Navigating FRCS: Paediatric Orthopaedic Webinars | Perthes and Trauma



This free on-demand teaching session will feature Dan Westcott, a consultant at Ry and Shire, who will provide teaching a wealth of experience to help medical professionals pass their FCS with topics on Perthes Disease and trauma. Mr. Waa will also discuss additional trauma topics before offering an opportunity for Viva practice. Special topics include differential diagnoses, family history, understanding of AVN of the Proximal Femoral Physis, and the two-hit phenomenon. Participants are encouraged to ask questions via chatbox for response at the end of the session. Whether you love it or just want to get through the exam, these highly experienced experts will help you understand and feel confident in their topics.
Generated by MedBot


Navigating FRCS: Paediatric Orthopaedics Webinars"

Topics - Perthes and Trauma


Mr Dan Westacott, Consultant Paediatric Orthopaedic Surgeon, University Hospital Coventry & Warwickshire

Mr Farokh Wadia, Consultant Paediatric Orthopaedic Surgeon, Southampton Children’s Hospital

For other BOTA events: https://share.medall.org/organisations/the-british-orthopaedic-trainees-association

Learning objectives

Learning Objectives: 1. Describe the epidemiology of Perthes disease and associated risk factors. 2. Recognize radiographic features of Perthes disease. 3. Differentiate between Perthes disease and other causes of avascular necrosis of the proximal femoral epiphysis in children. 4. Analyze the clinical presentation of Perthes disease. 5. Explain the possible underlying etiology of Perthes disease.
Generated by MedBot

Related content

Similar communities

View all

Similar events and on demand videos


Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

No, no, I think we're alive. Um So my Stephanie and welcome to everybody for joining. Um It might just be a few further to join, but we will start as it's eight o'clock and I'm going to start by introducing our faculties. So to start the evening, we're going to have Mr Dan Westcott and he is a consultant at Ry and Shire and a wealth of experience behind him with teaching, but also clinically and the bonus for tonight is that he's an effort, CS examiner. So he'll be able to um guide us through what we need to know for Perth phase. And then following off that, we've got Mr Waa and he is a consultant down in Southampton. Likewise many years of experience behind him and he's going to talk to us about a few trauma topics. And then Mr Waa is kindly going to do a Viber practice. So short, after, towards the end of Mr Warri session, we will invite a few people. Um typically the people towards the exam, if they would like to do some viva practice and I appreciate there's a big platform, but nobody knows anybody and it'd be a fantastic opportunity to get some practice and get some feedback as well. Um So if you would like to practice survivors, then please do put your name forward. Otherwise I will put out there and ask if anybody would like to join. Excellent. So Mr Westcott, if you are happy, we will start with Perthes. Have we got, uh has everybody joined and ready to go? I think they're coming in in dribs and drives. We've, we've got a good number and which I'll crack on if anyone has any questions or anything at any point. Can I please ask that you put them in the chat box? I will be keeping an eye on that and we would ask if it's possible that you keep the questions, we'll keep the questions till the end and we can obviously go over anything that you want with regards to the birth of the trauma talks that discussed. Steph. Can you see the screen? Is it working? Yes, I can see it. Perfect. Thank you. Great. Right. Thank you very much everybody for the opportunity to talk about one of my very favorite topics. Um And hopefully by the end of this talk, you will all love it as much as I do. Um So we are primarily going to try to help you get through the Perth station in your F CS. It is one of the, the big five pediatric topics which do commonly come up. Um, but we'll also talk about a few new concepts. Now, they might, if you want to play safe, probably not things to mention in your viva but things to, um, hopefully understand, appreciate, be interested by, but as with many things in orthopedics, nothing's ever new. So we may find these are just, er, old ideas, er, coming back to the surface and hopefully we might be able to dispel the sense of despair that many of you may have about Perthes disease and maybe even inspire a few of you to love the condition and be as interested in it as I am. So, why is Perthes difficult? So, as clinicians, we find it difficult because it's rare and we know from the recent boss study that only 2.5 cases per year per 100,000 susceptible Children. So it is uncommon. Um, and unfortunately many people do have some preconceived or strongly held opinions about it which they may have received from the people that have trained them and they can be hard to break down. Um, and because it's rare and many pediatric orthopedic surgeons do have broad practices and we all have limited mental resources. We might not take the time that we could to really get a decent understanding of a condition that maybe only comes up in our clinic once or twice a year. Why is it difficult in the exam? Well, it's common, unfortunately, unlike the condition, um, your examiners may have some preconceived or strongly held opinions. Um, and one of the things that really is, is frustrating is that people tend to waste quite a lot of time at the very beginning describing the x-ray and they sort of fluff around it and laugh about and, er, we, you know, the examiner knows it's Perthes, you know, it's Perthes get on with it and then we can start scoring you some points. Um, so when you get the little introductory vignette and you get show this x-ray, you're gonna quickly rattle off something like this is an api pelvic radiograph of a SCLE immature patient. The most striking abnormality is really useful phrase to have in your, in your locker for your viva sclerosis and flattening of the right femoral epiphysis, lateral sub patient and a large metaphysis consistent with the diagnosis of Perthes disease. But Right. OK. And then we can move on. Yeah. And you know, it's a pretty good tip to use whatever your Vira is. Now, you're flagged to the mask. Say what you think it is. Let's go for it. If you're wrong. They the there's prescribed questions now they can't take you, they can't let you hang yourself. Right. They're gonna pull you back and just go. Are you sure about that? And then, ok, let's, let's carry on. So what is Perth's disease? Hopefully, you are all shouting at your screen idiopathic avas necrosis of the pediatric femoral head. Ok. We can't disagree with that. But there are other causes of AVN of the proximal feminine epiphysis in Children. Um And it would be useful to have a list like this in your head. I think those trauma and infection are probably the most common and this is uh pretty fair to say this is a uh a list of how often we see these in reducing order. And so in your Bible, you're gonna make some reference to that. And rather than just saying, I would take a full history and examination and then your, you know, your examiner just sort of slowly size to themselves. You want to say something meaningful. No, the salient points I would like to elicit from the history include ruling out other causes of ava necrosis. Ok. Um Also, we need to think about not only what else could be causing the AV N but is it actually a VN what else could be causing the radiological abnormality? Ok. Hopefully you're seeing this x-ray and you're all having some ideas of what that might be. So, what is our differential diagnosis when we have an abnormality of the proxen, femoral physis? We're thinking multiple epiphyseal dysplasia, spon eys dysplasia. A good question always to think about is, well, why is this x-ray that we're seeing not Perthes because we could be saying there is loss of height and appearance of fragmentation of, of both proximal femoral fifties. Um but it's not Perthes because it's bilateral and it's symmetrical and Perthes is very rarely um contemporaneous, there's acetabular involvement because it's also using the, er, or also affecting the um, uh ossification centers of the acetabulum and the metastases is unaffected if you had birth, he that bad to cause that much abnormality in the epiphysis. You probably see some metaphyseal changes as well. So who gets disease? So we know this is more common in boys. There might be a family history, the textbooks will all tell us low socioeconomic status. I would just, er, you to think of that more as a family history of deprivation. Ok. So it might not be in that child, it might not be in their parents, it could even be a generation back. Ok. So it seems that there's, you know, some exposure to deprivation may switch on some kind of epigenetic factor which is then passed down through generations, has been linked closely with passive smoking. Dan Perry's epidemiological work has not been able to kind of tease out between passive smoking and the low socioeconomic status because they are so intrinsically linked. Um, you'll read a lot about ADHD, that's probably more from the American literature and it may be that there's some sort of different diagnostic criteria in the States to hear again. If you look at Dan's work, when he's looked at GP records of every child with Perthes, they are more common than other Children to have some behavioral disorder, but it's not specifically A dh D again, if you look at their GP records, they'll also have some urinary or ringin or congenital anomaly on that side. Um as well. And I've put coagulation abnormalities right at the bottom of the list. It seems to me that for every paper there is that links a particular clotting factor. There's another paper that, that disproves that link. So it, it may be the least relevant. Ok. Um There certainly is this concept of the susceptible child. They tend to be small for their age. They have a low birth weight and their skeleton is younger in years than their chronological age. The head tends to be a normal size. The trunk might be a little bit smaller and then the hands and feet are notably smaller with respect to the um lower limb or forearm, uh but also with respect to the body. So we're thinking that there's some kind of structural anatomical predisposition. There's some kind of environmental epigenetic trigger potentially. And then we have the classic this, this guy as being your kid with Perthes. Ok. His head's normal size, his trunk's a bit small. His hands are small. He's only got three fingers. Ok. He's small for his age, but he's always getting beaten up by Nelson. He's got some behavioral difficulties. He's relatively low socio status co I don't think Hamer gets paid much in his job at the power plant. Um But don't go thinking that every kid with Perthes is a is a little tear away. Cos these, you can be some of your absolute favorite patients. They're often lovely, lovely kids who've had a really, really bum deal. Er, no pun intended. Right? Ok. So how does it present? There might be a little shortlived acute episode, a bit like a transit synovitis which seems to go away and then maybe a month or two later, the symptoms will come back with a vengeance And this raises this theory of a two hit phenomenon. So when Harry Kim over in Texas Scottish, right, he tries to recreate Perthes and piglets by tying off their um, medial femoral circumflex. And if he does it once they don't get ra changes, he has to go back in and do it again before they then get the ra change. So it maybe this two hip phenomenon. Also, if you biopsy your Perthes heads, there's different stages within the same head as well. So it might be a not just a single episode. Now, whether Harry Kim's pigment models are a true histopathological model of Perthes is a discussion for, er, er, um, another day. Um, so