Book Review

Pediatric Orthopedics: A guide for the primary care physician

N Engl J Med 1995; 332:545February 23, 1995

Article

Pediatric Orthopedics: A guide for the primary care physician
(Critical Issues in Developmental and Behavioral Pediatrics.) By Richard J. Mier and Thomas D. Brower, with contributions by Brian T. Carney and David B. Stevens. 327 pp., illustrated. New York, Plenum Medical Book, 1994. $45. ISBN: 0-306-44796-7

Musculoskeletal symptoms are among the most common problems confronting the primary care physician. With the advent of managed care and capitation, pediatricians and generalists both will have to sift through more and more of these orthopedic puzzles. Pediatric Orthopedics attempts to give the generalist a framework for recognizing and evaluating the major musculoskeletal problems of childhood. Most training programs in pediatric and adult medicine provide little instruction in performing the musculoskeletal examination and a variable amount of teaching about the common bumps, aches, and pains that make up a substantial portion of primary care.

This book is organized logically, with introductions to the physical examination, evaluation of symptoms, and broad categories of problems. There is no attempt to be comprehensive in the diagnoses considered or in recommendations for treatment. The reader, having tentatively diagnosed the problem, is given a brief outline of treatment when it can be accomplished by the generalist and broad guidelines for the referral of patients with more complicated problems.

High points of the book include a glossary of otherwise confusing terms such as “varus” and “valgus” (often uttered by the orthopedist to confuse the generalist), chapters on arthritis and other joint problems, discussions of sports injuries, and excellent chapters on child abuse, caring for the child with delayed motor development, and evaluation of the child with pain in an extremity or limping. There are ample illustrations; however, most are radiographs that make sense to the orthopedist but probably have little meaning for the generalist who rarely interprets the x-ray film alone. The chapter on the orthopedic examination is well intended but suffers from the small number of diagrams and pictures. Orthopedics is a highly visual and tactile specialty, and the orthopedist's visual experience includes images of many normal and abnormal bodies and limbs. It would help the generalist, as well, to have an ample supply of pictures of normal and abnormal children's extremities and physical findings.

The style of the book is informal and friendly, with occasional irony or humor interjected in a wholly appropriate fashion. Some chapters have lists of differential diagnoses and highlight salient physical or radiographic findings. The book is brief and manageable, but there is the inevitable tug of war between brevity and completeness. In the attempt to cover all diagnostic possibilities for a given category, their relative importance or seriousness can be lost. The most severe or most common are not always listed first; rather, the common may be interspersed with the unusual, and the serious disorders that need to be ruled out may be intermixed with the benign, which need no treatment.

As a whole, this book is a good refresher for the generalist who needs to review the orthopedic physical examination and major orthopedic diagnoses. Some chapters, such as that on the musculoskeletal manifestations of child abuse, that on arthritis, and that on delayed motor development, are sufficiently comprehensive to serve as references for the generalist.

John Emans, M.D.
Children's Hospital Medical Center, Boston, MA 02115