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I might see the chat that way because I think I can't see it if I'm sharing screen. Right? Yeah. Feel free to, that's completely fine. I might do that because if I'm asking questions, I'm not gonna know how they're answering one sec, I've started recording. So, um, we'll probably give it like five minutes and then, ok, when people, when there's a few more results. Yeah. Yeah. Sure. That's fine. Well, I'll just be in the background then. So, and let me just draw on here as well. Should I start at like 5 lbs maybe? Uh Yeah, that's good for me. Yeah. Ok. Cool to join now. So sorry, I'll just put on the chart to join now. Ok, thank you. No worries. Hi, guys. We're gonna wait about two or three more minutes. Um, before how I get started with her presentation just to wait for people to join. Um How are you consulting up? Thanks, Gia. Ok, so, hi everyone. My name is Neha. I'm on the final years and this is gonna be a talk on M SK. Thanks for joining. Um, so before I start generally with M SK, the thing that a lot of people don't really like about it or thing that intimidates them. Um, if it does, it usually the fact that there's lots of new conditions that you may not have come across before or unlike to have come across before. Um, and that's what puts people off. There's so many different conditions and it's figuring out how to differentiate them. But once you know what conditions there are and once you know how they did from one another, in this case is actually really straightforward. Um I think it was one of my, I think, yeah, probably more preferred topics and ps last year. Um And with this lecture, um I know you guys are probably all at different stages depending on where you are with your revision and when you've got your P attachment, um so the content might be really familiar to you, it might just be revision and that's great. Um But also if all this is completely new, you have no idea what any of this means, then that's also absolutely fine. Um If you have any questions, whenever please ask, you can unmute, I don't mind or the chart, I've got it open here, so I'll be able to read that as well. Um But yeah, let's get started. So, uh one second, there you go. So with M sk the most uh common presentation that you're gonna get is a child coming in with a limp. So before I go into each of the different specific conditions. I'm just gonna give you some general tips and general advice with your history and exam that you can apply for basically any M SK um presentation. So with history, let me just get all these up. Um these are the really important questions that you do have to ask with an M SK history or if you want to go over family history, past medical history and so on and so forth. These are the specific questions that you should always ask with M SK. So, onset is really important to differentiate between different conditions. Pain is important to know. And when you do have pain, if you do really thorough Socrates, because I can give you again a good idea of how to differentiate between the conditions if you have any um weakness, if they have any trauma. Now, trauma is a bit of a um tricky one because it could be that they had a fall and as a result, they now have a limp, but actually, it could be the other way around. Maybe they've had a lymph for a completely different reason. And then because of the lymph, they ended up falling over because that's important, differentiating in your history. Um Infections are the important one. So either do they have a current infection or have they had a past infection um with birth and developmental history, it's a little bit more relevant if it's a younger patient. Um But with things like birth. You want to know if it's, uh, if it was a breach, birth for certain conditions with developmental history, you want to know whether they've always had a limp, whether they, um, didn't, whether they, um, were late with their milestones and maybe they didn't crawl on time, for example. So there are some important things to know and also red flags. So, do they have pain waking them up at night or do they have any floor symptoms? Things like fever, let appetite loss, um weight loss and sweats. So with red flag, I wanna think is it cancer? Um or could it be child abuse and things like that with your examination? Um I'd like to split it into general exam and M SK exam. So a general exam, you wanna take height and weight, you wanna do basic observations. Those are really important with your M SK exam. You've got your pediatric arms legs and spine assessment, but realistically, you're not gonna be doing a full p gals on every single patient. You're just gonna be examining the joint involved. Um And when you examine the joint involved, you wanna do generally look, feel move with the special test, that's the order you would go in. Um And also very importantly, you want to do the joint above and the joint below. So I gave you an example. You may get a patient where they've come in with knee pain, but actually the pathology is not in the knee, the pathology is in the hip and it's because they've got a dodgy hip that they're walking funny. And as a result of walking funny, they've got um like extra pressure on the knee, which of course, the knee to hurt if that makes sense. Um So, drawing above and drawing below is important because the pathology may actually be somewhere else. Um And again, red flags. So, is there any redness, swelling and stiffness if there is you want, you're immediately thinking, could it be septic arthritis? And is there any unexplained rash or unexplained bruising? And if there is either of those, you're thinking, could it be child abuse, could it be cancer? Um Those I would say are the most important general tips um for any of your MSK exams in terms of your investigations and your imaging, it will be specific to the presentation and to the condition that you're suspecting. So I'll go through those in more detail as I go through the conditions. So, with the conditions and the way I've made my slides is I wanted to make it more each slide kind of a summary slide that you could quite easily revise off. So they may be a bit info heavy, but hopefully they'll be nice to revise from even if they're not so nice to look at. But paes to