Welcome everyone. This is the latest installment of the National Fellow Online Lecture Series, which is hosted by AMSSM via the Education Committee and the Fellowship Committee. We are very pleased today to have Dr. Christina Wilson speak to us today on the pediatric limb. Before we, now of course my, there we go, great. There you can see Dr. Wilson. You probably see her video over on the panel. But before I get too far into introducing our speaker for today, next week, well actually later this week, we have another lecture. Dr. Sarah Razor will be talking on iron deficiency. That'll be Thursday the 11th at 4 p.m. Eastern. Then next week, just over a week from now, on Wednesday, March 17th, we have a lecture on low back pain in the athlete by Dr. Ellen Casey. And that'll be at noon Eastern. So for any of you on the west coast, that'll be 9 a.m. So thank you all for joining us again. This, as just a little bit of a background, these AMSSM online lectures are intended to serve as an adjunct to your individual program's education and not to replace anything that your program directors are preparing for you. It's to supplement and provide you access to some of our nation's experts on these topics which have been selected by our committees to be high priority and high yield for you as you prepare for your CAQ exam. And of course, caring for patients. So these are guest experts. At times, we do a variety of formats. These will be available later via the AMSSM YouTube channel. So you can watch and rewatch and refresh on things. Please, as a reminder, mute your microphone, turn off your video. If you do have any questions, do submit those through the chat function. I will be watching those and I will be moderating. After the speakers, after the presentation, I will be, you know, moderating and asking those questions. And we'll have a little discussion at the end, about 10 minutes after the lecture. Please remember to complete the evaluation afterward. We do look at those and we do use those. It's valuable for the speaker, for anyone who is going down an academic track. We, you know, evaluation is important and so we do want to hear from you. And I think without further ado then, we will go ahead and introduce our speaker. Dr. Christina Wilson is a pediatric sports medicine physician. She is in Phoenix. She trained in residency in Phoenix in pediatrics. Went on to do a fellowship in sports medicine at Vanderbilt University and later returned to Phoenix, where she now works. She is the medical director for adolescent and pediatric sports medicine and sports physical therapy at Phoenix Children's Hospital and is the co-director of the Pediatric Brain Injury and Concussion Program at Barrow Neurological Institute at Phoenix Children's. She's an assistant clinical professor in the Department of Child Health at University of Arizona School of Medicine in Phoenix. For 15 years, she's been a team physician for multiple high schools and youth clubs and been involved with a lot of Arizona Interscholastic Association and has been chair on the Sports Medicine Advisory Committee. I know she's involved with AMSSM and she does a lot. So we are very lucky to have her and hear her speak to us on atraumatic causes of limping in pediatric patients. And I'll turn it over to you, Christina. Thank you so much, Nate. I'd also like to just take a minute while I'm sharing my screen just to also thank the AMSSM Fellowship and Education Committees for inviting me to be a part of this. I've been involved with the AMSSM Education Committee for several years now, almost all the years that I've been a part of AMSSM. And so this was a really great thing. I think that was kind of a silver lining that came out of the pandemic to be able to do this for the fellows across the country. So I'm excited to be a part of it. Is that sharing screen so that you guys can see everything okay? Yep, perfect. All right. So this morning, we're going to just spend a little bit of time talking about atraumatic causes of limping in pediatric patients. This is a very in-depth conversation and obviously has a broad differential. So we're going to kind of talk about some of the highlights and just the most common causes that we'll kind of see in that pediatric population. I do not have any relevant financial disclosures. The objectives of this morning are really to list the most common conditions that will cause an intelligent gait in pediatric patients without a known injury, recognize concerning radiographic abnormalities of the growing hip, and then also to establish appropriate treatment and referral recommendations for pediatric patients presenting with an atraumatic limp. And so we are just going to focus on non-trauma related injuries. So as I mentioned before, the differential for a limping child is very broad. So this is just kind of an example of all the things that you can think about. And so I'm going to try to spend a little bit of time at the beginning of this presentation to try to help you figure out how do you narrow this list down when you're first seeing this kid who's coming in for a limp. We're going to focus on some of the most common things at different ages, and we'll talk about why age is important. And so really, I highlighted just developmental dysplasia of the hip, which we'll talk about. Most people think about it in an infant and worrying about it then, but I'm going to kind of talk to you and present a case to you guys about why it's also important to think about later. Also, some infectious causes like septic arthritis, transient synovitis, and then also then kind of finishing up with some degenerative things like late calf perthes, and then SCFI, or slipped capital femoral epiphysis. Hey, Christina, can I interrupt for one second? I'm sorry. Absolutely. You're fine. We're seeing this in speaker mode, not in the full screen presentation. Oh, let me change it then. Yep. All right. Let's do a new share. Let's see if this works here. All right. Let's try this one. Cool. There we go. All right. Does that work now? Thank you. Just tell me if it doesn't advance. Okay. Thanks for correcting. All right. So when we look at kind of the evaluation of the limping child, really the biggest thing is trying to narrow that differential, as I mentioned. And so one of the biggest things that's a great differentiator is age. And so I'm going to break it up into kind of three categories that we look at for age. Also then looking at the type of gait. So I will also, I think a lot of times we, as when we're first starting in our training, even in our primary care residencies, and then also in fellowship, don't really spend a lot of time analyzing gait. In orthopedic residencies, it's kind of focused on a little bit more. And then also location and in pain, whether or not there is pain or whether this is a painless limp is also important. Did that advance okay, Nate? Perfect. All right. And so five critical questions I think that are important to kind of look at are, is the limp due to pain, as I mentioned? Did the pain occur suddenly or gradually, or has it always been there? Is the child systemically ill? And does the child exhibit a specific gait pattern? And we'll talk about some of those and look at those. And then can the pain be localized? And so those are also kind of important differentiators in looking at how we separate this out. So the three categories that I like to put this in are toddlers, which are defined as kids less than four years, children ages four to 10 years, and then adolescents greater than 10 years. So the normal gait pattern really looks at where there's this initial contact, basically where you have heel strike and toe strike with both feet on the ground. Then you go through basically this loading response into mid-stance, where you're on one foot, and then kind of progressing through the terminal stance and then into the pre-swing. And so that's kind of how the normal gait pattern flows. When we look at sort of just normal gait variations, obviously, much like many things that we see in musculoskeletal care, not everyone is identical, but not everyone is abnormal. And so there are definitely variations in gait in children. And so one of the most common things that we see, and I live kind of in an orthopedic clinic and do sports medicine that way, is toe walking. So toe walking is absolutely normal and very common up to about three years. Part of that is just how kids develop lower extremity muscle coordination and balance. And so up to three years, we usually tell parents not to worry about it. After three years, we kind of assess, you know, tight heel cords and other things. In-toeing is also probably the most common thing that we'll see with the gait disturbance in kids. Every parent thinks it's the reason their child trips when they first start to walk, which has nothing to do with that, but really looking at the reasons that