How Many Referrals to a Pediatric Orthopaedic Hospital Specialty Clinic Are Primary Care Problems?

ORIGINAL ARTICLE How Many Referrals to a Pediatric Orthopaedic Hospital Specialty Clinic Are Primary Care Problems? Eric Y. Hsu, MD,* Richard M. Schwend, MD,w and Leamon Julia, RNz Purpose: Many primary care physicians believe that there are too few pediatric orthopaedic specialists available to meet their patients needs. However, a recent survey by the Practice Management Committee of the Pediatric Orthopaedic Society of North America found that new referrals were often for cases that could have been managed by primary care practitioners. We wished to determine how many new referral cases seen by pediatric orthopaedic surgeons are in fact conditions that can be readily managed by a primary care physician should he/she chose to do so. Methods: We prospectively studied all new referrals to our hospital-based orthopaedic clinic during August 2010. Each new referral was evaluated for whether it met the American Board of Pediatrics criteria for being a condition that could be managed by a primary care pediatrician. Each referral was also evaluated for whether it met the American Academy of Pediatrics Surgery Advisory Panel guidelines recommending referral to an orthopaedic specialist, regardless of whether it is for general orthopaedics or pediatric orthopaedics. On the basis of these criteria, we classified conditions as either a condition manageable by primary care physicians or a condition that should be referred to an orthopaedic surgeon or a pediatric orthopaedic surgeon. We used these guidelines not to identify diagnosis that primary care physicians should treat but, rather, to compare the guidelinedelineated referrals with the actual referrals our specialty pediatric orthopaedic clinic received over a period of 1 month. Results: A total of 529 new patient referrals were seen during August 2010. A total of 246 (47%) were considered primary care conditions and 283 (53%) orthopaedic specialty conditions. The most common primary care condition was a nondisplaced phalanx fracture (25/246, 10.1%) and the most common specialty condition was a displaced single-bone upper extremity fracture needing reduction (36/283, 13%). Only 77 (14.6%) of the total cases met the strict American Academy of Pediatrics Surgery Advisory Panel guidelines recommending referral to pediatric orthopaedics, with scoliosis being the most frequent condition. From the *Department of General Surgery, University of Missouri Kansas City School of Medicine; wdepartment of Pediatric Orthopaedic Surgery, University of Missouri School of Medicine; and zdepartment of Orthopaedic Surgery, Children s Mercy Hospital, Kansas City, MO. This Research Project did not receive funding from organizations or other industry support. The authors declare no conflict of interest. Reprints: Richard M. Schwend, MD, Department of Orthopaedics, UMKC School of Medicine, Children s Mercy Hospital, 2401 Gillham Rd., Kansas City, MO 64108. E-mail: rmschwend@cmh.edu. Copyright r 2012 by Lippincott Williams & Wilkins For 38 (7.2%) cases, surgical treatment was required or recommended. Patient age, referral source, or type of insurance did not influence whether the condition was a primary care or a specialty care case. A total of 134 (25%) cases were referred without having an initial diagnosis made by the referring clinician. These patients were more likely to have been referred from a primary care practitioner than from a tertiary care practitioner whether the diagnosis eventually made was considered to be a primary care condition (P = 0.03; relative risk, 1.9; 95% confidence interval, 96-3.86). Conclusions: Almost half of all new referrals to a tertiary pediatric orthopaedic clinic were for conditions considered to be manageable by primary care physicians should they chose to do so. Significance: This has implications for pediatric orthopaedic workforce availability, reimbursement under the Affordable Care Act, and pediatric musculoskeletal training needs for providers of primary care. Key Words: referral patterns of pediatric orthopaedics, primary care orthopaedic problems, pediatric orthopaedic problems, referral source of pediatric orthopaedic problems (J Pediatr Orthop 2012;32:727 731) INTRODUCTION/BACKGROUND The American Academy of Pediatrics (AAP) guidelines have recommended that pediatric orthopaedic surgeons be referred cases such as malignant bone tumors, benign bone tumors, congenital deformities, limb malformations, metabolic bone disease, dysplasia of hips, bone and joint infections, slipped capital femoral epiphysis, scoliosis, complex fractures/dislocations, and other growth-related musculoskeletal conditions. 