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Now. Ok. Um No problem. Yeah, perfect. Ok. Um So first of all, thank you everyone for joining us today on our fifth um talk on our um orthopedic um teaching series. Um Today we have um Mister um Viola who will be giving a talk on pediatric orthopedics. So, yeah, I think I'll pass it on to Mister Biola and then you can get started. That would be great. Yeah, that's great. Uh Thank you for having me. Uh So as you said, my name is, I'm one of the registrars on the Birmingham program. I used to be a Birmingham med student not too long ago. So I kind of know a bit about the curriculum and what you guys go through. I know you go to Roh, I don't know. Uh in terms of groups, have you got all 3rd, 4th, 5th years or is it, uh, is it a mix? I'm not sure. But anyway, we'll get started. So today I'm just gonna run through a few sort of pediatric orthopedic topics. I've got these from these sort of B OA curriculum and these are kind of some, a few things that I think are useful to know as, uh, as an F one day one, F one, where you're gonna be in GP, you're gonna be in A&E seeing these kinds of things come up. So having a system in place to look at these, look at pediatric patients and their orthopedic presentations is useful in terms of what we'll go through. So we'll look at a few common pediatric orthopedic conditions, think about some red flags and think about a few sort of management principles as well. But we won't delve too deep into that. Um, I'm happy to take questions as we go through. I do have some cases. Um, so if people wanna those some answers in the chat, that's absolutely fine. If not, we can just run through it like a sort of lecture. Er, great. So the most common presentation with Children is a limp and Children are, are a bit different to adults in that they won't necessarily tell you exactly where it hurts or what's going on or a detailed history of their presentation. So, uh, and they could have anything from, say, like a splinter on their foot to a bone tumor. So it's very challenging unless you have a good system in place to, to figure out what's wrong. So, but always as, as you know, with the med, uh, in med school, you're taught to take a good history. So you want to know the characteristics of the pain, uh, in Children, you always want to be thinking about non accidental injury. So, have they had any trauma? Does the story line up? Um, have they got any symptoms of infection? So have they got any fevers, recent coughs and colds, rashes? And then have they got any sort of other tumor like symptoms, night pain, night sweats, weight loss, and then any pediatric history, you want to know their milestones? So when did they start walking? When did they start crawling? Was that all normal? What about the birth history? And this will come into play later on when you go through some of the cases. Um But when were they born, were they born premature? Were they born by ac section or vaginal birth? Was it a breach delivery? All of these things are important and then you want to know in terms of social history. Have they had any social issues before? Do they have any known social worker? Um because obviously that's gonna affect your management. Uh Less. So, I mean, more in teenagers, you might ask about smoking and alcohol as well, uh But less important in the younger Children. So then the next step is obviously going to examine the patient and here having a system in place uh is useful. So whenever I see ap child with any limp, any joint pain or problem, the first thing you need to do is ask them to walk and observe their gait. Um So you see them walking, you're looking at everything so you want everything exposed. So, uh, if they've got BERS on, you need to see from the hips downwards, you need to look at their spine. You need to watch them walk for the first, uh, for a good few minutes. See if they can walk on their toes, see if they can walk on their heels. See, look at all the joints, what are they doing? Are the knees, knees, hips are they able to weight bear? So those are all important. And then you do a systematic examination from the spine down to the ankle. So look for your move. So look at the spine. Do they have any scoliosis? Any curvatures that you haven't picked up, move their hips around? Is there pain in the hips, knees, ankles, what's their range of movement like? So with this kind of systematic approach, you won't end, you won't end up missing key things in the in the examination. Then in terms of investigations, any child with a limp, it's always necessary to get blood tests cos you want to rule out the infection. So you want to know what the, what the inflammatory markers are doing. Then the next step as with any orthopedic case is we want x-rays and we always get two views. So for the knee would be an ap and lateral X ray and then for the hip, um what we usually get is what's called an AP and a frog leg, lateral view. So that gets