Computer generated transcript

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

Hello, everyone. Um, thank you so much for joining us this evening for our second event in the pediatric teaching series, which is on pediatric orthopedics. Um, just before I get started, can anyone confirm on the chat if they can hear me? Okay? Yeah, we can hear you. Ok. That's perfect. So my name is Ashley to Kennedy and I'm currently, uh F I ZERO based in the Belfast Trust and I'm the Events Officer for the Child Health Society. Uh, today we're joined by nine Drew Ravi Kumar, who will be speaking about pediatric orthopedics and he's also an F zero, uh, currently placed in the Southern Trust before I pass it on to Andrew. Then I just want to let me you know that I'll be sending in the feedback link, uh, nearing the end of the presentation. So please stay until the end, uh, to fill that out and then you'll be getting your certificate of attendance and the slides as well. And if you do have any questions throughout the talk, just pop them in the chat box and then I'll direct them to me through at the end of the talk. Um, that's all I have to say from my end, I'll pass it on to need dhruv. Can everyone see the slides you care? Yeah, they can see it. All right. So, um, thank you, Ashley to thank you for that wonderful introduction. Uh She said my name is Nature of Ravi Kumar, uh current Fy Zero based increase Gavin Southern Trust. And um, today I'm just going to be covering a bit about pediatric orthopedics and what we can expect in fourth year exams and in finals as well. Um, so can just someone, uh, see if they can see my slides moving. All right. Yep, we can. All right, perfect. Um, so we're just going to be covering a bit about DPH, which is developmental, uh, displays of the hip parties disease SUFI, which is slipped upper femoral emphasis. Uh, and then touch about what is irritable hip or transient sinusitis versus uh septic arthritis as well. And then finally in, uh, with a bit of oncology, uh, e uh, the common cancers that affect Children in the common cancers that we would encounter in exams as well. So we'll start off with developmental displays of the and, um, please fire in your questions in the chat. I won't be able to see the chat but, uh, I would let me know if there's any question uh, there for me as well. Thank you. So, yeah, so developmentally dysplasia of the hip. Um I refers to the structural abnormality of the hips caused you to an abnormal development of the fetal bones during pregnancy. So, so the main prognostic indicator, the main factor uh for adequate development of the hip in utero is going to be the contact between the femur and the acetabulum. So if there is any uh problems with that contact or if there is minimal contact with this improper contact between uh these two bones, it can lead to impair development of uh the hip joint as a whole. And this again leads to instability in the hips and therefore increases the tendency of subluxation and dislocation seen with developmental dysplasia of the hip. Majority of the patients that are affected with D D H are going to be female with a ratio of approximately seven is 21. Other risk factors that can predispose you to getting D D H include decreased you train space due to various reasons such as breech presentation being firstborn will echo hydramnios, which is reduced, reduced like a volume during pregnancy and the family history uh of D D H as well. So looking at in terms of the diagnosis, early diagnosis is very important because if the diagnosis is delayed, this would require more complex treatment and increase the disability of the child as well and uh impair the long term outcomes as well. And therefore, early diagnosis is key, which can, which means that you have early management strategies away that it as well. In terms of examining or identifying the hit. It is part of the newborn check in terms of the bar lows and or colonies test. All actress babies need this at birth and at six weeks and we will touch a bit upon this in the next slide as well and how to perform the test and what this actually means. Other clinical signs that you can identify include asymmetrical uh skinfolds just around. So looking at the hip creases, if there's any asymmetry between them, then you can. So that is suggestive of D D H as well. And the difference in knee level when the hips are flexed and the and the soles of the feet are placed on the uh on the bed as well. So there is a leg length discrepancy, discrepancy essentially which is against the uh indicative of D D H in terms of imaging. Uh an ultrasound is often used as first line, especially in younger uh infants with infants, less than the age of 4.5 months. If they're older or than that, then X rays off in the first line investigation of choice. Also, an ultrasound is offered at six weeks for all actress influence. So common question that would come up in uh exams would be uh child has been delivered through a C section due to reach position. Um So what would uh they required at six weeks? In this case, it would be an ultrasound because they're actress for uh BPH. Um So this is what an X ray of D D H would look like. Um This is purely just for um uh just, just to look at uh you won't be asked to interpret this X rays within medical school. So, as you can see over here, the left side of the hip, especially, so the