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What they normally do light, but we can always make a start if everyone's happy to. Yeah, I'm happy. Yeah. Ok. So I'll just introduce it then and then I'll let um Doctor Daniella introduce herself and then Harry, you can introduce yourself and then go straight on if that's ok. Yeah, sounds good. Cool. Cool. So welcome everyone. So this is the National Pediatrics teaching. So this is led by um Lincoln Medical School's Pediatric Society. Uh My name's Chloe, I'm part of the pediatric Society and I'm the lead for today's session. Um So we've had some of loads of our teaching series happen already. Um So we're just sort of trying to help, you know, give some more information to people on what a career in pediatrics is like. Um We've got, you know, fifth year students, consultant, we had consultant surgeon. Um last week give loads of talks. Um you get certificates for participation and speaking as well. Um And if you attend at least three teaching sessions, then you can get the certificates for that. Um I'll put in the chart at the end. Um some feedback for Harry. Um and on the session in general and then that'll be a good thing for, um, attendance as well and for the certificates. Um, we do have the chat box. So if you've got any questions on the session for Harry or for doctor do through those at the end. Um, so today we have Harry, um, and he's doing a talk on pediatric orthopedics. Is that right? Um, yeah, that's right. Yeah. Um, and doctor Daniella is here to help supervise. Um So I'll let Doctor Daniella introduce herself. Hello, I'm uh Daniella SEK, I'm consultant in community pediatrics. I work in Graham and uh thank you so much for inviting me to supervise this session. It's my pleasure and thank you for for being here today. So how if you wanna introduce yourself and then make a start that's up to you. Yeah, no problem. I'll just show him the powerpoint. Now. Can you see my powerpoint? Yeah, we can see it, see it. Ok, that's great. Um So, hello? Yeah, my name is Harry. I'm one of the fifth year medical students from um I have a special interest in orthopedics. So I'll be here in a talk today on pediatric orthopedics and the con conditions that you might see you'll get tested on. So let's start by talking about the MLA content map and the presentations and conditions they expect you to know. So these are the presentations and conditions that are listed in the MLA content map. So you have acute joint pain, swelling, limb M sk deformities and trauma and your conditions is your idiopathic arthritis, non accidental injuries, reactive arthritis, and septic arthritis. Um In this presentation, I'll go over a few more conditions than this just because there are a lot of conditions that can be classed as acute joint pain or limp or M SK deformities which aren't listed here. Um I dont each slide is kind of a flash code. So the after the presentation, you can have those slides and then use them for your own revision. So start with fractures in Children. So when comparing children's bones to adult bones, children's bones are more flexible, but they're also weaker. They also have growth plates. Growth plates are hairline cartilage that's found at the end of the bones. And what this does is it allows the bones to grow as the Children get older, they usually fix at the end of puberty. So 13 to 15 in girls and 15 to 17 in boys, there are also specific fractures that can be seen at the growth plate and they're defined as salt Harris flap fractures. There are five different types. You can have a straight across the growth plate. You can have above the growth plate, you can have below the growth plate. You can have through the growth plate or you can have a crushing type fracture of the growth plate. Other fractures that are commonly seen in Children are greenstick fractures which is where a fracture doesn't go completely through the bone and buccal fractures, which is a type of compression fracture when it comes to managing the fractures. The first thing you need to do is realign the fracture. So that can be by closed door, open reduction. And the second thing you need to do is stabilize the fracture. So this can be done by casts or by plate and screws and other methods. So, hip pain in Children, hip pain can present in different ways such as limping, um unable to weight, bear, inability to walk pain or a swollen tender joint. It's important to think of the age of the child presenting when thinking of hip pain because different ages can present with different conditions. So for a child, 04, um we need to think of D DH. So developmental dysplasia of the hip or transient sinusitis. Age 5 to 10, you also have transient sinusitis and Perth disease and age 10 to 16. You've got slipped upper femoral epiphysis or juvenile idiopathic arthritis. We'll go over all these conditions later in the powerpoint. It's also important to think that at any age you can get infection and you can get malignancies. So always keep that on your mind when seeing a child with hip pain, it's important to try and differentiate between something that is more serious, to less serious. So nice guidelines outline these things here for urgent referral of a limping child. So if you have a child who's under three older than nine with restrict restricted or painful movements, not able to weight, bear evidence