similar to a lateral view of both hips at the same time. So this really helps us tell, uh give us an idea of what's going on. And particularly if they've got a limp, I would always get x rays of both the hip and the knee because commonly pain is referred from the hip down to the knee and vice versa. So they might, they might come to you with knee pain. But actually the problem is more proximal up towards the hips. So, having an api and frog leg views of the hips really gives you a good idea and helps exclude other problems. Um, but we'll come on to that later. So, so the first case, we've got a four month old presents the ed with thigh swelling for three days. Ok. So if anyone wanna write in the chat, what they can see on the X ray and what they're concerned about, ok. I don't know if the chat working or not. That should femur. Yes, that should femur. So would you expect a fractured fem? Is that normal or abnormal in a four month old child? Would you be concerned? I'm probably, I'm leading, I'm leading you to the answer. But yes. Um, so in any child that's non ambulance, meaning that they're not walking. This is highly, highly unusual. So, um in this, in, in this kind of scenario, the foot, the automatic your all bells should be ringing that this is a non accidental injury until proven advice. So these are cases once you see them in A&E they have to be admitted into hospital, they have, you have to get the pediatric team involved, you have to get safeguarding involved. There has to be a detailed investigation because this is a not a common injury in that age group. If they're not, if they're not mobile, you know the Children, if they're 234 years old, then possibly you still, you still have a suspicion, but then it's more probable that they can, they could have fallen over and had this kind of injury. Um So this is non accidental injury until proven otherwise. So with non accidental injury, there's a lot of clues that you can gain from the history. So you talk to the, you talk to the, to the mother, to the father, you get an idea of when the, when the injury happened, did they present late? Have they had similar injuries? Have they presented to A&E before? Have a full look, you know, in terms of examination, top to toe, have they got any other bruises? Any other uh any other features on examinations such as retinal hemorrhages or bruising around the head, unexplained injuries. And the most important thing is to find out exactly how the injury happened. Um Cos most of the time in these cases, the mechanism doesn't really line up with, with the injury. Um And that's, that's the biggest clue that you can, that you can pick up. So that is non accidental injury. So, the next case, so you've got a two year old presents to a GP with a non painful limph. So they don't have any pain. But they've mum has said that they've been walking funny since they started walking and they've noticed that the one leg is slightly shorter than the other. The bloods are normal. OK? To give you a clue, I'll show you this x-ray. So it's an ap pelvic x-ray. Anyone tell me about what's going on here. Well, at least tell me which side is abnormal. I know you're not probably quite well used to looking at pelvic x-rays but like anything in the chart. Mhm No, no volunteers. That's fine. Um So goofy, not quite. So, so if you look at, look at the uh look at the hips in particular. So this is a, this is a patient's right hip. So you can see the, yeah, so abnormalities on the left side. So you can see the A acetable just about and you can see the right hip is centered right in the, in the acetabulum. So if you look at the left hip, you can see that it's migrated superiorly and it's also migrated laterally. So the left hip is not in the joints. So this is dislocated. So, what I was getting to here is what's called D DH or developmental dysplasia of the hip. So this is a, a problem with development of the hip joint. So that can result in the hip joint being subluxated, so slightly out of the joint or completely dislocated. Um It is quite common. It happens in about one in 1000 births. It's relatively common. We do screen for it. Uh Well, the pediatricians screen for it in uh yeah. D DH. Yeah. So the pediatricians screen for it when the baby is born. So they'll do a balo and no test which I'll explain in a second. So PDH has, we don't exactly understand the full length of why this happens. There's various risk factors that we know of. We know it's more common in females. We know it's more common in those who are first born and particularly those who have a first family relative or who present by a breach, breach birth. And uh we can also do what's called a Gallii test. Um We might have a picture of this later on, but it's just basically where we lie them down on the bed, bend the knees up and then you'll be able to see that one leg is slightly longer than the other. In terms of treatment. It depends on the age that we present that they, that