Rajvarun S. Grewal, BS¹; Adaeze OkoroAjuzie, MS²; Julieanne P. Sees, DO, MBA, FAOAO, FAOA, FAAOS^3
1California Health Sciences University – College of Osteopathic Medicine (CHSU-COM)
²Georgetown University, Biomedical Graduate Education, USA
³Saint Joseph’s University Haub School of Business, Philadelphia, PA

Abstract 

The pediatric orthopaedic workforce in the United States faces critical challenges as the demand for specialized services grows. Despite recent advancements, significant gaps remain in the availability and geographic distribution of pediatric orthopaedic surgeons, particularly in rural underserved areas. These disparities affect the quality of care pediatric and adolescent patients deserve. While efforts to improve disproportionality have shown some progress, overall gender and racial diversity remains low. Furthermore, the osteopathic approach, which emphasizes whole-person care and preventive strategies, offers valuable insights and interventions for addressing these workforce challenges. By integrating osteopathic principles, such as the interrelationship of structure and function and osteopathic manipulative treatment (OMT), into preoperative and postoperative care, pediatric orthopaedists can enhance patient outcomes and long-term recovery, benefitting both subspecialists and generalists. This article reviews the current state of the pediatric orthopaedic workforce, proposes recommendations to address existing gaps, and highlights the role of osteopathic distinctiveness in strengthening healthcare for pediatric patients.

Keywords: Pediatric Orthopaedic Surgery, Pediatric Workforce, Osteopathic Medicine

Introduction
The pediatric orthopaedic workforce is essential in addressing musculoskeletal conditions in children, ranging from developmental abnormalities to traumatic injuries. Over the past two decades, the field has experienced significant growth in fellowship programs and an increasing number of applicants, driven by the rising demand for specialized care and growing recognition of the importance of early intervention in improving outcomes. This data demonstrates a sustained interest in the subspecialty.^[1-4]

Despite this progress, significant challenges remain in the availability and distribution of pediatric orthopaedic surgeons, particularly in rural and underserved regions. Specialists are predominantly concentrated in urban academic centers, leaving marginalized communities with limited access to specialized care.^{[1, 5-7]} Children in these regions often face prolonged wait times or must travel long distances for orthopaedic evaluation and treatment.^[8] Additionally, inappropriate referrals from primary care providers contribute to resource misallocation and delays in treating more appropriate cases, highlighting the need for improved education on referral practices.^[9]

Osteopathic medicine, with its emphasis on holistic, patient-centered care, offers valuable insights into managing simple and complex musculoskeletal conditions. This distinctive approach being innate to the osteopathic training is particularly relevant in pediatric orthopaedics where the aim is to treat immediate musculoskeletal issues and also to promote long-term development and well-being of children. Many osteopathic orthopaedic surgeons, just as paralleled in primary care access, have traditionally and continue to fill these gaps for our underserved pediatric patients and families.^[10] While the field is making significant strides toward diversity, particularly in gender representation, challenges remain. There is still a need for more initiatives to enhance diversity and inclusion, ensuring that the workforce reflects the communities it serves.^{[5, 11-14]} Additionally, the integration of osteopathic manipulative treatment (OMT) and preventive care remains unreported which can enhance pediatric orthopaedic outcomes and provide a more comprehensive approach to treatment.^[15]

This study explores the current state of pediatric orthopaedic workforce, identifies key challenges, and proposes solutions to address workforce shortages, improve diversity, and integrate osteopathic principles into care.

Current Landscape of the Pediatric Orthopaedic Workforce
The pediatric orthopaedic workforce has expanded by approximately 31% over the past decade with a growing number of residency and fellowship programs.^[3] However, the geographic distribution of pediatric orthopaedic surgeons remains uneven, with many concentrated in urban and well-resourced areas, leaving rural and underserved regions with limited access to specialized care. In these areas, children often face delays in receiving treatment for conditions such as fractures, scoliosis, and congenital limb deformities, having their first encounter with professionals who lack subspecialized training or comfort in managing complex cases.^{[6, 7]} Furthermore, inappropriate referrals from primary care providers compound this issue, with studies showing that 64.7% of referrals to pediatric orthopaedic specialists do not adhere to guidelines, contributing to inefficient use of resources and delayed care for appropriate cases.^[9] This highlights the need for improved education on referral practices, optimal resource allocation, and trusted quality community care.

