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Hello, everyone. Thank you very much for attending this afternoon. Session run by the O. T. S, uh, and organized by Mr Steve Ball. And thank you very much. Um, we're going to start off the afternoon session with two, uh, lectures, um, and then have a brief coffee break and come back and split into four breakout groups. Um, are four breakout groups are going to be three sitting here and one in the boardroom. So if you guys can have a think either now or during the coffee break about whether for the breakout group, because it's gonna be pick one and go, it's not going to be a go to one and then swap to another one sort of scenario, Uh, whether you'd like to do the trauma Wheel of fortune. Uh, paraprosthetic fractures smash the tabula, um, or pelvic ring, Uh, four options for your breakup sessions later on. So if you can all have a better think about which one you fancy doing, uh, pelvic ring will be in the boardroom. Uh, smash. A tabula will be here in this middle section on the big screen. Uh, trauma wheel of fortune will be on the TV in that bottom corner will be splitting the room off during the break, and paraprosthetic fractures will be on this TV up in the far corner up here. Uh, so you can split yourself up however you like, um, and decide what session you'd like to come to. For now, though, it's my absolute pleasure to introduce or two speakers for the lectures for the afternoon session. First of all, we've got Mr Jonathan Dwyer, who's a trauma orthopedic consultant at, uh in in Stoke. I forget it's had so many names over the past couple of years North Staffordshire to NHS Foundation Trust Or so Mr Dwight, Who's the orthopedic consultant in, uh, Stoke? Who's going to be telling us about pediatric trauma? Uh, followed by Ms Sharon Scott, who's going to talk about fracture surgery? Are we doing on time? So thank you very much. Well, guys, I do love a challenge. It's good of you to spread yourself out so widely across the room. I must warn you, I've got a stiff neck and shoulders at the moment, so if I'm not looking at you over there or over there, it's because I'm in pain. So don't feel guilty or move or anything like that. But it's hard to work out what to talk to trainees about. Normally, you're interested in rotors, remuneration, holidays, having a good time in the bar at night. But I'm pleased to see so many of you here. I really am. It gives me faith that we can have reason. And I'm just going to talk to you about some things which are really topical at the moment. Because last May we got hit with some information by getting it right. First time. Um, uh, it's an interesting thing that pediatric girth is quite sensible. It says you should treat most simple fractures in the hospital. They turn up in, um, But then we got hit with a boast about forearm fractures at the same time, literally the same month, which says you should manipulate all forearm fractures in Children without admission to hospital. Bit of a challenge. If you've got an emergency department that sees over 100,000 patients a year, um and you say I need a bit of space, please. Uh, and some time I want a nurse and a safe sedation Pro protocol and a recovery area. So we rose to the challenge and we thought we'd have a look at what we were doing because Gerth says, Mr Hunter says, Does anyone know Mr Hunter is an absolute marvelous man? He reckons he's calculated on the back of an envelope or fag packet not been enveloped these days. Doesn't smoke anymore that we can save 250 weeks of theater time a year. If we do all the forearms and casualty, I don't think that's quite what will happen. I think other things will move into the space that we make available. But people started looking at this, and they are getting very good. Patient reported Outcome measures Parents are much happier to take their child home from casualty in a cast and comfortable than have them admitted to hospital for an operation. What's allowed is angulated fractures. What's not allowed is offended fractures because you've got a chance of pushing the image on the left there straight and maintaining line and length in a cast, haven't you? You're probably not going to get the one on the right, this one, the offended one back into a good position with a bit of whatever you choose to use to sustain the hyperactive child that's obviously attending because they've been so hyperactive, they've got a fracture, which just makes them worse, doesn't it? So we did a little audit, and in a month we found 11 fractures we thought could go into the audit, 10 of which were eligible for managing in the emergency department. These are the boast standards for practice. Easy reading as ever dense type. Lots of things to talk about. But you can see at the top you've got to have somewhere to do it and you've got to have protocols written down. That is quite difficult, because when they say should in standards, they mean it's mandatory. You can't get a choice. You've got to do it. So we thought we'd see if we've got any protocols. No, we haven't. We thought we'd see how many times the neurovascular status of the injured limb was actually accurately assessed and more importantly, documented. We thought we'd see how their pain was managed. Then we'd see if they were X rayed. Then we'd see if they were consented. The parents, usually for the child to undergo a procedure, then we'd see how many went to theater because in our hospital at the time, the only place you could achieve any of these standards was in theater didn't have to have a Iniesta's. You had to have a sedation protocol and someone who could administer it and observe it and then make sure they recovered. Oh, okay, well, actually, that's usually the anesthetist and the recovery staff, isn't it? But it's quite expensive way of doing it. Um, this were the orthopedic