COLUMN ONE : A Science Honed on Violence : Orthopedic surgery is one of the fastest-growing areas of medicine. It focuses on athletes and victims of inner-city carnage.

It’s 5 p.m. at Los Angeles County-USC Medical Center, the hour when trouble begins. Gunfire on the streets and rush hour on the freeways mean the emergency room is filling up.

In a crowded hallway no bigger than a closet, Dr. John Paul Harvey stands studying “the board,” a brightly illuminated wall displaying the X-rays of children whose bones have been shattered by bullets and smashed between cars. As chief of pediatric orthopedics, it is Harvey’s task to rebuild these fragile skeletons.

Across town, at the luxurious offices of the Kerlan Jobe Orthopedic Clinic, Dr. Robert K. Kerlan sits contemplating another X-ray. This one is of a football player, somewhat older and a good deal more famous than the children over at the county hospital.

Holding the X-ray to the light, Kerlan spots a hairline fracture, so small that even the radiologist has missed it. Kerlan turns to his speaker phone and punches in a pre-programmed number. Without so much as a hello, he says simply, “Broken,” a one-word message that will speak volumes in the next day’s sports pages. It’s Kerlan’s job not just to break the news to the player’s trainer but to figure out how to repair the fracture as quickly as possible, for the sake of not only the player, but the owners, fans and the nation’s television industry.

Harvey and Kerlan are at two ends of the same profession: orthopedic surgery. Both men are large in physical size as well as professional stature. Both in their late 60s, they have been around long enough to see astounding changes in medicine, especially their own field.

Once an obscure subdivision of general surgery, orthopedic surgery is now a speciality with nearly a dozen sub-specialities, many of which are among the fastest growing areas of modern medicine and--with salaries averaging well over $350,000 a year--among the most lucrative as well.

These are not doctors who routinely save lives. They save life styles. From one end of the age spectrum to the other, orthopedic surgeons relieve pain and restore function. They help crippled children to run and play; they allow arthritic adults to move and walk.

Now orthopedic surgeons are also focusing their attention on opposite ends of the social spectrum: the poor victims of urban violence and the multimillion-dollar participants in professional athletics.

The changes that Harvey and Kerlan have witnessed and helped bring about over the last four decades are in one way indicative of what has happened to health care: Spurred by technology and an explosion of knowledge, medicine and surgery have rapidly transformed human life. In another sense, however, the story of orthopedic surgery serves as a window on modern American society--a society preoccupied with physical violence.

“This is a war zone,” said Dr. Lance Weaver, chief of the division of orthopedic surgery at Martin Luther King Jr./Drew Medical Center.

“We’re getting injuries worse than in World War I and World War II,” he said. “This is Vietnam-era stuff. It’s the same weapons, AK-47s, M-16s. It’s the same injuries.”

Heart disease and cancer may take the lives of older Americans, but trauma is the leading cause of death in those under the age of 24. Each year, according to the National Safety Council, nearly 150,000 Americans die from various forms of physical trauma, and many more are crippled by accidents and attempted homicides.

For young white males, motor vehicles are the leading cause of death and disability. For young black males, it is guns.

King, a largely black hospital on the edge of Watts, has a reputation for specializing in gunshot wounds. The Army recently decided to send military doctors to King for tours of duty. Pediatrics and internal medicine can be taught at any military hospital, but it takes a special institution with a special patient population to train for combat.

Even the conditions at King are reminiscent of war. Wards are overcrowded. Nurses are in short supply. Surgeons complain there aren’t enough surgical gowns, except for the ones doctors bring with them from other hospitals.

Weaver, a private physician in Whittier and an officer in the Army Reserve, looks at the X-rays and tries to piece together the stories.

One set of X-rays reveals a broken hand and a broken foot. The patient, a 27-year-old female, had apparently jumped from a second-story window trying to flee a rapist.

Another set of X-rays shows a pair of feet riddled with bullets. That patient, a male in his 20s, was said to have been accosted by two men who demanded he “dance” while they got in some target practice.