that happens. And so in kids, in little kids, it's very common because of femoral antiversion and then also tibial torsion. And femoral antiversion is most common actually between ages in three to eight is the reason for in-toeing. And so in-toeing can last, you know, up as in upwards of eight years. Most kids by like five to six kind of start to develop that more normal out-toeing adult gait pattern, but some kids will still persist with their in-toeing. And then also metatarsus adductus, which is more common, a more common reason in the younger kids, usually resolves by about six, but many times kids will have that sort of foot progression angle that's kind of internal there, which also contributes to that. Genuvaris or bowlegs also is a common abnormality that we'll see with gait, and it is very common from birth to that early toddler phase, and then they sort of start to progress and grow out of that. And then it usually reaches its max at about a year, and it's generally without any out-toeing. So it's basically, they have a normal foot progression angle, but basically will have that bowlegged appearance. And then most of them resolve by about a year and a half. Knock knees or genuvalgus is associated with in-toeing, and that most of the time resolves around seven years, which is when we kind of see that in-toeing also resolve. And then flat feet, which I think many of us see frequently, the arch will reconstitute with flexible flat feet, and so that's an important differentiator between pathologic flat feet, which are sometimes a surgical condition, and then flexible flat feet, which are not. And then most of those will resolve by six years. So almost every kid when they start to walk does not have an arch, and that's completely normal. Every parent worries about it, especially when there's family history of flat feet. And so just providing that reassurance that by six, we usually will start to see where they'll have some arch that progresses. The adult pattern of gait typically develops between about three to five years of age, and so many of these gait abnormalities we'll see kind of resolve by about five years, which is what I mentioned previously. When we look at different types of gait, one of the most common that we'll see in a sports medicine or musculoskeletal clinic is an intalgic gait. An intalgic gait is really a compensatory gait pattern. So this is due to pain typically, and what they're trying to do is avoid the pain. And the pain oftentimes is coming from the pelvis or the leg on the affected side. And those characteristic features that you'll kind of see with an intalgic gait are they usually spend a decreased duration of the stance phase, so that's basically where they have that single leg stance, and that obviously makes sense because they're trying to avoid any weight that they're putting on that affected leg independently. And then there's a lack of weight shift laterally over the stance limb. So even when they have a double foot contact, you'll see that they're leaning a little bit to one side with an intalgic gait, the side that's not affected. And then they have a decrease in the swing phase of the unaffected limb. So they're just trying to minimize how much contact that foot is on the ground. Non-intalgic gait patterns, there's four common ones that are described. So there's an Aquinas gait pattern that more commonly is seen with CP, but can also be seen with leg length discrepancy, which we'll talk about just a little bit, but I'm not going to kind of give you an example because Aquinas, most of us are not seeing, those are usually kind of seen in neuromuscular orthopedic clinic. Trendelenburg gait, which is one that we'll see commonly, is very common with leg calperthes, also developmental dysplasia of the hip. As I mentioned, it's not just a concern that we have in infancy, mostly because it can be missed there, and so we'll see the sequelae of that later. And then also SCIFI, so slipped capital femoral epiphysis. A circumduction or a vaulting gait, oftentimes is seen most commonly with leg length discrepancies, but it can also be seen with cerebral palsy. And that's basically where they actually will swing their leg out, and they're basically just trying to clear that leg because it's longer than the opposing leg that they're on that stance phase in at that time. And then a steppage gait, which I'll kind of show you a picture of that. Steppage gait is basically where they have to sort of hold their foot up and have a very exaggerated swing phase to their gait, and that's seen commonly with a charcomery tooth, cerebral palsy, and spina bifida. So we're not really going to talk about that one much either. The one we're going to focus primarily on today is Trendelenburg gait, because that's probably the most common that we'll see. And then also an intelligent gait from pain. And so, and a little bit with that Aquinas, as I mentioned, with that leg length discrepancy. So this is actually a toddler who has volunteered for her little presentation. So I think it's just important for us to sort of know what that toddler gait looks like. And so they have a wide-based gait, and that's really to help with balance. They will also spend a little bit less time in that stance phase, so there's less single leg contact, and they have a pretty quick swing phase. And so that's basically what a normal toddler gait looks like, and I'll play through it just one more time with me not talking. And so you can see how she basically will spend a little bit more time kind of on that single leg stance, and then kind of waddle side to side. And that's where toddlers get their name from, they toddle. And so that's kind of a classic example of that toddler gait. And so Trendelenburg, many of us will look just to kind of when we're assessing core strength, looking at if you have a positive or negative Trendelenburg. But watching in gait is also important. And so what happens is there's weakness actually in the glutes, and so this can be seen like in muscular dystrophies, also in some motor neuron diseases. And then basically they just have a defective fulcrum. So instead of them actually pulling that hip up with the leg that they're standing on and using their adductors, they're weak, and it basically allows that to drop. And so basically on your standing leg, you'll have the drop basically on the leg that goes into the swing phase. Instead of this hemipelvis elevating, it basically drops. And so it's pretty noticeable when you see it. We'll commonly see it with Perthes. I've also seen it actually in some kids who've had developmental dysplasia of the hip. And so those areas, especially when there's a leg-length discrepancy, instead of them having a circumduction gait, you can see sometimes that they'll develop that Trendelenburg gait. The Aquinas gait is typically where they're walking on their toes, and this is really due to weak dorsiflexors. And it's really the compensation for that leg-length discrepancy. So on the short leg is where you'll kind of see that Aquinas gait come from, and it's basically them toe walking on that side because the opposite leg. And this is a leg-length discrepancy up to about two centimeters we consider normal. This is when it's kind of an upwards of three, four centimeters where it actually makes a big difference for them. You can usually see it when they're walking, but they'll toe walk on that side. And then the opposite side, they'll have that circumduction gait. And so it's kind of an interesting gait pattern to look at. Unfortunately, I don't really have a great example of it to show you. So when we look at differentials of these different areas that you can kind of see, antalgic or abnormal gaits, I like to break it up by age. And it's really because many of the conditions that we see are more common in certain age groups. And so that's what makes it a little bit easier. As I mentioned before, obviously when we're in training and we're sort of learning about developmental dysplasia of the hip, everyone focuses on the newborn exam, which obviously is not very relevant to a sports medicine doctor. But the reason that developmental dysplasia of the hip is still important for us to talk about is because about 10% of these can be missed in infancy. And it's actually a very common diagnosis. And so when 10% of it's missed, these are going to come into our clinic at some point. And I've seen many of them over my career who come in in the toddler phase. I've actually seen even some of them that are older. And it's really an important thing that we can pick up because the younger that you are, the better prognosis that you'll have long-term, even when we're seeing these kids after infancy, that prognosis already changes. And so we're going to talk about that a little bit of just how important it is. So the first case that I want to present for you guys is a six-year-old