of neurovascular compromise, severe pain or agitation, red flag symptoms or suspicion of abuse. I've listed all the red flag flag symptoms here, managing hip pain in Children. So, what you need to do is try and find out what the underlying causes. There are different investigations you can do to bind. This blood test can be useful to look at inflammatory markers. X rays can be useful to look for fractures and bony pathologies. Um Ultrasound can be used to look for any fluid that might be in the joint. You can also aspirate the joint to see if there's any infection and you can use an MRI to also look at the bones in more detail. So the next thing I'll talk about is Talipes. So Talipes is a fixed abnormal an composition, it is present at birth. Um It's also known as club football. So usually it's picked up as soon as the baby's born or during the newborn examination. There are two different types of Talipes. There is Talipes Quino virus which is seen on the left image here. So that's where there's plantar flexion of the foot and super nation or Talipes Calcaneovalgus. This is where the ankles endorse flexion and pronation. The management of tape is the Ponseti method. This is where the foot is manipulated towards the correct position and then a cast is applied and then this is done over and over again until the foot is in the correct position. At this point. The child is unable to walk until they're four years old in order to make sure that the bones fuse in the correct position. There's also a condition called positional tape. This is where the foot is resting in the incorrect position where there is no structural abnormality causing this. The management for this would just be physiotherapy. So the next thing I'll talk about is developmental dysplasia of the hip. This is a structural abnormality that causes an is caused by abnormal development of the fetal bones in the pelvis. This leads to instability and a tendency for subluxation and dislocation of the hip joints. The risk factors for this is first degree family history breech presentation, which is where the baby's in an abnormal position at birth or multiple pregnancies. Usually D DH is screened for as part of the newborn examination. There are two tests for this. There's the ola test and the bars test. So if you look in these images in the bottom left hand corner, um the olas test is the hip is abducted and pressure is applied behind the legs to see if it will dislocate anteriorly. And the bas test is where damage, pressure is applied to the knees. Uh and this will see if the hip will dislocate posteriorly. So here we've got the auto auto test and here, we've got the baler test. If there's a positive olaria bars test or if the child has risk factors for D DH, then an ultrasound scan scan should be done. And this can be used to diagnose D DH. An X ray can also be used in old infants. So if you look at the X ray, uh down here, you can see the D DH in the three year old. Here. Management is something called a public harness. So that's what's in this image here. This is the hardness that the infants put in. If they're less than six months old, this holds the, the femur in the correct position which allows the hip socket to develop into a normal shape. If the child's older than six, then surgery is required to fix the abnormality. So next, I'll talk about septic arthritis and transient sinusitis. So these are two conditions that present quite similarly, but it's really important to be able to differentiate them. Septic arthritis is where there's infection inside the joint. It has a high mortality of 10%. So it's really important that if you do suspect it, that you um move on to the correct management in order to be able to get treatment started as quickly as possible. The signs of septic arthritis is a red hot, swollen and painful joint sewn in this image down here, there'll also be other symptoms such as refusing to weight bear and you will get systemic symptoms. So a high grade fever, the maximal lethargy and you can also present with sepsis. So, the common causes are the most common cause is staph aureus. And then in older Children who might be sexually active, then it can be caused by gonorrhea. So when it comes to the management, a common question that's asked is, should antibiotics be started before aspirating the joint or afterwards. And you should always aspirate before antibiotics. Unless the child is severely unwell, then you would need to start antibiotics immediately. The reason to aspirate first is so that the sample can be sent to find out the antibiotic sensitivities. So, transient synovitis is where there is temporary irritation, inflammation of the synovial membrane, which is the lining inside of the joint. It's associated with a recent viral or peripheral tract infection and usually occurs within a few weeks of the viral illness presents with a limp, reduced ability to weight, bear groin hip pain and a low grade fever. The fever if the fever is very high. So over say 38.5 it's important to think of septic arthritis management is symptomatic relief with analgesia and then you want to follow up one week afterwards to make sure that it has fully resolved. So next condition we'll talk about is Perth disease and this is a condition where the blood fly to the head of the femur is cut off and this can lead to avascular necrosis of the femur, which