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Okay, We should be alive. Um, hello, everyone. Can you guys hear us and see the presentation? Can you please let us know in the chat? Okay. Perfect. Eso welcome. Everyone s So this is our orthopedic webinar Serious, but mind the bleep. This is our eighth addition the Siris about video recorder critic presentation today. Don has kindly agreed Teo deliver this topic so Ah, very big thanks to him. Uh, apologies for the delay, but without further ado. All handy after dawn so we can get started. You could take over there. Cool. Cool, everyone. Apologies to the delay. I was always working with once late with the need to rush out the door. But thank you for taking the time to be with this this evening. And thank you for taking the time to listen to me this'll. Evening. I have been given the brief of talking about some pediatric orthopedic presentations. Sort of general approach is to examine it. Kids and some safeguarding issues. Um, Andi, don't further ado. Let's have a look at what we're gonna be covering this evening, So I don't know if individuals been attending the last seven sessions, so I'm going to talk a little bit about a general approach to orthopedic imaging on managing orthopedic patients in general, I'm gonna touch a little about safeguarding nonaccidental injury on some potential issues with consenting of young Children in England on the cases that were gonna be discussing involved hips, soup, cans of fractures and forearm wrist fractures. And then, if I've got any time of the left, I'm going to sell you a while. Orthopedics is an awesome career, but the factory listening makes me think you already agree. Um, as always, disclaimer Before we start, I have used to it is stealing from Google images for educational purposes. So there's been no intended infringement. A copy, right? I'm a CT to I'm not on aspart so always escalate locally and program mm, just a bit about myself. So I finished up my undergraduate training in ST Andrews with a B S C arms in 2014. I don't finish my NBC A to be in Glasgow in 2017. After that, I took two years of foundation training in the auction number. F three year acts was six months of joint reconstruction that the world that will be a hospital working with a skin of the present on, uh, data. And then did you have any low coming? Because once it was local of your your eyes. I'm just finishing up my core training in your reason, the moment on a CT theme to program of those peaks. Um, I achieved my MRCS glass with issue and 2020 to add. I've just been appointed a s t three. Starting in the West. Got a notation for orthopedics on. I've always loved Bones. They're great. And I'm going to tell you more about why the great at the end. So hopefully that shows So a general approach to, uh, orthopedic patients a general approach to pediatric orthopedic patients. I'm going to talk a bit about how to approach examination on patients, about a sort of strategy to look at describing plain films so that you don't get flustered at some sort of general admitting advice for any pediatric patient that, you know, come across before you asked anything at any examination scenario, whether that is at the medical school level, whether you're doing foundation training simulation, whether you are looking at undertaking your initial membership exams, the safe approach to any patient is always to adopt a a TLS algorithm so advanced for the life support, which is a program around by the American College of Surgeons and sublicense by the local, deserves England, which teachers a system ask approach to managing patients with multi system polytrauma on the crisp course. The care of the critically or surgical patient course is looking at the the management. Off patients remain more medical perspective with a sort of an 80 format looking out to address sort of more medical type problems with a patient with a holistic view. What, looking all their permanent investigations on, sort of taking a approach. The patient that really sort of minimize is postoperative complications. So any time you ask anything, don't jump straight into talking about the fracture that straight up in front of you you start this an arrow saying, You know, I would approach this patient with a TLS off with, um approach. I would approach the speed of the crystal approach. Um, and when you get home to discussing examination and looking at the patient, won't you have assess that there's no part of life so threatening injuries within a TLS perspective from Chris Perspective, you want to ask yourself, Where is the pathology in the patient themselves? Is there the potential that there is referred pain, particularly with looking at patients with hip or knee pain, with shared femoral adulterated nerve supplies that these joints share? Quite often, you can see referred pain from one region. Presenting in the other equally is the issue. Actually, abdominal I have seen patients be referred with acute hip pain to the assessment unit who have actually don't have appendicitis and ended up going for a pen dissected or patients with. So it's abscesses A Z. You have abscesses down the posterior abdominal wall. Director parents in here, so always keep an open mind when you're assessing patients and trying to think, Where is the pain coming from on? Once you've established that and take it before a history, you know I'm gonna need to examine the pictures. On generally apparatus, look, feel move approach is the one which is usually happens at least this'll the level that will be discussing today. You want to look at the joints systematically from the fronts, from the signs from the back from underneath. You want to palpate the joints. You want to feel more joint line. You want to feel the soft tissues are doing. You want to feel for crepitus. Look for open wounds on. Then you're gonna gently passively move the joints after assessing the patients active range of motion. Because patient to move and see what they could do before you start aggressively moving they're looking for. That, Um, is well is examining the joint above and below, which is always good practice. It's always important to make sure that you consider examination of the patients spine, particularly for Children. With hit the fall injury, I make sure that you examine the gate. So when you're seeing patients with hip pain or knee pain or ankle pain, it's always a good idea to see what their gait pattern is. Whether it's antalgic where they're willing to move, it's all whether they're hoping on getting him to do. All of this can be quite challenging, expending what their ages. It's quite difficult to accurately assess somebody's on your vascular status and happened verbally confirmed this. If they're sort of told her off the crying or an extremist, and if that's the case, say what you see and keep it simple, you know, Is the child holding there are? Is the child moving the Are Are they moving their fingers? Is the child highly distressed? Doesn't cause the more distress if you move the drops in the particular matter. Saying what you see can be particularly helpful even to quantify whether the patient's condition is getting better or worsening, even if you can't document exactly what's going on with their your vascular status. Um, when you're looking at joints, always bear mind other other injuries, particularly in pediatric patients, when we are considering always, whether the injuries are isolated or whether there's a potential nonaccidental course of their injury. When you're examining joints, you want to describe any obvious deformity that you can see in the joints, such as this image on the left with this obvious ankle fracture, where you could see tenting of the medial malleolus where there's threatened skin, suggesting that this close fracture may indeed become open. If there is an emergent reduction in plaster cast immobilization whether the soft tissues are displaying bruising when there was tracking of any blood or hematuria. When you're looking at injuries, open wounds can be incredibly subtle or they could be less subtle on. It's important that if you see any graze or cuts or anything around the fracture site, the factor must be treated as open until proven otherwise. Which means the usual boast Rachel's be the Association of Trauma Guidelines, progesterone fractures with emerging cover and biotics within an hour. Tennis Current clear goals may be President Senior discussed with your local walking plastics. Uh, when it comes to examining the upper lip, it's quite difficult to start working out. Initially. Wear off the nerves. Go on. How to describe these in the documentation. Generally again boast guidelines. Rans injuries at a super condo, the fractures, forearm fractures in Children. All of these describe making sure that you individually name on. Describe the sensation and motor supply off the median nerve off the radio nerve and off the older nerve. And as you can see in this image, you can see that there's both apartment, a digital supply to the media nerve component. You don't need to worry too much about that. I will accept that if you tickled the index finger and documented that the radio nerve sensation is intact as a soon to be registered, quite happy with that, uh, the all the nerve supply on the little finger for sensation on the radio nerve supply for sensation at the base, off the thumb in the anatomical snuffbox region here, I wouldn't start getting to worried about the majority of nerve supply in the forearm or the upper limb. However, I would specifically mention the shoulder and clavicular injuries, making sure that you describe the regimental badge area over the deltoid supplied by the exhilarate there with a garden movements of the upper limit. Your upper limb movements are generally supplied down at the hands and the combination off the older nerve, describing the intrinsic muscles of the hand for both power and dorsal abduction. Adduction, the radio love taking control of both wrist extension on triceps extensions on the median nerve, taking a risk flexion on finger flexion. The shoulder. It's abort to quantify. Both flexion and extension of the joint is weather's internal and external rotation. And again, when you're examining the limb, you are looking to describe what the patients active range of movement is, what they're comfortable, where there's a passive range of movements on making sure that if there is significant issues in that range of movement that the, uh that will that is documents, uh, with regards to the hand, I think it's particularly worth mentioning that hand injuries are often missed on. I would always pay particular attention to those with distal radius fractures or fracture. Of the four are making sure you examine the house efficiently. Make sure that you palpate the entirety of the way along. Both the Philando is on the metacarpals palpate a rains. The thing corporal bones on with regard to examining the thumb and the skateboard itself, telescoping the thumb, applying axial load along the direction of the metacarpal to impact to the base of the That's carpal against the skateboard, along with our patient along the snuffbox On the scale for Tropical may ascertain tenderness of the skateboard, potentially suggesting fracture. It is less common in Children than it is in. I don't significantly, but if you are examining the distal radius, it's always just work with the guards. Examination of the lower lip. The motor supply off the lower lobe has a couple of assets, which is worth mentioning the deep peroneal nerve down the top supplies, the first also Web space in between thie the first trial with second so and making sure that you specify whether the deep air until the nerve sensation is intact, as well as the sensation from the nerve supplying the foot of the medial collateral planter nerves thie Saturdays know coming down the front of the five. So the front of the leg as a branch off the family of continuing from the front of the by day on the oral nerve on the lateral aspect of the leg, along ordinating of