Today we're going to talk about common lower extremity musculoskeletal conditions and injuries. I have no relevant disclosures. The learning objectives are diagnosis and treatment of common lower extremity conditions seen in children. The first one is leg length inequality. Leg length inequality is common with estimates of up to one-third of the population with a two-centimeter or less discrepancy measured between the length of their legs. There are two types, true and apparent leg length inequalities. True leg length discrepancy is present when bilateral leg length of the leg measurements between the greater trochanter and the medial malleolus demonstrate shortening on one side. An apparent leg length discrepancy is present when bony links are same but the joint alignment or pelvic femoral asymmetry is present. For example, what you see in adductor spasticity or pelvic obliquity. It can best be measured by tape measure from the umbilicus to the medial malleolus of either side. Radiograph imaging measurement is the most reliable with CT scanogram being the gold standard. The cause of leg length equality is either growth retardation or growth stimulation. For growth retardation, it includes conditions such as congenital hip dysplasia, leg calf Perthes disease, slipped femoral capital epiphysis, polio, achondroplasia and dyschondroplasia, and severe burns. Growth stimulation, on the other hand, includes conditions such as congenital giantism, Wilms tumor, vascular abnormalities such as clippal trinary Weber, thrombosis or femoral iliac veins, and traumatic arterial venous aneurysms. Tumors such as giant cell neurofibromatosis and bony fractures can cause growth retardation or growth stimulation. The treatment objectives include obtaining leg length equality, producing a level pelvis, and improving function. For differences less than 1.5 centimeters, observation is the best treatment. From 1.5 centimeters to 3 centimeters, you can add a shoe lift. For differences greater than 3 centimeters, consider surgery. This can include lengthening procedures which consists of stapling epiphysiodesis or surgical epiphysiodesis. So stapling technique consists of placing staples across the physicist of the longer side and can later be removed once equalization is achieved. Surgical correction is an all-or-none procedure that completely and permanently arrests the growth plate. Surgery is most commonly done two to three years prior to growth maturity. This is 11 or 12 for girls and 12 to 13 in boys. There's also shortening procedures. This consists of removal of a section of a bone or limb equalization performed in adults or adolescents who are no longer growing. For differences greater than 15 centimeters, there may be a combination of lengthening and shortening procedures. The next condition is developmental dysplasia of the hip. It used to be known as congenital dislocation of the hip. However, this is not always detected at birth so congenital was replaced with developmental. Developmental dysplasia of the hip is displacement of the femoral head from its normal relationship with the acetabulum. It is common with incidence 1 per 100. It occurs more than in females than in males at a 6 to 1 ratio and it's more commonly seen unilaterally. There are two different types. Typical, which makes up about 90 percent of cases versus atypical, which makes up the other 10 percent. Atypical can also be called teratologic. This is when you have a malformed acetabulum or femoral head in utero. It's associated with myelomeningocele, arthrogryposis and Ehlers-Danlos syndrome. Typical is associated with a positive family history in females, a breech birth, high birth weight, pre-imparity and otherwise normal infant. The severity is broken down by subluxed, dislocated and reducible or dislocated and irreducible. Also may be due to abnormal intrauterine positioning or restriction of fetal movement in utero which impedes adequate development and stability of the hip joint. Teratological or atypical dislocations of the hip represent a more severe form of the disorder and is probably the result of a germ plasm defect. They occur early in fetal development and result in malformation of the femoral head and acetabulum. Some associated congenital anomalies that are found in infants whose dislocations are atypical would include clubfoot deformity, congenital torticollis, metatarsus adductus and infantile scoliosis. For exam you may they may hold the leg in adduction and external rotation of the affected side. Skin folds may be asymmetric and affected side may appear shorter. Different diagnostic maneuvers that you're going to use is Galazee sign, Ortolani sign or the Barlow test. So for the Galazee sign you're going to hold the hips and knees in a 90 degrees flexion and assessing height of the hip. So flex hip and knees bilaterally looking at the level of the knees. In the diagram the level of the left hip is obviously lower which usually indicates that hip dysplasia is present in this leg. However the same sign is seen in congenital short femur but this is a much less common finding. For the Ortolani sign it's positive when there's a palpable clunk felt when the hip is AB ducted and internally rotated. This is when the hip is relocating. The Barlow test is positive when the knees are flexed and hips flex at 90 degrees. The hips then are gently AD ducted with pressure applied on the lesser