then leads to pain in the hip and a limp. There's no history of a trauma in Perth disease. And the investigation of choice is an X ray. When you look at an x-ray, you'll see damage to the head of the femur. As shown in this image down here. The management is conservative management with bed rest and physiotherapy. It's really important to do physio because this can try and reduce the wear to the head of the femur. I make sure it stays in the correct position, slip. Upper femoral epiphysis is a condition that presents in Children aged 15 is currently more present in boys, but this is changing. So in the near future, it's most likely to be 5050 boys and girls, but it usually presents in obese Children. Um slip feur or hy is where the head of the femur gets displaced along the growth plate. As seen this immature, it can cause pain, reduced me, reduced range of motion and a painful limb. The patient will keep their leg externally rotated and it will have limited internal rotation. The investigation of choice is to do an X ray management of this will be surgery in order to try and correct the abnormal position and hold it in place. So next we'll go over juvenile idiopathic arthritis. So this is a inflammatory condition, er, an autoimmune inflammatory condition of the joints. The reason it's a juvenile idiopathic arthritis is that it usually resolves before the child reaches adulthood. There are five different types. So it's important to just learn one or two things about each one in order to be able to differentiate them. So you have systemic JI A which is also known as still disease. This presents with er joint inflammation and pain, but you can also get a salmon pink rash. As shown in this image. There's polyarticular JIA and this is where it affects five joints or more. And this is usually the hands and the feet, oligo articular gi. So this is where it only involves four joints or less, usually affects the knee of the ankle, your neck get enteritis related arthritis. So this is where you get pain where the tendons insert the bone a commonplace to palpate where you, where the child will feel. This pain is the quadricep insertion at the anterior superior iliac spine. Patients also my with anterior uveitis as shown in this image. And then you get juvenile psoriatic arthritis, which is where you'll get the joint pain and stiffness along with psoriasis. And you also will see nail changes related to psoriasis. The condition is managed by rheumatology. Er but the con management includes nsaids, steroids, methotrexate, and biological therapies. Um and the final thing I'm gonna talk about is non accidental injury. So the risk factors include partner, violence and abuse inside the house, substance abuse in the caregivers, excessive crying in Children, especially 0 to 4 months um this is a trigger for shaking infants and developmental ch problems. So Children with developmental problems are twice as likely to suffer from maltreatment. There are many ways it can present, but I've just decided to talk about bruises and fractures. So, suspicious bruises include those shaped like hands or identifiable objects as well as that. It could be in a linear or ligature pattern fractures or fractures in Children with no medical predisposition should be investigated for non accidental injury, metaphyseal Corona fractures are pathognomonic of non accidental injury. So this is the small fracture that you can see here. So it's often when a child's been grabbed by the arms, you can also get a called rib fractures. So when the baby's being squeezed or shaken and spiral fractures because that cannot be caused by simple falling. So the management of suspected non accidental injury is firstly, you want to do a skeletal survey. So that's where we scan the head, chest, spine, pelvic pelvis, and the upper and lower limbs to look for any trauma. Um They should also be repeated 11 to 14 days after in an emergency. A CT hatchet also be performed once the patient is stable. Um as well as imaging, it's always important to report any concerns of non accidental injury. So children's services should be involved from very early stage shaken baby syndrome. Um When a baby is shaken, the brain bounces back and forth inside the head, which can lead to bre bleeding, which can then result in permanent brain damage or death. There's a triad of symptoms to look out for, for shaken baby syndrome. That's a subdural hemorrhage retinal bleeding and, and hypoxemic encephalopathy. There's a nice mnemonic here to look out for signs of non accidental injury. So 10, 4 faces, I'll let you read over that in your own time. But it's also important to remember that any bruising on Children less than four months should always suspect or think about non dental injury. So I've got five questions just to go over to see if you can spot the, the points that the questions are asking for in order to lead to the correct answer. So the first one, the 14 year old boy presents to the GP with a one month history of a limp. He complains of gradual onset of right knee pain over this time and does not recall any recent trauma. The left leg is not affected and he is otherwise well on examination, there is loss of internal rotation of the leg. There are no other abnormalities on examination. His notes not currently, his height's in the 55th percentile and his weight's in the 92nd percentile, which