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Yeah. You have enough for the show itself or not? I can introduce myself. It's all right. It's fine. So I'm on the clock. I'm an orthopedic consultant. I'm from the Children's Hospital in Bristol. Um, I was watching that talk thinking, always talking about stuff that I'm going to talk about in kids. And we just don't do it quite in the same details. So, thankfully, there is no massive contradictions in what you're about to here. Um, yeah. So, um, uh, pediatric couple in fractures will start at the top and we'll move down. I'm just going to go through, refresh your memory and try and see if we can give you some gems as we go along the way, starting at the clavicle. And look, I've put pendulum of management. I knew what was coming. So I sit in the adult trauma meetings, and it seems to be one week they're fixing all of them in the next week. They're not fixing any of them, and then somebody comes in there. So I'm going to fix them all this week, and I just sit there and go. I'm so glad I'm a pediatric surgeon because we but I'll tell you that's so. They're really common. We see loads of them. It's adolescents. Usually they fall off a mountain bike or they're doing some sort of, you know, karate or whatever, and they fall directly onto the shoulder and they feel a lot of our fracture clinics as well. Or they used to. So nowadays, what we do is the eights and unders. They don't even make it as far as our fracture clinic. So if you're 800 you've got a midshaft clavicle fracture. We will triage it as the consultants and then our specialist nurses will phone the parents and give them a device so they don't even make it unless there's a problem. So we've sort of got took 12 and under. Generally, you don't do anything, but you always have to think about all the caveats to that, so skin threatening or polytrauma, you might have a different conversation. So if that child's got a significant head injury and there we've had one who was sort of combative and couldn't sort of, you know, we couldn't keep them still, couldn't use the sling, and the skin was threatened. All those kind of things then you might want to go in and fix it, so there's always, you know, never say never or always in orthopedics. What we sometimes get is the adolescents that I've got a really displaced clavicle fracture and we say We're going to manage this non operatively and the parents look at you like you say what they're like. You know? Um, he plays Team G B rugby. He's been scouted for this. He's been scouted for that, and they can see they're not silly. They can see that it's miles away, so you have to have the chat with them about the Periosteum. You have to reassure them that the periosteum in a child is very powerful structure and that the osteoblasts will find their way across and you can reassure them. And if they're still worried about it, then I always bring them back 23 weeks later, and I show them that it's starting to heal, and generally they start to calm down and then spasm around the shoulders. Gone, it looks much better. My shoulder colleagues at the adult hospital next door have said that if they almost always heal, we very rarely see cases where they don't heal, and if they're worried about it later, then you can do a little bump ectomy. If it's cosmetically bothering them or it's pushing up against rucksacks and stuff. I don't know how controversial it is with the adult shoulder surgeon, so that's what my guys tell me to do. So I've done it once. Most of the time they get over it and they're not bothered, and I don't see them again. If you see a neonate with a fractured clavicle, then just always think pseudoarthrosis, because that's pretty rare. It can be a birth injury, but just think about it. And if it's on the right side, then really think about it. So as we said, there's no two Children that are the same. So, uh, this is a kid that I saw who is the son of two of my colleagues. So one's a respiratory respiratory physician that I went to medical school with, and his, uh, and his wife is a GP, and their eight year old was playing football and Dad was a bit overzealous on a tackle, pushed him over and he ended up with that fracture and we'd all look at that and go. All right. And it is a It's gonna be okay. And probably because he's a doctor. Well, doctor, child, I should say, uh, we x rayed him three months later and he still wasn't quite there. And I think that was partly his parents being doctors and pushing him and pushing him it'd be all right. I'll be all right. You know, it doesn't matter. Get back to football. Whatever. Let me push you over again. Um, but eventually it got there, so they generally do Fine. But there's always the odd one that you might catch you out. Another example of where we have had to fix one. This is a 14 year old, uh, he's mountain bike. A typical story, and he's got that sort of a