femoral head is quite small and this indicates that there has been some development of um issues. And so this is uh indicated of D D H. Again, in terms of the Bolus and Aquilani's tests that we had mentioned earlier. So you're Barlas test, uh tests for essentially dislocate ability of the hips. So how to perform that? It is uh indicated in the first picture on your left over here as well. So you add up the hip, so bring the knees close together, flexed at 90 degrees and the knees bent at 90 degrees as well. And you apply downward pressure through the knees. Um You apply downward pressure on the knees through the fema to check for this location of the femoral head. Mysteriously again, you should apply gentle pressure, make sure that you don't apply too much pressure and make sure that you don't apply to less uh pressure as well. Again, you're looking for dislocation of the femoral head in the posterior aspect uh in this for, for balance to check for dislocate obliquely, the or Gilani's test is again, is checking for relocation or dislocate ability, dislocate whether the hips are due to check whether the hips are dislocated. Um So in this case, the hips and knees again are flexed at 90 degrees. Similar to borrows test as well. Your palms are placed on the baby's knees with the thumbs on the inner thigh and the other four fingers on the outer thigh, as indicated in the picture over there. And then the pressure is used to abduct the hips and pressure is also applied behind the legs to check if the hips dislocate unclear lately. So this is exactly the opposite of what you're doing in bar lows, you're, you're moving the hips outwards and anteriorly or towards yourself as well to check if there's any dislocation in the anterior uh plane, a positive sign would be clunking and there should not be mistaken with clicking, um which is uh normal, but clunking is highly suggestive D D H clunking can be uh clicking is just like a click sound that you hear, but clunking would be more indicative of a displacement. So you actually feel that the joint is moving or dislocating if that makes sense in terms of managing you have your non operative and operative management. Uh So just with the previous slide over there with your balance and not Lonnie's test, it is very essential that you learn how to do uh these tests as this would be part of your newborn assessment as well. And uh it's a common are ski station as well that you can get. So just practice doing this on mannequins of you. Sorry. So in terms of management, you have your non operative and operative. Uh So in terms of your non operative, it can be developed to various strategies. So firstly, the watchful waiting, this is offered only up to six weeks and this is not usually preferred as if uh if this condition is left alone for a long period of time, it can be very difficult to treat as I mentioned earlier. So this is not usually offered uh too many people, then you have your abduction precinct or public harness, which you may have heard of. And this is often used for Children under the age of six months. And the main primary aim of this management strategy is going to be concentrically reduction. So what this means is that the hips are placed an abducted position uh with the knees flex uh to show you a picture of here. So this is how it's going to look like. So the hips are placed in abducted position with the knee um flexed as well. So that allows the femoral head to go back into the acid tabular and allows reduction to occur, but this is fairly mobile. So this allows some mobility for the child to be present as well. And that mobility allows the joint to develop further and does allow concentric um reduction. Then the next thing we have is close reduction and speaker cost. So this is for Children above the age of six months. And at this stage, bone remodeling does not occur well, or the fact, sorry, uh the development of the hip joint is fairly stable. It does not happen much. So you don't really care about that, that movement aspect of it. And therefore, speaker cost is often used when the joints, the hips are reduced into place. So the the the head of the female is reduced into the acetabulum to maintain that contact. But you have that you don't need that mobility as uh that would not make any difference. And therefore you put them in a more digit cost. As we can see. In this particular case, you still keep them in the same position, but it's in a more rigid uh cost in terms of your operative management. Again, you have your open reduction plus speaker cost, which is, which follows very similar principles to the previous close reduction of the speaker cost as well. But this is used only in cases where the the dislocation is not reducible. Uh So you can't manually fix the dislocation or put the femur back into the acetabulum uh into the into the acetabulum. And this is again offered for Children between the age of 6 to 18 months. Your last operative strategy is going to be an osteotomy. This can either be femoral or pelvic plus open reduction plus people cast and this is offered for Children, paid it in the age of two years who have ongoing this place here, an osteotomy means that part of the bone is removed to be just to keep it in. So to get the ideal position, place against uh open reduction takes place and you keep them in a similar uh has shown over here. That's what uh