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Ok. Hi guys. Er, welcome to our fifth session um on pediatric fractures and conditions. Um, so my name is Panji, I'm the president of the Orthopedic Society. Uh, and you joining us today is David, who's er, the lead, the lead of this, um, this teaching series. So today we're gonna go through three SBA S um three SA Qs, sorry and five SBA S um, all three of the SA Qs as before are all 10 mark each. Um, so I will um open the chat function. Um, so everyone can use it and now, uh we'll hand it over to David to, er, to start the first case and we should be done within 45 hour, 45 minutes to an hour. So you over due m can you hear me dad? So, yeah. Uh uh no, Dave, can you hear me just to give us a set of trying to sort out something? Oh, so maybe it's me not David and mhm. Thank you. Thanks. So thank you. Yeah. Yeah. Ok. All right. So you hear me by any chance? Yes. Uh Can you guys hear me by any chance? Hey, can you hear me I can hear you now. Oh, yeah, we ii don't know what happened. There might be, could you possibly present? I think it could be something to do with my computer. Oh, it seemed like. Yeah. Yeah. Yeah. Ok. So let me just get your email up one sec. Yeah, thanks. Yeah, for sure. Got you. Um, well, I can do the first three, A and you can do the SBA S if, if you wanna do that. Oh no, it doesn't, doesn't really matter. Um uh just uh just uh ok. Ok. Yes. Can you see, uh can you see the slide now? Yeah. Yeah, that's good. Yeah, perfect. Yeah. Nice. Ok, great. Ok, sorry about that guys. So, um the first case we, the slight moving problem. Uh Yeah. Oh, sorry. Oh no. Yeah, case one. So first case uh a five year old boy comes to your clinic with his mother. So the child has been walking with a limp off and on for five months now and complains of pain in his left hip. Er, the GP asked for a hip X ray but there was nothing I note you suspect PTH disease. So, um could you outline the pathophysiology of Perth disease? So this is two marks. Um So if you could think of 22 main points about the pathophysiology of per disease and feel free to answer and chat, don't worry if you get wrong, we're all here to learn. So don't be afraid. Um, and if no one answers then we'll move on and we can discuss, discuss the answers. Nice. You said aic avascular necrosis of the hy? Yeah. Yeah, that's, yeah, definitely. Very good. Yeah. So that's, uh, yeah, that's great. Any other ideas? So, yeah. So, um, yeah, we can have a look. So, um, yeah, so there's temporary loss of blood supply to the hip which causes ischemia and then over time, er this causes avascular necrosis of the er femoral heads, er, specifically, as someone said, the epiphysis and um this impaired blood supply can also lead to bone invasion as well. And so the reason for this is because um the blood supply to the femoral heads changes during the during childhood. So around age four, the metaphyseal supply um and the, and by age seven, the vessels of the ligament area have developed and between these ages, blood supply can be compromised. Um which is why it's quite common to see it within these age ranges because during the switchover, um it can cause er this temporary loss of blood supply leading to avascular necrosis. Very good. Nice. So um give two differential diagnoses. So what, what other possible um conditions could this present as any others? I septic arthritis? Yeah, that's a good thought. Yeah, definitely. Yeah, we, we wouldn't want to miss that at all. Yeah. So, although if we look at the time frame, so that's, it's five months. It's quite a chronic time. Yeah. S, yeah, Sufi. Safi. Yeah. Definitely. Um, so septic arthritis, we'll talk about that a bit later. Yeah. Transient sinusitis. Yeah. Definitely. Yeah. Definitely. Definitely. That, yeah. And Sufi will talk about that a bit more but it's less likely because of the, the age of the, the patient. However, shouldn't, that shouldn't, um, it shouldn't, um, completely rule that out. So, we have a, the answers. So, um, in a child, you always want to think about um possible attention seeking um irritable hip. So that's yeah, another name for transient sinusitis and possible soft tissue injury as well. So any trauma make sure you take a good full history. Uh but those are some some answers. Ok, nice. So um so given that the recent X ray was normal, what investigation would you do to confirm your diagnosis? So what other, what other things can you do? Ok. Any ideas, what other investigations any other scans you could think of? Ultrasound? Yeah, that's, that's a, that's a good thought. Um However anything a bit more anything which is can look at at the soft tis issue in a bit more detail. Yeah, MRI. Yeah, very good. Yeah, so definitely. Yeah, MRI. Um and also you can do a bone scan as well. So we have a look at the answers. Yeah. So a bone scan, bone incy or MRI. So you want to have a good detailed look at that, that soft tissue and um at the bones as well. So we go on to the next slides of just so, yeah, here's what a bone scan looks like. You can see. Um, there's a bit