the course of the lateral malleolus is it sends the leg with the short staffed. His vein. Uh, when you're examining the joints of the lower leg, I pay particular attention to flexion and extension of the hip. Um, particularly in pediatric cases where you are concerned about hips in Children s or toddler age baby age. What can often be quite telling is they'll be quite comfortable with the leg, help a certain position of flexion and abduction simply to open up that space in the drawing capsule. If there if there's a joint effusion or puss in there, potentially increasing the heart static pressure and the joints and Children will put their leg in this position. And I want to relieve the pressure on the joints, and it's quite telling if you walk in and they've got that sort of flexion deformities, you congenitally increase this range and then trying to internally and externally, rotate the hep a little in these patients as well to see whether that will worsen symptoms again, you want to abduct and add up the leg Internet to see whether that makes any significant difference as well, both with the leg on extension. I'm indeed inflection. Uh, the knee joint itself is a fairly simple joint. It's a hinge joints merely flags and extends, but it is worth noting where there is significant various or valgus deformity in the limb. Um, the non PC telling is that, uh, the they're US and valgus deformity is remembered by the government between the legs, sticking them together on the on the wrong, spreading them apart, which is probably the not something that we talked much about these days. But you certainly want to note whether there is any discrepancy in the alignment of the joints, Um, and again the ankle joint itself again, a fairly simple modified in the joint where again flexion extension emergency version of the ankle joint. And it could be quite telling consistently with the ankle the alignment of it when you examine the ankle from behind. So again make sure that you've done that 360 degree assessment. The patient and you've examined examine from behind to look at any level like the 40 or indeed, whether there's any significant abnormality in the gait or what the position of the hip is, it's hell, say, moving onto describing images from a orthopedic perspective. What you want to do is when you're starting to describe orthopedic images, I'll say, Keep it simple. Uh, you want to delineate which of you you're actually is. You want to describe what bone is being looked at, which region off the bone the abnormality is on. Then if you can look at describing the fracture pattern out, whether it's a closed or open type injured when you're looking at views off the foot, Uh, you've got and you're a posterior view straight through the back of leak views from the side and then lateral views as well. Uh huh, when you're looking at ankles, a pa, and lateral views are, hopefully ones that you come across before, but specifically when you're looking at the cold routine off the tibia. Taylor joint. A mortise view can help ascertain whether or not there's been any significant tame of shift of tailor displacement, indicating an unstable ankle fracture. So if you're unsure on a P and lateral view, uh, what we're looking at, you can always request a mortise for you for a hand Siris. Again, you can see a pa and lateral films or pa and lateral films on again. You can request a week views, if you are suspicious. Minute apology not being picked up. If you're suspicious off skateboard injuries, you can also buy a skateboard views in particular on the member. If you're examining the joint up, up below is always work. Imaging those joints and obtaining full length views of the bones and question if you're on shows you exactly what's going on in your you're unable to pinpoint the exact issue. When it comes to describing which region affects the bone, it's easy is really to describe it in either a proximal middle or distant thirds of the affected boat. And then when you Once you tell which third it's in, you can consider describing whether the injuries and the diagnosis so either in the shaft of the central part of the long bone in the Pegasys. So the ends of the long boat, um, and in on in in Children is always worth mentioning whether or not you think that the mental processes involved So the's overgrown between the episodes and the diagnosis on Do you think this region of the growth plate is potentially involved? We'll talk about more about salt a bit more about solder. Harris fractures on the patterns in a second, but you also want to ascertain whether the fracture, particularly in the joints, is intraarticular. Where so the fracture line extends up into the joint surface itself, or whether it's an extra articular component where the joint self, the joint surface itself, remains congruence with mentioned a soldier, Harris fractures. There are five types. Onda. There's a reasonably easy to remember to monitor, which I always thought helps where type one through the growth plate is straight through. So that's s, uh, the time to fractures through the growth plates of the taxes are remember, there's a with above. So these fractures are above the, uh, and purposes. At the end of the boat, the type three fractures are lower, so they are the lower half off the plate and through the purposes. Uh, the type four fractures are trashed because they go through all through each elements through the, uh, Prevacid. Solutabs is on dialysis on tight. Five injuries are the are, so they are wrecked injuries. Where you see crush injuries of the growth plates, which are very subtle to pick up on occasion on are very easy to miss. So when you break down, what's, uh, are the commonest presentations of soldier iris type fractures it's actually typed to themselves are the commonest type. Two fractures occur, called 75% of all fractures involving growth plates in pediatric patients. Unfortunately, the rare, hardest part type of five injuries are quite uncommon to the extent that this image doesn't give a percentage. But as you can see in this image here, if we have a bottle of these principles together to describe this X ray on the left, what I would say is that this is a a P and lateral forearm view off a skeletally mature individual. I would confirm when this actually was taken that that it was the most recent film available and could further based identity. The most obvious abnormality on this film is a closed fracture of the distant third off the radius, demonstrating a soldier Harris to pattern, Um, but when you take it back and actually apply all those basic principles, that potentially complicated timing presentation, often X ray is actually quite simple. I've talked about what film it is. I've mentioned what bone it is. I have said It's closed. I've mentioned the pattern and what you need here. The bone it's in on dive. Put the cherry on top by describing the soldier Harris to pattern. So you're not that hard. When you start getting active, you can start adding in fracture patterns Once you feel a little bit more confident in assessing multiple, you know, getting confident with X rays and on describing what patterns you're looking at on based on what the pattern of the X ray is that you is that you're looking at, you can start trying to work out what force has been applied to the bone and order to cause it's break. Generally commuted fractures with multi fragmentary bone components describe a high energy type injury that will the bone itself is physiologically abnormal on the small amount of stress has caused it to completely fragment spiral fractures of a particular importance. And I'd like you to pay attention to this pattern because a spiral fracture of the femur in a child is always a concern, particularly in those one nonambulatory, as the torch it'll force applied to the bone density suggest that this has been twisted in in northern accidental manner with regard to transfers, fractures and oblique fractures. Spending on the direction off the obliques policeman's. There is other medial collateral four supplied, and you can see that by bending on the other side on with regard to green stick on buckle fractures. These are particular fracture patterns, which are themselves unique in Children on The reason for that is the fact that Children's bones are more likely to bend the break completely due to the fact that they've got thicker periosteum. So the periosteum is this white layer of thickness on the outside of the bone. Here at that finger Periosteum is also responsible for the blood supply to pediatric put on. That's also a large fire and reason why Children heal faster. Also, why their bones got a much higher capacity for remodelling then, and Adam now this elasticity does lead to the's unique fracture patrons and green stick fractures, which have been named after a sort of green wood, which is when you bend one side of the boat and you get a partial fracture of the other side. Tourist faxed, on the other hand, occur at the tap A seal locations in this longer part of the bone that we described here on there said to, because my impaction with a force acting on the longitudinal axis of the boat on. Typically it's an actual force that's been applied through a fallen outstretched arm where you see a small buckling off the off the cortex. So he's more subtle ones that one's not be Ms. They don't need to be treated as fractures mobilize properly, followed up for purely as I have seen, the occasional buckle fracture, even my trigger stage, which has then going on to end up as a complete break, uh, the most important thing I like to see is that it is imperative that when you are getting X rays of any fracture that's demonstrated, you ensure that you have got post reduction images I've lost count in the number of times that I have ordered, proceed up in images on patients in the emergency department on they have been sent her home or discharge about these images occurring, and it doesn't make you look very good or cover patrol you take. So if you're able to I trying to do my best to stick around with patients that I'm concerned about, that I think I've got a high aspect. I sort of a higher risk of leaving juice, department of pressures or whatever. So if you've reduced it, or have you been involved in that reduction? Is your responsibility to make sure that you've got postreduction images that you are satisfied with them on that you are happy with the discharge off our patients? Um, and making sure that you documented pre post meal vascular scores will come up to the second with lots of general admitting advice for patients particularly working in leads as a major trauma center on complex UH, Turkey Pediatric Service. It's important to know the orthopedic issues may not be the only issues that change in the house. Much like in the way when we clock are adult patients suffering with elder elderly sort of fragility hip fractures. They're often pound off on the Ortho parts. These patients people see a fracture, and they assume that that's doing the problem that the patient has on. You always have to be thinking What else could be going on with this picture? Is there a suspicion of Nonaccidental injury? Is this the only traumatic injury the patient has? Is there social factors? Don't want a home that make you think that the patient is at higher risk? Are there potentially congenital issues of deformities, which need address? How's the patient? Got a cardiac issue, which potentially needs discussed with anesthesia? If you are looking at before my operation on this patient, don't just write them off is that's a fracture. It's a simple clock. It, um, but being said, that's the usual history that you're taking from patients. It's a history and presenting complaint on history. Presented complaint. Drug history, allergies, vaccinations. Any hospital stays staying long term baby units. Yeah, but as always, there are a few orthopedic, specific things to think about. But the patient is very unwell if you think they are septic from an infection. If you're concerned about the fact that they