th uh do you have any questions with regards to that? If not, we can move onto the next uh topic. Uh No, I don't see any questions in the chat box now. Perfect. Um Perfect. So in terms of Perthes disease, then what this means is it is an idiopathic osteonecrosis of the proximal femoral epiphysis that results in pre modeling and distortion of the epithets iss and generates abnormal ossification. So I understand this is a lot of jargon. I'm going to try and break it down step by step. Uh Idiopathic means that there's no cause identified for this. Um Osteonecrosis means that's death of the bone and this often occurs due to the disruption of the blood flow to the femoral head. It occurs to the proximal femoral epithets is which means that it is just a blood level of growth plate and that results in remodeling and distortion of that area. So just below the level of the growth plate, an abnormal bone growth occurs and therefore, changing change changes the bone uh structure essentially. And as I said the blood flow through the hip joint is very important as it can uh come up in various aspects of your exams. But it's also important for various reasons as well such as in pediatrics. It would be for these disease in older adults, this would be avascular necrosis as well. So the reason why this occurs is that there is a retrograde blood supply to the head of the fema. What this means is, as you can see here, the head of the fema is supplied by the retinacular arteries. And this is a branch of the medial and lateral circumplex, femoral artery and it goes in the backward direction e from distal too proximal, which indicates that it's a retrograde, that's plan. Now, if there's any disruption of any of these arteries, there is no other blood wrestle that supplies the head of the femur and therefore causing death or necrosis of that area. And this is what happens in the case of parties, disease as well. And you have the artery of ligamentum tree Terry's or the 44 ovular artery, but this tends to um resolve or uh it closes off uh as we progress as we page and therefore, um and Children uh between the ages of 5 to 12, uh this is usually closed and therefore, uh increases the risk of osteonecrosis as well. So, in terms of risk factors as well, it have uh there's an increase there is, it is quite common. Uh it occurs in approximately one in 1200 Children. It is more common in males as well with the ratio of forest to one. As I said earlier, it occurs between the ages of five declive positive family history. Again is an indicator for parties disease and it does, it can occur bilaterally as well in 15 to 20% of the population diagnosing history is very important as we all know. So, pain in the hip or knee and it's always important to remember that if anyone comes with pain in the knee, it can often be due to um referred pain from the hip. Therefore, it is very important to uh examine both in the knee joint and the hip joint to adequately assess the patient and identify that. Um the issue is so they have a pain in the knee or the hip on the knee and that causes a limp and affects the weight bearing capacity as well. It often occurs in a young, active, both in terms of examination, there's limited rotation of movement and all uh plains of the hip. There, maybe there will be a painful gate. Uh You may notice some loss of muscle bulk, there may be some Legoland inequality and these patient's are often um short in stature because there is an overall delaying development of the appointment. In terms of your imaging, your X ray is going to be your first line. Uh but an MRI can also be used if X ray is inconclusive, although uh and the history is highly suggestive of what these as well. So looking at the, the X ray over here, we have two sides to compare which is very good. Uh So we have, so we'll talk about the normal side first, which is going to be the left side of the patient indicated by the black arrow. As we can see, you can see the level of the growth plate there and you can see the emphasis and the price is uh clearly and there is no loss of uh the family head. But on the on the right side of the patient, as you can see indicated by the white arrow, there is um uh compression of the offices and this is highly suggestive of um uh about these disease. Uh This indicates that there is death of the uh bone happening over there. You can see this is in its early stages and there is some uh remodeling awkward ing and there is some um and also fication opening indicated indicated by the um highly dense um areas and more white areas as well. In terms of classification of Perthes disease, you can classify them based on the lateral pillar or herring classification. Again, you don't need to know this for your uh for medical school. But um just for general knowledge, if you want to know uh this is the classification and it is based on the lateral pillar, as we can see over here on the height of the lateral uh in terms of your face is you have four phases. So you have your necrotic phase, fragmentation phase, three ossification phase and remodeling phase. And as the names uh suggest. So, in your necrotic phase, you have uh death of the bone, you're fragmentation phase that is breaking of the dead bone. Riaz ification phase, new bone is being grown over there and remodeling phase, the whole structure of the bone has changed uh does not match what