Pediatricians see numerous leg and foot discrepancies, ranging from simple in utero “packaging” problems to red flags for serious disorders, such as cerebral palsy. Pediatric orthopedic surgeon Sanjeev Sabharwal, MD, MPH, offers his systematic approach to sorting them out, providing physical exam tips and metrics for assessing specific conditions, and clarifying whether treatment – from stretches to surgery – is needed and when referral to a specialist makes sense.
So as you know, the topic here is lower limb deformities for the primary care provider. And I put deformities in codes only because honestly they're not, Most of what we're going to talk about today aren't really deformities, it's what's part of developmental orthopedics. And uh and I think the prime purpose here is to differentiate between you know, what's normal or physiologic and what's not. And so for the most part we're going to stick to the lower extremities and we're going to divide it into sort of three parts within the lower extremity. You no one is in doing outdoing the risk flat feet. And then finally, you know, bow legs and knock knees. I'll show a few cases. Uh we can go over what the initial sort of history and physical exam should be in terms of sorting out, you know, physiologic versus pathologic. Um and then obviously like Maria's leave enough time for questions. So again, causes of limb deformities in general, I mean this is no different than most other, you know, disease entities if you will that you that you encounter in your clinical practice to see what's physiologic and within pathologic you could sort of sub categorize it is this congenital something the child was born with is a developmental in the sense that is this something that sort of happened in the growing years? Was it related to an injury or a fracture infection, metabolic such as rickets etcetera, neuro muscular such as cerebral palsy skeletal dysplasia, areas such as achondroplasia. And certainty us um which can cause, you know get deviations within towing, outgoing and politics and martinis. So these are the common, you know, complaints or concerns that uh you know come up either by parent caretaker or a grandparent let you know my child walks funny, he or she is pigeon toed. Uh well I got cured when I wore races in my legs. So how come you're not prescribing racist for my child? And uh you know, and this sort of is the undertone. If they don't quite verbalize it, it's always like anti just can do something because you know, I'm just gonna watch this happen. Uh And so I think we have to reflect back and obviously, you know, educate the families after we evaluate and make sure that it is physiologic. If it's not physiologic, then it's a different pathway. And we're certainly going to talk a bit about that. But for the most part I think um it's about having a systematic approach to these patients. Um and then sort of reaffirm what they're seeing is what you're seeing, acknowledged that and then educate in terms of what the natural history is, which for the most part is going to be pretty benign. So let's start with in toying, right? So in doing again, we're going to say this multiple times, You know, physiologic or pathologic. So the typical screening history and physical exam questions we're going to go into. Um and I think here the biggest part is what's called a rotational profile because the intoning could be coming from many different places, right? It could be a central thing, let's say cerebral palsy. Uh It could be something coming from the thigh segment of the femur, like federal anti version, which is a twist in the femur. It could be that that tibia is turned in or tibial torgyan, or it could be from the foot, like a merit tarsus doctors versus a club foot. And then again, it could be a pathologic issue. Um like we said, you know, hemiplegic, spastic hemiplegic could be a hip dysplasia. Um And you know, then the question comes up. Well, when do we order an X ray? And if we do an X ray witch X ray, So let's get into it. So in terms of history, it's the standard stuff in terms of when did you notice this? Is it getting better or worse? Is there pain? Is the functional limitation? What are their sitting habits like when you look at in tours, you can see the picture on the top is a classic tibial torgyan child. A child would be built origin in the sense that they will sit with their feet kind of tucked in underneath their barracks. Whereas if it's a child with excessive federal anti version, they'll sit in that so called w position and it's usually an older child in their preadolescent adolescent age group. Um So you could ask about the sitting habits, You could ask about shoe wear issues, especially if there's in doing and you know that the tripping falling, are they having troubles at shoot where colossus these are, there is the family having trouble getting shoes. Um, is the concern more the natural history of what's going to happen in the future? Or is it how the child looks or rocks right now and then always ask about prior history, A lot of these Children have seen a podiatrist or an orthodontist and are sort of coming to you for a second or third opinion. Um, What about birth history? Because I said once in a while you can have a child who has mild triple policy like a spastic hemiplegic. So always ask about, you know, the milestones, When did the child start walking? What was the birth history? What was the birth weight, things like that? And then finally family history more to sort of understand where is the family coming from? What are their expectations? Like we said earlier, if they've had other siblings or parents or aunts or uncles who have had similar cordon court issues with their legs and have been