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A distal tibial fracture. So I'm going to give her a really quick uh whistle stop to through um the uh pfizer which um and it assures me is back to medical school. So lots of vices. So we have uh the physis which sits between epiphysis and the metaphysis. Of course, what you have is the epiphysis. And then you've got the little resting zone, your resting zone is where your prodigy cells are. So that's really where it's all at. That's the most important part of EIS. Um just underneath that is your proliferative zone. So there's lots of, lots of them. Um and then it becomes hypertrophic. So you have the cells which are sort of bigger baggier, they're starting to become larger. Um And uh your hypertrophic zone is where, where your fractures occur because they, because they're baggier, it's the uh there's much more um risk of uh fractures running through them because they're just not as stuck. And also just underneath, you've got your primary and secondary spongiosis or your zone of endochondral ossification. So you've got the sort of harder surface and then the softer bit, which is your um which is your hypertrophic zone. Ok. So that's hopefully stuff that everyone is aware of. So this 14 year old has twisted her ankle and she's sustained an injury. Can somebody tell me what injury and what sort of terrorist classification it is? T fracture? So, three. Very good. So what's at fracture? So on. So, t fracture is a uh is a free free fracture, which is, are you cooking? No, I'm having a bit of lunch pots and pans and no, no, just a bit of a salt free factor, which is characteristic of, of late adolescence and Children um which occurs due to differential closure of the distal tibial. So you tend to get a fracture near the lateral portion of your distal. Yeah. So, and you can see it really nicely there. Can't you, it's the antra lateral portion. So if you're looking at that ap uh tibia, you can see where the split is. And then if you look at the lateral, do you see how that piece of the fuss sort of spat out? So that's displaced. This was actually missed by ad it was um the patient had to be recalled um because it was picked up. Um So, yeah, it's a Salta Harris free fracture. So it's running through that hypertrophic zone. I hope you guys all appreciate my artwork, by the way, uh free or hypertrophic zone and then it's coming up and through the epiphysis. So, what's the, what's the issue when you ha are going through that resting zone. Anybody else? Great arrest. Yeah. And why is, why, what issue might, well, why is that not, maybe so much of an issue in a, in a tile fracture. Well, not so much of an issue because the, it, it's a fracture that only occurs when you've got closing PS Yeah, exactly. So, it's a transition fracture, isn't it? So, um, so what happens and sorry, you can see it there. So do you see this just as an an lateral segment is, is what's left? And so what, what happens with your piss is your um as you as you're getting close to fusion. So this is a, this is an example of a girl's fiss. Um So you can see that you're starting to get pal closure and it starts on sort of medial side and then it starts spreading and it comes around posteriorly and then comes into the, an anterior segment, an interlateral segment. Um And so that's why, so that's the sort of strongest bit that's left. And you've got, of course, the ligamentous attachments just on the front there and all of that results in um when you're, if you're going to break that, you break with that, that uh piece of um of the uh vasser, it's, it's this sort of weak link as it were. Um So, yeah, so you can treat them with just uh you want to do an open reduction because of course, it's eight is a intra articular fracture. So you want that, um, articular surface be align and then you can put a screw across and for those you're not worrying about, oh, have I crossed the fiscus? Because actually the piss is toast anyway, because it's in the process of fusing. So you don't have to worry about all those other factors which, um, which we'll see in the, uh, in the other cases. Good. OK. Um So, um this is a child who's twisted their ankle and they're tender on the later side, specifically over the distal fibula, the lateral doesn't give you anything. It's the same. So just looks a little bit wider. It's a little bit questionable, but this was reported as a, so Harris, one of the distal Fibria, I've got to say um there are a lot of things that are reported as terri ones of the distal fibrillar and actually the child doesn't tend to there at all. But um but yeah, so, so Harris one that's literally just for your hypertrophic zone. So you don't see anything on X ray and the one that you'll come across far more commonly, um which will be a problem will be your uh slips because they're also occurring through that um uh that uh hypertrophic zone good. OK. Um And then we've got this uh chart I'm giving you the CT of the X ray this child. OK. So, for fracture. Yeah. So someone saying trip. That is beautifully saying, I tried a um A four which is exactly what I want from you, which