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uh, if we can invite you back to the back to elect and so and is going to talk to us about everything you need to know about pediatric shoulder and elbow elective 15 problems in 15 minutes. Thanks. Uh uh, Yes. So we will. I'm going to look at some common stuff, but unfortunately for you guys, what you need is the rare stuff. So we'll talk about that as well. Uh, and we'll look at just the broad sort of management principles of the kind of things that come through my clinic. So when I looked at, I thought, How am I going to do this? And I'm going to get my joints? Am I going to do it by you know, causation or by likelihood, that you'll see it. And towards the end, you'll see that there's more and more a hen's teeth. So, uh, starting at the shoulder, the things that I see are this list and I will go through them starting with instability. So bear in mind, I only see sixteens and unders. Okay? Instability. The instability that I see is usually post traumatic first time dislocation of 14 or 15 year old and Uh, by the time they've had the chance to Reedus locate, they're already adults, so I often don't see what happens to them if you see what I mean. I just see the initial presentation and we hope for the best. We do the physio and then they sort of disappear. There are a few exceptions, so I literally saw a kid on Monday who is pro acrobatic dancer, and she's on the bath sort of acceleration academy thing for her athletics, and she's started, develop some shoulder pain and she's got sort of subluxation of her shoulder. And that is a thing. So you can get a kind of repetitive, effuse phenomenon where you can cause similar amounts of damage on the inside of his shoulder. But you've never actually dislocated it, but she can do it. I watched to do it. She sort of went and it sort of popped out and flipping it. We're not popped out. You could just see that it was wrong, so that's really rare. So she's the first one I've seen in absolutely ages. And so she's going to get an MRI, ideally an MRI arthrogram, but weirdly because I work in a pediatric center. We very rarely do m r arthrograms because we don't like do them. That's an adult thing. So you'd be better off in Yeovil to get an MRI arthrogram. Then you will at the Children's Hospital. We can sort of get them, Uh, but it's tricky. So that is the gold standard. Obviously you guys know that, Uh, so she's going to have an MRI scan and then we'll figure out and then she'll get physio. And I've had one kid that used to always pop out the back, and he was a bit weird and he had some college. An abnormality, I'm sure, and I sent him to stand more, and that's it. Like in nine years. That's all I've seen. So it's not that common. To be fair in under 16, uh, spring gal's. This is, like proper. They love it. And the exam that they bit Sprinkles. Um, it's again. It's pretty rare, like I've seen a few in the last nine years. Maybe 41 of them is bilateral, so it's three kids. Um, there's this classification system, which is the Cavendish classification system that just looks at how it looks from the back, Um, and it's It's a, uh, sort of embryonic problem with a failure of dissent and failure of formation of a scapula. But the ones that you'll see might be associated with other syndromes such as Klippel File. That's the one that's always on all the bullets. Um, those are the ones where they've got a multitude of abnormalities, and it's associated with a known reversible bar. And, uh, cervical spine changes. Um, that's a clip on file. So they've got, you know, the low hairline, the classical triad. They've got the sort of sticky up scapula and the virtual part with all the other stuff that goes with it. So the renal, the long etcetera, etcetera. Um, you might see one of those in the exam. I guess they're static. They're stable. So it might appear, uh, they're not doing short case uppers face to face, but they're about to restart. So that was discussed at the last lot of exams. So don't don't relax too much that you might not have actually see an apple impatient in the exam because it's it's coming back. Um, this manage management is described. I've only ever seen one. I'll be completely honest, these guys would know better. Probably. Um, it's it's about patient selection. So if you've got bilateral, do you tend to operate on them more if they've got a restriction, a deduction, cause it's bilateral, or do you look at it that it's the unilateral ones that are cosmetically displeasing? So are you more likely to operate on those? Because if it's bilateral symmetrical, But if it's not, then you're not, um and it's big surgery. You sort of go in and you peel it all off. If there's a bar, you take it away. Um, this variable stuff about the results, I think they kind of like some people say, 40 degree increase in abduction again. These guys would know better than me because we don't know. Okay, they got a good, good, well, 40 degree increase in a be deduction. Uh, is what you can expect, But you might have to ask just, um, I the clavicle. And I don't know. I think it's really selective Patient's. They do do it in some places, stand more. I think they do some and I think up in Leeds. So that's more the sort of pattern that you see, and I think that's about function. So if they really, really want that high level of surgery and they think they'd be better with 40 degrees more of shoulder a deduction, I would probably try and talk them out of it. But if they really, really, really, really want it, then you might be in a situation where you have to think about doing an operation. Uh, that's just to say that when you do a chest X ray, it's often easier to see in real life than it is on a chest X ray. It's quite subtle, like the really mild ones are quite subtle, so you're gonna have to do three D imaging as well, so you have to scan the next scan, the spine scan both the shoulders. See if they've got these little fascial bands underneath the scapula that, apparently amenable to reception clavicle pseudoarthrosis Again, I see a couple of these every now and again. It's not that common. Um, it's a failure of formation of the clavicle. It's mostly a cosmetic problem, apart from if they get, like thoracic outlet syndrome sort of symptoms in later life. That is an indication for surgery. If they're getting