female. I saw her in clinic several years ago. And she actually presented to our clinic with her mom, who was a massage therapist. And the concern was brought forward to the mom by the PE teacher at school. She was in first grade. And the PE teacher was really concerned because she was kind of walking funny. And it got worse when she was running. And she was having trouble keeping up with the other kids at school and really encouraged mom to bring her back in. Mom was a little bit hesitant and talked to the PE teacher because at 18 months, she had been concerned about her gait. And she had had her evaluated by her pediatrician. They had done x-rays at that time. And she was told that everything was normal. And that was just the way that she was going to walk. But after talking with the PE teacher and mom hearing that she was having trouble keeping up with other kids, she was like, well, I'll just try to get this evaluated one more time. The little girl wasn't complaining of pain. She would run. She would play. She would do everything. She just basically was walking with this limping gait. And so she came in. She had a very intagic gait. And her gait was actually not intagic due to pain. It was actually, she had a Trendelenburg gait. And so it was very prominent. This is one of those examples that I told you where I've seen a kid actually with developmental dysplasia who presented with a Trendelenburg gait. And this was her x-ray. Her exam was actually pretty notable for having very limited motion on her right. And then on the left, she actually had increased motion, which is always very concerning for us when we've seen these kids because typically that means that the hip is actually not in the socket at all, which was the case. So this was her x-ray. At six, this is not an ideal x-ray that you want to have. And it's a very difficult conversation we have with the parent because what our hip actually relies upon for us to be able to develop our acetabulum and have that hip socket is really the pressure of the femoral head pushing in onto the pelvis throughout the entire time that we're growing in utero. And then even as we come out in those early years of us walking and putting weight there. And so what had happened with her is her hip was never in on both sides. Obviously the right side started to make a little acetabulum, but you can see greater than 50% of this head is uncovered. So this is actually a very shallow acetabulum, but at least it's in somewhat in the right vicinity. Over here, she'd actually made a pseudo acetabulum. So she had started actually trying to make an acetabulum here where the hip was actually dislocated. And so obviously that creates some problems. And then there really wasn't much of an acetabulum here at all. And so this is what it typically would look like where you have that nice acetabulum with greater than 50% coverage on the right-hand side. And so obviously we had a little bit of work to do there. And so the diagnosis of this is typically made by physical exam. As I mentioned, those findings that you'll find. This is also an interesting thing. And because of the emphasis in musculoskeletal education and training on ultrasound right now, at the end of this presentation, I will talk about some of the utilities of ultrasound, but this is one where you can actually find the hip dislocated on ultrasound pretty easily. And then after four months, we typically will look at x-rays. In the infancy, we do ultrasounds obviously, and that's really because the femoral head is mostly cartilage. And so we can't really see it on x-ray, and you can see it on ultrasound very well. And then also MRIs and CTs are usually only used in the pre or post-operative for pre-surgical planning. And then also just to make sure that it's located post-operatively pretty well. Oftentimes our surgeon will do an MRI afterwards. And then, so when we look at developmental dysplasia of the hip, as I mentioned before, in the toddler, it's not uncommon to present with a leg length discrepancy and a limp. And these are really due to screening failures. And so despite the emphasis being really careful examinations at birth, as I mentioned previously, about 10% of them are missed. And so this is a picture actually where you can see this kid's hip is actually out. And so you can see when they're standing that Trendelenburg position of how they drop there. These are just examples of some of the tests that we'll do like in infancy to kind of look for this. So obviously we always talk about changes in skin folds when you look at their little doughy thighs. And then also this is a Galiazzi. So when you bend their legs up and bring their heels to their butt, you should see that both of their knees are level. And when one of them's not, you're worried that that hip is dislocated and when it dislocates it actually migrates caudally and so that's what causes that leg length discrepancy on that side is the femur is a little bit shortened because of the position of where the femoral head is sitting in the pelvis. And so and then obviously Ortolani and Barlow which we talk a lot about but these are just some other things that can be done as well. So this is a picture of that little kiddo that this is actually a different child that we had this this was a three almost four year old but kind of a similar presentation so she actually you can see the joint space how wide it is here there's not very much coverage here. She has fairly good coverage on the contralateral side and the reason that I mentioned that this is important for us to be aware of and just sort of be able to diagnose and pick up is that you know when we get these kids in that zero to six month time frame it's ideal because we just put them in a Pavlik harness it's inconvenient for the parents but they get used to it and it's very inconvenient compared to all the other things that will happen if we have to treat this later. And so typically they're wearing the Pavlik harness for that first you know sort of anywhere from three to six months most of the kids do very well we follow it with ultrasound make sure that that femoral head stays located but if we miss it in that infancy period and it's greater than six months what is probably what the what's happening now is that they're starting to actually ossify that femoral head somewhat and so between six and eighteen months those kids actually we usually will have a hip arthrogram to sort of look and see what that acetabulum looks like and then most of those kids have to be in a Spica cast and that Spica cast is on for anywhere from like three to six months which you can clearly tell the difference you know a Pavlik harness that comes off to sort of we actually have them stay in it pretty much all the time but it's easier to clean around than when you have a Spica cast that's on all the time. These kids actually become quite functional in their Spica cast so this is like a little like chair that a family made out of like a little they use actually a diaper box it's kind of a mold and a pattern and then they can put the pillow through here so that she can sit and her bar is across the bottom and and she's completely content and happy but they have to be in it for a long time and the reason that we put them in this position is this is actually putting that femoral head back into that socket to form that acetabulum and then if that and also kids some kids actually fail is probably a bad word but they just they don't respond to the Pavlik harness as well and so then we do end up having to cast them after six months but most of them actually respond very well to the Pavlik harness and then if it's greater than three years where we were at with this kiddo unfortunately the only things we can do at that point are we actually have to do an osteotomy basically recreate that acetabulum put the the hip socket back in and obviously you can imagine long term there are some sequelae of this of you know it's not this perfect fix of how everything's back together but the great thing is is actually looking how well that acetabulum will sort of form over time we can still catch them sort of before six but this is multiple surgeries we also have to shorten that femoral neck and do some other things to basically put get that hip to fit back into the socket correctly so it's a big it's a big undertaking with multiple surgeries and obviously these kids go through a lot obviously as we mentioned and this is just really for for board preparation but you know risk factors obviously female breach family history and then any the first born and then there are certain ethnic groups as well that are more predisposed to this you know we used to talk a lot about the Native American population where they would papoose kids they basically were keeping their legs straight together they never had that abducted position where they were keeping that hip in