may need a surgeon, escalation to theater or involvement off pediatric team do toward wellness or there's any suspicion of no accidental injury, you must escalated to your consultants on call. You must ask you not to your register all with any surgical patient. If you think that they may need Optivite prevention, uh, urgently, it's always a safe idea is keeping know by bank. Then find out when your last meal walls. If you're going to keep in Millburn, I meant make sure that you have asked your pediatric team in the emergency department to be helpful on offer to get an IV line offer to start intravenous fluids. So, um, I was symptomatic medication, But again, always be careful in pediacare prescribing you anything like me. Your pediatric experiences last so that your adult experience or triple check your fluids. Triple checking medication dosages, uh, with regard to specific investigations and Children and my personal experience. Unlike adults, bloods or a bit last important. So, you know, most adult patients of the elderly persuasion will not be going to feel, too unless they had a coagulation unless they had a full blood count. Unless they've had their you reelect, your lights checked and they bought their group and saves available. Most pediatric patients do know necessarily need to have all of the blood tests and images. It's all of the relevant blood tests before that, said, If you're suspicious of something like a septic joint, receptive hip, it's imperative that you get CRP parents if you get a full blood count of sad using these, if you're taking them anyway, you was well doing your group and saves with the ulcer Got to imaging. We've talked about pre imposed reduction imaging imaging the joint above below. Do you need to consider any other images? Is this actually a patient who's presented the as something that should have been a major trauma on needs consideration for a CD trauma Siris? Do you need to organize an ultrasound of their hips? Or maybe he's looking for refuge in, particularly if this is the amount of hours. Has this already been before very recently. Do you need to consider things like an MRI scan again? If you're not sure, escalate with your patients. If they manipulation has been performed on, there's potentially gonna cast. Apply it again. Your postreduction images on making sure that you've given consideration things like traction, particularly for things like lower limb fractures and family fractures on with the guards. Things like elevation, you know, does the hand or wrist me the Bradford slip? Teo, hold that from the arm up. Do you need to ensure that they've got pillows underneath the ankle? There's an ankle fracture. Um, Andi, I was always told, If you're worried about a child, just admit that you will never be released. You should not be chastised for being worried about a kid and admitting them to either place of safety or a place where a senior can review them in the morning. Um, if they do don't necessarily need seat over, Not okay, so on the cases. So I'm trying to pick out a few different cases from comin presenting complaints on, but I hope to make this a lot more interactive, so I think that there's a chat function totally on moderate. I might be able to read out some answers from, um so we'll see how it goes. If the first case goes, maybe slowly. I will just start giving you the answers, which maybe is what you want. So it's very well, uh, forearm fractures. You are called by the emergency department team to review a sectional child with a non and actually tell you They say it's an R and you say, What's wrong with ER? They said over there quite upset and distress Doctor and the models quite upset the digging, and actually, but I don't really know what it shows. Do you have a look at the X ray image? Is what you're on this great. So my first question is, what do you want to know from history on? Uh, hopefully some folks are going to start typing out some stuff about what they want to know. So I'll be reading on the chat on people's Yeah. Excellent. We've got a few here that said mechanism. Good on, then. Uh, yeah. Mechanism of injury. Any possible trauma, previous injuries. People are asking how it happened. Does it look like it's a possible twist? Yeah. Previous admissions any any bone problems in the past. The time off injury? Yeah, on a few other. Yeah, How did it happen? And if it was witnessed cracking. So I'm really like in the fact that everybody is talking about mechanism of injury and making sure that that matches the fracture pattern. I'm loving the checking a previous hospital admissions on Do again. It sounds like we're having high concern from no accidents or injuries, uh, which is also good. So the usual points in the history always still apply, even in the orthopedic setting, you want to know about things like vaccination status? I don't mean for Kobe, but, you know, childhood vaccinations previous time on any high care baby units acting If there's any drug history of any history of drug allergies on, uh, making sure that you've checked, you know? So how they get all of school, what's the favorite subject? But social history aspect is again another potentially important point to bleed information for good. Okay, so the next question is how well you examine this patient, which I'm hoping the answer is going to be excellent for. Okay, so we'll just give them a second to type in their answer. Okay, so somebody said, assess the pain level. Yeah, we have closed or open fracture. Uh, new, uh, vascular sensation in the hands. Um, pain level again. Sensation and movement in the fingers and the pain level, the grip strength. And then in ER said, Look, feel and move. Good. Look. Non said motor and sensory exam in the wrist and also the elbow. Good luck. Feel move depending on the pain. Somebody said a TLS approach depending on the injury. Um, a few people saying 83 assessment and then doing in your vascular examination and checking the range of movement race. So the important thing about a lot of those answers is, uh, you know, you'll same safe on in any interview for court trading or again, um, RCs level the fact that you said, you know, you're going to approach it with a B C d e a TLS approach, and then examine the joints. Look, feel moving your vascular status. You've only school marks. Don't answer. So why? Let's try and make this a bit more difficult. Tell me how you're going to initially manage this patient. Okay, So ah, few answers are saying analgesia. So they're starting over the analgesia. Ah, back slab pain relief Pain relief on a lot easier. So can we take it a bit? Further peaks. So have a little look at that X ray on the lateral view on Haven't think about how you're gonna manage that somebody's asking. Is a patient neurovascularly intact? The patient in this scenario is neurovascularly intact. So we have a few. So somebody said No, she said, Reduction in their backs Lab Ah. So if he said, Do we need to reduce so close reduction and analgesia energy zero reduction of the fracture needs reduction. Somebody said admission and theater for Nancy Nail the attorney for a Nancy. They'll be eight. Sorry, I on is easier X rays and immobilize. Then check the X ray Afterwards somebody said Deanna referral So a D in our referral a t e n o d n over Europe, I was like, Are you talking about pediatrics here? So hopefully not way have a K wire closed reduction. So Okay, so we've got lots of answers and this is good thinking. So when you are asked any question about a surgical pathology never be too quick to jump in and offer a definitive surgical strategy. It in the exam or in your interview Okay, trick is to take a step back, and you would probably given answer along the lines off I after approaching this patient on assessing the new vascular status and determining that they're new vascular in tax, which they are, and presume the Army scenario, I would need a discussion with my, uh if you're comfortable doing it with my emergency department colleagues regarding providing a emergence. Contrast it a shin within the emergency department for emergent reduction at plaster cast. Um, a one C. Now all of you said below elbow slab or backs lab. No cigar. If you had simply said to me, I would need to do plaster cast immobilization. You've got the market. That's good. But with forearm fractures, particularly of the mid shaft involving a radius or the owner or the radius and ulna, it's important to make sure that you have got above elbow immobilization because if you haven't, you're still able to pronating super name with a below elbow slab, the point of a bolo elbows lab. Whether you've got backs lab or A or a volar slab is to prevent you from doing risk flexion and extension. Moving the distal radius when you got a fracture. When mid shaft fractures, you need an above elbow. Okay, so you reduced the fracture on after application of a cast on reassessment, the new vascular status you consider whether the patient needs to be admitted or discharge with discussion at former meter on. Then you need a consideration of whether this fractures and meaningful to conservative management options, as many forearms are or whether you need to consider surgical strategies. And then you stop talking, Um, because if the Examiner is very kind, that will move on. And if they're very cruel, they will start asking about your surgical strategies, which I made you in a second. But good. We're all thinking I love it. So when you are reducing fractures, there are three principles to reducing fractures. Well, there are many, but we're going to talk about three. With regard to bones, you need to get the make the length, so you need to apply sustained, gentle traction, which is increased in order to bring the boat back out to the appropriate length because as you can see in this previous image, this overlap here suggest that there's a bit of short today, so you need to correct that shortening. And then afterwards we need to talk about the alignment, so correcting the alignment allows you to correct for both Barris and Valgus deformity on significant ambulation of your fragments, you don't need to consider the rotation, so whether you need to do something to bring the bone back around to the position where it should be by dividing torture forced to the ER, and after you buy your length of liven and mow, take a shin. Hopefully, you got a fracture reduced. Now, when you're applying a plaster cast, you need to have a few things. Need a competent assistance to apply. The plaster on A is full of the 80 staff members who have done that Boston course are bad. The most marriages are covered, myself included, Um, and the trick is after you've got the bone in a suitable position, least you feel it's a suitable position. The aim is not to lose your reduction when you're applying the plastic cap. Sorry for fractures or before you want a hand in a neutral position flexed at 90 degrees. I heard lots of talk about whether you want the forearm in pronation super nation or neutral on at my CT to stage about start red straining. I still can't understand which is which. I have never been criticized. Bring the hand in a neutral position. So just to guide, say, once you've got their arm at that 90 degrees position, you want to apply a pounding to the arm so you can see the stocking it underneath the arm, which is just a big stock that pulled up the arm and a little fun whole cuts and then applying bandages over the top. You want to apply a half roll, meaning you've got a roll of bandage on. Then you want to put another roll around half the diameter off the bandage. Make sure you've got a minute. A little bit of overlap, but not too much is demonstrating this picture, and not to lose is it is in the picture about the other thing that is worth mentioning about these casts, and stopping it is that it shouldn't really cut well, you should not come about the level of the metacarpal heads need to make sure you're all the way up above the elbow. A good part of four. A small tick With regard to applying bandage. You haven't done so much like when you