of, uh, in the left side, there's a bit of loss of joint space. But, um, but yeah, so you have two radiological changes, you would expect to see an established disease. So, this can be on an MRI on X ray, on a bone scan. So, um any ideas what you'd see in, in past disease? Yeah. Very good. Yeah, lots of bones rupture. Definitely. Yeah. And any other kind of more specific. So what, what kind of changes would be, would you see more specifically with the bone structure of? So we can have good answers. So um there will be a flattened femoral heads so you'd see it uh it become less rounded, er the head size would decrease as well. So it becomes smaller because of the avascular necrosis. Uh It could also be er in the more sort of later stages it could become broken or damaged as well. Um And we have a couple of the neck slides, you can see a X ray of this. So you can see on the left side. So if we have a look at the right side, you can see the um so the femur, the normal femur, you can see the epiphys at the top and then the physio plates, that line which looks like a fracture, but in fact, it's normal, it's just the growth plate. And then below that is the metaphysis. And then you compare that to the left side, you can see that is just complete destruction of that uh uh femoral heads. And um in the early stages, you can see that flattening and it becoming yeah, completely um broken. Nice. Yeah, very good. So, um they have a difficult one. What classification is used in Perth disease? Does anyone have any ideas? A bit more of a niche question? But still in orthopedics, um they love classifications. So it's very important to have an idea of them. If not, we can have a look. So it's the cat staging and so can uh answer P MG. Thank you. Yeah. So the staging and then the next slide shows in brief detail what this entails. So you've got their groups. So group 1 to 4 and um starting from one. So this is the least amount of involvement. So it just involves the anterior epiphysis which is seen in the blue. And then number two is uh just a bit more and then it goes all the way up to four where that's total head involvement. Um Yeah, great. And then your investigation suggests purposes. What are your uh management options? So we can divide this into two sort of main categories. What, what categories could you could you do any ideas? Yes. So conservative and surgical. And when Yeah, very good. So, when would you, uh, when would you think about doing conservative over surgical or vice versa? When would you, what would be indicative of doing a conservative, um, sort of, right. Any of cat? Yeah, you can definitely do that. Yeah. So, if it's more worse, so, more severe then you'd want to operate on that. Um, and also to do with the age as well. So, um, always think about the age. So if you have a look at the answers, so, um, if they're less than six year old, 60 years old, they have a higher chance of that bone, um, kind of healing and the blood supply coming back. So you can observe that and, um, conservatively you could put the, um, to keep the femoral heads within astable you could use, I don't know, I think his probably wifi to cut out. Sorry for them. Yeah. Give thanks. I share my screen. See if it works. Ok. So just give a second and you will reconnect. Yes. Uh, sorry, man, I think my wife, I just cough. Oh, that's ok. Yeah. Yeah. Ok. Uh, can you see? Yeah. Yeah, perfect. Yeah, thanks. Yeah. Nice. So, yeah, someone greatly says so you can split it between, er, the conservative and surgical management. So conservative. Er, you'd want to keep that femoral head within that as a table. So you can use that either, either using a cast or braces and, um, if they're older, so older than six years old, then you would opt for surgical management and if at any age they have severe deformity, then you'd also want to think about surgical management. Er, which is usually the most common way is a osteotomy. So that's when you just, um, fuse the, um, the, uh, bones, the femoral head to the, to the, um, the neck of the femur. But, yeah, nice. So we have a look at the next question. So, yeah. So you decide to treat your patient conservatively without surgery and name three adverse prognostic indicators. So, what three things would suggest that um, the patient's prog would lead to the patient's prognosis not being great. Any ideas? Ok. Ok. Old age. Yeah. Very good. Yeah. Old age of onset. Yeah, definitely. And, uh, do you have any, any, um, idea why that could be, you know, this, yeah, worse ability and remodeling bone? Yeah, definitely. Yeah. Very good. Yeah. Nice. Um, that's correct. Any other, any other ideas, any other reasons? So, clearances. So, yeah, as, er, someone's correctly, er, suggested sort of older age of onset. So if the child is younger, there is more opportunity for the bone to, I should say grow and remodel naturally before the child stops growing so that it can, it can sort of, er, self resolve, er, gender is important. So girls generally do worse than boys as they finish growing at a later age and severity as well. So the more severe the