the socket and then females it's much more common in females with a ratio of six to one so some kids with mild developmental dysplasia will last all the way till adolescence or even early adulthood where we finally pick these patients up and a lot of times it's because they're starting to develop arthritis or other things that we wouldn't expect them to see and now we know that that's probably because they had developmental dysplasia of the hip that was missed as a child and most of the time it's because it's a very mild case but a lot of time these kids will present with pain in the groin with activities and so these tend to be kids who migrate to sports like gymnastics and dancing because they've increased motion in their hip which is great up until the point that it starts to hurt and so and then on x-rays you'll see that they have that shallow acetabulum with less than 50% ephemeral head coverage and then oftentimes there's associated labral tears which are kind of addressed at the time that we kind of addressed where they're the the developmental dysplasia in the position of their hip so that's and now I want to move on to sort of some of the kids that more commonly we're going to kind of see in clinic you know ages four to ten is kind of those early ages that we'll see I see a lot of kids that age and kind of the big things I like to focus on in this age are bone and joint infections and synovitis and then leg health perthes but you can see here's some other examples of other conditions that you should think about that could be going on as well so our second case is an eight-year-old female she's a one-week history of progressive pain with weight bearing she's unable to weight bear for about three days now x-rays were performed on day two of pain where she was limping and having trouble walking but could still weight bear they were read actually at that time as unremarkable at that time she was having some low-grade fevers and then she started to have higher fevers to 102 for the past 48 hours and now she's unable to walk has decreased range of motion or hip she actually has zero degrees of internal rotation and as a positive positive and just doesn't appear very well in my clinic I saw her several years ago as well so we think about pediatric bone and joint infections we think about things which transient synovitis typically is kind of believed to be caused from a viral mediation and then obviously septic arthritis and osteomyelitis the two where kids are much sicker and we want to make sure that we catch those so transient synovitis does have have oftentimes have a hip effusion associated with it but it's usually very mild but you can see some widening of that hip joint on x-rays you can also see this with ultrasound with minimal fluid in the joint these kids tend to have a t-max of less than 101 they're well appearing they can usually still walk their esr might be elevated a little bit but it's usually less than 50 and the right blood cell count is usually less than 15 000 but they will have some stiffness these kids tend to respond very very well to inset so if you have a well-appearing kid who's limping seems like their exam is a little like they seem like they have a little bit of a an effusion on their exam because they've got some limitations in motion but let you range the hip you can always try them on anti-inflammatories most of the time these kids will walk like nothing and they're like it doesn't hurt anymore it doesn't bother me at all and we keep them on it for about a week and it usually spontaneously resolves within a few days to two weeks but it can recur and so i've seen it multiple times in kids that if it's recurred later on in their life septic arthritis is kind of the thing that we're trying to make sure that we don't substitute you know don't miss and and chalk it up as to being transient incentivitis the difference and the distinguishing characteristics here are that typically with septic arthritis these kids have severe pain and significant limitations in joint range of motion like they will not let you even touch their leg to attempt to move it and the kid looks sick um and typically the hip is commonly involved but obviously as you know knees can be involved shoulders can be involved there can be other joints um and the best outcomes is really if there isn't a delay in diagnosis and i'll kind of show an example of why that's important that we kind of catch those kids um confirmation is done with basically doing a tap um and this can be done at the same time when you're doing ultrasound you see there's a big hip effusion stick the needle in it pull some fluid out which is great and then you can obviously start antibiotics and other things to try to get the white blood cell count decreased in the joint space as quickly as possible so differential diagnosis um there is about 15 percent of septic arthritis is that um are that coexist with osteomyelitis and so obviously a lot of times these kids will get advanced imaging um after we initiate treatment but you don't want to delay that treatment to wait for an mri or other things you want to make that diagnosis pretty quickly um they can't have things like leukemia which i have also seen present in an orthopedic clinic um um primarily in the heel um and then pelvic osteomyelitis transient synovitis as we mentioned and then discitis so don't always you know don't forget about the back the back can sometimes be the reason for the the limping child as well um as i mentioned before transient synovitis is um kind of a mild clinical presentation we think that there's there's a lot of viral mediation there um and then what we think about for septic arthritis is really looking at cocker's criteria um and so cocker's criteria is fever uh greater than um 102 typically um but um but basically anything over 38 degrees celsius um unable to bear weight um an esr of greater than 40 and a white blood cell count of greater than 12 000 um and then you over here i think this is just the greatest thing from this paper is there is kind of a you know you can look at the probability and so typically in those kids who have two we're already suspecting it um and it's that until proven otherwise from the tap and then if you have three or four cocker criteria that's pretty much septic arthritis um and so that's nice that we have kind of that to guide us um the diagnosis definitively is made with a hip joint aspiration um and that's why ultrasound is a really great modality there because you can just do it all at the same time and then um most of these kids oftentimes need drainage and irrigation followed by antibiotics so this is also somebody that you want to have the orthopedic surgeon involved with very early um because we need to get the white blood cells drained out of that joint as soon as possible that's actually what we believe causes the uh damage to the joint long term um and then early treatment is just important for that to good results so this is kind of um a kiddo who ended up having septic arthritis um this is just kind of a nice progression and so you can see this is actually the right side is the normal hip the left side you can see the joint space is just a little widened here which is oftentimes all we'll see initially the interesting thing about the kiddo that i mentioned that i presented is her initial imaging was read as normal but when i got access to it we went back and looked at it she did have evidence of there being a little effusion on that side and the joint space was widened just a little bit um and so kind of then as we progress uh through to the next thing this that joint effusion can get so big with septic arthritis that you can actually dislocate the hip um and it's just pushed out and so the problem with that is is obviously the hip the femoral head is really um the vast the vascularity to it um that you put tension on it when you start to dislocate that hip and that's what really causes one of the long-term outcomes of it where you can actually just get complete necrosis of that femoral head and that's um really like it's kind of like a perthes kind of thing where it's just um necrosis that happens from the blood supply being disrupted and so those are the things that we want to kind of avoid um and this is that that kiddo's hip over time um that was it was this was a different kid that was presented before but just imaging that we have on file which is great to kind of see that so uh case number three um is a six-year-old caucasian baseball player um he was limping while playing baseball which is why his mom brought him in um he occasionally endorses some mild pain especially after baseball but doesn't really endorse any pain during baseball he's able to play through the pain which he's been doing and it's been kind of going on for you know the last um month or so um and then the pain has been progressive over the