look at toilet roll in part from tells there's a right way and a wrong way to do it. When you apply the bandage with a under technique, trust me, it's a lot easier to look like. So next time you get the chance play and you'll see a unrolled much, much easier When you're applying it. However, we all know that that is the correct way too high. And you told When you're applying a back slap, you need to make sure that you apply it again all the way up the forearm on coming down. So it's either at the restaurant or extending towards at the MCPs. But again, uh, long as you have got, a slap covers a good old port of the arm. It supports it coming up around the elbow and the arm. Uh, you're covered on. Afterwards. You need to complete that with a bandage around the whole lot so that your layers are then patients, and then you've got attention stocking you've got, uh, bandage. You've got plaster cast and then you've got your other bandage. It'll there are excellent casting courses that are available nationally. There's good ones in Bradford in London. Most of the colleges run them. But I did my glasses when I was in undergraduate student like 20 quit, and it's the same course when you're about to your leg stuff. So if you get if you're interested, you want to do a casting course. Definitely recommend there's a good thing and, as always, reduced. Remember to Redox mint in your vascular status. Remember, get postreduction films. Okay, eso your patient returns to clinic on Day 10, and following films are taken on the's on narrowly images that you are seeing in clinical data. 10. So I would like our audience to tell me what's happened on. I would like you to discuss with me what the options are. So this waiting for the answers to come through, somebody said malunion. So, uh, somebody said it's not well aligned, so healing will be impaired. Needs a surgical, uh, backs lab not put on correctly, not healed as hoped, that that that's a way to full life with your register who I think you've applied to slap been greatly, Mr War. I said not here. This hoped. Poorly aligned likely operative management. New plan, child. Not resting limb. Somebody said for the trauma on. So we've correctly identified. Some of us have that the initial reduction, cheeky individuals. The initial reduction in application of the cash showed a satisfactory alignment off the off the bony fragments here. So you can see that we've got reasonable reduction here off these bones here. But unfortunately, forearms, especially of both of them, are fractured, are inherently unstable. So we have, unfortunately lost to the position of the reduction of data on we failed conservative management. So you are quite correct after failing a conservative management trial with a good reduction? Yes. It looks like a open to plan may be needed. Can anybody tell me what the options are for fixing These are? No. It's also an acceptable answer if you cancel it. So somebody said pins or plates. Question Mark, Uh, M u a. Or if, uh, K wires, Killer fixation, open reduction and played application. Cool. So we've ever done the heard of some fixation. All which I like Trick is and we're competing. There's many ways to skin a cat on It is a combination off about cereal of fans and parents from the fracture fixation course. So the old form a group describe a combination off the patient personality. So what does the patient needs? Get the operation? What's the fracture? Personality. So what is the fracture pattern like of what is that pattern going to be amenable to and what is the surgeon personality? So what can I as a surgeon off for the patient that is within my skillset? And it is less about looking at a particular fracture pattern, suggesting that's a four on fracture that needs to know if or that's a fracture pattern there that needs a Nancy nail. What is is trying to look at the fracture and determining what don't have it in my skills that to induce on environment conducted the bone healing and the two big bone environments that we talk about are, um, absolute stability environments where we are allowing the bone to heal by primary bone intention, um, with bypassing of fracture, callous formation on direct conversion, canal going by osteoclasts, or whether we're looking at a relatively stable environments where we are inducing secondary bone healing on allowing a small development of micro movement at the fracture site. Simulate callous formation on a little bit of human toga. Been lengthened sense of that now into adultery. Fixation using Nancy nails. Whether you needed to use one day or two nails on, it's perfectly acceptable and some sorry one because you know the tax fellow boat going to get you get one, and I think they look forward to that. To you, however, some will require two, and you can use intramedullary nails to inducing relatively stable environment in fractures with open reduction. Internal fixation. It's not just the fact that you're using plate and screws. The question is, what are the plate and screws trying to achieve? Do you? Ah, DCP. A direct compression plate where again you have absolutely stable Richard construct. Do you need a bridging plate where you have screws on either end of the fracture and nothing in the middle, allowing a little bit of relative stability of little room in the middle? Do you need a buttress plate in order to try and support the boat back up the way, like the leading tower of Pisa. Do you need a neutralization plate because you want to neutralize forces going through the joints? All this stuff to think about it? It's not necessarily saying it's one man that or the other. But the trick is to say something along the lines off. I would look to induce a a primary or relatively stability construct. I could do that using any of the following, and then you say your answers. You know, males, you're conducting a temper fixation. Your plates screws extra fixators whatever it is, uh, but good. You know, some options are very dressed, right? What we know. Fulfilling about four or fractures. Let's do some pediatric senses. So you were called by the EDTA into review a child with a painful left it. They are under one years old, and they are concerned, as the child has been unable to mobilize and has a low grade pyrexia. So question, why are you concerned about what are your differential diagnoses on? And I also want to know how you're going to approach assessing, um, off this patient. So there's a few subject arthritis, So septic arthritis, septic arthritis, septic hip, then they won't have any difference you a little bit septic joint. Somebody said they would like to know about the family history and of the observations of the patient. Good differentials, Mary said Hip dysplasia not need a said SeptiCare dysplasia or synovitis. Yeah, yeah. Living A. Said about approaching the patient will approach in a to the assessment. Uh, somebody said femoral fracture. There is a non extent of an injury here. Also. Good transient synovitis, but not sure of the age on that. So excellent defenses. I'm pleased that we all thought about accepting joint. And please, we'll talk about any tea assessment. I've thrilled somebody talked about nonaccidental injury. Um, the possibility or it being a need problem. I'd like us to try and remember. Well, what we talked about earlier with referred pain from hips and knees, it could also be proximal femoral osteomyelitis. Well, as accepted joint as well on. Always remember the weird and wonderful things. Always remember things like tumors. ALS remember things like myositis. Um, old remember things like taking a slightly older Children or things like past disease or or so, um, idiopathic arthritis or juvenile onset arthritis uh, d d h again in this age group and ms d d h can't be absolutely catastrophic. So excellently we remembered hip dysplasia. Uh, quite like the way that we're personal. Start with an 80 assessment before happening. The joints, uh, so with regard to the examination of the hip joint, I should ask is Well, does anyone know many tests for hip dysplasia? So ah, few people said follows. Cool a note along. Great. So if you don't have that back so borrowed, you are like in the night. First back to see if they have a dislocated below the court. Levinger, I'm talking the legs, Actually market. Oh, be honest. I've never done it. But I'm hoping by the pediatric. Um, cool. So does anybody know any criteria to a different situation of a septic joint from a normal? I think you do for a boat this point, Can you tell me what those parties off? But I do. Somebody said history off the temperature, right. Blood tests? Yep. Fluid in the joints. Maybe fever, hot, swollen or red joints aspiration. So we will write with temperature over 37.8. Caucus criteria doesn't necessarily use the, um, the way that the joint looks, what we're talking about with multiple Corker card. Syria is looking for the presence of four separate aspects. You need a temperature. You need a change in white cell house. You need a shot. More apple a tree on you need you don't actually need x ray evidence. But you also don't need to make sure the aspirated the joint either. Um, with regard to, uh, looking at a test for the patients, we're running out of investigations. Anyone know what tests we look for a while use? We want on the x ray. Somebody said frog leg, right. Fluid around the joint. Um, doing said a P and frog leg. Right. So your a b and fold leg use hands Garbs Who other? What test? So blood tests already? Somebody said earlier. These are yours. Are CRP white cell count going? He's got pyrexia sex in six cultures in a laxative young. I'm sure somebody was typing it. I want to know what those are. Well, well, on that, mainly because your initial management you know how one well the child looks. You may not want to mark about waiting on a lot of tests and dilly dallying. And maybe that somebody needs to go to the attorney for emergent aspiration wall shades. Um, so your initial management you need to keep your patient know my mouth until you're sure what's going on. You need to find out what's going on the drama list on what's going on the acute list to see if there's any capacity to get your kid in. Um, if you think that they're gonna need to go, I don't really. Even if the child is something from a low grandparents here and not themselves in kids, your systemic parameters of infection may only remain mildly elevated on a little, it's common saying, really, really well with their new score until they suddenly go off a cliff. Ah, on depending on how on well they are. Your options are there, admit them on Get my notes same in the morning and keep watching them overnight with cereal, nursing observations and re evaluating things that they start to look like they're getting more poorly, or whether they're coming back for an emergent ultrasound in orthopedic ambulatory service on sort of being seen. But to my mind, if it's a kids and a baby. I probably am on the side of caution. Um, so I suppose we just talked about talked to far, but okay, so if if instead of your child has a temperature over 38 a half on the unable to mobilize with CRP being pending what? Your options from management, how did you go about doing so? So look now said antibiotics. Okay. On analgesia. Okay. On a said antibiotics and pain relief keep overnight and observed by nature like that. So somebody said fluids, IV fluids. Yeah. Say, with a kid like this, if they're consistently pyrexia, they can't mobilize clinically. Everything is pointing towards a septic arthritis. Your initial management. What you're looking for is an essay job. Um, or at least a good after one was reviewed on excellent half. One is reviewing patients is starting to get the ball rolling. I want to know, um, that you have spoken to theaters. I want to know that you got me the relevant consent forms for booking and marking the patients. I want to know that they have started to be resuscitated appropriately. I want to know that the patient themselves eyes starved. I would be quite upset unless the patient is more buttons. I'm