patient comes in presents, presents, er, the worst of prognosis as well. So those are three indicators of a poor prognosis. Great. So that's the end of this first uh, case. Does anyone have any questions uh or anything they wanna add in, in the chat? Feel free. If not, then we can, we can move on. No. Sorry. Um So the next case is a seven year old girl was playing on top of the climbing frame when she fell off the frame onto her left arm. Er, which two types of fractures occur only in Children. Yeah. And the green stick. And so. Yeah, perfect. Very good. Yeah. Yeah. So um Buckle. Yeah. Uh Buckle I think can happen in adults if I'm not mistaken but um it, yeah, it'd be a green stick fracture and a salter Harris epiphyseal fracture. So those two can only occur in Children. Um and could you describe each type of uh each type of salter Harris fractures of each type? And so there's five marks. So there's 55 types. Yeah. So, yeah, buckle. Yeah, buckle fractures can help uh occur in like elderly patients, especially um for some reason. Buckle because of possible like osteomalacia or osteoporosis that can lead to softening of the bone and cause that buckling um that compression sort of fracture. Yeah. Yeah. So nice type one straight through the plates, right? Ok. Tattoo bo the plate. Yeah. Nice. Very good. Yeah. Yeah, great. So, um we can have a look at the, at the diagram. So is it 1 to 5? So a good way to remember it is um, a way I remember it is uh using the, er, first letter. So, so s being straight through, so that's straight through the epiphyseal plates a of salter. So a being above that plate. So you can see in the second picture it's above that epi er epiphyseal plates and then l being lower or below. So that's that epiphysis and then t being through so straight through some straight through the um metaphysis, epiphysis and uh the fighter splits and then er being sort of, or r being rammed, sort of a crush injury where it's self compressed. So, yeah. Very good. Yeah. And they like of any age classification, they worse, each, each step is worse than the other. So, um and for next, next question, could you describe what a greenstick fracture is? So, what is the kind of definition of a green stick fracture? No. OK. Any ideas before you go cha. Mhm. Yeah. Incomplete fracture. Yeah. Yeah. That's a very good thought. Yeah. Yeah. So it's a, it's a fracture in soft or uh young bone where one cortex of the bone is broken and the other is intact. So, um you have a look at the, the next slide you can see, have a, have a look here. So you can see in this in this patient in there. Um uh in the arm in the ulnar and radius bone, you can see that it's on the right s kind of on the right side. That's been, you can see that gap, the loss and the transition of the bone cortex, whereas on the left that cortex is still intact. So it's still running through. So that is a green stick fracture. Um I see. And then, so going back on to the, the current case study, the Dell's radiograph is shown above what is the diagnosis? So it's two marks. So you could say two things about the radiograph. Um mhm Yes. Also Harris type three. Yeah. Very good. Yeah. Um Yeah. Great of the radius. Yeah, exactly. Yeah. So you want to state which where it is? So the radius. Very good. Yeah. And more specifically the distal radius and the left, the left arm, I mean, it's quite hard to tell in this, in this um in this, in this picture in this radiograph. But er from the, from the history, we can deduce that it's left the left distal radius and it's a Salter Harris type three fracture because um it's above that. Um not above, sorry, it's below but because it's confusing because this isn't usually salter Harris er fractures. They're kind of um the most common sort of the, the distal femur. Um But in this case, the epiphyseal plate it's er lower. So below that plate so all kind of on the edge. So you can see if we, if you could click on the next the next uh slide. Yeah, you can see the arrow there pointing there. Um It's sort of the more the lower, the more at the tip. So that's uh type three fracture. Very good. Yeah, nice. And then um so can you give four aspects of your management for this patient? So what if you can name three or four things which you would do in, in terms of management? What would you do any questions? Mm. Analgesia. Yup. Very good. Yeah, definitely. So the patient, she's young, she's probably going to be screaming and crying in a lot of pain. Analgesia. Oh yeah. Very good. Yeah. So um we can look at the answers. So yeah, analgesia. Er so initial management you can also, yeah, give ice. So just to stop any bruising compression, elevate the arm, rest it. And then um the definite management would be an orif. So open induction, internal fixation using uh plate and screws. So we in terms of like house classifications, if it's a one or two. So if it's a type one, type two, you could possibly get away with um conservative management. So just putting it in a cast or possibly using K wire. So, percutaneous um K wires, however, because it's a type three, it's