Current Concepts on Pediatric Hip Disorders Dr. Donald W. Kucharzyk Pediatric Orthopaedic Surgeon...

Current Concepts on Pediatric Hip Disorders

Dr. Donald W. KucharzykPediatric Orthopaedic Surgeon The Orthopaedic,Pediatric & Spine Institute Crown Point, Indiana

“Developmental Dysplasia of the Hip”

CURRENT CONCEPTS UPDATE

Developmental Dysplasia Hip

TERMINOLOGYDysplasia: Abnormal tissue developmentSubluxation: Capsular laxity with some

displacement but maintenance of cartilage-cartilage contact

Dislocated: No cartilage-cartilage contact with hip external to the labrum NOW TERMED “DDH”


ETIOLOGYGenetic Factors: Race..Blacks/Chinese Twins(34-50%)Anatomic Factors: Primary Acetabular

Dysplasia…parents of children with DDH have incidence of shallow acetabulum; Increased Joint Laxity seen in children with DDH (33-75%)


Mechanical/Environmental: Increased risk in First Born, young mothers, and molded baby syndrome; Twins; Oligohydramnios; Breech(50%)

Breech Incidence: female 1/200 female breech 1/35 female breech FH 1/15Overall Incidence: Instability 2.7/1000 Dislocation 1/1000


ANATOMYEARLY STAGE: Capsular Laxity Blunting of Labrum Ortolani/Barlow Pos.LATE STAGE: Adduction Contracture Enlarged Capsule Hourglass Contracture Infolded Labrum False Acetabulum


NATURAL HISTORYBarlow(1962): 58% spontaneous stable at

1 week; 30% stable at 2 months; 12% remained dislocated

Coleman(1968): 22% spontaneous correction; 39% dysplastic; 26% dislocated

Wedge(1979): untreated 60% painWeinstein(1987): DDH leads to DJD


EXAMINATIONOrtolaniBarlowAllis/GaleazziAsymmetrical Thigh FoldsLimited Abduction


RADIOLOGIC EVALUATIONPlain Xrays: unreliable intially;

useful at 6-8 weeksUltrasound: most reliable but level of

dependability related to expertise of radiologist; useful with treatment modalities


TREATMENTBIRTH TO SIX MONTHSPavlik Harness: fulltime for 4-6 weeks

till hips stable then brace till acetabulum normal; Failure to reduce in 2-3 weeks- change treatment plan

Complications: AVN Femoral Nerve Palsy


SIX MONTHS TO ONE YEARClosed Reduction and Casting: must

achieve stable and concentric reduction, human position for casting, maintain safe zone(adductor release)


TWELVE TO EIGHTEEN MONTHSClosed Reduction with Adductor

Release followed by Double Hip Spica casting for 4 months

Open reduction: if reduction failure, hip not stable in a favourable position, or if reduction not concentric


EIGHTEEN TO THIRTY-SIX MONTHSOpen Reduction and Innominate

osteotomy with casting for 6 weeks followed by abduction bracing for 3 months

Key to Treatment: Capsulorrhaphy important to maintaining the hip and promoting development of the acetabulum


THREE TO SIX YEARSMust alter the Natural HistorySoft Tissue ReleaseOpen ReductionFemoral ShorteningPelvic Innominate Osteotomy


SIX YEARS AND OLDERUnrecognized Complete Dislocation:

Unilateral..should be treated via OR, Femoral shortening and Pelvic osteotomy; Bilateral..controversial

Failed Efforts at Reduction: Requires assessment of the cause of the failure and then a Salvage Procedure(Shelf, Chiari, Colonna)


Redislocation after Prior Reduction: Due to unstable reduction caused by acetabular incompetence, proximal femoral deformity or osseous necrosis; treatment aimed at correction of any femoral or acetabular deformities and reduce the hip

Late Dislocation: Instability..acetabular deformity


TREATMENTUnilateral Dislocation: Open Reduction

with Femoral Shortening and stabilization of any acetabular defects

Bilateral Dislocations: Controversial..painful,stiff hips result and successful reductions uncertain; BEST results in this group is EARLY DETECTION AND PREVENTION


COMPLICATION’SFailure to Document ReductionBrace Failure: inappropriate application,

poor compliance, failure in following the patient, anatomic obstructions and excessive laxity

Cast Failure: Narrow safe zone, cast application problems, and short immobilization period