trochanter by the thumb. A palpable clunk indicates a posterior dislocation. So positive Barlow is when the hip is being dislocated and whereas the Ortolani is when it's being relocated. Imaging you're going to have the femoral head located lateral and superior towards normal position and the acetabulum may be shallow. Ossification is not evident until three to six months old so ultrasound will be used to assess. Here are some pictures that show what a normal hip subluxed hip and a dislocated hip would look like as well as a dysplastic hip in the imaging. Treatment for typical developmental dysplasia of the hip within the first six months they're going to use a Pavlik harness which is seen on the picture on the right or you can do casting which is seen in the picture on the left. They're going to check it every two weeks and do an ultrasound exam monthly. The harness will be adjusted based on findings from age 6 to 18 months. They can do a fixed hip abduction orthosis and greater than 18 months they're going to do open reduction. So successful correction of congenital dysplasia of the hip depends on early diagnosis and institution of appropriate treatment. Hip flexion should be to 100 degrees and abducted to 45 degrees. Complications include avascular necrosis of the femoral head, lifelong pain, stiffness in the hip and an intalgic gait and as well as they could have shortening of the involved limb. The next condition that we're going to talk about is acute transient synovitis of the hip. It is the most common cause of limping and pain in the hip of children. The etiology is unclear but it's suspected to have a viral etiology. Age of onset is usually between three to six years of age and affects boys more than girls. They're going to present with sudden onset of pain and a limp. Sometimes it'll be associated with upper respiratory infection and a low-grade fever. On physical exam they're going to have limited internal rotation of the hip. The white blood cell count could be normal or slightly increased and the SED rate may be slightly increased as well. X-ray is going to be normal so this is a diagnosis of exclusion. Treatment consists of rest in SEDs usually going to resolve in the first five to seven days. Full activity should be avoided until the hip is pain-free and the child is no longer limping. Prognosis is good. Less than 10% of people are going to have a second episode. The next condition is leg calf Perthes disease. It is an impairment of blood supply to the developing femoral head which results in avascular necrosis. Etiology is unknown. This is going to occur between children ages 4 and 10 years of age with a peak age of 5 to 7. There is a higher incidence in males with a ratio of 4 to 1. It's usually going to occur unilaterally. Typically the onset is insidious and it may present like toxic synovitis without radiographic evidence. Most present with a painless limp and they may have a Trendelenburg gait. They can complain of thigh or knee pain and they're going to bear less weight on the involved leg resulting in hip flexion and they can even develop a contracture. They're also going to hold that hip in a slight external rotation position. The severity of the leg calf Perthes disease is going to depend on the extent to which the femoral head is affected. Imaging early radiographs may be normal. A bone scan and MRI may provide diagnosis earlier on. Later on x-ray you can see fragmentation of the femoral ossification center with flattening of the femoral head, extrusion, and frank subluxation. Treatment is usually self-limiting resolving in two to four years. So conservative treatment you're going to do rest maybe an abduction brace with the goal of treatment to retain the normal spherical shape of the femoral head. Currently therapy will allow for kids to weight bear but with the femur in an abducted position so that the head is well contained by the acetabulum. In mild cases the cataract classification 1 to 2 decreased activity and observation or that more conservative treatment is recommended. For more severe cases in the cataract classification 3 to 4 you're going to do abduction casting, bracing, or surgical treatment with a femoral or acetabular osteotomy to reposition the femoral head. Prognosis for leg calf Perthes disease is good when it's detected in children at an earlier age such as kids younger than 6. Also when there's less than 50% of the femoral head involved. Poor prognosis is seen in children when it's detected later. Also if there's going to be greater percentage of the femoral head that is involved. The next condition is slipped capital femoral epithesis also referred to as SCFI. A SCFI is displacement of the femoral head from the femoral neck through the growth plate. It's going to affect males greater than females and a two to one ratio. It occurs in boys between 12 and 16 years of age and females between 10 and 14 years of age. About 25% of the time it's going to occur bilaterally. Most commonly occurs at the onset of puberty in obese children with delayed sexual maturation and there's an association with endocrine disorders such as hypothyroidism, hypopituitarism, hypogonadism, and excessive growth hormone. The etiology is unclear. These kids are going to present with a painful lymph. They may report pain after recent mild trauma such as jumping, may complain of pain at the hip, thigh, or knee. So it is always important in