those kind of symptoms, it's associated with the syndromes listed there, and it's usually on the right side. You guys might be able to remember that I could never remember it. So I always thought, If it's on the right, then that's right as incorrect. That's why I always remember if it's on the left. There's something going on with the heart, probably. So just think that's a bit fishy. So if it's a left sided, then it might be because they've got ascites inverted or dextrocardia. And again you can operate or not operate, depending on what you read. But it's you take it down. You graft it, you plate it. You couldn't get anywhere. Yes, it could. So this is a true case. So 14 year old patient has been referred by their GP to the specialist shoulder therapists at the adult hospital up the road, and the physio has gone in to grab the adult shoulder surgeon Mark Rather okay, you know, and, uh, he's, uh she said, Can you come look at this kid because they've got really weird shoulders? And Mark wrote me a letter that said, Just in this kid They've got really weird shoulders. So she came to see me. She didn't have any pain. And the report says that she does these slightly strange trick maneuvers when she's trying to do things like Open the Fridge door. So she walks into clinic and one of my trainees was just come back from the exam and he'd seen a specific condition in that exam. And I saw this kid and I thought, Oh, she's got that So when I sort of had an inkling as she walked through the door. But there's no family history, there's no trauma and she's got really very strange winging of both of her scapula, and she just can't lift her arm up. She's an only child, and her mom says she's always done this really cute little thing when she opens the fridge, where she kind of goes like that and grabs the handle. I was like, Okay, that's strange. And her friends tell her that she's got a resting bitch face right? That's true story, right? It's hard, but she goes from all girls school, and that isn't her. But I couldn't find a better picture. Sorry on the Internet. Anybody want to shout out what they think is coming. I haven't told you the key discriminator. That is what everyone wants to do in the exam. Which is what we're getting up to anybody head where we might be going with this. I'll look away. He just shouted, Okay, it's that. Have you guys heard of that fascia scapulohumeral history. So they have a very distinctive face, so really sort of. It's sort of emotionless kind of face. And the thing that they ask you to do in the exam is can they whistle so they can't purse the lips? Um, and they can't often close their eyes properly because they're two week around the face and it's a it's a muscular dystrophy, and what you should do is check their CK, although it's not always abnormal, and you're going to have to send them to genetics and send them to the neurology expert. What you mustn't do is get really excited that you first seen your first one in real life and call in every single registrar to come and have a look. And then, as they're Googling it and the patient looking, they realized that 20% of them end up in a wheelchair and then you think, Oh, I really wish I hadn't done that. So they can be a spectrum of severity. So, um, it they love it, so just be aware of it. And it's the whole. It's the whistling thing that they like another random one. So, uh, 16 year old's been seen by my colleagues in another hospital, and then he's got stiff elbows and they're like, we've checked him over. We've done the US we've done M E R s. We've done X rays. We just can't get on top of it. And he's got really stiff elbows. So he comes into clinic and he's got really stiff elbows. You can't bend them. It's getting worse. There's no pain, There's no family history, there's no trauma. And he just looks really weak. And you think, Well, he just looks a bit muscular. Dystrophy. So, um, anybody heard of any muscular dystrophies that that might apply to deficit? No. Neither could I. So what you do is you send him off for up to date X rays while you quickly google it and you discover that he's probably got Emery Dreyfus Syndrome, which is another rare musket destry that sometimes you see and the reason this is important is because they come in with these week. Russell arms can't bend them, but it's associated with complete heart block, and they can just have a spontaneous cardiac arrest. So you do kind of, Once you see it, you need to speak to the cardiologist and the justice so it hurts. Most of you will have read about the spectrum of things that you see in a pert, and they have classical hand and facial features, but also they can have unstable shoulders. So that's one of the things that I've seen in the past in my clinic. It's a different kind of instability, and it's managed nonoperatively usually. So I'm an elbow, uh, in my specialist arm and elbow clinic. I see this list of things, uh, so we'll go through them. This is probably less common than it was, but it's still pretty common, so you'll have all heard of a Gunstock deformity, and that's why you get it. It's usually after a supracondylar, but it doesn't have to be, um, it's usually a sort of misjudged to be fracture Garland to be, which it can be difficult to judge. You know, we try and measure things that we but you can. And I for some reason I can't really predict because I've seen some elbows that look and some have been treated in traction that are completely not reduced, and they've had an amazing result. And I've seen some that you look at the sugar looks all right, and they end up in my clinic with that sort of picture, and I'm not entirely sure yet how to predict which ones. And it's a cosmetic problem that kids run around absolutely fine. They can swing off monkey bars, their arms look a bit funny. But if you leave it like that, theoretically, then it's gonna it's gonna destabilize the ready seal over time because it's the wrong shape. So there is an argument for fixing it, and you either go in early and give the parents what they want. So age sort of sixish you can do a closing my age osteotomy. Fix it with some wires, or you wait till the bigger and they can be involved in decision making, and then you can do an osteotomy and fix it with you know Precontoured, uh, specific plates. And there's different osteotomy describe. I tend to just