Computer generated transcript

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

Uh supracondyle fractures, OK? Are a bit of a pain to deal with. But I think the lateral condyle fractures are actually the harder ones. OK. So uh it's an articular fracture. Now, we don't need absolute stability in the way you would with some other uh articular fractures. But you do wanna make sure that the articular surface is restored. What you don't want to do though is say this is a fracture of necessity. OK. So you are going to assess these fractures radiographically, see if you can tell whether the cartilaginous joint is intact and if you can and you're happy with the position, you can treat it non operatively. If you're not sure, then you need to investigate further. OK. So the original classification milch, this is just a declassification. OK. So type one, everyone always gets a little bit uh kind of confused about this, but it's pretty straightforward if it goes through the ossification center, er it is a type one. If it's going lateral to the ossification center, then it's a type two, sorry, medial, obviously. OK. Uh In type one, a bony bridge would be more common. And in type two A forearm translocation. So it's one of my little bug bears. Everyone calls it a dislocation. I'm not sure that it is because actually the radius is moving with the capitum and that little bit of trochlear that's there is what the ulnar is moving with. Ok. Uh The milch is great for describing it, but it doesn't tell you how you're gonna manage it because what's important is the displacement. Now, what people have said is you can use ultrasound, you can use MRI, what are the problems with those guys? There's a method of assessing these fractures. So, ultrasound is operating dependent earlier swelling but no, MRI can get free swelling. Yeah, MRI, you're going to have to sedate A and MRI is difficult to get on kids, isn't it? Yeah. Yeah. OK. And someone else is that someone saying it quietly as well? A G? You're right, MRI, you're going to have to give them a G A if they're three or four years old, an ultrasound, you just say, are you really going to take the plaster off and go right. I want you to lie still while we swing a probe around your arm. OK. So for me, an arthrogram is the best way of doing it because they're under a G A, you do your arthrogram and then you can fix it there and then, so here's uh a lateral condyle fracture and this is, we're gonna talk about the song classification. OK. So I really like this classification. It takes elements of the Jacobs and Fowls classification. It takes elements of the Fin Bogin classification. OK. They talk about the four views, uh ap lateral and then the two rotation views. I personally don't think that those are that important. But what you do wanna do is look on that AP view and what you're looking at is this fracture line here. If this is two millimeters or more here and two millimeters or more here, then you're worried about whether that line is extending across the cartilage. If you're looking at it and this bit of the metaphysis is together, then actually, it's highly likely that all of this cartilage is gonna be intact. OK? Here, you can see on the MRI. Actually, it's very similar. OK? The gap here is no bigger than the gap there that you can see on the X ray. So I don't think you needed this MRI really. Um And what's interesting about this is this was about displaced, unstable lateral condyle fractures, closed reduction, percutaneous pinning, successful in about 70% of cases. OK. This is the original group in 2008. And this was an independent group from America validating that in 2020. So the reason why I put that there is not because I would do that, OK? If it's displaced, I'm not good enough to do a closed reduction. Uh But it tells you that you don't have to open every lateral condyle fracture. So this is the song classification here. OK. And that's that cartilage line I'm talking about. So when you got the fracture and it doesn't even reach the metaphysis, you know, this is an intact fracture, you're gonna treat it. They say 5 to 6 weeks, I think 3 to 4 weeks. OK. There's really good evidence that we over treat lateral condyle fractures. Uh Here, as you can see when the fracture line is small at the metaphysis, then actually you carry on with non operative treatment. These ones where the fracture line is as broad at the metaphysis as it is there. They're the controversial group. OK. And so yeah, I would take them to theaters do an arthrogram. So you can see this and once I'm in theaters and I've done an arthrogram, OK. Uh I'm not gonna leave them there. What I'll do is if it doesn't need any form of reduction, they either get two percutaneous wires. I think that's what they're more likely to get these days. Uh because of the lack of theater space that we used to have or they could get a single percutaneous cannulated script. And then yeah, if it's displaced and you'd see this on your films, then you know you're going for an open reduction. But if you have a look at this, OK, what they call the song for closed reduction. Percutaneous pinning. Ok. Er So yes, these are not fractures of necessity. So what do I do? So we just talked about that. Ok. If it's a type A in terms of the er Jacobin F and Fin Bogin. So, so fracture line not going all the way down there, they're gonna get on op management if the fracture line extends to the metaphysis and it's quite wide and you're not sure, arthrogram, percutaneous fixation. If the joint is intact, I don't actually care what the metaphysis