musculoskeletal injuries to check the joint above and below where they're complaining of the pain. Their lower extremity may be held in external rotated position. They're going to have an endontalgic or abductor lurch gait. On exam they're going to have diminished range of motion at the hip and may develop a hip flexion contracture. The clinical presentation for a SCFI is characteristic although the duration of symptoms can vary. On imaging an x-ray can vary. You may see a widened and radiolucent growth plate to a frank deformity with displacement of the femoral head posteriorly and inferiorly. Prompt intervention to prevent further displacement is an important factor in preventing lifelong problems and awareness of the condition. A high index of suspicion and early recognition are key factors in improving prognosis. Treatment for minimal or moderate displaced slips is going to be pin fixation. For severe slips they're going to do pinning initially but they may require a proximal femoral osteotomy and avascular necrosis can complicate the outcome. Children with unilateral slipped growth plates must be monitored closely for signs of involvement of the opposite limb. The next condition is femoral anaversion. This is going to occur in utero and at birth. The femoral neck sits in an anaverted position relative to that of the adult. During childhood it remodels to a position of slight antaversion and normal alignment of the lower extremities. In certain children however delayed rotational correction may result in persistent intoeing. These kids may complain of tripping while walking or running. Kids may have a history of W sitting. This is where when they're sitting on the floor their knees are bent and the lower legs are turned outward in a reverse tailored position. Imaging is going to be normal. This is usually seen in early childhood. It occurs twice as frequently in girls than in boys. It can be hereditary and it often occurs bilaterally. There is no treatment reassurance that the condition will correct with growth usually by age 10. This just shows a picture of the different angles of the femoral head. So it's based on degree of anaversion of femoral neck in the relation to the femoral condyles at birth. Normal femoral anaversion is 30 to 40 degrees. Typically decreases to normal adult range of 15 degrees by skeletal maturity and usually there's going to be minimal changes in femoral anaversion that occur after the age of 8. Multiple studies have been unable to reveal any association with degenerative changes in the hip and knee when increased antaversion persists into adulthood. To assess for femoral anaversion you're going to check the hip motion. So this can be done with the child laying in a prone position. Increased internal rotation of greater than 70 degrees or decreased external rotation of less than 20 degrees. The next condition is internal tibial torsion. Internal tibial torsion is also known as pigeon toe. It's a condition that is characterized by internal rotation of the tibia. It's most commonly occurs bilaterally. It's the most common cause of in-toeing in toddlers usually seen at age 1 to 3 years of age resolving spontaneously by age 4. So once again reassurance to parents is important. The exact etiology is unknown however it's thought to be due to intrauterine positioning. The kids going to present with in-toeing and may have a history of tripping and falling especially with running. Treatment is going to be observation. It is important to note that bracing and orthopedic shoes do not change in-toeing. So a lot of your families are going to be asking for that but you just reassure them that it will not help fix it. In the most severe cases you can refer to orthopedics and they will consider derotational supramalleolar tibial osteotomy versus a proximal osteotomy. To assess for internal tibial torsion you're going to look at the thigh foot angle in a prone position. Normal value in infants you're going to have a mean 5 degree internal with a normal value at 8 years of the mean of 10 degree external. So one thing you're going to want to assess for if a kid has in-toeing you're going to look to see is it coming from the hips or the tibia. Femoral anaversion when associated with tibial torsion may lead to knee pain in kids but usually by itself either the femoral anaversion or tibial torsion they're not going to cause knee pain. The next condition is genuvarum or physiological bow leg. This is usually a normal variation of lower extremity configuration seen in children ages 1 to 3 years of age. So it's usually going to be noted shortly after a child begins walking they may have a waddling gait and they might have slight ligament laxity. So infants generally have bow legging as a normal finding, by 12 to 18 months of age, the legs have straightened and may even progress to a mild knock knee or genovalgus. The leg is going to gradually assume its ultimate configuration by six or seven years of age. Radiographs are normal. Treatment is rarely indicated as the child, like I said, will likely outgrow this. So casting, bracing, and corrective shoes are unnecessary even though our parents are going to ask for these. There is no indication for surgery. Here is a picture of the bow legging. However, pathological genovarum can occur in rickets or other metabolic abnormalities, aphesial dysplasia, various forms of dwarfism, and pathological growth