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Intro to Pediatric Orthopaedic Surgery with Dr. Nigel Price

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Summary

This on-demand teaching session aims to provide medical professionals with an overview of pediatric orthopedics, covering topics such as congenital, acquired, and developmental conditions, osteogenesis imperfecta, achondroplasia, cerebral palsy, arthrogryposis, and muscular dystrophies. Through Doctor Price's presentation, participants will receive an in-depth look into these conditions, family support recommendations, and strategies to improve their patients' quality of life. This session is ideal for professionals looking to upskill and develop their practice.
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Learning objectives

Learning Objectives: 1. Explain the role of a pediatric orthopedic surgeon. 2. Identify the common conditions and deformities seen in pediatric orthopedics. 3. Describe the treatments for conditions such as Osteogenesis Imperfecta, achondroplasia, and muscular dystrophies. 4. Distinguish between classic spinal findings seen in pediatric orthopedics. 5. Discuss the importance of a multidisciplinary approach when treating patients with neuromuscular problems.
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Most folks on the call um, have been in these chats before. Um But today we have Doctor Price who's a Peds orthopedic surgeon, um, gonna be talking about the Subspecialty. Um Her usual with the Subspecialty series, we are gonna be recording the presentation. So if you would like to be in the recording, feel free to leave your camera on. Otherwise, um, you can turn it off and the recording shouldn't pick you up. Um And then once the presentation is done, we will um open up the floor for Q, turn off the recording and open up the floor for Q and A. So without further ado, Doctor Price. Well, thank you. This is uh one of those um, invitations that I really try to honor because, um, if there's anything a pediatric orthopedist wants to do, uh it's inspire other pediatric orthopedists. So, um, thank you for the uh opportunity. And um uh when in my old job, I was in Kansas City a long time, uh there was a similar group and they had as much as the uh uh enthusiasm as you guys have. So a way to go keep it up. Um So um, pediatric orthopedics. What do we, who are we, what do we do? Um, we basically are orthopedist to see, uh, even unborn, uh, consults all the way through young adulthood. And the, um, the, the high end the ceiling on age is, is, is highly variable depending on where you practice. If you practice in a dedicated pediatric setting, like a freestanding children's hospital, chances are, um, 18 will be a kind of a, a hard stop for a lot of conditions. Although sometimes we'll transition into the young adult years of being on certain chronic conditions. Um, and we're gonna touch on that, that, you know, that theme a little bit. Um, so basically, um, you know, as, you know, we're all about the musculoskeletal system and, and, um, we tend not so much to do to, to focus on uh degenerative conditions. We're all about congenital, acquired and developmental conditions. And, um, the neat thing about pediatric orthopedics is that we, we tend to uh focus on, on the whole body. So, uh, you know, I'm, I'm, I focus a lot on spine but, um, we tend to operate from skull base to toes. Um, and we, we look after a lot of different conditions and that's one of the interesting things about peds orthopedics is that, um, I, in the course of a day, you probably will see some similar uh conditions and diagnoses. But there's a very good chance that, you know, you, you'll have seen 10 different, 15 different diagnoses. Uh you know, ranging from rickets and metabolic problems to obesity related problems of the hip or knee to neurofibromatosis and inborn error. CP spina bifida down syndrome muscle diseases. And, and, you know, in the course of a week, we'll probably have touched on all of these in our clinics. Um You know, one of the, um the more dramatic conditions we look after is osteogenesis, imperfecta brittle bone disease, which is increasingly being alleviated through um genetic analysis. And, and um and so the s classification is being modified, but essentially, you can have the worst form of this, which is um in utero deformities um to a milder forms and, and um with the advent of bisphosphonates, we've definitely modified um the condition, but there's a lot of surgery that still goes on with this. And these kids can be very dramatic and they really, we need to live on a essentially a, a down pillow because they're just so fragile. You have an tran elf and face and helmet head, short stature and um they can have involvement of the spine and it can be short statured and, and um they, they basically become a patient, you get to know from birth all the way into uh adolescence and young adulthood. And this was one of those conditions that tends to linger in the, in the pediatric clinic because um of the relationships we form and you know, the kind of uniquely pediatric things that we do for them. And they classically have the blue sclera and they um they present either fractures in utero or they acquire fractures with time. It can be a mimicker of uh child abuse. So that's one of those great, you know, mimicking um conditions that we have to be aware of. Um So we sometimes have to enter the phrase of sygen to perfect your child abuse and for a lot of molecular gene can help us but not all the time. Um One condition that we see a lot of, but it, it