The representation of women and underrepresented minorities (URM) in pediatric orthopaedics has seen some improvements, particularly compared to other orthopaedic subspecialties, but still lags behind other medical and surgical fields. In 2014, the Pediatric Orthopaedic Society of North America (POSNA) reported that 19% of active members and 34% of candidate members were women, reflecting a significant increase from prior years and exceeding the broader orthopaedic surgery field, where only 4.4% of members in the American Academy of Orthopaedic Surgeons (AAOS) were women.^{[1, 12, 16]} As of 2021, 17% of orthopaedic surgery residents were women, with pediatric orthopaedics seeing slightly higher representation at 34% for candidate members. Despite these improvements, pediatric orthopaedics still falls short of the gender diversity seen in other surgical fields like general surgery, where women make up 44.8% of the workforce.^[17]

Racial and ethnic diversity in orthopaedics remains a significant challenge. As of 2018, 84.7% of practicing orthopaedic surgeons were white, with minorities making up a smaller percentage: 6.7% Asian, 2.2% Hispanic, and 1.9% African American​.^{[17, 18]} Pediatric orthopaedics shows a slightly better representation with 29.6% of residents being from minority backgrounds^{[17, 19]}, but the overall diversity remains low. These disparities are further compounded by the lack of visible role models and mentors from underrepresented minority (URM) groups. Programs like the Perry Initiative and Nth Dimensions have helped to introduce URM and female students to musculoskeletal care early in their medical education, fostering mentorship and interest in orthopaedics. However, the overall impact of these initiatives has been limited, with only incremental gains in diversity over the past decade.^{[17, 20]}

A contributing factor to this issue is the limited exposure to musculoskeletal medicine in many United States medical school curricula. Early exposure through dedicated rotations and mentorship programs has been shown to increase diversity in orthopaedic surgery. For instance, one institution reported an 81% increase in female applicants and a similar rise in underrepresented minority applicants after implementing a required musculoskeletal surgery rotation .^{[21, 22]} Expanding these efforts across medical schools, especially given that osteopathic medicine already emphasizes musculoskeletal health and holistic patient care, could help foster greater diversity within pediatric orthopaedics. Osteopathic principles, which focus heavily on the interconnectedness of the body’s musculoskeletal system, offer students a deeper understanding and early exposure to this field, further encouraging diverse candidates to pursue orthopaedics.

Challenges in Pediatric Orthopaedic Care
In addition to the maldistribution of specialists geographically, the increasing complexity of pediatric cases poses significant difficulties for the pediatric orthopaedic workforce. Advances in diagnostic techniques and treatment modalities have expanded the scope of pediatric orthopaedics, leading to a rise in complex cases such as neuro-orthopaedic disorders, congenital musculoskeletal deformities, and sport-related injuries. These cases often require advanced orthopaedic knowledge and multidisciplinary care, which can be difficult to attain and moreover coordinate, particularly in regions lacking robust pediatric care infrastructure. As a result, pediatric orthopaedists are faced with heavier caseloads, and in many instances, they must manage patients with complex medical and surgical needs without adequate support from subspecialists or rehabilitation teams.^{[23, 24]}

Burnout among pediatric orthopaedic surgeons is another growing concern. The increasing demand for specialized care, combined with the high-stakes nature of pediatric surgery and the emotional toll of treating young patients with lifelong conditions, contributes to high levels of stress and burnout.^[25] In a 2018 unpublished survey of POSNA members, 38% of respondents reported personal burnout and 46% reported team burnout. In addition, 57% of women reported experiencing burnout compared to 30% of men. Factors contributing to burnout may differ among men and women, influenced by perceived gender roles, hierarchical structures, and power imbalances in the workplace. Burnout not only affects the quality of care but also threatens the sustainability of the pediatric orthopaedic workforce, leading to concerns about retention and recruitment in the field.^{[25, 26]}

Furthermore, barriers to residency and fellowship training in pediatric orthopaedics further heighten these challenges. Despite an increase in training programs, many fellowship positions remain unfilled. For example, in 2023, 15 pediatric orthopaedic fellowship positions were left vacant, highlighting that the challenge lies not in the number of available positions but in attracting and matching qualified candidates to these programs.^[3] For osteopathic orthopaedic residents, recent trends reflect a steady increase in numbers, with a 32.9% rise in osteopathic orthopaedic residents from 2010 to 2020. However, the proportion of female residents remains low, with only 9.5% being women. Forecasts predict this could drop to 5.8% in the next decade​​.^[27]

