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Right evening, evening to those who have joined. I don't know how many of you are, but yeah, thanks for, thanks for joining us for our third, third episode in our bombs are teaching series. Um So my name is Harry and I'm going to be focusing on, on pediatric pathologies as you can see here. Um So I might just get, I'll just give it a minute. Uh, and then we'll crack, crack straight on. Don't want to hold, hold you guys up that have turned up promptly. But yeah, I'll just give it, I'll give it a bit longer and then we'll crack right on. Yeah. Yeah. Right. That will do so. Um, so, yeah, pediatric pathologies, here we go. Obviously quite a broad, uh, broad topic area, but I've just tried to focus on the key, the key aspects really from a med school point of view. And, and having actually spent a bit of time recently in, in pediatric orthopedic clinics, these are the kind of things that you do that you do see in the, um, you know, in the flesh. So it's certainly useful to go over. So a bit of a bit of a contents page. We'll start with going over these sort of structure and differences between adult and pediatric bone. Well, then move on to sort of broad recap of the fractures seen in Children. Uh and then we'll move on to the sort of more specific pathologies. So hip, knee, foot spine, um and then we'll end with with a few sort of infectious uh pathologies which are quite commonly seen. So quite a busy slide here, looking at the differences between the bone uh in adults versus Children and two key aspects which I want to focus on. So, first of all growth plates, a pretty key point here and uh and these are seen in pediatric bone but not in adult bone. And these are seen between at the end of the bone uh between the metastasis and the hep if Asus. So looking at that far right diagram there uh in between the both distal and the proximal up if Asus and then the meta fossas just inside them. And so these are areas made up of highland cartilage. And what happens during adolescence is that the epiphany sis and the metaphysis fuse and this growth plates becomes what is known as the epa fizzle line also indicated at the top of that same diagram. So a key point with growth plates is as seen in that X ray in the middle there. They can quite easily be mistaken for fractures, especially if you're in a rush you know, you're, you're rushing through an X ray perhaps if you don't even know it's a pediatric X ray, you know, you may, you may uh consultant may try and trick you out, you may be unaware, it's a pediatric X ray and think it's a fracture when in fact, that's just a growth plate. So something to bear in mind there. And then the second aspect on this slide is the actual structure of the bone itself. So, in Children, you've got counselors bone and this is, as it says here, you know, soft spongy, it's much more vascular um than the cortical bones seen in adults. And this. So this results in in three key things. First of all, pediatric bonus, prone to what we call green stick fractures, something you may well have heard of before. And this is when one side of the bone breaks as if you're snapping a stick that's still alive and the other side will stay intact. And we'll cover that in a bit more detail. Later on, this bone also has a much better blood supply than adult bone. So, healing is much quicker and this is reflected in in the various management seen in fractures which again will, will cover in a bit and then lastly buckle fractures, which is when you got compression of the bone. Um These are much more common in Children because there's less strength against this compressive force. And then you're in adults as it says there at the bottom, you've got cortical bone which is much harder, um heals more slowly and you won't see green stick fractures in this type of bone. So I want to sort of broad overview of, of fractures. And here you've got a fairly good diagram of the, the sort of buzz words you can use to describe the different fractures. You can see bottom right, you'll see green stick, which I just mentioned and then bottom second from the left, you'll see a growth plate fracture. And Salter Harris mentioned there is the classification system we use to uh multi classify these type of fractures. So any fracture going through the growth plate, as you can see, there will be classified using this system and I'll come on to cover um Salter Harris in a second. So key thing to mention actually is in what any vulnerable person and in this case, in Children, nonaccidental injury is, is a key cause of fractures. Uh specifically, if these fractures are in the posterior ribs in any of the long bones, if the fractures are multiple or if the fracture's involved the scar and a complex in nature. So always worth thinking about, you know, safeguarding uh and and the risk or the the chance that it could be a nonaccidental injury in this case. So a few specific types of fractures seen in in Children. First of all of the clavicle, the collarbone and this may well be seen in a child falling onto an outstretched arm. So it's a really quite common, got to be careful here of uh neuro vascular injury and also the splintered edge of the fracture causing pneumothorax. So, so pretty key things to be aware of that and management wise, collar and cuff fairly common. You'll see these in, in A and E uh pretty frequently and these typically put on for about three weeks. Uh and internal fixation may be used in more complex cases or if union can't really be achieved um by, by sort of reduction and then by the collar and cuff super condo the fractures on the right there. So these are fractures just above the elbow affecting the humerus. And again, there's a scene when a child falls onto announced stretch hand, got to be careful of brachial artery injury. So, you know, in all fractures, it is, it's