I am Dr.
Ryan Murray.
I am an orthopaedic surgeon specializing in pediatric orthopaedics
and sports medicine here at MedStar Georgetown University Hospital.
The patients I see typically are very diverse.
They range from small babies and children up into adulthood.
My primary focus is on orthopaedic sports medicine conditions.
But I also see patients with fractures,
as well as other orthopaedic issues related to childhood.
My philosophy of care really centers around shared decision
making with patients and their families,
getting to know the patients and what their goals are, and
then explaining the way I'd like to approach your treatment
so we can arrive at a
conclusion that results in the best possible outcome for the patient.
Orthopaedics is a really rewarding field.
We get to see patients of all different ages and activity
levels and goals in life, and we are able
to, in a short period of time, prescribe
some type of treatment, whether it's operative or not operative
treatment to get patients back to the activities they enjoy.
And that makes it a really gratifying specialty in medicine.
The future of sports medicine, particularly pediatric
sports medicine, is really exciting.
There are a lot of innovations happening
not only in technology, but also in terms of research
where we can really apply the best techniques
and practices that we use in adults, including high level athletes
to younger patients, while considering the unique
anatomic and age-related changes in pediatric patients.
The best part about this job is coming into
the clinic and seeing patients who I previously met when they were not
so happy and they had recently been injured, or they had a setback in their rehab.
And then they come back and they have overcome that and they can say,
you know, I'm really happy because I'm able to do this activity or
was able was able to play in this game,
and that makes all the difficult times worth it.
When you come here to MedStar Georgetown, everyone has a soft spot
for the pediatric patients and they really go out of their way
to make sure the experience is a positive one.
And I personally work really hard to make sure
that my patients get the best possible care
so they can get back to the things they want to do.
Pediatric orthopaedic
surgeon takes care of kids of all ages
from the small children and babies all the way up
through the adolescent growth period and into adulthood.
So, we
approach orthopaedics in a similar way to adult orthopaedics, but we have younger
patients that have certain considerations related
to their growth.
Orthopaedics has a lot of different subspecialty
areas, and pediatric orthopaedics is one of these subspecialties
that deals with the growing and developing
child in the treatment of orthopaedic or musculoskeletal conditions
in that population of people, which is slightly different
than adult patients because children are still growing in
the treatments need to consider and respect
the growing skeleton.
Among the most common conditions
that people come to a pediatric orthopaedist for include limb
alignment abnormalities,
particularly bow legs or knock knees.
And oftentimes these are normal variations of growth.
However, because they're so obvious to the families,
they oftentimes spring them for treatment.
Other things that commonly present
worth being surgeon are fractures, ranging from small buckle
fracture to a displaced or angulated fracture,
all of which require varying degrees of intervention or care.
And then as children get older, particularly
into their early adolescence and teenage years, oftentimes injuries are related to
to sports or recreational activities
that require some treatment
in order to get them back to those activities.
Many orthopaedic conditions
are the same in children and adults.
The things to consider are the unique anatomic variations of kids,
which include their growth plate that each bone has
one or two growth plates
either end and oftentimes those are the weakest parts of the bone,
if you will, because they are still developing and their cartilage base.
So a lot of times injuries exist around the growth plate,
which doesn't exist in adults.
But many of the same principles and
treatment considerations apply among adults and pediatric patients.
The unique aspect of pediatric orthopaedics is considering
how these injuries and the treatment will affect growth.
I think the biggest indicator that someone should seek
medical treatment, especially from a pediatric
orthopaedist, is when their child's not acting themselves.
Parents know their kids better than any doctor ever would.
And oftentimes parents say, I noticed that he wasn't, you know,
climbing the things he likes to climb or running as fast as he used to. And
I think that's
the time, when you feel like your child's not doing the things they used to do, that
you should seek attention and treatment from a pediatric
orthopaedic surgeon.
Children have growth plates
as part of their long bones, and as they get older,
the bones grow longitudinally or lengthwise
from both ends of the bone, and those growth plates are responsible
for transforming cartilage
cells into bone cells that then increase the length of the bone.