start off with definition is an idiopathic avascular necrosis of the developing femoral head. So what this means is that where you have your um the ball and socket joint of your femoral head and the acetabulum normally, um it's nice and smooth and round. But when you have like a disruption, the blood supply, for example, that can cause the femoral head to become necrosis and then the joint is no longer nice and round and smooth, it can become more jagged. Um And you may actually have like a lot of the space as well. So that's an example of where you may have some bone, some necrosis in that joint. So how does it present? Um firstly, it's more common in boys and typically in boys 3 to 10. So in terms of age of onset, the way I like to think of things is is it primary school is a secondary school in my head that's provide it much more. So with Perthes, your classic presentation is a primary school boy onset generally about weeks, typically happens in one joint. Um but it can be on both sides and also typically they're systemically. Well, they don't really have any other joint involvement, there's no real inflammation. Um and they don't really have any history of trauma. So that's all stuff that you would get in terms of general presentation with specific symptoms, you may have a limp, you may have a limitation, how, how much they can move the hip. You may have pain in your hip and the hip pain may actually could be referred to the knee or to the groin as well. When you're examining the main um findings would be limited motion. So they may not be able to move their hip as well. And on imaging earlier in imaging, what you will see is increased density in the femoral head. But later on it as it progresses and becomes worse, you can see it, it becomes more fragmented and more regular. So I'll show you what that looks like. So here, um if I can get the pointer, there we go. So this is a normal joint and this is the necrose joint. So as you can see this bit over here is very different, very asymmetrical to this foot over here. So this is the avascular necrosis, but sometimes it's not that obvious. Sometimes it might just look like this. So you have increased density here. You may have some fragmentation as well of the joint. So hopefully, that's all clear and that all makes sense. Um in terms of how you manage Perthes, it's um well, generally, the main goal of the treatment is to relieve the painful symptoms. That's the main goal and you want to protect that shape of the femoral head as much as you can. So depending on their age, the opposite, the um man will be a bit different. If they're younger, they generally have a better prognosis. So you'll probably fine to just watch and wait and give them analgesia as they need. If they're a bit older, then you're more likely to go in with surgery and with surgery, the most common procedure is an osteotomy. So they basically cut the bone, they reposition it and, um, make sure that it fits nicely snugly in that tubulin and they may put some screws in to keep it in place. Um, and if they do have a particular like that, they're typically put in a cast as well for a few weeks. So that's what you can generally expect for a surgery in her. But as always, we're nice doctors. So we also wanna give them analgesia. Always remember that that is always part of your management for a lot of these conditions. Um and physiotherapy as needed, cast and brace settings as needed and advice on limiting activity as needed progress is again, very good, but it depends on how old they are. It depends on how early you pick it up. All right. So next, we have SUFI. So this is basically where you have a displacement of that femoral head and I'll show you what this looks like. So the SUFI stands for slipped off a femoral epiphysis. And the name is very descriptive of what it actually is if you look at the images of the bones here. So in an adult, you have diaphysis metaphysis and it's quite simple. But with the child as well as a diaphysis and metaphysis, you have the growth plate here, just the piss and then you have your epiphysis as well. So that's the main difference between adult and child bones. You will have your growth plate and the epiphysis. So in SUFI, the issue is where you have your growth plate. The above and the below will detach from one another, they will displace. So if you look at this image, um next door, you have a normal hip on the left where it's all nicely connected. But then the SUFI hip here, you can see where the growth plate is. It's essentially slipped between one another and that is the pathology hip. So that's why it's called slipped, upper femoral epiphysis because the epiphysis of the upper femur has slipped essentially. So I think that makes sense. Um So how does it present the tricky thing with SUFI is the presentation of SUFI is very, very, very similar to Perthes. So more likely in, in boys, weeks to months, unilateral stomach, well, not, not real, a no real trauma history and the symptoms are quite similar where you have a limp, restricted range of movement and pain in the hip could be referred to knee and groin. There are two main differences on presentation. One of them is the age. So this tends to be in secondary school Children. And the other thing is the risk factors. So in SUFI, you tend to have Children that um may be a bit overweight. They may also have endocrine disorders. It may be during a period of rapid growth. Hence why it tends to be in secondary school Children. So those are the two main differences on presentation that's good to remember because those buzzwords can help you differentiate with exam. Um SUFI tends to have a few more um things to look at with gait that's important to look at. So that could be a waddling gait. It could be a Trendelenburg gait, antalgic gait, the affected leg, the SUFI leg might be externally rotated as they walk. Um And if any of these words don't mean much to you, I would highly suggest um watching youtube videos of what each of these types of gait look like because that would be really helpful. Um But that's on gait with motion you want again, it's very similar. So internal rotation, hip abduction as in Perth, these will be limited in Sufi but here and you may also have some difficulty with flexion as well. And another thing that you may