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To hear him from the other room. Yeah, it's recording. Ok. So femoral fractures, they, they make up um about 1 to 2% of childhood fractures. Of course, you know, the upper limb, we see a lot more of um and um and about a third occur under the age of six years. Um and she is going to be talking to us about uh N A. So I won't go into it too much, but just to highlight that um femoral fracture is definitely high risk for um being non accidental injury um in Children under 12 months. So it's something that you need to be thinking about from femoral fractures just generally, um tend to occur in a bimodal distribution. So you see see toddlers and then you see older Children who are doing the higher energy um injuries, non injury is definitely a thing. So, um what's the etiology? Well, generally it's trauma, we've got to think about non accidental injury, but then you have to think of the other things that can occur. So things such as Sygen effector ie that they've got brittle bones, so they're just more likely to fracture um osteopenia. So I see that a lot more in my neuro kids, um, with the, uh, the nonambulatory Children tend to have weaker bones. And so more likely to say in these, uh, fractures actually really innocuously. And then of course, uh, nasty things like bone tumors. So, femoral fractures, I quite like this as a sort of descriptor of vaguely what to do about them. So, if they're less than six months, you can put them in a harness. If they're at less than 18 months, you could treat them in gallows traction or, um, one year to five years, you could treat them in hip FICA. Um And then, uh, and then you've got some in meu options such as tens now or if they're bigger lateral entry. Now, all you can do is have a painting. So we're going to sort of talk through those things. So, um, what are the implications of, of having had a femoral shall fracture? Well, um, having had one means that you're likely to end up with some sort of leg length discrepancy. Um, so, but just under centimeters is sort of predicted. And that's from, um, about a 45 year old, um, paper. Um, and, um, and you do have to worry about rotational malalignment. Now, that's much more of an issue in older Children than younger with regards to, um, degree of remodeling. But as we know, um, rotation doesn't remodel nicely. So this is a 56 day old baby. Uh Can people tell me what they would do for this child, open reduction, internal fixation? I mean, obviously nail plate, plate, plate and screws. It needs to uh I can get leg screws, you could do some sort of combo. Um Yeah, anyone else, it's definitely something that I have my head as well just to make sure that your, it's like a um I was got um so uh it's a spinal fracture of the proximal third diaphysis into the metaphysis of the uh left femur this 56 day old. So I'd want to know a bit more about the mechanism of injury, um especially as, as you mentioned, non accidental injury, um all the other injuries around the body. Um but in terms of management of the fracture itself. Yeah, manage it in a pelvic part. Yeah, absolutely. And p harness does absolutely not nothing to stop the bones moving. So it can seem quite barbaric there kids. Uh those of you who have seen II think I've got a picture of harness, um the Children that kick their legs. Um And so it really does seem to be the um sort of uh just a terrible idea regards to holding a bone still, but it provides enough sort of pain control and being able to handle the child so you can lift that baby up. Um And that leg is supported as opposed to if you, if you sort of left them floppy and that leg is bending in the wind and actually that's quite horrible for the parents but particularly horrible for the child. Um, I read somewhere that less than 30 degree angulation, although that's a bit questionable because I'm sure you get more than 30 degree angulation in your fractures. By the time you've jammed it into ap harness. But you're only going to do that in the very little ones, aren't you? Um, so, uh, this one was treated in Han, um big fluffy cloud of callus. Um And then actually within, I think it was only about four months or so, they'd already remodeling nicely and, and healed beautifully. So, uh you know, these little people do incredibly well good. Ok. Um So we call G traction is another option for our little. So, um you want to be using that on Children who are not particularly heavy. So they say up to 15 kg, but really sort of once you're over a year, you're probably not going to be utilizing that. And I don't know if you guys have seen a G, it's like the picture up on the board there. It is, um uh literally hanging a child from their legs and you either put weights on the end or actually you just use the gravity so you tie them over a little swan neck device there on the bed. Um There's pluses to it and the fact that um it's keeping uh the um the child sort of in a little bit of traction. It's hold, it's reasonable pain control and, um, and they heal fairly quickly the way you do. You, you do. Exactly. Is that that long piece of skin traction? Uh, you have to use the tape, skin traction for it. Um, and then what you're doing is you're tying them so that their bum is just slightly off the bed. So it's just, the sacrum is just sitting off the bed so you can pass a hand underneath it, but you've not slung them all the way up so that you're not sort of, you know, half the body is off. It's literally just, just lifting the pelvis up. Um And what you'll find is as they get more comfortable, you'll start seeing when the things are better because the child will start bringing, kicking that, that leg. I've only had one major fail with the gallows and that was in a child who had a sensory level of their abdomen. And so I put them in gallows to, uh, to treat their femoral fracture and they were swinging off their legs. So that wasn't ideal. Um, so I thought he had something we got the hip. Um Right. So, and then there's other, there are other forms of traction. So in the older Children, you can be, you can consider to sort of stand skin traction because just like the gallows with the gallows you're looking at depending on the age of the child a couple of weeks and, um, traction, then they're healed in an older child. You could also treat them in traction. It's a very well, well, drug path. The reality is the majority of people won't want to spend 25 days in hospital for their child to have, uh, skin traction to treat their femoral fraction. And also we're possibly not as good as we used to be with managing traction because it's not used so much. So, things like pressure sores can be a real issue. Ok, so we've got a three year old now who's got, um, got this injury. Can somebody else come up? Hello. I think this is a complex fracture. Yeah. Yes. Carry on and this is a complex fracture with any, the internal fixation. Uh Yes, I need at least uh uh three weeks or 21 day, the rest and the cast after uh both operation. Yeah. So what did you say you're doing internal fixation or you're just putting a cast on? Uh, I will do the internal