treated with a certain kind of brace, then they have a certain expectation and you've got to sort of address that so they don't leave uh sort of not satisfied with your explanation. I think this is an important slide because firstly, it's important to look at the child, examined them in shorts or a gown that's pulled up. And I think this picture on the left is really important because if you look at a right, you see that the feet are turned in. But then you look at the knees, the knees are pointing forward. So this child most likely has to be a torch in or there's an internal twist to the tibia, right? But then how does this child typically walk? You know, most of us like to walk with their feet sort of pointing straight as opposed to turn in or turned out. So look at figure be here when their feet a pointing straight, their knees kind of turnout. And so it gives you the appearance of bow legged witness. So a lot of times when you see a child where the parental concern is bow legs, it may actually just be internally built origin that's been somewhat, you know, overshadowed by the adaptive behavior or the adaptive alignment of the legs when the child is walking. So that's important. Then if you look at figure, see here you can see not only the feet turned in, but the kneecaps are sort of pointing towards each other, what's called the squinting patella. Um And so here you can probably make out that the twist is above the knee so that's more likely to be ephemeral anti version but you're not going to stop there, you're gonna still do a more sort of systematic exam. Okay so this is another way you can look at, you know remember how we talked about tibial torsion which can look like both legs. So this is a cover test or a cover up test. So all you do is and you can demonstrate to the family, you just keep the knee pointing straight up. The child sort of laying down, you know looking at the ceiling or on a mom's lap or dad's lab and you just hide the foot and say we'll see that. Now the knee is not bowl, he's not he or she is not bowlegged. So that's another sort of live demo of you know when they think the child is bootleg but it's actually internal tibial torsion. Um Then I think it's good to sort of do this to national profile. So you if the child is a walking a child and you know have the child walk and document the foot progression angle. Now I don't expect you know every primary care provider to sort of do this every time. But at least you know you have the concept and this is what we do when we see a child like this in the office. So you know just I'm going to share with you how we evaluate a child like this. So you see the child walk uh and you do this foot progression angle meaning what is the angle in your mind's eye between an imaginary straight line and the way the foot turns in or out. So I would probably document this as you know, External foot progression angle of 30° on the left and 20° on the right. Um This I have a picture with the child line proven and this is how we examine it because that stabilizes the pelvis and you have a more accurate uh assessment of hip rotation. But the problem is that Children have been so um you know, prying into thinking if they're sort of phased down, they're going to get a shot or something. So I leave that for the last, but since we're sort of going through it or some profile, we're going to talk about it. So the child's laying flat face down and then you turn the legs out and when the legs lower legs are turned out, that's actually internal rotation of the hips. And so you document that in relationship to a vertical straight line. So in this case I would say probably a 60° or a 50° internal rotation of the hips bilaterally external rotation as you move the legs the other way you cross them. And so here I would say it's about a 15, 20 degree external rotation at the hips. And you know it does two things. One obviously it's good to document this. So you know where the turning in or turning out is coming from. And secondly it helps you in terms of a sequential exam when you see the child back, if you do need to see them back. And thirdly I think it validates the concern that the parents have brought brought forth. And you know, it's not like you're blowing the concern off and you're actually documenting things. So I think they do sort of like that and it doesn't really take that long. Uh So so going down the leg, then you can also assess a thigh foot angle, which is an imaginary line through the mid portion of the back of the thigh, and through the back of the foot, which is the hell by sector. So here you can see In sort of picture be, I would document that as a 5-foot angle on the left of external 20°, not typhon angle helps determine tibial rotation, whereas hip, internal external rotation in the past lied was for, you know, the femur. So let's say the child had excessive federal anti version, you would have excessive internal compared to external rotation at the hips. And if a child had tibial torsion, internal tibial torsion. Unlike the picture here, their foot would be turned in quite a bit. Uh And then again the internal entering. So from the foot itself, and there are two sort of common diagnosis. One is metatarsals abductors which typically can be just observed. And the other is a club foot, which typically does need treatment with starting with serial manipulation and casting. So I think it is important to know how to differentiate the two. But in terms of documenting you do this, he'll by sector, which is again, you draw, you bisect the hell either with a and sale or a ruler or just in your head or a finger at really. And and typically the hell by sector goes through the second toe or the second web space. And here