see in 2 ft but not always is the affected leg might be a bit shorter. Think about it when the top of the femur has slipped off on one another. Um It's not in a nice straight line anymore. It's kind of like that essentially. So you may have a shortening of the leg and it's because one leg is shorter, possibly shorter that you may have these funny um ways of walking where you have the antalgic gait or waddling and so on. So how we investigate it? Um You want to do an endocrine screen just to rule out any of the risk factors, any possible. Um And then with imaging, you want to image the pelvis, so you want to do an AP view in frog leg position and also a lateral view as well and you look at the line of client. So I want to show you what that is because I didn't quite understand this when I was doing it um last year. So the line of cline, basically, if you follow um the superior edge of the neck of the femur and you continue continue that line along the normal side. If you continue this line along what should happen is this line should intersect at least a part of the femoral head. Here's the femoral head and here it intersects and you can tell it intersects because a little bit of the femoral head lies above the normal, the kind of client in the SUFI leg on the other side. Um It does not intersect the femoral head at all. So in an abnormal leg, you may have an asymmetric um intersection or you may have no intersection at all. So it could either be decreased intersection or no intersection and that's how you would see you on an X ray. Um You can um yeah, MRI is not really indicated in this case, it's mainly x-ray in terms of management, you want to do an immediate orthopedic referral. And the reason for this is because the treatment for SUFI is just surgery. You want to use screws to fix the growth, to fix the epiphysis and the metaphysis together across the growth plates to make sure they don't slip. And actually, you can also um put uh put the screws in the contralateral leg as well as like a prophy prophylactic kind of um procedure. So to stop that from happening, um and there's always cast as needed, physical therapy as needed and limbic exercise as needed and analgesia, those are four things you're always gonna say for most of these cases, for most of these presentations. OK? Um The next one is Osgood Schlatter. So with Osgood Schlatter, this is osteochondritis of the patella tendon insertion at the knee. And I'll explain what this means. Basically with Osgood Schlatter, this is an overuse injury. So um if you imagine uh a really sporty kid that does lots of running lots of jumping, um they are going to cause a lot of uh like impact trauma, basically where their knee is and the reason or actually I say impact trauma, but specifically what's happening is as their quadriceps contract, their quadriceps insert into the ossification center at the knee and each time it contracts, it puts pressure on the ossification center and it causes like um micro fractures. And as you get more and more micro fractures. That's how you develop osteochondritis of the knee. So the sportier you are, the more likely you are you are to get these micro fractures in osteochondritis. Um And with the presentation again, it's more like common in males this time, it is more common in secondary school Children as in um SUFI. Although I have seen in exam questions, they may have a younger child as well. It really depends, it's quite variable. Um onset is gradual unilat system. Well, no other joint involvement, no obvious trauma. So, so far, not really much that you can differentiate with Oskar Schlatter. The main thing that differentiates is with Oskar Schlatter. Your main symptom is pain and the pain is quite specific. So if you do a thorac sos you'll be able to see that the pain is specifically at the anterior knee, it's localized there. It gets worse after exercising or after kneeling and it gets better as you rest. And also if you do read thorough history, you may get that they are a very sporty child, which is um one of the main risk factors. So if you're thinking about uh sports that are a bit more risky when it comes to Oscar Glater, think anything that involves running and jumping, so that could involve football, that could involve basketball, that can involve volleyball, anything where you have runners and jumpers, you, you possible to get Oscar latter. So examination, you may specifically get some swelling of the tibial tuberosity, you may have some tendon there as well and it may hurt when you extend the knee. Um And on examination of the knee from a lateral view, you may see some irregularity and some fragmentation. So I'll show you what this looks like in the corner up here. Um Here is where you can get. So this is the um knee joint here is the tibial tuberosity and you can get see little fragments just here. Hopefully it's big enough on your screen. Um And with management, typically you don't do much other than give analgesia and you want to give NSAIDS unless they're contraindicated for, for whatever reason. Um, but you manage this conservatively. So NSAIDS modifying, uh, any activities, ice physiotherapy. That's generally what you do and progress is quite self limiting. Um But one thing that is good to make them aware of is that it may last onto the end of their growth spurt. So even though it may feel like it doesn't get better for years, even it will get better because it is a softening disease. So, just to see how well you guys have been listening, I want to ask you guys to put in the chat, what you think each of these presentations are. And, um, I want you to put either Perthes or Oscar S or the three that we covered and I'm not going to give you a lot of history. I'm just going to give you buzzwords to see if you can figure out what the differential is withw word alone. And without any of the symptoms, actually, I think this really helps with your written. So first one is a 30 year old girl BMI of 28 systemically. Well, no trauma. So can you put in the chart or me if you want under your mind? What which of the three conditions we just covered? Do you think this is likely to be? And if you go on it's also absolutely fine. I'd rather you get it wrong. So I want to teach you that way. Yeah. Brilliant, Sufi. Exactly. Well done. So this first