practitioners challenging What's an orthopedic practitioner? Um, you meet people called practitioners all over the place in the health service. These that is quite often brought in to help support the NHS, which is struggling with the backlog. And you do wonder rather what they practice. But practitioners, I think, means someone who can perform an examination after an appropriate history, undertaken appropriate maneuver to reduce a fracture and safely apply a splint. I think that's what it means. You have to be able to do all of those things to the required standard. Then you need to x ray it again. So we thought we'd look at Hammond, got an X ray again to see what you've done, and that you also most importantly, when they do something to a fracture, you must record whether there's been any change in that previously obviously no detectable vascular abnormality detected before you did anything you need to make sure it's the same. But this standard requires you to do it in detail. You can't just say no detectable neurovascular deficit. That means not done, and you have to write it down. You need to give them pain relief to take home, and you need to have a review. And this was interesting. You need to have a documented consultant. Orthopaedic SURGEON review within 48 hours of the injury. Bit tricky if that happens on a Friday evening and next. Children's Ratched clinic is Tuesday afternoon, and all of your colleagues say, I can't touch a child. Maybe they're thinking of another reason. I don't know, but you know, you get this from adult people are very Children, are the most delightful, easiest patient's. You will come across in the main. They're completely fit and healthy. They're charging around and then they fall over and someone goes snap and it wants to heal straight away. Why would you worried about managing a child. I don't get that, and this is the other thing you have to do. You have to audit your results. So you do need to know what the outcome is, and you have to write that down as well. So that was the result of our audit of these 10 patient's. It's not very good, is it where it's complete? Gray COLUMN. Yeah, so complete gray means none of the patient's had any of it done. This means that one patient had their pain assessed. This means that they all had an X ray except for one of them. You wonder. How does one not getting there for that one went to theater straight away? Um, they were all done in theater. Initially, they were all seen by the orthopedic on call team. None of them had follow up X rays before they were sent away. None of them had secondary documentation of whether it was any change of the neurovascular status. One of them we could find was sent home with some pain relief, and two of them had had review within the month of the audit, not within the 48 hours, and that was as generous as I could make it. Pain management was appalling. Hands up. Who's had a fracture? Now put your hands down now. Those of you had a fracture. Did it hurt? Put your hands up. Did it really, really hurts? Put both hands up. If it really, really hurts, they're quite bad, aren't they? So do not do this to people. They might go away thinking, Well, that wasn't very good, because either the parents think it's not very good because the child still crying or the child doesn't think it's very good because they're still in agony. Um, we didn't have any protocols written down for an lt's and sedation. Um, and we didn't have it anywhere to do Non impatient management. So we actually did this in the plaster clinic. We got it opened up and staffed it. Uh, there were no consents documented. I don't think there might have been one which was found after we made a fuss about the being none. And there was no recording of what happened to the patient. Asked that they've been pushed straight and put in a cast. So what we did was added to our monthly MDT, uh, and we highlighted with everyone managing a child in pain, that they needed to look after their pain, that they really did need to know whether it was a blood supply to the hand that they really did have to have consent and document that they had consent granted to perform any sort of procedure and that they did need to check on what they've done. Um, so we ordered it again and it improved slightly. But you can see the thing that's really missing this second, you're a vascular. Status assessment isn't done. People are not doing it. And we hadn't been running it long enough to do the audit. We have now done the audit, and we haven't had any catastrophes. Um, and the real difficulty is trying to justify the cost to develop a service that doesn't exist against the savings that you think it will make. And you can see the savings. Well reduced number of procedures under G. A is a huge saving, but not from the whole hospital, because there's a pressure on theater time. So something else moves in to fill the gap. Um, so the management just see this quite correctly as increased expenditure and you then go through a year's worth of sanctums. Yes, but it's any increase because we're under resourced in the first place and people are telling us that this should be the standard we achieve and we're not achieving it. And the real problem is people in this country are so forgiving of the health service. They don't make big demands. Everyone says on being sued with this. I'm being sued for that. The vast majority of our patient's go away saying, Well, at least I could go to the health service and they help me. Even though I'm in agony and my arm is bent, Uh, they tend not to complain. I'll just show you what were treated. So that's a typical case. Seven year old boy, slightly bent, very easy to treat, and it turns it from a two day stay in hospital at least part to both days. 22 hours in hospital. If you just sedate them, push it straight. Take an X ray. Put a cast