These growth plates are typically active in children until about 14 years old
in females and 16 years old in males, at which point
children are mostly skeletally mature at that time.
So, the interesting thing about taking care of children is that
every child is a little bit different and everything exists on a spectrum.
And so children, when they're first born,
their legs are actually kind of bow-legged, but they don't.....
no one really pays attention to that.
And as they start to walk, they walk a little funny with a waddle, and people
then may take note that one child's legs are more bow than the other.
Interestingly, as children get older,
they actually, in the preschool age, start
to have some knock knees, and this is just natural physiologic variation.
And then some kids are more knock kneed than others.
And this oftentimes raises some concern,
especially when kids are close in age, but not,
you know, exactly the same age
because they can have different appearances of their lower extremities.
And this can be really concerning to parents, particularly when, you know,
they maybe they didn't have that with their other child or with their
child's peers.
So, a lot of orthopaedics, particularly sports
medicine, is the treatment of overuse injuries and in
pediatric orthopaedics, the unique thing about overuse injuries is oftentimes
they occur in the same places as adults, but for a different reason.
And that's because tendons insert
on kid's bones via a growth plate, and that's called an apotheosis.
And that essentially is a growth plate that grows under tension.
And when that growth plate is pulled on a lot by a muscle or tendon that's
being overused, you can get inflammation of that growth plate
and it can be slightly more sensitive than perhaps the same injury in adults.
And the important thing is that this doesn't necessarily affect
the growth of that area of the bone, but it does need to be treated
typically with rest and rehabilitation
before aggravating that injury again.
Pediatric fractures
and adult fractures all occur by the same mechanisms.
However, pediatric fractures are different in essentially
two ways, one of which is we're very fortunate
pediatric fractures that a lot of them can be treated without surgery.
And the reason for that is in part because they are growing children.
And so even if a bone is not
exactly aligned, the way it should be in adulthood,
as a child grows, their body has an amazing ability
to remodel the bone back to a normal shape.
So, there's a lot more tolerance for the way a fracture is lined up,
and then that allows us
to treat these non-surgically in the vast majority of cases.
The other factor that is unique to children is the presence
of a growth plate.
Fractures around a growth plate
occur, in part, because that is the weakest area of the bone.
So, if child lands on their wrist and they have a fracture of their wrist,
that involves the growth plate, that is because that area of the wrist
is sort of the weakest part and it doesn't exist in adults.
And so there are certain considerations in treating a growth plate injury
that are unique to kids because adults don't have a growth plate.
Pediatric fractures require operative treatment
for a couple of different reasons, the most
obvious one would be if a fracture is open or the bone is exposed
to the outside world that requires surgical treatment.
The other reasons for surgical treatment of pediatric fractures are those which
cannot be held in place with a cast
or some other type of a mobilization device.
Those may require operative treatment or fractures that have been attempted
to treat, not operatively in a cast that have displaced
outside an acceptable window of variation in measurement.
Those fractures are best treated with some type of operation
in order to get them to heal in the best possible position.
So, there's this notion
in medicine that children are not just small adults.
And that is, in fact, true when it comes to pediatric orthopaedics.
However, I think, in treating pediatric sports medicine
injuries, you kind of have to have both viewpoints in that
pediatric athlete is
very similar to a high level professional or college athlete
that all they want to do is go back and play their sport.
And so you have to approach them with the respect of what they want to do
the same way you would as someone who does that as part of their career.
However, you do have to sometimes give them a little bit of a reality check
and remind them
that as a young athlete, there will be plenty more time to play sports.
And so they have to, you know, slow themselves down.
And in many ways, treating pediatric sports related injuries is as much
about managing their expectations
as it is about managing their injury and treating kids.
You kind of have to get to their level and realize that for this young person,
the next weekend's game is the most important game in the world to them.
And my job as the doctor is to treat them
in such a way that they realize that maybe this game
was important, but the subsequent ones will also be important.
You have to get them back out there for all of them.
Pediatric ACL
injuries are among the most common things I see.