we catch it. So if you catch it at an early stage, so either when they're less than six months of age, then you can actually manage this non operatively by putting them in what's called AP harness. And if they're older than six months, it typically means that they're going to need surgery. So that's why it's so crucial for us to pick these up early on so that they can get treated and not have to go through, uh, the, uh, arduous headache of going through multiple operations. And, uh, and ultimately ending up with a, with a worse outcome. This is what's called the Barlow at Alto test. So, uh this is commonly done in a newborn. So in the, the first six months of life, you can do this. So what we're aiming to do with the Barlow test is we, we add up the hips, so bring them together and then we depress down on the hips and the aim is to try and dislocate the hip. So you should feel a little bit of a clunk uh or a little give as the hip comes out. And then when you do the otala test, what you're trying to do is abduct the hips and then elevate them. So to bring the hip joint back in. So uh a positive Barlow test is if you're able to dislocate the hip, you feel that clunk, you feel that give as it dislocates and then you feel another clunk as you try and bring the hips back into place. So, remember, this condition is not painful. So in a newborn, you're not going to cause them discomfort or anything by doing these tests. But it's very useful to give us a guide. And then we will then arrange further imaging ultrasound uh or X ray to determine whether the hip is and joints or not. And this is what I previously mentioned, the Gallii test. So you lie the child down, you bend the knees up and then you should be able to see the length of the leg that one legs slightly higher than the other or shorter than the other. You'll be able to see that. And obviously, the leg is short because as we saw on the X ray, the hip has migrated superiorly and laterally as it dislocates, that's what it means. One leg is still shorter than the other. So this is a very useful test to perform in these kids. So this is just for demonstration purposes of what, what AAB harness looks like. Um So they basically wear this for 23 hours a day. Um Yeah, it basically brings the hip up into a position that allows the joint, the hip joint to be relocated and it basically holds it in that position. You can only do use it up until six months of age. Um Cause after that baby stop just lying on their backs and they start crawling and then you can't use it anymore. Um But it's a very useful uh useful tool to treat these patients. OK. We'll move on. So I've given you the answer there. That's a shame. But anyway, uh, so the case three. So this is a five year old boy presents to the emergency department with a two day history of right hip pain and limping. So, the clue here is that they've got a mild cold a week ago, uh which is resolving on its own and then examined them. The temperature is not massively raised, they're limping, but there's no swelling, no warmth. The blood's not massively abnormal. The X ray is normal. What's the diagnosis? Well, you're thinking transient sinusitis. So, transient sinusitis is the typical history is ac a kid who's had a cough or a cold in the last few, the last week or so and then suddenly their hip starts aching or, and they start walking with a limp. That's your kind of typical sort of M CQ. If it comes up in the M CQ, that's the history. Um The reason it happens is kids often get, it's, it's kind of like a reactive arthritis. So similar to adults that they've got, if they've had a uti, they might have a reactive arthritis in the um in the hip or in the knee, similar, similar in Children, but it's very, very common. And what we use is what's called Cocker's criteria. So, coccus criteria is a set of sort of prognostic cri diagnostic criteria that allows us to distinguish between transient sinusitis and septic arthritis. So, if they've got a fever, if they're not weight bearing on that limb. If their white cells are raised, if their E SR or their C RP is raised, then you add those up and then if you've got all four of all four of them, your likelihood of septic arthritis is 99%. So this, this is based on a, a study that was done uh by uh Cocker as, as, as the name suggests and it's a very useful tool. So usually when I'm seeing patients in A&E, I'll, I'll think about all of these different things. So I think about if they've got fever, if they're non weight bearing and then if they, if they're having more of these criteria, then I would be thinking, OK, I need to admit this patient. They need to be, I need to involve the orthopedic team here cos it might be a septic arthritis. Whereas if they've only got one or less than one of those criteria, then uh they might be safe to go home and just follow up in clinic. So that's how it's useful. Uh You still have to use your clinical judgment. It's not like any tool in medicine. It's