these kids might have a painless limp, they may get some groin pain, thigh pain, knee pain, ok. When we're looking for, uh, we examine them, they're gonna have most prominently restriction in abduction. There might be some loss of internal rotation. I remember about 7% might be bilateral, but it's very rarely at the same time thinking about how we're gonna put this succinctly into our vir answer. We may want to say after we've mentioned about the history, we're gonna say something like my examination of focus on range of movement, particularly abduction and then looking for any leg length discrepancy, be that real or apparent. And these kids can get a really big apparent leg length discrepancy because of their adap to tightness. So what happens? We're familiar with this concept of the phthisis being a vascular barrier. So the epiphysis being supplied predominantly by that lateral ascending cervical artery and slightly by the medial on the other side, which will um give a little bud by in many cases. But the majority and particularly that um lateral pillar being supplied by that lateral ascending artery, the terminal branch of the medial femoral circumflex. And it's most likely that vessel that that gets the insult. Now, we're all familiar with the stages and it would be reasonable enough I ever to be expected to talk these through. Ok. Now, moving away from the Fr CS five for a second to anyone who wants to um kind of understand some more current concepts on Perthes disease. We would I I would ask you to not think of fragmentation but to think of more the term cond. Ok. And we'll come back to this later on. Alright. And now this is one of these new concepts, but it's not new at all, ok? If you go back to cater's work from the seventies, you go back to retta in the sixties who was a, his pathologist in, in Oxford. They were all talking about conation, all the early Perthes papers, conation. And somewhere along the line, we've lost it. And we've gone to this term of fragmentation, which gives the idea that there's some kind of loss of structural integrity of the EPY, but that's not the case. Ok. So we know about the blood vessel, but what really happens in Peric is what is going on. Ok. So the first response to the ischemia is hyperplasia of the cartilaginous portion of the epiphysis. All right, we also are going to get conation of the bony part of the epiphysis. Ok. So the bone is turning back to cartilage and that's why it looks like it's fragmenting on the x-ray. We then therefore got a swollen soft deform ball which is gonna get laterally subluxed out of the joint. It's then gonna become, we're gonna get extrusion of that lateral epiphysis. So we're gonna have a misshapen ball which is getting squashed out of the socket. We then get subsequent re ossification in that deformed extruded shape that then is gonna cause impingement, that's gonna cause chola damage, secondary of dysplasia and early joint degeneration. Ok. And what also happens, it's not all about just the joint, it's also damage to the PSIS. In more severe cases, the epiphysis gets revascularized by blood vessels growing up through the PSIS and they bring bone with them and that's what causes the pal bar. Ok. That's gonna give us a short neck. The cocci Breer. We're gonna therefore gonna lose our lever arm. That's gonna cause abduct dysfunction. That abduct dysfunction can be worsened by relative overgrowth of the GT which is then gonna detention, the glutes, make that touch dysfunction worse. If that GT overgrowth gets really bad, you're even gonna get GT impingement on the outer wall of the pelvis. So quick um tangent about conation. Now, I can't take any credit for this all rights reserved to John Shea at Vanderbilt in Nashville. He just won the Basic Science Prize at Posner this year. Um when he presented all his um basic science stuff from his lab, he's er incredibly clever guy. He's got mice that grow all sorts of different colors depending on which cartilage cells are activated. Um And I will do my best to do justice to his theories. So, conation, this is a physiological response to the high strain, low O2 environment that's happening in Perthes. OK? And we should think of this second stage as part of the healing process, not the disease. OK. This conation is the body's way of healing the insult that's happened. All right. So it's not the fact that the epiphysis has been injured and is then collapsing down like an adult. A VN. OK. The conation that fragmentation that we see this is, this is part of the healing. All right, the exact process is remains unclear, but it's probably reverse trans differentiation of osteoblasts. So, the osteoblast is actually turning back into chondrocytes. OK. And those hypoxic chondrocytes are wonderful cells because they have this amazing capacity to resist strain. And also they create, I think loads amount of growth factors F and BM. And it's that, that's then gonna drive through the ossification. OK. So you've got these wonderful cells that have great mechanical properties. They've got great biological properties. Um And they're doing, they're driving the healing. It's worth just thinking for those of you that are currently deep in Ramchandra. So I should probably phrase that better. Um Of where else you might find um chondrocytes in a high strain, low oxygen environment. OK? Because this isn't something that's specific to Bey's disease. This is going on in the fetal skeletons, normal ossification. OK. Of that cartilaginous alar turning into bone. It's happening in Callus. Yeah, we've got a, the blood vessels are damaged. We've got a low oxygen environment, we've got high strain environment. It's probably also happening in BLT'S disease as well. It's probably the same process and it all goes to show further evidence if we needed it. As we know, Children are lizards. OK? And this is one of the great things about herpes. They have this wonderful regenerative capacity. We just have to allow them to heal in the right way, right. Back on to the uh the viva. OK. So what we trying to achieve when we meet a child with Perthes in our clinic, what are our aims of early treatment? Ok. And any Viber you're doing after you've gone through, you said the salient point, you're gonna listen from your history, you've told us the things you're gonna look for in your examination and why they're relevant and then you're gonna say something like the aim of my treatment is or the principles of managing this condition are OK? And it just lays it out, gives you time to think, gives you to structure your answer and, and, and you can think through what you're gonna say because you're gonna be sitting in that vir your head is absolutely full of things you want to get out and you just, you don't want to just explode all over the place. You want to throw another bad express, you want to be able to order your thoughts. So a nice statement like the aim of my treatment is, and as we all know with Perth's disease, the aim of treatment is containment. OK? And that's gonna be the buzzword that you're gonna get out in your Viber. All right. But what does that mean? Well, it means ideally we want the ball within the socket, ideally a spherical ball and if not spherical, then at least congruent. OK? And then we can say that we contain that hip. So how do we achieve containment? It can either be passive or active and really that means non surgical or surgical. Ok. So what is passive containment? Now? I think Adam Galloway is in the audience. So this comes with a big early apology because he's currently working his way through a phd of establishing what is the optimum non surgical treatment of birth disease. And I'm gonna squash that down into two lines and do him a gross injustice. So I'm sorry. So most people will use some kind of restricted weight bearing and some physiotherapy. Ok. And the main part of the physiotherapy is gonna be maintaining abduction. If we can keep the range of movement, then we're gonna keep that extruded mass up inside the socket. We're gonna roll the pla dough, keep it into a nice round ball of the nontoxic modern laser available and we're gonna um hopefully keep a contained spherical congruent hip. Ok? Sorry Adam, quick note on restricted weight bearing. OK? Because this is a big issue um in Perthes and four Children with per disease and the parents of Children with births disease. Ok. So again, over intake of Scottish rights, it was not unfamiliar and it's probably still the case that when you were diagnosed with Perth disease, you were put in a wheelchair for two years and they struggled to prove a benefit of that. They have recently published a paper that shows if you've got severe hypoperfusion on MRI, then there is a small improvement in femoral heads if you have a really prolonged period of non weight bearing. Benjamin Joseph showed that if you have surgery for Perthes as a lot of his patients do, which we'll talk about later. Um, if you remain nonweightbearing for six months after surgery, then it was more likely you were going to end up stall, beg one or two, um, versus those who had a short period of non weight bearing. Ok. So it might be useful, but it really isn't a harmless intervention. Ok. There's more and more understanding now that it just makes these kids miserable. All right, please don't underestimate the impact like a prolonged period of restricted weight bearing will have on a child. You're taking a, a seven year old boy and you're essentially removing him from doing any sport, playing out in the playground with his friends. You're taking away his formative years as a child. I say his, I mean, I'm saying his because it's much more common in boys. Ok. He's, he's not learning sports. It's in, in fact, in impacting his self esteem, his idea of who he is. Ok. All, all he's ever hearing is what he can't do, being emphasized to him, why he's different. Ok? And it is heartbreaking when you finally got a kid into the ossification stage and you say, right, you can go and play football now and he looks at you and he just says, but II, I don't know how to play. I will say, well, the, but they don't let me play because I'm rubbish and, and you've know, it's, it's very easy to, you've taken that child's childhood. So please don't underestimate the effect of restricted weight bearing for what may be fairly limited benefit. So, we've talked about very briefly about what's passive or nonsurgical containment may involve, we'll talk about active attainment because I expect most people on the court are surgeons and that's what you wanna hear about. So, active containment primarily means surgery. All right. So big question is how do we know who might benefit from an operation? Ok. And that is a really hard question. And really what question we're asking is, how do we know who's not going to be contained passively? Most importantly, how do we know in time before it's too late in time that we can still help them? Ok. And this is the great difficulty. So what can we use to answer that question? Are there any classification systems that help? Everybody reminds me for an exam? The loves the classification system. Let's have a think about the ones we've got in Perthes and if they're any use to us, so everyone remembers Stolberg. All right. And it's been shown to really clearly correlate with longterm outcome. We'll talk a little bit about that later. OK. But it's not used to us in siding, getting an operation because it's done at the end of the disease process. It's finished. Yeah, they're, they're fully growing the sle and mature. It's not, it's not gonna help us, right. So next classification, everyone thinks about herring. Great. Ok. Again, it's been pretty clearly linked to prognosis, but you know, it can tell us how that kid's gonna do. Does it actually help us with our decision making process? And I would argue no, because it's, you'll read Herring in two different volumes of Tagi. And he actually says two different things, but it's at least the mid