the anatomical uh structure normally was. Again, you don't need to know the faces of Perthes disease as well. Uh But just if you want to know that it's there, terms of your management, you have your, again, you have your non operative and operative. Um So non operative is often reserved for patients who are less than the age of six if I'm not wrong. Uh So you keep them nonweightbearing with crutches, provide them adequate analgesia physiotherapy and embraced to abduct the leg to maintain the head into the uh acidophil. Um Your operative management is used for majority of your patient's above the age of uh six. Uh So you apply traction. So this is just to um allow the femoral head to sit properly in the acetabulum. So you're essentially correcting that leg length discrepancy. You, you can also apply an external fixator. So this is applying screws from the outside into the pelvis and the, and the fema uh and your plates are going to be on the outside as well. And you're just manipulating it to achieve uh that same uh correct position as well. You can do a valgus or a virus osteotomy depending on the type on the, on the X ray findings essentially of approximal uh fema. So in this picture over here, we can see that this is a valgus osteotomy. So part of the bone is removed over there and just put it more in, in that position, um which is more anatomical. Uh or you can also do an innominate or a pelvic osteotomy when you do the same in the same principles that apply, but you remove part of the pelvic bone uh for this to sit more anatomical position. Again, you don't need to know the different operative strategies that are offered, but you need to know that you need to refer these patient's on onto, onto orthopedics and that surgery is often uh warranted. So that's birth use disease. Before we, we move on to the next topic. Any questions so far, I cannot see any questions. No, no. All right. Um So then moving on to the next topic which is slipped, upper femoral epiphysis or SUFI. So, SUFI is a disorder of the proximal femoral feces that leads to slippage of the epithets is relative, the relative to the femoral neck. Again, that is a lot of jargon. What that essentially means that the health fema is displaced or it slips along the growth plate. And that's what the name suggests as well. And it usually affects Children during the pre adolescent, an adolescent stages. And this is because the because because of the position of the growth plate. So ben you uh when you're undergoing the transformation from the pre adolescent to the adolescent phase, your growth plate also undergoes transformation from being more in a more horizontal position to being into more league position and any impairment. And so therefore, uh there is a high risk of slippage of the uh offices during this particular stage. And therefore, uh patient's that most comedy are affected are in this particular stage as well. Uh Therefore, so that would mean between the ages of 12 to 15 years, you get your majority of your patient's and there would be this uh pre adolescent adolescent status. Um as I mentioned, meals are again, predominantly affected. Um With the issue of two is to one, it can be bilateral in, in 25% of the cases. And some of the risk factors include obesity, which is very classical in the sense that you would be getting in medical school. Other risk factors include endocrine disorders which can lead to obesity, obesity as well and rapid growth during adolescence is um because as I mentioned earlier, that transformation, if it happens too quickly as well, you can get slippers of the emphasis. In terms of your presentation, you can divide this into uh when the slip. Uh so you can get. So in patient's that present you before uh the slip or pre slip, they can have pain in the hip side or knee. And this is associated with limited internal rotation. So they can't get their foot inwards in the acute slip phase, which is less than three weeks. It usually follows significant trauma and there's often a salter Harris type one fracture. In these patient's where when there's a fracture along the level of the broke plate and a chronic slip, uh patient's are present with a chronic slip, which is majority of the cases and over 60% of them brother slip has occurred, create more than three weeks ago, you would often expect a fixed flexion deformities. So the hip is in a more flexed position and this flexion causes them to externally rotate the hip as well. With this call again, as as it mentioned earlier, causes a limited internal rotation affairs. You can also in 20% of the cases, you can get acute on chronic presentations as well where um you would get features of both acute slip and tonics terms of diagnosis. Again, X ray is going to be your first time, but you can use other imaging modalities such as MRI or CT if this is not, uh if the X ray is inconclusive and the history is highly suggestive. So you have, you have to do both A P and frog like lateral views of both hips. Uh The positive finding is that the head of the femur does not appear about the clients like so again, if you look at this X ray, sorry, the images are not to create quality, but I I hope we can make out uh the the findings from this. Um So if you look at the right side of the patient, uh in this case, this is going to be a normal side and the uh and the clients line is indicated by the white