last month or two that he kind of endorses that he's had a little bit of pain and he currently lives at home with his mom and two older brothers there isn't a dad involved and he also has a younger sister um mom does smoke but she smokes outside the home so he is um obviously probably exposed to a little bit of secondhand smoke which is important for this diagnosis so this is um what his x-rays looked like um and so this was it kind of initially and then this is kind of the progression over several months and so what you can see is this femoral head is very flattened and um sort of looks like it's almost um going away particularly on that lateral column we'll talk about why that's important and then this is like several months later about six months where he starts to continue to sort of have that lateral column collapse and so what this is is leg calf perthes um this is believed to sort of be an avascular necrosis and see that happens in in childhood we don't really know all the reasons why it happens but the peak incidence is really between four to eight and males are much more affected than females at a ratio of five to one risk factors which were kind of highlighted in the case that i gave you are low socioeconomic status caucasian um and then passive smoke exposure so this is one of the things that is much more common in kind of our caucasian population um typically it's an insidious limp um that they present with um and they're not really complaining of much pain um and on exam they'll have some limited hip abduction and internal rotation and that's really just because that collapse of the lateral column um we don't really know um as i mentioned before why it happens we think it's from a disruption to the blood supply that just causes avascular necrosis um the stages of it um are kind of defined and they're important because we actually look at staging this as far as prognosis during the fragmentation stage so this is sort of what it looks like in those stages so the initial is kind of just the synovitis so that sometimes you'll have a little bit of widening in that hip space um because of the effusion from the synovitis um and then you'll actually start to just um kind of progress into um getting a little bit of fragmentation typically kind of around the nine month mark after diagnosis um and then reossification sort of starts around 32 months and then by 10 years um it's healed obviously it doesn't look like a completely normal hip but actually most of these kids depending on sort of what stage they were in and what um stage you define them as which we'll talk about in a second they actually do pretty well and this is a fairly functional hip which is which is great and so this is kind of self-limiting um occasionally there's some things going on or they're in a higher risk category where we'll intervene before that or the orthopedic surgeon will um most of the time they don't so the two kind of classification systems are caterpillar and then the lateral pillar classification so caterpillar is just the involvement of the femoral head so um classification they're number one they're numbered one through four so one two three four and it's basically just the amount of the femoral head that's involved so if it's uh just the the tip of the head here where it just collapses and it's flattened that's caterpillar one and it's important to stage these during the fragmentation stage because if you stage it before then you're you oftentimes misclassify it and that becomes problematic just when you're looking at outcome and how you counsel the family and then basically it just progresses with increasing amounts of the femoral head that involves just caterpillar four which is the entire femoral head collapses and then the lateral pillar is also another classification system this is where I was talking about we look at that lateral pillar of how it collapses and so there's just degrees of collapse with no collapse here to minimal less than 50 percent of collapse and then greater than 50 percent of collapse and those are the three lateral pillar classifications so the best prognosis is really a kid who gets diagnosed before age six and that the extent of the involvement is lateral pillar a which is basically where there is just femoral head there's not really any lateral pillar collapse and so that kind of is that caterpillar stage one or two at best where there's just that very tip and top of the femoral head that's involved and then also looking at the duration of the disease process and so the longer that those the quicker those kids move through those stages the better they usually better outcome that they have and then clinical range of motion so the hallmark of this is really maintaining range of motion and so our goals for treatment are to maintain the sphere the sphericity and of the femoral head and that we can do a lot by range of motion so we really work with these kids in PT a lot we try to keep them active and so sometimes that just means modifying what we're doing activity wise and then using insets to help with treatment we do want to keep that hip contained within the acetabulum just like for the other diagnoses once it comes out we don't kind of form that acetabulum and have that nice matching acetabulum to the femoral head so as you saw in that picture that I showed you at 10 years out that kid had sort of formed his acetabulum to what his femoral head looked like and that oftentimes will happen if we can keep the head the head contained most of these patients are managed conservatively as I mentioned and do fine and then long-term prognosis just depends on what that deformity looks like in the end and so the deformity often results if there's growth plate involvement so if that femoral head collapses all the way down to the epiphysis those kids tend to have sort of premature closure and they'll sort of form an abnormal head or you know the kids that really have lost that lateral column it's hard for them when they're missing one side of that growth plate to kind of form it pretty evenly across to make that nice round femoral head so the last group that I'm going to talk about today are the adolescents which we see a lot of these so obviously the by far most of the the gait abnormalities you see in adolescents are antalgic from injury but obviously the one I want to focus on today is really a slip capital femoral epiphysis because it does happen fairly commonly and sometimes there is this injury that they elicit but I think it's important to remember that it may not be injury related so my fourth case is a 13 year old male he comes in actually to clinic presenting with a three month history of left knee pain he is limping by the end of the day but oftentimes starts the day without limping he is active in football flag football primarily and then he does he hasn't missed any practices because he'll just plays through it and doesn't really endorse much pain while he's playing but does have some afterwards and then there's not really any history that he had of injury he denies any night pain or fevers and then on exam he does limp but he is able to run he jumps and then he doesn't have any tenderness about the knee and so that's kind of the take-home point of this we see many kids who come into clinic complaining of knee pain and it's actually radiating from the hip and so especially there should always be you know we talk about the joint above and below but really especially when you don't have any knee pain you should really kind of focus on that hip exam and see if they have a normal hip exam so this is the classic slip capital femoral epiphysis kid but you know they still play sports we still see them but cultural deconditioning is usually in their wheelhouse as well and so it is the most common adolescent hip disorder and classically it's that overweight male many times when we don't have that classic presentation of the overweight male we will do an endocrine workup in these kids to see if there's a reason why this happened because we just don't typically expect it but we do see it sometimes and they'll complain of pain in the groin hip or the knee the pain oftentimes doesn't start very bad they're able to participate in activities through it and then it progresses to the point where sometimes they get to the point where they can't walk and that's not a good thing and we'll talk about that many of these kids just because of where the pain presents oftentimes in the knee or they have this injury that you know they did something funny and they think that's why it hurts and everyone's like oh it's just going to get better and they don't x-ray it we often have this missed or delay in diagnosis the etiology of it still remains unknown we think it's multifactorial from all these kind of areas and then the the age range for this is pretty narrow for males it's typically around 13 and a half years