A third set, the most gruesome X-rays on this particular day, shows a leg, a knee and a shoulder shattered by bullets from an AK-47 or some other high-velocity weapon. According to police, this young male patient had been visiting from Nevada when he suddenly became the latest victim of Los Angeles’s infamous drive-by gang shootings.

“Just your basic, simply impossible operation,” said Dr. Rodney Gabriel.

Gabriel, the chief orthopedic resident at King, will do his best to repair the damage in the operating room. He will use high-powered water picks to clean out debris left by the bullets. He will use metal plates and rods, orthopedic nails and screws to fix the shattered bones so that the patients will not have to remain bedridden or confined to wheelchairs. Afterward, for those who are conscientious enough to return to the hospital’s outpatient clinic, he will oversee the weeks and months of painful and tedious physical therapy.

The one thing Gabriel will not do is waste time trying to figure out who is responsible for these acts of violence.

“The story is always the same,” Gabriel said, as he pored over the latest lineup of X-rays. “It is always ‘some dude.’

“ ‘I was just minding my own business,’ that’s what they always tell us, ‘when some dude came up and starting shooting.’ ”

Because the dudes sometimes show up at the hospital to finish off a job they failed to complete on the streets, King administrators have installed a metal detector outside the pediatric ward. Inner-city hospitals, like airports, must now be on the lookout for deadly weapons.

City violence and freeway madness are not the only causes of physical trauma in Los Angeles. One need only look at the Monday morning sports pages: A football player ruptured a knee ligament in a blind-side collision with a 240-pound linebacker; a jockey suffered a fractured pelvis when thrown from a fast-moving Thoroughbred; a pitcher ripped a shoulder muscle by repeatedly throwing a baseball 90 miles an hour.

But multimillion-dollar athletes are rarely treated like ordinary trauma patients. Dr. Robert W. N. Chandler, a 41-year-old orthopedic surgeon, knows something about both worlds. Trained by Harvey at County-USC, hired by Kerlan as an associate at the Kerlan Jobe Clinic, Chandler is on the clinical faculty at King.

At private orthopedic clinics, Chandler said, there are no six- or eight-hour delays in spartan, overcrowded hallways. Surgery, if it is necessary, is almost never done under emergency conditions. Treatments are not only carefully executed, they are also meticulously planned in advance by teams of doctors and physical therapists.

The best doctors, the latest equipment--that’s what a patient at the Kerlan Jobe Clinic can expect, along with a waiting room full of business executives, movie stars and, of course, star athletes.

When Kerlan, founder of the Kerlan Jobe Orthopedic Clinic, went into private practice in 1950, there was no such thing as “sports medicine.” Yet, like most orthopedists, he had always had an avid interest in sports. Indeed, most orthopedists, including the few women who have entered the field in recent years, competed in some kind of sports in school. That’s how many of them came to be orthopedists: they got to know something about the profession through their team doctors.

Today there is no better known sports doctor than Bob Kerlan--unless it is his partner--Frank Jobe, who was trained by both Kerlan and Harvey at County-USC in the 1960s.

Together, Kerlan and Jobe, along with a team of 14 other top orthopedic surgeons and as many fellows and residents, are orthopedists to the Dodgers, the Lakers, the Angels, the Kings, the Rams and the jockeys at Hollywood Park and Santa Anita race tracks.

When professional athletes have serious injuries they end up at highly specialized sports centers like the Kerlan Jobe Clinic primarily for one reason: The financial investment in American sports is enormous.

In some cases, orthopedists offer non-surgical remedies. For years, Sandy Koufax was able, despite a damaged elbow, to continue pitching for the Dodgers simply because his doctors decided he should stick his arm in a bucket of ice after every game--a technique that has become de rigueur for many pitchers, injured or not.

In other cases, orthopedists have found spectacular, high-tech cures. Tommy John, the man with the “bionic arm,” pitched for 29 years in the major leagues, including 15 seasons after he had had a tendon removed from one wrist so that his pitching elbow could be rebuilt.