COMPLICATION’SJoint Problems: Not addressing the soft

tissue contractures especially about the capsule(hourglass) and inverted labrum; Loose redundant capsule; Femoral Head Malposition;

Femoral Osteotomies: shortens femur, trendelenberg gait, persistant instability and no remodeling over 8


COMPLICATION’SInnominate Osteotomies: failure of

concentric reduction and increased femoral head pressure

Combined Osteotomies: may uncover head posteriorly, difficult to obtain correct alignment


COMPLICATION’SAvascular Necrosis: AVOID Keep Femoral Head Centered Maintain Acetabular Coverage Overgrowth of the Greater Trochanter Early Degenerative Osteoarthritis

Legg-Calves-Perthes Disease

CURRENT CONCEPTS UPDATE

Legg-Calves-Perthes Disease

ETIOLOGYChronic sequence of changes initiated by an

avascularity of the femoral head: less developed blood flow

Specific cause is unknownSeen age grouping: 4-8 years with range of

2-12 yearsFour-five times more common in malesBilateral in 10%

Legg-Calve-Perthes Disease

CLINICAL FINDINGSProlonged limpWaddling gaitPain in groin or thighLimited painful motionTenderness to palpation over hipGluteal AtrophyTrendelenberg sign PositiveLeg Length Discrepancy


RADIOGRAPHICDiagnostic Changes Lateral Displacement of Femoral Head Subchondral Fracture Line Increased Epiphyseal Density Smaller Epiphyseal Nucleus than Normal


Head at Risk Signs Lateral Subluxation of Femoral Head Calcification Lateral to Capital Epiphysis Metaphyseal Cysts Horizontal Growth Plate Gage’s Sign: V-shaped Defect


CLASSIFICATIONCatterall: Based on xray appearance at the

time of maximal resorption Type I: less than 25% involvement Type II: 50% involvement, lateral border

spared Type III: 75% involvement, lateral head

collapse Type IV: total involvement


CLASSIFICATIONSalter-Thompson: based on extent of

subchondral fracture line Group A: less than 50% involvement Group B: over 50% involvement


PROGNOSTIC FACTORSSex: girls have poorer prognosis than boysAge at Onset: younger children have

better prognosis than olderExtent of Head Involvement: more

involved- Worst PrognosisFemoral Head Containment: loss of

containment-greater risk of deformity


PROGNOSTIC FACTORSHip Range of Motion: major factor in

pathogenesisPremature Physeal Closure:

asymmetric growth and inadequate remodeling


TREATMENTGoals: good containment and

congruence and reduction of weight on affected area of femoral head; maintenance of ROM


Treatment Options: No Treatment Intermittent Traction Abduction Orthosis Femoral Osteotomy Pelvic Osteotomy


No Treatment: Children under Five require

observation only Containment Orthosis does not

affect the natural history in children under Five


Containment Orthosis Texas Scottish Rite Brace: effects the

natural history Disadvantages: bilateral useage,

interference with activities of daily living Brace Use: over Six Years of Age and

with greater than 50% head involvement


Containment Orthosis: Prerequisites for Bracing: full ROM

especially in abduction; no residual hip irritability; round femoral head

Contraindication: noncompliance Time of Bracing: 6-12 months Does not alter the Natural History


Surgical Treatment: Advantage over Bracing: period of

restriction less than 2 months; no end point to determine discontinuation; permanent improvement in femoral head containment

Indications: bracing contraindicated; bilateral involvement at different stages; coverage not obtainable


Surgical Treatment: Containment obtained by altering

the acetabulum or femur Varus Derotational Osteotomy:

maximum coverage of femoral head; disadvantages include shortening, trendelenburg gair, nonunion, excessive varus angulation


Surgical Treatment: Innominate Osteotomy: anterolateral coverage

with improvement in gait and only mild lengthening of extremity; disadvantages include inability to obtain coverage and mild limb lengthening

Reconstructive Procedures: include valgus osteotomy, cheilectomy, chairi osteotomy, trochanteric advancement,or a combination of above


Clinical Results69% good results with no treatment71% good results with containment

orthosis87% good results with pelvic

osteotomy86% good results with femoral varus

osteotomy


Natural HistoryAge of Disease OnsetDegree of InvolvementPresence of Head at Risk SignAge of Patient at TreatmentStage of Disease at TreatmentCongrous Hip at Skeletal Maturity