fixation, blood for the cast and the internal fixation and the cast. Ok, cool. All right. And what internal fixation are you planning? Uh, as near as possible? Sorry, as soon as possible. I will put it in my or I will uh, do it this operation because it's big. But, ok. So what, um, the main thing with three year olds just like you saw with that, um, with that, uh, little baby who's only a few, couple of months old, um, is that they actually have a really good ability to, um, straighten if you've got, um, if you've got fractures or if you've got, um, uh, some sort of, um, gapping or slight angulation. So, for this child, we actually treat them in a different way. Does anybody else have a, so, so rather than do internal fixation, does anybody else have an idea? Hi, Miss Chase. I put in a hip spiker. Yeah. Excellent. Ok. Yeah, that's also so I think, I think that was a mass um plan as well was to put some metal work as well as a hip spiker. Um But yeah, I'd probably just go go the hip biker actually. So hip spikers are like a pair of plaster trousers. Um There's different options, a single leg spiker or something that hasn't quite been sold enough to me yet. But um uh some of my colleagues are very enthusiastic about and um and then uh one leg or, or uh two leg spikers. Um and uh it's quite a simple um technique. You just need a spiker table of some description which the majority of hospitals have, some people have them. Um II and some cast plaster cast. Um and there's a really good youtube video that the lovely Mr from um Broomfield will um will tell you the single spiker I will point out that so from an evidence point of view. Um If you're going to put them in a single leg, walking spiker, you are going to be expecting about a quarter of them will require wedging because you get some displacement of the pressure. But if we look at this child, so they just got a standard spike. Me fairly displaced looks a bit rubbish. It's not that reduction. Um that the matter was, was suggesting. Um but actually within six months, um that child had healed and straightened out because little people are really, really good at remodeling. So actually, we don't need to decorate things with me work. We don't need to do um perfect reductions because actually, um these Children will heal and remodel really, really well. So it's just something to be aware of when we're, when we're treating these um these little people's um uh femoral fracture and then we moved to a little bit older. So a seven year old, um I think she was on a rope swing and she uh sustained this fracture. Can I have some suggestions? Are we gonna put her on the spiker? I think maybe tens nails for her would be suitable. Yeah, she's got so tens nails are flexible nails. Um I completely agree. So, um the uh the nails are going to be wanting to get um fit in the is so they're not uh tens are not great for um really um metaphyseal fractures. Um But they're, they're very good on diaphyseal fractures because it sort of filled the canal. So, um that's what she, she did get. And I could certainly cause for how much bend I've lost at the top there. So they should tip over a little bit. But as you can see, fill in the canal, so you're aiming for 80% of the canal filled. Um And you get a really lovely reduction with them. Um They're not necessarily particularly rotationally stable having 10 snails. It depends on how much you manage to dig the um that tends into the um uh at the other end of the fracture. Um But actually, as long as you've got a good spread across the fracture site, then actually, you don't need to put these Children in cast and that's definitely a bonus and we probably are doing some more younger Children. So certainly I know Anish will, um a four year old will get 10 tails with his hands and I've, I've certainly been convinced to do that. Um And I think uh just recently, one of my colleagues did a well, but that was a slightly different fracture. So they, it is um it is there is definite benefit to not having to have them in plaster good. Um So you need uh to aim for 80% of your canal, you're going to be putting your entry points above the puss and you're gonna bend your nails three times a diameter of the bone in order that you create that sort of force which sort of brings the nails out. So it pushes against the bone and holds it in a good position. Um You can use something called naps. I don't know if you guys are familiar with naps, but in essence, they are um where you screw them into the bottom of the bone and they stop the nails falling back out again. Um Very early on as a consultant, I did a femur, which was slightly segmental and about a week or two later, um the uh child was seen because the nails had um was starting to try to poke through the skin because the fracture had collapsed a bit. And um the tens nails had um come out uh distally. So, um if I'd put NCAP in, that would have helped prevent that happening. So it helps with a less stable um fractures. And, and she's asking how many people have used encap s for elastic nails. This is the first time I've even heard of naps. Real. Oh. And can you source a picture of an ncap? I haven't gone on my presentation just so the guys can see it. They look like um like little metal wedge, but they are essentially just cats with a screw on them. You do have to be aware, you can shred the skin horribly with them. So you do have to make sure you leave the skin um open. But um the majority of people. So 88 84% have not used any cats. Um So yeah, we, we will, by the, by the end of my presentation have sourced a picture of N cat. So you guys can see that. So that, that is useful. If you've got one that's potentially unstable is gonna be sing down to help um uh support, then we, we've got another child. This one's seven. This one's actually, I think uh I think this was one of your kids. Um I can't remember how they did it anyway. We'll go with Mo Motocross. Let's see how it heals and then we can decide it was a really bad. Sorry. S ave go ahead. Sorry, I've just joined. Oh OK. You're just coming to say hello. Sorry. No, no, I do. I think I'm in the wrong area. Seven year old with a femoral fracture. OK. So I've just joined. I was, I was just literally tell me the fixation that you would do. Would you put them in a spiker? Would you put them on traction? Would you do something surgical? 