not uh a definite, this is, this is the gold standard and you follow this through the LA. But uh it's a useful, useful tool to guide your judgments. So, so if the same child comes back, um I don't know, it's, it's, the animations aren't working on the slides. I apologize for that. But um so the same child comes back with a temperature, unable to weight, bear their bloods are raised. Then you're worried about septic arthritis. Of course, uh septic arthritis in Children is more urgent than septic arthritis in adults. Uh The reason for this is because in Children particularly w what happens is as the joint fills up with pus and fluid that pus um cause this what's called chondrolysis. So it breaks down all the cartilage in the joint and it's, it's basically an emergency. So if a child presents with as septic arthritis, we would want to wash it out as soon as possible. Uh So even overnight if that's the case, which we don't tend to do in adults, we generally, if they're, well, we would wait until the next morning and these can be, these can be have devastating consequences. As you can imagine if the cartilage wears out in a child, which is uh 10 years old, then they're looking at a hip replacement when they're 2025. So it's not a good, not a good outcome. So it's really, really important, uh, to catch these, uh, or be aware that's uh these, this, this can happen. So the next case. So you've got a six year old child who's brought in by his GPS complaining of three months history of the right hip pain. So it's gradual onset. So, come on about a few months, it's worse for activity, but improves at rest, there's no history of trauma or injury. Um He's got limited internal rotation and abduction of the hip and the bloods are normal. You get an x-ray, this is what it shows anyone can tell me diagnosis or tell me what they can see on the X ray on the top. I'll give it a minute cause I think that is a bit safe. No. OK. So yeah, perfect. Yeah. So again, so always compare the size when you're looking at a hip X ray. So you can see right side, got a nice full uh This is your epiphysis, this is your growth plates here. Um So you can see it's a nice uh full epiphysis. You can see the, the curved shape, it looks like a nice uh spherical around femoral head. And then on this side, you can see the epiphysis is what's called flattened. You can see there's areas where that's more gray than others. So that's what's we have sclerosis and there's areas where it's, you can't see the bone at all. So that's areas of lucency. So that is very much in keeping with Perthes disease. So, Perthes disease is what's called avascular necrosis of the uh femoral epiphysis. So, lack of blood supply. Again, it's one of those things, we don't fully understand why it happens. There's a lot of different theories. Um But if you imagine if there's lack of blood supply, you're gonna have areas of dead bone and then areas where it's starting to remodel and that's why you get areas of sclerosis and areas of lucency. So, so this is commonly in age groups of 4 to 8. So, um it can commonly pick up uh findings on X ray, but sometimes if it's very early stages, you might not be able to see it on x-ray. And in which case, you then need an MRI scan to help diagnose. Generally, if they present at a younger age, their outcomes are a lot better. They don't tend to need surgery. They can do with just activity modification. Meaning we just tell them, um, can you s uh avoid sports or any big physical activity for a period of time? Give them physio to maintain their range of motion and then they tend to do very well. If they're over the age of eight, then we tend to do, tend more to lean towards surgical management. Uh just because they don't have to have good outcomes. Uh, they don't tend to have good outcomes with conservative treatment in that age group. And the reason for this we think is because in younger Children, they have more growth, more time for the bone to remodel. So they therefore tend to do better without surgery. Ok. So we'll move on to the next case. So we've got a 12 year old obese girl who presents to Ed with a two day history of pain in her left hip. No history of trauma on examination. As you can see, she's walking with an antalgic gait. She's got pain on hip movements, including hip flexion investigations. Your blood tests are normal. You do an X ray. This is your A PX ray. So that looks fairly normal. Nothing out of the ordinary there. But when I know you get a, this is why we get two views. So we get a, a frog leg view, you can see something uh abnormal in this hip. Again, it's very, very subtle. Um But so if you imagine a straight line going across this ridge of the femoral neck, if you follow that line, it's not quite continuous um with the epiphysis. So this epiphysis has slipped i inferiorly. So this is what's called a sufi or slipped upper femoral epiphysis. So this is more common in obese Children. Uh It's also common if they've