pattern. Um, and even I can tell as a pediatric orthopedic surgeon that a is older, so his bones are a bit more like adult adult bones in terms of how they're gonna behave, and that doesn't look like Well, unless he calls an uber, I don't think those osteoblasts going to get across that gap. So, uh, it was we opened. It was all trapped in the muscle you know it needed fixing. So I learned a lot that day because I hadn't had to fix an adolescent clavicle for a little while. I learned that our table doesn't bend the way I wanted it to bend, and I also learned your fancy shmancy clavicle. Plates don't always fit, so that was a top lesson for me. So I had to use an opposite side one on that side, and then it did fit. That's what I meant. It's your but they're not my place to your place. I don't have a place for this, but we have to borrow it from next door anyway. It worked in the end, coming down so humorous again, similar in adults, but even more so, we tend to manage most of our human fractures and Children non operatively again. There's always going to be, you know, the outliers to that polytrauma patient's we've talked about. If it's open, it's open in the street. And, like an open fracture in these adequate wound excision in these or the plastic management potentially, uh, and it needs adequate stabilisation. Particularly there's any soft tissue sort of injury. Um, adolescents are a bit different this is a case that I was involved in. He came in. He had his arm out of a car window when the car rolled. Thankfully, my consultant colleague that was on spotted that his elbow looked a bit funny, organized a CT that was open just for information. The humerus was open, and he also had an election on fracture on the radial neck fracture, which I don't think that he's not seated. Missouri's in cast. So had he not see TDM, I think another day we might have missed it. So he had a proper open. Everything fixed, uh, soft tissue, you know, management as appropriate. This is the one that everybody gets excited about, and you should do because it is an exam prerequisites. So you need to know your supracondylar. You need to be super confident in how you're gonna manage your super condos. You need to chat the chat, talk the game mirror signal maneuver when you get to the exam. If you're presented with one in A and A, it's always a bit hairy if the kids screaming, but you have to do a documented nerve and artery check, um, so make sure that they've got reasonable cap refill. If you can feel a pulse, that's great. It's not always that easy and a little kid, but try and feel a radial pulse. Check what? That that the hand is pink and refused. It looks like the other side and do the best nerve check that you can. So what we try and do in our unit, and it's because we've been caught out before is often. What happens is the kids always come in at six o'clock. Don't know with a supracondylar. They've always just had a McDonald's. It's always a nightmare, the register that's always neurovascular intact and you've actually intact. But the number of times I've come into the anesthetic room and got the kid to do a proper neuro as best I can, a bit calmer by then started nice drugs, and they have an AI am. Palsy is really more common than I would like, And if I didn't know that about that, I'm going to feel really bad when that kid wakes up in the morning and it's still doing this and not this. Okay, so it's difficult, but just try your best to get as much out of it as you can with distraction, whatever. To get a decent nerve assessment, there's new, both guidelines. We'll talk about those in a second, but essentially you can look them up there. A really good guide. They tell you everything you need to know. They recommend that you use to mill wires and a minimum of two wires. They say that you can go from either side. You go to laterals or three laterals. If you need it, you can do crossed. If you're gonna do cross, that's fine, but you have to do a documented. The nerve was not through my wire, so you have to have seen it and you have to have written it down. Otherwise you could get yourself into trouble. Um, the other situation that we sometimes get into is if What happens if you can't reduce it. So this these these sort of things that I get asked what happens if you can't reduce it, so I'll talk to you about the technique in a minute. But don't forget with these that it's better to have a straight arm with a nerve and an artery that's working and just put it in a little Thomas splint overnight. And if you need to or leave it in, you know in in traction, if you can do straight pull, which is what they do in Stoke, that's absolutely fine. That's better than ripping away at it, opening it if you're not happy and doing more damage than you intended to. So don't forget. Traction is the message. Pinkham Pulses is controversial, Um, so I might move on to. Actually, what the old guidelines