line on both sides. So the clients line is gonna be the angle of your, of the neck of the femur and you draw a straight, so you draw this imaginary line across there and you see whether the head of the femur has indicated over here is above this line or not. So, in the, in the right side of the patient, you can see that the head of the female slightly above uh that line indicated by the white arrow as well. That means that it's normal. But if you go on to the left side, you can see that the head of. So fema is not about this line and this has highly suggestive of a slippage. Uh And therefore, we can diagnose this patient with SUFI hope that makes sense. Any, any questions regarding that or are we happy to move along? I don't see any questions. All right. Um So in terms of management, uh this is one case where you need early surgery. Um And the main surgical option available is going to be in situ pinning without forceful reduction. So what this means is that a screw is inserted through the great trochanter into the head of fema. And you don't want any forceful reduction as this would crush the growth, you want to maintain that growth it and Anchorage growth. But you just don't want the the family emphasis to slip out of place. So you just put a screw in to keep it in place, but you don't want any reduction. And therefore, this type of screw is particularly useful as this allows some compression as well. Uh osteotomy can also be used, but this is very badly recommended and therefore, uh we don't need to know much about it as well, but it follows the similar principles as uh we had discussed earlier with these diseases. As I mentioned earlier, 25% of the cases are bilateral and therefore, we should consider a prophylactic pinning of the other uh the normal side as well. Uh Again, there's not a decision that you would make, but you should just know about this, that that can occur bilaterally as well. And that, and you may need to operate on the other side as well. So that's that with SUFI moving on to the next topic, which is going to be septic hip or septic arthritis. Uh So what this means is infection of the joint. It can occur at any age, but most common in Children, less than four years, it is a surgical emergency and I can't uh stress that enough. Uh So if you do suspect a patient with septic arthritis, you need to send them to any as soon as possible or to orthopedics as soon as possible. Um, for immediate treatment because if uh the infection is left, if if the organisms or if the infection is left in the joint for too long, it can cause irreversible, don't joint damage as it can cause a damage to the synovial membrane. It can cause damage to the cartilage and finally, uh the bone itself and therefore, um cause irreversible joint damage and they may require it uh replacement as well and therefore, you need to um prompt treatment is very important. So how do you get this uh infection? It can be due to various routes, you can get through blood. So that is your uh um it genius uh spread. It can be through metaphyseal osteomyelitis. Uh When there is a there is a uh infection, the manifest is or the bone uh and that has transferred to the joint as well. We can be due to surrounding soft tissue, a soft tissue infection which then uh comes into they have joint or can be through direct inoculation either due to trauma uh mostly due to trauma in terms of presentation. This is going to be a rapid onset hot, red, swollen, painful joint. So these are your cardinal features of septic outlet is um in any patient that is presenting with, this needs to be seen by a specialist as soon as possible. The patient often refuses to weight bear because of the pain. There will be stiffness and reduced range of movement, both due to uh pain and you to swelling of the joint and they will have systemic symptoms such as fever, lethargy and sepsis as well. In some cases, in very early cases, they may not have any systemic symptoms. But you need to always keep this diagnosis in the back of your mind if they're presenting in this in this matter, in terms of your cost of organism. So for Children, less than 12 months, you will be worrying about staphylococcus or group B streptococcus between six months to five years. It can be staff uh Hemophilus influenzae between 5 to 12 years. It's staff warriors and from 12 to 18 years, it's going to be similar to your adults, which is Israel gonorrhea and staphylococcus aureus as well. In terms of diagnosing, you need a full set of bloods including an F B C E S R CRP, which are your info information markers and blood cultures as well. You always need to do an ultrasound, uh pus or minus an aspiration and this needs to be done before you give them any antibiotics. Now, very use useful criteria is going to be a proper criteria. And uh if any of these of the three features are present, there's a 90% chance that this patient is going to have a septic, uh gonna have septic arthritis and it's very important to uh check these features as soon as possible. So if they have an inability to wait there, if they have a fever, operated in 38.5 degrees Celsius, if the white blood cells or greater than 12, if the ESR is driven 40 or if they're CRP is greater than 20. So CRP is not in the actual cock of criteria, but you can use this as an indicated factor is um as well and it's recently uh included in uh recently influence