one is Sufi. Um and you're looking at with the buzzwords, they are in secondary school and they have a um heavier weight. So that is where you're thinking, OK, this is probably gonna be Sufi. Next one. You have an 11 year old boy who plays basketball systemically. Well, no trauma. What is it like? Differential? Yeah, Fab Oscar Slusser. Brilliant. Easy. So far. What was the last one you have? Nine year old boys? Stem well known trauma. That's all you've got was like differential. Fab. Yeah. Perthes easy. So with um yeah, Perthes fantastic. So with all of these conditions, um with these three in particular, as long as they are systemically. Well, as long as there's no obvious signs of trauma, your answer is probably going to be one of SUFI dial per and then you can use these bosses, basically figure out which of the three. It is obviously you want to confirm the buzzwords with the rest of the clinical picture, but this will get you halfway there. So hopefully this is helpful for exams, the written. So, so far, we've been looking at um conditions where they're systemically well and there's no real trauma. Now, we're going to look at the conditions where they may not be systemically well. So firstly, we have transient sinusitis. This is basically where you have inflammation in your synovium. And this is the most common cause of hip pain in Children. And whilst that's important, it's also important to know this is a diagnosis of exclusion. So even though it's the most common cause, you have to exclude things like septic arthritis before you commit to a diagnosis, transit sinusitis. Um So how does it present again? Quite similarly. So it's typical percentages of primary school boy can happen in females as well. Um The onset is very variable, it could be acute, it could be insidious um and it can affect any joint, but you will typically have it in the hip or you may have heard of it as irritable hip is not really common way of talking about transient sinusitis. Um in terms of the history, an important buzzword is a recent upper respiratory tract infection. Um now, with symptoms, they may have a fever, they may not if they do have a fever, it's gonna be a low grade fever. And in terms of other symptoms, they may have some pain, they may have a limp. So the symptoms are quite nonspecific. Um, if you suspect that there could be like a joint kind of infection, you want to really think about examining an investigation. So with examination, you may have some restriction of um, the joint movement, but importantly, it is not red hot and inflamed. That's really important because if it was red hot and inflamed, your differential changes drastically with investigations, they're all normal. So you're basically looking for any signs of infection. So CRP esr white blood cells, they're more or less normal, they may be slightly elevated, but it wouldn't be anything like really high joint aspiration would also be normal. And when you image it again, it's going to be normal. Um And when you, you can, you can ultrasound it as well and you can see some possible like um thickening of the membrane on ultrasound, but typically you wouldn't use ultrasound to confirm a diagnosis. It would more be the rest of the clinical picture and with the investigations as well. Um I just put an image so you guys know that you can do that if you want, but generally speaking, some normal imaging is normal. So once you've confirmed, OK, this is like to be trying a v there's not anything sinister, then you manage it conservatively. So you give nsaids because again, you're nice doctors. You want to give them analgesia. Um And it's just watchful waiting from there. It's suffering from disease. There's nothing much to worry about having said that. Remember, there's a dinos of exclusion, you have to rule out septic arthritis, which is what we're gonna be coming on to now. So this is an intraarticular in and this is much, much, much, much more serious than trans sinusitis. So, with the presentation, um I don't think about it as a male, female or at a certain age, it could be anyone at any age. Technically, because you always want to be thinking about septic arthritis and the onset tends to be quite acute. So it tends to get worse very quickly. Um And whilst it commonly affects the hip and the knee, it can affect any joint. But the other important thing to remember, septic arthritis, it tends to affect just a single joint. It's not impossible to have septic arthritis in two joints, but you'd have to be very, very unlucky for that to happen to you. It tends to be one joint. Um Also you may in the history have recent trauma, recent infection. Um and you should in your drug history part for antibiotics. The reason for this is they may be on antibiotics for a concurrent infection, but the antibiotics may mask the symptoms of aseptic arthritis. So if that's something that's just good to know. Um also immunizations. So with our um pediatric immunizations program. So many um uh infectious diseases um and infections such as septic arthritis have decreased. However, not everyone takes up immunizations. Um or they may be too young to have a certain type of immunization. So you want to do a thorough history as well. Um And if for whatever reason they're not up to date, then that is good to know. But symptoms, you tend to have a fever, you don't have to have one, but you do tend to have one as well as just signs of being systemically unwell. Like on observation, they will look a lot more unwell than if they had transient sinusitis. Um you will have a lot of pain in the affected joint and the pain might be so bad that they refuse to wait there as well. So on examination, doing basic obs is really important here because you want to know how stable this patient is. But then on an M SK exam, you will see a red hot swollen joint. Um and that is classic for a septic arthritis, it can be other things as well. But if you do see the red hot swollen joint, think septic arthritis first. Um when you are examining the movement, um the hip may naturally rest in a Faber position. So this is flexion abduction and external rotation. That's what Faber stands for. And the reason for that is because when you're in that position, the volume of the hip capsule is maximized. So it puts slightly less pressure and