used to say is, if it if it was pink and pulse that you could leave it, it wasn't a surgical emergency, but that little bit that I've highlighted there says that it should be provided urgently when there's an absent radial pulse or clinical signs of impaired perfusion. So that is a change, and they've tried to keep it deliberately vague. I would say, if the if the hand is pink, it's 10 o'clock at night and they just had the McDonald's. I would still leave that until the morning. If there's a nerve injury or you're worried about cap refill or anything that has to. It has to go because the nerve injury kind of implies that there's an arterial injury as well. So if they've got both, you'd be a bit like I should probably do it, you know, even if it's getting quite late. Um, but just remember that little change, because it is It is a change if they're pink, um, pulseless at the start. And they're pink, um, pulseless at the end. That's okay. All that means is you have to keep them in for two days. You have to observe them because you want to make sure not gonna get compartment syndrome. And if you're lucky, which most of the time you will be when you recheck the Doppler the day after the day after that, it will be back. And it's just gone into spasm. If the day after they're still they've got a median nerve issue or a a I an issue, then you might want to have a little think. And there's some. There's some literature that suggests early exploration in those We've not adopted that approach, and we've not had any kids who got long term, long term nerve injuries or any issues with, uh, kind of vascular problem later on. So the technique you you might have your own way that your consultants have taught you how to do it, but the basic algorithm that we use is that you pull on it for five minutes and it's a proper five minutes and five minutes is a really long time when you're sweating and it's 11 o'clock at night and you just want to go home. But watch the clock, pull on it for five minutes, or milk it or do something but at least five minutes attraction. You should try get it lined up on the AP so it looks beautiful. Get it all set up so you know where your X rays coming in from and you got your assistant that, like, with the bottom by the head and you're doing that and you're pulling on it, and then you do the electron technique with double thumbs and electron flex it up. If it feels good, it probably is good. So if you can get it up and it feels all nice and you can pin it with one hand, hold it with one hand around here probably means there's nothing in the way. And when you get your laterals, it's gonna look nice if it feels a bit a bit squishy, then it probably is a bit, and that's because there's something trapped in it. It's not quite reduced, and it's often hitched to the back with the periosteum. If that doesn't work. What I've sort of taught myself over the years is you can get it flexed up and then grab the distal bit and you can kind of like in a small kid you can use. That is the translation that sometimes difficult to reduce so you can get the bit distantly and you can kind of sort of feel it and sort of pull on it and put it where you need it to be. But with it in a bit of flexion. And the other thing that really, really works that not everyone thinks to do in the heat of the moment is if you really pronated or really super nace it. Sometimes that does help, and you can watch on the actual Oh, that's better. Thanks. Uh, so don't forget pronation Super Nation for reducing your columns and then whatever wiring technique you want, we normally do to laterals where I work, but you don't have to. You can do crossed. If that's what you've been taught and you prefer the other one that sometimes catches people out is the sort of it's not really a super condo to like. It's a distal humerus fracture in an older kid, so it's a bit commuted. The Periosteum is not as favorable a four year old with a super condo as a dream because they got really thick periosteum and it normally just clicks back in eight year old gymnast Acrobat. Whatever you're looking at that I think that's a bit. It's going to be harder in in my practice. I think these are slightly Dodger. Uh, so you just have to be a bit cautious and they're not always amenable to wiring, so I'll show you the picture of that one in a second. The other one is floating elbows. You got supracondylar and associated forearm fracture. That's kind of high risk for compartment syndrome, and some people would recommend that you do a fasciotomy on the table. You can. I mean, you can assess it clinically, and if you're worried, then yes, but certainly even if it's a relatively on undisplaced, not too bad forearm fracture of some nature, you probably better to fix it because you can't put a restrictive cast on it to hold it and expect them to not get compartment syndrome. So they've got two fractures. Don't treat the