on, check their okay. Eight year old, fairly straightforward three year old rib fracture. Alarm bells ringing. How does a three year old have time in? It's busy life to get re fractured shouldn't be fractured in the first place, should it? So you have to think about the nonaccidental injury. That's the very angulated one. It pushed back beautifully straight, healed very quickly and very rapidly down syndrome. We had a bit of fuss with this because people are saying, Oh, you need an east this and this that and the other. And Mom said, Well, really, she just freaks when she sees in her niece this could you not just do it here? Uh, and they were much happier. Um, 10 year old girl and I have got all of these patient's into a follow up clinic by agreement, not by funding. Uh, and I will review them. Um, at two years after in jail, I was going to do it this year, but I've had some challenges, which meant I couldn't do it this year. So I'm going to do it next year. I've written to them all. We wondered if this one would streak it streak its way into the craft study. But as you can see, it's obviously, um, not um, a tacis. And one of the problems with Kraft is when you use the Muller Square to diagnose the metastasis of the distal radius on the AP radiograph pre reduction. The distal part of the bone is foreshortens, so you can't accurately tell where the metastasis begins and ends for the purposes of the study. Uh, straightforward. So I think you probably all agree that we shouldn't be admitting patient's for things that we can treat in the emergency department quite safely. What is the point? Worry concern. You might be sued. People might be unhappy. The quality might not be good enough. I think audit is not a good tool for determining in quality, and it probably should be studied properly. But it's something that's got popular support at the moment. So who's got to do the exam? Your hands up. There's a lot of senior trainees in here. This is something that will you will be asked about this at some stage during your your exam. Now that's an interesting fracture, because I don't think you can have a pediatric gal iatse. But you'll see that the epithets ISS of the owner has remained with the distal radius and the metastases, a departed company. So he was really easy to reduce. Never it reduced such an easy fracture. I think it was so mobile. And you're getting to these at a point when they haven't had a chance to stiffened. Swell. Periosteum is not contracted, so you can reduce these really easily. The quicker you do than the issue it is. Um, that one's another one that probably would in the early stages of craft, have got in. But I've noticed following the craft website that craft is getting more specific about what it includes now. And based on what was said yesterday, this wouldn't get into craft now. So I think there is a challenge coming, Um, with the interpretation of those very big studies that was the one, as you can see, that he's off ended and she went for elastic, stable interest. But Hillary nailing saw a reduction in theater and closed treatment. So at the moment, I think the questions we need to ask ourselves is we can do as we're asked. It's actually, once you get it set up and running, you can tell this is the best thing ever. I can reduce the mores that can treat the child better and quicker, get them home, save utilization of a bed utilization of a theater. Give that to someone else who needs it more. But if you rely on patient initiated follow up, which is all you really got when you're doing audit because this is not funded research, this is audit. Are you going to see any problems coming back? Because Children do one thing better than any other human being, and that's adapt. So if they got a slight restriction in Super National pronation, they won't come back. They generally he'll, so they don't come back with pain. And at the moment, we haven't had any patient initiated follow ups once they've been sent on my way. Um, the other thing I have an issue with because of my generation is Is it reliable? Is modeling reliable? Can I use modeling of a fracture as part of my plan for management? Is that reasonable and acceptable practice? My generation would think not. Maybe your generation will think differently. And, of course, the only people we need to convince are the lawyers. When you come right down to it, almost all kids will model to a degree. They will adapt to minor restrictions in ranges of motion and they'll just get on with their lives. Very good friend of mine who's an extremely good mountaineer has run the mountaineering school in Lezin uh, for 12 years now, But he can't super Nate because he had four. You've got banana shaped forearm from a childhood fracture, which means I'm even when I was slim, I wasn't a great rock climber, but if we went climbing with him, I'd always find a route that needed under under clings because he couldn't hold on if he had to hook his hand around like that. It's great to bring people down to your level. My find, um so I think those are things you need to know about the, uh, forearm, I think is an area of it used to be said. People used to say, I can't see the reason for fixing a child's forearm, and they probably had a point when it involved in open reduction and plates and screws, then another operation to get the plates and screws up high infection rates. High refracture rates high nerve injury rates, but it's not like that anymore. There is a better way of doing it, but If you see this, this is a nine year old. I came in the day after he'd been fixed at night and I went to see him on the ward and he's in pain. He can't tell me what he's numb or tingly or anything. He's got perfusion. Um, he's not really moving his hand. It's just like he doesn't want to move. He's obviously in agony, Um, and this is what had been done. So what do