The Hip in Myelodysplasia

Muscular ContracturesHip Subluxation and DislocationAcetabular DysplasiaStiff HipPelvic Obliquity


MUSCULAR CONTRACTUREFlexion Contracture More frequent in high lumbar-thoracic

level lesions Caused by hip flexors unopposed Spasticity of flexors Prolonged sitting or lying Surgery: greater than 2 yrs or greater

than 20deg. contracture


Surgical Treatment: Anterior Hip Release: release the

sartorius, rectus femoris, iliopsoas, tensor fascia lata, and anterior hip capsule

Extension Osteotomy: for persistant deformity or if hip flexor power needs to be maintained


Flexion-Abduction-External Rotation Contracture

Common in thoracic level lesions and complete paralysis of lower extremity

Usually Bilateral Caused by external rotation of hip in

supine position-contracture in posterior hip capsule and short external rotators

Surgery: interferes with sitting/brace


Surgical Treatment: Complete hip release: release the

iliopsoas tendon, sartorius, tensor fascia lata, gluteus medius and minimus, short external rotators, and the anterior and posterior capsule. If Bilateral releases at same time


Abduction Contracture Seen in T2-L2 High level lesions May cause scoliosis and pelvic

obliquity Caused by contracture of tensor

fascia latae and iliopsoas Surgery: Pelvic Obliquity, Scoliosis,

and Functional Impairment


Surgical Treatment: Tensor Fascia Latae Release Yount Procedure


Adduction Contracture Frequent in high level lesion Occurs with hip subluxations and

dislocations Caused by spasticity and

contracture of adductor Surgery: Pelvic Obliquity and

interference with sitting or walking


Surgical Treatment: Adductor Release Femoral/Pelvic Osteotomy


Hip Subluxation and Dislocation Congenital: seen in sacral lesion; treatment

similar to DDH Teratologic: no treatment initially; goal is

FUNCTION not reduction Paralytic: seen in 50-70% of low lumbar L3-

4 lesions, muscle imbalance of adductors and flexors, frequent before age of 3 yrs.


Surgical Treatment: Reduction of dislocation is controversial No Quadriceps then soft tissue release

only: community ambulators Strong Quadriceps then consider open

reduction, correction of muscle imbalance, release contractures, correct bony deformities(fem/pelvic)


Acetabular Dysplasia Chiari Pelvic Osteotomy Shelf Procedure Varus Derotational Osteotomy


The Stiff Hip Most Serious Problem: Stiff in

Extension..can’t sit; Stiff in Flexion..can’t stand; Stiff in between..can’t sit or stand

Treatment: Proximal Femoral Resection and Interpositional Arthroplasty


Pelvic Obliquity Infrapelvic: contracture of abductor and

tensor fascia latae of one hip and adductors of the opposite

Suprapelvic: uncompensated scoliosis due to bony deformity of lumbosacral spine

Pelvic: bony deformity of sacrum and sacroiliac


Surgical Treatment: Infrapelvic: prevention by splinting, ROM

exercises, positioning; fixed contracture-soft tissue release; severe deformity-proximal femoral osteotomy

Suprapelvic: control scoliosis by orthosis or fusion

Pelvic: Fixed Obliquity>20deg. Pelvic Osteotomy(Lindseth: Triple Transfer)

Transient Synovitis of the Hip

Most common cause of hip pain in childhood

Classic signs include: monoarticular hip pain, limp, restricted range of motion, and resolve over several days to weeks

Etiology: active or recent viral infection, trauma, or allergic hypersensitivity


Incidence: 0.4-0.9% of the annual pediatric hospital admissions; risk of a child having at least one episode is 3%; seasonal occurrence in autumn months; right and left equal occurrence; 2:1 male to female ratio

Clinical Presentation: average age of onset is 6 years, acute onset of unilateral hip pain, groin pain, or thigh pain


Clinical Presentation: associated limp and antalgic gait, refusal to bear weight, Leg held in flexed attitude and externally rotated with restricted range of motion, muscle spasm seen.

Laboratory Studies: nonspecific and normal

Radiographic Studies: negative but ultrasound is promising


Natural History: limited duration of symptoms with average duration of 10 days; no residual clinical or radiographic abnormalities; Recent literature reports a 1.5% incidence of the development of Legg-Calve-Perthes Disease(followup now important for at least one year)


Treatment: Bed rest and relief of weight bearing on the affected joint until pain resolves and motion returns; period of cessation of strenuous activity; observation and followup for the development of Perthes.