07 year old. What was the age? Sorry? Seven year old boy. 07 year old boy with a uh femur fracture. Um isolated vly intact. Uh I Yeah, yeah, they're absolutely fine. So literally just a fixation. Don't worry about anything else. Um For this. I'm just trying to see if it's going to open. Um um seven year old. Yeah. Yeah, seven year old. Um, I would use, um, elastic, um, elastic Ns. Yeah, you certainly could. The only problem with it is it's a little bit close to the metaphysis. So, whether you'd get a really good hold with your, um, with your 10 snails. So, in this case, um, uh, and put a plate on, um, so you submuscular plating is also an option, I suppose, is, um, is a, and that's the reality for actually along the age groups. Not really that you do spike it. But, um, if you look where the fracture is, I do wonder whether you'd be able to hold it sufficiently with the tens now. Ok. Yeah. No, absolutely. It's, it's definitely an option for people to tell it. So, um, you can do femoral shaft plating. So, submuscular uh plating, minimally invasive. So, if you do an open plating, it's uh you get significantly more blood loss has been shown. But actually it's a, it's a shorter, um, it is a shorter operation. Submuscular plating has longer operative time than 10 snails, which I found really interesting. That was from one of the papers I've quoted on the bottom there. Um, but I sort of understand because actually it's a bit of a fiddle. You get this idea, you're going to just slide the plate down and it then attaches the bone really beautifully. But there's often a lot more involved than that, certainly in my hands. Um, but it, uh useful for length, unstable or particularly comminuted or as I say, it, s like more um more metaphyseal fractures. Good. OK. Oh That's not come through. Well, I was going to show you a um a mi fracture in a 11 year old. What the, what technique shall we do to fix? So this is, so this is a um lac entry now. Thanks Tom. Um this is a lateral, so a lot has come back into vogue. So there was a whole thing of you can't put um uh intramedullary nails through um for the first, you can affect the uh the blood supply and you'll give AVN to um the um and you'll give AVN to the child. Um Sorry, just really quickly, Maddie was just asking. So, Maddie, that particular um plate was a um pediatrics, pediatric proximal femoral plate. But actually a lot of the time you can just use the generic um uh plating system. So usually the 3.5 not the 4.5 but um you can use the, the standard plates. So this is a specific nail for Children. So there's the, there is different options. So there's like the peddy nail um or um well, PNP or there's um Ortho fix, have a nail or there's a la entry nail from Smith nephew. So there's loads of different options. Um and um the nail, the benefit to it is that you are um fixing fracture in such a way that just like with an adult she fracture that you can then get the weight bearing immediately. Um So there was quite a nice paper from the US where they talked about the fact that you can, um you can actually go down to eight or nine using these nails and with a good effect. The only thing I will say, if you're planning on doing a pediatric femoral nailing, you want to get a, a canal size because they only go down to seven millimeters. So you need to um you need to get a sa sized film. So you're actually accurate with your sizing. So what you don't want to do is have a plan for a nail and then the canals too little, which is definitely a risk. So as I said, Lary nails useful for larger Children. There's a lot of debate about what age is two or how big is too big for tens nails. It used to be 50 kg that's gone up to. There's been some papers saying they do 10,080 kg. Um But it definitely the older Children, it's a, it's a very good option. Um But yeah, as I said, do make sure you're templating. Um So those are the sort of um a A Os and the American Society um got almost a decade ago, came up with um guidelines which II think still are fairly reasonable for now, which is, is exactly the ones I showed you at the beginning and then we've got um femoral neck fractures. So it's the uh um Gilbert sorry classification soy basis. And so, you know, just one more on, on what you'd be looking at for an adult and in essence, just like uh an adult. Um So this is a, I can't remember what they were at that time. Uh I'm gonna go with 13 year old um, car accident but you've done a, is an isolated injury who's taking that Simone? I have appeared on my screen. Go. Um Yeah. So um uh II treat this with a uh a compression screw that going basically distal to the FS. Um or can you make it bruise again? Just getting short of the? Yeah. So we do uh no, open this one will need an open reduction. So anterior approach, um angio approach, surgical dislocation um to ensure that you're protecting blood supply at the posterior aspect of the femoral neck. I'm not sure you meant surgical dislocation because the hip. So I'm just going through mode and just turning out. Yeah. No. Um a way of doing it though. I bring the shaft out, then I deliver the head. Yeah, I mean, it would make the fixation easier if you could just put the two out of the body, fix it and then pop them back in. Um uh But no, you're absolutely right. Just like you would do if you're young adults, you're going to be wanting to make sure that that's anatomical because what are you worried about for this patient? Uh So uh 8 a.m. is yeah, is concern. Yeah, definitely. Sorry. I ask the question of that. What I was gonna say something? Is this, is this the last X ray for this case or does it? No, there's one more but yeah, sorry. Carry on. What, what's the problem you guys would be a bit worried about if you look at that um reduction there. So to me, it looks a bit balance of rotations. Yeah, so, well, so you could say that there is a bit of valgus and there might be a little bit of malrotation. It can be really difficult to fix these. But so is valgus good or bad? Valgus is tends to be good, doesn't it? Yeah. So you definitely want to go valgus rather than be um sorry, he and carry on. No, what I was going to say. Sorry Simone you were saying and they, that's what they've done is try to not include the piss in it sometimes, especially if it's quite close to the piss, you're going to have to cross the piss with your fixation in order to actually get any sort of fixation. And so it's just something you have to be aware of. Um But um but no, that particular child um ended up with avascular necrosis. Um and that is unfortunately a complication to, to this um this really nasty injury. And so, you know, that that child will have done badly from this and probably need a hip replacement or have a hip replacement banner. Uh, so the only thing I was gonna say is the one controversy in this area is whether it's, uh, I think the vogue is to tend to use a locked device. Ok. So, rather than cannulated screws, actually, it would be better to put a locking plate on. Yeah, the worry that it's going to rotate. Yeah. Yeah, sorry. So similar to the um the one for previously the sort of osteotomy type plate. Yes. Yeah. Um So there are available the thing in a technical sense, just beware. Um Some of them don't have long enough screws. Yeah, that's true. But can I ask why do you think a locked device is better because we know that the cannulation configuration can sometimes does provide rotation stability depending on the configuration. Why do you think that a plate with a locked con with a locked screws is a better or is a better? Um I think it's essentially stability Sylvester. I think the problem with the three screws, especially in these younger people, I think, and I think even in some of, you know, people have, you know, the threshold for cannulated screws has become higher and higher, isn't it? But when you look at something like this, you're not going to get that good bone on