do a wedge. Um, OCD. I'm not going to labor too much because they're really, really common. You know all about them with there's a classification, but just don't forget about panners. So if you see what is an OCD in an under 10, it might be panners, which is an idiopathic avascular process on the capital side. It gets better. It doesn't need surgery. It's birthdays in your wrath lateral side of your elbow. Essentially, that is the classification. Um, if they're stable, you can manage them nonoperatively. If it's unstable, then you need to adopt a different approach. The problem. The main difficulty with this particular condition is that they are so active these kids that it's a stress fracture. So they're always doing something boxing or whatever it is. And it's trying to manage the expectations of how much time they need away from sport. And that is the one of the most difficult conversations I ever have in Clinic is trying to just get these kids threw their treatment because they just want to get back to it straight away. Congenital radial head dislocations. The controversy with these is when parents don't notice it until their kid is like 11 or 12. They assume that there's been they try and associate it with the trauma. Well, he did fall off his bike when he was eight, and it was probably then, and it's trying to get them to understand that there's probably even present through birth. And it's not something they've missed. And it's not something that they, you know, they've done. Um, and there's different types. It's associated with different conditions, so you have to check them out for other conditions and generally the management. You try and keep it non operative. But if it looks like that and it's abutting the back of the capital, um, as they're getting older, you might want to consider a radial head excision. But it's not a great operation in kids, and it's associated with risk, pain and things because you get instability, any forearm. So, um, just look out for it. Do a scan check. They haven't got anything else, and, uh, explain to the parents that it's one of those things in America. They're trying to identify them in the neonatal period and put them back in like a hip. So we haven't adopted that in England. So radio on the synostosis is again kid presents. It can be unilateral bilateral. They go to nursery, they can't do something. Somebody notices that they can't do something. And they present with these kind of pictures, um, can be inherited that autosomal dominant condition and it's associated with other conditions as listed there. Um, if it's bilateral and they're struggling, then you might want to consider a D rotation osteotomy of whichever arm is in the wrong position. But what we think about is position for forearms has kind of changed over the years because a lot of what we do is is pro nation now, whereas this whole sort of taking change, I mean, who had one the last time you took money? Do you know what I mean? So those things change a little bit, so you just got to do a functional assessment, see what they need and then make a decision. There's lots of different osteotomy is described either through the actual synostosis or you can do distal in this different series. Uh, and that's classification. Multiple heretics. Osteosis this is common, and it's great exam, father. There's lots of them. They're stable. They've got loads of signs. Um, they it can cause a dislocation of the radial head. If you get so with these ones, like I've got a family and every kid they have has got it. So they're looking out for stuff, and this kid's got one in a in his proximal rays. Only three. And I saw him six months ago and he had full range, and I saw him yesterday, and he's now getting a block to pro nation from his radial head. So I'm in a situation. I'm thinking I might actually have to do something. So, um, they if you leave them, that can happen. So again, this I've got one patient with this in my list of that. I see she's got your fibrosis, as does her mom. And they get this all the pseudoarthrosis, which is rare rare. It's much rarer than clavicle and tibia, but it does happen, and even rarer is a radial one, which is really, really, really rare, and you sort of have to treat it a bit like the tibia. So you have to expect that the That whole segment of bone is very abnormal, and you can see the hammer home. And where it's pushing up against the radius, you can see the radius looks a bit weird and a bit thick. That's because of the compression from the from the illness sort of side of pathology, and it's difficult to get into you night and you have two things like free. Fabulous. But I've sent her to gos, actually, for a second opinion. Cerebral palsy, um, is common. We see it mostly in my your muscle clinic. I see the Hemiplegic patient's, um, sometimes I see very severe total body involved. You've got problems with hand hygiene and dressing. Um, and the management is bespoke, depending on the patient's general health. If it's unilateral CP, then you're looking at sensation in the limb and rehab potential before you make any decisions about what you're gonna do. And the typical postures is pro nation flexion at the wrist and from impart, and you can do quite a lot for those in terms of re routing and things. If they're a good candidate and we'll respond well to the Splinting and the rehab and the therapy that comes afterwards. But if it's a completely neglected limb, which would assess on a Shriners hospital, upper extremity assessment is what we do. Then it's probably not going to do well with surgery no matter what you do. So there's a lot of rest off. It's varied. Kids are different. Just remember growth plates. Remember that growth is a thing. Unfortunately, you have to read all the bullets for the exam. Done. No offense. Any questions for you? You're running away already, But any questions for mhm? And what about Botox? Using that for First CP in the kids? Yeah. Just gonna be ssep. Catch up about it, though, Where there's more units moving away from it because they're a bit worried about long term changes within the muscle. But at the moment, we're still very pro. It's a bit trust dependent, but yes, we do in Bristol. And it's a good treatment. My patient's ask for it, so they like it. Brilliant. Thank you very much. And, uh, any questions? Thanks very much.