looks like. It's all about the articular surface. Ok? And if it's massively displaced, then you're gonna do an orif. So this fracture, for example, you're looking here going well, that looks quite displaced there. And actually here it doesn't look particularly displaced. So it's about how you call it. So I was feeling nervous that day and I thought, well, let me take him for an arthrogram here. You can see that actually the articular surface is intact. And so all we do there is percutaneously pin, ok. But again, you could say I'm looking at this in hindsight thinking, well, it's pretty wide there, but it's pretty narrow there. I could have left that alone, but the arthrogram is just for reassurance. But as I said, then you're gonna do something, ok? If you are fixing these, it's not a Cocker approach. Ok? You're gonna do a direct lateral approach. Uh You use the supracondylar ridge and you're basically cutting over that. Um Once you get through the skin, you'll start finding that everything else is torn, you'll find the hematoma and what you want to do is get a really good look at the articular surface. Ok. So you uh open up the joint, you go down as far as the radial head and the annular ligament, you might need to nick that. And then what you're gonna do is slide your mcdonald over the front of the distal humerus so that you can really properly see the articular surface. It doesn't. So the problem with chondral fractures is they don't key in the same way bone does, but you can definitely check, you haven't got a big step. So you do the articular surface first and then you can line up your metaphysis if you want to. Ok. And remember you're not gonna strip the periosteum off the back because that's where the blood supply is coming in. So one of the questions people ask is, oh, talk me through an open reduction and they want to hear you say, and I'll be careful with the soft tissue at the back of the distal humerus because of the blood supply and the risk of a BN a screw or wire. The honest truth is there's no difference. OK? A screw is definitely gonna be better in terms of compression. But given that you can treat things with K wires, it's about the size of the fracture. OK. So if you're gonna use wires, always two millimeters, that's what I liked about Mr Blanco's talk in that paper that he talked about. If you notice for schon fractures, it said use wires greater than 1.6. So, although I didn't say two, it implies you have to use two. Ok. So divergent K wires going at 90 degrees to the fracture line, you do not need to bury these. That's really old fashioned thinking the whole, oh, we better bury them because there's this risk of infection. So we're going to have to leave them at six weeks. You don't need to leave the wires for six weeks. You can take them out at four weeks. We actually get the elbow moving at four weeks out of plaster casts. But some people will take the wires out at four weeks and then put a plaster on for another couple of weeks. It's because of this concern about synovial fluid washing through the uh fracture and delaying union. If you're gonna use a cannulated screw 3.5 or four millimeter. Uh And again, you could put them in a plaster that comes off at three weeks and then you take the screw out at about three months. Ok? I really do like screws. It means that you can get them moving quicker. But the big problem was having to take them back to theater to take the screw out, which you don't have to do with your percutaneous wires. And again, that's why I think bearing your wires is the worst of both worlds? OK. Right. What's the fracture here? Any questions about lateral condyles before we move on? I did say it would be quick. Hopefully, that makes it clear though. No cool anyone tell me what the fracture is we're looking at here. Right. Yeah. Ra radial neck fracture. Yeah. Brilliant. OK. And sh how are you gonna manage this? Does it need reduction? Right. I think personally for this particular fracture and what angulation can you accept? Yeah. So again, it does depend on what book you read and how you're feeling on the day, right? So some people say 30 degrees, I think 45 is a good number. Cos some people say 60 degrees. Uh Again, it's gonna have to depend on the age of the child, but that's why I think 45 is safe. And what's the method we want you to talk about in this situation? Yeah. Brilliant. Can you talk us through it? So it's where you use a 10 retrograde from the radial styloid. Um You have to do a curve at the, at the end of the nail in which you sort of hook it into the radial neck and you basically rotate the the rotate your nail. So that when you line up, you, you will Yeah, now I've put here avoid open reduction unless absolutely necessary. Can anyone tell me why? That is? Yeah. OK. So remember this is so these epiphyseal uh there's certain joints where there's a single epiphyseal vessel as the blood supply. Uh So, for example, the femoral head and in this case, also the radial epiphysis. OK. So you've got to, there are some times where you're gonna have to open it. You can never say never. But that's why the Metazone technique is so cool. OK. So, always do arthrograms with these cartilaginous structures. Uh And then people talk about thumbing the radial head back uh and then using K wires. But yeah, uh in this day and age, OK. You are gonna do this, you're gonna put your um elastic nail in through the radial styloid, as Schumann said. So here you're not going for the max fill that I was talking about with normal forearm fractures, use a skinny nail. So 1.52 millimeters, some