a bit more severe. You would uh want to uh most likely do an or if so, open, open up the arm and then put in a plate and screws to fix, fixate it. So. Yeah. Very good. Yeah. And then, um, the next question suggests two pieces of advice you would give to this patient and her parents to help prevent further accidents. It's a bit more broad, a bit more broad question. What can you think of? I just three. Ok. I one, any ideas? Ok. It be careful. Yeah. Yeah. Yeah, definitely. Yeah. So, um, yeah, definitely telling the parents to be more, um, wary of where their child are playing. No, no fun for the child. No more climbing. Yeah, you can definitely say that. But, um, you know, you don't wanna stop some Children, er, developing and having fun so you can have a look at, look at the, um, the suggestions. So you'd want to encourage regular exercise and a healthy diet to build strong healthy bones. So, you know, making sure they get their calcium and Vitamin D and also exercise can, uh, will improve bone density, wear, safety equipment. So, um, like knee pads, helmet, stuff like that and appropriate supervision. So, yeah, you could say no more fun and games but, er, just telling the parents to, you know, watch out, be careful. So, so some general advice you can give, um, nice and then the next question. So I give three features which might make you suspect a non accidental injury. So, so, you know, the parents have said that she's falling off a cli frame. What, what, what other sort of features would suggest otherwise that it's a more sinister reason, any others? Yes. Yeah. Bruising around body. Yeah. Very good. Yeah. Yeah. Great. Yeah. Do you know specifically, you know which parts of the body tid child? Yeah. Yeah. Very good. Yeah. Yes. Look at the answers. There's a, there's a few you could give how long it took them. Yeah. Very good. Yes. So you, yeah, very good. Yeah. So, uh, you want to have a look at your inconsistent story or history, um, any injury out of the context of the age of the patient. So, you know, if it's a massive, um, massive wound, maybe it could be something more sinister, delayed presentation. So, yeah, someone correctly says how long did it take them to present to a and a, um, any repeated injuries? So if you look through their past medical history as this, you know, this patient come in multiple times for, for traumatic injuries. So, and that comes in with recurrent admissions. So coming in, er, often a withdrawn child. So, yeah, a timid child, child is withdrawn, you know, usually a seven year old girl, you know, she's been, she said they've said that she's been playing on ac frame but they, you know, she seems like a bit withdrawn, a bit scared, um, scared of the guardian of, of, of, of their parents that could be a sign of something of a maybe safeguarding issue and bruising in suspicious areas. So we want to have a look at ears neck back of legs, er, possibly even, you know, the stomach area, the, the, er, the back of their, their calves, these are very kind of less likely areas to have bruising when you think about a child who's like running around and, you know, maybe falling over, they're more likely to get bruising around their, their shins and their knees and their sort of arms rather than these areas. So, yeah, very good. And that's the end of the second case. So, um, does anyone have any, any questions? Any thoughts they want to put in the chart? Feel free? If not, then I'll hand over to you. I do the next case. Can you, can you hear me? Yeah, perfect. Yeah, I can. Yeah, if you just, er, if you can probably man the chat. Um, no worries. Oh yeah. Um, lovely. So case 30, I think the answer's already given away on the slide. Oh, sorry about that. Oh no, I think I forgot to do a transition. Oh, the, oh the, yeah, I mean I could do that real quick now and then what should do, do that? Yeah, you kind of do, sir. Um um, yeah, so yeah, good cases so far. I mean, do, does anyone have any questions about, um, about Perth disease or um, pediatric fractures? In general. Yeah, it's always good in exams to know about how, how they can connect these questions with other topics. Um, so things, things like, um, safeguarding is quite big in fourth year. Um, so it's always good to, to be able to link these questions with questions that can indicate some other things that are happening. Um, but overall resend. Yeah, I'll just send it to your email. Yeah. Uh, I figure that it's an updates version, uh, you sent via email you said? Yeah. Uh, let me just double check. Right? Ok. Yeah. Nice. Yeah. All right. That should be sending now. Yeah. Yeah. Er, if someone asked is, er, pediatric practice likely to come up in third year or is it more likely in fourth year? It's most, most likely fourth year, cos you cover it all in fourth year. Um, yeah. So I wouldn't worry too much about in your third year exams, but it's good. It's a good head start for when you get to fourth year. Yeah. And if you're interested in, you know, pediatrics and, uh, they don't, I, yeah, I mean, in my orthopedic block I didn't get much teaching on