is all in one picture it showing you going through the pfizer. It's not classic for a um trip. I show you a more classic trip planner. So a slightly more classic triplanar um is the um is on the AP you can see this lovely um splitter across and then on the lateral which apparently I haven't uploaded. Uh But you've got act scan, you, you see a PSTA Harris two fracture. So AP looks like three. a the lateral looks like a two and therefore, it must be a Salta Harris four. So your triplanar is a really sort of jigsaw puzzle um type of fracture. And if you guys ever do the a a course, um it's uh we actually do it on the SOR bones because if you make the fracture, you sort of, it sort of slightly makes more um more sense when you're doing it. But in essence, you've got this split running through that, then um goes round to then becoming a posterior aspect piece. So, so it is a, a chunk of bone, you can sort of see it there. So on that medial side, you've got this chunk um that then comes up and is attached to the shaft as well. Um And so with these fractures, so how do you, how might you go about treating? So, for example, for this one. What what might you guys think about doing for it? So I think uh to, to treat this uh you, I mean, attempting a closed reduction is not going to to be used for. You need an open reduction because the the soft tissue uh uh interposition between the fracture fragments, you need to realign the facial plate and you need to fix the mesial fragment. So I think conduction internal fixation for this child. Yeah, it's a difficult one because actually I would just generally and this was actually the CT was post reduction actually. So I don't II think it's perfectly reasonable to try and reduce them. But if you've got like you had on the original picture, fairly clear gapping and that um and you see um in the joint surface, you'd certainly be worried that there's going to be a displacement and that's, the CT has really confirmed that hasn't it? Um So yeah, so you're going to be wanting to think about and you've now got a displaced fracture which is intraarticular. So you're gonna be wanting to think about how you're going to um how you're going to fix it. Now, what sort of fixation are you going to do? So you can open, open, reduce it, you can do an anterior incision to just make sure you close that, that gap at the front there. How are you gonna fix it? Um So for the, if you fracture, you could reduce them. Absolutely. Um If you get a good anatomic reduction, you could put a partially threaded screw to um to close that fracture which provide compression and absent stability. And then the other fragment, you could use an ap to posterior screws to um to close the, close to reduce and um secure the large fragments fine. And so does the piss matter in these fractures? Is it is um is the, this a fracture of um of uh just like the t uh transitional? Yes. Yes. As in the pus doesn't matter. She didn't like that answer. Mhm Miss Chase if you're talking, I can't hear you just really gone down. Hold on. Are we all good? I think I've upset Miss Chase with my I think Miss Chase is just disconnected. Oh man, Sylvester. Ok. Yeah, I can hear muttering in the battery. We're all in the kids clinic here. See, see. So uh I'll show you what's going on, right? I'm here. Uh There's Joe and Vicky M seeing. Uh and then yeah, sorry, my internet went down, right? Give me two seconds. I'm just reloading my sl sorry guys, talk among yourselves. I just said, I think my answer was so bad that you got upset and turn it laugh, just laugh. So guys, sorry you were telling me is a triplanar a transitional fracture. Yes. N no, maybe, maybe, maybe. Yeah. So, no, no. So it's really interesting. So traditionally it's suddenly been considered a transitional fracture and therefore, you know, that whole, do we need to make sure our screws don't cross the US when we're fixing it. But, um, but they, you do see younger trip, you see Children who are, who are still growing, um, who aren't in the process of fusing. And actually there was a paper published, um, I think it was two months ago, uh, bone and joint, I think, um, just recently, which, um, they did quite a nice review where they looked at it and actually found in a second, I will show you some pictures from it, which actually found that there was no difference between those young Children who were nowhere near the pfizer closing and those who were in the process of their Pfizer closing with regards to fracture pattern for triplanar. So triplanar is an entity of itself. It's not dependent on whether they're, um, they're transitioning to, uh to fusing or not. Right. OK. We're gonna plow through this, sorry, sorry, sorry. There we go. Right. OK. Um So, yeah, you can fix that and we will talk about. There we go. Um, aacs, I thought this was quite a nice picture because it shows that sort of jigsaw puzzle piece with the piece of metaphasis as well as the piece of the, er, phys. Um And yeah, and so you're going to keep your fixation within that, either the Pfizer or the metastasis exactly as uh Sylvester described to us and it's an intraarticular fracture. So