exaggerating a little bit for effect, but if you give antibiotics and a septic joint before you get aspirate, it's you may have next. The culture is owns now, even in individuals who come in, see, really very unwell. These individual, um, sometimes gonna go to theater overnights on. I would always caution giving antibiotics to somebody that you haven't discussed with your senior first, because I did it once and they were quite upset simply because it can really affect your biopsy results and and affect you affect what she would do. It's sensible to think about it because of individuals of Florida accepting You're correct. We do think about giving him antibiotics within an hour. Bones, discuss that with your consultant discussed that with your Reg. Say, I'm you know, I think it's very reasonable to say to them, You know, they've been persistently tachycardia, been persistently pyrexia. The BP is not very good. Despite from the resuscitation I want to get, the passport will get better. You're not gonna be shot down, that's all. But for somebody who is mildly pirate, you know pyrexia well, but their blood's coming back. Everything else looks fine. It's just the temperature. Hold off. Antibiotics. So you spoken to somebody senior? What? Uh huh. Those haven't seen frog legs at a P views. That's what they look like. The advantage of the, uh, program uses it allows you to measure a Southwick amble, which is a thing that you look at it set up a family services disease, but you don't need to worry about last. Um, you only see X ray changes incentive joints where you have erosions of femoral head at the very late stage. That joint has been unhappy for a very long time. There, Right? Well, you may see is a very sort of subtle sclerosis around the joint. It's been going on for some time, then the very acute stage is often the X rays were normal. What they actually are useful for. It's trying to determine whether or not there's an obvious cause on the X ray for why this child is presenting, such as a fracture. Um, hip ultrasounds are incredibly useful on. Do what you can sometimes see on that ultrasound is a fusion between the joint capsule on the femoral neck. And if that space is increased with fluid, it could suggest that something's going on out of a reactive nature or often effective nature is no uncommon for in individual Children, with Grumbly hits to have over us several week periods. Sort of the grumbling along and have an ultrasound doesn't really show too much. They grumble along that come back. It's still a bit unhappy. Maybe they have a second over. Same CRP has gone up, and then, well, the end of having is an MRI after a consultant of you're staying as an inpatient. So your first line investigation is ultrasound, and it's important to make sure that both hips are ultrasounded. It's about to make sure that both knees are ultrasound, because again, things like juvenile onset arthritis and the like living on this over the one you know. But it's important to make sure that this designer isolated or sort of polyarteritis, um, with a guard to operative management. I haven't seen this being done, but to give you an example, what you can do are after scopic washout lower than over what fans open washouts are are indicating some cases, but the vast majority are at least initially managed after school openly, where you put Windows imports into the joint capsule and you to wash it out. Morning at the answer. Your spirit. I explained the greatest cancer and going in, uh, going in between the in order to access to joint capsule right aware that is now 10 past eight and there are two cases left to discuss. Or I could go to know accidental injury. I don't want it too long what people think. I think generally people are going towards discuss one. Continue the cases. Really? Uh, there is a few nonaccidental injury on a few that want you to continue with the cases. It's up to you don't, But maybe if you want to discuss that and I sent the injuries and do their cases. So the people that want none of something injuries can stay behind. Okay, Cool. So let let's do any I mean, people could be pulled it sticking around. Um, give me giving. It was for the lights. Right? So we'll skip on a little bit to saved in any eye. So Okay, So we always banging on about nonaccidental injury in Children and there's a reason why it is incredibly important in the Western world. Nonaccidental injury is the second commonest cause of infant or tallit, so that is why it is important on every week after it. On Netflix, there is another documentary about unfortunate, unfortunate child but suffered horrific events on multiple stages. Builders responsible for looking actually failed times. In my mind, if I am seeing a child, I I have that bonus of responsibility there and then to do what I can afford it. And that's not to say you have to go and be pessimistic and miserable about every patient you see and treat. Everybody shouldn't impair with suspicion, but it is important to make sure everything matches up. Does the history make sense? Does this child have the ability to be ambulatory? Do they seem a so they could have inflected the injury that they have? Um, does the mechanism makes sense with the pathology that's being showing? What is the fracture pattern? Is it a a sort of a concerning spiral fracture of the femur that we discussed earlier? But it's sort of torture, forcing the nonambulatory child. Have you got concerns about it? Fractures where quite someone that's actually it's not blowing up. You can see these little subchondral lines here and sclerosis on these little ribs, particularly on the on the salt posterior aspect there. You know, our rib fracture is something that needs to be picked up as the kids got. Multiple bruise is, is the suspicion of a head injury either from one force trauma or accidental from where a child has been shaken? Um, how is the child presented? Have they come in with their parent as the parents rushed him in urgently, highly concerned, too stressed upset. Good the parent, not give the monkeys? Do they seem a little bit withdrawn and concerning themselves have over social risk factors? Is this a child who is doing well in school? Is this a child from a single parent household from a low socioeconomic area from a household where there have been significant recent stressors? And I don't say this too generalized or judge these patient demographics? It is simply the case that these these bouts of evidence, you know, evidence suggests that these are social risk factors for nonaccidental injury, Um, and again, it's important to have the risk factors in mind when we assess, people remember that there are different times of abuse that Children can experience. There are physical violence. There is no collectible violence. There's emotional violence, their sexual violence. And again, all of these things need to be considered when you are examining patient. I've always say that if you are being concerned about any particular type of abuse, um, again, making sure that you have documented the red flags that you have come up with and documenting your suspicions clearly, even if something is just not quite right and you've got that got feeling sensible thing to do is to sensitively escalate that to your immediate register on call or your immediate consultants on cool Speaking in confidence, particularly to your senior nursing staff, your A li pediatric consultants on organizing additional X rays and school it'll surveying images as well as making sure that you have admitted your patient to a place off safety. It may be that is a human set of rib fractures that you can see that in principal don't actually require medical management. But from a social point of view, you must admit that child and the other thing I'd say is, and it's difficult when these are very emotive. Subjects on day are challenging into personal situations, which we can feel particularly stressed or angry or angst full four. But trying not to be quick to judge because there may be other factors going on. Um, I try to be as supported and non judgmental on a Sunday standing as you can be, given the circumstances of what's going on. Well, a little Surveys are a choice study to evaluate suspected cases of child abuse on there. The gold standard for detecting additional injuries so they should include frontal views of your particular skeleton. They should include the operant lower extremities with frontal and axial views of the skull, the spine, the ribs on, depending on what your survey. Fine. They may need additional imaging, whether those are specific X ray plain imaging, where the CT scans one of those MRI scan of the brain is again looking for accidental type trauma from brain injury. Uh, interestingly, head injury is the commonest that's the most frequent cause of morbidity Mortality. Secondary to child abuse is not usually the rascal, abdominal or lymphoma that causes these Children in long term detrimental effects. If if something is going to affect the long term more often than no, it is, unfortunately, a head injury. Um, some evidence suggests that usual obtain a small little survey and all patient with suspicion on to the age of three on selecting patients. Treat the ages of three and five. Um, after the age of fine, there was a paper published in America where Kocher it'll looked at all the cases of child abuse in one of the American society is it was fairly big paper. But they suggested that after the age of five, you could potentially use a skeletal survey less sparingly on. You can rely more on the physical examination. Shots are stage. It's not necessarily opposite on escalating a program lesion. Mayport, of course. UM, a sleep survey is reported more often. It's, well, most usually by two consultant radiologists on They are usable in a court of law, so scaly ulcers are often used as evidence in child abuse cases. Um, with regards keeping it open minds, one should keep a open mind regarding differential diagnoses in these patients. Um, maybe it is a true accidental injury on. It's just a funny mechanism. Have they gone underlying bone disorder? Have they got something like an undiagnosed case of osteo genesis and perfect er? Have they got osteopenia for maturity? Hence it's important to make sure you want to buy time. Special baby, you know method of delivery on all that stuff. Are they attention the suffering from a deficiency, whether it's vitamin C, causing scurvy, whether it's a culprit, efficiency on if there are significant nutritional deficiencies, have you got to go hunting for alternative additional pathologies? Is that potentially guts? Pathology? Is there a metabolic disorder that you need to diagnose? Is there a an issue with consistent failure to thrive in the child on the normal for the way to the percentile? Otherwise, does it look a those you are concerned regarding the collect in the child as well, willful or deliberates of leading to a deficiency of anything? Is this a dish? Use osteopenia, perhaps, from a child who suffers from a neurological condition where their bones and weakened through misuse is the child suffering from a chronic case of kidney or liver disease, leading to metabolic disorders affecting bone metabolism? I have seen, even in my leg starts fairly weird and wonderful things of the sort of things that you hear about medical school and think. I'm never going to see that what I need to know about that. But despite the fiber told our horses zebras, you do see a fair number of separates once you start working in your own definitive specialty. Um, before it was worth mentioning, consenting for patients on bias towards England in the slide, I'm afraid. But for those was working in England, when it comes to things like Nonaccidental injury concern for patients need for operative intervention, all that sort of stuff. Gillick Competence is a term used to describe a court case, which was about a young girl under the age of 16 who was prescribed contraceptives by her general practitioner on the parents. Took the GP to court on the basis that the