When is the right time to refer to an orthopedic surgeon?

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Matthew A. Halanski, MD, discusses the relationship between the pediatrician and orthopedic surgeon when it comes to referrals and sports injuries.

Interview highlights

  • Pediatricians should refer to orthopedic specialists for musculoskeletal concerns, involving a team of specialists beyond just surgeons.
  • Clear communication between pediatricians and orthopedic specialists is vital, prioritizing urgent surgical cases while managing non-surgical cases appropriately.
  • Common school-related injuries include those from monkey bars, trampolines, and sports, with a rise in ACL injuries and concussions among female athletes due to increased sports participation.
  • Pediatricians generally refer patients well, but the misconception that certain orthopedic issues require waiting until growth stops should be dispelled, emphasizing the importance of early intervention.
  • Timely interventions are crucial; innovative techniques can use a child's growth potential for less invasive corrective surgeries, highlighting the significance of early assessments and interventions.

Interview transcript (edited for clarity):

Matthew A. Halanski, MD:

Hi, my name is Matt Halanski. I am current division chief at Phoenix Children's over the Orthopedics and Sports Medicine program.

Contemporary Pediatrics®:

When should pediatricians refer to an orthopedic surgeon?

Halanski:

Over time this question has come up and it's a common one. I think as the healthcare system has grown and matured, I think orthopedic practices have as well. I think there's been this notion in the past, that pediatricians shouldn't send somebody or should really try to prevent, overloading the specialists from from getting referrals, and I think our system has grown to the point where it's not just an orthopedic surgeon, we're a musculoskeletal team that consists of specialized advanced practice practitioners. We have physical medicine and rehab partners that work with us, we have non operative sports physicians, as well as the sub specialized surgeon. So I think anytime a pediatrician is concerned about musculoskeletal problem, feels that they may be getting over their head about something, or just have that family that needs a little extra reassurance from a specialist, they they should refer. I think it's really important though the messaging from the pediatrician that when being referred to orthopedics, that may mean they may see a surgeon, that may mean they may see one of these other individuals, and that doesn't mean they're going to get less-appropriate care. We're trying to get them the best care they need for their condition. So I also think it's important for the pediatricians, while it may take a little bit extra time filling out a referral form, to give us really what what the child is being seen for because the children that do need urgent or more urgent surgical care, we do want to make sure they get in to see the surgeon but there are a lot of referrals that can be worked up appropriately by somebody who's not a surgeon until we get to that point. I think we have to work a little bit better as a healthcare team to kind of be consistent with that messaging and get the right patients to the right providers.

Contemporary Pediatrics®:

As children are back in school, at recess, and participating in team sports, what injuries are commonly seen around this time?

Halanski:

Some of my answers have changed since moving to the Southwest as the seasons are a little different than they are in the north. Overall, monkey bars, trampoline, sports injuries are what keep our fracture clinics busy year round. As the school year approaches, for sure, we do see increase in sports injuries, particularly in our female athletes, with the increase in popularity of female sports. With that has come quite a large increase in the number of ACL injuries that we do see in female athletes. It's become a lot bigger news recently, but a lot of concussions as well. They end up seeing a lot of our nonoperative sports providers and so we do tend to see that both with football and with soccer. I think overall the increased participation in youth sports year round has caused all of us to see an increase in youth overuse injuries and that is something that I'm sure the pediatricians see quite a lot of. And again, some of it is with that consistent messaging that often growing children should not be in a single sport year round, but should try to be more well rounded. That goes counter to the sports culture in our country right now, but it definitely does cause skeletal immature individuals to be more at prone for these overuse injuries.

Contemporary Pediatrics®:

Generally speaking, what issues do you notice in children you feel could have been addressed sooner by the time they are referred?

Halanski:

It would say overall, pediatricians do an excellent job at referring patients appropriately. I would say if there's one myth I would want to dispel it's that we have to wait until you're done growing to do something. We commonly hear that, particularly with limb deformities and spine deformities. There's enough innovative new technologies and techniques that we have to actually harness the child's own growth potential to correct a lot of those deformities that allow the surgery, the recovery, to be a lot less invasive, if we're able to do it while the patient is growing. So, while we probably don't need to see every 2 year old that looks like they have bow legs, we're happy to, but we don't want to see that patient when they're 16 with bow legs because between then, there's some very minor surgeries we can do to straighten out those limbs that we can't do once they're done growing.

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