portion of the fragmentation stage. If not his initial um description describes it at the end of the fragmentation stage. OK. And I would argue to you that that is too late to try to contain a hip. OK? And because really you need to be, if you're gonna be trying to do containment surgery, it needs to be done before the, the second half of fragmentation. So when the, it's got broken down, the modified Elizabeth Town classification sort of breaks each of those initial stages that we er the w strong stages into two. So two B just means a late fragmentation, we really should be operating before that. OK. Why do we need to operate early? If the head's already deformed? When you try to stick it back into the socket, you'll try to put a square peg in a round hole. OK? And that's not gonna be comfortable, it's gonna be stiff, it's gonna be painful, right? And also if we think about conation, yeah, that's part of the healing process. So by late fragmentation, fragmentation, OK, that ball is healing up. So if we're gonna change the disease process, we need to do it earlier than that. OK. Going off a quick tangent again. So another warning light don't mention this in your fs for probably. But it's a really important concept I think to try to understand and it's about square pegs in round holes. And this is the concept of reducing hinge abduction. OK. So we're all familiar with classic hinge abduction. We've got a healed up Perthes that's done badly. We've got a big extruded lateral mass that's impinging on the edge of the socket. Um And as we abduct, it's creating a sort of lever at the edge of the socket or even the GT levering on the um on the outside of the wall of the pelvis. Um And we're getting that big medial clear space with our arthrogram. And you can imagine that that's a really stiff, horrible hip. OK. That's, that's pretty straightforward. And that's everybody agrees with what that is. All right. But I would ask you to think about this concept of reducing hin abduction. OK. So this is a nice example. So this is the x-ray we had at the beginning and we're looking at that and we're thinking, well, it's, you know, there's loss of height, there's a big metastases cyst, there's lateral subluxation. That's a hit that might do pretty badly. All right. So then we, we go to theater and we do this arthrogram and we put the dye in. All right. And then we abduct. So this picture on the right here and we're thinking, oh, great, look that that's containable. OK. Because the big, big extruded lateral mass is coming up within the, within the confines of the socket. And if you can see my arrow, but here's the labrum, here's your little rose thorn. Ok. And we've got our extruded mass. It's sitting inside the socket. So great. Ah, that hip's still containable. Yeah, there's not clear, classic hinge abduction. So we might, you know, decide, oh, we're gonna ize that kid and we'll put him into that position and great, we're gonna, we're gonna make him make his hip better. But can you see what's happening? Ok. He's getting, yes, it's reducing. But then there's this pivot point. It's deforming that chondroma complex. There's still hin abduction. That kid's gonna be walking on this tiny surface area that's gonna cause second dysplasia, it's gonna cause pain, it's gonna cause stiffness and you would have made him worse by trying to contain him too late. I should, this all comes with a big red flashing light saying this is very much my opinion and other people will, will disagree. Ok. So, back on to what classification systems you've got to help us. So Thompson, I think this is really useful. All right, what we're looking for is the crescent sign, this little subchondral fracture. Ok. And it is, and it's simple. Alright. If that subchondral fracture is across less than 50% of the head, it's group A, it's probably not that bad if it's more than 50% of the head like this picture, it's group B and it's likely bad disease. The real reason it's very, very useful is because this is in, this is early. Yeah, we've got loads of time to intervene if we want to. All right. So it's really, really useful. But why is it maybe not still that helpful? It's great if that crescent signs there, but you probably only see it in a third of cases, right? So yeah, I I expect it's always there. It's just whether you, when you take that snapshot x-ray, whether you catch it or not. OK. So if it's there, it's really, really helpful, but it's not always there. OK. Um Another thing that we do expect to know for survival would be cats, radiological head at risk signs, Gaer sign. So it's like a big rat bite out of the uh um epiphysis and the adjacent metaphysis. And I think this is a really, really bad sign and it tends to happen in older kids. All right. So if you see a Gauer sign, that's the hip that's gonna get really bad. Um And our other ones, lateral subluxation, horizontal physis. Now, I don't think the, the femoral, the, the physis actually change its shape. I think it's, you, it's a, it's a radiological artifact by the fact that you've got a painful hip which is held a little bit, flexed, a little bit, turn rotated. And if you do that to a kid's proximal femur and look at the PSIS hip just makes the p look horizontal, um meta cysts that we saw earlier and calcification lateral to the PH sys. And I think this is, that's probably already started kind of re ossification of that extrusion, lateral mass. So it might not be a head at risk. It might be a head that's already gone bad. Um Top, top left, top, middle uh gauge sign and you can see, you know, that's a, that's a relatively old kid. Um Top, right, we've got meta cyst and we've got um er um sort of a degree of later extrusion. Um probably another gauge sign there. This is a kid of mine who's got a big natural sub location. So bottom, middle picture, I don't know if you can see my arrow. Um And then this huge area of contra communication here. So it's probably bad disease, but getting early with an operation, you can have a really good outcome. Um And then we've got clinical head at risk signs. We have our radiological, we've got a clinical and really what clinical head at risk signs mean. There's loss of abduction and there's a lot of centers, you know, particularly older hay would be the classic that tend to operate as soon as a child loses abduction. That's their trigger. Ok. And in the boss study, that was the commonest reason for surgery thinking about why they lose abduction. I, you know, I wonder whether it's chicken or egg? Ok. So is it that we've got a painful hip? So the child tends to protect it and hold it abducted and it's that, that then uncovers that um, vulnerable lateral epiphysis and causes the extrusion or have we got extrusion that's then causing early impingement and to try to relieve that. The child then holds the head across. Um, sorry, holds the leg across to sort of relieve the impingement. I don't know. Right. So, if we've decided that we, so if we've got a hip, we think's gonna go bad for those various reasons. So, maybe they're um, sorry, top and B or they, we think they've got lots of head at risk sides. What operation are we going to choose to achieve containment? So, what are our options? We've got something simple. We've got Duno and Petch casts, we've got femoral osteotomies, pelvic osteotomies. So, reorienting osteotomies or we've got um, a shelf procedure kind of, that's maybe a reshaping procedure or whatever you might, you might turn it and they've each got their pros and cons, we'll have a little think through those, er, this picture is from the Oxford Textbook of orthopedics. Um, and I think it's maybe one of Colin Bruce's old patients and it's the reason I love it is it al already, it's the reason it's in there is because it's for an example of a crescent sign. Um, and you can see this child has just developed a crescent sign over more than half their head and they've already had their shelf done. So, it just kind of goes to show how, um, interventional some people are with Perth's disease, right? So, what are our options in terms of surgery? Um, so a Duno toy is Petch cast. What are the benefits of it? Well, it's pretty low risk. Ok, if you're trying to talk to someone in or persuade some parents to have surgeries and you're gonna say a little incision in each groin and some plaster casts, that's a relatively easy set. Ok. But it's incredibly inconvenient. If you imagine trying to look after a 6789 year old child with their legs in that position. That's, that's really hard work. You can't fit them in a car, you can't fit them in a wheelchair. It's, it's really, really inconvenient, don't underestimate how difficult it is. And also it's only gonna work for as long as you've got them in the cast. Ok. So you're limited in terms of your duration of effect. So what options have we got for kind of recreating that position, but permanently. Well, we can do that with a femoral osteotomy. Ok. Benefits. It's easy. Yeah. Anyone can do a feri osteotomy and you can get an awful lot of correction in there if you need to. Ok. But there are some significant disadvantages. So, if you, if you do it over age eight, that varus that you put in won't remodel or at least not, not reliably. Ok. And that's what we're thinking if we've had a kid with bad enough Perthes that we think they need surgery, chances are they're gonna have some PS or damage, they're gonna have co to Breer g overgrowth, they're gonna get some abduct dysfunction. Ok? We make that even worse by then vais them. That's, that's not a, um, necessarily a, a, um, er, harmless procedure. They're also gonna be getting, you know, they're gonna already be short from their kind of, um, apparent leg length discrepancy. We're gonna make that worse by vais them. So don't underestimate the effects of leg length discrepancy, particularly also if they're gonna have cups of bre. And there is also a theory that if you've got a really vulnerable lateral pillar and you vais them down, then you're kind of creating some really, quite unhelpful sheer forces through the most vulnerable bit of the epiphysis. But it's just a theory. So you might think, well, a sold ostomy pros, well, it's pretty easy, um, cons you're limited in how much coverage you can get. Ok. And again, there's a theory that because the salter is pivoting around the um um I lost the word er symphysis pubis. Um You've got a sort of fixed pivot point. And so the idea is that you might create kind of increased forces um through the hip because of that fixed pivot. That's a theory. Um So for that reason, people might consider doing a triple because you can get great coverage, you're not only going to rotate, you can also laterally translate the fragment as well. So you can get really good coverage. And in theory, because you haven't got that fixed pivot point at the symphysis, you've kind of got tension free coverage. Ok. So that's why it might be beneficial. Disadvantage is it's a bit harder. It's a bit riskier. OK. Shelf procedure. I've only ever seen one. I went up to see Dan do one in Liverpool. Um, you can get amazing coverage. Disadvantage is it's pretty sketchy um fixation. It looks, it looks like it's gonna fall apart if the kid sneezes. So you might have some prolonged non weight bearing or a spiker afterwards. And I do wonder about kind of late impingement afterwards. But I, um, you'd need to speak to someone with more experience than I do off the shelf as to whether that's an issue. Ok. So why my surgery work for Perth's disease? We've talked about the kind of mechanical concept of containment and that seems to make sense, but surgery might work for other reasons. Ok. It might just be that we give the kid a big local surgical hit that causes a hyper response as we know happens. And that may just kind of force revascularization. It's possible we also know that early surgery in the initial stages, you can actually skip that fragmentation contr stage. OK. In, in quite a lot of cases that's been shown by