you think of that? Can anyone see any challenges with what's been done? Do you need to get closer? Well, there's a cast on. Do you need a cast after you've performed an adequate, elastic, stable intramedullary nailing No good. There's a man. They're shaking his head out of all of it. One person you shouldn't need a cast to have stability. Casting for pain relief when the fracture is not reduced as it's unstable can help. Um, so that's the first thing. Shouldn't need a cast. But the doctor who did it said, uh, well, I thought it might not be safe to leave it without a cast. Why would it not be safe? You just fixed it Well, maybe didn't fix it very well. Do you think the pre contouring of the nails is anywhere near what was recommended by the non see group? We developed this in 1980. This isn't new technology. It's been around since before I became a consultant. The nails should be equally prevent, and what I choose is the curvature of the radius on the uninjured side. Because then I know that if I get the radius reduced, the now that's in the bone won't be exerting any force unless I exert a force from the older to bend the ulnar away from that. And then I get balanced equal forces in the two bones, so I bend them both the same. I don't have one straight nail and one curve. Now that would be silly. It's elastic, stable, intramedullary nailing, which relies on pushing the soft tissues against the bone and tension ing everything. And it's the pull of soft tissues on the bone that's being pushed apart. That aligns it. That's how it works. Anyone got an issue with those entry points? I can't use this thing ones in the radial styloid, and one's in the proximal owner. What passes the medial side of the proximal owner. Come on. What? On the negative. Where is that entry point in the OMA. So is it straight through just behind or just in front of the on the nerve? Yeah, it's media. You wouldn't leave it there, would you? That would be stupid. So it does show you that some people don't think about what they're doing. That's basic anatomy, isn't it? So you don't use that one. If you're going to use that entry point, you go on the lateral side of the proximal there. And I don't like this entry point because I see quite a lot of superficial radial nerve neuromas and that agony if you've got one. So I don't use that entry point anymore. Um, do you need to think about the orientation of the nails at all? Yeah, well, the obvious answer is yes. She just, uh they're both pointing in the same direction. So if you bent them away from each other, then you put them together, so they're spooning each other. They're not exerting any force, or they're exerting a force in one direction. So that's likely not to be a stable configuration. What about the diameter of the nails they're the same hands up for they're the same. Hands up for their difference. Oh God, I thought he died. Thank goodness. So they should be the same, shouldn't they? Because if you use one piece of curved metal to exert force and then you bend another piece of metal to the same curvature, but it's thicker. You have to use more force on the thicker nail than the thinner Nalle, so they don't push equally and oppositely against each other. So this isn't three point bending to produce an interference fit in the canal. This is generating a construct of at least six points of force that are pushing each other apart. Yeah, really important concept, and you have to get that in your mind. How am I going to get the reduction? It's not the nail that does the reduction. It's the nail that generates the force that allows the soft tissues to be set tensioned to produce the reduction. Is that reduction any better than you get by? Just bung it hit the cast, having given a bit of sedation and pushed on the cast, it's not easy. There's no radio bow and there's a transverse plain deformity. You can see that the rotation can't be right because the width on one side of the fracture, the width of the bone on one side is different to the width on the other. And if they're both rotated the same, there's no difference. So who'd revise it? I'm breathing down your neck. Your career depends on this. Were you just stretching, or were you thinking Come on, Who's going to revise it? Hands up. How better they you can't tell? He's just in pain. And that's just what happens if you leave someone in the back slab with an unstable fracture. They remain in pain at this age. All they do is yell at you or, worse, go very quiet. That's worse, isn't it? With Charles Quiet, Um, so no one's going to revise it. So you've all taken this kid to theater. You've done an absolutely pathetic job. You've demonstrated no clinical skill or acumen. The lawyers are going to eat you alive. Hopefully, and we'll get a new set in for next year. Come on, you can't do a bad job. What do you do if you go to the car and say that engine is not working very well. You're going to pick the car up, but it's going worse. Are you pleased with the mechanic? Do you take it back to the case? I I told you to fix it. Would you say thanks for trying and beetle off. Really? You do have to look at things and you say, Well, that's not good enough. Because otherwise why did they take the post Operative X ray? All that ever is is a quality assurance check, isn't it to an X ray immediately after a procedure? What? What what good is it so the boss can give you a kicking? Yeah, hopefully the parents in the lawyers wage. But you know, you have to think about we do the X ray as a quality control measure. So if you got a clinical situation which is not good, you've got an X ray. That's not good. There is only one thing to do correctly, which is to make it right. So this one was revised very simply. What's changed? Larger diameter, nails, more force. They're equal diameter nails. They're equally pre bent. And you can see here Massey