Published: Oct 28, 2013
By Charles Bankhead, Staff Writer, MedPage Today

Full Story:  http://www.medpagetoday.com/MeetingCoverage/AAP/42518

ORLANDO — Primary care physicians can manage almost all cases of “in-toeing” in children without consultation from an orthopedic surgeon, according to a retrospective study of referrals.

The review of 146 consults for in-toeing showed that more than 95% of the cases could have been managed by the child’s primary doctor. In 15% of the cases, the patients had a condition that had been misdiagnosed as in-toeing.

“In our series, 1% of patients required casting for in-toeing, and one of every seven patients seen for this diagnosis actually had another diagnosis entirely, including subtle neurologic conditions, such as cerebral palsy, in 2% of patients,” John Sielatycki, MD, of Vanderbilt University in Nashville, said here at the American Academy of Pediatrics meeting. “No patient that we saw required surgery.”

In-toeing arises from the foot, hip, tibia, or a combination of the three and includes conditions such as metatarsus adductus, tibial torsion, and femoral torsion. Although most cases of in-toeing resolve spontaneously without treatment, parents or grandparents may seek orthopedic assessment because of concern that the condition will become permanent and interfere with activities, said Sielatycki.

Previous studies have suggested that as many as 50% of referrals to pediatric orthopedic clinics involve primary care problems such as in-toeing. Sielatycki and colleagues sought to determine the proportion of in-toeing cases that require active treatment, such as casting or surgery, for which referral to a pediatric orthopedic surgeon would be appropriate.

Investigators reviewed records for 146 consecutive patients referred for evaluation of in-toeing. Each patient’s evaluation included a complete history, physical exam, and rotation profile. Treatments offered primarily included counseling, education, reassurance, handouts, and scheduled follow-up. In a few cases, casting was offered.

Primary care physicians accounted for 88% of the referrals, general orthopedic surgeons for 6%, and the remaining 6% were by self-referral. The review showed that 85% had accurate diagnoses of in-toeing, whereas 15% had different diagnoses, such as flat feet or subtle neurologic conditions.

Sielatycki said 74% of patients were discharged after the first visit and 18% after a follow-up visit. No child required surgery. Five patients required casting or shoe support for rigid foot deformity, and physical therapy was offered to six patients.

“The goal of every patient visit is to provide excellent care in an efficient and effective manner,” he said. “When a pediatric orthopedic surgeon evaluates a child, the six core competencies remain very important. As we have shown, the majority of patients with diagnoses of in-toeing have nothing wrong with them.”

“Nevertheless, their parents can still fill out patient satisfaction surveys just like parents of a child with a 90-degree scoliosis curvature.”

The findings have implications for pediatrics musculoskeletal education, raising the question of whether pediatricians should be trained in the diagnosis and management of in-toeing.

“There are also implications for pediatric orthopedic reimbursement under the Affordable Care Act,” said Sielatycki. “If pediatric orthopedic surgeons are performing primary care functions in the clinic, then perhaps they should be reimbursed as [general] pediatricians are reimbursed under Medicare rates for Medicare patients.”

Lastly, the results have implications for workforce planning, he said. If as many as half of referrals to pediatric orthopedic surgeons involve conditions that can be managed in the primary care setting, perhaps orthopedic practices should considering adding nurse practitioners, pediatricians, or primary care physicians to see such patients, with supervision by orthopedic surgeons.

Acknowledging that some patients do require consultation with an orthopedic surgeon, Sielatycki and colleagues suggest several circumstances for which referral is appropriate: pain, rigid foot deformity, asymmetry, severe in-toeing beyond age 8, and parents’ or grandparents’ demand for a second opinion.

Another study reported at the same session called into question the adequacy of pediatricians’ knowledge of musculoskeletal medicine. More than 100 residents and faculty physicians at a large pediatrics hospital completed a questionnaire related to common musculoskeletal conditions.

Trainees’ scores ranged between 58% and 72%, hospital-based physicians averaged 69%, and outpatient physicians averaged 62%.

An unidentified physician in the audience asked what pediatricians should make of the two studies. Sielatycki suggested the studies can be used to make a case for better education of pediatricians in musculoskeletal medicine and to reassure parents that almost all cases of in-toeing resolve without need for surgery.