Benjamin Joseph's group that with an early femoral osteotomy. in that initial stage, you can completely jump uh fragmentation and go straight through ossification. The Japanese have also shown that happens with a Salter as well. OK. And if we're thinking about why the surgery work, we have to ask the obvious question of well, does surgery work? Ok. Now, you should all have a good understanding of the bus study before C Survivor from both the point of view of Perthes and Sufi. OK. It's, it's, it's laying an awful lot of stuff out for you, ok? And it's kind of giving you the answers if you want to use them. Ok. And as we know, the boss study did not show a benefit of surgery, OK. They looked at a number of different um patient reported outcome measures and they didn't show a benefit of surgery. Now, there was no self-analysis regarding timing of surgery. Ok. And if you look at it closer, 20% of the surgical cases ie the kids treated with surgery were diagnosed at two stage two B or later. Ok. Further to that half of the kids that eventually had surgery didn't even have a definitive plan at diagnosis. So there's a chance that a lot of these cases will be doing quite late into the disease process. So there's probably a lot of square pegs being stuck into round holes around the country during the study period. So, what about if we look at um, uh hips that we know in theory were treated early enough? And the classic paper is going to be Herring study. OK. So these only included hips, they, they're not specific, but they say in initial stages. OK. And their outcome measure was pretty simple. Is it still b one or two or is it worse? OK. And we know from the abstract if you read it that it supports surgery for patients with the age over eight and A B or BC border. But actually if you look into it closer, there's more in there to support surgery in Perthes, OK. There's an overall benefit of surgery in this population which they, they don't really report. So now of all the kids that had an operation, 6% of them end up still be one or two compared to 46% of the, if you don't have surgery. Furthermore to that, if you are chronological age under eight with a um pillars with a group C um Herring C, you're three times more likely to end up stall, beg one or two. Those numbers are pretty small like that. Ok. But surgery may have a place, I feel obliged to mention other treatments because there are people doing other things. Ok. It's not just physio or surgery. There are other options. You might read about bisphosphonates. You know, I don't think that the femoral epiphysis is fragmenting or fracturing. Ok. So, I can't really see why there's a role for bisphosphonates, epiphyseal drilling. Yes, it might have a role really a disease. You might stimulate radio vascularization. Ok. You'll hear about stem cells. Well, you've already got the perfect cells in there. OK. Those hypoxic ond cys are the exact cell you would want to be driving the healing of the Perthes. So I don't think any kind of stem cell that you can put in there is gonna be better than them. OK? And yes, you've got a hip distractor. Um I think it's just me, but I don't have direct clinical experience of them. I've met Children who have been treated with hip stratas and you can tell. So, how do I treat Perthes again? Big red light. This is just my approach, in my opinion. All right, I will offer surgery for a child who is. So, Thompson B, it's a crescent sign of more than 50% or has two or more head at wrist signs and as progressive loss of abduction. Ok. If they're under eight years of chronological age, then I will offer them a femoral osteotomy. If they're over eight, I'll offer them should perfect ostectomy. I've so far treated 16 patients that got to me before stage two. B so if they're already into that second, that second stage of fragmentation, then I don't consider them for surgery. And so therefore, they're not included directly in these results. So I've had seven other kids who came too late. I operated on 10 of those 16, which is higher than the national average of 40%. If you include the seven that came to me too late, then it's consistent with the national average. Um, four of those kids are on course or either have reached, um, still beg 18 at still beg two and have got a few that still three but none less than that. And I'm in the process of, um, I finally posted out the, uh, the patient reports, outcome forms today. Ok. Quick bit about treatment options for leg disease and then we're done. So this is our classic x-ray of someone who has had Perth disease as a child. Um What options do we have for them? We need to ask a couple of questions. What am I actually trying to treat here? Ok. Is it, they've got impingement pain, is it? They've got a dutch dysfunction and they've got that crampy pain in their buttock after five minutes of walking. Is it leg length discrepancy or have they got arthritis? Ok. Or is it any combination of those and we've got a few different options we can choose from or we, again, we can kind of mix and match off the menu. Ok. Valgus, osteotomy is probably the most common procedure for late Perthes that you'll see. And it is great in the short term. You know, you can take these kids from being completely miserable to playing football and being really happy. Ok. And, er, you will give them their, you know, a few years of their childhood back, ok? And they'll be very, very happy for a few years. Then their expectations go up and then they start getting unsatisfied again. Um, don't underestimate, you know, it doesn't make the abductor function better. People say, oh, I'm gonna vow guys it, I'll distal the tracer and that's gonna make the abductors work better. It doesn't because as you vow guys, it's actually, if you remember our free body diagrams, ok, you're reducing your lever arm, you're actually making the abductors work worse. So don't k yourself. And actually in time, yes, you might relieve that impingement, but it comes back because they, they've had bad Perthes, they're not growing. Ok. So similar to, we all know about long leg dysplasia. We've got a long leg, our sockets uncovered as their leg shortens their socket drops and the impingement returns. Ok. So they will be happy for a few years, but not for long mor osteotomy can be a good option. Um, if you've got really bad cocker Breer and GT overgrowth. Ok. This is one of my kiddos. She's gone from, you know, buttock pain after five minutes to, you know, trying to get back to rugby. She's doing, she's doing really well. Um, so it can be pretty, really, quite effective at, um, restoring the, leave her arm and relieving that kind of buttock ache from the abduction dysfunction. Um, you can do a KL omy osteochondrosis, whatever you want to call it and you can do that late, but you can also do it early. This kiddo has gone from, you know, four times a day, paracetamol and Ibuprofen to now playing football in the playground with his friends. It's he's, he's very, very pleased. So it is a good option but it's not for the fainthearted. Um ok, or you can do a combination. This lad had a valgus osteotomy got back to playing for his school first team at football, but now worsening pain impingements come back. You can see how short he is so you can do a combination. He's had an MRI which shows his cartilage in his joint is actually well preserved. So you can do, you can take the bump off, you can do relative neck lengthening, you can distal um and you can valgus him with it as well. Um I feel obliged to mention head reducing osteotomy. Er, there are people doing it. I think it's gone out of fashion a little bit seems like a good idea. Um This is from the kind of paper, the biggest series of them, I think it was Caroline Blakey who um said last year at VO A that you're gonna put your best x-ray in the paper. And if this is the one they chose, then maybe it's not a great option. Um OK. So what's the longterm outcome of birth? Um There's a couple of good studies recently. Um So Dan again has correlated really quite clearly, um, stall beg with patient reported outcomes in adulthood. Um And the international birth study group just recently did this big survey, basically adults, her Perthes kids are just fairly miserable in every, um, metric you choose to look at and it was all those things were again worse in females and you kind of know that. Ok, so I appreciate that since I've been talking for a long time. I hope you kept up and thanks for sticking with me if you have. Um, so in summary, I hope you feel it's not all doom and gloom. I hope we are starting to un you, you can believe me that we're starting to understand it better and that there might be hope about working out how to treat it. Um And yeah, if you do, when you meet a new diagnosis, the Perthes, you know, watch them really closely and operate early if you're going to. All right, um, and have to put a plug in for Dan's upcoming, er, RC, which I think next year will be starting to recruit and that will hopefully finally give us some, give us some answers as to the role of surgery for Perthes. My, before I go, I would like to just plug Perthes Kid Foundation. I do a little bit of work with this charity. Um, if you've got any Children that you're treating for Perth who are fed up of feeling different, fed up of being told what they can't do, then they can come away for a week's activity holiday. They can spend time with kids, like them being told what they can do and it's, er, it's really, really great. Um, and yeah, wonderful, um, wonderful charity and they do wonderful work. So, thank you very much. Indeed. That's it. Thank you, Mister Well, Scott. Um, does anybody have any questions? So just to go over things, um, will the recording be made available so frequently? I, I just need to clarify with the presenters that we're happy for that to be made available and that will uh are you happy to? Yeah, Mr as well. So yes, we can make them available subsequently. Um I just need to liaise with the med how we do that. But yes, we do have that facility to make it available, which would be fantastic because there's so much information to take in and it's wonderful if you can access that later. So that's great. Um Adam left the chat. That's all it is great. I just saw that because I just, I've just basically kid down three years of hard work into two lines. I'm no surprise. So um just for clarity. So Adam is basically that my understanding of it, he's designing the non operative arm for the RCT. OK. Just for clarity. And we will all find out in much better detail. What is the true and optimum non surgical management? Um Fran just to clarify. Did you want to ask a question about the town? Oh, so yeah, modified Elizabeth Town. So, yeah, it's, it's, it's, it's essentially just breaking up those um classic wald and strums into um each place, each, just broken up into two. But the reason it's useful is trying to decide is this early fragmentation or late fragmentation, fragmentation. Um And really, if you've kind of got, er, what they say is sort of two obvious vertical fissures in the, in the femoral head, although they are just a ra large class fact, they're not fis in the femoral head. Um Then that's probably, er, stage two B and me and other people, not everybody would say that's too late to try and contain. Um Got a question about, oh, how, yeah, how frequently would you review them after first station? Yeah. So I, I tend to, I'll see them every six weeks. Um And I'll look really carefully and I'll um get them started with physio and I'll really emphasize it and we talk about the play dough and why it's so important to be doing those, you know, getting the exercises because the exercises are painful. Um, so, yes, I, so I, I'll see them every six weeks until I've made a committed decision to either operate or not. So, once they're either have had an operation or are into, um, uh, to be so late fragmentation, then it, then I'm not going to operate on them after that. Um