pediatric fractures. So, um, I was just interested in orthopedics or pediatrics. Yeah. Um, and yeah, if someone's, as some, uh, someone's asked for Salter Harris. Yeah. Conservative management. It would more likely be a type one, type two. You would think about conservative. But you can also do, um, you can also use per percutaneous pinning, which is like K wires. So instead of using pins and plate, you kind of go, you don't, you don't make a cut in the arm, you just go straight using um like a kind of like a drill and then a pins. Um sorry wires, you can fixate six without needing to cut open the skin. Um And that's done as well on the X rays as well. I'm just loading, loading up nowadays if you want to give me a sec. Yeah, no worries. Yeah, no problem. Uh Can you see it now, dude? Yeah. Yeah. Oh yeah. Case 3000, we'll give away the first one anyway. Um So 14 year old boy uh who's obese C comes to see you in GP with pain in his right hip that spreads to his groin and is worse when he runs out. But um it's worse when he runs but, but there is on walking previously, the GP said that it was growing pains but the mother is now worried and has brought that um brought you into for a second opinion. So given he's 14, uh we spoke about perf before I know the answer on the on the page. So the good way to differentiate between perf disease and SUFIS which has slipped upper femoral epiphysis is a kid. Usually a lot older, it can be associated with trauma. Um So it's always good to, to know the difference between the two. What are two likely differential diagnoses? Is there anyone in the chat? Um No, not yet. Not yet. Just let you know. Yeah, young teenager pain in the hip. What some differential diagnosed you? So we had a few good ones before for the uh for the first case on perfect disease. So herpes disease is one, a traumatic hip fracture is another um potential. Yeah. So these are the kind of differential diagnoses. You should kind of think of uh what three features in the history are consistent uh with the potential SUFIS. So you kinda give him one or two of them. Yeah. So the fact that he's a boy, the fact that he's around 14 as it is as it usually ranges, usually ranges in the higher, higher, higher ranges of, of Children, er, whereas per is more younger and the fact that he's a bit big, er so being obese is also um a potential er risk factor as well. Uh What two features would you look for to confirm your thinking? Just a bit of a harder question? Um So movements in all er, all movements of the pip are kind of painful, so they'll have reduced range of motion. Um their leg um might be slightly um externally rotated and it might be slightly shorter than the other side. Um The key, the key usually symptom that uh past me does like to tell is the lack of internal rotation. Um So yeah, so kind of all movements are gonna be a bit painful, there will be a lack of internal rotation. Um and the other leg will be a bit shorter. So these are kind of the the key key parameters you kind of should be looking for when you're examining the patient on hip exams, which I think you do learn in third year, I think and second year um so briefly outline the pathophysiology of the condition. So what actually happens in Sufis? So it's kind of in the name a little bit. Um Has any anyone got any options um in the chat? No, not yet that someone said a displacement of the metaphys relative to the hy. Yeah. So that's, yeah, that, that's correct. Yeah. Sounds, sounds pretty, sounds pretty good. Um during the prepubertal stage. Um and during a growth spurt, the immature fis of the proximal femur is too weak to resist the increased stress put on it by the body weight. So this imbalance um causes um there's an imbalance in the pituitary hormone, stimulating bone growth and the gonadal hormone. So it encourages five FF or fusion. Hence, it's usually seen in obese or tall, tall and thin adolescents. So it can also be caused by trauma. So essentially in, in, in, in, in kind of breaking it down, it's kind of, they're kind of a bit they're putting weight down. Their fighters can only take so much and then it's a kind of a, it's kind of a slip, I'm sure they'll be in very soon. Um, you have two ways. Um, you would manage the, the patient in your GP surgery. So how would you manage this in like an acute setting? So, I think it's, it's gonna be a bit painful. So you give analgesia, um, you're determined to kind of rest until they have their review with orthopedics. So you, you then send a referral um and then you request a lateral and a PX ray of the hip of the hip and knee. And you can also do, um there's a view called the er frog view. Um uh so you can, those are the kind of the x rays you should, you should look for. So it's kind of analgesia refer, come to rest and, and get them to have um, x rays before they see them. Yeah. So here, here's kind of, we see the um, on the right hip here. Um We can see uh this, the kind of the, the, the, it's kind of slipped up. I don't know if you can see it if you compare it to the other side. Um, it obviously doesn't look