the following is the most likely diagnosis. Um Is it possible for be able to talk answers in the chart? I think they can, I think they can put the answer in the chart. Yeah. Oh, perfect. Yeah. Thank you. Oh, well, I think I just accidentally showed the answer. So yeah, slipped up a few moral exercises. So when looking at this question, we're looking at a 14 year old boy, so slipped up with female arthritis is more common in boys around this age. We have a gradual onset and then we have lots of internal rotation. Um When looking at the child's height and weight, we can also see that they're obese. So the next question, a three year old boy is brought into the emergency department by his parents who are worried about his walking. He has been refusing to wait, bear for the past day and has been more irritable than usual. His parents informed me that the child has two doses of calpol today after they recorded his fever as 38.5 degrees in the morning. On examination, the child has noticed to have a red and swollen left hip joint. What is the most appropriate next step in the management of this patient? So I'll skip 15 seconds. Have a think and an answer, Harry. Do you think you could just click, hide on the sharing bit and then we can see the bottom answer if that's OK. Yeah, no problem. Thank you. Uh I'll show you the answer now. So joint aspiration was the correct answer. So when looking at this question, um we look at three year old boys. So it's important to think that infection comes in at any age. Um we have a high fever of 38.5 degrees and they're worried about his walking over an acute period of time. So when seeing the fever and the acuteness of the injury, it's always important to think of septic arthritis as well as the red and swollen left hip joint. Uh as we talked about earlier, if possible, it's best to aspirate the joint before starting treatment so we can find out what's the best antibiotic to use. So next question, a five year old boy is taken to the GP by his mum because he has had a limp. The limp has only been slight but his mum says it's got worse over the last six weeks. The boy says that his right hip is a little sore when he runs. There is no report of fever, weight change or any recent illness. He is otherwise healthy. On examination, the child appears well and the hip appears normal movement of the right hips are mildly restricted by pain. An X ray of the right hip shows an irregular fragmented outline of the femoral head, which of the following is the mechanism of this child's condition. Again, I'll give 15 questions before I share the answer. So the answer is avascular necrosis. So what we're looking at here is Perth disease. The things in the question that point towards Perth disease is we have a five year old boy. Um We've had a gradual onset over six weeks, there's no report of any fever. So we can think less about an infection. Um weight change or any recent illness um moves the hip are mildly restricted by pain. And X ray shows the irregular fragmented outline of the femoral head. So as shown on the X ray for Perth disease, earlier, when you lose the blood supply to the head of the femur, you get avascular necrosis, so you get um the shape of the head of the femur starts to change and this can then lead to pain and arthritis in the future. So next question, a four month old infant girl is brought to the doctor's office by her mother with concerns about the appearance of her hips. The mother notices that one hip looks like it is dislocated and the or the hip clicks when the baby has been dressed, which of the following is the most likely diagnosis. 34. So D DH. So when we look at this question, we have a four month old and we have dislocation of the hip and clicking of the other hip. So this points towards the diagnosis of D DH. So the final question, a 15 month old infant is brought into the emergency department by his babysitter. I see is worried that he has not been using his right arm. She claims he injured his arm when he fell off his tricycle. His medical records show that he's behind on his immunization and GP visits for the last six months on examination. He cries when his right arm is touched and there is a marked tenderness on palpation of the elbow. There is an area of swelling just above the elbow. He's had some bruises in his left axilla, X ray of his forearm shows a fracture pattern in the humerus that does not correspond to the mechanism of injury. Non accidental injury is suspected which fracture pattern typically occurs due to a twisting force applied to a long room. One answer in the checkbook, spiral Nicholas responded, spiral fracture, spiral fracture. Yes, that's the correct answer. So when we look at the non accidental injury that's suspected in this patient, we look at a 15 month old who has been brought off after they fell off the tricycle. So we've got a bit of a strange story initially. Um We also have the the patient who is behind on the immunization and GP visits. There is also bruising and pain on multiple areas on the child. And then yes. So a spiral fracture would not be suspected in a accidental injury in a child. And that was the last question. So thank you for listening. And these are some topics you can go over for further reading if you would like to. Thank you very much, Harry. If you go back on the second case, there is a question from Oil