I, so I, I now basically I don't really um do activity restriction, I'll just say to them that if it doesn't hurt and you want to do it, then do it within reason. Um Because yeah, it's, and that's one of the great things about working with that charity is getting to meet a lot of kids and a lot of parents. Um And just really understanding about the, the impact that the rest weight bearing and not being able to take part in things has and, you know, even if, yeah, if, if they do nothing fun for two years of their childhood and it delays their hip replacement by five years. Is that worth it? You know, they, they're, they're really, really unhappy. Um And it changes them, it really changes them as kids. So, yeah, I, I, that for that reason, I'm doing really not restricting weight bearing anymore. Great. Um Just to clarify someone's asked about the feedback for certificate Yes. Just at the end of the session, you will automatically get that. So don't worry until you get, until you give us feedback. Um, you don't get the certificates. Yes. Pretty standard for these kind of things. Um, cash. I don't know if there's anything else that we can clarify. I mean, I think, I guess the question is, how do you answer this question in FC as to whether you're going to intervene or not? So, I think you could say, um, the, the fact is that I would be so I, I would monitor the child carefully every six weeks, er, in the early stage of the disease. And if there is, and if I am suspicious or I think it's likely that um, we're not going to achieve containment through passive means based on either the radiological findings of them being sulfa and B or multiple cats head at risk signs or clinical head at risk signs of progressive loss of abduction. Despite physiotherapy, then I would offer surgical intervention to try to maintain, er, or try to achieve containment. Ok, great. Thanks Mr Westcott. Uh, just to clarify Carla. Yes, as we've mentioned, it is being it, it will be made available at a later date. So, um, for that didn't catch the beginning because it's been a fantastic presentation. Er, yes, it will be available and I'm sorry, I said I can't take half an hour. Yeah, don't worry, Mr Baria, you're on the clock. That's fine. Um, and then we, we may have a bit of time for vi a practice again if anybody wishes to volunteer. Um, I don't want to have to pick somebody out of the many people that are attending. So, yeah, if everybody wishes to volunteer it just, it's on the topic. It's on the trauma topics that have been discussed. So it's, it, you know, it's, uh, the stuff that you've been taught anyway. So that just to mention, uh, if Professor Clark was in, in this recording and your shelf quite easily, he would have been very upset. No, no, it's just that I don't, I just don't, I can't offer a good opinion on it. Um, so, you know, they as say a lot. Yeah, a lot in Southampton, a lot in Liverpool. It, it, you know, the proponents of it must be so for a good, for a good reason. I don't want Mr Clark coming after me. Sorry, forgive me. That's for another day. Fantastic. Well, yeah, thanks again, Mr Scott. Um, so Mr Baria take the stage, um, on some trauma topics again. How yield F CS stuff, guys. So fantastic stuff. Thank you. Right. Can everyone see my screen? Yeah, we're good. Can you? Yeah. Good. Ok. Right. So I'm gonna cover just a few topics in peds. I'm not covering the whole of peds, trauma because that would be impossible to do it in half an hour. Uh, this is the outline of the different fractures that I'm gonna cover. So we gonna look at some basic stats, epidemiology. What is unique about those fractures? What is the standard management and basically what are the pitfalls and controversies and outcomes? Ok. Starting with lateral condyle fracture of the humerus. It is the second most common bow fracture. Obviously, the most common is supracondylar. Uh We see 12 to 20% of pediatric upper limb fractures are lateral condyle fractures. Commonest age is 4 to 10 years of age. Now, there are two mechanisms described for a lateral condyle fracture. Uh One is a pull off where you fall on the outstretched hand with the forearm, supinated and elbow extended and the fragment is pulled off by the extensors or there is a push off mechanism where there is a valgus impacted force which basically shears off the lateral condyle from the distal humerus. So what is unique about lateral condyle fracture? It is an intraarticular fracture. The synovial fluid is present in the elbow joint which kind of dilutes the good stuff, which is required for healing and there is a sheer force as well as a distraction force which is acted upon by the extensors. And again, this is not good for fracture healing. Um When we talk of classification, I know that the first thing that comes to mind is the milk classification, but I think we should probably give up m classification and I don't think we should use that anymore. Even in the Fr CS R exam, Jacobs classification was described basically uh they described three types. And the song classification, which is kind of the most recent published in JVJS in 2008 is an extension of the Jacobs classification and it describes five types. So if you mention song classification, I think you are scoring higher in your exam. So basically, what are these five types? There are type 123 and four and five. The type one has. So and you basically look at the three things. So you look at displacement, you look at an articular step and you look at the stability of the fracture. So type one displacement is less than or equal to two millimeters. There is no articular step and it's a stable fracture. Type two is again, displacement is less than or equal to two millimeters. There may be a lateral step but there is no articular step and the stability of this is a little bit undetermined. Type three is again less than two millimeter displacement, but there is an articular step present medially as well as laterally. And these fractures are classified as unstable. Type four is more than two millimeter displacement, but there is no rotation of the fragment. But this is still unstable. And type five is greater than two millimeter displacement. There is rotation of the fragment and the fracture is unstable. So I know I can't really ask people questions. But uh if you look at this fracture, this is a Song five classification. You can see that the fracture is displaced and rotated. This is a very obvious one, whereas this one is a song one fracture because you can barely see the fracture line. It's less than two millimeters. It is undisplaced and it's a stable fracture. However, when you basically look at Song classification, you are not sure whether the articular hinge is intact or broken because you are looking at a static x-ray. So although it may look like it is intact and as you should especially see it on an internal oblique view, whether it's intact or broken, but it may, it may be intact and yet it may be unstable. So how do you basically know whether this articular range is intact or broken? So the best way of knowing it is an MRI scan because that will show you the cartilage and that will show you whether it's intact or broken. But again, doing an MRI scan in acute scenario is difficult. You need a G A because the Children are small. So if you're gonna do a G A might as well do an arthrography. So once you do an MRI or an arthrography, there is another classification that has been described, which is the wi classification. Oh sorry. So these classification basically again, divides them into three types and I will talk about this a little bit more in detail. A little bit later, but it basically, once you do an arthrogram, um and you can see whether the articular congruity is maintained or broken with the arthrogram. And if it is maintained, then it becomes type one. If it is broken, then it's type two and if it's completely displaced, then it's type three. So what is the standard management? If it's a wheeze type one which you can probably see on the x-ray itself that it's an undisplaced fracture. There is very little displacement. You can treat them in an available cost. But if you treat them in an above cost, you should take a weekly x-ray and you should try and take this x-ray out of plaster and you should do that for two weeks. You should also take an internal oblique view. If the fracture remains undisplaced at two weeks, then you can continue with cast for six weeks until the bone has healed. If it's a type two fracture. So typically it, it uh the, the, the we classification has said that if it's a 2 to 4 millimeter displacement of the lateral cortex, then you take the patient to theater, you treat it as an unstable fracture. So you take the patient to theater and you do an arthrogram. And if on the arthrogram, you find that the articular hinge is intact, then you can get away with doing a close reduction and a percutaneous spinning of K wiring. If it's a wi type three fracture, which means that you've taken the patient to theater and you find that the there is a step, there is an article step and it's incongruent. Then you should just proceed with an open reduction and internal fixation. You can either use the Cocker approach. Cocker approach is the interval between the extensor carpal and anconeus or you can use a Kaplan approach most of the time the approach is made for you because of the fracture and the muscle is kind of dissected out. Uh what Karr configuration is used. So again, um you should never use a parallel kwire configuration because the fracture can actually slide on your KVAS. So the K VAR configuration should always be divergent. You must always have a bicortical fixation, which means that it should engage the other cortex, all your walls. And they've also talked about this transverse wire which kind of reinforces the divergent fixation. Plus, it also reinforces the articular step which is there uh whether you bury the wires or leave them out again. This is still controversial. Uh Most of the time we leave them out and we pull them in the clinic. If you bury the wires, then it means you have to take the patient to theater again, give another anesthetic. And in that increases the morbidity and the cost. Some people also describe using a screw, you can use a screw. Uh ideally your screw should go through the non efi part of your fracture. So right at the edge and you can get away with single screw screw. Uh in some studies, uh they've shown that uh screws are slightly better than KVAS. But again, the problem with screw is that it requires subsequent removal, which means another anesthetic, another surgery and adds to the cost and morbidity. Uh This is just an example to show that what initially appears as a type one w which has been managed in cost. This figure I've taken from a textbook, uh This is not one of my patients, but you can see that if you take weekly x-ray the second or the figure c, it shows that the epiphysis has displaced a little bit, it's angled, which means that this fracture is unstable and it should have been picked up at that stage and fixed, but then it wasn't. And then you can see subsequently that the fracture has gone into delayed union uh in figures enf so not all V type one fractures. Uh are we type one? So you have to be very careful when you treat them conservatively. Um So this is uh another statistic. So basically nondisplaced fracture and most go on to bony union, but some don't about 14% is the rate uh described in literature which can displace and require further intervention. So why do these fractures displace even in plaster? And it's again the pull of the extensors uh that causes the fracture to kind of distract out of position. Uh There, there is another paper which basically looked at closed reduction and percutaneous pinning of displaced pediatric lateral condyle fractures uh published in 2015 and they basically reported satisfactory outcomes in 89%. They also reported that overall pinsight infections was 3.9% but