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The East Side, but there are some people who aren't. So thank you very much for joining us. So we're gonna talk a little bit about the basic science in very simple terms, we're gonna talk about forearm fracture management and we are gonna include the Monte injury. Uh So you all know that kids aren't little adults and their bones definitely aren't. Ok? So you've got reduced stiffness uh with kids, ok? Uh you have this lower modulus of elasticity. So that means that you get more strain with less stress. So kids, bones, people say, oh they're tougher than adults. They're not actually, but they can absorb more energy before they fail. And so that's why you get plastic deformation and green sticking. So you are less likely to get comminuted fractures in kids. So this is why, you know, as, as an artist, I wanna work with the best materials. So why would you ever choose to work with osteopenic parotic bone? Ok. Er, on the left of my screen, er you can see a Chewy cereal bar that's like a kid's bone, ok? You put some force and with very little force, it will start bending but it will take quite a bit of that energy before it snaps. That's like a kid's bone on the right. You've got a digestive biscuit, other brands are available. Uh You put some force on that and actually it takes a lot of force but then it suddenly goes, it won't bend and that's adult bone. OK? So different bone, different fractures, different treatments. And I think that's the bit that people forget. It's the whole, I've got a hammer and I can do everything with it. Uh With kids, you're gonna do things differently. Uh So essentially you're looking and is the bone bent or is it broken? And then you can decide what you're gonna do in terms of the treatment goals. Uh We're gonna get the bones straight ish. Um And remember the forearm doesn't remodel as the distal radius does. I think the key is actually we've not been brave enough to test that. Um And maybe it remodels better than we think, but uh I'm not gonna be the guy to find out and we wanna minimize invasion. Ok. So by that, what I mean is surgically, but also in life, you don't want this kid to not be able to play sports for a prolonged period. You don't want them coming back to your fracture clinic every week. So you can go oh, has it slipped? Has it slipped? And then you write in the notes. Uh There's no significant changes from the last x-ray. So everyone's just kicking, uh, back to the first person, aren't they something that you guys are doing? And so here at the N and N Jose is doing a project looking at this but, uh, in recent years and I think COVID helped kick start it everywhere, er, rather than Muas in the operating theater. You guys, the registrars primarily are performing closed reductions in the ED at the N NN, er, Jose Iggy have shown that that's reduced our workload for forearm fractures in the operating theater by 50%. Ok. It's been massive. And so when you see a child with a bent forearm, the standard of care and girt says this is you should manipulate in your ed Children unless there are specific reasons. For example, compliance should not be going to the operating theater just for a manipulation. OK. Um Then the question is what angulation is acceptable. Um And usually it's kind of like, well, whatever it is add 10 degrees and that's probably fine because there isn't any real evidence. OK. In the Nottingham paper where they looked at these, they defined acceptable angulation after reduction, as you can see here 15 degrees if you're less than 9, 10 degrees, if you're over nine in the diaphysis in the metaphysis, they were more accepting, OK, 20 degrees and 10 degrees. And that's angulation uh in the JP O Sir Christine Hoe from America. They said actually with over two years of growth remaining, you could have 15 degrees of angulation or less. So that number's come up twice now, hasn't it? So you could go with 15 degrees of angulation, but you've gotta make sure your child is young enough. OK? Bayonet apposition is not a bad thing, but one of the reasons why I say this and you'll see why. Uh but I'm highlighting rotation reduction isn't assessed. OK? So other factors that you're gonna consider uh the thing that we aren't very good at is working out which fractures are going to drift. So today, for example, in clinic, we've seen um an 11 year old girl with a fracture of her distal diaphysis ulnar and radius. The guys reduced it in the ed. They did a great job, but the distal ulnar is angulated about 15 degrees at the diaphysis and I'm worried that next week it'll be worse. So I'd rather get on and do something now rather than waiting a week then going. Oh, well, it looks kind of