distal one with the plaster because it's two tights. Bad. They might get compartment syndrome. That's a disaster. So that particular kid did have a floating elbow, but the wrist was not very exciting. Ky it it, uh, and I ended up using our little I won't tell you which brand small little plates. Uh, so we've got a set that's got lots of plates to fours, 22 fours and two sevens. And it kind of means that you've got more options, so you can just go in and treat it like an adult fracture. Really? Lateral condyle fractures next. Most common one that we see tend to be in a younger child, usually a fall from height. Is it a pool? Is it a push? We don't know. We don't know what knocks off the condyle doesn't really matter. Um, the common and they they're they're more Well, super condos are more neurovascular sort of issues. Lateral condyle are more nonunion sort of issues, so they're slower to heal and their intraarticular. So you've got to treat them like an intra articular fracture. Uh, safe approach. Everyone sort of wonders how displaced is displaced. And, you know, there's all these classifications. Is that the now with the Yakob and those sort of things, if you're not sure, you're probably just best to take it to theater and do an arthrogram and prove how much displacement there is because you'll never regret fixing it, really. But you might regret not fixing it. So if in doubt, look at it a bit harder, think about taking it to theater, thinking about doing an Ortho Graham and thinking about fixing it while you're there and different techniques. So close reduction. Percutaneous pinning is fine. Um, do you bury the pins? Do you leave them out? The most recent stuff says that leaving them out, they heal just as quickly as if you bury them. So just leave them out, take the mound clinic. Um, and if it's really really displaced, then you're gonna need to open it and pin it or open it and fix it with a screw. So the this is one of mine. Um, you can approach it direct lateral, so you can do direct lateral. That's fine. You need to be able to see the joint or some of us do it through through the back. And we fix you the back. And people are worried about that because of the blood supply. But actually, if you're cautious in your dissection, you understand the anatomy and you don't strip all the way around the front strip all the way around the back. Then put a screw in it and expect it to work. Then the blood supply isn't a problem, so just pick an approach to stick to it is what I would say. And then with this technique, you can do an extra five seal screw supposed having to cross the Fyssas, but going straight from the side and and putting it across, it's fine. You just need to know that you're gonna have to remove it later on. So I'll just put this in for interest because they're much rarer. So this is a milch one. Um, I've only ever seen too. So they're really, really, really rare, Like less than 5% of lateral condyle is that we see the ones that I've fixed there sort of a bit more like a capital, a fracture. I think they're kind of more like a sort of sheer. It's a smaller bit. And I would advise fixing those from the side rather than from the back, because you won't get the angle from the back. Um, so fix it on the side and just sort of get it wherever you can get it, Um, and be prepared that it's just a bit funny. Just doesn't behave in the same way. Uh, so, yeah, this one that my colleague fixed, unfortunately, is not a big fan of the fossil, but I quite like a fossil. But anyway, who needs elbow extension? Uh, so many kids. And he did fine. It's fine. It's all removed. All fine. Uh, so radial neck fractures. Uh, these are rare and we have 40 degrees in your head is the number that you can accept in terms of ambulation. The reason it's quite high is because their kids and kids are amazing and you know you can accept an awful lot more, but it's deliberately set like that because the complications of opening them and getting stressed about it are worse than accepting a bit of angulations because they are prone to a vascular process. And the problem is, once you get in there, what do you fix it with? There's no real implant for this that works. Why is aren't brilliant. It's tricky. So we say 40 much more than that. Or if you're not sure, I mean, that's not going to do well, is it? That's gonna block rotation so you wouldn't accept that. And the argue of them is you take it's theater, you stick your thumb on it, you hope for the best. You shove, shove, shove you that Israeli technique where you sort of their eyes, it rotate it, hope that it's going to go back on. If you're lucky, that will work. Or although it doesn't always work because the arm is swollen and I don't know, my thumb is not that big. Um, if that hasn't worked, then you move on to the Esmark technique, wrap it in an esmarch bandage weight. Hope that that's gonna work again. I'm not sure how long