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BACKGROUND

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Specialists in pediatric hospital medicine are commonly involved in the care of patients with a broad variety of orthopedic conditions, including a newborn with congenital anomalies, the postoperative care of patients undergoing elective orthopedic surgery, evaluation of a patient with bone or joint pain (or both), and care of patients with musculoskeletal trauma. A vast spectrum of issues therefore confronts the hospitalist in the evaluation and care of patients with orthopedic conditions. This chapter addresses some of the more common scenarios and diagnoses that are encountered by the pediatric hospitalist and emphasizes the early diagnosis of complications in patients hospitalized with orthopedic conditions.

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CONGENITAL CONDITIONS

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Many congenital orthopedic conditions are associated with anomalies of other organ systems, as they develop at the same time in embryologic development. All patients with congenital orthopedic conditions therefore require a thorough evaluation to diagnose associated anomalies, since some of these may potentially be life threatening.

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DEVELOPMENTAL DYSPLASIA OF THE HIP

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Developmental dysplasia of the hip (DDH) may occur as an isolated finding (so-called typical DDH) or in association with a variety of syndromes (e.g. arthrogryposis or Larsen syndrome) or neuromuscular diseases (e.g. spina bifida or spinal muscular atrophy). These associated syndromes and diseases typically require further evaluation and treatment from other specialties, whereas typical DDH can be treated by an orthopedist without further medical evaluation. Nonoperative treatment with a Pavlik harness or splint is usually successful for typical DDH when the diagnosis is established shortly after birth, but surgery is frequently required for cases of DDH that present late or are refractory to nonoperative treatment, and those associated with syndromes or neuromuscular diseases.1 Historical features suggestive of a risk of DDH include family history, breech birth, first born, and female. Screening in the newborn nursery is completed by physical examination, including the Barlow and Ortolani maneuvers. Patients with an abnormal examination are commonly referred for orthopedic evaluation, and those with equivocal findings or significant risk factors are often referred for an ultrasound examination.

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LIMB DEFICIENCIES AND DEFORMITIES

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Ultrasound screening during the prenatal period has led to detection of limb deformities in utero. Examples include congenital limb deficiencies (proximal femoral focal deficiency [PFFD], longitudinal deficiency of the tibia or fibula), tibial bowing, arthrogryposis, congenital dislocation of the knee, and amniotic band syndrome. All of these conditions should be evaluated by an orthopedic surgeon. A spectrum of femoral dysplasia may be encountered, from the congenital short femur to the more severe proximal femoral focal deficiency in which the proximal femur may be absent. Longitudinal deficiency of the tibia involves partial or complete absence of the tibia in association with a variety of abnormalities of the limb such as femoral hypoplasia, absent knee ligaments, fibular bowing, tarsal coalition, and absence of the medial rays of the foot. Treatment recommendations are based on whether or not the quadriceps are ...

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