makes it slightly less painful and the patient will do that unconsciously. Um You will have really severe pain on passive movement, things like leg rolling and you may have pseudoparalysis. So, what this means is the patient is not actually paralyzed. If they really wanted to, they could move their limbs, however, they're in so much pain that they will refuse to move and they will tell you that they can't move their leg. Um Oh yeah. And lastly with investigations is the exact opposite of uh transient sinusitis. You will have high infectious markers on more or less everything. So positive blood cultures um and high white cells. Crp esr now with management of septic arthritis, this is a emergency. So you want to do urgent surgical irrigation and debridement and you then want to follow up with antibiotics and generally with any antibiotics you want to think start empirical and then narrow down based on cultures based on sensitivity, start with IV. Because in septic arthritis, you want to start with really strong antibiotics, you start IV and you step it down only when they are um improving in terms of their physical symptoms and improving in terms of their infectious infection markers. And also when you're deciding which antibiotics you want to use, you would think about their age and low sensitivities and immunization status. This is all just pace spiel basically at that point, you don't have to know specific ones. Um, with prognosis, generally it is good. Unless the diagnosis is delayed. If it's delayed, then it can be disastrous. And some poor prognostic factor indicators is if they have, if they're younger than six months old, so they're really young or if they also have concurrent osteomyelitis, you have a much poorer prognosis that way as well. So, very quick, um, minute on course of organisms. So these are the most common ones. Staph aureus, GBS, mice and the hay like organisms. You'll come across these more when you do path. Um GBS is the most common in neonates. Staph aureus is most common in anyone over two years old and gonorrhea is most common in adolescents specifically. Um and haemophilus influenza is one of the other ones that you there's another common organism. Um But with the HIB vaccine that's declined in terms of how commonly uh h influenza causes septic arthritis. That's also why you have to take a good history so that you know, if there is a risk factor for them. But yeah, I mentioned this multiple times before surgical emergency. Always suspect septic arthritis in a single red hot, swollen joint, always. Ok. And then another uh systemically unwell patient, you have osteomyelitis. So this time, it's an infection of the metastasis of the long bone. So it's of the bone itself as opposed to the sinovial joint. So presentation uh quite similar. So it can happen in uh boys or girls can happen at any age and tends to happen quite quickly. It's a very rapidly progressing disease. Now, this tends to affect the long bones. Um So things like the distal femur, proximal tibia, for example, and again, like with um septic arthritis, you want to think about if there are any antibiotics, think about any immunizations, ask about um local trauma or uh infections in terms of what differentiates this from septic arthritis is on presentation. You may not always have a fever. So you may, may not have fever at all, but you might do otherwise, it is actually very, very similar. It's hard to differentiate on um uh history alone, some risk factors however, are important to know is you're a bit more likely to develop osteomyelitis. If you have things like diabetes, any hemoglobinopathy, if you have JIA varicella or if you're immunocompromised for whatever reason. So, on exam, um the main difference on examination is that you may have point tenderness along a bone along with of the long bones of Osteomyelitis where you won't typically get that in septic arthritis. But otherwise the rest of the examination is very similar. Um and investigations are also very, very similar. So you may get positive cultures and um high infection markers. Imaging is probably quite important with osteomyelitis. Um So depending on the joint, you wanna image it accordingly. Um ap view, lateral view frog leg, depending on where you're imaging. Now, what you will see, it could be normal and early disease, but it could have signs of bone destruction or osteopenia. So, if you look at this like black little circle um within the bone here, so it is the foot, if you couldn't tell there's the foot there here in this bone, this bit is darker than the rest of the bone. And that is an area of osteopenia or bone destruction. So that's what you will see with osteomyelitis. Um It's probably gonna be more uh visible on an MRI, but you're not gonna be able to interpret an MRI in your uh written. So don't worry about that. Um But yeah, MRI would probably be better to re re visualize it with management. Again, you do wanna do an urgent referral for assessment, especially if they are unable to weight bear and antibiotics same as before, start with empirical to start with IV, going to step down to po and then based on age sensitivities and in surgical intervention is not necessary with Osteomyelitis as it is in septic arthritis, but they may still require it depending on the presentation. Um Typically like your the mainstay of Osteomyelitis is giving IV antibiotics and again, with course of organisms very similar to before. But this time you also want to think about salmonella because that can happen in sickle cell patients. OK. Good. So that is mm um Everything in terms the infectious MSK presentations. This is something completely different. So DDH, if you guys come across, it is developmental dysplasia of the hip. So what this is is when you have abnormal development of the proximal femur and the acetabulum. So again, that ball and socket joint is when it has not developed properly. And this is a presentation that you typically see in patients that are a lot younger. So how it will present. This one is far more common in females. So that's really important to remember tends to, um, present in infants. So, um, it could be anyone from a newborn to someone who's just started to walk. Um, typically it's unilateral and it's more common in the left hip, but it can be bilateral as