bone contact necessarily. Whereas actually, if you've got a locked device because what you're not looking for is compression. Ok? You don't want anything to move once you've done your reduction and that's why the locked plate would be the best thing to actually hold it out to length and hold it in the correct place. Also, you've not got the best fixation, so you're not going into the head. So you've just got neck there. So it's not, there's gonna be more ability for that to move if it's going to. Ok. Um Right. Uh distal femoral fractures. Um So distal femur um produces 40% of your leg growth. Um It, the distal femur is a bit of a sod really, it's got um this sort of um undulating uh pisis which means that um it is much more likely to um have problems if there's an injury to it, of um of the fighters deciding to give up the ghost. Um And of course you can get uh ligamentous injuries as well. So this was a case that um that uh we dealt with uh fairly early on in my consultant career and um I uh this was your kid. Well, we didn't do that. No, no, no, we really didn't. So they'd, they'd gone skiing and the professor of um of uh the center that they were at as in abroad um did the, the best work and told them it was awesome and they arrived back and were fairly disbelieving when told that it wasn't quite as awesome as they, as they believed it to be. Um, but, uh, what would you guys do with that? So it's about a week and a half, two weeks, post, um, post injury. It's about a week and, yeah, so af after this fixation, so they've come back to the UK now they're, they're with you and they're saying this professor has done an awesome job, but our child's really sore. You guys need to sort them out or actually not even that just, you know, they're really sore. Ok. I mean, you could, you could revise it or you could potentially run with it. See how he's ho how old was he again? Uh, it says on there 1111. Ok. Ok. So he's got a lot of potential for remodeling overall. It's, it's straight and uh does not look particularly rotated on the X ray. So, do you think it's straight the cream if you look at the shaft? Uh-huh. And you look at the distal femoral joint line or the knee? Do you think they are straight? It's a bit of a loaded question. It a bit of, isn't it? Yeah, he's. Yeah. Yeah. And what's the other thing that you notice screw and external fixation if you understand my uh or my sound is clear. Your sound is clear. Yeah. Oh, yes. I think he need an external fixation. Uh, plus two or three screws. Yeah. So, and what about is there anything that worries you in the distal femur towards the joint? It looks like there's a split going down into the spondylar knot. So probably get a CT scan or yeah, a CT scan to confirm that. But you would want to anatomically reduce that um with a, with a plate. I think. So, I think uh Tom and um Marissa, I think we, we, we took a hybrid of your ideas really. So we're worried about the joint. So, uh and actually Kim, you know, so we're presenting this case at other meetings and other people have said, look, you could run with it and deal with it if it becomes an issue. So that's, this is, this is the problem we kind of face isn't that there's many ways of trying to deal with them. The concern we had was uh what if it starts to go wrong? What if there are bigger problems down the line? It, it's, it is malaligned, it doesn't look stable. Um And so yes, so do you wanna carry on? Sorry? No, that's all right. So, yeah, we got that intercondylar split and that's what it looked like on the lateral side. Um And then uh got that scan. Um And exactly as you guys noted on the x rays, uh decent size split heading downward. Um And so that child got some decoration of metalwork and, and realignment. So, um if I just go back um just with the you know, when we're talking about alignment wise, if you just look at the nails coming out. Um I don't think I can draw on these. Can I, is there a way of me drawing anybody any experience with this whole metal? I don't think you can. No. OK. All right. So we've interpreted dance. We even followed the sha down. It seems to come off slightly to the side which suggests that there is a little bit alignment. But the trouble is neither of the pictures I've shown, you have, have particularly shown alignment. Well, so, you know, you'd want to really assess that, that sort of long life for you. So, yeah, so that child got um got a plate and a and they and the family were delighted. Um And then, so you grew, there was a combination, right? So Tom was saying plate fixation, Marissa was saying external fixation and that's why we slid up this locking plate. So he wanted compression across that articular split. Um And we did wing it a little bit because we thought, well, it the articular surface is intact. So again, one meeting I presented this at someone said, surely you should have scoped the knee to make sure. And I say, well, I don't really want to know, but uh we did actually get an MRI once we removed the metal and uh it was all good. But yeah, what was the reason you got the MRI? And the the, the, the thing II was just gonna point out that dystrophy, you know, I was saying is really unforgiving and you'd be definitely forgiven for being concerned about there being a problem with the growth there. Um If you see them a little bit later, you can see how that the plate and those grows have been growing up. So that actually is forgiven, which is awesome. Um And so this is a child who was in Edmunds who had um had an injury to their knee and you just really can't see anything. I sort of, if you look super, super close, you can sort of see it something around the medial side of the um of the distal femur. Um But uh they had an MRI scan which demonstrated a fracture running along the and up that medial side and they presented about um a year later because I just reassured that the, the knee was doing fine. They presented um with um a concern about the position of their limb and they or their long leg x rays. So what's happened then, I suspect that the patient had a unidentified uh fasso injury which has led to arrest. So you've had um where is the arrest occurred though? Silver Sylvester, where is, where is the arrest occurred? Is it across the whole? No, it's got a partial, it's got a partial where the fracture was. So I think that's happened on the media side where uh Yeah. And you could, it wasn't even undiagnosed. They actually worked out that there was a fal injury but they, um, that they, um, but the, uh, it wasn't really sort of, um, uh, recognized at that, uh, that, that, that was going to then cause this. So, or at least the family were unaware that it was going to cause this. So it's just, it's making sure that you're counseling your parents really because there's nothing you do differently. It was all in a good position. I wouldn't have done surgery to fix it, but you've got to worry about that. So what would you do about that? Um So how old is the child at that stage? 