generally the outcome was good. 99% regained full range of movement coming to orf uh looking at the outcomes again, there are quite a few papers. Uh uh There is one which was published by uh Leon Leonid Do and he looked at 105 patients who had open reduction, internal fixation with KVAS. And about 96% of them achieved excellent scores and 4% achieved good scores. So basically, 100% of them achieved excellent good scores and all of them had proceeded to union. Um I don't think this is representative of the general population. Uh I think uh we, we don't see such good results. Gilbert El looked at Kar versus candidate screws. Um They found that 16% went on to delayed union and Nonunion in the Kar Group versus only 3% in the screw group. So yeah, screws are better. We know that it achieves compression. But again, screw removal is a second surgery. Uh The other uh complications that can happen with later Condy fractures are basically maun um Now maun can happen uh because the fracture is displaced and you treat them conservatively or the fracture can displace even with KVAS if the KR fixation is not adequate delayed union and nonunion is a known complication with lateral condyle fracture of the humerus. Uh Some people describe it as a fracture of necessity, which means that you need to uh have a good a protocol and a good plan and you need, you shouldn't be hesitating to operate on these and even opening open, reducing these avian of the trochlea and fi tail deformity is described. So this is a specific um complication that happens uh usually seen after open reduction. And the idea is that when you do an open reduction, you should avoid any posterior dissection. So you should try and stay lateral and you can go as far anteriorly as you want. But you should not do a lot of subperiosteal or a lot of soft tissue dissections posteriorly because that's where the blood supply of the trochlea is. And if you damage that, then there is a chance that you can get a VN, you can also get lateral spurring and overgrowth. This is a relatively common complication that happens after lateral condyle fracture union. These are usually asymptomatic, apart from bony bump that you would see on the lateral aspect, faial arrest is again a known complication. A faial arrest can happen uh whether you fix it or you don't fix it. So it can happen with conservative treatment as well. And of course, the treatment of I shall arrest would depend on what sort of deformity it produces. So this is an example of a nonunion of lateral condyle fracture. Uh And again, I can't really ask people questions, but I might put the slide up again in the vi a session. Um So these are very difficult uh uh to treat. Basically, you want to achieve union as well as you want to correct the deformity. You, you can see that he's got a significant cubitus, valgus deformity. He's got a flexion deformity and you need to correct that with an osteotomy, you also need to try and achieve union if you can. Uh it's not easy. This is just to show how uh lateral spurring occurs and how the there is a prominent bone uh which you can see over the lateral aspect of the distal humerus. So, as I said, lateral bumps are virtually uh painless and it's only a cosmetic deformity. And you should, I mean, surgical intervention is virtually never necessary failure to intervene early when a fracture demonstrates displacement will lead to nonunion. So you must keep a close eye on lateral condyle fractures, which you're treating conservatively again, the the pins uh try not to pull them out too quickly. Uh So typically in supracondylar humerus, you can pull the pins out in three or four weeks time and still they will be ok. But in lateral condyle, you, you should try and leave the pins in for at least 5 to 6 weeks. Uh And that's one of the reasons why some people tend to bury the K wires in because it increases the risk of uh pin trac infections. Uh if there is a growth disturbance, so you should not discharge these patients very early, you should at least follow them up for a year because some may get growth disturbance and some may get cubitus valgus or virus. Uh The pins are very close to the joint and they actually travel through the joint. So if you get pin trac infection, then there is a high risk of creating septic arthritis. Ok. So that was about the lateral Condy fracture. Uh Now I'm going to talk about the fractures around the knee. So looking at the distal femur fracture. So these are not very common. They are about 2% of all facial injuries and 8% of all lower limb injuries. They are high-energy injuries and up to 50% of them develop faial arrest and pople artery is very close to the back of the femur. So you need to be aware of a risk of vascular injury. So what is unique about distal femur fracture? So, the anatomy of the physis is unique. It's it's an undulating physis and that basically, if there is any displacement or translation of the physis, it produces sheer forces across the physis. And therefore, there is a high risk of growth arrest. So typically in a Harris two injuries say in a distal radius, you wouldn't get a growth arrest commonly. But a SOTA Harris two in a distal femur has again, a very high chance of growth arrest because of this undulating nature of the fires. The other uh unique feature of distal femur is the rate of growth of the spices is very high. So typically described as 9 to 10 millimeters per year. But during the adolescent growth spurt, it can even go up to 10 to 12 millimeters per year. And therefore, it can result in an angular deformity or leg length discrepancy even nearer skeletal maturity. Uh So to had a classification, we use it for any facial injury. But that was the classification we use for distal femur fracture. So, other unique part of uh the distal femur fracture is that in, in an adult with a high-energy injury in the knee, you typically get a ligamentous injury. Whereas in an adolescent or in a chil in a child, the physis is the weak point. So your ligaments don't rupture or break, but your physis disrupts. And the other unique bit bit is the posterior uh neurovascular structures. So you can see that the popliteal artery uh is very closely tethered to the bone. Uh and it is tethered further to the bone by these two genicular arteries, one on the medial and one on the lateral side. And that's present on the distal femur, it's present in the middle part of the knee joint and it's also present on the proximal tibia. So basically any displacement of a femur fracture or a proximal tibia fracture and your pop artery is at a very high risk of injury. So, what is the standard management of a distal femur fracture? The principles are you want to do an appropriate reduction depending on the type of injury. You want to avoid any additional damage to the fis, you should have a high index of suspicion for vascular injury and manage these urgently and you want to have an early functional range of motion. So you want to fix these as, as rigidly as as possible. Um So typically a so had is one injury which is quite rare. Uh You can try and do a closed reduction and immobilization. If it's an undisplaced fracture, then you don't need to reduce it, but you can do an immobilization and typically in a younger child. So somebody who's four or five years of age, then you would again try and use close reduction and immobilization and not use any metal work crossing the P FIS. However, just close reduction and immobilization should be used with a lot of guarding in older child because there is a 40 to 70% chance of displacement in cost even after reduction. Uh The other bit to know about is the is the periosteum. So on whichever side is the textile side, the periosteum ruptures and that can get infolded in the fragment. So it may make the reduction difficult. So some Children, you can do a closed reduction and internal fixation. So typically, it should be under a general anesthetic. It should not be more than two attempts at reducing it closed. If the close reduction is if you can't get close reduction. Uh think about the periosteum. This is typically suited for oughta Harris I I injuries and you can fix these with either trans faial smooth K wires in a cross configuration or more appropriately, you would use extra faial screws and by extra faial, I mean, in this particular example that you see on the screen, you can use a screw through the Thorsten Holum fragment and you can compress the fragment together after reduction and you can do this percutaneously if you manage to get a close reduction under G A. Uh this is just an example to show this was a so to Harris one injury, more or less, I think maybe there may be a very small metaphysical segment, but you can use two cross K wires typically in SOTA Harris three and four fractures, you would use open reduction internal fixation because you want to get a congruent articular surface. So this is how you would treat it in an adult approach would depend on the fracture pattern and whether there is an associated vascular injury. So if there is a pop artery injury and the vascular surgeons want to do something at the back, then you would approach it through the, through the pop fossa. Uh Sometimes if it's a, if there's a severe articular com condition, you would use an anterior approach like you would use in a tr a long incision. And perhaps this is better because who knows, they might need a TKR in the future. Again, because of the severe art acco condition. Uh you should avoid crossing the physis with the screws. So if you're passing screws, you should pass it from epiphysis to epiphysis and from metaphysis to metaphysis, you should not try and get your screw across the physis. So this is an example of aorta Harris two injury, which I talked to you earlier about where you can pass screws through the thirst and ho and fragment. And this is a type four sota Harris injury where you pass screws either in the metaphysis or in the epiphysis and in the epiphysis. Sorry. So what are the outcomes? Um So they, so there was this paper which was published quite recently 2020. So they looked at if you do surgery, does it improve the outcome? Uh So basically, they looked at 70 patients. It was a level one, pediatric trauma center in us. Uh The mean age was 13 years and the commonest injury was a. So Harris two and majority were treated surgically. So 63 out of the 70 were treated surgically. However, the overall complication rate was 36%. And interestingly, they compared their data with a historical cohort from the same center where they were doing more close reductions and they had a 40% complication rate in the historic cohort. And they found that there was no statistical significant difference between the two studies. So that's interesting. So one would have thought that surgical would produce better outcomes but not necessarily. So basically, uh uh uh A ARCA el they showed that the two most important predictors of outcome is your Salta had classification and the initial displacement of the fracture, uh growth arrest following distal femur fracture. I already mentioned this. About 50% of them go on to some form of growth disturbance. 