sort of has some common features um to a variety of conditions. Uh This is a dwarfing condition, the most common achondroplasia. And um we have um rhizomelic shortening, meaning that the proximal segments are short, short stature, but we have normal and chondral bone formation. So, um so that means the uh some aspects of the skeleton are normal, but we certainly have short long bones and we can get deformities of the long bones. We can also get also get deformities of the spine. And um and so these, these patients also can be frequent flyers in our clinic. The cla the the classic spine finding is that the low spine has um a a diminished in a particular distance compared to the upper spine. So that's a, that's a classic pimping question in the uh in the operating room, Mylo Perison and knock beat or or both legs pretty common. And so they, they, they present sometimes very early with some really dramatic problems because, because of their, um, very narrow foramen at the base of their skull, they can have hydrocephalus at birth or very shortly after they can present in the clinic. And I, in fact, had the kid present to me as an orthopedist with breathing issues, breath holding and it was an achondroplastic dwarf, uh, child and it was an infant. And I said to the parents, as you've been doing this for a while for a few months, no one had really sort of recognized the fact that apnea in a dwarf is really relating to their brainstem compression. So we got that, that patient fixed up the classic finding and a lot of these achondroplastic kids and it's a common theme and, and s and genetic conditions particularly inborn s like uh glycosaminoglycan disorders like hunters hurlers, um and uh other mucopolysaccharidosis. They get this kind of give us deformity or round back at the thoracolumbar junction and a bullet shape at the apex. So that's something we, we sometimes just see in our clinic and, and we can be the harbinger of an early diagnosis, which is hugely helpful because then they can get either enzymatic treatment or they can get bone marrow transplant. So, so we're sometimes at the forefront of the diagnosis of some of these kids. Um And this is this is that child, I told you about who eventually required um a tracheostomy because of the breathing problems, which, which then was uh resolved after decompression of the hind brain. So we see, as I said, lots of conditions that historically, patients didn't survive into adulthood. And now we're seeing and I'm in the clinic and they, they present to us with persisting problems with the musculoskeletal system. So the cognition may be better. They may um not have, you know, some underlying, you know, uh bone marrow cardiac problems, but their musculoskeletal problems persist and, and it can be really dramatic. Um The other condition that we see a lot of it's in the neuromuscular realm is cerebral palsy and they can um they can be walkers and, and have some mild tone problems all the way to a um graded uh functional motor score of five on a, on a scale that we use and their wheelchair ambulator and they can develop scoliosis early on and, and uh that's where we come in. So we can do a lot of things that will improve their quality of life. We can stabilize their spine, but we can also reconstruct their hips and, and if they're ambulate ambulatory, we can uh evaluate their gait and we can help them um achieve a more functional gait um by um tendon lengthening and, and um tendon transverse and keeping your feet flat and making them braceable. So there's lots of things that we can do for the CPK, one of the most dramatic conditions that we see in P orthopedics. And, um, often it's lends itself to multidisciplinary clinics. There's a, a variety of spinal defects or spina bifida or sacro agenesis. And I've seen versions of all of these over my career, uh, everything from just the little bulge of fat all the way to, you know, huge bulge of fat and a dimple and, and, um, very poorly formed lower extremities to large defects that require dramatic surgery to fix them. And they have invariably have some brainstem issues. They may have hydrocephalus at birth. In fact, 90% of them do and they need a shunt and they may have this wide dysraphism in their spine and, um, and require at some point some spine surgery. So these are the kids who really are busy, these kind of kids. And, um, and there's a, a huge variability in these neuromuscular kids in terms of what they need to, to get them walking. They may need a custom wheelchair. They may need crutches and a Thoraco lumbar or I'm sorry, a, a thoraco uh hip, knee, ankle, uh foot orthosis T HK AFL, or just a knee, ankle, foot, a, uh AFL, uh, and, and a reverse walker to keep them up, right. A lot of these kids early on would walk and eventually some of them at least decide that it's not worth the energy and they, they get back in the wheelchair so they can attend to their schooling and, and be be um quicker around so they can hang, hang up, hang in with their friends. Um One of the other conditions we see is a, a fairly dramatic condition called arthrogryposis, which is um basically a contracture condition. And it can involve just um uh a mild form of, of hand and wrist, uh maybe some elbow, but in a more dramatic form, it can be involving most of the large joints of the body and the small joints. And so to help them have better quality of life, sometimes we'll do some interventions to uh to make them more functional. Um to Shanes and Beckers are, are uh have really evolved in, in my um 29 years of practice. Um This was essentially a death sentence for