this. Well, so these are, these features need to be kept in mind when assessing a patient who may be suggestive of skeptical titers in terms of your treatment, empirical IV antibiotics. Again, you need to follow local trust guidelines. With this for up to six weeks, need to be given as soon as possible if it is more severe. Uh So they have more systemic signs present as well than a washout and drainage of the joint uh needs to be performed and not to clear the infection completely. Again, all these patient's need to be monitored very carefully and very closely in terms of both clinical status and the CRP as well to see if the infection is settling down at all. So that's with septic arthritis. The next thing is irritable hip or transient sinusitis. And this has a very similar picture um to septic are threat and then very important to distinguish between the two. So again, let's break it down as to what transient synovitis actually means. So it is it temporary, that means transient irritation and inflammation of the synovial membrane of the jump or sinusitis. It is often associated with the recent viral upper respiratory tract infection or any other viral infection as well most formally. Uh and it's the most common cause of hip pain in Children under the between the age of three and 10 years. Um in terms of an analogy, this is very similar to meat centric adn itis. But in this case, it's not a lymph node that is affected, but rather or any gland that is affected, but rather the synovial membrane that is affected and it often follows any viral infection present as well. In terms of presentation. Again, as I said, usually occurs within a few weeks of a viral illness. It can be a acute or gradual onset as well. They may have a limb, they will refuse to wait, they may refuse to wait there, you can get. So if it's affecting the hip, you can get groin or hip pain, they will have a mild, low grade temperature, no signs of systemic illness, but you should have a low threshold to consider septic arthritis in most cases, especially if you're working in the G P setting. If you um see a patient that presents uh with this kind of picture, and you're still thinking it might be transient sign of Ettus and not separate cultivators. You still need to send them to the pediatric assessment unit and get them assessed by pediatrician before you can rule that out. So, but in terms of M C Q s, you need to identify that this, you're not going to get any systemic uh signs you have, you're gonna have mild low grade temperature. As we saw earlier, the cockroach criteria, the temperature was greater than 38.5 uh for, for septic arthritis. So that is again going to be a distinguishing uh factor. You will also not get a get hot, swollen joint with transient synovitis. So that is another distinguishing factor. Terms of diagnosis. Um In terms of examination findings, there's going to be pain and extremes of movement. Uh So it's, it's not going to be painful throughout your range of motion, but it's just gonna be painful in the extremes and there's gonna be no limitation uh motion as well. It is a diagnosis of exclusion. Therefore, you need to perform all relevant tests. And therefore, that's why you needed the further little pediatric assessment unit if you're in the G P uh setting. So you need to have normal bloods, extras, you need to have blood and x rays as well. And all of these are normal in kind of sinusitis. In terms of your management, rest analgesia is uh enough. You're just supporting, uh you're just providing supportive care for location before we move on any questions so far. No questions. Okay. Thank you. So then in terms of red flags and orthopedics for pediatric, in terms of a pediatric, pediatric history, these are the following that you need to look out for. So if you're, if you're, if you're getting a patient with acute onset, severe localized joint pain, that would be a red flag if you had an acute inability to walk or weight bear, if there's any concern about nonaccidental injury, this is very important in terms of pediatric orthopedics. So the signs that you need to look out for its awake history or delay in attendance for treatment. But other signs that you need to look out for, if the pattern of the injury, the mechanism of injury does not match um the, the, the injury itself. So for example, if um a non mobile child is getting, is getting a fracture of the shin or something like that, of the female or something like that, that is very unlikely to happen because you're not going to be falling anywhere and you need to consider uh nontaxable injury in that case. So again, your history is very important uh and the mechanism of injury is very important in assessing uh nonaccidental injuries, but they have a persistent limb for a grid in seven days or if you have night pain fever, weight loss, fatigue, and night sweats. So these again are red flags. Uh, in terms of your pediatric history, if you're ever concerned about non excellent injury check if the child is on a protection plan and if you have a name, social worker, intimate, you're seniors at the earliest. Uh you should not discharge this patient, you should not discharge them. So, uh the parents might ask what the carrier might ask. Can I take the patient home? Can I take the baby home? Uh, you should be firm in your decision by saying no until you get the MDT meeting