it's right before that femoral head starts to close and for females it's a little bit early at about 11 and a half years and then we have started to see younger and younger kids and we think that's also because kids are getting to skeletal maturity at younger ages and this tends to happen right around that time of skeletal maturity so here's an example of sort of what happens this is what a normal hip looks like on the left hand side of your screen on the right hand side this one actually was missed initially by an outside by an outside radiologist and then when they came in we were like oh no that is already slipping but many times these can be very subtle at the beginning you'll just see some widening of that femoral growth plate and what's great is you have two sides and most of the time skiffy is not going to happen in both hips at the same time leg calperthes does the same thing it tends to be simultaneous instead of at the same time and so this this widening you can always get the other hip and look at it and see does it look more wide or does it look the same and then it's also important just to be able to get a frog leg lateral as well as an ap because sometimes you can't see this until you look at the frog leg lateral but you and you miss it on the ap obviously this is when it's starting to slip here and it has slipped and then this is slipped as well here and this was the same kid six weeks later so this kid didn't initially have the diagnosis was allowed to continue to participate in stuff six weeks later he wasn't able to walk at all was in severe pain and basically represented or he'd been presented to our clinic this is when we actually saw him and of course at that point had already slipped the reason it's important to kind of catch these kids early this is also where there's unstable so that's already slipped um so unstable and stable skiffy is an important differentiator and unstable just means that they're not able to walk at that point stable means that they're able to still walk we want to catch these kids when they can still walk and it's stable they have a much better prognosis long term so um most of these kids basically get a big screw we want to catch them when they're still stable they haven't slipped they're walking and we just basically um and we pin them basically to not let it happen um with a big screw um and so this is basically just what that sort of looks like over time and so they'll continue to grow develop and do everything and it's fine um this is a 12 year old female who presented with right knee pains the outside they referred her into ortho but never x-rayed her hips three weeks later she got into cs and unfortunately she had also gone from basically just having hip pain where there wasn't really much uh kind of going on uh to having some whitening and starting to slip there and by the time she saw us in three weeks she wasn't walking on this so technically she was already unstable um and so this is basically what that looked like at that point when we did the frog leg lateral or this is actually her ap but so she had already slipped um and so three weeks before she hadn't slipped yet um She had some widening. She had started to slip, but it was really subtle. And you can only see this on the frog leg laterals. So this is her AP, and so that's why it's important to get both of those views. And so we want to identify these really stable to prevent that progression to slip and then also just to minimize those risks of AVN and chondrolysis, which gives them the best long-term progression. There is a lot of debate on whether you should pin the contralateral hip in our younger kids, which we consider kind of younger than 12. Typically, our orthopedic surgeons will pin the other side, particularly if they have that cultural deconditioning body habitus. We will pin the other side prophylactically. So just the key points with SCIFI. Any child with knee pain, you want to make sure that you examine the hip, particularly if you can't palpate any pain in the knee or re-elicit that pain in the knee. And then making sure you also check an AP and a frog leg lateral, particularly if they have a limited hip range of motion. You want to make sure you read all of your x-rays. We have so many kids who come in where the radiologist on the outside read it as normal. The primary care physician or whoever saw them on the outside never looked at the x-rays themselves. And they come in to see us, and we get their old imaging. And you could see it on their old imaging, and it would have prevented them from being an unstable slip by the time they came into us. Also, any SCIFI is an urgent referral. This is where you need to call the orthopedic office. You need to send them to the ER if you can't get ahold of somebody. These kids need to be made immediately non-weight-bearing because if they are weight-bearing at the time that you see them, we want to keep them that way and not let that slip to the point that they're non-weight-bearing or they're unable to weight bear, and they become unstable. As I mentioned before, ultrasonography, I think, is becoming, obviously, a big part of our curriculum. And so really looking at those things like effusion and hips. And so you can kind of differentiate transient synovitis from septic arthritis by looking at the echogenicity. And so typically, transient synovitis is echo-free. And then septic arthritis is positively echogenic. And so that can sometimes help. And you can also see the widening of that space and measure it. Greater than 2 millimeters, typically, there is an effusion. With SCIFI, this can also be seen. So you can see early slips. You can see the joint effusion starting. You can also sometimes see the step between the femoral neck and the epiphysis. And then also with osteomyelitis, sometimes you can pick up on the periosteal thickening and the subperiosteal thickening. And so those are kind of important things as well. Just really quickly, because I know we're short on time, I just want to mention some of the other things that are important to think about outside of the hip. I focused a lot on the hip because most limping kind of leads back to the hip. But obviously, osteochondritis desiccans is something we commonly see in kids. It can be in the knee. So this is just an example of what that looks like. You see kind of that half moon sort of darkening and that femoral condyle. Medial femoral condyle is more common. And then also, this is what it looks like on MRI. And you can see actually joint fluid tracking under. So this is actually an unstable OCD. Also, looking, you can see them on the lateral side. You can also see them in the posterior aspect of that lateral femoral condyle. And then on the patella as well or in the trochlear groove. So kind of looking in those four places. As I mentioned before, imaging for OCDs is typically radiographs. We will typically do MRIs on all of our OCDs to assess the stability. Not really to look at how big it is. We can already see that pretty well on x-ray. It's really determined if it's a stable or unstable lesion. An unstable lesion means that joint fluid is able to get up under it because there's a break in the cartilage cap. And so those kids, depending on their age, sometimes we send more quickly to surgery than the stable ones, which we just manage conservatively. Tarsal coalitions, which I won't go into a lot. This is just an example of a subtalar coalition here. This is a calcaneo-navicular coalition here. These are also sometimes a reason for a kid who's limping. And then accessory naviculars. I see these like a couple times a week. They hurt. They can sometimes be precipitated by injury. And so that can sometimes be a reason that a kid is also limping or has an intelligent gait. And then obviously we never want to forget about tumors. Osteoid osteomas are probably, you know, are benign. But one of the more common ones that we'll see, they have this kind of onion skinning appearance. That's kind of classically what they get called. But other tumors we've picked up on. I've actually had two kids with Ewing's who presented into my clinic with a limp. And so those things are always important. Imaging, I think, is very important when you have a limp. And if you're not sure where it's coming from, image the whole leg. There's no harm of doing that. I've actually had Ewing's in fellowship that we diagnosed in the pelvis. And so those are just important places to look. So in conclusion, you know, obviously limp is a very common musculoskeletal presentation, particularly in the pediatric population. It's important to kind of determine the gait pattern, determine whether pain is associated with it or without it. Looking at the age of the child really helps you to kind of narrow that differential. And then also the location of the pain. Establishing a broad differential, I think, is important at the