well. Um, but this systemically, well, they won't really have any obvious trauma. Um, and with symptoms, they may just be asymptomatic and actually, it's picked up on screening on their, um, either their newborn assessment or their eight week baby check. It's actually picked up on those examinations. But what the parents may present with is actually the child is not crawling or there's a delayed crawl or it could be an abnormal gait. So either they're waddling along or they're dragging the affected leg as they walk. So, risk factors, um, are really good buzzwords for DDH. So if there's a family history of it, if they are female, if they are the first born, if they are breech, and also anything in within pregnancy, which means that the uterus space for the baby was more crapped. So either if the baby was too big or if there was too little amniotic fluid for them. And again, there was multiple pregnancies to think cramped conditions are more likely to develop DDH. Um With examination, it depends on the age of the patient. So if they're less than three months, you're far more likely to elicit signs by doing the bar and, or test where you will abduct and adopt the hips as well while they're flexed. Um You will, you may see Gallii signs. So what that is is where there is a difference in the height of the knee. I don't, I didn't put a picture. Unfortunately, I would highly, highly, highly recommend searching up by a youtube video that and also see what Gallii sign looks like. Um Something else that's a lot more subtle. You may see asymmetric skin folds um because of because of the way they've developed. Um But that's if they're less than three months, if they're between three months and one year, uh you won't always pick up the signs on things like the instead what we wanna look at is leg, leg, leg length, discrepancy. So if one leg is shorter than the other leg, um and also if there is any limited or asymmetrical hip abduction, think about it with DDH because that ball and socket is not, the ball is not fit into the socket very nicely. When you try to abduct the leg, it, it's like stiff, it's limited in the movement because it's not fitted nicely into the socket. So it will be difficult for them to abduct to their full potential. With one year and older. You want to think that they have now started to walk because one year is a milestone for being able to walk. So when they're walking, what you may see is a trendelenburg gait and you may see toe walking. So if I explain the toe walking, when you have DDH, you may have one leg that's shorter than the other. If you think back to um where having an issue at that socket can lead to one leg being shorter. It's similar DDH because again, the pathology is in the hip and when one leg is shorter, what they might do is the DD leg will actually walk on their toe a little bit to compensate for being a bit of a shorter leg. So that's where you may see toe walking. So with imaging again, it depends on their age because as they grow older and their bones start to ossify, you're less likely to be able to pick up things on ultrasound and more likely to have to pick it up on an X ray. But if they're too young, you can't x-ray it because there's not enough ossification to pick up the supple signs on an X ray. So hopefully that makes sense. So depending on the age is, well, we will tell you whether to use ultrasound or X ray. And if you are gonna do an X ray, I show in the next slide, I'll show you on the next slide what Shen's line looks like on the X ray. Um because that's something else that I didn't completely understand last year. Uh with screening, I mentioned it briefly but you will have for all infants, they'll be screened for DDH on their newborn baby check. Um and their six week, 6 to 8 week baby check. But also if you have certain risk factors, you will additionally have an ultrasound at 4 to 6 weeks. So either if they have an abnormal physical exam or if they have a family history of DDH or if they were born or if, when they were born, they were in breach position. And that's even if they've had a successful um B um then on examination. Sorry. Hm. That's meant to say management my bad. So this is meant to say management. So when you're managing the patient again, it would depend on the age. So with DDH, if you think about it, they're a little, little tiny baby and as they grow, the way you look at it, the way you, the way you um examine, the way you investigate and the way you manage is going to be very different based on how old they are and how strong their bones are, um, so with watchful waiting, you only really do that if they're less than three months old because quite a lot of Children do have BDH. But it can spontaneity resolve. You don't want to intervene. If you don't need to, the body can fix itself with. Um, if they're between three weeks or six months, you may choose to do a PT harness and that's something you have to wear constantly. So you can't even take it off for nappy changes, for example, and I'll show you what ap harness looks like in the next slide. Um That's really important to counsel when, if you had a, a station like this, that AP harness has to be worn all the time. Um And if at six months you find actually it's still not worked, you may then consider surgical reduction in the cost. Um Yeah. So then here is an X ray showing the Shen's line. So if you can see my pointer on this side, you have the Shen's line which is really smooth, it connects and it forms a smooth semicircle, but this is a normal hip. But on the right side, when you follow the shins line on this side and the shen's line on the other side, they don't actually connect, they don't form a smooth semicircle. And that's because there is D DH on this side just that hopefully, that makes sense as always ask me for any questions. Um And then here on the other side, we've got a picture of a baby in Ap Harn thought it was quite cute. So I, so I was just gonna ask like, how they like nap you change if they can't take the harness off. Yes. So basically with the harness, um, it's not like stuck to the skin. So there will be like gaps between like the straps here and the skin if that kind of makes sense. So if you like kind of go under the straps to like undo the nappy on this side and the same one that side, then