disturbances such as Blount disease. So Blount disease is an isolated growth disturbance of the medial tibia epiphysis manifested as an angular varus deformity of the proximal tibia with apparent progressive genovarum. This is due to abnormal function of the medial portion of the proximal tibia growth plate and results in bowing of the proximal tibia. Unilateral and bilateral involvement are seen with nearly equal frequency. The etiology is unknown, though it is seen more commonly in African-American children. It is the most common morphologic cause of bowing in young children and is found most commonly in obese children who walk at nine to ten months of age. On exam, there's going to be a localized angular deformity of the proximal tibia, whereas in the physiological bow legging, you're going to see diffuse bowing. These kids are not going to have ligament laxity, which can be seen in physiologic bow laying. Imaging, there's going to be fragmentation of the medial epiphysis of the tibia associated with beaking and loss of height in this region, as well as a characteristic angular deformity. Treatment, bracing or surgical osteotomy for realignment of the leg may prevent further progression, and sometimes this surgery may have to be repeated one or more times. So in this imaging, you can see that there's beaking at the medial portion of the proximal tibia, causing an angular deformity. The next condition is genu valgum, or physiologic knock knee. This is noted to be in children between three and five years of age. It's usually part of the normal growth and development of the lower extremities. The condition usually becomes apparent when a child is two to three years old and may increase in severity to age four. It usually self-corrects by the time a child is about seven or eight years. However, if the condition doesn't appear until a child is six or older, it could be a sign that there is an underlying bone disease. In some cases, especially in children who are six or older, it may be a sign, and you may want to think of osteomalacia or rickets. This occurs in females greater than males. It may also be associated with ligament laxity, just like the genu valgus or varus. On imaging, there's going to be no osseous or fesial abnormalities. You may see an angular deformity due to ligament laxity on weight-bearing view. If the tibiofemoral angle is less than 20 degrees, no treatment is indicated as it's going to correct with growth. If it persists into early adolescence, there is possibly a surgical correction that may be done by orthopedics. So here's some pictures just showing of knock knees. The next condition is Augsburg-Schlatter disease. This is a traction apophysis of the tibial tubercle that tends to develop during the adolescent growth spurt. It's going to occur more commonly in males than females and usually occurs bilaterally. It's thought to be due to vigorous physical activity putting stress on the apophysis. It presents as gradual increasing pain and swelling around the tibial tubercle. The pain is going to worsen with physical activity, kneeling, or crawling, and the pain is relieved by rest. So in this picture here, you can see that there is going to be a protuberance of the tibial tubercle. On image, it may only reveal soft tissue swelling in the region of the proximal tibia apophysis or irregularity of ossification of this structure. In long-standing cases, frank fragmentation of the apophysis may be seen. On exam, they may have localized swelling at the tibial tubercle. Otherwise, the exam is going to be normal. Treatment is often self-limited. It typically persists for 6 to 24 months. In mild cases, no treatment is necessary most of the time. In moderate cases, they can use Motrin as needed, and you want to try to avoid pain-inducing activities. In severe cases where they're having severe pain or limping, a short period of immobilization in a splint or a cast may be beneficial. It's important to note that steroids are contraindicated in this condition as it may cause deterioration of the tendon and provides little in the way of long-term relief. The next condition is a popliteal cyst, also known as a Baker's cyst. This differing from adults in that popliteal cysts in children usually do not communicate with the joint capsule but originate instead beneath the semi-membranosus tendon, presumably as a result of chronic irritation. It occurs between ages 5 and 10 years of age and occurs in males more commonly than females. So you can have a fibrous tissue or synovial cyst located in the posterior medial aspect of the knee joint in the region of the semi-membranosus tendon and medial gastrocnemius muscle belly. On exam, they're going to be soft, non-tender, or a cystic mass, normal range of motion at the knee. An MRI can be done to show the delineation of the cyst and its position in relation to the nearby structures for treatment. It's going to be benign and may resolve over time, though some people may opt for surgical excision. Here is just a picture of the cyst behind the knee. The next condition that is common is anterior patellar disorders. They are going to present with pain located in or around the patella, and this is going to occur especially in adolescent females. The true source of pain is unknown. The primary causes of the anterior patellar disorders is there can either be a mechanical malalignment of the patellofemoral mechanism, either