child was unable to consent be below the age of 16 on the legal ruling essentially states that if we deem a child to be capacitance onto the age of 16, they can consent to a procedure provided they meet the terms of being able to understand the information of retaining way up and communicate. It the same way that we do rabbits. Um, if the legal guardian isn't present for the child, you can't consent that child. Um, if the kid turns out from school with a teacher, the teacher is not legally able to consent for the child. Um, however, uh, you must clarify where the guardian is. Do your best to discuss it with them and contact the parent in order to try and, uh, make sure you filled the consent form, too. So that England accent form twos of the forms that we use for pediatric patients on the going surgical procedures on, if there are no available need to escalate your consult your legal team. Um, it is quite rare that you need to take a child to theater there and then or overnight super consular fractures. Even what used to be operated on overnight. The Post guidelines Sutent called the fractures. Either there's no special neurovascular deficit. There was always the next day for four daylight operating list for patients who are unable to consent due to mental state alone. Wellness. We do have things a physical, the consent for four and England, which is the sort of ones that we use in patients with so advanced dementia or, if they're so well, that they are delirious. Um, but if you cannot consent, child of the parents is where we'll try doing this. Well, it's a port to escalate. It, um, had a couple of signs of water to beat. Exercise will do those one here. If I'm selling especially to you as a side note, it's It's awful. There's a There's a massive a Rieti. We will talk today pediatric cases for about an hour, and we're going to cover two topics. When I go, it's teaching. Know we told about one topic for a Now, our really understand the whole gamut of spectrum of agent patients. You're working with me in a child, Children, two pediatric patients on the way up to about 70 patients. And there's a wide range of abilities of those patients as well. You're working with the elite athlete all the way down to Doris. He just wants to play balls on a Sunday. There's a huge procedure variety of orthopedics. You're working all the way from the clavicle to the fingertip, the pelvis down to the toe on. There's a huge variety procedures that you could develop your skill. Sets it. Uh huh. On its ever every day is different troller on the way that you approach strategies and develop ways to manage these these injuries. I just like a fascinating. It's an incredibly exciting specialty. You know, you never know what's going to come through the door for Michael. It's incredibly innovative. It's not just a habit of nails. I mean, at the moment, people are developing skill sets and computer guided and CT and laser guided hip joint arthroplasty and minimally invasive procedures. New approaches, new approaches to developing peripatetic joint infection. I'm sort of centralization of off a plastic revision services across the country of the next few years. There's extensive academic opportunity with all this stuff, if that's what you're into. REM these PhDs a. So the publishing research papers for those of you who may have been put off by the fact that it's traditionally been stuffy man between blazers. Fortunately, it's an increasingly diverse group of the Procrit representation the Women in Surgery Group, spearheaded at the front by the College of Surgeons. England is really pushing to make sure that we are more inclusive group clam mark. She was initially the B o a president Original Pedic association president, first female president. Local deserves England. So it's more for leading the charge of that front of the original. A PT training Association culture and diversity group is again working very, very hard to make sure that the group is representative of the patient population that we have out of the people who were training in the profession. It's got some of the highest levels of patient satisfaction that exist. The patient support outcome Measures for hep joint, arthroplasty suggest, is the most successful procedure that has ever been invented. Um, it leads to a complete new lease of life in individuals. If you could fix them after you're on manage their elected conditions on, there's an increasing need for our services. Numbers for troller are going up exponentially, you know, year. In fact, it's suggested that we're gonna have around 30% more hip fractures in an elderly population by 2030 or 2032 on the elective back log is ever increasing as you probably are well aware from a use media on. But if your financial incline there is excellent private opportunity which is always what? Say, um, I could take questions now for people if they want to shoot off. Like I'm happy to stop talking and stop waffling. I'm happy to go back on discussed cases. I I will take it from a sippy pulse. Yeah, that's perfect. Don't we just have one question here from Mary? She said. Do you admit, if you suspect any eye? Yeah, 100% definite. Get him in the It's often very, very sensitive to hiring. You're going to approach these issues on. It's often a very challenging conversation. Um, you know, do you, You know, do you confront individual directly? Do you refer to the safeguarding TV and let them deal with it? Well, she happens off. It's but I what my personal approach is to kind of go somewhere down the middle. I open season. Why it's important to admit the child well, what we're concerned about the injuries that they sustained and that we would like to order further investigations. I had some tests. I observed the child with Progenta worry about it, and that's normally how I explained things to people because I was true. We are concerned about the child were saying about the injuries of molars to the for for safety reasons. If you push on, why that reason is just what tribe spoke to the conversation, trying to escalate things and emphasize that you know, you want to keep their kids stinks. Uh, I've yet to come. Sure. There are scenarios that exist where people have refused to admit the child of things a little more forcefully. I've never been to that position, but I always think, you know, we have specially trained teams to deal with this. I know. Especially trained to deal with this. And so I was sore. Do the best I can get in a circumstance like that. Thank you very much for the answer. I think that cleared it up. Okay, we we still have, uh, 57 people here. Um, it's entirely up to you, though. I know we took a lot of your your, uh, evening, uh, longer making the presentation that if if if people wish to sign out now sign are my senior policeman, read the email me with any questions Are orthopedic or career related? Happened is in the other couple of presentation of people get to stick around. Okay, Cool. So, until, uh, so if you're still interested in the chat for the cases that we can go back to, please let us know otherwise. The rest of you, uh, the feedback form for your certificate should be, um, lt or but it will also be in the chat box. So once you fill it, you automatically receive your certificates. I look, or to your one start of you again. No, honestly, I've been listening to everything you said, and I and I thought it was really interesting. I myself, like, learned a lot from from from everything very interactive, very well delivered, getting people one minute to escape. So you a few people are interested in the cases on. We have a lot of people, actually, from the cases so far, right? Yes. So super called the fracture. So we've done before our fractures. We've done a septic joint. So those are two of the British Orthopedic Association Standard guidelines for trauma with particular emphasis on kids. Super comfortable of fractures are another topic with a post guideline. They sleep really come up in post graduate same nations, and they're really important topic because they're one of the more serious kid injuries. Um, we're putting out a couple of it's off details on this X ray. That's a normal. That's a radius about your epicondyle. That's come on the north end on as this is a lateral view with the elbow at the back here. Your anterior humeral line is literally just a line drawn on the front of your humerus. And I thought I wasn't gonna need to explain that, people. But when I tried this on the fifth year medical students earlier for this presentation, they thought this was a knee. So I had this X ray explanation in. So in this scenario, the ent department call you on. They were worried about seven year old right hand dominant boy who fell from a trampoline onto his left hand, and they've taken the following X rays. So can anybody describe to me what this actually shows on how they're going to approach the acute management of this patient? Okay, okay. Everything's on the x ray. I think, uh, people is a bit hesitant reporting the X ray, but I have somebody here who said Medial displacement. All right, your clue. If it's a question on Super Condo. The fracture is what we think it might be. Uh, that's a top Taper med school finals. By the way, take the clues from the stain. Um, so yeah, so? So this the way I approach answering this is again Stay what you see? Okay, so this is an AP, and it's a lateral view off a left elbow. And you can tell that this is the left elbow, because, look, there's a Radiohead, and there's your capital comes up right back. So, um, this is a left elbow in a skeletal, immature individual again. You can tell that this clearly in the chair because you can see that you've still got all stick a shin centers over in the back of their look. So a, uh above elbow back side has been applied. So that's what this big thick line is here. This here is a back slab about the elbow on this buzzing. No stone side is also plaster cast. All right, so if you can see a cast on the image What say? Okay, um, what this actually displace is a garland three super condo, a fracture which you don't necessarily need to worry about the classifications. But what this has here is quite rightly said, it's not medial translation off the epicondyle fragment. And this anterior humeral line you can see has been disrupted. So it doesn't for dental Congo joint surface here. Um, so, yeah, I got to shoot the possible fracture. Excellent. So was our approach to acutely managing this injury. Now we're going to assume for the purposes of your approach to acute management, that's the above elbows. Lab has already been applied on going down to three D and they say, Can you see this kid? So you're there. It's been reduced. We did looking a said that. Tech the neurovascular status. Love it. Eleanor said, Examine the patient. Love it on review postreduction x ray. Rebecca said Conservative management on algesia. So with the with this case, okay, when you already go down to see the page and e d. You are currently correct. That must really examine the new, uh, vascular states is remember the boast guidelines. The street, because of the fractures, states that you must individually document a function of the median nerve. The radial ulnar older nerve. Okay. Taking the emphasis on the median nerve. The anterior interosseous Brach of that nerve is quite it's more risk with these fractures and some of the other nerves around there. Really want to make sure that documented this battery, which will come on to the second You can see me, so you must document function of each individual nerve. But before you jump to examining your patient, remember, revisit the history is the history that is presented to you again, consistent with the history that been documented by the emergency. And if you do, you have a documented anything which they often don't go and speak to them. See, the doctor that looked after the nurse looked after them. What seems them? How is the interaction with the child in the parent? Does the parents seem appropriately concerned? So how did they tell you what happened? See