you can like it off from under. Does that make sense? Yeah, it's hard to explain a baby in front of me. Um But um yeah, that's basically how you would do it. Uh And you don't have to be the one that counsels them. You just have to explain to them, don't take it off even if it gets dirty, you don't take it off. Um, because as soon as you take off the public, you're undoing all the work that it's done. Um So that's one really important thing. Yeah, thanks for asking. Um Cool. Let me go to the next one. So here we're gonna do, we'll have a look at some um, fractures and see if you guys can spot what it is. Now, I haven't actually uh properly gone over any of these, any of these conditions or fractures or presentations with you So if you have no idea, that's absolutely fine. You know, if it's a complete guess and it's wrong, honestly, it's fine. Just have a go. So here, firstly, is there a fracture or is it normal? That's the first question I'm asking, is it normal or is there a fracture and just put in the shower? You can unmute fracture. Yup. I agree. There is a fracture. Do you guys know what kind of fracture? This is collies fracture. Um You're not wrong, but actually if I give you a hint, um this is a fracture that has not gone all the way through. It's only fractured on one, like it's only actually broken the bone on one side. I don't know if that gives you guys a hint and it's kind of caused this. Yeah, exactly. Green stick fracture, well done. So a green stick fracture is really common in Children. Um And the reason for this is because children's bones haven't completely ossified. They're not as strong as adult bones, they're a lot more bendy and because they're quite bendy, there's a lot more give in the bone before you start actually breaking the bone, which is why you may have pos fracture and you may have like a slightly bent bone um on an X ray. So this is definitely abnormal. It's a partial thing, this fracture and typically it's something like this, it's caused, but all the typical trauma is falling onto an outstretched hand um which is what stands for? Cool, well done. OK. Here's the next one. Firstly, is it normal or is it abnormal? Is there a fracture or is there no fracture? Have a guess? It's definitely a bit harder this one fracture? OK. Does anyone else think it's a fracture? It's really tricky. Not sure. Yeah, that's absolutely fine. This is actually important instability. Don't say that again. Is it a part in stability? Um So II didn't quite catch that patellar instability in. Oh OK. OK. I got you. No, actually here, this is completely normal. And the reason why I put this in here is because it's good to understand what normal looks like. Um And the reason why it may look like there are some fracture lines or it may look slightly odd, slightly displaced because it's in a child and in a child, the anatomy is a bit different. You have the growth plates as well. So I'll show you what it looks like on top. So here this is what it looks like before it is an annotated um view of that same X ray to show you what each of the different parts are. So in this case, it's completely normal. Um And then the last one, is there a fracture or is there no fracture fracture? Right? Femur. Yeah. Fantastic, good. And do you know what kind of fracture we have here? Spiral? Yeah. Fantastic. So if any of you guys can see it here is the fracture over here and you may be able to tell on your screen, you've got a slightly jagged line to it. Um And that's what is a spiral fracture. So really important about spiral fractures is that whenever you see a spiral fracture both in real life and especially in cases, especially in your written until proven. Otherwise, this is a non accidental injury. The reason for this is the only way you can get a spiral fracture is by a twisting injury. So, or twisting force rather. So for a baby, especially for Children that are not able to crawl and not able to walk, it's extremely unlikely that they are in situations where they've managed to get their femur, which is quite a strong bone and have it twisted without someone who is an adult who is much stronger than them doing that instead. Um, so n to a proven otherwise, other things that you may see in the presentation, they may have some signs of neglect, they may have unexplained or some inconsistent injuries which don't quite fit with the history. You may also see shaken baby syndrome as well. Um, so this is, uh, a triad of retinal hemorrhages, encephalopathy and a subdural hematoma. So, for that reason, it's important for you to also do a fundoscopy and a CT head if you suspect shaken baby syndrome. Um, but importantly, when there is a spiral fracture, you want to immediately admit the patient alert your seniors and alert the safeguarding lead of the ward of the department. And following up, you want to do four skeletal surveys as well to check for any other injuries. Um, yeah, hopefully that makes sense. I want to really emphasize that point because it's a really easy exam question, a really important differential to not miss as well. Ok. So we're back end of the conditions. I've got just, I think 33 sbs for us to quickly go through before we finish up. So here's the first one. You have an eight year old boy which is presented to the GP with a limp. His parents are concerned about intermittent pains in his legs which have worsened over the last few days. His temperature is 36.5. Heart rate is 100 and 10 BPM. Respiratory rate is 22 BPM. What is the most likely diagnosis and just put in the chart, whatever you think, if it's wrong or absolutely fine. Just have a guess. OK. One of them see anyone else c OK. Got two people for c So the answer if you have a look, it is indeed. See, well done. So looking at the buzzwords, we have an eight year old boy. So a primary school boy, he's coming with a limp. He has some pains in terms of systemically. He is systemically. Well, those observations are normal for an eight year old child. So I put the pediatric normal values on the side there. Um, and no real other buzzwords that you want to think about that would suggest anything else. So most likely diagnosis is disease. However, um if it was something like the most important to exclude in a child with like intermittent pains over the last few days, you that and if