Children and who would pass on in their late teens and twenties that they had to change now with um not only steroids but also um a molecular genetic interventions. Um They're, they're uh not only is their functionality improving, but their cardiac status is improving and um the scoliosis is at bay and they're walking longer. For the first time in my career, I saw a 15 year old who walked in my clinic with, you know what I would describe as fairly mild manifestations of duang and, and, and well, I never uh in my dreams thought I'd see that in my uh in my practice, but it's really um heartening to see how these kids have um have benefited from um electrogenic otherwise they wind up uh with early onset scoliosis that needs rods into their pelvis. So the muscular dystrophies are really um still, still out there. Um However, the interventions are, are uh pretty effective these days. Uh NF one, the most common uh genetic condition that we see in, in a very large chain and, and of course, in their uh most dramatic manifestations, we see plexiform neurofibromas, caffe a a spots, uh freckling and axilla and maybe the um the groin and um and they can have nerve fibromas, um just isolated ones and, and of course, they can have these big lesions, uh neuromas and, and other nerve lesions that, that contribute to some dysplastic or concur. So this is one that um it's a common condition that we see in clinic all the time. Uh rickets, believe it or not is actually not a rare thing. And this is definitely something I pimp um med students on in the clinic where, you know, if you see um a very wide growth plate and a cupping of the um of the uh growth plates and, and that's uh nutritional rickets until proven. Otherwise, there are other forms of it as you know, but uh nutritional rickets is still the, the one we see. So we, we do love asking about this one and um with, with um medical treatment of either the um Vitamin D responsive versus Vitamin D resistant versions of it. They, we can, we can improve their alignment and, and we sometimes don't have to do bone surgeries on, on these kids if we can get to them early enough. Um, other metabolic uh bone conditions um can mimic uh rickets and it can be uh osteoporosis, uh uh conditions. But this is kind of a more dramatic version of a kind of a whole body involvement with uh with rickets. It's a Vitamin D resistant version. Um We see lots of holes in bones in clinic. And um and this is kind of a one that has a typical kind of look to it. In this case, it looks like there's a pathological fracture through that. So, um kid who may have had some antecedent pain and then had a very innocuous injury and then they've broken through a cyst. So it's a pathological fracture. So we see lots of cysts and, and bumps, particularly osteochondromas. And we um we take care of those and be Ortho clinic. So we do benign tumors sometimes, you know, we'll, we'll, we'll be part of AAA cancer operation. I did a, a partial sacrectomy with the cancer doctors, uh MSK Cancer doctors um about nine months ago. So, um sometimes we'll be involved with uh with actual tumors, but most of, of what we do in peds Ortho, it's ki kind of benign stuff. And so we have various options with this, we can um I inject it with uh uh calcium uh phosphate uh uh substance called Prodan or we can um we can actually bone graft it and sometimes these things get large. This one looks more like an ABC. It's kind of thin walled and multiloculated. And um and what we'll do with this is sometimes we'll open it up and we'll collapse the walls and cure it out and maybe do a phenol treatment or, or um some kind of ablation and fill it with some kind of um filler, either bone graft or bone proteins. And we get a lot of kids who come in just with crooked necks and crooked backs and, and these are kind of just situational uh rye neck. This is kind of a classic um uh torticollis kid. Um So, um if it presents a birth, it's probably um a congenital muscular torticollis. But if it presents in childhood, it may be uh what we call rotary fixation. So, um depending on the age, um it, it sort of dictates the treatment, but we also always have to consider some kid who comes in with a tilted head that they may have a eye problem or they may have a tumor in their posterior fossa. So, you know, there's never a dull moment in the orthopedic, uh the ps Ortho clinic cli a file that's kind of an interesting condition where it's a little tough to see this, but basically it's a very short neck with a lot of fusion with not a lot of motion. And, and this kid is kind of a classic and this is, uh, uh it's sort of a classic look that we, we sometimes will quiz um uh men students residence on this sort of high riding, uh bilateral shoulder blades and, and um, this is a kid who can't abduct and he's got bilateral, um, bilateral sprinkles, deformities and uh depending on their functionality, we might operate on both of these actually pull them down to make them more functional. Um, scoliosis, obviously near and dear to my heart. That's kind of what I do. Um, we, um, we do a lot of scoliosis care in our clinic. We have at least three out of four of us who do scoliosis care. A lot of it is observer observational. Sometimes we brace, sometimes we, uh, we treat with casts if it's early onset and, uh, the minority requires surgery. So, um, if, uh, if we have somebody like this who presented with Sherman's kind of close, you can see this very dramatic round that we might have to do something pretty dramatic to help him out. He had a pretty significant, um, ninety-degree curve. So we, um, we, we