13? And are they female or male, uh male, male? So 13, the 13 years? Oh, sorry, sorry Vester. Good question. Can you explain because there'll be people there that don't know why you asked that question. Um The reason why I asked that question is because um, you're trying to calculate, um, how much growth have they got left um, to what is predicted when they will be finishing that growth or when that should close. So for um, boys, I think it's between, it's between 14 and 16 for girls, about 12 years old. So if some, somebody's um, 13 years old and a boy, then you think he has only got almost one year left of growth. So it's 16 for a boy. So he's got two years left. So you could predict how much, if you live, how much leg length discrepancy they have or what level of deformity they, they could have. Well, exactly. So it's leg length discrepancy. But actually in this lad's case, it's more about the fact that he's developing genu varum, isn't it? Um, so you want to assess that fi seal bar, you want to work out whether it's resectable, which it wasn't in this case. Um And then you want to work out what you're going to do about it. Um So, um you can complete the fi seal arrest, can't you? So you can stop it growing. But then you make a decision as to whether you do that on the same the other side as well. So you don't end up with leg length discrepancy. Ok. Ok. Good. So, distal femoral fascial uh rest. So, um uh distal femurs apparently up to 30 to 60% of um of them have uh of uh dystrophin braces, pal injuries. Um And sorry, have a growth arrest after seal injuries. Um And they tend to go um slightly more into angulation, but actually leg discrepancy is definitely an issue. Um You can consider excision of bars, but um uh my limited experience of that is, is fairly unrewarding. Um And you do need to work out what your prediction leg discrepancy is going to be. So, you know, you can use the man air through which uh and she is particularly keen on. Um So in conclusion, always think of it n I when you've got a non abator child who's got a femoral fracture, um you don't necessarily need to fix kids, they actually remodel. So for a large proportion and do choose your treatment dependent on age and size and then if you've got facial injuries, particularly just still femoral, then um do make sure you're appropriately counseling the parents. Thank you. Any questions from that? Yeah, I've got one. you, you have four young, really young patients with the Delbert one. Um, do you, would you fix them with a candidate screw or would you fix them with a wire and with a, with a view to sort of taking it out at a future date? And the only thing I struggle with with that is, is it genuinely, is it just an acute skiing? Right? Yeah. II, no, I, I'm, I'm, I'm, I'm going for a younger patient. So someone who's, yeah, young, younger than a skippy age. Yeah, it's still, so I did. So I had a very young child who actually had a skiffy. Um, so I did not, not a traumatic, so a, a Skiffy, she was seven years old and I actually used one of the growing hip screws, which is an option now. Um, and she's in the day. Um II did quite a lot of research about what options there are for young patients. So you can use KWS they have a very high failure rate and an incredibly high revision ie or removal rate because of course, they cause so much soft tissue irritation. And one company produces a pediatric hip locking plate where the distal tips of the screws are actually not shredded. And so if you do, if you were faced with that, then that's what I'd say would be best to use because then what you're doing is screws going across the vs. But they're essentially like wires, but they're approximately threaded so that they're screwing into the femoral neck. So that would be the implant. They look terrifying though. They're really pointy. Yeah. And we can not for a fracture for an Os, but that's a great implant to use in that specific situation. Yeah. So um one quick question, what was the Salter Harris classification for that last, that, that distal femur fracture that Miss Chase showed that then went into V? No, we can't talk about Salta now because we're going to do that in my distal tibial talk to death. I mean, this is medical student stuff, right? These guys should tell me that they don't need your talk about that bit. There may be many other bits that you could talk about. Thanks and I feel really bad off. Yeah, I had an appointment with the two. Yeah, it did on the Mr. But what would you call it on? And so this is the thing, isn't it? They did the Mr, but what's the classic, uh, sold Harris fracture? That isn't something that, that we say is a diagnosis of retrospect, cos it then presents with deformity. It's the five. Yeah. Um Right. So any other questions, otherwise we're going to move on? And I will, can I ask you a quick question about, um, the peddy nails? Um, just, we've had a couple of kids that I've seen in previous trust who've been sort of too heavy for them. Maybe my understanding is that their suits are up to 50 kg. Is that right? No, that's, I don't think you're flexible now. Oh, sorry. Ok. So the peddy nails do they have a fairly limitless weight, um, tolerance because we've had quite a few sort of large Children who still don't have their, um, fe clothes yet. So, the thing I would say is, uh, the 50 kg rule is really not true. It does depend on how good you are at elastic nailing. Uh, and it's all about those N caps. So I've seen a patient who was about 70 kg, a, a rugby player from Norfolk who, uh, unfortunately had a quite a nasty spiral fracture of his left femur. Uh, but luckily he did that in Nottingham. So he had his femur treated by, uh, Mister James Hunt who is, uh, a kind of well establish, uh, trauma surgeon, but pediatric orthopedic surgeon. And I'm not joking it, it was when I saw that, that I suddenly thought, ok, elastic nose genuinely do work in larger kids. It was awesome. So that 50 kg rule was from one paper published in the American BJ. Si think it was definitely an American group. Uh, the French have always disputed that 50 kg rule. But it is the thing that you have to trot out in the exam. Yeah, but you can use them. Um, but yeah, the pedy nail, no is sort of slightly limitless. It's just, do you want the si size of the canal measured up? Um, because even if they're a very heavy kid, they may not have the right size for that nail to be appropriate. Got you. Thank you. Ok. So I just had a question about the, the really young ones, the sort of the ones you're gonna put in a spike of the role of traction before putting in a spiker cast. But things say about when it's, when there's significant shortening. But I've never really seen that in, in Adelaide. They argued that you're more likely to end up with increased pain if you didn't have them, um, attraction for a few days, you know, up to some people were even quoting 10 days before you put them in a spiker because then it's less traumatic for the child as it, you know, you're not throwing off a load of blood because it's, um, it's basically healed by that point. So it's slight nonsense really. But no, there's not, um, there was one systematic review that compared delayed with immediate spikers and really there wasn't much in it. So, uh, we tend to