1 However, recent studies found that up to 95% of the new referrals to a pediatric orthopaedic surgeon were for common conditions or normal variants, with surgical treatment rates ranging from clinic patients range from 3% to 10%. 2 Although pediatric orthopaedic surgeons have traditionally been willing to see these patients, pediatricians also believe that pediatric orthopaedic surgeons are 1 specialty with a severe workforce shortage. 3 As a result, having a large number of referrals for these primary care types of conditions can lead to longer wait times and make it difficult for children with urgent and pediatric orthopaedic specialty problems to be seen. We felt that further study was needed to determine how many of the referred cases seen by pediatric J Pediatr Orthop Volume 32, Number 7, October/November 2012 www.pedorthopaedics.com 727

Hsu et al J Pediatr Orthop Volume 32, Number 7, October/November 2012 orthopaedic surgeons could be considered manageable by primary care physicians. The 2002 AAP guidelines only delineates diagnosis that should receive pediatric orthopaedic management but not conditions requiring general orthopaedic management, such as displaced fractures. We used it in conjunction with the American Board of Pediatrics (ABP) referral criteria, dividing the patient population into 2 groups: those conditions manageable by primary care physicians and those requiring either general orthopaedic or pediatric orthopaedic management. We defined these primary care cases by excluding those cases not meeting our combined criteria of AAP referral guidelines and the current ABP Review Committee s criteria. We hope that these data can help determine how many cases managed by pediatric orthopaedic specialists are primary care problems, develop improved pediatric orthopaedic referral criteria, and perhaps assist in future workforce projections and training needs of pediatric primary care clinicians. METHODS All new patients presenting to Children s Mercy Hospital Orthopaedic Clinic during August 2010 were studied. The Children s Mercy Hospital, located in Kansas City, Missouri, has numerous pediatric subspecialty clinics, 241 inpatient beds and nearly 400 pediatric specialists. It is the only level 1 pediatric trauma center in the region. The hospital receives referrals from Missouri, Kansas, Iowa, Nebraska, Oklahoma, Arkansas, and beyond. Patient age, sex, insurance, referral source, previsit diagnosis, postvisit diagnosis, and treatment were prospectively abstracted from the medical record. Patients who were admitted through the emergency room but did not get seen in the orthopaedic clinic, inpatient consults not seen in the clinic, or patients who were already established in our practice were excluded from this analysis. To define a pediatric specialty care problem, the AAP guideline for referral to a pediatric orthopaedic specialist, from the AAP Surgical Advisory Panel (SAP) guidelines for referral to pediatric surgical subspecialists, was used. 1 This included malignant bone tumors, benign bone tumors, congenital deformities of the upper extremity, limb malformations, metabolic bone disease, dysplasia of hips, bone/joint infections, slipped capital femoral epiphysis, scoliosis, complex fractures/dislocations, and growth arrest. However, other conditions not listed under these AAP guidelines problems may still be considered specialty care. A specialty care condition that did not meet the specific AAP referral guidelines may be a condition needing referral to an orthopaedic surgeon but not necessarily one specialized in pediatric orthopaedics. We divided the patient groups according to our combined ABP and SAP criteria, to study how many referrals were made to orthopaedic surgeons, both pediatric and general. As our institution is a children s hospital, all of the referral cases were seen by pediatric orthopaedic surgeons. The combined criteria details are those referrals that requires a specialists management, for example long cast application of upper or lower extremity, treatment of displaced fractures, scaphoid fracture, intra-articular fractures, open fractures, compartment syndrome, nerve or vascular injury, and injuries, lesions, or developmental anomalies. Specialists care includes both general orthopaedic surgeons and pediatric orthopaedic surgeons. These referrals are grouped together under the same category of referrals that should be managed by a specialist. The ABP 2010 certification criteria and competency 4 was used to define a primary care condition. A condition was considered a primary care problem if it was not included in the list of specific AAP SAP criteria or was not included by our combined criteria for orthopaedic referral. Primary care conditions included buckle fractures, sprains, nondisplaced