A Career in Paediatric Orthopaedics: Training, Fellowship and Practice

A career in paediatric orthopaedics means treating a skeleton that is still growing. A fracture that would need fixation in an adult can often be treated in a cast because the bone will remodel, while a screw placed carelessly across a growth plate can cause a limb-length difference years later. The Pediatric Orthopaedic Society of North America (POSNA) (opens in a new tab) describes the work as covering infants, children and adolescents "from the spine to the toes", with long follow-up and lasting relationships with families.

The route in is a full orthopaedic training followed by at least a year of paediatric fellowship. This guide covers what the work involves, the fellowship systems in the US, UK, Australia and Europe with their official dates, what selectors look for and what practice is like. For the general mechanics of fellowship applications, see the orthopaedic fellowship application guide.

What does a paediatric orthopaedic surgeon do?

The caseload is broad, and much of it is non-operative. Casting and bracing sit alongside surgery. A typical practice covers:

• Hip: developmental dysplasia of the hip, slipped capital femoral epiphysis and Perthes disease.
• Foot: clubfoot, treated first with the Ponseti method, and other congenital and acquired foot deformities.
• Neuromuscular conditions: cerebral palsy, including hip surveillance and gait surgery, and other neuromuscular disorders.
• Spine: adolescent idiopathic scoliosis and early-onset deformity.
• Trauma: supracondylar humerus fractures, physeal injuries, forearm fractures and adolescent sports injuries.
• Limb deformity and rarer conditions: limb-length difference, congenital limb deficiency, skeletal dysplasias, osteogenesis imperfecta and bone tumours.

On a single clinic day you might see an infant with a suspected unstable hip, a teenager with knee pain that turns out to come from the hip, and a toddler in clubfoot casts. The specialty suits people who did not want to narrow their practice to one joint.

Why children are not small adults

Growth changes every decision. Open physes, a thick periosteum and the capacity to remodel mean that many deformities correct with time, and that over-treating is a real risk. Implants that cross a physis can tether growth, so planning has to account for how much growth remains and where it comes from.

The diagnosis is not always where the pain is. Hip disease can present as knee pain, and a bone lesion that looks benign can be a malignancy. An injury pattern that does not fit the story, or a delay in presentation, must raise the possibility of non-accidental injury; every paediatric orthopaedic surgeon needs a working knowledge of safeguarding.

Systemic conditions are common. A child with osteogenesis imperfecta or spastic cerebral palsy needs a different approach from a healthy child with a fracture. Surgery for neuromuscular hips or feet rebalances soft-tissue forces as well as realigning bone.

Follow-up runs for years. POSNA notes that paediatric orthopaedic care "necessitates long-term follow up". You may see a child with hip dysplasia or clubfoot from infancy into adolescence, through growth spurts that need serial casting or implant changes.

Working with families

Every consultation involves at least two patients: the child and the parents or carers. You need to examine a frightened toddler without them noticing (turning a neurological check into a game helps), explain the natural history of a condition in plain language, and agree a plan with parents who may be anxious or disagree with each other. Consent and confidentiality change as children become adolescents.

The best paediatric surgeons treat this as part of the clinical skill, not an add-on. It takes time in clinic, and interviewers will test it.

Training pathways by country

United States and Canada

Paediatric orthopaedic fellowships are matched through SF Match as part of the single orthopaedic fellowship match supervised under the AAOS Board of Specialty Societies. Applicants register with SF Match, apply through the Central Application Service, and must sign the BOS Code of Conduct; programmes and applicants should not arrange non-interview visits during the match cycle (POSNA fellowship match (opens in a new tab)). POSNA maintains a directory of paediatric fellowships (opens in a new tab).

The dates POSNA lists for the current cycle show how far ahead you must plan:

No board subspecialty certificate. The ABOS (opens in a new tab) offers subspecialty certificates only in surgery of the hand and orthopaedic sports medicine. POSNA states plainly that "there is no subspecialty certification process for pediatric orthopaedic surgery, although most practicing pediatric orthopaedic surgeons have completed at least one year of fellowship training."

United Kingdom

UK surgeons train in trauma and orthopaedics, take paediatric posts during specialty training, and then usually complete a post-CCT fellowship. The British Society for Children's Orthopaedic Surgery (BSCOS) (opens in a new tab), founded in 1984, keeps a list of UK and international fellowships (opens in a new tab), while noting that it is not responsible for the posts. Examples from that list show how varied they are:

• Oxford: an RCS-accredited fellowship, running in its current form since 2018, designed as a transition to consultant practice.
• Evelina London: a 12-month post usually advertised in November on NHS Jobs, with interviews in mid-December for an August start.
• Coventry: supernumerary posts with no on-call, usually 6 months and extendable to 12, applied for through NHS Jobs. Previous fellows include surgeons who needed paediatric experience for CESR applications.
• Royal London: a paediatric fellowship running since 2010.
• Edinburgh: a post-CCT senior clinical fellow post at a major trauma centre.