kind of treated him with a, a fairly, uh corrective surgery. Scoliosis is a lateral deviation. It's in a different plane and, and uh, we sometimes see it in siblings and, uh, uh, one of the things we'll ask you about is how do you measure carb angle? And that's the, uh, the Burp Nicker um, that subtends the end plate lines and that's called a calm angle. Anything over 10 is a scoliosis. And so we, we treat a lot of scoliosis and it's a three dimensional deformity with a lot of eventual rib changes. And uh you have to, you have to examine it to, to see, to see the high right shoulder, asymmetrical shoulder blades, asymmetrical flanks in this kids. Uh I've got a little hemangioma even just for, for variety. And on forward be we'll sometimes see a high righty rib and a Scolio can help us uh figure out uh how much rotation and sometimes we see some dramatic ones. Bracing works for some of the milder ones and sometimes there's night bracing if they won't wear one to school. One thing that you, you will hear us say a million times in peds Ortho clinic is that Children are not just small adults and that this is one of my favorite things to kind of show in all the cartilage, all the islands of cartilage in a kid. And um and they are growth plates and they also are cartilage um blog. Right. Right. So, so we, we kind of have to remind our colleagues in the Ortho in the impede or I'm sorry in the adult world that you know, kids deserve some um some specialization because the growth is really the factor that leads to deformity and we can actually recognize it as something we can harness. So, um, in some cases, we'll, um, will accommodate their growth. And this is an example of an early onset curve and we put some growth rods in. And, um, we would, and this one, this is a kind of a, a classic or um, traditional growth rod where we'd go in every six months and lengthen these um in some cases, we'll actually put rods in um this kind of a hybrid system. And in some cases, what we have to do come with um a double curve treatment. And um uh as I mentioned, sometimes will harness the growth and in this case, um and occur between 35 and 50 degrees will actually even tether with a um uh an anterior vertebral body tethering procedure. So, it's a common theme in peds Ortho that will, will use growth as a uh corrective force. Um We do see a lot of fractures um in, in fact, we see fractures as really the bulk of what we'll see as walk-ins. Um You know, and there's some common themes you can see the, the top five here, clavicle radius fractures, mostly wrist elbow forms are pretty common, lateral weightless salter ones, particularly of the of the ankle, finger fail, uh or finger phalanx fractures, super collar humerus type ones, twos and threes. So we see a lot of buccal fractures and most are amenable to either splinting or brief amounts of casting. Sometimes we'll get a forearm fracture. Um, and, and this is what the residents, particular junior residents get very adept at is reducing these and putting them into a cast. There's a greenstick version that then gets casted and, and, um, that works out really well in kids, kids up until even early, uh to mid teens can do very well with closed treatment. So that's a theme in pediatric orthopedics is that we get very adapt at closed management. We don't put, have to put plates on everybody. We start to get a little bit more operative in, in late childhood, early adolescence. Um because of um a lack of remodeling potentially for some fractures and um sometimes these are open fractures and need a little bit more aggressive treatment. Um Super Condors, uh A lot of kids come in with broken elbows. It's our most common surgery. And uh these are kids who have a big swollen elbow after a fall and out your hand and this is a type two. So this one end up with some pins and happy kid comes to clinic, gets the pins out in clinic at three weeks or so, starts to move your elbow. Um We get a lot of patellar dislocation, some, some plans, I swear that's all we see. Um But um but we do see a lot of these, most of these require just some rehab and a protective brace with a lateral stabilizer and they get back into and just for uh minority require surgery. Um Osgood sliders, jumpers, knee see a lot of those um you know, um overuse syndromes in Children often involve growth plates. So knowing about the natural history of a growth plate, it really is reassuring to a family and we reassure uh Os Good Schlatter's uh family said you will eventually grow out of this. Um We see a lot of kids with rotational problems and it's a and historically was a real concern and we had all sorts of treatments for this stuff which we almost never treat anymore because we know that they resolve. But we do see a lot of them like Perthes disease um which is a still a uh an enigma to us 100 and 20 years after it was diagnosed in a uh early part of the 20th century, we still um struggle with getting good outcomes with Perthes, particularly in older kids. Um Coxa VGA and Vera and, and hip conditions that require osteotomies. We do a lot of that too and uh we can really improve a lot of functionality by, by judicious timing of an osteotomy. We see a lot of club feet and uh we do the pos method now and kids are um are casted until they have a neutral foot and then go into holding braces. We rarely do the big operations that I did a lot of in my um and when I was doing comfort treatments and uh they wind up in boots and bars and that's uh I believe that's Ignacio ponseti that uh do that's Doctor Ponti himself. Uh growth plates, you gotta know about growth