Elgin Baylor, Wilt Chamberlain, Magic Johnson, Danny Manning, Fernando Valenzuela, Joe Montana, Bill Shoemaker--all star athletes--are other orthopedic success stories.

Virtually every professional athlete now playing has at one time or other gone to an orthopedist for diagnosis and treatment of some musculoskeletal problem.

Knees are the part of the body most likely to be injured. And the tool most likely to be used to diagnose and treat knee injuries is the arthroscope, a specially designed microscope attached to a miniature television camera and inserted inside the joints with needles. The arthroscope allows orthopedic surgeons not only to peer inside joints but to repair damage--using tiny instruments--without making major incisions.

Yet it is not just big-time athletes who want to take advantage of these high-tech procedures to stay active. So do morning joggers, evening aerobics dancers and weekend softball players.

“My father was a doctor,” Kerlan said. “If one of his patients came to him and said, ‘My knee hurts when I run on it,’ his answer would have been simple: ‘Stop playing.’ Now, that isn’t an answer for anyone.”

“If the 1950s saw the emergence of the high-powered professional athlete, the 1970s was the beginning of the era of the amateur athlete,” said Dr. Carl Stanitski, an orthopedic surgeon in Pittsburgh who is one of a growing number of doctors specializing in sports injuries.

Though not subject to nearly as much physical abuse as professional athletes, recreational athletes in many ways face even greater physical danger simply because their bodies are not as well-conditioned. In fact, there are some injuries--tennis elbow, shin splints--that routinely plague novices but hardly ever trouble professional athletes.

Many people are actually proud of their orthopedic injuries, as if they were the new American status symbols--the orthopedic badge of honor.

“Every kid in America, every jogger wants to undergo arthroscopic surgery because they see that’s what their favorite athlete has done,” Harvey said.

Things were different, Harvey said, when he first got into the business of orthopedic surgery.

In those days, the tools of the trade were fairly simple. The problems, though not always fixable, were at least straightforward. Casts and pulleys, crutches and slings were used to straighten curved spines and realign clubfeet in children who had congenital deformities. The word orthopedics came from a French term meaning “straight training of the child.”

By the late 1950s, when Harvey and Kerlan had begun training the doctors who would go on to train the residents at King and other hospitals throughout country, orthopedic techniques had begun to change dramatically.

Vaccines had all but eliminated crippling polio; antibiotics had drastically reduced cases of osteomyelitis, painful and deadly infections of the bone. Hormones, especially cortisone, were beginning to control the pain and inflammation that so often accompany arthritis and injuries to joints and muscles.

New surgical techniques perfected in wartime allowed orthopedists to reconstruct hands deformed at birth or damaged on the playing field. Like sculptors on the human musculoskeletal system, orthopedists used newly created materials--plastics and stainless steel and other metals--to reshape bones and replace joints damaged by gunfire, accident or disease.

By the mid-1980s, orthopedic surgeons seemed almost like magicians. They were using CAT scans and magnetic resonance imaging, the latest in computerized imaging systems, to detect hairline fractures and minute tears that X-rays could not. They had even learned to trick bones to “grow” with a revolutionary Soviet technique called the Illizarov external fixator system. By surgically splitting open a bone and attaching what looks like a crude Erector Set to a limb, orthopedic surgeons can actually lengthen limbs by as much as six inches--enough to alleviate many of the deformities of dwarfism and to return at least one severely injured Soviet gymnast to competition.

But in many cases, Harvey now tells his students, the problems have grown faster than the solutions.

One of the more baffling orthopedic problems of the latter half of the 20th Century, for example, is what is known as “computeritis.” Burning fingers, aching wrists, crippling arm pains have long plagued piano players and oyster shuckers, but repetitive strain injuries are now epidemic among officer workers.

