should read this paper, not just because musculoskeletal illness represents a large portion of all childhood office visits. It provides a concise synopsis of the most common orthopedic concerns presenting to primary care clinicians, beginning with the newborn exam, and often resulting, not necessarily appropriately, in referral to pediatric orthopedic surgeons. The authors present a developmentally-based approach to infant, childhood, and adolescent musculoskeletal complaints. They highlight the range of normal variation that drives much of parental concerns and emphasize the critical role of reassurance with periodic reevaluation. It emphasizes the principles of anticipatory guidance and education and a welcome, careful approach to diagnostic imaging. There is also a clear delineation of pathologic conditions and the importance of timely referral. The authors acknowledge a limited scope; they do not review fractures, sports-related concerns, bone tumors, or infectious processes.

Bent, Stork, and Nemeth present their topic in an easy to read style that belies its comprehensive content. They achieve the conceit of the addition of a wise consultant in the exam room, walking through the encounter, assisting in the physical exam, and answering patient and parental concerns. For each topic there is a bolded question of "what is . . ." followed by "how do I evaluate," "risk factors," and ending in "treatment and when to refer." The authors place all topics in a developmental context, and their description of both angular variants (bow legs and knock knees) and rotational/torsional variants are extensive. Pearls and pitfalls are frequent and sometimes bold-faced or capitalized, jargon and acronyms are minimal, unmistakable figures and extensive references round out their work.

The authors artfully weave the importance of the physical exam into the context of the age-appropriate and longitudinal general office exam. Critical thinking and placing important but unlikely etiologies of common variants in proper perspective (e.g., cerebral palsy and in-toeing, hypothyroidism and SCFE) are abundant. The section on the causes of foot pain without injury is also excellent.

Our strength as child health clinicians is our knowledge base of growth and development and our ability to recognize and appropriately manage disorders and health promotion. The popular chronologic model of childhood office visits has limitations. Better is a developmental model based on the needs, risks, and vulnerabilities of individual children and their families. Bent, Stork, and Nemeth offer such a wellness-focused, developmentally driven, and vulnerability-defined timeline. Our pediatric orthopedic colleagues have well documented the deficiencies in our medical school and residency pediatric education. Their paper could be a model for child health education and it should be included in every educational packet for students and trainees regarding children's healthcare and pediatric orthopedics.

Let us embrace the power of poem, lullaby, or song to enable a better future rooted in the best of the past where the art and practice of medicine are valued, education in children's health is developmentally sensitive, and the pursuit of excellence is an unwavering commitment to children, their families and our profession. The accompanying paper is an affirmation of all that is best in education and the clinical care of our young patients.

The diagnosis and management of common childhood orthopedic disorders: an update