if it will match is off. Okay with the regard to the acute management again, this is a pretty significant injury. This is a garland three. So it only goes 123 and four. All right, So fact, it's an off ended distal humerus. After rechecking your neurovascular status again, depending on the time and the injury and all that sort of stuff is worth clarifying with the page when their last meal walls. But when they last had anything to eat and drink the past. Medical history, previous surgeries looking at explain to that's a significant operation. I don't know who said Conservative management, but the these are very serious injuries. So anything but the most minimally of displaced supracondylar fractures are likely to need theater. To the extent that, uh, certainly as a new red next year, I will. Anybody with a super called The Factor is anything about hair line. I'll be admitted, Um, because they guidelines suggest that we should be fixed on the next available day light operating list. Unless you're concerned about newer vascular dysfunction, which we'll talk about in a second. Yeah, you you should that makes you think about using, um, are you can't for a fixation, Right? So we talked about going to go about got 12 and three exactly. Even at the MRCS. Well, they're not gonna ask a fracture classification times. But when you were thinking about your main question is, is it in normal place? Fracture? Is it some what happened with the posterior erected with only just the anterior humeral line. That line that we said we stand there or is it offended? There's a new, uh, Boris type Where are really Is it completely upended? The whole thing is confusing, so that goes into town. But a thing, But really a timing is looking at getting fixed. Okay, today's if instead off, uh, had that was new of acid intact. I know this is a model hands, but if the other the pale was hand and you could feel a radial pulse, you ask them to their fingers and they were doing it wanted to percent. Somebody said Doppler, Very good. So work is somebody, Sergeant, that don't lose a great on that. I don't want to use them on the front of my new unit where I got masters and I said, Why you don't You can't feel it can't be that. But I agree. I think the doctor was very sense right arm, too. We have also checked Break your pulse good like that and they go So it's a pale ghost. Let's hat. When they question is on, you go into a discharge papers be on, make the patient the ward. See, have a discussion with you registrar about Take the theater. Uh, so many. What's that? Don't said, Would you need sedation and immediate production? So, sedation, Any reduction to try are better into a better position. Know entire is very sensible. Got well, look at these garland threes are often 10 to 20% chance Presenting with these injuries present with an absolute okay, Pale essentially suggest that there isn't an appropriate color. May be breaking lottery Come down splits into an older radio, the older for the deep home or a Claritin forming the two official Palmer. And if it's PayPal A. And get enough blood. So if is that that's, you know, with the outside consultant, because terms happens, got it? And that is going to feel overnight or emergent reduction and perky to be a spin it okay, if any, of management overnight, this patient needs to go. So it is all of the stuff that you wouldn't normally do bearing a patient for the port. It's just keeping the mill by checking, but they've got a program. Fluids in your allergy state is discussing it the prisms. See what's on the breast. Looking of depending on market for that. But you'll develop those Skittles as you go through your training. It's it is useful. Then the boss comes in to say, Actually, I have done. And you see, you fought through some of the stuff that needs doing. And you don't You can to contribute to the reputation getting ringing anesthetics because you want to expedite their treat much as possible. So there are loads of options for for ah, managed to these cases in suppose. Actually, if anybody can tell me what any of the guidelines are and have, you can approach fixing these before I should be on the next light. I might be very impressed. Uh, but hopefully what time to be a super clear answer. But I was worth mentioning the difference, right? Anterior. And to injury the hand of addiction as the okay. When you see you give him a half, right? Be bad. Yeah. Yeah. So you're into your interosseous is responsible for movements here for your pencil grip. Because remember, your median nerve supply is responsible for your flex a digital and profound this and you're flaccid. It's warm superficialis as well as your FBI. So you got your low muscle so your flanks opposes long with your finger. Now, the benediction sign is one of two things. You get this from either a When you flex the fingers, you are unable to flex your, um uh your your and to your interosseous muscle. Can't flex that because you're a I was off or be what? You actually got another claw because you may know is that the old one claw similar to that have been addiction sign. It's pretty similar. I remember that the older claw is not to do with an issue or flexion. That is an issue off extension because you have paralysis off your your Flexer, uh, on the on the oversight because the older half of that DPS supply But the all the nerve as opposed to the flexor half or the the other side being supplied by the median nerve does that make sense? I hope it does. Uh, it's a very fun thing. You could be about for post graduate zapped, but anyways, the point is, check that they can do this. All right. Anyways, hopefully somebody's timed an excellent answer to managing these operative Lee next line giving him outside, right? So, essentially, you are using Kyi's to manage these fractures. Now, when you are looking at K wires, they come in a variety of thickness is some are used for holding bits in place while you put plates on. Some K wires are used a sore that temporizing things. But the guidelines now recommend that you using minimum of two millimeter K wire for your fixations. Now, there is some controversy as to whether you should use these wires in the medial or a lateral configuration. Remember that around the medial epicondyle where your funny bone is, you're older. Nerve runs posterior to that. So if you go sticking in wires blindly around the medial epicondyle, there was a reasonably five risk doctor current all the nerve injury. So the guidelines again suggests that you must document your techniques to preserve the older nerve, mainly called if you internally rotate the arm shipped out the way. So if you if you pronator hands and try and move the older about the way or you do perpetrate a stab incision on, then make sure you work your way down to the cortex directly. You must document that your post operative note now is well, as you do media wire. If you use a lateral wire on the lateral epicondyle, any any sort of configurations crosses over the sun by mechanical studies that suggest that that is a more stable construct. But equally, some people use to lateralize and said they don't put a media wire it some people use to lateral wires and the medial wire. The key point is that when you are in theater, you consider the risk of the injury to the older nerve. You try and learn from your consult of whining during what they're doing on. Do you use a technique when you develop seniority that you're comfortable with for reference? I am not yet comfortable doing this at all without supervision on, and I will do what the bones tells me. But as you're going through your training, you poor thing is to start trying to recognize why they're doing what they're doing on the anatomy of why you doing what you're doing. And then hopefully we'll be able to do it. Eso The last case is a a fibroid pediatric hip on down to the last child that was a tiny baby with a pyrexia. This is a happy child who's actually all of a sudden now complaining of hip pain. They don't always look like this. But the common example Ara is it. It's It's always in a beast. 12 year old boy every time. Okay, you called. Review a 12 year old boy. Need it filled. So you told us. What painful. Let me have you gotten antalgic Gates. So an intelligent gait is simply a poster for hobbling along and pain Kid is a fever, and there's no other change to his new score or parameters. Um, so we've done the approach, the patient's death. We know that we're gonna have a high suspicion for any I we're going to do a systematic approach with an 18 less approach. Examine the joint above and below. So I want to ask you what your differentials are for a kind of itches presented with remember, left knee pain. Eso Mary said Soof onda uh, Ellner. So all of them are saying, understand the disease, uh, slipped up a femoral advice is, except for more of the prices. So three of them Yeah, So remember you presented with need A we might also have many problems with anybody or any differentials to me. Is the whole knee problems you have? Somebody said, Can it also be growing pains? Yep. Where is it? Could be anything. Um, I'm particularly one thing that's really important when you start. I'm not sure how senior, you are good guys because I can't see the chart. But when you start clocking in people, I'm looking after people independently. The trick is not to make assumptions. Now I have given you a picture off the typical her these Sufi patient. But when you're looking at people you must know, assume that what's come before you is correct. You know, I have seen patients who have been admitted with a gastritis on the medical war. Two ended up having pancreatic obstruction secondary to a malignancy who have ended up going for gastric bypass procedures. You know, people who present with something written down by somebody else, or or with a preconceived you in mind, you must cast your net wider. It may be the fact that this is trauma. It may be that actually has gotten any pain secondary to nonaccidental injury, and I'll be back in all about in my big. It could be that he's got a infection of the joint, which is grumbled along insidiously, and he's not yet Rexall, but he certainly got some osteomyelitis picture going on. It could be a tumor off the boat. I have picked up tumors and kids even working six months in l G I. It could be also good flatter syndrome. Could be patella tendonitis. It could be protected families syndrome. Could be fat pants syndrome. Could be a spontaneous hemarthrosis because they've got an undiagnosed hematological disorder. Castro mind wide is a infection. Is it? Tumor is a trauma. Is it other? If you try and keep those things in mind, you're you're not likely to go wrong anyways, right? So we've got some sensible differentials now. My next question is you do some blood because you were suspicious about septic arthritis on a CRP and is why it's kind of both normal. And you examined his knee on you've done the flexion extension you tested for his ACL PCL with your bacteria posterior draw test. You apply Paris and I'll get stressed to the knee looking for any deficiency. The video, a lateral collateral ligaments. You've also been super super cruel and goes or it's just been this guy using a McMurray test anyways, all that's completely normal on this plane lethal was assuring anything. So what you gonna do that? So we have examined the joints above and below. Really? Genuinely. No, that's not excellent. So you examine his hit on? Um, yes, it's history. History as well as well is examining the hip. Did anyone remember what I said is worth examining earlier? All somebody said spine by examining spine and check your gait. Well, don't cool, right? I've done that. We've done a full history on da, uh, with some of the hip and we think the hips of it. Dickie. So we've got some plain hip pills. So what does that show so stuffy? Somebody said, Sandra says with my right ovary happy. What? Must, like force quit? Yeah, dear, just give. This is so yes. Sorry. I know you guys can't see anything. Dominic just had some technical issues with his