again, you can quantify it by saying, you know the hell by sector, let's say in this picture on the on the cartoon on the left, the far right is a is a severe metatarsals the doctors. Because the hell by sector goes through the 4th web space. On the 5th web space home Actually the 4th web space. So this doesn't quite differentiate between meritocracy is a doctors without a club foot and with a club foot. But it does quantify that some of the entering is coming from the foot. Um And then again, you know, there are some normative values that are out there. And that picture on the top left tells you how you can document that. Um in terms of rotational profile. And nowadays, you know with the EMR and Epic et cetera, we've got these smart sets so we just plug in the numbers as we examine the child. Uh once again typical torch in. Um It's it's a benign problem. It's a physiologic problem for the most part. And again you can see pictorially that the knees pointing straight in the uh center picture and the foot's turned in. Um And you know, if the child really isn't going to cooperate with the pro exam, you can also have the child sit on the parent's lap and with the knee pointing straight. You could pretty much examine them like that and look at the foot. And then you can also look at the foot from the bottom to sort of look at the hell by sector and you'll get a pretty good estimate of what the problem is. And the slide also demonstrate that there's really not much of a difference between treatment with or without a brace. Um And these are, you know, this is sort of a cumulative slide based on multiple studies. Federal anti version like I said, is more in the older child, a preadolescent uh more common in females. Uh And here again, you can see that the knee caps are turned in towards each other as a defeat. And in a prone exam you can see excessive ephemeral uh internal rotation at the hips compared to external rotation. And once again, just like with tibial torgyan, there are studies out there which demonstrates that there is no role for, you know, special braces, twister, cables, night splints, etcetera. And I think this is sort of the media of the conversation that we all seem to have. The families is to sort of, you know, bust the myth about, you know, that they need a breeze to fix this. Then there are these variations, one of which is called a miserable male alignment, where you've got excessive federal anti virgin, meaning that the femurs turned in on top of which you've got external tibial torgyan. And these sometimes can be a problem, like, and these again are more common in adolescent girls and they can have, you know, knee pain, patella femoral pain and sometimes even patellar instability. While bracing does not help. Occasionally we will need to treat these surgically. This is like very occasionally of course we could try physical therapy for you know, patella femoral symptoms. But if that doesn't help then sometimes you've got to do D rotation osteo autumn ease to sort of improve the biomechanics of the leg. Um Coming back to the foot, You know, metatarsals. The doctors again you can document, you can take a picture in the old days, we would take a photo copier and have the kids sort of stay in on the photocopier. I don't think we do that anymore. Um But this is how you differentiate between a club foot which this child has and the merit tarsus of doctors with the previous get had. And they're like if there was one physical finding that differentiates to do it is LTD dorsal flexion or a quietness in a child with club feet. So once again, a child with metatarsals, the doctors will not will have normal ankle dorsal flexion, where as a child with a club foot will have limited ankle dorsal flexion. Or you cannot even get the foot past neutral. Um And occasionally you can also see that medial crease, which that blue error is pointing to, which is again consistent with a club foot. Um What are sort of the pathologic causes? Um Those include, you know, like we said, uh um things like cerebral palsy and they can both have entering and outdoing typically hemiplegic, which is one sided weakness. Uh The foot will be turned in and again, you'll see that they're posturing with their upper extremity as well. They'll have a birth history that's uh you know, concerning for prematurity delayed milestones and sometimes you'll have die apologetics where the feet are actually turned out. Again, you can miss hip dysplasia and that's why it's important to do an entire exam, including limited hip abduction, which is typically seen in infants and toddlers that have hip dysplasia, especially if the hip is totally dislocated, then going on to outgoing. You know, sort of a similar screen screening with a history and physical exam. I'm not going to go over the exam again, because it's the same thing, you get a rotational profile and then think about the differential, which here would be again, your muscular disorders like spastic quadriplegia slipped up if Asus and flat feet. Um I think outgoing has sort of a by model distribution. Either the child will be brought in as an infant with the feet turning out or it would be sort of in the adolescent age group where again the differential is a slip hypothesis or flat feet. So this is sort of the classic abduction, external rotation contractors of the hip. So the child maybe, you know, a few months old, not even standing yet barely pulling up to stand and someone notices that the feet are turned out, You do the same exam and on the top you could see an attempt at internal rotation at the bottom, excessive external rotation. And this is what we call, you know, code and code a packaging issue. So, you know, being in Euro for nine months, they're sort