22% of all distal femoral growth plate fractures developed a leg discrepancy which was more than 1.5 centimeters. Sota Harris one fractures had the lowest incidence of growth disturbance 36%. Whereas Alta Harris four had the highest rate which was 64%. And there is a greater incidence of growth disturbance in patients who are treated with fixation. So again, you have to be very careful of how you are fixing. Although this did not reach any statistical significance in this paper. So what are the pitfalls and uh how do you prevent it? So, misdiagnosis. So sometimes uh so to Harris, one injury may have displaced and gone back into position. So you should always be have a high index of suspicion. If there's a high velocity injury, you should immobilize and re-examine if uncertain. MRI may help because it will show a lot of uh edema around the fis. And especially it's important uh to recognize nondisplaced injuries if somebody has a head injury and somebody is in ICU. So you need to have a high ne of suspicion, red displacement of fracture. So you should try and get a high long leg cast if you're treating it conservatively, sometimes even a hip spiker in a younger child and you should always have an x-ray at one week, follow up growth disturbance. Uh You should try and minimize the trauma when you are manipulating and you should keep following these up at different intervals, knee joint instability. Uh Again, this is not very common with distal femur fractures. It's more common with proximal tibia fractures. Uh But you should always check these in a slightly older child or a child who has already reached skeletal maturity. Septic knee, you need to be wary about how you pass your KVAS. If you're using KVAS to hold the reduction, you should try and stay extra articular as much as possible. Peroneal nerve injury is also described. Uh So you must always assess neurovascular status, uh preop and you should avoid excessive virus during reduction, especially if you've got a valgus type injury. Ok. Next, coming to tibial spine, avulsion fractures. So, uh these are more common in Children aged 8 to 14 years, it's a rare injury. So it's not something which is commonly seen, it's three per 100,000 a year. The common mechanism is a noncontact sporting injury. So the commonest mechanism described originally was fall of a bicycle. But however, with increasing athletic participation and at a younger age, this is becoming a common mechanism. So sporting injury and contact sports is one of the mechanisms for tibial spinal bulge and fracture. And the classic mechanism described as a forced valgus with external rotation of the tibia. So we are, we know about the classification for tibial spinal bul and fracture. So it's the males and MVA classification which basically uh describes them into three types. Type 12 and three where type one is undisplaced. Type two is displaced and angulated anteriorly and type three is completely displaced. Now, these have been subsequently modified. So, Zivko and Goran modified the three into three A and three B where three A is just a tibial spine avulsion, whereas three B is the whole intercondylar eminence that is evolved. And then Zarni, I don't know how to pronounce it. Zarni basically added 1/4 type where it was a tibial spine, avulsion, but it was a ted fracture of the tibial spine. Uh It is important that we sh we we classify these fractures on the lateral view of the x-ray. So a P view may be misleading. It may not even show the fracture. So it is important that every child gets a lateral view of the knee and a suspected to be spinal Aulin. Uh what is unique about this. Uh So it's an intraarticular fracture again. Um There is a lot of uh structures which are attached to the tibial spine itself. The the menisci are or the anterior roots of the menisci are pretty close to the tibial spines. The lateral, the anterior root of the lateral meniscus is many a times detached along with the tibial spine, avulsion fractures. And uh the anterior horn of the medial meniscus can get entrapped between the evolves, tibial turo and the tibial plateau preventing its reduction. Sometimes it may be the inter meniscal ligament which can get entrapped between the fracture fragments. And these are important because you would try to get a close reduction in a type two and you will not get a close reduction because there is this meniscus fragment sitting there or the intermuscular ligament which is sitting there. So as I mentioned, lateral view of the x-ray is important, MRI, I wouldn't call it a gold standard, but it is, it will be helpful to have an MRI done preoperatively. Uh Sometimes a nondisplaced fracture can get picked up only on an MRI scan or if it's a purely cartilaginous fracture, which means that you can't see any bone which is flicked off. You would do an MRI of the knee in, in those cases anyways, because you don't know what the diagnosis is and a child has presented with a hemarthrosis of the knee. So you want to do an MRI urgently to look for any chondral fragments. The 60% of tibial spine fractures are associated with other soft tissue injuries. So I mentioned anterior horn of the lateral meniscus, sometimes it can be medial meniscus as well. So therefore, MRI is helpful. So you have at least you know what you're dealing with. Uh meniscal injuries are known to occur in 40% of Children with tibial spinal bul and fractures. You will see bone bruising in 90%. And you can also see some uh ligament injury like medial collateral and lateral ligaments in 33%. So go to the standard management. So uh MVA type one, you can easily treat it conservatively. You would immobilize it in a cast for 4 to 6 weeks. The position of immobilization remains controversial. Uh The AC L is relaxed or under least tension uh in 30 degrees of flexion. So that is the recommended position. However, uh in some Children with a type two, you want to reduce the fragment and you would want to treat it in hyperextension. Uh So I think the current recommendation is you can hyperextend to reduce the fragment, but then immobilize in 5 to 10 degrees of flexion, type two and type three fractures. Uh Basically, you have a lot of options. So you can still go ahead and do a close reduction and immobilization. You can do an open reduction and immobilization in a cast. You can do an open reduction and internal fixation either with a screw or A K A. You can do an arthroscopic reduction and internal fixation. Usually with a screw like an rac screw or you can do an arthroscope, arthroscopic reduction and suture fixation. Uh You should try and do your fixation uh to stay within the epiphysis and not cross the phys it as much as possible. Some people even describe using K vials, but K vials usually migrate inside the joint and it is not a good option. So I already mentioned this uh uh before. So there can be blocks to close reductions, anterior horn of medial meniscus incarceration, inter meniscal ligament incarceration or the anterior horn of lateral meniscus, which can be a part of the tibial spine articular cartilage and it can keep it distracted. So this is just an example to show a screw fixation. This is not one of mine. Uh This is taken from a textbook. Uh This is a short video. Um So this is an arthroscopic reduction um and a suture fixation. So you can see the tibial spine fragment there. Uh You're clearing the tissue underneath the tibial spine, creating a nice bed for the tib spine to sit. Uh you're then using a suture passer and passing a suture around the AC L. Uh you can use an AC L jig uh AC L jig is sometimes tricky. So this was a slightly older child. But if it's uh open phys, then I wouldn't use an AC L jig. I would use a freehand technique under x-ray control and try and stay within the epiphysis. So you can see how the suture has been pulled through a tunnel underneath the fracture. And you can see that the fracture is now reduced. You can use one more suture and that really helps with reducing the fracture quite well. It's a stable fixation. Uh You can use an endo button or any kind of fixation outside. Uh You I've used in the tunnel in within the epiphysis itself and then tie the suture over an endo button. So what are the outcomes? Um So there was a systematic review which was published in 2014 and it looked at open reduction versus arthroscopic assisted reduction and fixation. And basically, it showed that the arthroscopic reduction and fixation had less morbidity, shorter hospital stay and earlier return of range of movement and function. But there was no consensus as regards to best fixation method. There are two main complications which are described for tibial spine fractures. Again, there can be a lot of complications, but the two main ones are after fibrosis, which occurs in 10% of Children. And therefore, AAA rigid fixation is useful. So you can start mobilizing them early. And then AC L laxity was observed in about 60% of patients at long term follow up. It was typically seen in type three and four fractures and up to 20% of these Children uh later on went to get an ACL reconstruction. So that's quite a high number. So, so I've already mentioned this. You should have a true lateral radiograph to avoid the misdiagnosis of fracture classification, early treatment, secure fixation and early mobilization can help avoid a fibrosis. You can use the mid patella portal which allows good visualization. So it's it's the portal which goes through the patella tendon and it allows an easy placement of a screw which is perpendicular to the fracture site. You can do a provisional fixation of the fracture fragment with KVAS. But final fixation should not be with KVAS. You can use a washer uh inside the knee. Typically, it's not recommended because then the screw will remain, the screw head will remain prominent and it can impinge against the intercondylar notch. Uh I already mentioned this, you can use candidate AC L guides and in com fractures suture techniques with the loop around the AC L can bypass the combination. Ok. Next fracture is your tibial epi facial fractures. Uh These are again uncommon injuries, 0.3 to 2% of all epi facial injuries. They are again associated with high velocity. So fall from height, automobile accident and uh lawn mower injuries typically seen an 8 to 14 year old and boys for some reason are more common than girls. What is unique about tibial epi uh tibial epiphysis. It's a stable epiphysis because there is a fibular strut which is present on the lateral side. There's a tibial, the overhang anteriorly and the medial collateral ligament attachment is below the physis. So it's on the mesial side. Uh I already mentioned this, the popliteal artery is in close proximity to the posterior metaphysis of the tibia and it's tethered to the bone by your medial lateral, inferior geniculate vessels. So, again, a high risk of injury to the pople artery. It's seen in the year. There are again, no specific classification which is described for tibial epi facial fractures. Uh the mechanism injury, you can classify them based on the mechanism of injury. So, hyperextension. So these have a risk of vascular disturbance. You can have a varus valgus injury and you can have a flexion type injury. So this is again, typically seen with tibial tubercle, avulsion fractures which extend into the epiphysis. And again, you use the salter Harris pattern to describe uh these epifix injuries. What are the standard management for these? Uh you can do a close reduction and immobilization especially in a OTA Harris. One and two, you can do a closed reduction and percutaneous fixation in has one and two that are unstable after reduction. And for so to Harris three and four, you would do an open reduction, internal fixation. Again, you can use a screw or smooth k wires and sometimes sort of has two fractures that are uh irreducible. So there are some things that can block your reduction. The commonest ones are the medial blocks. So these can be your SGS tendons. So your sartorius gracilis and semitendinosus tendons that can block the reduction or sometimes it can just be the periosteum which enfolds again, same thing. So gentle traction and reduction maneuvers to prevent further damage to the phys, they describe 90 traction and only 10% leverage. If there is a vascular or a neural compromise, then you should aim to reduce a fracture urgently, sometimes even in the emergency department because just by relieving the pressure on the blood vessels, you can get your muscularity restored. It is also described that you should not leave these fractures reed for a long time. So you should try and reduce these urgently because it can cause a delayed vascular and neural compromise. You must always watch for compartment syndrome with these fractures. And if you're using K wires, you should go from distal to