just do it on the first available list, which means one where we can get us and a pediatric anesthetist together. Cos they tend to be the younger kids. Yeah. Ah, brilliant. We have, we have, um, thank you very much. So, that's brilliant. We have N capps that you guys want the link to where you can purchase your NCAP. It shows a picture of them as well, right? I'm gonna move on. OK? Because we are uh pushing a bit. So I've got to share entire screen. Sure. Uh And then can you guys see that? Yeah. Yeah. Brilliant. OK. Right. So uh three year old closed neurovascular isolated injury. Uh What strikes you about this fracture? Anything what? Transverse, transverse? Oh yeah. And there's a butterfly fragment is. So what does that tell you about the fracture? Is that normal for kids fractures? All it means probably maybe direct force through the blunt force? Yeah. So ex exactly brilliant. OK. So it suggests that it's a high energy injury. So actually this three year old fell out of a window. That was about second story. Uh How would you manage it? So, uh fortunately they are otherwise completely fine. No head injury, no other concerns. How would you manage this ultimately keep us in the sp Yeah. So the concern about the spiker is it's really not gonna be that stable, right? Yeah, and it probably would be fine. Um But ii was looking at that thinking you've got that lateral combination, essentially that butterfly fragment um and a spiker I think would be fine, traction would be fine. Um But this is what we did. So this is two weeks after surgery. Ok. So this kid is not in a plaster of any description, but what you can see is the end caps there. And so all the end caps do when you've got these comminuted fractures is they have got a literally a cap. So it screws into the bone. You can see that there and it doesn't allow the nail to slide. So you can imagine if your proximal fragment was collapsing down, the nail would theoretically just start sticking out of the distal end more. But then this, that's what the NCAP stopped. And so this is two weeks POSTOP. You can see good colors formation there. And actually his butterfly fragment is starting to become part of the bone graft that's gonna heal the fracture. So that's why the N capps are quite nice. And yeah, so the whole you should do elastic nails after about the age of five has become four. And in this situation, I did use it in a three year old. I also thought it would be easier for the family to look after the child rather than having them in a spiker. So socially, we thought it'd be a bit an easier thing to do. But yeah, that was just to show you a recent example of us using N CPS. But we're going to talk about uh non accidental injury. Can I ask a question if I was to get such a question in the exam? And I said high energy injury butterfly fragment. Um and initially, I was gonna say do an open induction and use the Tetrix. Uh w what would you think about that? Because I for such a fracture configuration, I wouldn't have confidence to use a, a tens nail. And I was thinking spike are probably know, then you have to fix it, get proper stator onto that community fraction. So my um the reason why I think part two is more straightforward than part one is because you're allowed to voice those thoughts. And actually, as long as you're voicing sensible thoughts, then they'll be all right with that. So, actually, everything you said there, Sylvester is perfectly true. If you'd said submuscular plate, then I'd be happy with that. What you don't, I don't think you need here is an open reduction. OK? You don't need to see the fracture site and try and piece it all together. But if you said I'm gonna slide a locking plate down, uh a couple of screws in the proximal fragment, hold it out cos I think it's length unstable and a couple of screws in the distal fragment that would be fine. Yeah. But the bit that I would dispute is the I need to open up the fracture to see it actually, as long as you leave the soft tissue envelope intact, uh they will heal really quickly. So that's what I like about elastic nails, uh or submuscular plates or I am nails is you're not actually opening up the fracture site, you're leaving everything intact for healing. Does that make sense? Yeah. Yeah. Brilliant. Right. So, yes, inflicted injury. Um So this is a seven month old, not moving their left arm. Th this is a true story. They presented swollen elbow, er, no fever and people were a little bit concerned about uh infection, what is going on here. So he's got evidence of callus posterior aspect of the distal humerus. So you have to suspect suspect a A I as a a delayed presentation of a human cap also see evidence of on the human dislocation and a possible dislocation of the radio capital join as well. Again, delayed presentation of an injury in a seven month old, which is another red flag. Yeah. So you're along the right lines. Do you know what the injury is Schumann? Um There anyone else can, I'm not sure if it's a corner fracture. I don't think it's a corner fracture. I mean, my screen doesn't really show that. Is it, is it like a a delayed supracondylar type fracture that's healed. Extension types condyle that's healed injury. Yeah. Who said that? Sorry, I can't look at the names and look at the at the same time. Um So Ben, you're right, but someone else has nailed it. Who's the trans vice heal? Um Yours is the same as, oh, hey, Jason, I didn't. So yeah, so guys it is. So Schumann, you gave a good description, then you're along the right lines. Essentially the distal humerus is this cartilaginous bit here. Let's see if this does work. Uh Can you guys see my red drawing? Yeah, yeah, that's the cartilaginous portion of the distal humerus. So that's why your radius and ulna have stayed together. So it is a posted uh fracture but it's gone through the piss. How would you treat that? And we will put the screw uh this uh K wire because this is a good fixation. So I need the internal fixation with the K wire and they will uh both cast for this baby for two weeks after that, he will come and I will review him. Thank you. So that I think there are a lot of people out there who would try that. So actually what we tend to do, if you just leave it alone, they remodel just fine with all of this callus. You'd have to be really causing some significant take down damage to try and bring the distal humerus back to where it should be. So, no, at this stage and in all honesty, with all of these trans vice seal, I just tend to leave them alone. They really do remodel very well. Um But yeah, what we're gonna talk about is so the first part is recognizing this, your differentials would be infection, but then they should be systemically unwell. And the reason why it's important, OK. Is um these Children really do present and you need to pick it up. So for me, this is a really important topic. Ok. Uh, so baby p you might remember when he hit the headlines in the UK 60 separate injuries during an eight month ordeal. Uh, just think about what the poor child actually went through. And the problem is, uh this was that article, these guys of the 10 years. Uh, but then