of crumpled in there. And what it does is it causes contractors of the hip hop doctors and external rotator and typically these improvement time. But what I will tell a lot of families is that you can do some stretching exercises with every diaper change where you twist the legs in like turn the knees in towards each other and then Eddie duct and meaning cross the legs and do it with every diaper change, You know, 10 times with every diaper change. Cal kenya valdas foot is another one of those packaging things which improves the time and you could, you know, again do some stretching exercises to have them stretch the foot to come down as in plant reflection. Oh, flat feet. So flat feet is another one of those things where either the child is brought in just with a foot problem or you discover it as a cause of outgoing and a lot of times these kids with flat feet also have knocked knees and the two kind of compound each other. Um it's important to recognize that, you know, normally the arch of the foot develops over time. So you can see, you know, toddler, pretty much the footprint is pretty flat and as they get older, you know, the developed an arch and then again, you know, sort of in the late middle age and elderly you sort of lose your arch a bit. So I think it's important to sort of understand that. Uh and once again, you know, flexible, which is what I think you and I mostly see versus pathologic. So let's get into how to sort these out. So, you know, flatfoot is a sort of a sign of of sort of progress and prosperity, both sort of genetically as well as, you know, as a society. And as I think the population is getting more overweight. There's no question that overweight individuals, including kids, have more foot pain and flat feet. Uh and of course it's also related to shoot, where in societies where shoe wear is not a given. Um There's less in the prevalence of flat footedness compared to more affluent societies with shoes. Um And of course, you know, ligament, this laxity also predisposes to flat feet, most of which are not symptomatic. So you know when you're examining these child, I think it's a busy slide, but it's just to remind us that look for generalized ligament laxity. I think most of us are familiar with this burden score, which is you know, hyper extension of the elbows. Um You know if it goes past 10 degrees, each side is one. So both sides is to, you know, you see if their fifth digit or the pinky can hyper extend past 90 degrees same way if the thumb can touch the front of the forearm, if their knees hyper extend when they're standing and if they can touch the floor with their knees extended and palms touching the floor. So so that just gives you another quantifiable measure off their ligament. This laxity. I think a lot of us when we look at flat feet we think they're just flexible, but it's important to look for a tight achilles tendon or the gastric solely is complex. And so your picture in the bottom here, to the left and the centre kind of demonstrate that this is the Silver School test, which is you you know, gas truck soldiers are are two muscles right. The gas truck name is which crosses both the knee and the ankle and the soldiers which only crosses the ankle. So you do this test to sort of look and typically it's the gastronomy is that's going to be tight. So here we're trying to Dorsey flex the ankle with the knee extended and you'll typically get less ankle dorsal flexion and then you sort of do the same thing with the knee flexed so that you relax the gas Rodney mias. And then you see if there's more dorsal flexion and if it turns out that both with flexion and extension, you still cannot get foot uh past neutral or let's say five degrees or so, then, you know, you've got a tight gas trucks police complex. And these Children, you know, they have a tendency to be flat footed because their achilles is tight and they need to get their foot on the ground. So here, I think rather than just observation, you could certainly recommend heel cord stretching, physical therapy, etcetera. So I think those are important things um just to go back, also examined their shoes, you know, because that tells you the story a little bit about how are these kids walking and examine sub taylor motion as well. Uh, once again, you know, just like with rotational issues, flat feet, the natural history is not changed by using different inserts, etcetera. Now granted if somebody is symptomatic and has a colossal T and it's still a flexible flatfoot, Yes, you can give them some kind of an art support or tell them to buy sneakers with an inbuilt arch. Uh but you really don't need special customized orthotics for the majority of Children who have flexible flat feet. On the other hand, if you have a painful flatfoot, you've ruled out tight gas trucks, coleus complex or an achilles tendon. Um Then you know it and they are painful. Then I think it's good to get x rays. Um you probably order them as standing x rays three views. Um and we didn't really talk about this physical exam, which is you you want to assess whether this foot is the flatfoot is flexible or not. So you have the kid stand on their tiptoes and you look at the heel. So here normally the hell would kind of inward a bit, meaning that the hell would turn in towards the midline. And on this picture on the right, you can see when the child is sort of going up on their toes, their left foot, the heel is starting to sort of turn in a bit, it's in line with the calf, but on their right side, the hell is still out. So that tells you that this is this patient doesn't have normal sub dealer or hind foot motion. And so a child like this with asymmetric circular motion and painful flatfoot, I would get an extra ray