fractures not requiring reduction or long casts, finger fractures treated with buddy taping or splinting only, nondisplaced toe fractures, fractures that received only a sling for comfort, developmental anomalies or variations that needed only counseling and observation without surgery, and simple injuries or laceration. In general, a primary care condition is a problem that could be managed by a provider with basic musculoskeletal education and experience and not requiring advanced diagnostic evaluation, complex reduction, or surgical treatment. Data were compiled to determine the number of cases that met AAP referral criteria for specialty care, combined criteria with ABP for specialty care, and criteria for being a primary care condition. Further analysis evaluated referral pattern differences in age, location, insurance status, and whether the patient presented with an established diagnosis. RESULTS During August 2010, a total of 529 new patients were seen in the Children s Mercy Hospital outpatient orthopaedic clinic. Of these, 246 patients (47%) were considered to have a primary care condition and 283 (53%) a specialty care condition. A total of 38 patients (7.2%) were scheduled for surgical treatment. Of the total 529 new cases, 77 (14.6%) met the specific AAP SAP criteria recommending specialty pediatric orthopaedic surgery referral (Table 1). Scoliosis was the most common problem (35/77, 45.5%), followed by a bone lesion (11/77, 14%), spine anomaly (7/77, 9.1%), developmental dysplasia of the hip (7/77, 9.1%) and syndactyly (3/77, 3.8%). A total of 283 (53%) patients with a new specialty care condition were seen using our combined criteria (Table 2). The most common specialty care condition was a displaced upper extremity single-bone fracture (36/283, 13%), followed by both-bone displaced fracture (31/283, 11%), scoliosis (31/283, 11%), lower extremity fracture requiring a long-leg cast (24/283, 8.5%), and significant knee injury with 3 of them requiring surgery (20/283, 7.1%). There were 246 (47%) new cases that were considered to be a primary care condition, but nevertheless were still seen in the pediatric orthopaedic clinic (Table 3). 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J Pediatr Orthop Volume 32, Number 7, October/November 2012 Pediatric Orthopaedic Primary Care Problems TABLE 1. Conditions That Should Be Referred to Pediatric Orthopaedics (AAP Surgery Advisory Panel Recommendations) Specialty Problem N Percent of 77 Scoliosis 35 45.5 Bone lesion 11 14.3 Spine anomaly, spondylolysis 7 9.1 Developmental dysplasia of hip 7 9.1 Syndactyly 3 3.9 Other 14 18.1 Total 77 100.0 Other problems, 1 each (1.2%): achondroplasia, synostosis, lumbar gibbus, Kabuki syndrome, slipped capital femoral epiphysis, 1q36 deletion syndrome, Noonan syndrome, McCune-Albright syndrome, Splengel deformity, Scheuermann disease, Perthes disease, spondylocostal dysostosis, and Van Der Wonde, San Filippo, Hurler, Ehler Danlos syndromes. AAP indicates American Academy of Pediatrics. 5 most common primary care problems were nondisplaced, nonangulated phalanx fracture treated with a splint or buddy taping (25/246, 10.1%), femoral anteversion (24/246, 9.8%), nondisplaced single-bone fracture of the upper extremity (22/246, 8.9%), normal examination (17/246, 6.9%), and radius buckle fracture receiving a short splint or cast (13/246, 5.3%). There were 38 (7.2% of total) new patients who received surgical treatment (Table 4). The 2 most common surgical cases were osteochondral lesion excision and angulated phalanx fracture management, 4 patients each, 10.5% of the total 38 surgical cases. Other surgical conditions included release of trigger thumb (3/38, 7.9%), treatment for adolescent idiopathic scoliosis (2/38, 5.3%), developmental dysplasia of hip (2/38, 5.3%), single-bone upper extremity fracture (2/38, 5.3%), both-bone upper extremity fracture (2/38, 5.3%), foreign body (2/38, 5.3%), and bone cyst excision (2/38, 5.3%). Of the 246 total primary care conditions, 229 (93%) were referrals from primary care physicians/facilities and the remaining 17 (7%) were from tertiary care physicians/ facilities. Of the 283 total specialty care conditions, 254 (90%) were referrals from primary care physicians/facilities and 29 (10%) were from specialty care physicians/ facilities. There were no differences in referrals patterns for problems that we considered to be primary care versus specialty care, based on patient age, whether the referral came from within or from outside our institution, whether the referral came from the emergency room, and whether the family was on Medicaid. Of the 529 total cases, 134 (25% of all cases) arrived without a diagnosis. Of these 134 cases without diagnosis, 68 (50.7%) were from primary care providers and 66 (49.3%) were from specialty care. These 134 cases were further divided into whether they were considered by us to be a primary care condition or a specialty condition. If a patient was seen without an initial diagnosis and later determined to have a primary care condition, then the patient was more likely to come from a primary care referral source (P = 0.03; relative risk, 1.9; 95% confidence interval, 0.96-3.86). TABLE 2. Specialty Care Problems: Conditions That Should Be Referred to Orthopaedics (Either Pediatric Orthopaedics or General Orthopaedics) Percent of Problem N 283 Displaced upper extremity single-bone fracture 36 13.0 Both-bone displaced fracture 31 11.0 Scoliosis 31 11.0 Lower extremity fracture requiring long-leg cast 24 8.5 Knee injury 20 7.1 Bone lesion requiring surgery 11 3.9 Spasticity of lower extremity 9 3.2 Deformity requiring surgery (upper and lower) 8 2.8 Cyst removal, surgical 7 2.5 Developmental dysplasia of hip 7 2.5 Phalanx fracture, displaced 7 2.5 Displaced metacarpal fracture 7 2.5 Spine anomaly/vertebral fracture/spondylosis/ 7 2.5 spondylothesis Clubfoot 5 1.8 Trigger thumbs 6 2.1 Spondylolisthesis 4 1.4 Avulsion, displaced 4 1.4 Foreign body requiring surgical excision 3 1.1 Toddler fracture of tibia requiring long-leg cast 3 1.1 Tibial triplane injury 3 1.1 Syndactyly 3 1.1 Arthrogryposis 2 0.7 Metaphyseal fracture 2 0.7 Left wrist fracture 2 0.7 Cavovarus, severe 2 0.7 Leg length discrepancy 2 0.7 Tight heel cord 2 0.7 Scaphoid fracture 2 0.7 Other 33 11.0 Total 283 100.0 Other problem, 1 each (0.4%): metatarsal fracture, achondroplasia, avascular necrosis, hallux valgus requiring surgery, synostosis, pseudoarthrosis, equinous contracture, fibrous subtalar coalition, lumbar gibbus, Kabuki syndrome, slipped capital femoral epiphysis, severe metatarsal adductus requiring surgery, monteggia fracture, muscle contracture requiring surgery, 1q36 deletion syndrome, Noonan, cortical irregularity, osteopenia, mandible fracture, McCune-Albright syndrome, Splengel deformity, crush injury/displaced/angulated requiring surgery, Scheuermann disease, Perthes disease, spondylocostal dysostosis, shoulder dislocation, tillaux fracture, torticollis, degenerative joint disease/trochlear dysplasia/idiopathic erosion, right cervical rib, and Van Der Wonde, San Filippo, Hurler, Ehler Danlos syndromes. DISCUSSION A recent survey by the Practice Management Committee of the Pediatric Orthopaedic Society of North America found that up to 95% of the new referrals to an orthopaedic surgeon were for common conditions or normal variants. Relatively few (3%) of these referrals resulted in surgical treatment. With a perceived shortage of the pediatric orthopaedic specialists, longer waiting times for more urgent cases are common, whereas a large number of patients with primary care problems also wanting to be seen. 3 We wished to determine how many of the referral cases seen by pediatric orthopaedic surgeons are really primary care conditions, defined using all cases exclusive of AAP specialty referral guidelines, our combined criteria and the ABP Review Committee s criteria for a pediatric general practitioner s competency. r 2012 Lippincott Williams & Wilkins www.pedorthopaedics.com 729

Hsu et al J Pediatr Orthop Volume 32, Number 7, October/November 2012 TABLE 3. Conditions That Can Be Readily Managed by Primary Care Physicians Problem N Percent of 246 Phalanx fracture 25 10.2 Femoral anteversion 24 9.8 Single-bone fracture upper extremity 22 8.9 Normal examination 17 6.9 Radius buckle fracture 13 5.3 Metatarsal fracture 12 4.9 Minor knee injury 11 4.5 Sprain 9 3.7 Tibia torsion 9 3.7 Planovalgus foot 9 3.7 Humerus fracture 8 3.3 Bow legs 7 2.9 Both-bone fracture forearm, nondisplaced 7 2.9 Tibia fracture 6 2.4 Simple laceration injury 5 2.0 Ankle fracture 5 2.0 Clavicle fracture 5 2.0 Deformity, minimal function inhibition 4 1.6 Hip flexor 4 1.6 Crush injury 4 1.6 Idiopathic pain 3 1.2 Chronic back pain 3 1.2 Contusion 3 1.2 Metacarpal fracture 3 1.2 Postural kyphosis 3 1.2 Avulsion fracture 2 0.8 Benign cyst 2 0.8 Metatarsus adductus 2 0.8 Cervical spine injury 2 0.8 Curly toe 2 0.8 Other 15 6.1 Total 246 100.0 Remaining problems, 1 each (0.4%): axial distance increase, mild bunion, capillary malformation, fascia hernia, fight bite, foreign body of foot, idiopathic lesion requiring no management, wound care, mild shoulder instability, corner fracture, rotator cuff strain, granuloma annulare, Osgood-Schlatter, Sinding- Larson-Johansson syndromes, enthesopathy. During the August 2010, all new patients seen in the Children s Mercy Hospital Orthopaedic Clinic were prospectively evaluated. We chose the month of August as representative of our