Many UK posts are advertised on NHS Jobs or the Scottish equivalent, so set alerts a year before you need the post.

Australia and New Zealand

The Australian Paediatric Orthopaedic Society (APOS) (opens in a new tab) lists paediatric fellowships in Australia and overseas, and the AOA accredited fellowships directory (opens in a new tab) can be filtered for paediatric posts. The Royal Children's Hospital, Melbourne (opens in a new tab) runs 12-month, AOA-recognised fellowships for surgeons who hold a Royal College fellowship or equivalent, in four streams: general paediatrics (sports, adolescent hip, upper limb and foot and ankle), spine, neuromuscular, and limb reconstruction and oncology. Specialist fellows spend 75% of their time in their stream and 25% in general service, take part in on-call and carry out several research projects.

Europe and Ireland

The European Paediatric Orthopaedic Society (EPOS) accredits fellowships: BSCOS lists 12-month posts at the new children's hospital in Dublin, two of them EPOS-accredited general paediatric fellowships and one an RCSI-accredited spinal deformity post.

What do paediatric fellowship selectors look for?

Long-standing, genuine interest. Programme directors spot candidates whose interest began when applications opened. Use every paediatric rotation: arrive early, follow patients up, attend the multidisciplinary meetings and spend time in a children's hospital if your own rotation has little complex work.

Comfort with children and families. Surgical skill matters, but directors also look for patience and the ability to build rapport with a five-year-old and a worried parent in the same consultation. Show you value physiotherapists, orthotists, paediatricians, anaesthetists and social workers.

Finished research. You do not need a PhD. You need completed work. Align projects with rotations (paediatric forearm fracture outcomes during a trauma job, for example), offer to write up a consultant's case series, and present at a national meeting such as the BSCOS annual meeting or POSNA. A long list of projects in progress can read as a failure to finish.

A tailored application. Avoid "I have always wanted to help children". Explain what drew you in, such as watching a child walk after Ponseti treatment or the problem-solving of neuromuscular surgery, and say what you want from this particular unit. If it is known for limb reconstruction, say you want frame experience; if for spine, say so.

Referees who know you. A detailed reference from a paediatric consultant who has watched you operate and run clinics beats a lukewarm one from a famous name. Give referees your CV, statement and reminders of the cases you shared.

Interview themes

• Core paediatric knowledge: DDH screening and treatment, SCFE fixation, Ponseti, Salter-Harris injuries and the paediatric ACL.
• Behavioural questions: a mistake you made, a disagreement with a consultant. Structure answers around what happened, what you did and what you learned.
• Communication and ethics: anxious parents, safeguarding concerns, or parents who refuse recommended treatment such as a blood transfusion.
• Humility: you are applying because you still have a lot to learn, and arrogance counts against you.
• Your questions: ask about supervision, case mix and what recent fellows went on to do, not salary first.

Logistics: moving for a fellowship

Paediatric fellowships cluster in a few tertiary children's hospitals, so many involve moving city or country. For an overseas post, start registration, immigration and hospital credentialing paperwork as early as possible, including primary-source verification of degrees, and talk to the hospital's international office. Weigh cost of living, family support and schooling before you rank a post: a fellowship year is busy, and a settled home life helps.

What is the working life like?

Practice settings vary. POSNA describes surgeons working in multispecialty orthopaedic groups, in university departments, in paediatric-only groups, as hospital employees and in solo practice. Whatever the setting, they are often closely linked to a children's hospital, which supports multidisciplinary clinics, teaching and research.

On-call is trauma-heavy. Children's fractures and infections arrive at all hours. Fellowship on-call varies: Royal Children's Hospital Melbourne fellows join the rota, while Coventry's supernumerary posts have none.

A general or a focused practice. Some surgeons keep a broad practice. Others focus on spine, upper limb, lower limb deformity, foot and ankle, neuromuscular disorders or sports, the areas POSNA lists. Spine-focused surgeons overlap with spine surgery; limb reconstruction overlaps with adult deformity work.

Where you can work. A tertiary children's hospital handles complex reconstruction, while a district general hospital needs a surgeon who manages routine paediatric fractures, hips and feet and knows when to refer. Decide which you want before the fellowship so you can shape the year towards it.

Is paediatric orthopaedics right for you?

It suits surgeons who like variety across the whole skeleton, enjoy working with children and families, and value outcomes measured over years rather than weeks. It is less suited to anyone who wants every problem fixed in theatre: knowing when to cast, brace, observe or wait for growth is a core skill.

Decide early enough to build paediatric experience and finished research, learn the application calendar for your system (US applications close almost two years before you start), and recheck the official pages every cycle.