key to assess neurovascular status pretty early on just to check that none of that has been compromised. And what you see watching this X ray at the bottom is that the fat pad around in and around the elbow will typically be displaced and this causes what is called a sale sign on the anterior aspect of the humerus. So it's difficult to see. I I appreciate the without those red and yellow dotted lines, it may not be so obvious, but that is what that's what's happening there. Management wise, you're gonna internally fix the super condo fractures and the bottom left, pulled elbow. No, it's not strictly a fracture, actually a dislocation. Um and these are seen when Children are lifted up by their arms. You know, it's something you see quite a lot. Um And so the radial head dislocates um from the uh from, from the humerus, from the in the elbow joint, I'm managing this, you're gonna do four super nation of the forum and then you're just going to rest the joint for a couple of days, a few more specific uh fractures seen in Children. So the top there, Mantega and Galiazzo see these can be confused, they're fairly similar in location. So a bit of an acronym there in the middle to help remember those two. So Monte Jay a top left. So this is a fracture to the proximal third of the alma alongside dislocation of the radial head. Uh And to manage this, you can either do closed or open reduction and then plaster cast for about five weeks afterwards. And the gal iatse fracture on the top right, this is a fracture to the distal third of the radius um and then dislocation to the distal radioulnar joint. So if you look at that X ray there, you can see that fracture in the distal third of the radius. And then you can also see a slight um dorsal displacement of the radius showing that it's dislocated from that distal radioulnar joint and the key thing to watch out for here is a palsy to the anterior interosseous nerve. And so these pools is actually quite difficult to pick up on mainly because uh there's only a motor component to the nerve. So there's gonna be no sensory loss at all. Um And it's going to result in basically a loss of your pinch mechanism. So that's a key thing to test for after injuries in and around this area. You may also have a wrist drop due to radial nerve injury. Uh And you're gonna manage this with a closed reduction and then bottom there, spiral fracture to the distal tibia. This can also be called it a toddler's fracture. Uh And these occur just when simple ground level falls as it says there, probably resulting in a limp or refusal to weight bear and management for this will be with a long lead cast for for five or six weeks. So I said earlier, I mentioned growth plate fractures when the fracture is involving there's growth plates which we touched upon earlier. And these are classified based on this classification system, salt to Harris. So, you know, it's all on the slide here with that diagram there as well. But type one is when the fracture is straight across the growth plate. So the s for salter straight across type two is when the fracture is above the growth plate. Um So that's, that's obviously the a um type three is when the fracture is below the growth plate and the L for that, the L for below uh sort of fits in with the L of the salta and then type four is when the fracture is through the growth plate and that tea fits in with the t of salt. Er and then lastly a crush. Um so it's not sort of so much a fracture um but a crush injury uh is the are of Salter. So Salter sometimes felt without the just to fit into that acronym. And the higher the grade on the Salter Harris classification system, the more likely the fracture is to disrupt and interfere with growth. So a more sort of generalized look now at management of these fractures, as I mentioned, keep safeguarding and nonaccidental injury. Firmly in mind, the first thing to do is to achieve alignment of the fracture. So either this can be done close to your just manipulating the joint and this, this can sometimes be done under anesthetic um or openly or. So you're gonna have to go to theater for that. And then secondly, you want to provide stability. So the healing process can take place and this is done by fixing the bone in, in place to allow it to heal. And so for this, you can use a few modalities, external costs can be used typically three weeks for the upper limbs, six weeks in the lower limb. And it tends to be about double this in adults. So six weeks, upper limb, 12 weeks, lower limb you can use K I S which you can see bottom right image here. And these are typically put in uh and then will be removed at, at an interval when um you know, when, when the surgeon feels that the bone has been fixed and it started to heal appropriately. Um And yeah, and then you've got, you know, various wires um and nails. And you've probably heard of the term or if open reduction, internal fixation and typically this will involve a plate as seen in that top image there. Um So you have a variety of ways of providing that stability. And then of course, the key point to mention is is analgesia for this. So in Children, obviously, parasites, not ibuprofen pretty standard. Um And then morphine can be used. Children will need admitting if, if this is the case, codeine and traMADol have to take care with purely because the metabolism is is pretty variable in Children. And so you don't know um how sort of potent that's going to end up being even at the same dose in different Children, it'll be quite widely variable. Uh And then aspirin you tend to avoid in Children because of the risk of something called Reyes syndrome, which is quite a specialist aereo that you won't need to know too much about it. But effectively, that results in the liver and brain pathologies. So, yeah, something something to bear in mind. So, onto the sort of more specific pathology