Osteopathic Medicine in Pediatric Orthopaedics
Osteopathic medicine offers a unique and valuable perspective to the field, focusing on whole-patient care that integrates physical, emotional, and environmental factors into treatment. This holistic approach is particularly relevant in pediatric orthopaedics, where the goal is not only to treat immediate musculoskeletal issues but also to promote the long-term development and well-being of children. Osteopathic principles emphasizing the interconnectedness of body systems and the importance of prevention align with the comprehensive care needed for pediatric patients, who are still in crucial stages of growth and development.^[15]​

The growing presence of osteopathic physicians in pediatric orthopaedics is also noteworthy. According to the 10-Year Report on the Trends of Osteopathic Medical Students in Osteopathic Orthopaedic Residency Over the Past Decade^[27], there has been a steady increase in osteopathic medical students pursuing orthopaedic residencies, with a 32.9% increase in osteopathic orthopaedic residents between 2010 and 2020. This trend reflects the expanding role of osteopathic principles in musculoskeletal care, particularly in addressing the unique needs of pediatric patients. However, challenges remain in achieving gender diversity within osteopathic orthopaedics, as the report highlights that only 9.5% of osteopathic orthopaedic residents were female over the past decade.

Furthermore, the preventive care approach central to osteopathic medicine is particularly beneficial in pediatric orthopaedics. Early intervention guided by osteopathic principles allows for the management of conditions such as scoliosis before they progress to more severe stages. As demonstrated in cases of infantile idiopathic scoliosis, OMT was associated with improved spinal alignment and a reduction in curvature severity during early stages, potentially avoiding the need for more invasive surgical interventions later on.^{[28, 29]} Additionally, OMT techniques, such as lymphatic procedures, can help improve lymphatic flow, reduce inflammation, and facilitate recovery postoperatively by promoting optimal immune function and clearing metabolic waste, which is especially crucial in pediatric orthopaedics where inflammation can play a significant role in healing and recovery.^[30] A randomized controlled trial assessing OMT following knee or hip arthroplasty in adult populations found mixed results, with some limitations in the effectiveness of OMT in this context.^[31] The study suggested that while OMT may not significantly enhance rehabilitation efficiency in adult post-arthroplasty care, pediatric populations might respond differently due to the growing and adaptive musculoskeletal systems of children, warranting further research into its benefits in this age group. While evidence supporting OMT exists for certain pediatric orthopaedic conditions, such as scoliosis, there is emerging interest in exploring its potential role in other areas, like developmental dysplasia of the hip (DDH). However, current evidence is limited, and further research is needed to better understand its applications in these contexts. By addressing the musculoskeletal system in a holistic manner, osteopathic pediatric orthopaedists are well-equipped to consider how each intervention impacts the child’s overall health trajectory, including their growth, mobility, and emotional well-being.

In addition to clinical care, osteopathic pediatric orthopaedists are leaders in promoting collaborative care models.^[32] These models emphasize close coordination with other healthcare professionals within the field of the osteopathic orthopaedic surgical community. This includes high-quality, continuous medical education programs targeting pediatric subspecialties for general orthopaedists, as well as collaborative sessions focusing on specific anatomical areas of the musculoskeletal system. Additionally, they promote teamwork with providers such as nurse practitioners, physical therapists, pediatricians, and social workers to ensure comprehensive, multidisciplinary care for pediatric patients. As one study outlines, the 1:1 surgeon-nurse practioners (NP) mode in a Level I pediatric trauma hospital improves access to care, streamlines discharge procedures, and enhances patient outcomes by offering continuous, patient-centered care. NPs, as part of these teams, play an integral role by managing post-operative care, providing education, and performing necessary procedures, which allows surgeons to focus on more complex cases and increases surgical volumes.^[33] This collaboration is especially important in complex cases where multiple systems are involved, ensuring that treatment plans consider the child’s long-term development and health trajectory. The osteopathic approach fits well within these collaborative models, as osteopathic physicians can address both immediate musculoskeletal issues and the broader physiological and emotional well-being of pediatric patients, integrating their expertise into the larger care team and ensuring comprehensive care throughout the patient’s journey. With increasing recognition of osteopathic methods and a growing number of osteopathic-trained surgeons, the field is well-positioned to address the evolving needs of pediatric patients, particularly in underserved areas where access to specialized care remains limited.^{[27, 34]}

Solutions to Address Pediatric Orthopaedic Workforce Challenges
Given the challenges outlined in this review, improving pediatric orthopaedic workforce requires a multidisciplinary approach, focusing on better distribution of specialists, enhancing educational opportunities, promoting diversity, addressing burnout, and strengthening mentorship and collaborative care models.