we've got these two in 2020. Ok? It just keeps happening every couple of years. Another big case comes. So that's why it's so important that you're gonna pick these things up and you're gonna make sure that we protect the Children. So what does that mean? So in that case, the seven year 07 month old, you need to take a history, you're gonna ask about injuries. Ok. Was there an injury, the mechanism, does it make sense? The timing of presentation? So if, for example, that mum said yes, uh I've uh accidentally pulled their arm when I was trying to change them. Er, and that was this evening and you're looking at an X ray with callus, you're gonna have alarm bells ringing. Ok. Were there witnesses because sometimes these Children, there may be a toddler who falls over in one room and actually the parent genuinely didn't see it. Uh And what happens is they present saying my child is limping, then there's an X ray that shows a fracture and it's like, well, there was no history of injury that can complicate things. Ok? So what you're gonna do is repeat the history. Um I was teaching medical students over the last couple of weeks. Uh and I was surprised cos you suddenly realized how old you are, how many of you here can tell me who Columbo was? Oh, yeah. Yeah, he's the um the detective. That's right. The shabby American detective from the 19 seventies. Ok. And he'd always just go, oh, just one more thing and I always think of Columbo when you're thinking about nar, you are being the detective, you're gonna ask some questions and then you're gonna walk away and then you kind of come back and go, oh, just one more thing. And then you ask them the same questions in a different way. Ok. Uh Ask them about the mechanism again, ask them about who was around, you're going to ask them about the Antenatal history and in particular, were there any problems with the scans? Were there any evidence? Was there any concern about the size of the baby size of their femur, the birth history you're gonna ask about and I'll explain why in the second decade. And then of course, you're gonna ask all about the family who's in the house, who would the child have been with in the last 24 hours or however long that you know, the, the kind of history presents with? Ok. Ok. You are really being a detective and of course you're gonna ask about past medical history uh including fractures. Is this their first fracture? How can you check that bit? If the parents seem a bit wooly about it, you can check previous A&E admissions. Perfect. Yeah, that's what I was getting at. Ok. So always look at that uh look on your PAC system. Have they been in there before? Look on your e sorry guys, there's someone who probably moves to mute. Ok? Can you give them awesome, right? And then when you look at the child, ok, this is genuinely a head to toe examination if you are looking at a child where you are remotely suspicious that this could be an A I you don't have to strip them completely, but you will see in turn, look at one arm, look at the other arm, lift up the top, have a good look at abdomen and chest spin them around. Have a look at the back. Then you're gonna have a look at the legs you are going to look for and document that you did look for and didn't see things like bruises, bites, cigarette burns because those things do happen. You're gonna look at the child overall. Are they? Well, k, uh, do they look like they could have a skeletal dysplasia? What kind of things would you guys be looking for in someone with a skeletal dysplasia that could predispose to a fracture? Small size, small size. Yeah. Yeah. Short stature, you said bowing. Yeah. Um it depends on their age. Bowing could be normal if this is a a one year old abnormal pfizers. You won't see that clinically though, right? So, oh no, clinical sorry. So radiologically. Yeah, but abnormal flares. Very sorry. And yeah, abnormal faces. Ok. So you might wanna look for. Is there a big forehead? Is there a small triangular chin? Look at their eyes? Ok. And then I always put this in the examination section but you're not gonna be doing this. You're gonna ask an ophthalmologist to come and have a look inside for retinal hemorrhages. Ok? Then your general management. Ok. What you are gonna do is obviously discuss with pediatrics but remember that's not just their uh responsibility. You also especially in an exam, but in real life need to be able to take it further and say, right, what I am gonna do is discuss this with the safeguarding team, the lead for safeguarding. There's always someone on call for safeguarding at every hospital you might need to make what we call a mash referral, which is the multidisciplinary agency referral, uh which will involve the social workers and things you're gonna keep the child in a place of safety. So for example, if it's a femoral fracture, sticking them on traction is the best way of doing that. So in terms of Ben's question about, when do we use traction if there's any doubt about, is this something that could be na I actually, we keep him on traction for a few days to allow all of these things to happen. Ok. The most important bit is you will have an open, honest and sensitive conversation with the parents and carer. If they are presented with a an injury that can't be explained, you need to explain that and say, look, we found this fracture. Obviously, we need to understand how that's happened. And so we're gonna need to do some tests to work out whether there's something that could be a problem with your child that's predisposing them to fractures and to work things out and most parents will be happy with that explanation. Ok. Obviously you're gonna do it in a very non accusing way. Um Do let me know if there's any questions you just speak up cos I can't see the chat and so once you're down this route. Ok, what investigations are you gonna order? Skeletal survey? Brilliant. Uh so skeletal survey, anything else? Yeah. So blood skeletal survey, any other imaging investigations that are mandatory if you're thinking na I A scan of the head. Yeah. A CT head. Ok? Because you are looking for skull fractures and intracranial hemorrhages. Um So remember a skeletal survey, you have to specify for NA I because then they'll x-ray every bone if it's just skeletal survey for skeletal dysplasia, they only do one half of the body. Ok? You get a whole chest, you get the spine. Uh but for skeletal dysplasia, you'd only get one upper limb, one lower limb. What are the differentials? So what kind of things, you know, when we say, well, it could be other things. What kind of things could it be that a child could present with multiple or easy fractures? I suggest simple fracture. Yeah. So that's the obvious one. Ok. But it's the one that is actually difficult to diagnose. And you've got to think about there is no single blood test that will prove or disprove o why, what else you fibromatosis? Um No, no, no that would present with, you know, the antra later, bone tibia, maybe pseudoarthrosis tibia but not fractures. Ok. No, not really. So don't forget rickets. Ok. But multiple fractures are uncommon. Ok. The reason why the