Common Pediatric Hip Disorders

THANK YOU

Dr. Donald W. Kucharzyk

Cerebral Palsy

CURRENT UPDATE

Septic Arthritis of the Hip

Developmental Dysplasia of the Hip

Slipped Capital Femoral Epiphysis

Cerebral Palsy

Cerebral Palsy is a term used to describe various clinical syndromes whose common feature is the abnormal control of motor function by the brain

Abnormal control results in a disorder of movement, posturing, and sometimes sensory functioning

Cerebral Palsy

ETIOLOGYCan occur in the prenatal, perinatal, and

postnatalPrenatal: maternal infection, maternal drug or

alcohol, or congenital malformation of the brain

Perinatal: trauma, placental complications, hypoxia, low birth weight, prematurity, and breech

Cerebral Palsy

ETIOLOGYPostnatal: head trauma, vascular

insults in the brain, central nervous system infections, kernicterus, hypoxia, and postnatal infections

Cerebral Palsy

PREVALENCE1 to 7 per 1000 children throughout

most the worldTwin pregnancies result in 12 times

higher incidence

Cerebral Palsy

CLASSIFICATIONNeuropathic type of motor

abnormality Anatomic region of involvement

Cerebral Palsy

NEUROPATHIC TYPESpastic: upper motor neuron syndrome,

velocity-dependent increase in tonic stretch reflexes(muscle tone) with exaggerated tendon reflexes, may see weakness,loss of muscle control,

interference with balance, joint contractures(pyramidal)

Cerebral Palsy

Athetoid: type of dyskinesia seen with purposeless writhing movements that are aggravated when the child is frightened or excited; dystonia can occur with atherosis(extrapyramidal)

Ataxia: uncommon, disturbance of coordinated movement, most notable when walking, intention tremors

Cerebral Palsy

ANATOMIC PATTERNSQuadriplegia: involvement of all four limbs,

mental retardation, drooling, dysarthria, dysphagia, seizures; cause is severe hypoxia; initial presentation floppy baby

Diplegia: both lower extremities are involved with upper involvement to some but lesser degree; caused by prematurity and perivent. hemorrhage

Cerebral Palsy

Hemiplegia: one side of the body is involved with upper being more involved than the lower; cause due to focal trauma, vascular or infectious lesion; seizure disorders seen,limb growth affected with the involved smaller

Double Hemiplegia: bilateral and symmetrical involvement with upper more than lower

Cerebral Palsy

DIAGNOSISHistory: not a genetic disease;

search for possible etiologies; assess benchmark developmental milestones especially sitting(6 mo.), crawling(8 mo.), cruising(9 mo.), and walking(12 mo.)

Cerebral Palsy

Physical Examination: to determine tha grades of muscle strength and selective control, to evaluate the muscle tone and determine type, to evaluate the degree of deformity or muscle contracture at each major joint, to assess linear, angular, and torsional deformation, and to appraise balance,equilibrium,and standing/walking posture

Cerebral Palsy

Common Types and Management

Cerebral Palsy

SPASTIC QUADRIPLEGIA

Cerebral Palsy

Only 20% of these children will walkGoals aimed at maintaining balanced,

comfortable sittingA Straight Spine and Level PelvisMobile Painless Hip that Flex and ExtMobile Knees that Flex and ExtPlantigrade FeetManagement of malnutrition and seizures

Cerebral Palsy

Hyperkyphosis: due to weak spinal extensor musculature and a resultant long C-shaped kyphosis posturing of the entire spine that’s flexible

Scoliosis: seen in 25% of the patients, it develops earlier and is more

progressive; less responsive to orthotic use and more likely to require surgery

Cerebral Palsy

Hip Disorders: limitation of motion, contractures,valgus inclination, subluxation and dislocation seen; causative factors include muscle imbalance, acetabular dysplasia, pelvic obliquity, femoral anteversion, increased hip valgus, and lack of weight bearing; common before the age of 6 and in children with limited abduction and flexion contractures

Cerebral Palsy

Hip Management: Best treatment early is the prevention of the dislocation-these lead to pain

Hip at Risk: often progress to subluxation and dislocation unless treated; Treatment consists of lenghtening the adductors and flexors, tenotomy or elongation of the psoas