you had perhaps a slightly higher temperature, for example, then you want to think about things like Osteomyelitis, but that is not the most likely diagnosis. Perthes is um and good. I would also just before I forget, make sure you have a general idea of normal vital signs for different age groups. Um because in an adult heart rate of 110 and respiratory two would definitely be abnormal in a year old boy. That's absolutely fine. So make sure you know, um the general ranges, OK. Next one. So here we have the mother of a six year old boy presents to ed concerned that he has been persistently crying since yesterday. He systemically. Well, there is no history of trauma, an X ray was taken and the image is there on the side. What is the next step in management? What do you guys think? OK. So one going for E one going for D anyone else? Another of the E OK. So the answer in this case was actually e so I'll explain this here. We have a six month old boy. So when I see that, I already know there's a boy that is not able to walk yet and possibly crawling if he's, if he's there. But you don't really know, generally they're not very mobile at six months, but he systemically. Well, that's good. Um, and there's no history of trauma, but when you look at the X ray and to be, that's all you really need to look at here, this is a spiral fracture because you see it's like a diagonal line. When you see a line like that, you want to think about spiral fracture. And then when it is a spiral fracture, because your top differential is non accidental injury. The first thing you do is admit um with prescribing antibiotics, there's nothing to suggest that he um has an active infection. So and again, he's systemically well, so you wouldn't really do that. But even then, even if you were to prescribe antibiotics, your top priority would still be to admit because of spinal fracture, hip. Um and also in a situation where it's only a spinal fracture and no other symptoms anti is not generally needed. The reason why we admit patients that um that we suspect are victims of child abuse is not necessarily for medical follow up. It's more for the patient's safety because if we let them go home, then we don't know what other injuries we're subjecting them to. So we keep them in a safe space, which is the hospital. Um Hopefully that makes sense. All the other, all the other options are possible steps that you may do at some point eventually in treatment, but it would not be your next step. Um And then last question before we finish up, 12 year old girl turns to Ed with three weeks of left knee pain. The pain feels worse after running and has been difficult to keep up with football training. There is tenderness at the left tibial tuberosity. She's systemically. Well, how would you treat this patient? Ok. Two people have gone for D Yeah, well done de is correct. So again, buzzwords, this is a secondary school child. She has left knee pain. It's worse with running and you can tell her she's sporty because she has football training. Um The symptoms are all the Simpson um examination all fit with Os Good Schlatter. So that was the first step to figure out was Os Good Slatter. Second step is to know the management and with Oscar Schlatter, all you do is conservative treatment. Um, but you would just send them home with nothing. You would still give them nsaids because you're nice doctors and you want to manage their pain. Good, brilliant. So hopefully, um I've been able to demystify some of the uh quite new MSK topics for some of you. And you can see that actually MSK is pretty straightforward. It's nothing too difficult as long as you understand the differences. Um And just a little, there are some things that I haven't covered. So, things like osteomalacia JIA reactive arthritis and so on. Also malignancies and he conditions I haven't covered either. What I covered are the more msk classic ones which in my opinion, are very high yield, um, sickle cell hemophilia, all that stuff you'd more likely cover it in like a heme topic. So I didn't go into that. Um, I put those up there because they can also present with just a limp. So that's really important. So you think of those conditions as well? Um But otherwise these would be your the the most important ones that you guys um learn first for M SK. So hopefully that is useful before I leave. There is a list of useful websites. So all of my information I got from these four websites. So nice C KS for acute childhood limp that is super helpful to give you a general overview. Um And so that was really good. It's a good place to start. Ortho bullets is really good. If you want a lot of details, you want to really understand the anatomy, you want to understand the pathophysiology, epidemiology, it goes into loads and loads of detail. So or is good if you really want to like get deep into uh a presentation or a condition, radio pia radiology masterclass. I use those two websites for imaging and for x rays, they're really helpful. Um So yeah, for MSK, those four websites I think are the way to go and also anything that you pick up on placement as well. But that's everything. Thank you very much. Invest of luck. And if you could, please, please, please scan the QR code as well. Um, for feedback. That would be amazing. Yeah, if you have any questions, just let me know. Hi. Um, just a question. Did you say that? Um, sickle cell and hemophilia can present on the lip? They can do? Yeah, they can do it. It wouldn't be the only thing in the history. You have lots of other things as well, but it can present with a li ok, great. Thank you. Yeah, it it should be obvious from the um the stem that there's other things going on but just to make you aware. Ok, perfect. Thank you. No worries. Oh and yeah, you guys will be able to have the slides. Um gi will send you the slides now. Um and you'll, you'll get those. Thank you so much. That was amazing. Thank you for no more questions. I will head off then my email is there if you do wanna ever get in contact with any questions. Um Yeah, message me anytime but yeah, that was useful. Perfect guys. Just make sure you fill out the feedback. Now, we will need it for her portfolio and then we'll put the slides and the recording on the page. Thanks everyone. Bye bye guys. Thank you so much. Thank you.