like it did the, the other week. And to be quite honest, these fractures normally look worse before they get better. You, you'll all have been there where you see a fracture at two weeks and think that looks OK? And then when you see them at four weeks, you think, whoa, but then you'll pretend they look the same and then as I said, the impact on life. OK? OK. Am I gonna say something? Thank you. Uh so there are lots of options. So you saw with femoral fractures, you could plate, you could spiker, you could uh elas elastic nail, solid nail, same with forearm. Ok. OK. You've got lots of different colors that you can choose from and sizes, but this is what you will use. Ok. Unless you've got a really good reason. Uh, your implant of choice is gonna be the elastic nail, er, systematic reviews. Er, no difference. Im NP er, provides improved cosmesis but requires a second operation to remove hardware. I would argue that. So does a plate. So actually that doesn't work. Ok. Um, and this is because people keep saying, oh yeah, plates are as good. Plates are as good. In fact, plates are better because what's the argument is anyone here particularly keen on plating forearms? I mean, you'd be a brave person to say yes after I've talked about why it's a bad thing. But anyone want to talk about why they might feel uh what are the purported benefits of plating? Well, anus if you open up a um, a fracture to reduce it, to put the tens nail down, you might as well just put a plate on. Yeah, there is that. And we'll talk about that. I suppose you anatomical. Yeah. And what does that benefit? What's the benefit there? Because you're right. That's what people say. Right. Yeah. I mean, uh, especially for adult hormone factors, you treat it like a joint. So you want to find your bone. He um uh that, that, that, so yeah, that's exactly it. She, that's what the adult surgeons say and what they talk about is rotation, isn't it? You've got to get your rotation correct. Um And the reason why I said none of those papers that I showed you that assess rotation is how many of you when you do your manipulations in the emergency department for these forearm fractures, uh line up rotation. And when you show him in the trauma, meeting how many of your bosses go? Oh Yeah, but look at the bicipital tuberosity and its relationship to the radial styloid. So that's my argument. There is actually when it suits us, we don't care about rotation. But when it, when we wanna use it as an argument because we want a plate. Uh I think if people can't nail, they should learn how to OK. Um But yeah, in both of these papers, there was no difference in terms of outcomes. OK. So then I'd be saying, well, why do you need to plate? Um in terms of your nailing? OK. Remember one nail per bone, it's not the same as the lower limb. You're gonna go for at least 50% max diameter, but personally, we try and fill it as much as possible. Uh You're gonna bend the elastic nail at the level of the mid shaft of the fracture. So not wear the um sorry of the forearm because you're tensioning that intraosseous membrane, you're not. Uh So for the lower limb, I would say you bend the nails at the level of the fracture site, the forearm just as Schumann said, it's a joint. You're treating both bones as uh one. And that's why you're tensioning at the midshaft level. Single bone nailing definitely works if you've got both bones broken. But then I feel you've got the worst of both worlds. OK? You put a nail into one but because the other one's broken and you can't be bothered to nail it, they're gonna be in a plaster cast for 4 to 6 weeks. So why not nail both? OK. In terms of which bone first, uh go for the least displaced one first but really make it the radius. OK? Because with the ulnar, you can get to it easily if you have to do an open reduction. Whereas if you go and fix the ulnar and then you haven't got so much mobility of the radius that can be tricky. Er And I remember Kareem being me with me once when we had someone where they had plated, the radius left the ulnar, then the ulnar slipped and then trying to put an elastic nail into that ulnar was an ointment and as I said, avoid plaster, OK. So when the French described elastic nailing the whole point just as it should be with plating and any other time we use internal fixation would be to avoid plaster. But I'm aware a lot of people don't like doing that. Uh So the radius, remember we go retrograde um radial started and list as cubicle. We are gonna be for those of you who are coming to the workshop next week, we're gonna be doing that so we can talk through those. The ulnar. The classic method is retrograde. OK. Sorry antegrade through the er electron. but the retrograde is a useful