Cerebral Palsy

Hip Subluxation: uncovering of more than one-third of the femoral head; the subluxated hip has increased valgus and anteversion; Treatment requires corrective proximal femoral osteotomy and if acetabular dysplasia exists then corrective pelvic osteotomy as well

Cerebral Palsy

Hip Dislocation: If seen within one year: open reduction, soft tissue releases,and proximal femoral osteotomy combined with acetabular procedures; If seen after one year: when the hip is painless-no treatment and if painful-proximal femoral resection and muscle interposition

Cerebral Palsy

SPASTIC DIPLEGIA

Cerebral Palsy

Most diplegic’s walk although delayed usually around 4 years of age

Motor improvement reaches a plateau by the age of 7, if not ambulatory by then, there is less likelihood of it

Severity of involvement of the lower extremity is important to walking

Seizure disorder,flaccidity,persistent primitive reflexes,or dislocated hip are deterrents to walking

Cerebral Palsy

Categories of ambulators: Community: walk indoors and

outdoors with use of braces or crutches Household: walk only indoors and with

apparatus, able to get in and out of chair or bed without assistance

Nonfunctional: walk in PT but otherwise are wheelchair bound

Cerebral Palsy

Children with spastic diplegia are less often afflicted with scoliosis, seizures, speech impairments and major problems in other systems as are quadriplegics

Treatment includes drugs,physical therapy,intramuscular injections, casting,orthotics,dorsal rhizotomy and musculoskeletal surgeries

Cerebral Palsy

Drugs: systemic muscle relaxants, antispasmodics, and neuroinhibitory medications have been tried without success: Intrathecal Baclofen has shown promise as it interfers with the release of excitatory transmitters and decreases lower extremity spasticity for up to 8 hours: acts on the spinal cord synaptic reflexes

Cerebral Palsy

Physical Therapy: improves joint contractures, motor status, and social motivation; maintain or improve joint range of motion, regain muscle strength, maximize ambulation, and improve function

Recent advances in the use of low-intensity transcutaneous electric stimulation on weaker antagonistic muscles at night shows promise

Cerebral Palsy

Intramuscular Injections: help weaken a muscle and thereby balance the forces across a joint, the most common muscle injected is the gastrocnemius-to reduce equinus

Botox functions to block the myoneural junction and the release of acetylcholine from the synaptic vesicles; effect seen in 12-72 hrs and lasts for 3-6 months

Cerebral Palsy

Botox may be repeated after 2 weeks and up to six injections given at the site of desired response; contraindicated in the presence of fixed joint contractures

Cerebral PalsyManipulation and Casting: can at times be

beneficial in the elongation of tight or contracted musculotendinous units or joint capsules; inhibition casting reduces normal muscular tone and when combined with PT and braces post casting, improvements are seen

Orthotics: prevent deformity, improve function by substituting for a weaker muscle, or to protect a weakened muscle

Cerebral Palsy

Orthotics: common types include UCBL inserts(maintain forefoot,hindfoot,and subtalar alignment); Solid AFO(spastic foot with mediolateral instabilty); Articulated AFO(prevent equinus and extensor thrust and allow free dorsiflexion); Floor Reaction AFO(prevents knee flexion crouch and gain stance phase knee extension during gait-eliminates use of KAFO)

Cerebral Palsy

Selective Posterior Rhizotomy: reduces spasticity by balancing muscle tone by the control exhibited by the anterior horn cells in the spinal cord; limit the stimulatory inputs from the muscle spindles in the lower limbs that arrive by the afferent fibers in the dorsal roots;

Cerebral Palsy

Best patient is the young child(age 3-8 yrs.) with spastic diplegia, voluntary motor control, no fixed contractures, good trunk control, the ability to walk with good strength and balance, pure spasticity; Not indicated for athetosis, ataxia, rigidity, dystonia, hypotonia, and fixed contractures and hemiplegia

Results: lasting reduction in spasticity, increased hip,knee,ankle ROM and gait

Cerebral Palsy

Surgical Intervention: Best results obtained if all the abnormalities are identified and corrected at the same surgery; Best timing is after the child is at least cruising or ambulating, after age 4-5 yrs but before age 8; Overall, the goal is aimed at restoration of joint motion, muscle strength, and improved gait