birth history was important when I said we'll come on to that is there is a condition called osteopenia of prematurity and Children who were born before 29 weeks and who are less than 1.5 kg at birth are at greater risk of fracture in the first year of life. So it's an important question to answer uh to ask. Rather scurvy is making a bit of a comeback. You might remember Vitamin C deficiency. So it's something we're now getting into M CQ territory. Ok. But always have this in the back of your mind. Copper deficiency and then Menkes disease, which is essentially a problem with copper metabolism is X linked recessive. So what does that mean? Who's gonna be getting it in terms of your genders if it's excellent? OK. And they can present with on their skeletal survey and X rays, they'll have this metaphyseal fragmentation with subperiosteal new bone, which can look like fractures. So that's why uh you've got to just have that on your radar. OK. But genuinely for us, the first two are the big common ones. OK. Now, one of the things that you will always say spiral fractures uh are suspicious for NA I because it's a twisting injury, but which of those would bother you more. Yeah. OK. Just like you saw in that three year old where you're all going, that's transverse. It's high energy is, isn't it? Um And actually when most kids slip, they're running along, they twist their leg and they get a spiral fracture. So I would personally say you've got to be more suspicious about transverse femoral fractures than spiral fractures. OK. Most na I injuries will be spiral. But actually the transverses have probably got a higher probability. And so, uh Schumann, I think you mentioned the classic metaphyseal corner fracture. This is them. Uh and essentially, it's a fracture through the spongiosa. And it's supposed to be because someone has grabbed the limb, shaken it and the capsular attachments to the periosteum result in this um avulsion fracture. OK. They were traditionally considered to be pathognomic for abuse, but that is not the case. OK. So again, people will want to hear you say that if you see it, you've gotta be really suspicious, but it's not a given and we'll talk about that. So this was a great paper. OK? 2008, a systematic review. And they basically set out to say what features differentiate fractures from abuse from those sustained from other causes. Uh They looked at 32 studies. Uh Peter Warlock is an orthopedic surgeon who wrote this really big paper. Uh before this systematic review, I think this was in the late eighties, early nineties. And what he found was that 80% of all fractures from abuse were in kids under the age of 18 months. So if a child is under the age of 18 months and they present with a fracture, you've gotta be very suspicious and 85% of fractures not caused by abuse occurred in those over five years. But then you're kind of like, well, what about between 18 and five years? Ok. If you're not walking and you're not mobile, you can't have a fracture. It's a little bit like a plant pot. Ok? If you put a baby down, just like a plant pot, if it can't move, unless someone does something to it, it won't just break. So this is what they found with this systematic review, child with rib fractures. 70% chance of abuse, femoral fracture, one in 3 to 4 chance of abuse. So rib fractures are the most sensitive fracture for NA I uh and I suppose specific but even then there's a 30% chance that it's not abuse, humeral fracture, excluding supracondylar or 50% chance of being abused. Ok? Skull fracture, one and three. So what you can see. And so in this review, they found no evidence for metaphyseal corona fractures and nothing between spiral or transverse femoral fractures. So the problem is no one fracture is gonna say to you this is na I and that's the thing you ought to take home from this. Ok. So coming back to that seven months old, what you can see is the clavicle fracture there and they've got rib fractures as well, ok? You can see one there and they had metaphyseal Corona fracture. You can see how, if you don't know what you're looking for, you could miss it. The other thing with the skeletal survey is these days it has to be repeated at two weeks after the first one. Cos you may pick up more injuries that become obvious, ok? But this is why it's really important at that first presentation that you pick up that suspicion and you go down that route. Ok? Um There was this paper from East Anglia, this was led by Piers Mitchell. Uh We contributed from the N and N. You can see names from West Suffolk and Adam Brooks as well. And basically, um, what they found was that not enough Children were being assessed by a pediatrician prior to discharge from the ED and maybe were missing. Na I, what I would say is that it's every healthcare professionals, responsibility should be thinking about it, but just because they haven't thought about it doesn't mean you should. And I would say you need to actively say that you've thought about it. Ok? And when you change trust, just have a quick look at what the safeguarding protocols are. It doesn't take long. Ok. Um And so this was a paper from, er, this American group up. You can see it's got pediatricians, radiologists and orthopedic surgeons as well, actually. And they broke radiologic findings into high specificity, moderate. And then uh sorry. And here you can see common but low, high specificity. Uh the metaphyseal fractures, the rib fractures, the scapular fractures, spinus process and sternal. The problem is these are things that we might not even pick up. Ok. The ones that we're gonna see are the ones that are common and low specificity. So, unless you think about it, you're not gonna pick these things up. This was from the same paper. So when should you worry when there's a fracture with no history of injury obvious when the injury, uh, doesn't fit with the mechanism described those inconsistent histories. We talked about fracture in non ambulatory child, uh, rib fractures, multiple fractures, especially of different ages. And essentially what I'd say is when you are suspicious. Ok, if there's a delay in seeking care for injury. Uh but it all boils down to history and examination and then your investigations for us with na I it starts the wrong way round, doesn't it? You'll get given an X ray with a fracture. You need to go back and make sure the history fits with what you've been given. Ok. Right. Any questions about na I guys? No, you in the light of silence, I think. Yeah. Yeah. Yeah, thanks. Thanks right over to you now. So, um so I'm going to be doing um this to just practice. Yeah, and sorry. I don't mean to sound so uncertain. I'm just trying to load up. It takes a surprising time to upload the slide deck. Um, but um we there is a tea break scheduled for this sort of time. Should we give people five minutes to just get a quick bathroom break and a cup of tea before returning or do we not do breaks? Yeah, we can do five minutes. Five minutes come for a break. 510. Yeah. Yeah. She was like, yeah, I could do with a break. Yeah. So, should we come back at 315? Yep. That sounds good. So, 315 everyone. Yeah.