practice, because historically there is a heavy load of trauma, school physical referrals, sports referrals, and the usual new referrals. Specific AAP SAP guidelines for referral in conjunction with our own criteria were used to define a specialty care condition. We wanted as broad a definition of specialty condition, either a condition that should be seen by a pediatric orthopaedic surgeon or one that could be seen by a general orthopaedist. We used the ABP 2010 certification criteria and competency, as well as all cases that did not meet our definition of a specialty care condition, to define a primary care condition. Essentially, a primary care condition was considered a condition that a reasonably trained general physician or practitioner would be able to manage should they chose to do so. Only 77 cases of 529 new cases (14.6%) met the specific AAP SAP criteria for needing pediatric orthopaedic surgery referral. The 5 most common conditions that required involvement of a pediatric orthopaedic TABLE 4. Patients Receiving Surgical Treatment Percent Total Problem N of 38 Osteochondral lesion excision 4 10.5 Angulated phalanx fracture 4 10.5 Trigger thumb 3 7.9 Adolescent idiopathic scoliosis 2 5.3 Developmental dysplasia of hip/chronic left hip 2 5.3 dislocation Single-bone upper extremity fracture 2 5.3 Both-bone upper extremity fracture 2 5.3 Foreign body 2 5.3 Bone cyst excision 2 5.3 Other 15 39.3 Total 38 100.0 Other problems, 1 each (2.6%): polysyndactyly release, nonhealing wound excision, patella instability, idiopathic sclerotic growth excision, bone grafting, slipped capital femoral epiphysis pinning, percutaneous pinning procedures, meniscus tear/repair, right thumb duplication excision, synostosis, heel-cord contracture release, spastic quadriplegia/elbow/wrist contracture release, bone infection excision, right tibia displacement from triplane fracture fixation, Van Der Woude syndrome. specialist were scoliosis, bone lesion, spine anomaly, developmental dysplasia of hip, and syndactyly. Although only 77 cases were considered to need management by a pediatric orthopaedic specialist, all of the other cases were not necessarily primary care, as specific AAP SAP criteria still allowed many cases to be managed by a general orthopaedic surgeon. A primary care provider should recognize the need for referral to orthopaedics, either to a general orthopaedic surgeon or for specific conditions, to a pediatric orthopaedic surgeon, whenever one of these conditions is encountered. A larger number of cases (283, 53%) were considered specialty care by our combined criteria. To be considered a specialty care condition, a patient must either has met AAP SAP referral criteria, received surgery, had a long cast applied, or had a displaced fracture needing reduction. The most common specialty condition was a displaced upper extremity single-bone fracture, followed by a both-bone forearm fracture, scoliosis, lower extremity fracture, or knee injury requiring surgery. Any traumatic injury requiring surgery or a long cast application, closed reductions under sedation, other surgical procedures, or situations that primary providers are often uncomfortable with were all classified as specialty care. There were 246 (47%) new cases that we considered to be a primary care condition. This study was similar to Hennrikus et al 5 recent study in that close to 50% of all new patient referrals to an orthopaedic specialist clinic were determined to be a primary care condition. In our study, simple nondisplaced fractures that may be readily managed by a primary care physician were classified as a primary care condition. Application of a simple splint, short-arm cast, and buddy taping of nondisplaced finger injuries are examples of problems manageable by primary care clinicians. The most common primary care condition was a nondisplaced finger fracture that could have been managed without the need for specialist referral. 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J Pediatr Orthop Volume 32, Number 7, October/November 2012 Pediatric Orthopaedic Primary Care Problems stable fractures that were nondisplaced and did not require long casts were considered manageable by a primary care physician, a saving of both time and resources. A total of 38 patients of the total 529 received surgery (7.2%, 1 of 14 new patients). This is a much smaller percent receiving surgery than seen in other studies of new adult orthopaedic patients. In recent studies by McCarthy et al, <3% to 10% of all pediatric orthopaedic referrals resulted in surgery. 2 The study from the POSNA Practice Management Committee found that pediatric orthopaedic surgeons saw 13 patients per scheduled surgery, whereas adult orthopaedic surgeons saw 2.7, general surgery 4.1, and neurosurgery 3.2 patients per surgery scheduled. 