sorted. Um And there are other things that we need to do as well such as during the bone scans, take a picture, photographs with the license camera as well of the different injuries. Um But yes, you should not discharge them until you have spoken to your seniors and had an M D T meeting and then to our final topic for today. Um apology or cancers or in Children. So you have what's your sarcoma? Uh This is the most common type of bone cancer in Children. It typically affects adolescents and younger adults. So between the age of 10 to 20 years, it most commonly affects the femur uh but can also affect other bones just the tibia and the humor. So it mainly affects your long bones in terms of presentation you can get. So again, as I mentioned, in terms of your red flags, you can get persistent bone pain worse at nighttime. You may notice a swelling for a palpable uh mass in that area as well. If there's not enough muscle bulk or uh it's some, some place like the tibia where there's not a lot of fat present as well. In terms of your diagnosis, an X ray is very important and this needs to be done within 48 hours. So we're disaccorded, very urgent. You can get a poorly defined pond Asian, you can get destruction of the normal bone and a fluffy appearance and this is very patchy um as well can get periosteal reaction which causes the the infamous sunburst appearance and you can get the card mons triangle as well. In terms we'll have a look at the exchange just a couple of minutes as well. Terms of your bloods, you can get raised the LP, which is a very good market for any bone related issues. Uh Other uh imaging that you need to do include CT MRI bone scan, a pet scan just to stage uh the cancer and also bone biopsy just to get your histology uh as well to make sure that this uh to check whether it is benign malignant or what treatment in terms of treatment, resection, resection of the lesion uh is required. And sometimes the limbo application may also be uh formed along with it. German chemotherapy is very important and uh became. But as always with any type of cancer is very important. Some complications of osteosarcoma can be that you can get pathological bone fractures because of the reduced bone quality. And therefore, um you may consider prophylactic uh nailing, which is that in the Bering, I am nail is inserted into the uh into the bone. Uh This can either be the femur or the to be uh and this is often reserved only for patient's with a high risk of pathological constructions. So this is the Cartman's triangle that I was talking about. So if you look closely, there is a triangle shaped lesion, uh there's a triangle ship just as part of the lesion over here. And this is very suggestive of an osteosarcoma. This is going to be a very late stage uh osteosarcoma and ensures the sunburst appearance very clearly. So as you can see this very austere reaction over here is very indicative of the sun uh called the sunburst reaction is very indicative of osteosarcoma. You can also see this very fluffy appearance uh through the medal uh of the femur as well in this ap view. And this shows that this patchy breakdown of uh the bonus. Well, you can uh if you strain your eyes enough, you can convince yourself that Cartman's triangular present over here here just around here, here, here as well. Um So this is quite severe and this needs to be uh dealt with as soon as possible. So, the next thing we have is even sarcoma. Uh So this is a small round cell tumor of unknown origin that usually affects uh people between the ages of 5 to 25 years. Um you can get, so in terms of your presentation, this would be with fever. Uh Plus the man is raised by, it sells based inflammatory markers and raised Elliot as well. Your diagnosis again is made using an X ray. Uh So you can see a dye official. Uh you can see a dietician, a large soft tissue mass present biopsy is often required as well. And again, with osteosarcoma, you need your other staging scans is birds, just CT MRI pet scan. Uh bone scan management wise surgical reception very similar to the previous one as well. Surgical reception is key chemotherapy, auditing therapy can be used both can be used as well and MBT uh involvement is very necessary again and an X ray, this is gonna be leaving software. So this is gonna be so this is uh an X ray that is highly suggestive of feeling sarcoma. You can see some soft tissue, you can see a soft tissue mass indicated with the red arrows over there. You can see some uh diaphyseal changes over here as well. And you can see that the onion you can convince yourself this is uh an onion skin appearance present over here. And this is very highly suggestive um in terms. So that's us done with the bulk of the presentation. Um So for your M C cues, if you learn this slide is very, very good because this is very stereotypical of the questions that you're going to get. Um and the questions are very stereotypical as well in the patient cohort uh that they represent. So if you get an infant or toddler with any kind of hip problem, it's going to be a D D hitch. If they're less than five years, you can uh consider septic arthritis or transient, you know what sinusitis if it's between 5 to 10 years, but this disease is going to be your best bet and if it's greater than 10 years, uh and if they're obese as well slipped up a feminine emphasis or sufi, it's going to