beginning. And then really just choosing those appropriate studies to confirm the diagnosis. And hopefully it helped you guys to see some of what those look like today. And then no appropriate treatment for the cause of the limp and make appropriate referrals. I think the most important thing is knowing when you need to get the orthopedic surgeon involved right away, primarily with like Skiffy, obviously early on with Perthes as well as helpful. And then always read your own imaging. I can't emphasize that enough. There's so many kids that I see that really would have had a different outcome if we would have, you know, kind of seen their, if somebody would have looked at their imaging aside from just the radiologist early on. So with that, I will turn it back over to Nate and stop sharing and then answer some questions that I'm sure you guys probably have. Cool. That was awesome. That is, as you pointed out, there's so much to cover. But thank you. Amazing. I have some questions that I've been taking note of that I think that fellows might be, so far, I think they're being shy. But I do see one fellow asking a question here. This is Amy Hample. I know you were saying, I'm just going to read her question. I know you were trying to speed up, but do you mind going back quickly to the last few slides after OCD before tumors? Thank you. I'm a resident. So probably looking at applying to sports, which is great. Maybe she's not, but that's okay too. Yeah. Do you want me to share it again? I can share it again. If you don't mind, that'd be great. And while you're doing that, maybe I'll pipe in with a question for you to think about that I've heard before, but I'd like to hear your viewpoint on this. Do we need to be careful in a patient with a SCIFI or a suspected SCIFI, do we need to be careful examining them with any particular maneuvers or putting them into a frog-leg lateral position? It's a great question. So no. So the biggest risk to them is actually the weight on the joint. So it's really actually them standing on it. We even had a kid who, this was like, I mean, it was crazy. So he was barely walking into our clinic and we're just like, where's the wheelchair? And then he went to get up to go to radiology and he's, I mean, it was probably, I mean, it was in the process of slipping already. We knew, but he like went to stand up to like, just move himself over the table. Cause he didn't think much of it. Cause he felt so much better sitting. And when he stood up, it just completely like, I mean, I'm sure that was the kind of end of the end for him and just was screaming in radiology. And we were like, oh, that's just really unfortunate. But I mean, technically he was probably already unstable. So the exam itself and putting them into that frog leg position is not going to harm them. And so that is completely safe to do. It's obviously, you know, usually our techs and I'm sure your guys' techs would be very, you know, gentle with them. And if they can't quite get their leg up into that position, most of them are kind of holding it a little bit in an abjected position anyways. And so it's sometimes easier than actually just getting them straight for their just AP, but we do all of our imaging for our pelvis with them just laying on the table. So that's usually not as concerning. So you don't have to be careful. Obviously don't force their range of motion when you're examining them. If you're like, oh, you only have zero degrees of internal rotation, then, you know, you're not going to be like, let me see if we can get a little bit. So yeah. Yeah. Great point. Well, thank you. I I've heard people say that they're concerned, but I bet that that's one of these things that gets passed on from one generation to the next without any real basis. And so it's nice to hear that from somebody who sees these. And I'll just go back to Amy's question. Hopefully this is helpful to you, Amy, to be able to see these slides on tarsal coalition and accessory navicular and so forth. So if you have any further questions, please do chime in. I have a few others that again, I think our fellows are being shy today, which is okay. You mentioned well, I, so why don't I go with this one first? What kind of things are you looking for on the joint fluid aspirate for a hip when you're suspecting a possible transit synovitis versus a septic joint? Yep. So that's a great question that I didn't put in there. So so the different, so typically with a septic hip, you're going to pull out pus on the aspiration. So it's going to be there, you know, it's going to be greater than 50,000, you know, white blood cell count. And then oftentimes, most of the time, unfortunately, these come back as sort of an aseptic purulent discharge. And so we don't ever get an organism, but that's what we're obviously trying to get, which is why getting that aspirate before you start antibiotics is, you know, kind of important, but obviously we still don't delay antibiotics. If for some reason you can't get the aspirate right away. And then with transient synovitis, it's usually a serious effusion. So you pull it out. It's mostly if you have any predominance of white cells, it's usually lymphs. And because we really think there's a viral component to transient synovitis. And so it'll just be more of this serious kind of sanguinous at times fluid. And those kids, you know, are fairly easy to usually get the tap because it's not as painful with the septic hip. You know, we actually usually already have our kids kind of, there's usually a pretty high suspicion for most of our septic joints, the kids look really sick. And so many times we actually do that aspiration in the OR already with our orthopedic surgeon. And then they just go wash it out when it comes out as pus, they're like, this is a done deal. And just, and get it out because the sooner you can get that effusion with all that pus out, the better those kids do. We believe also that there's a component of just having high white blood cell count in the joint, especially with it being neutrophils that really causes some damage to the femoral head as well. And that's where we see some of the long-term sequelae from a septic hip that was missed for a while. And so getting that effusion, getting that hip washed out and drained or the knee or whatever it happens to be as soon as possible is really important. That's great. And I think in answering that, you also answered Peter's question, which was about prioritizing, you know, aspiration versus getting them on antibiotics and, you know, how urgent is this? So move on to Carson's question. Are there theories behind secondhand smoking and does that correlate with Perthes? Yes. So actually one of the risk factors for Perthes is exposure is either a smoking history, which most of these kids are not smoking. This is like four to eight, we hope. But secondhand smoke has been linked to that. So low socioeconomic status, as I mentioned, male predominance, and then also exposure to secondhand smoke has also been linked to development of Perthes, which when you think about vascularity and then us thinking that this is kind of an avascular necrosis, it kind of makes sense because it's a small, you know, those are small vessels. And so it's just interesting to think that you don't have to be smoking and your parents can be smoking and expose that and put you at risk of having like Cal Perthes. But we do counsel our families afterwards to like stop smoking because we think that potentially it might help in the recovery of it as well. So we don't know, but, you know, it never hurts to use another, you know, kind of thing in their life to kind of encourage them to stop smoking. So we take advantage of that opportunity as well. Great point. So this is Jordan asking on stable OCD lesions in the knee, specifically in pediatric patients. What are your thoughts on weight bearing status and activity level and return to activity? You know, how often do you re-image versus just clinically treat based on pain? Yep. So that's a great question. So we actually, so we let them weight bear as long as they're able to do it without pain. So I've had a few kids that we've had to put on crutches for like a week or two. I typically tell them that once they are pain-free, that they should remain kind of on their crutches if we do put them on crutches for about a week. And then I let them start progressively weight bearing off and weaning off crutches. Most of our kids though, as soon as you stop sports or their athletic activity, their pain gets a ton better and we don't ever have to make them non-weight bearing. And so we typically will not cast. There are some centers that do cast for OCDs of the knee. Typically in the knee, we don't occasionally in the ankle, I have or booted them to get pain control and to get them to start healing. We shut them down for three months. It's devastating in our office. I