plates. And that's a very common question in the or um, so if you're gonna impress this, you should at least walk in knowing the Salter classification. And if you want bonus points and it's not depicted on this one, you'll know what a Salter six is cause II work at sick kids with Ring and, and Salter. So if you're in the or with me, I may ask you about what's a Salter six um clavicle fractures. Um We see a lot of those um spon and especially in football players, gymnasts, um dancers, we see a lot of spondylolysis and listhesis, a defect in the pars um slipped epiphyses. Um They masquerade is something that gives rise to thigh, your knee pain and they come in and they require um a screw or two in their femoral head. So one of the things that I got asked to talk about was um you know, just why peds Ortho, well, what attracted um me to it was really, I was inspired by my mentors. I really um like the people who practice Peed Ortho. Um I love the diversity. So if, if you wanna do a lot of um similar cases, then you probably are, are more hardwire to be a sports doc or um or possibly a joint um surgeon because you do, uh you know, a version of restorative resurfacing, you know, arthroplasty of knees and hips, sports doctors do a lot of, you know, meniscal repairs, um ACL repairs. Um So, so if you, you kind of really relish a diverse population with a lot of different conditions to look after, then Pete's Ortho is very appealing. Um There's within Pe's orthopedics. Um there's a lot of opportunity um to just be a person in your group who, who knows more about peds and is a generalist. Um uh but you can also, um you know, do adult stuff too, you know, hand surgeons or particularly. Um Yeah, yeah, of that ilk, I've worked with people who did, you know, put on the hand care and they were p to orthopedist, they could do some general stuff as well. And if you're in an academic practice, you can subspecialise even within por though. So, a lot of my career I spent, um and, you know, doing spine care and I had sports colleagues, I had hip colleagues. I had people who did deformity and alignment surgeries and feet and lower extremities, um, tumor. Uh So, you know, even with P's Ortho, particularly if you're in a large group, you can subspecialized. Um Most uh if you're gonna join a group that's uh pediatric orthopedics in nature, um you probably wanna do a fellowship and either POS or a C GME and some have um a credit it in both of those areas. So, um that's just two different uh accreditations. There are many more fellowship slots than applicants. So, um there's at least 10 to 25 slots that are not filled every year in P to Ortho. So, you know, there are the big guys who kind of um snap up a lot of the fellowship, um, applicants and have, you know, fairly large programs like, um, San Diego for, I think, uh, Dallas, uh, Scotch, right? Is maybe four or five, chop is 4 to 6. So, Boston is, you know, 45 to 6. So, you know, these, these, um, do snap up a lot of the people wanna do pizza or there's a lot of smaller programs as well. Um, so you can get your job choices fairly frequently. Job market will likely be pretty strong for pediatric orthopedics as, uh, folks of my vintage will be probably hanging it up the next few years. Um, you know, next 5 to 10 years. So I think there's gonna be a lot of opportunity out there. Um, what can you do to get into orthoped residency? Well, um, I'm seeing a lot of your forms now and, um, and it varies from program to program, but basically, you know, getting good grades in your clerkship, uh, you know, honors makes, makes a difference because that's something that gets check marks AOA designation, gold Humanism Awards. Um Obviously, usm le step one, getting it the first time. And then, you know, we're aware of the scores on the second one on uh on part two military background and a lot of programs, there's some acknowledgement of that um sub eyes. So if you've managed to do some work, um get in front of some other people making decisions about um the applicants that that doesn't hurt. In fact, it's increasingly de uh designated as one of those, you know, somewhat must dos. Signaling is a newer thing. It used to be kind of a minor thing. But now I think many programs have this concept called signaling, which you can kind of basically telegram, you're very interested in, um, uh, publications always is, um, is helpful. Um, and if you can get um, a handful of publications that will, um, definitely, uh, put you in a stronger position, sustained interest. I this is something I, I've always looked for in a candidate. You have a sustained interest in a sport and, uh, you, you pursued it for many years and, you know, or music or volunteerism. I personally have a, uh, uh, you know, having reared a couple of eagle scouts, II know what that means to be dedicated to scouting for instance. And that's something II will ask a candidate about. So, you know, these are, these are things that, um, and um, II know, draw attention, uh to yourself. So I'm just at my 30 minutes as I promised and I'm gonna stop sharing now. So uh mission accomplished. Hopefully. So to some degree I'm here for you. Ask away, what can I tell you? Can I give you the secrets? I thought I just did. But if there's some left to give you, let me know. Hey, Doctor Price, would you mind talking about what your work-life balance is like? Well, it's, I probably should make sure my wife isn't listening. Um I'll be honest with you, I came from that era as a resident where we didn't have work hours. Um So, uh I had a, I came from a relatively smaller program, so, uh you know.