Pediatric orthopedic evaluation leading to an accurate diagnosis is the first and important step in optimal management. Every condition requires a diagnosis, but only some require active treatment. The evaluation of the child is often more difficult than that of the adult. The child is a poor historian, and examination of the child can be difficult. Dealing with the family may be challenging. The history given by the parents is often laced with emotion. Reporting may be complicated by varying gender and generational hierarchy. The physician often finds that managing the child’s problem is easier than dealing with the family. Establishing rapport during the first visit is essential.
The goal is to reduce the fear in the child and establish confidence with the parents and family.
Studies have shown that casual dress promotes approachability and more formal dress enhances confidence. Dress in a way that suggests you have good judgment and are appropriate for the situation. More formal dress may be more appropriate in a major referral center than elsewhere. Avoid making a statement by dress. This usually translates into selecting conservative clothing that promotes an image of good taste.
On entering the examination room, acknowledge everyone in the room. Consider the cultural background of the family and conform to gender order for introductions. Shake hands with everyone, including the child. Determine the relationship of each person with the patient.
Be professional, yet friendly. Establishing a good rapport with everyone in the family may be critical to properly managing the child. Later, when difficult management decisions must be made, having rapport with every member of the family is necessary to avoid pressure on the parents to seek additional opinions. Once started, serial consultations usually end with some unnecessary treatment of the child.
Calming the Child
Reducing the child’s fear is the next objective. Consider examining the infant or younger child on the parent’s lap. Ask the child on whose lap he or she wishes to sit. Children will often select the family member who they believe will offer the greatest safety.
Be friendly with the child. Suggest that this will be a game. Make some positive statements about the child, such as “Mary, you are such a nice child.” Ask some child-oriented questions, such as “What is your pet’s name?”
Start gently examining the child while taking the history from the family. This first step is to convince the child that the examination will not be painful. This is the time for the screening examination, starting with the area most removed from the problem. Being gentle often results in the child becoming less threatened and more cooperative.
Sometimes, these measures fail and the infant or young child remains aggravated and uncooperative. This is the time to move to strategy two—a firm approach.
Present Orthopedic Problem
The concerns usually fall into the categories of deformity, altered function, or pain. Assessment of these complaints should take the patient’s age into consideration. For example, the toddler usually manifests discitis (an intervertebral disc space infection) by altered function in the form of an unwillingness to walk. The child with discitis may primarily show a systemic illness, whereas the adolescent often complains of back pain.
A common pitfall in diagnosis is inappropriately attributing the child’s problem to trauma. Although trauma is a common event in the life of a child, serious problems such as malignant tumors or infections may be mistakenly attributed to an injury.
Deformity Positional deformities such as rotational problems, flatfeet, and bowlegs are common concerns but seldom significant. More significant problems, such as congenital or neuromuscular deformities, require careful evaluation. Inquire about the onset and previous management. Are there old photographs or radiographs that document of the deformity? Is there associated pain? Does the deformity cause a problem and embarrass the child? Is it noticeable to others? Finally, be cautious about relying solely on the family’s estimation of the time of the deformity’s onset. Often a deformity originates long before it is first noticed.
Altered function Function can be altered by deformity, weakness, or pain. Pain is a common cause of altered function in the infant and child; the most common example is a limp. A toddler’s fracture of the tibia may manifest itself by a limp or an unwillingness to walk. The young child with toxic synovitis may simply limp; the older child might complain of pain. The newborn whose clavicle is fractured during delivery shows a loss of arm movement on the affected side. This may be confused with a birth palsy. Altered function due to trauma, inflammation, or infection without neurologic damage is referred to as pseudoparalysis.
Pain The expression of pain is age related. The infant may simply avoid moving the painful part, may fuss and cry, or cry continuously if the pain is severe. The child may show altered function, avoid moving the affected part, or complain of discomfort. The adolescent usually complains of pain.
The perception and expression of pain differs widely among individuals, particularly as adolescents grow more adult-like in their responses. A herniated disc or an osteoid osteoma may cause scoliosis. This scoliosis results from positioning the spine in a pain-relieving posture. This secondary deformity rather than the underlying condition may be the focus of the evaluation. Unless the underlying condition is identified by the physician, a serious diagnostic error can occur.
The past history is essential, not only for understanding the background and general health of the child but also for gaining insight into the current problem. Important aspects of past history include the following:
Birth history Were the pregnancy and delivery normal?
Development Have the developmental milestones been met at the appropriate ages? When did the infant first sit and walk? About one-third of late walkers are pathologic. In children with conditions such as cerebral palsy, walking is always delayed, and this may be important in establishing whether the condition is progressive.
The mother’s intuition is surprisingly accurate. For example, the mother’s sense that something is wrong with her infant is one of the most consistent findings with cerebral palsy. Take the mother’s concerns seriously.
Family history Do others have problems similar to those of the patient? If so, what disability is present? A surprisingly large number of orthopedic problems run in families, and knowledge of the disability, or absence of disability, provides information regarding the patient’s prognosis.