2 These ratios indicate that pediatric orthopaedic surgeons are seeing a large percentage of primary care problems that do not require more specialized surgical management. Despite pediatric orthopaedic surgeons willingness to treat these primary care conditions, many of these problems could be cared for by primary care providers if they had adequate education and incentives. Reeder et al 6 recommended better education in musculoskeletal diagnosis and treatment of simple musculoskeletal conditions such as nondisplaced fractures. There were no significance differences in referral patterns among the demographic characteristics of patient age, visit source, and insurance status. However, when a patient was seen without an initial diagnosis and was later determined to have a primary care condition, then she/he was more likely to have been referred from a primary care provider rather than from a specialty care source. This suggests that a specialist maybe more likely to refer the patient back to their primary care provider for these types of problems rather than to another specialist. This study has limitations. The geographic location of our study in a large midwest city may not be generalized for other metropolitan area of the United States or for rural locations. Although the study was prospective and captured all new referrals, it covered only 1 month, August 2010. New residents were working in the hospital, which may have affected primary care referral patterns. We do not have data on how many cases are already treated by a primary care physician, before 1 referral is made to an orthopaedic specialist; thus, we may be only seeing a small percentage of the referral problems. The noted difference in referral patterns between primary and specialty care providers, although clinically significant, has a confidence interval that crossed the number 1, thus making it of questionable statistical significance. The combined criteria for a primary care problem that we used were subjective and have not been validated as a basis for determining what is or is not a primary care condition. Larger, multicenter data collection and analysis would allow for more accurate and generalizable conclusions. Lastly, a primary care physician s comfort, knowledge base, and credentials should also be considered, as our study purpose was to demonstrate what are the problems that primary care physicians could readily care for, should they chose to do so. The Affordable Health Care Act 2010 may have several effects on the practice of pediatric orthopaedics. Because almost one half of the conditions seen in our ambulatory specialty setting are considered primary care conditions, pediatric orthopaedics may need consideration as a primary care specialty, as is the case for obstetrics and gynecology. This has implications for manpower decisions, training pediatric orthopaedic surgeons, hiring of advance practitioners, and equitable reimbursement for care delivered. If pediatric orthopaedic surgeons are considered as primarily tertiary care providers, then improvement and expansion of the musculoskeletal education and competencies of primary care providers is needed to care for these primary care conditions. In conclusion, this prospective study of all new referrals to a hospital-based pediatric orthopaedic specialty clinic found that 47% of the new referrals were for conditions we consider to be a primary care, manageable by a primary care physician. This has implications for pediatric orthopaedic workforce availability, reimbursement under the Affordable Care Act, and pediatric musculoskeletal training needs of primary care providers. REFERENCES 1. Surgical Advisory Panel. Guidelines for referral to pediatric surgical specialists. Pediatrics. 2002;110:187 191. 2. McCarthy JJ, Armstrong DG, Davey JP, et al. The current medical practice of the pediatric orthopaedic surgeon in North America. J Pediatr Orthop. 2011;31:223 226. 3. Schwend RM. The pediatric orthopaedics workforce demands, needs, and resources. J Pediatr Orthop. 2009;29:653 660. 4. The American Board of Pediatrics. A guide to evaluating your clinical competence in pediatrics. Chapel Hill, NC: The American Board of Pediatrics; 2011:1 9. Available at http://www.app.org. 5. Hennrikus W, Kobilis J, Hamp J. Referral patterns to a pediatric orthopaedic clinic: pediatric orthopaedic surgeons are primary care musculoskeletal medicine physicians. Pediatrics. 2010. [In press]. 6. Reeder BM, Lyne ED, Patel DR, et al. Referral patterns to a pediatric orthopaedic clinic: implications for education and practice. Pediatrics. 2004;113:e163 e167. r 2012 Lippincott Williams & Wilkins www.pedorthopaedics.com 731