people talk about sharpening the distal end. Um I don't do that. You put a real bend on the distal end, not in the middle. OK. So you're using it as a hook. So here you can see the arthrogram that we've done. So there's the radial head is being nicely demonstrated cos otherwise all you can look at is the epiphysis. And what we've done is engaged, caught the radial neck with a elastic nail and then you spin it and when it works, you feel like a surgical God. And then some, you know, you can see, I basically cut out all the middle bits. There are times where you're then trying to use AK wire onto this bit here, trying to push the epiphysis, obviously not at the radial neck cos of the risk to the pin. Um But that is radial neck fractures in a nutshell. OK. Even if you have to do an open reduction, you'll use the cocker approach. Uh But then you can stabilize it with an elastic nail. It works really well. Trust me. OK? Cos some people would try and talk, put little plates and screws on. You just think, man, that is so fiddly just use this. OK. And then what's the fracture here as a 10 year old falling over swollen, painful elbow? Yeah. How are you going to manage that? So you, for me, usually these, you can treat these no operatively. Yeah, that's how I treat you in the past 34 weeks. And is everyone agree. It's controversial, isn't it because of the science? The science study anyway. Um There's risk of nonunion and giving you the instability. Yeah. And so, exactly. And that's why I did, did science. Now, one of the things I'd say, especially in real life, OK. In an exam, you'll be looking for it in real life, you could get caught out, you might not notice that. So that's why I put a circle there. So people weren't sure what we were talking about. That's the medial epicondyle and it should be a little bit closer to the metaphysis there. So, basically this child's fractured, but the giveaway is the soft tissue swelling as well. Ok. So when you're looking at these kids in real life, if they've come in and you can't see an obvious injury, uh do look for soft tissue swelling on the X ray and obviously on the patient in real life, uh the ulnar nerve is a structure at risk and it can be injured in these cases. Um and there is really no good evidence and that's why the science study was a necessary study. OK. So these fractures, people talk about 10 millimeters, they say, oh, if the fracture is displaced by more than 10 millimeters, then you should fix it and then you're kind of like. But where OK. Is that from here to here? Is that from here to there? Is it from there to there? And actually these displace anteriorly rather than uh in the medial lateral plane. So, you know, that's why there is this controversy, the upper limb surgeons tell us that these people will get upper limb instability, but I'm not sure it's as common as everyone says it is OK. If you're fixing it, you're going to do a medial approach, you're going to find the ulnar nerve, protect it and then you can use one screw or two screws. Some people put wires. I don't think that's a great plan myself. I would normally go single screw. But yeah, what I can say science is in the process, I think maybe by the end of this year, actually, they'll be reporting their outcomes. It was a randomized controlled trial where you got randomized if it was displaced any amount, if you could see it, they said that that means it's displaced and you got randomized to fix or not fix plaster for no more than three weeks. Uh And it will be really interesting to see. But again, I think we want to see what the long term results are like as well. Ok. Um And that is it, that's our elbow fracture talk done. So have we covered everything you guys wanted to cover? Really? Sorry. We had to change around the month because Joe's uh worked really hard to try and put a timetable together. Then it's, yeah, he's here. He did it really. Um But yes, then we had the AA research day. So we changed things around there. So that's why we've lost a day of teaching. But you've got the ACA research day instead. Next week we've got a practical face to face. You've got a whole afternoon of pe spines. That will be cool. I'm sure. Um But any questions on anything that we haven't covered or any questions that we've raised? Cool. I think we'll call it then. What do you think, Miss Chase? What do you think Mr Pan? Yes. Oh Wow, that's really loud. Ok. Uh And then guys, in terms of VR we're always happy to give Viber practice So when you're coming up to the exam, give us a shout. You can see we've got lots of x rays we can quiz you about uh, however you want. Ok. So guys, thank you very much for coming along and spending what looks like a really sunny afternoon outside in here. Ok. Uh Have a good evening. Oops, sorry, there's someone in the chat. Hang on a sec. That's pretty saying about nerve palsy. Yeah, it tends to be in the acute valgus, of course, which makes sense, doesn't it? It's just gradually being stretched and which is more common with lateral condyle fractures, cubitus, varus or Cubitus, valgus, august, august. That's right pit. Just virus because of the lateral overgrowth. And that's why I say it like that because actually it is a, it's a weird thing, isn't it? You think? Well, it's gonna be a condyle. So it should be valgus. But actually, no, because it stripped the soft tissues. You often get a bump on the distal lateral side when you've got a lateral condyle fracture anyway. But yeah, they can develop Cubitus, varus. Ok. Brilliant. Right. See you guys later. Bye. Thank you. Bye. Thank you.