and I think this kid had a parcel coalition which is an abnormal bony connection between two bones of the foot. Um And so that's that's that's a good test to sort of screen. I think you're all familiar with you know, outdoing in a typically heavier adolescent. Um could be a slip up if Asus and you know this is the classic which is obligate external rotation of the leg as you try to flex the hip. You could certainly also do the prone exam and you'll find that on the affected side if it's not bilateral there is excessive external rotation and limited internal rotation on the side with a slip capital from Aleppo emphasis mm. You know for these is not a very common problem but you know just put it in there because it is an orthopedic thing and you know it is common in more common in boys. Unlike slept with emphasis. These kids are like very active there typically thin built and you know, they'll have limited internal rotation at the hips and then once again, you know, always examine their spine. You know, sometimes a kid may have entering like this kid had um And it turned out that they had a tethered cord or a mile, a very mild sort of uh uh like coma of the of the lower end of the spinal cord. Um And again you've talked about hip dysplasia and skeptical emphasis okay switching gears to bow legs and knock knees. Um I think we all know this natural progression but I'll just reiterate it when a child is born there bowlegged and they're maximally bowlegged at birth Over the next 18 months to two years, their knees get straight and then they sort of go in the other direction where you know, they get not need, Which typically is sort of at its max between ages three and 4, and then by 87 it sort of plateaus to what is going to be, there, sort of adult alignment of the knees, which in most of us is like physiologic Valdez or physiologic mild knock knees. Um you know, if you wanted to quantify that, you certainly can, and there are some normal values. Um you can look at what's called the inter candler distance and also the inter molecular distance. You know, you look at the inter candler distance if you're concerned about both legs or gina vera, and you look at the inter molecular distance, if it's not knees, right? And again, like we said, when Children are born there maximally bowlegged. So you can see on that little graph for two standard deviations of normal values, the inter consular distance at birth Can be up to six cm. And then as a kid grows, they become knock kneed. Another number to sort of look at is the inter molecular distance at age seven years And kind of the cut off is 8cm. Now you'll do this exam typically with the child just laying flat on their back, um and with their hips and knees straight. Um And you know, it is not the most accurate measurement, but I think it is, it is one way to do it. You can also just look at the width of your hand, you know, with a ruler and then you can sort of look at it that way too, and then get estimate, you know what the distance is. Uh And certainly, you know, we will sometimes use ago nanometer and look at the tibia ephemeral angle, which honestly, I don't think most BCPs need to do that. Um And this is primarily to just say that, you know, things happen in multiple planes just because you've got this child has laid answered Blount's disease, which is a problem of the growth plate of the upper end of the tibia. But so and it's common in obese kids. Um So here you can see the child has various, there's also broker boredom or apex and deregulation and a little bit of internal tibial torch in. So this is a pathologic cause for gina, Barone. So when do you get an X ray for you know someone who presents with both legs? So for us, I think if it's severe deformities, if it's a symmetric, if the child has extremely short stature, either you're thinking of skeletal dysplasia or something or if they've got other dysmorphic features in the rest of their body, including the spine, the face, etcetera, you get it. But for the most part, I think if you've got any of these concerns, it's probably best to just refer them to a pediatric orthopedist and then, you know, we can look at the X rays or order x rays ourselves just a little, I think minimize the radiation exposure. These are the X rays we get. These are standing full length X rays with the kneecap pointing straight. Sometimes we do it with a ruler to also look for leg length and then, you know, there's a whole bunch of sort of angles and distances that we measure off these X rays and I'm not going to go into all those. But you know, we have personally done a bunch of studies to establish normative values of these various sort of radiographic parameters to sort out what's normal for certain age groups And just like that earlier graph I showed sure enough when you look at these Children, normally there is that same kind of distribution with the start off in various and then the plateau into valdas around age seven or so. So you know sometimes we do need to use those measurements. So this child is someone I saw probably a year and a half ago for the first time. And yeah, so he was 18 months old. So by now there should have been, you know, the legs should have been straight but he was pretty bowlegged, not just a built or shin. So we got an X ray and you measured all these angles. But I think the gist of it is that this did not seem pathologic and most of the various was coming from the femur and the tibia and just as an over generalization when the various is coming from the femurs and on the tibia in a young infant or toddler, usually it's physiologic and that improves the time and that's what happens six months later, you can see it resolved and the numbers got pretty pretty normal. So