on the second question. Second case. Yeah, this one. Yeah. This one. Yeah. The question from will is uh joint aspiration, then antibiotics. So what will be the management for this child? Um Yeah. So with this child, because we're suspecting that it could be septic arthritis if the child is not acutely unwell where they need immediate antibiotic. So you're worried that it's life threatening, the initial management will be joint aspiration first. The reason for that is that we can then find out the sensitivities. Um and what's causing the septic arthritis and this allows us to guide our management better and provide better care. Yeah, good. Any more questions? There is another question. Do boy with PEX need referral to emergency department? I think it's with pest disease? Yes one. Um So it doesn't need immediate referral. It's not a acute emergency, but it does need a referral to pediatric pediatric orthopedics. Yes. Ok. Regarding your case with uh developmental dysplasia of the hip. This little one. So has something been noticed at birth or soon after birth when he had the first check. Um So on the case that I showed on this powerpoint, I assumed that there was nothing that was noticed after birth. I'm not sure. Um But yeah, on the case I talked about it didn't mention anything we found after birth. So this was the first presentation of and in general what would be the management if uh after birth? Yeah. So after birth, if D DH is suspected, then you want to start the patient on a pelvic harness as soon as possible and this allows the hips to grow into the correct position. Um And means that they don't have to have surgery in the future. Totally. Yeah. Can you tell us a little bit? Yeah, more about the one patient? Yeah, you saw with a fracture and yeah, can give you give us a bit of more details. What happened? How did he present with? Um So these, these questions I've got on patients that I've seen myself. These are things that oh no in general. So I'm just talking about a patient that have you seen any patient with fracture? For example, child? Um So yeah, so fracturing Children. First thing yeah, like I said, first thing you think about is are there any signs or concerns that this is a non accidental injury? Yes. So again, you want to look at the location of the fracture if the fracture um makes sense with the story that the parents have told you and also the age of the child. So like I said, Children before months fractures are very suspicious. Um After this, it's really important that you do the skeletal survey. If you're worried at all that there's any signs of non accidental injury, then just admit the patient, uh you can admit the patient and this lets you talk to the patient on their own and also gives you more time to talk to the parents and find out if there's anything that's been missed in the history, which might point towards an accidental injury after this. If you've done the skeletal survey, it's important to do another one, around two weeks later. So this is to see if there's anything different in the two surveys, um, as well as do a head ct to look to see if there's any head trauma after this and if you've contacted. So if you're the F one, it's important that you talk to your supervisor. If that's the reg of consultant, they will usually then involve child support services. And then once you've involved child support services, they will usually make decisions looking at the evidence, whether this is a case of non accidental injury or if the stories and the injury makes sense and it's accidental injury. Yeah. So it will be a multidisciplinary meeting with the social services, everybody involved and decide the strategy. Next strategy. What is very important every time to think about non accidental injuries, especially in nonmobile Children. If they come with bruises or fractures and they are only 23 months old, they are not mobile. This is a red flag for us. You are thinking of uh non accidental injury. Thank you. Another question for Maria. How long do joint aspiration results take to come back? Um I don't know the specific time but if there is suspicion of septic arthritis, then it will be very quick within a few hours. Um But if you do believe that the patient is at risk of a life threatening condition, then instead of waiting these few hours, you will start the antibiotic straight away. Yeah. Yeah. Any other questions in the chat? I have got one question tape in babies. Yeah. Can be seen straight away after birth when we do initial examination, how long would it take for the, for the treatment and what would be the general management? Yeah, of these babies. Um So in Talipes, it can take um it depends on the severity of the Talipes. Um Because what happens is you put the patient in the cast for until the joint is in the correct position. It can take weeks or it can take longer in some Children. But then once you've finished with the cast, a brace is used to hold the foot in the correct position in the until the child is four years old. So in total, it will take until the child is four years old to correct the condition. You stole my question, Daniella. I was gonna ask, how long are they in the cast for? Um Yeah, it depends on the severity of the the. We've got lots of thank you coming in for you, Harry. Has, has anybody got any more questions for Harry or for Daniella? So I'm I'm putting