A pediatric orthopedic patient is not a small adult
Childhood is a fracture-prone time. Fractures in growing bones are different from those in adults and require expert care. According to Professor Yrjänä Nietosvaara, there is still room for improvement in the treatment of children’s fractures.
“A reduction of just one percent in medical errors would mean less pain and harm to quite a few patients.”
Yrjänä Nietosvaara started as a part-time Professor of Pediatric Orthopedics and Traumatology at the University of Eastern Finland at the beginning of February.
Pediatric orthopedics and traumatology is a field of medicine that focuses on the study and treatment of injuries and diseases of the musculoskeletal system, with patients ranging from newborns to young adults. Fractures are the most common cause of treatment, because at least one in three children sustains at least one fracture during their growing years. Most often, fractures are caused by slips or falls, and two thirds of all fractures are located in the upper limb – usually in the forearm or in fingers.
“This area is exposed to a lot of force when people extend their hand in an effort to break a fall,” Nietosvaara says.
In many cases, a child’s bone gets fractured while doing a physical activity, nowadays increasingly when bouncing on a trampoline.
“Bouncing on a trampoline is, as such, good exercise. Many fractures could be prevented with a safety net and by making sure that a trampoline is used by just one person at a time.”
“Children’s bones are softer and more flexible than adults’. They get fractured by less force; however, fractures in children are usually less severe than those in adults. Children also have specific fracture types that do not occur in adults, such as torus fractures and bowing fractures, where the bone bends but otherwise remains intact.”
Growth must also be taken into account in the treatment of children’s fractures.
“In some fractures, growth supports treatment by adjusting any possible malalignment, and there is no need to reset the fractured bone. Without skilfully performed surgery, however, fractures extending to the articular surface may lead to bone growth disorders, limb malalignment and osteoarthritis.”
There is still room for improvement in the treatment of children’s fractures
In his research, Nietosvaara explores, among other things, how the quality of treatment relating to children’s fractures could be further improved.
“According to the patient injury claims we have studied, the risk of a compensable patient injury in the treatment of fractures in the femur, tibia and lower humerus has been around one per cent. Since not all those entitled to compensation apply for it, my guess is that the real percentage is higher.”
“It may not sound like much, but these are usually avoidable injuries. Every year, thousands of children sustain a bone fracture, so a reduction of medical errors by just one percent would mean less pain and harm to a lot of patients.”
According to Nietosvaara, an X-ray is appropriate if a child is suspected of having a fracture. Although not all children’s fractures are visible in an X-ray image, not taking one may cause unnecessary delay the diagnosis.
“However, follow-up X-rays are rarely needed. Traditionally, they’ve been used far too much, and there is now a tendency away from this practice. A child shouldn’t be exposed to ionising radiation without a good reason.”
Treatment of brachial plexus birth injury sustained during childbirth is exemplary in Finland
The field of pediatric orthopedics and traumatology, and Nietosvaara’s research interests, include birth injuries and congenital defects. In newborns, the most common birth injury is brachial plexus birth injury (BPBI), affecting around 100–150 newborns in Finland every year. Most of these injuries will heal naturally, but one in five newborns will be left with a permanent handicap. Nowadays, Finland is among world-leaders in the treatment of BPBI, thanks to a protocol developed by Nietosvaara and colleagues.
“Parents will start doing passive motion exercises with the newborn right away. Some have a risk of dislocated shoulder, which is diagnosed with ultrasound imaging, treated with a Botox injection into the rotator muscle and, when necessary, with a surgery performed when the patient is 12–24 months old. With strict screening and systematic treatment, most cases of shoulder dislocation have been successfully prevented.”
Nietosvaara has developed new surgical methods for the treatment of BPBI and syndactyly, i.e., webbing between adjacent fingers. Syndactyly is one of the most common congenital limb defects, in addition to extra fingers.
“In finger syndactyly, fingers are usually conjoined only by skin, but it requires skill to separate them without causing scarring and so that the outcome will be pretty, and the fingers function normally.”
The treatment of pediatric orthopedic patients is also being developed, and issues in their treatment addressed, by international experts panels, in which Nietosvaara actively participates. Working in Australia and visits to the best hospitals in the US have shown that Finnish care stands the test of comparison.
“In some respects, we are more advanced, and others are in others.”
Academic special qualification programme for the challenging field
Pediatric orthopedics also deals with the treatment of malalignment resulting from, e.g., cancer, rheumatoid arthritis, cerebral palsy, or a progressive muscle disorder. Pediatric orthopedic clinics also perform scoliosis surgery and correct limb-length discrepancies.
“The field is broad and challenging, and we have only a dozen qualified pediatric orthopedic surgeons actively working in Finland,” Nietosvaara says.
Efforts have been made to strengthen expertise in the field by launching a special qualification programme in pediatric orthopedics and traumatology. The recently launched two-year programme is available to physicians specialised in orthopedics and traumatology, or in pediatric surgery.
According to Nietosvaara, the situation of pediatric orthopedics varies from hospital to hospital, but pediatric orthopaedic surgeons also travel as needed. For example, Kuopio University Hospital and the New Children’s Hospital at Helsinki University Hospital have agreed on collaboration in cases of demanding surgery.
“However, each university hospital should have at least two physicians qualified in pediatric orthopedics. While it makes the most sense to perform pediatric orthopedic surgery in university hospitals, it has also proven to be a good practice for pediatric orthopedic surgeons from university hospitals to visit smaller central hospitals to provide outpatient treatment.”
Nietosvaara, who’s made a long career at Helsinki University Hospital, started as Chief Physician in Pediatric Surgery at Kuopio University Hospital in 2019. According to him, pediatric orthopedic patients receive good care in Kuopio University Hospital.
“Kuopio University Hospital now has two qualified pediatric orthopedic surgeons. In the treatment of older pediatric patients, we work closely with orthopedic surgeons treating adults. The hospital also has really skilled pediatric radiologists, and better availability of magnetic resonance imaging and cone beam computed tomography than in Helsinki.”
- Professor of Pediatric Orthopedics and Traumatology, University of Eastern Finland (part-time, 30%), 1 February 2022 –
- MD 1989, PhD 1996, Specialist in General Surgery 1998, Specialist in Orthopedics and Traumatology 2004, University of Helsinki
- Specialist in Hand Surgery 2000, University of Tampere
- Special Qualification in Pediatric Orthopedics and Traumatology 2006
- Title of Docent in Hand Surgery, 2007, University of Helsinki
- Chief Physician in Pediatric Surgery, Kuopio University Hospital 2019–
- Head, Department of Pediatric Orthopedics and Traumatology 2011–2017,
- Attending Pediatric Orthopedic and Hand Surgeon (part-time), HUS New Children's Hospital, 2018-
- Pediatric Orthopedic and Hand Surgeon (part-time), Aava Medical Center 2007 -, Pohjola Hospital 2014–
- Pediatric Orthopedic and Hand Surgeon, HUS Children’s Hospital 2004-2007
- Hand Surgeon, HUS Children's Hospital 2000–2003
For further information, please contact:
Professor Yrjänä Nietosvaara, yrjana.nietosvaara (a) kuh.fi, tel. +358 44 717 6883
Print-quality photos, photographer: Raija Törrönen