now, but he's just telling me that it's going to take him a minute or two, and he'll be back on with us. So apologies, but just please bear with us for for a minute or two. Hello, Dona. You're back on stage. No, I can't hear you, but I can see you so I can also see your slides. Oh, I cannot hear you. However, maybe you can try leaving the you call. Leave the cooler. Coming back to be, like here. If you press on the Reds and brought in there and just try and join again. No, it's not working yet. Damn, I can, you know. You know, I don't yet. Okay? Okay. No, just I've got I've got the boss on the phone and on the screen. So when somebody time once again, if you can hear me now on this if you stuck around to the last minute, all right, you can. Okay, They're gonna have to make you this. Okay. Uh, Grant? So I suppose I could just ask what I'll flip between the two. All right. Cool. I'm I'm gonna hang up on, you know. Uh, okay. Right. So, uh, did we have any again? Thanks. Thanks for waiting. Uh, sorry I kicked me out the chat, right. Do do we know what? Sorry. I kicked me out the chat, right. Do do we know what. So I am Pretty goes lost only even as back, right Should be fine with the final time. Um, can anyone should be fun time? Cool. Thank you for being with the I T issues. Okay, So can anyone tell me what this X ray now shows ms AP view of the pelvis? I promise we're gonna get through these cases really quick. One life can see the slides off goodness sake. And you see this? No quality. Right? Okay. Can anyone tell me what this X ray shows? Now, if you can all see it. Thank you. Yeah. Excellent. So this is a It's a slipped upper family purposes, So I realize that the actually is not the best one to see. So if you look at a little bit closer here on this AP view, so the only one actually suggest to me that this was a fracture line. However, if it matches on both sides exactly, it's probably less likely to be a fracture. Well, that's bad for 10 minutes or less. Like to be a fracture. Potentially more like to be a growth plate. So when you're looking at dysplasia, the question is whether or not the actual head of the femur is well within the socket on, as you can see on both sides that it looks like there was nestled in quite snugly. But this epifix is here. It doesn't quite match up on both sides, and hopefully I'll be able to show you a couple of tips for picking up in a second. Um, Jake, this is a different actually from a different patient for a different condition. Did anyone tell me what this X ray shows? Sanders slashing again? Yes. So this is a patient who is presented with bilateral, uh, Perth's disease. All right, for a bonus point show off. What stage is it now? It's all right. It's really cool question. Right? Okay. So slipped up a family picks ist so, uh, essentially, it's a It's a condition. Where, as it sounds, you've got the head of the femur. Uh, you got the proximal bit of the femur here with the counters. And in between two, you've got the purposes of this bit end here where the growth plate lives on. Essentially what happened is the ball of slipped down off the head of the femur into the joint on, Do no longer have a congruence or that the tap assist of the boat on the attack. Attaching to this this growth plates here. And when you're thinking about fixing Sufis, it's essentially they're they're, well, they're really quite controversial. Topic, um, not going too much detail into it. The main point of detail regarding a slipped up a family, Pepsis is looking at stabilizing the hip joint itself and minimizing the risk of any further slips of the hip on. Really, it's that discretion off the consulting surgeon as to all timing of the surgery should be whether attempted reduction is needed or whether they think that's going to likely impede any potential efficacy of blood supply. That remains, if there's any cortical contact left. Much the same way is when we see individuals with young hip fracture on the going fixation to attempt to spare the family head, which should be done on a consultant operating list with a dedicated hip surgeon. So that is done perfect first time. Similarly, if you see somebody with a slipped up a family purpose ist, the key point is, don't start wiggling around the lake too much. Keep them non weight bearing, so they're not doing any weight through the effect of joint. You don't necessarily need to immobilize them, but it's worth quantifying what the mobility states that the patient is some classifications distance for Sit up a family. Pepsis looks so that that's a clinical perspective. So I think the Lord L Classifications looked at where the patient is. Ambulance or not on other ones, look very specifically at angles are in the hip. You can look at things like the line of Kline, which draws through the lateral aspect here off, not latches, for the superior aspect of the family that can see whether that comes down and intersex as it should. Or you can look at frogslegs use at the same time. I can go and see if there's been collapsed. You can read about them your time if you want to be a bit with this group of this talk, But when they're gone to managing these patients opportunity again, it's controversial. It may be the case that you need to add in things like a femoral neck osteotomy, so taking chunks of cutting out the bone or to change the angle of the bone in order to change of the line of force. Going through it and then applying additional screws on it may be the case that surgeon things. It's worthwhile doing a prophylactic fixation on the other side. No, every surgeon does this. It's the same thing when you explore testies, torch it. Often they will put a stitch in a day other side so that you prevent washing of the other side. But no every several profilactically x thea other side. If there's no suggestion that there will be a slip on the other side, all right, so you want to mark them. You want to consent them. You want to keep them nonweightbearing for a prophylactic fixation on suggested them that it will be in the consultant discretion. But you just want to make sure that they was ready. You know it's possible now. The other hand persisted is EAS uh really describes a condition where you have got a vascular necrosis or the femoral head on. What you eventually see is a weakening and flattening of the family head as it sits well with the socket on, it goes through a number of stages, essentially on the vast majority of management for perfect disease is is conservative initially in the first stage. What you see is that the severity of the AVS on the time of progress alters the blood supply, leading to progressive erosion on fragmentation off the femoral head on, provided you are able to manage things appropriately with physical therapy, with conservative management strategies to keep the hip Norway bear and keep it and join to keep that contact, you may actually be able to induce spontaneous healing in that without any need for Optivite prevention. And as time progresses and the with the family neck increases, what happens is the femoral neck itself you can see here happens out in order to try and support the weight very aspect of the joint, better as your cortical contacts from the head itself. In the Joint Producers, the main part about management process ease is again. It is highly controversial on it is super complex, depending on what stage you get it. Now you've got these all time in textbooks which give you examples of prophylactic measures to try and manage these patients where you've got traction on suspension of the leg and or two try and actually pull the joint there up into the actual as a tablet of in order to try and increase that contacted, the family had strategies to keep their their legs in towed in order to try and again internally rotate help so that you juice the space in the palace and increase again the contact with family head and sometimes that doesn't work. Now, if you were looking at managing these operatively, you're well within the realm of specialist orthopedic consult territory. But it is worth pointing out some principles which you may find interesting. Certainly this sort of the less invasive type approaches with osteotomy zork, attention fixations. And you hear you have a variety of screws which is being used to hold the osteotomy in place, and you can see that there's little rings around these screws here. The reason that those have done is to try and stop the counter, sink the screws into the bone itself and give a little bit more contact. What for that? But if that doesn't work, you don't need to go for much, much more extreme measures. Where you've gotta go for acetabuloplasty often is where you can see these screws come in here to all the acid, have a place you can end up need to do further controlled breaks of the hip in order to try and rebuild it with plates and screws and hold it in place on I've seen in any rare number of cases and again I want to hear. But individuals who are in their late twenties early thirties with some bad, intractable hip pain that they're coming in for a hip resurfacing procedures where you essentially shave down the acid tablet to try and open that set of seems down or, um, sort of the minimally invasive femoral head replacement type. Things are going for a total hip arthroplasty with circles, wires and want to try the whole back place. So it really was the whole spectrum of management. But the key point is that the majority that's conservative on depending on the patient's symptoms, you may want to admit them anyway. Teo, make sure that they follow up, probably by the pediatric specialist and expect plan, particularly if they are looking at those they're coming through at one of these much, much later stages. But individuals with some hip pain settling down. Uh, you know, you may you may think it's worth, uh, discharge. Um, but again, I'd caution against it simply because of the coming in to get my weight very. They could start getting appropriate. Physical therapy plan won't be accused. Causing any further damage like that is our eyes. Now it's I've taken up enough time of everyone's again. I'm offering the floor questions. If anybody has any. Oh, I will take. Think you? That's why we have that. That's more question, but that's fine walking. Verify. My can't put anything in the chest a lot of complex. So I thank you for the feedback. Sure for anything to add, you can either put speak again. You know, I was watching for that slide of my email address. Yes, I'll keep on email address and screen. First time you want to take a stance if anybody is at the stage where they're thinking about a career in orthopedics and they want to ask any questions if anybody is thinking about tips and tricks for course surgical training on looking at getting into that or the evening questions about that recording process or getting involved with hives and prepare yourself for that later on down the line. Hips and tricks. If anybody needs anything for the MRI C s. I'm happy to discuss that. If anybody is thinking about playing for things like the academic foundation program, Uh, I also Nash to do that success of those interviews as well. So if anybody's at that stage is Well, um or how did you ask him off of that as well? Um, so, yeah, if you get my inbox, I'll do my best to apply. I can. Who? I thank you very much. Don't. That was over three. The interesting talk. Uh uh. If somebody has any questions like I was saying myself twice, I mean, at least the heart issues we just started that because I can hear myself three times. I don't know what's the problem. Ah, but thank you very much, everybody for being with us today, especially those who were all the way till the end. We've sent the feet book for, uh, just make sure to fill it in and get your certificates immediately on. Thank you very much for your time. I know it was like two hours of your time, so thank you. very much for most of that was I t in my defense. So Grant, you know. Thanks, guys. Okay, it was I t There was a lot of, uh I mean, we usually have I th use. Yeah, but