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Children’s orthopaedics focuses on the unique musculoskeletal needs of growing children and adolescents.

 

Expert care is provided by specialists who treat the full range of orthopedic disorders and developmental conditions, including traumatic injuries.

Our goal is to help each child become as healthy and independent as possible. We are dedicated to providing a complete range of appropriate medical and rehabilitative care to achieve this objective, including surgery, physiotherapy, plaster care, occupational and recreation therapies; and orthotic services.  Each patient receives an individualised care plan incorporating the full range of necessary multidisciplinary services, always incorporating the patient and family’s goals and addressing their concerns. 

Our service is divided into two disciplines - Trauma and Orthopaedics. 

Trauma - this is the aspect of our work that deals with injuries and, though the numbers treated annually are predictable, the types of injuries seen daily are variable and seasonal. Typically the ‘fracture season’ extends from April to October. Up to August 2017, the waiting time to be seen at a Fracture Clinic was inappropriately long but since then our outpatient trauma service has been under control. 

TAC (Trauma Assessment Clinics).  This drastically improved service has been facilitated by the introduction of Trauma Assessment Clinics (TAC), a type of Virtual Fracture Clinic. This new pathway of fracture care, in conjunction with our colleagues in the Emergency Department, has greatly improved the efficiency and standard of care provided to Trauma patients. To date 65% of patients referred to the TAC do not have to attend the hospital again. 

Surgery for fractures.  Most fractures are not deemed as medical emergencies and those requiring surgery (often, therefore!) may be delayed in accessing theatre because they compete for surgical time with emergencies in other disciplines. However due to the volume of patients we see with fractures, the system rapidly becomes overwhelmed if surgery is not performed in a timely fashion. We have been working with the hospital for the provision of a Trauma list each morning to improve the efficiency of care for these injured children. 

Orthopaedics is the area of our practice that covers most other aspects of musculoskeletal pathology. Children can be born with congenital conditions affecting their skeleton that deteriorate with growth. The more severe the problem is at the time of diagnosis then the higher the risk of further deterioration with growth. For many conditions we see that the axiom, 'growth is not your friend' applies. 

The commonest congenital conditions we see are those relating to the hips ( DDH and its variants ) and the (feet  clubfoot / ctev etc ). These problems are all time critical and there is a constant need to deal with them both surgically and non-surgically as soon as possible. Delayed treatment risks more complex interventions and poorer outcomes. 

Many children develop other problems in the hip ( SUFE, Perthes disease) that require urgent operations and numerous outpatient attendances. 

 

Children with neuromuscular problems such as Cerebral Palsy need regular assessments with multidisciplinary teams, numerous physiotherapy sessions, occupational therapy, orthotic provision, Plaster care and Botulinum toxin (Botox) injections as well as major limb deformity corrective surgery. 

Spinal disorders, pain or deformity, is another significant group of conditions that require the input of many different disciplines and consume major amounts of time and resources. Historically long waiting times for outpatient assessments and access to surgery are, at last, becoming manageable. This improved care has come about by the HSE recognising, and delivering, the major investment in resources required to provide a proper service. This is a result of the advocacy of parents and clinicians. 

Outpatient Services. 

Children seen at outpatient clinics are referred by their General Practitioner. The referral letter is seen by the consultant and triaged, or categorised, as Urgent or Routine. Because of the historically inadequate numbers of orthopaedic consultants, the waiting times to be seen, have traditionally been too long and inappropriate. Now, with improved consultant numbers and novel ways of working the excessively long waiting times, this  has improved: though they are still a long way from ideal. 

Telemedicine 

The TAC service, already described, is an example of a more efficient, and very cost effective, way of providing care. Another example is the Virtual Hip Clinic (VHC). Children with DDH, (whose hips are not displaced) can be monitored safely and efficiently without having to attend an outpatient clinic. Run by DDH Nurses and Consultants this service allows children to have X-rays wherever is convenient and their results can be reviewed remotely at the VHC. Care plans can be put in place safely to avoid unnecessary hospital visits. 

Physiotherapy triage clinics have been running in Crumlin since 2010 and since then, thousands of children have been seen. Advanced practice physiotherapists see patients according to agreed protocols under the governance of the orthopaedic consultants. This has had a major impact on the numbers awaiting outpatient appointments. This service is associated with a very high parent satisfaction rate. 

More recently another new outpatient service has been introduced. Specifically aimed at patients waiting the longest - as opposed to those triaged as Urgent - this appears to be a very effective means of dealing with the enormous backlog of referrals. It will continue for the foreseeable future. Like other successful initiatives however, it will create an increased surgical waiting list. 

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