Addressing Maldistribution and Workforce Challenges
One of the most pressing challenges is the uneven distribution of pediatric specialists, with a majority of surgeons concentrated in urban and academic institutionalized areas, leaving rural populations underserved.^{[1, 5-7]} Expanding telemedicine services and facilitating collaboration between rural clinics and larger urban hospitals has shown promise in improving access to pediatric subspecialties like orthopaedics. Telemedicine has facilitated visits for pediatric orthopaedic patients, with high satisfaction from both patients and providers. Adaptations such as provider-guided parent procedures and screen-sharing for reviewing lab results have enhanced its effectiveness.^{[35, 36]} While many physical exams, such as assessing joint stability or post-surgical conditions, still require in-person visits, telemedicine can effectively address follow-up appointments, consultations, and pre-operative assessments. However, it is important to acknowledge that telemedicine has limitations, particularly in rural and underserved communities where families may lack reliable internet access, devices, or technological literacy to participate in virtual care. While telemedicine can reduce travel burdens and extend care to underserved regions, these barriers must be addressed to ensure equitable access and effectiveness across diverse patient populations.

Another promising solution to the workforce shortage is the emergence of Non-Operative Pediatric Orthopaedists (NOPO), who help bridge gaps in care. NOPO physicians focus on treating common pediatric orthopaedic conditions that do not require surgery, effectively reducing the burden on pediatric orthopaedic surgeons. By expanding access and shortening wait times in orthopaedic clinics, NOPOs can help ensure that surgeons focus on cases requiring operative care, further improving access in both urban and rural settings.^[37] Implementing such models can improve patient care, as seen in studies where NOPOs reduced clinic wait times and improved patient satisfaction.

Reducing no-show rates is another critical factor in enhancing patient access. A study examining no-shows in pediatric orthopaedic clinics found that longer waits between scheduling and appointments, along with payor type (such as government insurance), were significant predictors of non-attendance.^[38] By implementing interventions like appointment reminders and optimizing scheduling windows, clinics can reduce no-shows and ensure more consistent access for patients in underserved areas who rely on limited pediatric orthopaedic resources.

The maldistribution of pediatric orthopaedic surgeons across the United States remains a significant barrier to equitable healthcare access. According to Ehrlich et al. (2020), 187 out of 435 congressional districts had no pediatric orthopaedic surgeons, and all districts had suboptimal numbers of specialists, as shown in data collected from the Pediatric Orthopaedic Society of North America (POSNA).^[8] This shortage forces families in rural areas to travel long distances for care, leading to delays in diagnosis and reduced access to timely interventions. A more recent study by Farivar et al. (2024)^[6] reinforces this issue, showing that patients in “surgeon deserts” travel an average of 141.9 miles to the nearest pediatric orthopaedic surgeon, compared to just 30.9 miles in “surgeon clusters.” These underserved areas also tend to have lower median household incomes and higher rates of uninsured children, exacerbating the barriers to care.^[6] To address this issue, expanding fellowship programs, offering financial incentives such as loan forgiveness, and developing telemedicine networks are essential strategies. Additionally, urban hospitals partnering with rural clinics to establish satellite locations can help ensure consistent access to specialized care in underserved regions. Policy reforms targeting workforce redistribution could further bridge the gap, ensuring pediatric orthopaedic services reach all children, regardless of geographic location.

Enhancing Pediatric Orthopaedic Training and Residency Programs
The underrepresentation of women and minorities in pediatric orthopaedic residency programs is a systemic issue that needs to be addressed at both the medical school and residency levels. As previously mentioned, despite some progress, the number of female and URM residents remains low.^{[12, 16, 17, 20]} Medical schools should increase exposure to musculoskeletal medicine and offer mentorship programs, specifically targeted at these individuals, to encourage interest in pediatric orthopaedics. Structured programs such as the Perry Initiative and Nth Dimension have already shown success, but broader implementation with the American Osteopathic Academy of Orthopedics (AOAO), American Academy of Orthopaedic Surgeons (AAOS), and medical schools is needed. Furthermore, medical curricula must include mandatory rotations in musculoskeletal care, as emphasized by osteopathic medicine, and evidence shows this can lead to a substantial increase in applicants to orthopaedic surgery.^{[39, 40]}

