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An Introductory Surgical Anatomy Case Series: Paediatric Orthopaedic Surgery Abdrahman Yu and Tiam Sahraie University of Edinburgh SSC5 Orthopaedics ProjectLearning Outcomes • Enhance Understanding ofPaediatric Orthopaedic Anatomy • Identify ImportantSurgical Landmarks of the Upper Limb and Lower Limb in Children • Discuss Paediatric specific Fracture and Injuries • Recall Fracture Demographics and Mechanisms of Injury • Revision of important UKMLA Orthopaedic Presentations • Provide an Introduction to real surgical procedures through images • Inspire FutureOrthopaedic Surgeons!Edinburgh Curriculum for Paediatric OrthopaedicsThe Origin of Orthopaedics ‘Ortho’ = straight, correct; ‘pedic’ = childWhat’s different from adults? Healing PotentialWhat’s different from adults? Growth ArrestsWhat’s the Difference from adults? Ossification and FusionDevelopmental Dysplasia of the Hip • 1 or 2 per 100 infants • Female • 1 dislocations per 1000 infants • First Born • Left Hip is more common • Family History • Congenital associations that • Flipped (Breech) Presentation occur with tighter intrauterine • Oligohydramnios space (e.g. metatarsus adductus)Clinical FeaturesAssessment Newborn Examination ScreeningAssessmentScreening GuidelinesInvestigationsInvestigationsManagement Conservative: Surgical • Pavlik Harness • Open reduction + spica casting • > 18 months or failure of closed • < 6 months approach • Closed reduction via SpicaCasting • 6 - 18months • Open reduction and femoral • Or Failed pavlik harness/ osteotomy bracing • > 2 years < 4 • Open reduction and pelvic osteotomy • > 4 years of ageConservativeSurgical Open reduction +/- CapsulectomySurgical Open reduction and femoral osteotomySurgical Open reduction and pelvic osteotomyCase 1 Varus Derotational Osteotomy (Lateral approach)Landmark Identification What are we cutting through Incision after the subcutaneous layer?DissectionGuidewire PlacementBlade MeasurementShizzle + K-wire PlacementFirst OsteotomySecond OsteotomyBlade InsertionDerotationWhat kind of wedge was used? Original PostWhat muscle are we closing?Case 2 - Introduction • What is a Supracondylar Fracture (SCF)? Fracture of the distal humerus, above the humeral condyles • Common in children around the age of 8due to falls on an outstretched hand (FOOSH) with elbow extended th • Relevance: Most common paediatric elbow fracture,1/5 of all paediatric fractures1 • Requires accurate diagnosis and timely management to prevent complications management, and outcomes. MusculoskeletSurg. 2020Jul;104(2):153-162. doi: 10.1016/j.mpsur.2020.06.015.y,Mechanism of Injury • FOOSH(Fallon Outstretched Hand): Leads to hyperextension of the elbow • May result in a direct blow or fall with the arm in an extended position • Other Causes: High-energy trauma (e.g.,motor vehicle accidents) • Sports injuriesAnatomy Recap and Fracture Site Key Structures: Humeral condyles, olecranon fossa, physis Neurovascular structures at risk Fracture Location: Typically occurs just above the condyles, close to the elbow physis Credit: Teachmeanatomy Anatomy Recap and Fracture Site • Median Nerve • Close to the medial side of the distal humerus • Type II (displaced fractures with angulation) and Type III (severely fractures) fracturesed • Radial Nerve • groovecture extends into the radial • involving significant displacementse or rotation. • UlnarNerve • Less frequently injured • Affected ifthe fracture involves the medial aspect of the elbow joint Credit: TeachmeanatomyAnatomy Recap and Fracture Site SCF Classification • Gartland Classification • Type I: Non/minimally displaced • Type II: Displaced, intact posterior cortex • Type III: Completely displaced,unstable Credit: Radiopedia SCF Classification • Importance – can alter treatment approach and prognosis • Type I: Conservative management often appropriate • Type II/III: Surgical Intervention likelyClinical Presentation • History: Common after a fall on an outstretched hand • Signs and Symptoms: Pain, swelling, limited range of motion, any obvious visible deformity (especially in displaced fractures) • Neurovascular compromise: Check radial pulse, cap.refill, sensation,and motor functionDiagnosis X-ray: AP and lateral views: Key to diagnosis. Displaced Anterior Humeral Line. Fat pad sign: Indicator of joint effusion. Further Imaging: CT/MRI for complex cases or unclear fractures. Neurovascular Examination: Ensure brachial pulse, capillary refill, sensation, and motor function. Type I (Non-Displaced): Management • Splinting or long arm casting. • Follow-up to ensure correct healing. Type II & III (Displaced): • Closed reduction (if possible). • Surgicalfixation (K-wires or open reduction) if closed reduction fails. Rehabilitation: • Post-cast or post-surgical rehabilitation to restorefunction.Complications • Neurovascular Injury: • Risk to brachial artery and median nerve. • Can lead to ischemia or motor/sensory deficits. • Cubitus Varus (Gunstock Deformity): • Cosmetic deformity due to malunion. • Growth Disturbances: • Limb length discrepancies or angular deformities. • Compartment SyndromeCase #2 • 7 year old boy • Fell onto outstretched arm onto patio whilst chasing brother. • Inconsolable – parentstook to A&E. • Examination: Difficult examination, neurovascularly intact • Investigations: 2 xX-rays • What classification of SCF is this?Case #2 – Gartland III • Proceed to reduction and K-wire placement • Reduction achieved with axial tractionResults in improved reductionProceedto elbow flexion & pronationJones ViewThe Surgeon turns to you…. • Asks what nerve are they cautious of here?SCF Key Takeaways • Common Presentation in paediatric populations • Earlydiagnosis and accurate classification are vital. • Neurovascular assessment is essential to avoid missed injuries. • Surgical interventionis often required for displaced fractures. • Postoperative care and rehabilitation are key to restoring function. • Always follow-up for potential complications like deformity or stiffness. Operations Video Credit: https://www.youtube.com/watch?v=w7tMHXPDEcI(SCF) https://www.youtube.com/watch?v=TeX6zFnyuEc&ab_channel=Caseclips(DDH)