congenital or acquired. This is where the patella does not track properly in the femoral groove or it could be due to an overuse of the patellofemoral joint, leading to chronic fatigue of the tissues and painful inflammatory response. The onset of symptoms may be insidious or abruptly following a trauma. The patient's going to complain of diffuse aching behind the patella that is exacerbated by climbing stairs, pedaling a bicycle, or prolonged sitting. On exam, patella is tender. With pressure over the patella when the knee is slightly flexed will produce pain. In malalignment, tenderness may be greatest on palpation of the lateral or medial edge of the patella near the facets. In overuse problems, tenderness may be noted either at the quadriceps attachment proximally or at the inferior pole where the infrapatellar tendon attaches. Treatment is aimed at the underlying cause, so in malalignment you can work on quadriceps strengthening exercises. Patellar tracking braces can be used or surgical release of the retinaculum on the lateral side may be necessary in the more difficult cases. In the setting of overuse, you want to do reduction of activities with a slow stepwise return to activity and may use NSAIDs. The next condition is Sever's disease. It is also known as calcaneal apophysitis. It's one of the most common causes of heel pain in growing children and adolescents. It is an inflammation of the growth plate and the calcaneus. It is caused by repetitive stress to the heel and most often occurs during growth spurts when bones, muscles, tendons, and other structures are changing rapidly. It affects the part of the growth plate at the back of the heel where the bone growth occurs. It serves as the attachment point for the Achilles tendon. Children and adolescents who participate in athletics, especially running and jumping sports, are at increased risk for this condition. However, less active adolescents may also experience this problem, especially if they wear very flat shoes. Repetitive stress from running, jumping, and other high impact activities can cause pain and inflammation in the growth area of the heel. You may see symptoms in both heels, although one heel may be worse than the other. Symptoms may include heel pain and tenderness underneath the heel with mild swelling at the heel. On exam, calcaneal pain near the site of insertion of the Achilles tendon is usually seen and they're likely going to have difficulty with heel walking due to the pain. For treatment, in most cases of Severs disease, simple measures like rest, over-the-counter medication, a change in footwear, and stretching and strengthening exercises will relieve pain and allow a return to daily activities. It is not unusual for Severs disease to reoccur. This typically happens when a child once again increases sport activities. Wearing sports shoes that provide good support to the foot and heel may help prevent reoccurrence. Severs disease will not return once a child is fully grown and the growth plate in the heel has matured into solid bone. Here is just a picture of where the Achilles tendon inserts into the calcaneus and the growth plate. The next condition is congenital clubfoot, also known as telepis aquinovaris. So it consists of three associated deformities. You're going to have aquinas or plantar flexion of the foot at the ankle, varus or inversion deformity of the heel, along with forefoot varus. It is fairly common with the incidence of about one per 1,000 births. Clubfoot follows a hereditary pattern and may be part of a generalized syndrome or be associated with anomalies, especially of the spine, such as in spina bifida children. 50% of the children eventually require surgical correction. Here you can see a picture of what the clubfoot looks like versus a normal foot. For treatment purposes, surgery used to be the main treatment for clubfoot, but orthopedic surgeons now prefer the Ponsetti method. This is done in two different phases. First, there is the casting phase, which is a gradual movement of the foot into the correct position, followed by the bracing phase, which makes sure it stays there. So casting by an orthopedic surgeon who has been trained in the Ponsetti method usually starts when a baby is a week or two old and lasts for about five to seven weeks. When the foot is in its final correct position, the baby is then fitted with a brace. The bracing phase will last from two to five years. A child will wear this brace all the time except during baths, so usually 23 hours a day for about three months, and then they'll only wear it during naps and nighttime thereafter. If need be, surgical correction is an Achilles tenotomy. The next condition is metatarsus adductus. This is characterized by adduction of the forefoot on the hind foot with the heel in a normal position or slightly valgus. Flexible deformities are secondary to intrauterine position and usually resolve. The rigid deformities may require splinting. 