symmetrical so you can kind of see on the right. Um There's kind of a slipped um of the upper, it kind of slips upwards. It's always good to when you, when you're diagnosed, when you look at this, it's cos like it kind of covers the the femoral neck a little bit. It kind of always looks different compared to the other side. It's hard to diagnose without seeing the other side. But it's uh it's quite a good condition to have a look at radiographs, especially for this purpose of diseases like kind of differentiate between the two. Um So suggest two complications of this, this of this condition. I think it may be perhaps a bit long term. Someone said that a common one, sorry. Oh, I was just reading out the chat. So someone said avascular necrosis uh po potentially. Um Yeah, arthritis is usually always a good safe one to use in orthopedic questions about complications. Um But other good ones to use are chronic pain. Uh You can potentially have the other side slip, um Coxa vara deformity. Um So that's kind of a pos a positional deformity in the way the uh hip looks and it will present with a characteristic gait pattern. So, yeah, mo most likely I'd go for arthritis. Um, here. Um And then perhaps chronic pain is another good one. And what's a definitive treatment? So I know in perfect disease, we said if it was less than six years, you can kind of do it conservative and if it was more than six, you're looking for surgery. However, in SUF Sufi, uh you're looking mostly surgically. Um, and it's done by a cannulated hip screw. Um, usually by a percutane. Um So it's usually percutaneously um in situ fixation. So it's very similar to a DHS. Um if you've seen a DHS um with elderly patients, um, however, they, it's just a screw part of it is not the um plate across the side of the uh femur. So you kind of just kind of bring it through that. That's kind of brings the metaphysis down and kind of makes it nice and strong, tends to stay in. Um, but it can also be taken out as they get older. Um, and the key is when you're looking at these fractures, um, you don't wanna er, I know this is beyond our, well beyond our, but you don't want to screw into the acetal as you and you, unfortunately, we will just fix the, er, fix the hip. So, yeah, that's uh so we've covered a good range of conditions today. So we've done um, Perthes and Sufis and we've done, we've looked at other types of fractures as well. So let's go on some, some SBA S. So just pop the letter in the chat, er, once you've got the answer. So a six year old is brought to the pediatric clinic by her parents due to concerns about the appearance of his legs on examination, there is bilateral lower li lower limb deformity characterized by increased lateral bowing of the legs. The child has a normal gait pattern and no complaints of pain or difficulty walking. Which of the following is the most likely diagnosis. So, what do you think? So it could be, it could be as well. Yeah. So, yeah, GG varum er and valgum. So varum is always, I always remember it as kind of more than if that makes sense. It's always going out. Valgum, always, always inwards. So not need is more. Valgum. Varum is um bow legged. Um, yeah. So rickets can cause that which is lack of Vitamin D if someone has rickets, you kind of wanna give them lots of Vitamin D and supplementation, calcium, et cetera, oxygen degen imperfecta. It is a good one to throw you off in this situation. Um, uh, but it's more, that's, that's, that's got a different er, type of physiology and I'll be honest, I don't even know what blunt blunt disease is. So, um, so a nine year old child, let's move on to question two. So a nine year old child presents to the pediatric clinic with a swollen, painful right knee. The child's parent reports that the symptoms developed suddenly without any preceding trauma or illness. On examination, the knee is warm, erythematous and tender to palpation over the joint line. The child is reluctant to weight, bear on the affected leg. Laboratory investigations reveal normal inflammatory markers and a joint aspiration yields clear fluid and no evidence of infection, which the following is the most likely diagnosis. So, the key thing to differentiate here, um, is, could this be something serious. So any answers in the chat? No, not yet. They're not, they don't wanna wait. Bear, which is obviously Alarm Bell should be ringing. If there's anyone who's a kid that doesn't wanna wait bear, they've done, they've got normal inflammatory markers and the joint operation is clear. So that kind of leads us towards a way from septic arthritis and it's transient si so there is a criteria that you can use, differentiate between the two. and that's called Kious criteria. Um So it's kind of if you, if you, if there's four points and if you've got more than two, you're probably leaning towards a septic picture. So it's something that is. So the four parameters are non weight bearing if your inflammatory markers of E sr over 40 your um white cell counts are over 12 and um there is 1/4 1 which I've forgotten now. Um So yeah, that's kind of leading