And there is
a growing number of ACL injuries among adolescents
and young children related probably to the abundance
of opportunities for sports year round. The thing in treating an ACL
injury is I'm always asked whether or not
they need to have ACL surgery.
And oftentimes I do recommend ACL surgery
after discussing the reasons for that which include
persistent knee instability if someone does not have their ACL
operated on, and that can result in cartilage or meniscus injuries later on.
However, specific to the ACL surgery, when you
approach a pediatric patient, there are certain things to consider.
Traditional adult style ACL reconstruction
goes through the growth plate and violates it.
So, in younger children,
we have to take certain considerations about the growth in how
we treat the ACL injury, whether that's using an alternative technique or simply
being in a position where we monitor their growth after surgery
to be able to detect any abnormalities as a result of an operation.
Cartilage injuries in
pediatric patients can occur for a number of different reasons.
The most common I see are osteochondritis dissecans,
particularly of the knee and occasionally the elbow.
And these are conditions where the bone underneath
the cartilage can become detached
or inflamed related to
repetitive injury.
And oftentimes I see these patients and they either have
longstanding mild knee pain or elbow pain, or they have an acute or
relatively sudden injury where their knee gets very swollen and aggravated.
And in these different cases, there's things to consider
as to when you treat these patients with not without surgery or with surgery,
particularly in children that are still growing and have open growth plates.
They have a tremendous capacity to heal these
these problems non-operatively,
whereas those that are older, more skeletally mature,
oftentimes, we need to consider other treatment options.
Patella
instability or the kneecap sliding out of place
is commonly seen,
particularly in adolescents and young adults,
and it oftentimes is related to either a sports-related injury
or in folks with risk factors for this.
They can have it rather insidiously with everyday life.
And when we see these patients,
they typically have a swollen and painful knee,
and they don't really want anyone to touch or move it.
And the question then is how do you figure out,
number one, that they had this dislocation of their kneecap?
And then how do you treat it?
And oftentimes the initial evaluation involves x-rays
and then potentially an MRI scan or advanced imaging.
But fortunately,
the treatment for a first time dislocation of the kneecap oftentimes
is with physical therapy and non-surgical treatment and only when they
have difficulty returning to activities after this treatment,
do we consider other options.
Shoulder
instability is common among young adults and adolescent patients,
particularly those involved in sports activities,
and when someone dislocates their shoulder one time, there are things to consider
in terms of the likelihood a shoulder would be to dislocate again.
Things to consider are the hand dominance of the patient, the sports
they participate in, particularly contact and competitive sports.
Their general ligamentous laxity or just the loose jointed-ness
or lack thereof of a patient,
as well as other things related to their first association,
including the amount of bone injury at the time of their initial
dislocation.
Return to play in sports medicine is oftentimes
one of the most challenging things to decide
because patients are typically feeling pretty good
well before we let them go back to sport.
And so, there's a period of their rehabilitation recovery
from either non-surgical or surgical treatment
where they want to go back and we're basically not letting them.
And the reason for that is oftentimes because even though a patient feels good
and they've recovered from their injury, they've lost some of that
edge that makes them better.
Whether it's muscle mass or some agility or some elements of their game
that they need to gradually get back into
before they go back out and risk repeat injury.
So, I oftentimes tell patients, particularly patients
who have had surgery, that there's going to be a period of time
late in their rehab where they think I don't know what I'm doing
because they're going to say, well, I feel fine, I should go play.
But we know from research
and experience that patients that go back to soon
risk, repeat injury or a different injury that can set them back
further.
I think parents of families should bring their children
to MedStar, Georgetown for their pediatric orthopaedic care
because not only is this
a leading academic center
with cutting edge research and technology, but also we have a great team
of subspecialists and all the different areas of orthopaedics,
whether it's hand surgery or foot and ankle surgery or spine surgery.
So, although they may meet me for the first time, I have many colleagues that
I can
interact with and share cases with and
and really get the patient the best care that they deserve
from an orthopaedic department that is well-rounded and all subspecialty areas.