Expanding fellowship opportunities in pediatric orthopaedics, particularly in underserved areas, is another essential step. Collaborations between urban teaching hospitals and smaller, community-based programs can help extend fellowship positions to more geographic areas, increasing the number of pediatric orthopaedic surgeons. This solution not only addresses regional shortages but also provides more diverse training opportunities for fellows.^{[2, 3, 13]}

Comparing Burnout and Improving Surgeon Wellness
Burnout is a growing concern in pediatric orthopaedics, especially given the emotional and physical demands of the specialty. To address burnout, hospitals and training programs must prioritize surgeon wellness by implementing more flexible work schedules and providing mental health support services. As previously noted, burnout rates are significantly higher among women in the field.^{[25, 26]} Tailored interventions, such as gender-specific wellness programs or mentorship from senior female surgeons, could be beneficial in helping address the challenges faced by women in pediatric orthopaedics. Encouraging work-life balance and providing institutional support for work-related stress are vital to sustaining a long-term workforce.

The development of wellness programs similar to the American Academy of Orthopaedic Surgeons’ “Wellness Initiatives” can provide institutional backing for managing the high demand for care, especially in high-volume centers​.^[41] Additionally, group mentorship and peer-support programs may help reduce the sense of isolation and pressure, providing a safe space for discussing stressors and emotional challenges associated with pediatric surgery.

Expanding the Role of Osteopathic Medicine in Pediatric Orthopaedics
As emphasized throughout the paper, osteopathic principles, with its holistic approach, can further contribute to enhancing pediatric orthopaedic care. The incorporation of OMT has shown promise in managing complex conditions.^[42-44]​ Encouraging broader use of OMT within pediatric orthopaedics, alongside traditional surgical treatments, can help optimize patient outcomes, particularly in cases where recovery and pain management are significant concerns. Institutions should encourage the use of osteopathic techniques by providing training and Continuing Medical Education (CME) courses for orthopaedic surgeons.

Strengthening Mentorship and Collaborative Care Models
Mentorship plays a monumental role in shaping career trajectories in orthopaedics, especially in pediatric orthopaedics. To strengthen this aspect, organizations such as the AOAO, AAOS, and POSNA should continue to be involved in formalizing mentorship structures within pediatric orthopaedic residency and fellowship programs. These programs should offer continuous guidance from experienced surgeons to ensure skill development and professional growth. As previously mentioned, exposure to role models, especially for women and underrepresented minority (URM) students, is essential for improving diversity in the field.^{[1, 14]} In addition, interdisciplinary mentorship programs involving professionals from different healthcare backgrounds (e.g., pediatricians, physical therapists, and social workers) can help residents and fellows provide comprehensive care to patients.

Collaborative care models that integrate pediatric orthopaedists with other healthcare professionals, such as our general orthopaedic surgeons, non-pediatric subspecialty orthopaedists, NPs, and physician assistants, can also enhance patient outcomes. These models foster an interdisciplinary approach to complex cases where long-term management requires coordinated efforts across specialties. By promoting collaborative models across medical schools and residency programs, pediatric orthopaedists can develop a deeper understanding of holistic patient care and the benefits of interdisciplinary collaboration, ultimately improving patient outcomes.^[33] By embracing osteopathic principles and fostering education, practice, and community connection, the pediatric segment of our healthcare system can provide improved care that supports the well-being of families and professionals in in mind, body, and spirit.

Conclusion
The pediatric orthopaedic workforce is at a critical juncture. Geographic disparities, workforce shortages, and appropriate representation are impacting the accessibility of care for pediatric patients. Now is the time for bold, decisive action, particularly by our osteopathic orthopaedic profession, to reshape the future of pediatric orthopaedics and ensure that every child, regardless of their socio-economic and personal background, receives the specialized care they deserve. 

Integrating osteopathic manipulative treatment (OMT) into pediatric orthopaedic care presents a significant opportunity to enhance preoperative and postoperative outcomes. Techniques such as lymphatic procedures and myofascial release have shown promise in reducing pain, improving inflammation control, and promoting recovery, especially in conditions requiring both surgical and non-surgical management. While some applications, like the use of OMT in scoliosis, are supported by initial evidence, broader research is essential to explore its role in managing a wider range of pediatric conditions. Incorporating OMT into clinical practice would benefit from interdisciplinary collaboration and well-designed studies to determine best practices for its use in the pediatric population. These efforts could pave the way for holistic and effective care protocols that address not only immediate musculoskeletal concerns but also the long-term growth and development of young patients.

By addressing these challenges through a holistic lens with strategic solutions, the orthopaedic community can create a future where every child has access to the specialized, compassionate care they need to thrive.

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