you know, some kids just are a little behind the normal progression of various to Valdez this on the other hand, is a child who had asymmetric Varis and it's subtle but he has what's called early onset Blount's disease. And in this child we needed to do what's called guided growth with an art program just to sort of guide the growth so that the medial site can go a little faster than the lateral side. And this is a temporary you can sort of think of it as an internal splint if you will where we are guiding growth by putting hardware extra curiosity lee across the affected growth plate. Um and so we intentionally try to overcorrect the various into a little values because once we take the plate out it will typically rebound into its normal value. And so we still have to follow this child along to see whether it Rikers further or not. But this is a much simpler uh procedure with, you know, limited post op restrictions. So it's the same day procedure, the child can go home the same day and there are no weight bearing restrictions as opposed to doing osteo autumn ease and lengthening and frames etcetera etcetera. So, you know, for the right patient guided growth is a much simpler option, even if they may need a second or a third procedure down the road. So I'm going to finish with two other cases just to sort of show you sort of what else we see. Um And how we treat them surgically. Um This again is a child whose sixties, she's essentially an adult 16 years old with no one hypothesis. Fatima crickets who came in from another institution previously treated with guided growth that didn't actually work that well. And she's got a right leg that's excessively bowed the leftist too. But main concern was the right leg which had various it was short and the deformity was again you know based on all these measurements et cetera. Um And looking at the side view it was a multi plane or deformity multi a pickle deformity in the femur. And the tibia was in various broker Bardem and was short. So you know we did uh like a poor catania's to level osteo to me with the intermediary nail. And then for the tibia we needed some length and realignment. So we did that gradually with an external fixate. Er And so here she was sort of early on with the leg. That street. She was very pleased. We actually just recently took the fix it later off and we're gonna do a smaller procedure on the left side in a couple of months. And finally this is sort of the other end of that extreme where you know this is a congenital shortening of the femur. But they also have Valdez at the knee and the ankle. And I'm really showing you this to sort of demonstrate how we work as a team. So my sports partner dr Pandya actually did uh so these patients have SCL deficiency as well. So he did the A. C. L. Reconstruction and I did guided growth just to get the legs straight because if you look at the mechanical access from the center of the hip to the center of the ankle. Normally it should go in the center of the knee. This one was you know a little bit on the outside meaning that he was not need. So we want to sort of set the stage before we lengthen the femur. Um and you know he had a 78cm Legoland difference which was which would certainly get worse uh with growth. Um so once his leg was straight his knee was stable. We went back and then did this sort of magnetic lengthening with an intermediary nail. Where instead of using an external fixate er we cut the bone we put a magnetic rod inside and then the patient just sort of has a magnet that they put on the outside of the leg. And then the nail sort of lengthens. If you look here you know, this is a solid portion of the nail. This is a cylindrical portion of the nail and you know, with one millimeter a day we can achieve a fair amount of length. He's still a little short because you don't want it like just lengthen the born and forget about the soft tissues. And I think closer to skeletal maturity, you will most likely need a second lengthening. So I think in summary um lower limb deformities and quotation is you need a systematic approach. You know, sort out what's physiologic, what's pathologic uh and really you don't need any fancy test. Just goes back to organized well documented history and physical exam. You know, if there's ever a question, even if you know its internal tibial torch in and nothing needs to be done. I think some families do want that. Gordon? Got second opinion. So we're happy to see them. And then you know, imaging is something for the most part I think will take care of unless that someone like you think this patient may have a slip capital family pith Asus I think then you know getting an ap pelvis and a frog lateral would be helpful. And you know these are some you know website info um including you know um I did a little thing for the british medical journal which has stuff on entering outdoing etcetera. And then just a plug for Lindland thing and reconstruction center which is a multidisciplinary clinic where we take care of all sorts of uh lower limb issues uh including Legoland difference and all types of deformities. Um The team approach this is our group of pediatric orthopedists um of these uh nine or fellowship trained pediatric orthopedic surgeons. We've got a few primary care uh fellowship trained sports medicine providers. And then um we've got here Dr Metz, who's uh who does adult and pediatric spina from the but then we have other other providers in this group. Pediatric orthopedic surgeons who also do spine and hair. And Dr Zimmel here does our oncology. You know, this is how you can certainly have your patients um uh you know, get an appointment with us. Um As I said, you could also reach out to me or one of my partners as needed.