be um for diagnosis in all age groups, always consider trauma including non accident injury. Uh And this is very important, some of the topics that we did not cover today, but it's not highly um likely to come up in pediatric orthopedic section is gonna be different types of fractures that you can get in Children, but this is not going to be different to what you would get adults as well. And the principles of management are going to be very uh similar in both. So, uh not going to go much into much detail with regards to fractures uh and Children before we move on to the questions, do we have any questions from the audience? Anything that needs to be clarified? Or are we happy to move on to some sample? Um Scuse, I do not see any questions so you can move on to the um secure. So perfect. Um So if there are any questions just let me know and I would like some audience participation uh for the next section as well for our sample MCQ. Uh So if you could just put your answers down in the chart, that would be very, very helpful. So for our first question, we have a six year old boy who presents to the E D with a limp and pain in his right hip. This has been ongoing for months but worsened in the last few days. Otherwise, well, usually active, no history of trauma and no recent illnesses. Examination reveals pain and passive movement of the hip observations and bloods are normal. What is the most likely diagnosis? So let's give you a minute over there to uh send through your answers and then discuss if you could pop in your answers in the chat book. That would be great. Yep. So I see one on today forties. Anyone else wanna try and answer this question, make a guess, calculated guess, firm decision or I'll be happy to move on. All right, I guess in the interest of time just gonna move on. So yes, the correct answer is going to be parties. Um So as we mentioned earlier, the age, the age group is um highly suggestive of that. There's no history of trauma otherwise. Well, uh there is pain on passive movement of the hip. Uh and the floods are normal. So you can rule out uh fractures, you can rule out septic arthritis, you can rule out directable help. You can rule out D D H as well with the age group. And you can essentially rule out Sufi as well because they are, is like the younger than what you would expect for uh Sufi as well. So parties is going to be the answer for that. The next question, I'll let you read, you read it yourself and just pop your answer in the chat. Um When you're ready again, I'll give you a minute. Anyone fancy a goal? Yeah. Yeah. So we have a couple of answers there. Um All suggesting Sufi. So yes, the correct answer is going to be Sufi. So again, the stem uh clearly is very stereotypical of uh presentation for SUFI as well. So you have a 15 year old boy intermitted right hip pain with associated them penis person movement. There's no history of trauma can see that it is flexed and externally rotated, this limited internal rotation and abduction of the right leg. The patient is also uh slightly is overweight uh and this is all highly suggestive of soupy. Then we have our last question there. So it's a three year old boy presents to the any with Lim. Um extremely left the chick at home and refused to put any pressure on his left leg due to have pain otherwise fit and well, I had a throat infection last week. Examination reveals mind lee swollen in arithmetic, left hip, uh limited range of movement and all pains do two planes. You're a pain, vitals are temperature is 37.2. Portrait is 1 20 for respirators, 22 oxidants. After 98% bloods are unremarkable. So what is the most likely diagnosis gonna give you a minute for that? Um Yes, this could be slightly confusing given the history but really. Yep. So I see a couple of people going in for deep. So, yep, that is the correct answer. So it is going to be eligible hip. Uh So the key so you can get confused between septic arthritis and irritable hip. Based on the history about with the vitals are very important in this case. Uh 37.2 degrees. It's not that uh it's not uh indicative of fever. Heart rate is normal for a three year old, respiratory normal for a three year old oxygen sats are normal bloods are normal and they have been they have had a throat infection last week. So this is again uh suggestive of political hippo transition synovitis. But again, it's easily confused with skeptical Thetis. Um Therefore, you need to reach them very carefully and that's us for today. Thank you for attending this talk. If you have any questions, you can pop it in the chat box now, or you can always send me an email or uh contact me by a messenger and that's my name there. Thank you all for attending. Thank you so much. Now, Drew, that was an amazing talk. Um I've sent in the feedback link in the chat box. So if you guys could fill that up and then the catch up content will be available in the next couple of days with the slides as well and the certificates will be added to your medal account directly. Um We will stay about for a couple more minutes. Are there any questions? Um And again, we do aim to run these sessions every week, every Monday around six PM. So please do keep a lookout for these events on our metal page as well as uh as our social media pages as well. So we look forward to seeing you again in our future events and thank you so much. Thank you, everyone.