proximal so that you keep your wires out of the joint in case they get infected. So this is just an illustration again to show how you pass your KVAS distal, the proximal, stay out of the joint. Uh There are not a lot of uh there's not a lot of literature for these fractures. Most are small case series and most have reported good outcomes uniformly. The only exception is lawn mower injury. So if there is somebody who's got a tibial epi facial fracture due to a lawnmower injury, then the outcome is poor regardless of the type of injury. Popliteal artery injury occurs in 3 to 7% of cases and therefore prompt recognition and early reduction is successful in 90%. So, up to 90% can get their vascularity restored just by close reduction. Uh growth arrest with leg length, discrepancy and angular deformities do occur with tibial epi facial injuries. In 10 to 20% of the cases is not as common as a distal femur fractures, but it is described and it can occur even with auto Harris two, but it's more common with 34 and five. So what are the pitfalls again? Reemphasizing vascular injury, even minimally displaced fractures may have arterial injury because the fracture may have been displaced at the time of injury and then gone into a more better position on its own compartment syndrome. Oh Great compartment syndrome is also a known complication. Uh medial collateral ligament injury as the ligament attaches on the metaphysis. Uh Any significant opening of the medial side along the physis suggests that the ligament is not in continuity. Uh I already mentioned intraarticular pins. Ok. So coming to tibial tubercle fractures, uh tibial tubercle, epiphysis is initially continuous with the proximal tibial epiphysis. So this is the uniqueness of it. Uh Sorry, can you just hold on one second. I've got somebody at the door for some reason, step, I'm just gonna be two minutes. OK. S step when I jump in for a sec, of course, um Just while we've got a second, I just want to really emphasize the value of the song classification. So I agree. I genuinely think this is useful, not just for the exam but for practice as well. And this picture that you can find just by Googling, it really makes, it makes sense. So the point is where is the fracture ending? So one is an incomplete fracture that's finishing in the bone. OK. You'll see the fracture gaps coming together and meeting that's inherently stable. The two they're coming together, but you won't see where they join because they're joining in the cartilage. And that's why we don't know the stability of those. These ones tend to be parallel because they're running all the way down into the joint surface. The type threes. OK? They're unstable and these are obvious. OK? Non op questionable. So number with type one, non up type two, questionable type three probably needs perk wires and an arthrogram to check type four, you might be able to jiggle it into place closed, you're probably gonna open it type five, you're definitely gonna open it. So that's why I think it's really useful cos you've got a clear stepwise progression and then there's a couple of studies that show these are about a 20% non union rate. These type twos if you don't operate on them. Thank you. Hi, sorry, I'm back. Just I jump in and uh just, just keep an eye on time as well. Just slightly over. Yeah. Ok. Yeah, we are over time. Ok. That's fine. I'll, I'll quickly came through the slides. Um ok, so Tiber tibial tubercles are cartilage in as until 9 to 10 years of age, we know that they develop, you share your slide. Mister, sorry, if you share your slides. Ok. Sorry. Uh There are two mechanisms from injury described active. Am I not sharing? No, sorry. Oh, I'm not. Ok. Uh Yeah. Can you see them? Yeah, if you go to your power point. Yeah, perfect. Yeah, that's it. Yeah, thank you. So there are two mechanisms of injury described uh you most often it's active extension of the knee with sudden strong contraction of the quadriceps as seen with jumping s So do you typically see these injuries in basketball players or volleyball players? Uh And then you also see it with acute passive flexion of the knee against the contracted quadriceps. And you see this typically during a tackle during football or rugby. Um The controversial part here is whether there is any association between ost Slatter disease and tibial tus abul. There are lots of studies that have looked at these two. Some say there is some say there isn't, it's not entirely clear. Uh There is also a study which looked at. So there is a change in the secondary ossification center from a primary fibrocartilage to a hypertrophic columnar cartilage. And that results in weakening and fracture. And this is typically seen in, in that adolescent age group uh classification. So typically, it's a Watson Jones classification. We classify them into three types 12 and three. You can see the figure here. Uh Then Ogden subdivided them into one A one B, two A two B, three A three B based on combination of the tibial duroc. And then there is a type four fracture which was added by Rio and Inu where there is a tibial tuberosity fracture which extends into the tibial uh physis completely. And this is like a salta Harris one injury uh standard management. So one can be treated in a cast in full extension for six weeks. Some people say you were treated in a cost in 30 degrees of flexion. I probably would think full extension will be better. Uh And for OIN two and three fractures, it's open reduction, internal fixation. You can use two screws depending on the size of fragment. You can use a four or a 6.5 millimeter screws and you can use washers, tension man fixation or suture. Ankles are described for committed fractures. And again, cost immobilization is needed even after fixation. Just some examples. Uh So compartment syndrome is a known complication of tibial tubercle fractures. And the reason for this is when the fracture happens, it pulls the recurrent branch of the anterior tibial artery, the tip and the recurrent branch then retracts into the muscles within the anterior compartment and bleeds and that causes the compartment syndrome. So, routine fasciotomy is recommended by some in all patients undergoing open reduction, internal fixation growth arrest may occur. Uh That's another complication. Uh Again, it rarely causes a functional issue or recur as most injuries occur towards skeletal maturity. So this was a review published very recently and basically, they said the outcomes are generally good to excellent with conservative as well as operative treatment. And the most common complication is a prominent screw head and bursitis. And uh some injuries are associated with meniscal tears, especially if it's an Ogden three, which is an intraarticular fracture and that's it. Thank you. Fantastic. Thank you very much, Mister Radio. Uh So there's just uh one or two questions um throughout the session, no one has volunteered just to say that no one has volunteered for the vi Mr Warri was very kindly going to do some vi practice, but I certainly don't want to pick on anyone. And um there's the opportunity to do so if anybody wishes to do so, but um I appreciate they may not want to on this platform. Um But the opportunity is there. So if in the next few minutes, you want to put your hand up, feel free, otherwise we will not do any of that. And I appreciate we're short on time as well. Um So uh Aie um he was asking about, what's that? I think Dan has already answered the question. I run further down. That is a, a wonderfully niche question about pics ossis. I think I know the answer. I think it's similar to osteoporosis. So the the idea is that the bone is more brittle. And if we think back to our stress strain curves, that means that the final point of failure is very close to the yield point. And so therefore, our total area under the graft is smaller. So our total toughness of the material is less. And hence why? Yes, it seems like you have harder bone, but you're more prone to fracture, I think sounds political. Uh great. And you've asked, answered the question about the type four. Um um No, yeah, that was that I would put that Toro Francesca's question about um Yeah, CT angio. No, not routinely. So I think the first step is to try and reduce the fracture. If the fracture reduces and your pulses still don't return, then I would get the vascular team involved and it would probably be taking to toto and doing an angiogram on table. I think the scenario, if you get a displaced proximal tibial five fracture in a trauma viva, then just treat it exactly as you would an adult knee dislocation. OK. So whatever your answer is from an adult knee dislocation from point of view of the common cranial nerve and the popliteal artery just do exactly the same treat it as the same injury. Just what they will. They'll just, the, the, the pass fail is identifying the high risk of neurovascular injury because, uh, some, some people won't appreciate that and just, you know, open the Vival with this is a serious injury. Um, there is a high risk of neurovascular compromise. I would treat this like an adult knee dislocation and then just go from there. Yeah, I thanks. Um uh what else was never asked? Uh Chris. No, no. Oh, everyone's just send it to me and that's, that's a good guys. Uh Yeah, so there's just a few things that have been sent out there. But um can I just remind you? So I didn't actually mention it, but I've put it in a few times. So as part of bota and we've got a survey that's got, I'm sure a lot the bo um members have received it. Basically, it, it, it's in your hands in order to try and make peds Ortho training better. It's to try to establish what exactly training is like out there nationally, um, and improve it and make it better for you guys. So if you could help us out by completing that. So I would be grateful whether you're interested in peds or not. And we're interested to hear everyone's um, opinions on how their training is and what they're achieving et cetera. So, um, it's, it's there to hopefully make improvement. So the link is there. Um, I've put it on twice after these four talks on pediatric orthopedics. I think all the trainees should take up pediatric orthopedics. This is, this is part of the reason as well. Mr Waa, we want to entice you into peds or like how great it is. Uh, kids. Has anyone else got any questions? Um, Mohammed. and there's one more about, would you routinely do MRI to investigate tip tubs? How would you distinguish between them and or good s letters, history and examination, history, examination, acute in um you can have an acute injury and you have, you have big soft tissue swelling as well. They don't only rip off the tuberosity, they rip off loads of anterior periosteum a bit. The anterior compartment comes off as well. They, it looks like a bomb has gone off in their knee. Perfect. Ok, great. Well, if no one's got any other further questions, thank you very much to our speakers for giving up your time. That's been so many topics and an amazing things um covered um all high yield stuff for your effort. CS. So hopefully you've been listening and like I said, they are going to be recorded and available later so that the details of that will be available. A feedback form has already gone out to you. Obviously, there's a question on there about five of us which we haven't done. You can answer that as you wish. Obviously, you know, we've offered that, but I appreciate that wasn't taken up. Um But yeah, thank you very much to everybody. Uh If you two got anything final to say that you wish to say, thanks for your attention. Great. And so there's two more um webinars planned for the next two weeks. Again, advertise through all as a pre congress events, again, pediatric orthopedics. So feel free to sign up to these. If you find this useful, then the further to again how you'll see us topics, have a look at them and that'd be great to see there as well. Fantastic. Ok, great. Well, thank you. Take care.