method, but you really don't want to be doing it in younger Children because things are just too small to try and get into that ulnar Tylo. So here's your forearm. You're gonna take the nail and you're gonna bend it at that midshaft level. OK? Not where the fracture site is, bend both nails together so that they're facing opposite directions and you've got to bend in a similar manner. This is a person and you can see here, you know, six years older, I wasn't brave enough to treat this non operatively. There's too much displacement. Uh This is her two weeks post nailing and that's her two weeks post nailing. Uh And you don't need, you know, she's cheating with the Super Nation, Pro Nation. OK? But she's wiggling around. You don't need a plaster cast. OK. Then. Oops, sorry. Uh And then, yeah, this was on Twitter. OK. Now, I have to be honest. OK. That fracture was a sitter for elastic nails. Couldn't get a decent closed reduction and opened both to remove interposed soft tissue. Then I plated cos I was there. Uh And then Iggy replied, OK. So this is us with our um entry point. And actually there you can see the incision that I've made over the ulnar to reduce the fracture. I could not put a plate through that incision. OK. For the radius use uh Thompson's approach. OK. The dorsal approach, it's safe. There's nothing to worry about. You literally cut onto the fracture, crop, clamp onto each end and then you stick your nail across in the same manner because then you don't have to do this. OK. So here you can see plate removal, bone buried over it. Uh And if you look at the West and here you've got the cat's paw, OK? And here you've got the other end of the cat's paw and this is where we're getting our elastic nail out and that's the size of the cat's paw. Why would you do this to a child? There is no benefit. OK. Uh And yeah, this is why in that paper that said ooh, but you have to remove elastic nails. I would say you should remove your plates too because this was a nightmare. OK. Uh That was us in theater. And what you can see is the radius is in the middle of the Medullary canal. I'm sorry. The plate is in the middle of the Medullary canal of the radius. So when should you plate? Ok. If the child is someone who's got closed, ps cos 14 year olds can have, then you should be plating. Ok. As soon as the phys close treat them like a grown up nails don't work in grown ups. People have tried that. And what you can see here is, I've written metaphyseal diaphyseal fractures. Ok. Hopefully you're all aware that those can be that difficult group and that's what I firmly believed. The only other indication I would add is some people's bones are genuinely too narrow to nail. Uh The one I was talking about today, we've got a templating ball and even though she's 11, it looks like we're gonna have to use a 1.5 millimeter nail. So do look at your x rays pre op uh and it may be very rarely that it's too narrow and interesting the way the forearm grows. Actually, you can put wider nails in the three and four year olds, cos they've got more appositional growth than longitudinal and then the bones get narrower before they get bigger again. So the metaphyseal diaphyseal fracture. Ok. This is an example. This is an eight year old boy. Um And this is one that, you know, you kind of go well, actually, this is gonna be a nightmare. It's completely off, but you're all aware of the craft study that's going on. We didn't take part in kraft, but the weekend that I saw this kid, I'd just come back from Edinburgh having had a chat with, uh, the chief investigator for Kraft who isn't allowed to share data, but shared some stories. And so I said to the family when we took him for an MU a cos they'd already been booked for an MU A and I didn't want to undo that plan. It was if I can move it, I'll move it, uh, and wire it. But if I can't, I won't open your child and they agreed to that six weeks later, that's him. Ok. So, uh, no obvious deformity at the wrist. Pretty good range of movement for six weeks after fracture. And that's him there. He's already remodeling significantly and it's already fully healed. Uh So even the metaphyseal diaphyseal region, I'm not sure you need to plate, but this is the, the kind of difficult area. And as a, as a general orthopedic surgeon, you might not feel so comfortable. Uh So you could talk to your pediatric orthopedic counterparts. Ok. But remember younger, the child closer it is to the phys, the better they're gonna remodel. Uh, there are bio degradable im now for the forearm, but we're gonna ignore those they're being used in some countries. They haven't taken off in this country. And the problem is they just sound like they're too difficult to put in. You