you want to make sure it's reduced. So if it's beautifully reduced, you can do it percutaneously. But the majority of the time you want to see that joint line and see that it's nicely reduced. And this is from that paper that I mentioned, which um demonstrated that it, considering whether they, the pink was partially closing and blue was the PFI was fully open. The fracture lines are still in that Y shape which is a classical triplanar fracture pattern, which classical one that I just showed you good. So they say it and there's no difference to uh age v maturity, right? OK. So um that injury please anyone that sort of Harris three fracture of the distal uh tibia with a uh do you mean three? She says loaded question, sorry, two, sorry. Two, right? Yeah. OK. For, for the metastasis. Exactly. Yeah, and it's displaced, isn't it? And I mean you see these fairly frequently and you try to reduce the line. So it's all two fracture. Um And um for this particular child, they were seen they um they had a um an open reduction and then they had a screw popped in and then this is their follow up picture uh at about three months, I think. Yeah. So um it looks like the uh growth plate is the f is fused on the medial. Yeah. And just like we just like we saw with that um distal femur, what might be the issue if you've got, um if you've got fusion deformity of the, but this is a, this is a, oh, sorry, sorry. No, no, I said distal, I said ankle but I meant distal tibia. Yeah. Um So yes, you'd worry that if that medial side is stopping growing, the lateral side is going to continue to grow and that heel is going to tip into varus, isn't it? Um And for these Children, uh this can be quite a significant injury but why is, why have they got a bar and they did have a bar? This is so two, so two are just through the um zone and then heading down the Metas, they shouldn't be causing this and you can see it's quite a very large bar this kid had. So why has that occurred? Is this because you come in and get the periosteum going into that? Well, actually, I mean, in that particular child's case, they had the periosteum taken taken out. But actually there is a paper that says it makes no difference whether you leave the periosteum in or, or take it out as to the rate of f arrest. So we don't really know, it doesn't really follow the sort of traditional argument that IP two. Therefore, the PFI will be absolutely fine. There probably is more injury to uh to that um uh to the phy than we're aware of and the Salta. Um And So for this particular child, I actually stopped his fibula growing and completed the um the physeal um fusion. Um so that he wouldn't develop um an angular deformity to his ankle because he had another few years left of growth. Did you do the same for the contralateral ankle at the same time or for this lad? Because he had, he had um he was only 12. So, um I was worried that he would have a clinically significant leg leg discrepancy. Although you could certainly argue either way, given the fact your distal tibia or you're only getting a few millimeters of growth. Yeah. So you're not looking at significant differences. Whereas if you're a distal femur, that'd be much more significant good. So cell tariff too. So there's actually quite a large, there was a recent paper a few years ago which said that the pal fusion rate in distal tibial fractures ran from uh 12% all the way to uh 42%. However, they said the Salter Harris, I has about a 12% by cell fusion rate. And this was a sort of systematic review of the various papers that are there. And there is no difference if the persin is removed. What they did find though is if the patient had had more than two manipulations or if it was a delayed process for um for the uh reduction, then that increase her risk of five cle fusion. So it makes sense, doesn't it? And it just suggests if you've got a child, don't keep re manipulating, um, a five seal injury, you know, do, do it once and do it properly or don't do it at all if you think they're going to remodel. Um, and then, uh, this was my, my version of veal Terris five. It was one where they distal tibia and sort of squashed. Um So in conclusion, counsel your patients and parents appropriately. So if you've got a distal tibial fracture, you need to be warning about fascial um arrest, there is some remodeling that can occur in young patients and there's a trial going out on at the moment in the UK or just starting called O SOS where they're actually looking at distal tibial um fractures about whether these can be managed conservatively or not. Um You want to make sure that if you've got a fascial injury that you follow them up. So you need to see an X ray at at least uh six months to 12 months to see if there's any evidence of uh fal arrest because you want to be getting in there before they've actually developed a deformity and if it starts healing, leave it. So if it's over a couple of weeks, you really shouldn't be playing with it. Um And um you can consider a PSIS but do think about limb length discrepancy good. So I'll stop at that point, right? Um Anish is going to be teaching us on four.