So is lower back pain, a malady that, according to the American Academy of Orthopaedic Surgeons, afflicts four of five people sometime during their lifetime. After the common cold, lower back problems are now the most frequent cause of lost work time in adults under the age of 45.

For older patients, arthritis is the chief crippler, but for most forms of the disease there is no cure. One solution--generally regarded as the greatest single orthopedic advance of this century--is to remove the diseased joint and replaced it with an artificial one. Each year in the United States 150,000 total joint replacement operations are performed. But they do not always work the way they are supposed to.

Harvey himself, once crippled with arthritis, had a total hip replacement five years ago. He now walks comfortably, his 6-foot, 1-inch frame erect. But his colleague Kerlan is not so lucky. After three unsuccessful hip implants (two in one hip, one in the other), Kerlan, the dean of sports medicine, now walks with metal crutches, his 6-foot, 3-inch frame bent at the waist.

For a growing number of problems, orthopedic surgeons can offer temporary fixes but, as many physicians are quick to point out, they can do little if anything to treat the underlying social ills that brought their patients to the hospital in the first place.

Child abuse is one example. Orthopedists, especially those who work at county hospitals, have become legendary in their ability to spot such cases.

One recent patient at County-USC was a boy with a broken leg. His parents claimed that he had fallen off his skateboard, but X-rays revealed a type of fracture that, according to surgeons, could only have been caused by the wrenching motion of human hands.

Another patient was a 2-year-old girl who arrived at the hospital with two broken hips. Her mother had fallen on her, but this was not a case of parental abuse. Mother and child had fallen together as they were trying to escape a neighborhood playground that had erupted in gunfire.

It is not just that the technology and tools of orthopedic surgery have become more sophisticated in the years since Harvey and Kerlan began their careers.

The doctors have changed as well.

Forty years ago--even 10 years ago--”orthopods” were thought to be the dumb guys of medicine, the big jocks who were strong enough to manipulate large bones but who were not smart enough or talented enough to make it as general surgeons.

You know what they say about orthopedic surgeons, the saying went: strong as an ox and twice as smart.

Today, the same jokes are still told by medical students. But, in fact, the young doctors who now choose to specialize in orthopedics are not at the bottom of their medical school classes; they are at the top.

But to hear Harvey talk, orthopedists are still big, dumb jocks. “Cadillac doctors, that’s all they are,” he insists. “That’s all they want, to make a lot of money and drive a big Cadillac.”

Remembering the haranguing they got throughout their residencies, his former students, now in practice all over the country, got together a couple a years ago and took up a collection. For Harvey’s 65th birthday, they gave him a bright blue Cadillac. It seemed to symbolize not only their regard for their former teacher but what many of them had in fact become: rich doctors.

According to a nationwide survey by the journal Medical Economics, orthopedic surgeons are now among the highest paid of all medical professionals, averaging slightly less than neurosurgeons and plastic surgeons but, at $353,980 a year, considerably more than the $200,250 average for all doctors.

But even the averages are somewhat deceptive, for they do not reflect the huge disparities that exist between private doctors and those who work in public hospitals. An orthopedic surgeon at Kerlan Jobe Clinic probably earns four or five times the salary of a doctor at King or County-USC. In some cases, especially for star doctors with star patients, the salaries may run seven or eight times as high.

Such disparities explain in part why orthopedists, like other physicians, are reluctant to do what Harvey has done: devote most of his professional life to treating poor patients at county hospitals. The cases may be as interesting and the need as great or greater, but compared to treating a pro athlete, a typical victim of inner-city crime simply doesn’t offer much in the way of financial incentive.

The very existence of orthopedics, or at least some of its sub-specialities, is in some ways a sad commentary on how violent the nation has become, said Chandler, who continues to work as a private physician at Kerlan Jobe and as a teacher at Martin Luther King Jr./Drew Medical Center.

If all orthopedists had to do was take care of deformed babies and crippled octogenarians, it would be sad enough. “As it is,” he said, “we are dealing with an epidemic of violence that is almost incomprehensible.”