Cerebral Palsy

Ankle Equinus gastrocnemius overactivity Achilles Tendon Lengthening Foot and Ankle Equinovarus equinus due to gastrocnemius hindfoot varus due to overactive tibialis

posterior forefoot supination and varus due to

overactive tibialis anterior

Cerebral Palsy

Forefoot and Ankle Equinovarus Treatment of hindfoot equinovarus is by

split tibialis posterior transfer Treatment of forefoot varus and supination

is by split tibialis anterior transfer Treatment of nonfixed varus of the

hindfoot occurs with forefoot supination is by adding tibialis posterior lengthening

Cerebral Palsy

Foot and Ankle Equinovalgus Most common situation seen in

diplegia Muscle imbalance of triceps and weak

tibialis posterior with overpull of peroneal

Ankle Valgus is commonly seen due to this combincation

Cerebral Palsy

Foot and Ankle Equinovalgus Treatment of ankle valgus is via AFO

or UCBL inserts if mild and supple Treatment of ankle valgus that is

more severe will require subtalar fusion: indications are failure of orthotic use and lateral subtalar subluxations

Cerebral Palsy

Foot and Ankle Equinovalgus Severe ankle valgus may require

subtalar arthrodesis, medial displacement osteotomy of the calcaneus,opening wedge osteotomy lenghtening osteotomy of the distal calcaneus, or triple arthrodesis; Must achieve muscle balance despite the type of procedure to be performed

Cerebral Palsy

External Tibial Tiorsion shortens lever arm effect of the foot

to generate plantar-flexion-knee-extension couple, stance is shortened and pushoff power compromised

Treatment is derotational osteotomy of the tibia and fibula

Cerebral Palsy

Knee Flexion Deformity associated with hip flexion contracture and

crouched gait, caused by spastic and tight hamstrings; in addition, occassionally the rectus femoris will be spastic resulting in stiff-knee gait post hamstring lenghtening-transfer will be required

Cerebral Palsy

Knee Flexion Deformity Hip extensor power is lessened by

hamstring release Pre-existing hip flexion contracture

and lumbar lordosis can become increased due to iliopsoas and this needs to be addressed

Cerebral Palsy

Hip Adduction Contracture results in scissoring gait and

predisposes the child to subluxation and dislocation of the hip

functions to stabilize during gait and provide more effective hip flexor and extensor activity

Do Not Overlengthen or Overweaken

Cerebral Palsy

In-Toeing result of excessive femoral anteversion may be due to increased spasticity in

the internal rotators of the hips, medial hamstrings, tensor fascia latae, and gluteus medius

Treatment is derotational femoral osteotomy

Cerebral Palsy

SPASTIC HEMIPLEGIA

Cerebral Palsy

Involvement of one side of the body with the arm or hand more severely involved than the lower extremity

Comprises about 30% of all the casesHistory of Head Trauma or Intracranial

hemorrhage is frequent causeAll are Community Ambulators

Cerebral Palsy

Classic Presentation: equinovarus of the foot and ankle, flexion at the knee and hip, internal rotation of the lower limb, internal rotation of the shoulder, flexion of the elbow, pronation of the forearm, flexion and ulnar deviation at the wrist, and thumb-in-palm deformity

Cerebral PalsyTreatment: Type 1 Hemiplegia Foot drop gait with steppage due to

weakness anterior tibialis-AFO Type 2 Hemiplegia Equinovarus is treated with Achilles tendon

lenghtening and split tibialis posterior transfer(if active during stance) and split tibialis anterior transfer(if active during swing)

Cerebral Palsy

Treatment Type 3 Stiff-Knee gait with equinovarus is treated

with hamstring releases and tendon lenghtening and transfers

Type 4 Hip Flexor and Adductor Spasticity is treated via iliopsoas release and hamstring releases

Cerebral Palsy

ATHETOID CEREBRAL PALSY

Cerebral Palsy

Dyskinesia(abnormal muscle tension and tone)

Limb movements are involuntary and almost continously changing

Muscle tension changes with emotional changes

Gait is random, inconsistent and influenced by external stimuli

No Basis for Surgical Intervention

Cerebral Palsy

THANK YOU

Current Concepts on Pediatric Hip Disorders Dr. Donald W. Kucharzyk Pediatric Orthopaedic Surgeon...

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Transcript of Current Concepts on Pediatric Hip Disorders Dr. Donald W. Kucharzyk Pediatric Orthopaedic Surgeon...