that they're opposing each other tips of pointing at each other, not in the same direction. The entry point has changed for the Ulmer because I didn't fancy making a hole on the other side of the elbow. I just decided to use a new entry point. If you're using a larger nail than the one that was in there already, because you're using a new entry point, it will gain a secure grip. You know, it's not like a little nail wobbling around in a big hole, and both those nails had an equal pre bend on them, although the one in the elder look straight because when the elders reduced, it is straight, isn't it? And, uh, the reduction was improved. The child in recovery was pain free and went home that afternoon pain free so you wouldn't have left the first situation alone because you have been cruel. And what did they do to People are cruel. Two Children was in the news this morning. They send their mother out with a knife to stab them to death, don't they, poor lady, and they heal beautifully. They get moving really quickly. The only problem with these kids is sometimes you do have to tell them. Don't climb a tree for six weeks. Please don't go back to rugby for six weeks. Please. You really have to restrain them. Can you do better than that? Okay, well, of course you can. I wouldn't ask the question of those, would I? These new entry points aren't new anymore. But the disk loner entry point, I think, gives you better access. Um, two, the ulnar. Generally, it's easier to put it in from proximal distal because you're going from a funnel into a tube. But actually, you've got two entry points close together. I'm using a list of tube ical, third dorsal compartment and fifth dorsal compartment for the ulnar. So the two entry points are close together. The spread of the nails is better. The fixation points are easier to get equal and opposite because it's sort of easier thinking. I've got to turn the nail tips of the pointing each other, and you properly spread the interosseous membrane, which makes these really stable. So I think the state of the art is to do it well. And if you do anything well, the way it was intended tends to work. Well now, The other thing is, if you use a list of two Big one point, the complication is not in your oma. It's an EPL rupture occasionally, and you can very easily repair that with an extensor industries appropriate transfer. It is sensible to check that they can do that before you do it, but they've got a broken arm so they can't. So check the other hand. You still know about this. Do you all know about this? Yeah, 4 to 10 year olds less than seven days from injury, and you either put them in a cast or take them to theater and put them in a house after a manipulation. They're trying to find out whether the need to go to theater is required or not slightly ambivalent about it because of my generation. But I'm contributing patient's to it. My worry is that they include the Salter Harris ones and twos and the metaphyseal injuries. Um, I would personally would, when you look at their design specification, it says Metaphysis Seal and Salter Harris. I would never put a Salter Harris three or four into the study because that would be silly. There articular fractures for a start. Um, it's amazing how difficult it is to use the Muller square there before you've reduced the fracture. So I'm a bit worried about what they're collecting, but they're doing it. It can't be wrong. Everyone knows about the science trial. It's the medial epicondyle trial. Yeah, they're recruiting to see whether or not you need to reduce and fix the medial epicondyle. Where's this medial epicondyle? Come on. Where is it? Yes, in the joint. Well done. So you do need to reduce and fix this one. And you do need to reduce and fix the ones that I would suggest that I've got all the nerve injury because very often the nerve is between the epicondyle and the surface of the joint, and they don't do well if you try and do them late. Um, sciences diff difficult to recruit to because it's not a very common injury. But you should know going into your exam about the craft studies and about the science studies. They're both pragmatic trials. They're both well on the way to recruitment. I think Kraft might help us not take so many patient's to theater. I've got a sneaking suspicion. Science will tell us that you do need to do fix someone. You don't need to fix all of them, which is what we already know. But I I hope to be proven wrong. No, I think 45 minutes. So I think that's enough of an update. There's lots more in kids, orthopedics, and I can talk to you about anything at coffee that you care to wish for. But I thought, What do you tell the trainees, and you tell them what they need to tell the Examiner. So I'm sorry if I've board some of you, but thank you very much for listening to me. Anybody got any questions for Mr Dwyer? Anything burning other than the bit? Yes. Question about the removal of the fentanyl? Uh, it's still some people have to say that. Well, you know, is this working? It's not difficult. I mean, I would always suggest that you leave the nail. There's a very nice set of pliers on the on the instrument kit. Just make sure you can put the plier at 90 degrees to the axis of the nail. And don't leave them in forever. Just wait until they're healed. Now, when's it healed is what you should ask me, and you take these nails out when the bone looks like a bone again. So when the calluses modeling back to cortex and it's looking like an intact bone, not not like a snake that swallowed an egg, then I think it's reasonable to take them out. It's, uh, it's interesting. I don't seem to have very many trouble taking nails up. My colleague short, bald and less good looking than me and considerably older always sends me his necessary. I think I've lost the end. Just be sensible. Leave enough out to get it out.