can't actually bend them, you've gotta put these tubes in, uh to kind of reduce the fracture then squeeze this thing in cos it's quite brittle. And you just think, man, uh I'm not personally feeling like you wanna try that. So can anyone tell me what's going on with this x-ray? This is a kid fell over monkey bars, plastic deformation. So how would you manage that? It is a green stick. What's the first thing you're gonna do when you see someone with an injury? Be it plastic deformity or a fracture of the ulnar, you can get an X ray, same child. OK? But that happened a week later and they had a radial nerve palsy by then because you can see how on the forearm view, it doesn't look that bad, does it? You'd think? Well, it can't be that off, but it really is. OK. So, uh if you see an ulnar think of Montia and actively exclude it. OK? Um And so remember in Children for a montage year, you do not need anatomic reduction. OK. Uh Cos this is what you're told, right? The forearm is a joint. These fractures need anatomic reduction, not in kids and we'll give you evidence. So 1967 core uh this was a big year for um elbow fractures. OK? You'll see this was the paper that said, oh, whatever position your elbow is in, in terms of flexion, the radiocapitellar line should be intact. And actually, he didn't say that with any evidence. And then when people have looked at it they found that that's not true in about 15% of kids. That isn't true. Uh, the ulnar bow sign. This is a good sign when you look at your lateral of the ulnar. Ok? It should be straight. You shouldn't have this elevation if you've got that, that means there's plastic deformity and then you've got to look at your radiocapitellar joint on an elbow fracture. Ok. So, I mean, like I said, it shouldn't exceed one millimeter. That's why I'm saying it's straight. OK. Um But of course, if you've got tilting, then that's gonna cause a problem. But all I'm saying is if it's not straight, check the elbow. Now, in terms of management, I used to say not in Ed, but one of our registrars uh at the N nn did do one in Ed and she got a great result. So you're like, OK, can't say that anymore. Um Remember you're gonna deal with the, er, with these fractures, you get the, er, out to length and then the radial head will pop in as long as you're doing it in a timely fashion. If it comes at six weeks, three months, then it's gonna be a bit trickier, but you're still gonna start with the ulnar shaft. OK. I've put here, consider arthrogram. I would say an arthrogram is essential. I think the guys that have worked with us have seen that that will always start with the arthrogram and work from that point. Because if you've got a radial head that is largely cartilaginous, how else can you actually assess your radiocapitellar joint in theaters? Ok. So that kid, uh that's the arthrogram there. And cos you can see, ok. Even here you can't see much of the radio head and you'd be kind of guessing. Oh, is that lined up? Ok. But with the arthrogram, you can see that it's nicely lined up and, yeah, all we did was stick an elastic nail in. Now the Americans. Uh This is a really good paper for 2015. Um And this is from Boston. And what they have said is that if you've got a lent stable plastic deformity or green stick, then you do a closed reduction. If it's length, stable transverse, oblique or short, sorry, transverse or short oblique, you go over the nail and if it's length unstable and comminuted, then you consider plate fixation of the ulnar. OK. But actually what's interesting when you look at their own results, uh what they did here was if it was treated suboptimally according to their strategy, uh that's this group here treated according to strategy or over treated according to that strategy. Let's look at the suboptimal one. OK. So long oblique 12 got an im nail, zero failures, two comminuted, I am nail zero failures. So actually, even in their own group where they've said you should plate, actually, they didn't have any failures. So even their paper where they're talking about plating, I would say go for IM nail first. OK? So forearm fractures, OK? Most don't need anything more than a closed reduction. And you guys know that cos you deal with the brunt of the working in Ed, you have to give a really good reason not to do an elastic nail. If you're looking to put an implant into a child's forearm and pediatric Montia fractures are not the same as adult Montia fractures. You're gonna watch out for the Montia variant, which is where there is no fracture of the ulnar, but you do not need an anatomical reduction. Ok. So keep those plates for those people under who are over the age of 16. Ok. Thank you very much. Hi, good here. Can I just, uh I just