towards septic arthritis. So you're looking towards, um you wanna, you wanna, you wanna rule out between the two. So transient tran, so, transient can also be after an illness as well. So it's always good to, it's good to know the difference. So a 37 year old child presents to the GP with complaints of joint pain and swelling in multiple joints, including the knees, wrists and ankles, the parent child, uh the ch the child, sorry, reporting morning stiffness lasting for about 30 minutes upon walk upon waking as well as a recent history of low grade fever and malaise on examination. There is tenderness, warmth and swelling in several joints with limited range of motion labs. Uh Blood testing reveals an elevated uh inflammatory markers including erythrocyte. Um ES RCR P and A N A are all raised which of the following is the most likely diagnosed. So, they've got a, they've got a, had a recent history of low grade fever. Um Any answers in the chat. Yep. Yep. D Yeah. People have said two D Yeah. Ok. Yeah, that's right. June. Now, idiopathic arthritis. That's a good answer. Um So they've, they've kind of had a bit of a low grade fever. So that's a good, that's a good, good point. Uh Kawasaki is easier to throw you off that does give arthralgia. Um but it's got more uh systemic symptoms. Um We spoke about uh these two, so a four month, a four month in question for um a four month year old presents to the Peds Clinic for a routine check up on examination. The pediatrician noticed asymmetry in the thigh and gluteal skin folds. Uh with limited hip abduction on the affected part, there is a positive or lai maneuver and with a palpable clunk felt as the femoral head relocates into the ace T with a abdo abduction, which of the following is the most likely diagnosis. Yeah, fine. We've been getting, getting ease in the chart. Yeah. So Yeah, sounds good. D DH um, another good topic. So I, I'd say for fourth year exams go over D DH PFS Sufis Septic Arthritis. Those are kind of your four main, um, M sk, uh, topics. And there are a few more that, so, Lanny's Maneuver and Barlow's is, uh, done when the baby's kind of at a six week check. And I think, and the 72 hour check, uh, post birth. So one is to um relocate a dislocated her and the other is to dislocate a femoral head um at certain positions. So to dislocate a femoral head, you're going to um abduct the hips, um and then to relocate, you're going to abduct the hips. Um So last question for today, uh a seven year old child presents to the to A&E with a painful swollen right knee and a fever of 38.5. The child's parent reports that symptoms started abruptly yesterday and the child is refusing to lay down the affected leg on examination. The right knee is warm, erythematous, tender to palpation. There is limited range of motion with marked pain and on passive flexion and extension. Laboratory investigations reveal elevated white cell count and inflammatory markers, which the following is the most likely diagnosis. So we kind of, so 11 thing you should be thinking about here is um, yeah, big gang season. Yeah. Yeah. Yeah. Yeah. So anyone who's got a high temperature, um, the lab testing shows high white cell count, high inflammatory markers. You're kind of leaning with that co criteria. You're leaning. Oh, yeah, the, the fourth one was high grade fever. Um, you're leaning towards a septic arthritic picture. Wonderful. Um So that, that kind of summarizes our, our, our talk. Um Thank you very much for David for doing the slides. Um Yeah, so, uh we've got a QR code here if you can uh fill out the feedback. That'd be great. Um And uh David, do you mind? Just stick in the uh in the chat as well? Yeah, of course. Yeah, just put in the chat. So yeah, you guys to fill that out and you can uh use the the slides with the answers on and um yeah, thank you for joining us today and yeah, we appreciate, yeah, I was, it's been a good session. So in third year, I wouldn't worry too much about pediatric fractures. It's good to be aware, but in fourth year it's something that you do need to know and it will probably come up in exams of some sort. Um And probably for finals. Um but yeah, it's been a been a good session. Um I'll, I'll leave the QR code here. Uh next week the no, in two weeks time the sessions on spinal fractures and spinal conditions. So yeah, be sure to check out our Instagram page. Um and we'll uh we'll, we'll get that going as well and if anyone wants to do a session, feel free to reach out. Um, just EMS, if you want to do a session or anything, we're a very open book, er, society. So, um, more, more, more help the, er, the merrier. Um, if anyone has any questions about today, er, pop them in the chat, it'll be great to do the forms and we'll send you the slides. Great. Yeah, like I said, wonderful. All right guys. Well, well, thank you very much. Um We'll see you all, uh hopefully in two weeks. All right. Cheers David. Um Yeah, thanks for, yeah, no worries. It's a good session. Um Yeah, I'll catch you, I'll catch you soon. I'll give you a catch you in a bit. Yeah. See you see you guys.