85% of these cases are going to correct by age three to four. The lateral border should be straight. A medial soft tissue crease indicates a more rigid deformity. So here in the picture you can see that the metatarsal bones are deviating inward. The next condition is a calcaneal valgus foot deformity. This is when you see excessive dorsiflexion at the ankle and eversion of the flat foot. This is usually due to intrauterine positioning. Treatment may include stretching and rarely are you going to use splinting. I've also seen therapists use kinesiotaping. Planovalgus is the next condition. Here you're going to see the ankle rolling inward as seen in the two pictures. So if it's significant enough we can use a supramalleolar orthosis. That is the bottom left picture. It's a custom brace that kind of holds the foot in proper alignment. You can also use a UCBL. Those are the next two pictures down in the left bottom corner. That also holds the calcaneus in a proper alignment. For kids who aren't going to use a brace sometimes what I call the poor man's brace are going to be your high top tennis shoes that are nice and sturdy that go above the malleoli. So that could either be the work boots, Michael Jordans. I tell families they don't have to be expensive they just have to be sturdy. And then I use Converse tennis shoes as an example of what is not sturdy. Also I'm here in Texas and so I'll tell families you know a cowboy boot can kind of act as a brace as well by holding the foot in alignment. The next thing is condition is pes planus or a flat foot. Important to note that this is a normal condition in infants. Kids do not obtain arches until five or six years of age. You can also see flat feet run in families and I just reassure the parents that flat feet normally does not cause any problems or pain in the future. Cavus foot and claw toes. So a cavus foot is usually high longitudinal arch due to muscular imbalance within the foot. It may be hereditary or associated with neurological conditions such as poliomyelitis, Charcot-Marie tooth disease or Friedrich's ataxia. Usually associated contractures of toe extensors or claw toes can be seen as well. For treatment you usually want to treat the underlying cause if able. Non-surgical treatment is going to be customized shoes, adding a metatarsal bar to relieve pressure off the metatarsal heads and to correct any extension deformities and ameliorating symptoms at the base of the toes. Surgical correction is often needed in these cases. The claw toes you're going to see metatarsophalangeal joints are hyperextended and interphalangeal joints are flexed. This is due to a muscular imbalance within the foot. Usually congenital and seen in disorders of motor weakness such as Charcot-Marie tooth or pes cavus foot deformity. These people can get pressure sores at the PIP joints of the toes. Treatment once again is going to try to treat the underlying cause if available. Non-surgical you're going to use customized shoes, once again a metatarsal bar to relieve pressure off the metatarsal heads and to correct extension deformities and try to ameliorate the symptoms at the base of the toes. And once again surgical correction is often needed. Next we're going to talk about toe walking. Toe walking is common in children who are learning to walk. After the age of two however most children are going to outgrow toe walking and begin to walk with a normal heel-to-toe pattern. In the vast majority of cases however persistent toe walking is idiopathic which means that the exact cause is unknown. Older children who continue to toe walk may do simply out of habit or because the muscles and tendons in their calves have become tighter over time. You're going to want to rule out medical conditions such as spastic diplesia seen in cerebral palsy. You can see the muscular dystrophy or any spinal cord abnormality. In the behavioral kids you're going to see a lot with kids with autism or any sensory related issues. Most of these kids are going to be able to walk on their flat footed when you ask them but like I said however many of these older children who continue to toe walk may start to develop tightness. Treatment for persistent toe walking often involves a period of casting or bracing to help stretch the muscles and tendons in the calves and encourage a normal gait. These children may complain about problems wearing shoes or participating in sports or recreation activities that involve wearing roller skates or ice skates. So what's important you want to get a good history. Were there any pregnancy complications or was your child born prematurely? How old was your child when he or she reached developmental milestones such as smiling, sitting, and walking? When did the toe walking first start? For example did it begin when your child's starting to walk independently or at an older age? Is the toe walking on both sides or only one side? Is there a family history of toe walking? What percentage of the time is spent walking on the toes? If asked is your child able to walk flat footed? Does your child complain of foot or leg pain, weakness in the legs, or difficulty keeping up with children of the same age? Your physical exam is going to include neurological exam and a gait assessment. You may want to get imaging such as MRI of the spine or brain. Your treatment is going to depend on the cause. You may just do observation for behavioral kids. Serial casting, bracing, botulinum toxin injections, and surgery are fairly common in kids who are toe walking due to spastic diaplegia and cerebral palsy. Thank you for your time and these are the resources that I used for this presentation.

leg length inequality

developmental dysplasia of the hip

diagnostic maneuvers

acute transient synovitis

Leg Calvé-Perthes disease

slipped capital femoral epiphysis

foot deformities

treatment options