you meant to wait. Uh, and some people swear that they get this to work and other people aren't so lucky. If you're going to use a wire, which is the next step. Um, don't be confused by where you put the wire so it doesn't go. It's not a cup, Angie. You don't shove it through the fracture site. You nudge the proximal bit back on. If you shove it through the fracture site, you're going to destroy the blood supply and possibly the pin. Don't do that. It's bad. So get the blunt end and just try and nudge the proximal bit back on if you can. And then next in the algorithm is metazoan, which everybody loves. Uh, the metas oh is the technique by where you put the nail tens nail in with an extra bit of bend distally, and you use as a reduction under stabilising tool. So this is one of mine, so you can see that nail looks quite far in. Everyone gets really worried about how far in it is, and that's because it has to be that far in. Otherwise, it's not gonna grip onto anything. So if you worried intraoperatively, you can stick some dye in it and prove that it's not in the joint so that the person that sees it next. In fact, a clinic is gonna know that it wasn't in the joint, and it's reassuring for them. But my top tips for metas o r put a little bit of extra bend in it, get it up to the fracture site, and once you're there, you get your hook, so it follows the angle of the fracture. So if you get back so get back, get back. So it follows the angle of the fracture. Get your hook round, and when you think you're in enough, just tap it just a couple of times just a little bit. So you feel a bit anxious, tap it and then carefully rotated according to the pronating curvature of the arm. So for that one, it's the right side. You're going to be going from about nine o'clock as you look up the arm to midday, okay, for right arm. And if it's the left arm would be the way around three o'clock to midday and then, if you're still not sure, do it under X ray guidance. And if it looks like you're doing it wrong, just stop and don't do it again. But if it hasn't moved the first time, back it off a bit and then tap it a little bit more. But don't just keep rotating it and rotate it. It's not gripping because you just gonna make a big hole and it's never gonna grip, so it's never gonna work. And if you do it like that, it'll work. Promise. So. Mantega. I'll risk through really quickly load, but montage. A fracture of your ulnar dislocated proximal radius. You all know the classification. You'll know it for your exam. Uh, if you see an isolated radial head dislocation, that's weird in a kid. So be looking at the forearm and think there's something going on with the owner. If you can't get a piece of paper to run along the straight border of the owner on the lateral view, there's something wrong with the owner, okay? And that you just need to be aware of it, because because just pop out on his own doesn't doesn't really happen. Uh, this one of mine open montage. That's pretty obvious that that needs sorting, and you can choose to plate it. You can choose to nail it. Most of us would nail it because we were Children. Surgeons and that's what we like to do. But if it doesn't work, then you need to be ready to open the joint and get the annual ligament out, and it might flicked under. And that's what's blocking your reduction. And if it still doesn't work, if you haven't got a really obvious fracture in the owner, then you're gonna need to break the owner to to, you know, if you got a plastic defamation, you're gonna need to prepared to do an osteotomy to get the radial head in forearm shaft. This is the last bit, um, mostly we treat them closed. Sometimes we need to tens nail them if you need to. Tens nail them. It might be because they're not reducible or they're not very stable. If they're either of those things and you're gonna tens, nail them and then it might be difficult. Therefore, you might need to prepare to open it, which I'm not recommending. But if you do need to do it, just make a little hole so that you can get your finger in to reduce it and pass the nail across. Um, no. 4 to 4 on Factors are the same. This is a child who felt matri somewhere else. She's got to open injuries. As you can see by the dressings. It's just horrible. It's a horrible injury. It's got grass and mud and all sorts in it. She was fixed somewhere else, and unfortunately, it all fell apart because it was infected and she ended up with a one bone forearm. So open injuries don't fall instructor because their kids and it's an arm. You can just do it all. If it's full of mud, you better To do it in stages would be my top tips. So come back to it 48 hours and see what's pouring out the holes. Just back it, wash it out, back it and come back to it so you don't end up with this situation. So we got loads of upper limb injuries there really, really common. We've got new implants so we can do a bit more