is now starting with the hip and it's quite a useful diagram here which separates the various differentials into the age bracket, uh which they occur. And of course, it's not a hard and fast rule, but for your, for your exam questions, it can be quite useful just to have that in the back of your mind with exam questions, typically trying to focus on a fairly typical presentation and typical age. So yeah, useful to, to have that in mind starting with developmental dysplasia of the hip. And I apologize quite a busy slide here. I know but there's quite a lot to to get in. So yeah, so D D H developmental dysplasia of the hip is a structure abnormality um caused by abnormal development during the pregnancy, the gestational period and this is typically picked up at your newborn examination. Um or alternatively can be picked up with reduced range of movement or even a clinical limp seen in that child. There are few risk factors which you can see there top left family history is a key one. If the child is in a breech presentation after 36 weeks gestation, then that's a risk factor. Breach of birth as well. Of course, is a risk factor, the multiple pregnancy and oligohydramnios as well. So just a few things to look out for a few things you can be asking about in a history there from the mother to try and, you know, just to try and risk stratify um the chance of the of the child having this in terms of screening. So it's, you know, these are normally picked up at the newborn or infant physical examination. Um and these are examinations carried out within 72 2 hours of birth. And then again at about 6 to 8 weeks after birth and a few suspicious findings from this might be discrepancy in leg length, a restricted hip abduction on one hand side or a clunking of the hips during the special tests. And these may be familiar with Aldi Barlow and the Ortolani test, which you can see uh top right off the screen. And this is effectively, first of all, with Barlow, where you are intentionally trying to posterior dislocate the hip and then also Lana, you are then reducing that back into place. And if that happens with these, you may well get to try it on a, on a dummy baby um to sort of get a, get a measure of how, how easy it is in a patient with D D H. So those those are useful tests to carry out further investigations. So any any child with risk factors um or positive findings in these special tests will undergo an ultrasound scan. All this will be an X ray if the child is older than than 4.5 months in terms of management of D D H. Typically, this will spontaneously resolve. Um But if not, then there are a few options available. So if the baby is under six months when they're diagnosed and something called a public harness can be used and typically the baby will be in this harness um, for 23 hours a day for the first six weeks and then for the next six weeks, just at nighttime with obviously regular review and then surgeries carried out either if the harness fails or if the diagnosis is made after this six month age period. And then after the surgery is something called a hip spica cast will be used just to immobilize the hip for stability. Uh and, and a that healing process. And there is, there is a risk with D D H that early onset osteoarthritis can, can come on in later life, moving on still with the hip here. So, purse disease, uh and this is avascular necrosis of the femoral head. And it's, it's thought, you know, the sort of cause of this isn't really well known. Um uh but age of age of onset, typically between five and eight years. So it has a presentation, it's going to be fairly uh fairly slow onset. You may have pain in the hip. Groin can be referred pain down to the knees. You may have a limp or a Trendelenburg Gate, which is when you're sort of dragging one leg due to weakness in the pelvis and also restricted hit movements. And there won't typically be a history of trauma which of course may rule in other differentials in terms of investigations. X ray is the key. And on X ray, your typically going to see as as in that top right image a much smaller epiphany cysts at the very end of the bone. In this case, the femoral head much smaller in size and you also sometimes see a widened femoral neck. And that's just because it has to make up for the the weight bearing load due to the smaller epiphany, sis gonna take bloods. Um as a standard, a technician, bone scan, quite a lot more specialist. Um um and then an MRI can also be used in terms of management. So bed rest is key, you can sometimes use traction, um and then crutches, analgesia and physiotherapy. Those are that the more conservative measures in more serious cases. Um those that aren't healing with these conservative measures or in older Children and surgery is is often uh required slipped upper femoral epiphysis. So it can also be called slipped capital femoral epiphysis, which is where the S C F E acronym in the bottom image comes into play. Uh This is effectively when the head of the femur and the growth plates are displaced. Uh and this is slightly older age group. So 8 to 15 year olds typically um and risk factors. Um those who are obese and black patient's as well, typically have an increased risk uh of this pathology. So key features, it may well be a history of minor trauma, not always but sometimes uh the pain is gonna be disproportionate to the sort of other other symptoms that the patient is experiencing. The range of motion of the hip is going to be restricted. And there's this thing called the Draymond sign, which is when um passive flexion of the hip occurs during forced internal rotation. So a few things to look out for on clinical examination, investigation wise, you're going to carry out an X ray in multiple views. A frog leg view is when the patient is lying on the bed with their feet together and they're sort of legs flopped out side to