you up now, Daniella as well for the questions. Yeah. Not at all. I want to share with you a case I had six months old baby came to a with uh vomiting, fever, unwell, not drinking, did not have any bruises. Parents did not say anything when he took the history. He was well, apparently until the day before and the child was admitted because was not well in, in himself, admitted on the world and then because the vomiting was continued, uh he had full examination and was noted. The head circumference was at the 95th percentile much higher than the head circumference. At the beginning when he was, when the child was born, there was a significant difference in head circumference in this little child, little baby who came with vomiting and well not drinking. At that time, he had CT straight away and uh was found to have uh uh that child was uh shaken. So actually he he it shaken baby syndrome. The and parents did not say anything when the history was taken. So at that point, non accidental injury, of course, social services was uh contacted strategy meeting. And at the end, uh that child was uh sent into foster care because uh was not safe to go back to his parents. Of course, police continue to investigate uh parents, but the child went into foster care placement which was safe for, for him. So they present the Children with non accidental injury, they can present in different shapes and forms. What is important every time to think about uh non accidental injury, anything else, which make you thinking of nonaccidental injuries in general, if you saw or any cases or if you think about bruises, usually Children, if they fall over, they have bruises on the nose, forehead, um on the hands. But if you see a bruise on the ear, for example, that raises suspicion of non accidental injury, or if you see a bruise on the back of the child, you need to think about mechanism. And if there is no explanation for parents, too much with what you see at that point, again, you need to raise concerns regarding a possible non accidental injury fractures uh as well. Exactly what you said we need, you said you, we need to do a skeletal survey uh in these cases and CT and also we do vision check just to uh yeah, to see if something has been damage there. And also sometimes we do blood test as well, but skeletal are very important. Can doctors talk privately to these Children? Yes, they can. But what is important? Um What is important? Speak to parent separately, you can speak to child separately. You need to ask the parent to leave the room because you want to discuss with the with the child. So you need consent from the parent. Usually they are fine. Uh The main problem is if the child doesn't want to stay without the parent being present, but if the child is happy to stay yeah, we ask the parent to, to wait in the waiting area and then we have a face to face discussion with the child. How common are non accidental injuries? Like how many of you sort of seen Daniella or Harry as well? Not very common, not very common but uh oh um there are mainly from uh yeah, coming from deprived areas or Children from families well known with domestic violence, well known to police domestic violence with uh difficulties during the pregnancy as well. Domestic violence in in pregnancy. So these are cases no one to social services, no one to police or midwives as well. We do uh a child protection medical examination for any child who is referred to pediatrics. And currently uh child protection medicals are done by acute pediatricians in the hospital. We see any child who is referred to pediatric because of bruises. And for example, the child, a child is in school presented the bruises on the forehead, on the, on the arm and the teacher asked the child what happened and at that point if there are suspicion of uh non accidental injury, the injury, somebody or probably another child cause the bruise. Um these Children are uh referred to pediatric for so for uh uh child protection medical and then we'll discuss, take the history do examination and decide what, what was the problem, what happened and what strategy needs to be taken if another brother or another sister cause the, the bruise to, we may think about not being well supervised. E especially in little Children, depending on the situation on the age of the child on the oxy. Yeah, exactly what happened. Any other questions for either Harry or Daniella, I've put the feedback form in the chart. Um If, if everyone wants to give feedback on the session. Um and then after you've attended three of our sessions, you can get the certificate from, um, you know, attending. Um, and then we also have the next session for next week. Is there any more questions before we wrap up? And thank you, Harry and Daniella for today. It's been really, really interesting. Thank you very much, Harry. I enjoyed the topic and I did see you clearly put a lot of work into your slides and presentation. Well done. Thank you very much. Um If anyone wants the slides, just let me know the pediatric sites know and I can send them out. You are muted Chloe. Thank you for that. Um I was saying we've got quite a few. Thank you coming through and if no one's got any more questions, um we can end the session there. So thank you everyone for coming and thank you, Harry and Daniella again. No problem. Thank you for inviting. Yeah. Bye-bye. Bye.