hate talking to families and kids about this. This tends to happen in kids who are extremely active. And so telling them that even PE at school, they can't do, they can't participate in recess. They basically cannot go outside and ride their bike. We basically sit them on their butt for three months. I'm like video games are your new best friend. It breaks my heart, but this is your new best friend. Or I've encouraged them to like take up a musical instrument. Yeah. So three months. And then I typically follow with x-ray. One of our orthopedic surgeons follows with a repeat MRI. It's sort of four to six months. I repeat with x-ray. If x-ray looks like it's already improving, then I actually start gradually. I usually put them in a month of PT and then we start return to sport or activity on month four to five, basically. And if they don't get recurrence of their pain, I do follow them with x-ray on monthly visits when they're coming back. And if they don't get any recurrence of their pain, their OCD still tends to be healing. Then I don't ever repeat the MRI. If we are not showing healing on the x-ray or they get recurrence of their pain or their pain is kind of coming back as they start to return back to activity, then I do repeat the MRI and just look at that. Some of them, it shows that it's healing. It's just taking a lot longer. And then we'll shut them down for six months and give them up to six months. If in six months, this still isn't healing or mostly healed, they're still not able to return to sport. Then I usually turn them over to our orthopedic surgeon. And oftentimes he will kind of drill out that area. He basically kind of trephonates it and then basically puts that piece back on and sort of attacks it in to get it to basically heal and be better. A lot of times we ended up finding that there was probably an area that was unstable where there was just a little kind of leakage of the cartilage, but it just didn't show up on MRI at the time initially. And so that's kind of how we manage them. The vast majority of them actually don't ever go on to need surgery. Definitely older kids above 12. 12 is kind of the cutoff that most people use for OCD as being old or young. The 12-year-olds, that group tends to more often need surgery than the group that is younger 11 and below. Excellent. You clearly have treated some of these. Just a few. Yeah, just a few. Good for you. I don't see much of that in my practice here in the military. But, okay, we have another question from Amy. And I would like to... So Amy, I'm going to do my best with asking this question. Feel free to clarify. So she's asking about child... And Christine, I'm sure you can see these too. But with a child who's toe-walking, where you mentioned it's normal to have a child toe-walking ages two to three, but is there any cases where that's abnormal or where you might find something that, even in an age range, where that could be considered normal? Is there any other positive review of systems or any other situation where your antennas would go up and look deeper? And also the same question regarding flexible flat feet. Is it always normal under age six? When do you worry about something suspicious going on? Yeah. So that's a great question. A couple of questions there. So with the first one, just looking at sort of toe-walking in little kids, most of the time it's not anything. What I would say is if you have a kid who... So this is kind of like pattern recognition too. So we tend to worry a little bit more about the kid who only toe-walks on one side. And so most kids that are little will kind of go between toe-walking and flat foot walking. They don't toe-walk all the time where they're on their toes constantly. There are a few of those kids. Those kids tend to persist after age three. But if there's only one side that they tend to toe-walk on, as I mentioned before, sometimes leg length discrepancy can present with toe-walking. And so if you're only seeing it on one side, really making sure that it looks like that kid doesn't have a leg length discrepancy is important. The other thing is it shouldn't be associated with pain. So if there's pain, that would also be a red flag that we kind of maybe need to look into something. And then also most of the time the kids, if there's a family history of like CMT or Charcot-Marie-Tooth, sometimes you can see like a limp start on that side as well, that on that affected side, you'll start to see like a higher arch and things like that where you see some of those changes that you have with that. So I would say those would be kind of things that I'd be more concerned about than like the kid who is toe-walking most of the time, but can get to a flat foot. And so that's the thing we also look at on exam is we'll like range them and make sure they can at least get to like neutral dorsiflexion. You know, most of the kids, because they're so stretchy at that age can still go to like 10, you know, minus 10 degrees of dorsiflexion. But basically if they can't, you know, even get to a neutral position and they're still stuck in that, what we oftentimes, and it's bilateral, we'll just start with stretching with the family. And so, and have them be doing stretching on a regular basis with that kid to try to get them to that neutral position. But tethered cord sometimes can do that as well. So if there's, you know, a dimpling in the lower back and you're worried about that, you know, you can always, you know, image and problem with that age group is obviously it requires sedation to get an MRI. So, I mean, I would have a high index of suspicion before I would kind of progress into that. And most of those kids will have, you know, pain or other things you'll notice from a neurologic standpoint, if that's kind of the, that's going on there. And then the other thing that you mentioned was just about like six and flat feet. So, some flat feet will persist after six that are flexible flat feet. So usually there's a family history of flexible flat feet. So I always kind of couch it in my clinic as, you know, look at mom or dad's feet. And if one of them or a grandma or grandpa on either side, usually there is somebody at each generation that has a flat foot that's flexible. And most of the time it does not cause kids pain. And so I typically, you know, I have lots of families that come in, it's not bothering the kid, but they're really worried about their flat feet. And I'll just tell them, you know, it's not bothering them. It's not causing a problem right now. They're, you know, participating in sports, they're doing great. If it starts to become a problem or you're starting to feel pain, let us know. The one thing I will say is obviously with patellofemoral pain, we do know that, you know, having that flat foot and overpronation and things like that will cause some problems. And so I do put arch supports in those kids, but more for the patellofemoral pain, not because they have a flat foot. And then, but otherwise, you know, unless it's rigid, like they cannot get up on their toes, which is the difference between a flexible and a rigid flat foot. They, you know, kids with a rigid flat foot cannot actually go into releve. They can't actually get up on their toes at all. Like it's just really like stuck. It's kind of interesting to see. Otherwise you don't really need to worry about those flexible flat feet. But the rigid flat foot, obviously, you know, looking at perineal tendon dysfunction, other things is important in those kids. Oftentimes we refer into our surgical partners and have some counseling and discussions about those, but hopefully that kind of answered your question. Yeah, I would say it did. That was great. I certainly learned a lot from listening to all of that. And it's for me, a great refresher who I don't see a lot of kids in my practice, but certainly for the fellows, this is a high yield. There's going to be stuff on this on your boards. So I'm glad you were here. And for those who are listening asynchronously, you know, this is time well spent. Well, so on behalf of, you know, all of the fellows and those in attendance, I'm sure a lot of, you know, graduates are listening to, or will listen. We really thank you, Dr. Wilson, for sharing your expertise and your time with us. And yeah, this has been awesome. So we will go ahead and conclude now. I do, I'm in the military. I think I have to say that I do not represent the military. I, none of my views or whatever are representative of DOD. So I'll just throw that in for the recording, but thank you all have an excellent rest of the day. And thank you again to Dr. Wilson. Thank you.

3rd Edition, CASE 45

3rd Edition

Pediatric Issues

pediatric limping

atraumatic causes

developmental dysplasia

transient synovitis

septic arthritis

slipped capital femoral epiphysis

gait evaluation

imaging techniques

ultrasonography

early diagnosis