side with the knees bent. Again, a technician bones back scan can be useful, more specialist in this case, uh and then a CT or MRI as well, management wise. So surgery is required um to fix that, that femoral head in its correct position, uh followed by crutches and then extensive physiotherapy and then transient synovitis. So this is again, hip irritation can all of these can really present quite similarly with, with the refusal to weight bear. Um and sort of a limp, but the age uh and the sort of a more systemic nature of symptoms can pinpoint to a certain diagnosis. So, yeah, so this is um information, irritation of the Sinovel membrane of the hip and it's often seen after a recent upper respiratory tract infection. So again, a limp refusal to weight bear, there may be pain in the groin or hip. Referred to the knee. The patient is likely to be a february or possibly a low grade fever. But if they've got a high fever, you've got to consider septic arthritis, which will come onto a bit later, the patient will typically be well otherwise. And then at the bottom here, I've mentioned something called kotcher criteria, which are four criteria used to distinguish transient synovitis from septic arthritis. Um So if these four criteria are present, uh then you're gonna want to, to sort of carry out initiate management for septic arthritis on a pretty urgent basis and management is analgesia for symptoms. Uh If the symptoms get, you know, you're, you're gonna want to red flag for um septic arthritis. So ask the patient to return to A and E um if the symptoms worsen or, or fever develops and then you want to continuously follow up just to check for improvement onto, um just got one pathology of the knee actually pretty common and I'm sure you've all heard of it, Oscar slash latter's and it can also be called osteochondritis chondrocytes. Typically age of 13 to 15. Although actually in those adolescent years, it's um you know, it can occur right the way through risk factors for this are, are those that are sporty athletic mail and then those were the family history as well. And so what happens here is you've got inflammation of the tibial tubercle, which you can see in that top right image there. Um And this is normally associated with growth spurts or after intense periods of unaccustomed activity. So this will normally be unilateral pain, worse with movement and it does sort of tend to gradually progress over time, investigation wise. It's a clinical diagnosis really. Um But if it's sort of a persistent or atypical presentation, then you can uh you can get some imaging done as well. So, so yeah, that's always always available and the management wise, activity modification is key. So stopping the problematic um exercise, for example, cold compress always helps nsaids and physiotherapy surgery is is pretty rare in in these cases onto the feet. So two key pathologies here, flat feet also called fallen arches. And this is when the head of the talus uh becomes displaced both medially and distally from the navicular bone so that the ship shaped bone in the foot. And you can see those two bones on that middle bottom diagram there. Um And this will typically be picked up between one and five years old. Um However, it's, it's actually physiological, it's just normal at this at this age. And 95 of these Children will go on to develop a normal arch afterwards. And then out of the 5% remaining only a very small proportion will actually have issues in later life with this. So on examination, uh you will see that the plants surface of the foot is convex. You can use an X ray to help visualize this. And what you, what you'll also be able to do is on getting the patient into their tiptoes or were passively extending. Um They're big toe, you will be able to visualize an arch if it's present. So uh if they don't have an arch, you won't see an arch when, when doing that, management wise, uh mainly conservative with insoles, um certain types of shoes, mainly for symptom relief. Uh and then later down the line or in more extreme cases, surgery may be required. Okay. And then the second foot pathology talipes also known as club foot and this is due to the position of the um of the fetus when in the uterus and it's seen in around one, in one in 1000 births. So what you'll see or you'll, you'll see a sort of visible deformity. Uh And there are multiple types, the three most common scene in that diagram, on the right hand side, tickling of the foot causes will cause correction. And then what you'll see is the convex nature to the lateral foot border rather than the normal straight border seen, seen others management wise, you do see spontaneous resolution by the age of four and in the majority of cases, uh cereal stretching is sometimes used and cereal casting can be used in sort of severe deformities onto the spine. Now. So, scoliosis something, I'm sure you've all heard of, uh, normally picked up at the age of 10 to 15. Uh And so this can be, can range from being very obvious. So, you know, visibly curved spine um to being a bit more subtle. But yeah, there are a few, a few features here which, which you can look out for. So the patient maybe lean to one side, uh naturally their shoulders, maybe a bit more curved than expected. You may be able to actually be able to see ribs sticking out on one side, more than the other close may not fit particularly well, patient may have back pain. Um So yeah, few few things to look out for that and there are a few causes as well, 80% on are known, but then uh they can be secondary to the following. So, congenital, can we do to spina bifida uh or the VAC Tail syndrome which is, you know, made up of, of a variety of pathologies, neuromuscular conditions. So, cerebral palsy or Marfan's Syndrome, they can speak degenerative over time in this case, more likely in older patient's and then they can be due