than we used to be. Able to Sue Perkins are a bit tricky. Everyone should be a bit stressed about them, but there's loads of stuff that you can do that you have learned from this, that you can apply to make them easier. So your pulse remains nice and low when you're doing them. Um, and they're associated with complications. That's not your fault, necessarily. That's the problem with the fracture. So, uh, that is it? Any questions? Thanks very much. Always love your talks. They're always clear and, uh, really helpful. Good practical tips. Any questions for, uh, so I've got a couple of questions, If I may. Uh, you've you've arrived now. I wouldn't have questions. I liked it before. So when your wiring Yes. What size wise? You may have a note to, uh, emails. Disipal humeral Super emails has to be to always to, Unless they're really little like I've done three year olds. And if you hold a two mil wire next to a three year old humorous, it's the size of a humorous. So I do. 1.6 is for that. But the guidelines say to and you showed a nice radiograph of the K wires coming from the lateral side. Divergent. Parallel. We do maximally divergent. So your capitellar entry is really close to your electron on your first one, and then the other one is a common wire as close as you can get. But we do there is. I mean, I think it's Skaggs. There's something about doing them parallel. I don't know. It doesn't make me feel a bit awkward, so divergent, divergent. And if you had to do cross wires sometimes because the fracture configuration you need to consider that there a bleak laterally distantly, any tips for for everybody about that, it's just sweaty. Just be careful. Find the nerve. Don't be fooled into thinking it's a quite a lot of kids. Nerves are anterior, so they're already transposed. So just be aware that they might not be sat in the groove where you'd expect it to be. And don't forget that once you put the wire in, see where the nerve is in relation to your wire because you can be fooled into thinking it's all fine. And then, as you put your cast on, a slight flexion is just touching up against the back of the wire. That's a bad thing, and I'll wake up with the dense polls. So look at it at the end before you close, always dissected out and protected. And if the patient, when you go and see them, Post Operative has got an older nerve palsy. What would you do? I would get my mate guy to take it back, because that's happened to me once, so you can't ignore it. If it wasn't there before then you've done it and I wouldn't ignore it. Take them straight back. That's really helpful. Any other questions for me? Because I've got one more with plastic definition. So it's That's a really good question. So usually with plastic defamation, you can sort of see where the apex is, so I would do it there. If it's not entirely clear, then you're meant to do it where the interosseous membrane sort of starts so more proximately, sort of meta diet asili sort of bit, and you have to accentuate the deformity to get it to work. One last question and, uh, really practically, how do you do your arthrograms? Because not everybody has been shown to do those. So how do you do it? So I do. Seven mills of Omnipaque 23 meals a saline because I don't like it too strong, and I don't like it too weak, and I you can do it through triceps. I'm not a big triceps fan, because if it goes into the fiber, the triceps. It kind of ruins your picture. So I just go soft spot. So feel the three landmarks and then stick it in the soft spot. It works for me, but do under image intensifier. Get the needle in check, you happy little squirt. And then once it's in, it's in. Thanks, Anna. Fantastic. Uh, is that from you? You could have just asked me. I'm still right here. I'm gonna I'm gonna type my answer. Uh, so, um, it depends. Um, I like if they're really displaced, and I'm having to do quite a lot of opening to get them back. I like a screw because I like it really stable. And I've move away from doing partially threat. I used to be partially threaded and engage the other cortex as well, which you don't really need to do should if you know, you buy basic science of screws. But I always used to engage the cortex. And then I had one that just wasn't just didn't grip. So I now do a fully threaded 3.5. But if you if it is wearable, it's wearable. You know, if it's just, it's just sort of like it's a bit displacing not doing it, then that's fine. But sometimes I like compression. And I'm the person that picks up when they don't unite. So for me, I'd rather know I've squeezing it properly first time because I don't want to have to fix my own mess. 22 hours. Yeah, yeah, yeah. Uh, if it's been compulsives, I take it, Yeah, but most of you, you know, like you couldn't get anyone to cover if there was a vascular like Are there places that you can't get? Yeah, I'll still take it. Thank you very much indeed. Great talk.