to a leg length discrepancy management wise, uh often it's not too problematic. So doesn't need treatment. You can use braces, um back braces to stop exacerbation with growth. Uh and braces are actually more commonly used in all the Children. Uh after which surgery can sometimes be carried out and then on to infection. So, uh as mentioned earlier, a key key thing to look out for in uh in all these pathologies really is the risk of septic arthritis. Um Before covering that, I'll just talk about osteomyelitis. And so this is an infection of the bone and of the marrow. Uh and typically, uh staph aureus is the problematic microorganism. It can be e coli among others, but this is the most common. Um And so the microorganism can be introduced directly into the bone. So an open fracture, for example, uh or may have spread hem a ta Jenness Lee through the blood presentation wise. Uh the patient maybe refusing to wait there. Uh There may be tenderness, warmth and swelling over the affected area. Patient maybe a federal will have a low grade fever. And, and then beyond that infant stage, when the patient's slightly older, there may be back pain or a limp or growing pain depending on where that infection is actually manifesting itself. In terms of risk factors. Two boys under the age of 10, if there's an open fracture, of course, has, has just mentioned previous orthopedic surgery because microorganisms can be introduced. Then if the patient is immunocompromised or has underlying sickle cell disease, the patient has HIV or tuberculosis and then also you can have spread from malignant otitis external. So some of your E in what some of your more uh severe E N T pathologies can actually result in Austria myelitis in terms of investigations. So X ray is, is always first line. However, it can take a bit of time for the changes to actually show up. So 7 to 10 days um in some instances, so I can't necessarily always be relied on radio isotype isotype scans will show changes a bit earlier. But of course, these are a bit more specialist and, and require more expertise in carrying those out. And what you typically see on X ray is, is dense bone with areas of, of sclerosis which give what's commonly called a honeycomb appearance. Uh MRI can also be used, um This is considered sort of gold standard. Uh And as says here, you're gonna see subperiosteal pass, um and purulent debris in the area, you're going to carry out blood tests. And of course, you'll see raised white cells and also your inflammatory markers to CRP and ESR will also be raised. And then you're gonna carry out a blood culture to establish the cost of organism. Sometimes you're gonna do a bone marrow aspiration, um or bone biopsy and the management wise. So IV antibiotics, um you're going to just rest that affected limb, sometimes using a splint and then it may well be um required surgery may well be required to drain and debride the area. And then lastly susceptive arthritis, key differential to consider due to the time critical nature really of its management. And this is infection of the cartilage and the sign of your fluid around the joint. And this will eventually result in destruction of the bone. Normally, just one joint is affected. Um and hematogenous spread is the most common common cause here. The common. Um yeah, the most common reason this occurs can also however, occur from adjacent Osteomyelitis, especially in Children. So, risk factors here. So, if patient's diabetic, any previous joint damage, any surgery, they've got an overline spreading cellulitis. Um uh not so likely in in Children but intravenous drug users are also at increased risk. So, clinical presentation wise, the affected area will be warm, um will be read, the joint will be tender and the patient will often hold the joint um in a certain position with a reduced range of movement. Uh they'll be acutely unwell. So, whereas in transient sign of Itis and Osteomyelitis, the fever is typically is typically low or even absent in septic arthritis, patient is much more likely to be federal. And then yeah, there may well also be a joint effusion investigation wise. So this is fairly time critical. Um So you're going to want to aspirate the joint and you're going to want to start antibiotics um within about an hour. So this is relying on your septic sepsis six protocol. You also want want to take blood cultures and you're gonna want to do that before you start the antibiotics really, unless that's gonna massively delay uh starting the antibiotics. Uh Male Karen an X ray to exclude trauma. But, but the key thing is to get the orthopedic team involved, get that joint aspirated, um, cultures done and antibiotics started so that you're already, uh you know, managing that infection is the first thing. And then you may well see an adjacent osteomyelitis, which is the root cause on an MRI scan. Um And then you're down at the bottom there, as we said IV antibiotics. Um sometimes you may wash out the joint, uh drain it in, in the surgical theater and then sometimes you will spend the joint, um you know, just to make sure that that that healing process can occur. So, yeah, pretty key uh pathology, septic arthritis and, and as you go through the adult, you know, some of the adult conditions in, in orthopedics and indeed, rheumatology, you know, thinking about things like gout pseudogout, you'll realize that whilst uh there are a number of differentials which that particular presentation could be the hot red, swollen joint by far and away. The key one to rule out. Uh and to start treating is septic arthritis. So, yeah, pretty, pretty important one there uh to end on. So I hope that was helpful. Uh It's quite whistlestop tour, but those are definitely the key uh the key things that that you'll see. Um And yeah, it's really really worthwhile just having a bit of a, uh, you know, an idea of what to prioritize.