got preexisting endocrine disorders, thyroid disorders or hypogonadism. And um what again, it's not something we fully understand, but we, we know that something happens to the, to the, to the growth place and particularly in obese Children. So imagine the stresses going through that growth place are more if they've got, if they're heavier. And as a result, it's more likely for the pfizers to slip. The reason we're concerned about this. Um cos one it can slip even further. And if you imagine the blood supply to your femoral neck is coming in a retrograde fashion up here So if your piss is slipping all the way down here, that's gonna affect that blood supply and they end up with a avascular necrosis. They get degenerative changes in the hip. And as a result, it's, it's uh it's a problem and we treat this essentially with in situ pinning. So we just put a big screw all the way up into the epiphysis to fix it in place like this. So that basically stops it from slipping further. And then you can see this, this child has al also got a slip on the other side. So yeah, uh it's SUFI, so this is just a summary of what I've talked about. So based on the child's age, you can kind of gauge what kind of common causes of limp in that age group. So if they're for all ages, you're thinking about infection, you're thinking about malignancy, you're thinking about trauma, you're thinking about non accidental injury. Um But in terms of your other differentials, you can think if they're less than three, it could be D DH if they're between the ages of three and 10, it could be Perthes disease. If they're more than 10, it could be ACP. Uh There's obviously various other causes as well, but these are the important ones not to miss in our, in our case. So we'll just quickly go with some other pediatric presentations. Uh because these, these tend to come up more sort of in MC Qs So a three day old infant is born 38 weeks via vaginal delivery. There's bilateral deformities of the foot at birth. So, this new, uh, no family history, your birth weight is normal. You look at the feet, it looks like this. Anyone know diagnosis. Give it about 10 seconds. It, again, another very common orthopedic presentation. Yeah. Club foot. Yeah. Good. The club foot is a congenital rigid deformity of the, of the feet. Um, again, it's one of those things we don't fully understand in, in certain neuromuscular conditions it can be associated with. Um, but, um, it's one of those things you don't fully understand there's various theories for it why it happens. Um, the good thing is that we now have a very effective way of treating these, these patients without surgery and that's what's called ti casting. So these, these are the kind of deformities that we s that we see. So the foot gets supinated, it goes into various alignment and then the ankle goes into a qui so that the toe is pointing downwards. So what we do is we try and correct all of those deformities with a series of casts. So the plaster technicians will put them in a series of casts for different numbers of weeks and try and basically mold the foot back into position and actually, it tends to work really well. Most of these patients will do absolutely fine with pontic casting and never need any more treatment. A few of them might relapse later on in life and then will need surgery. And that's when we, as the orthopedic surgeons tend to come in. So, after they've had a series of calves, they go into what's called boots and bars. So it's basically 22 boots and a big bar stretching up up. So that's to hold the foot in position again. They wear this for, I think, 23 hours a day, uh taking it off for an hour just for cleaning and hygiene. Uh But other than that, and this actually tends to work very, very well. So the next one, a seven year old falls off a slide onto an outstretched arm. She presents the ed with the following X ray. The arm is to fall and the hand is pale and there's no radial pulse. Anyone know what or we know it's a fracture and you can see something there, what type of fracture this is, give it 10 seconds, you know. So we're looking at uh essentially a lateral view of the elbow here. So this is in the supracondylar region of the frac of the humerus, there's a supracondylar fracture and these are very, very common in Children in incredibly common. And the biggest problem with this is I I'll explain. The next slide is damage to the neurovascular structures. So the brachial artery runs just in front of this bridge here. So it's very common for these fractures. To either impede blood flow through the brachial artery or completely disrupt the blood flow altogether. Um So that's why we are very, very cautious with these injuries in Children. If the, if the arterial blood supply is, is interrupted, it becomes an emergency. And we do have to operate on these fairly quickly to try and get the fracture reduced. And we may even open up and explore the artery if it's very, very badly damaged. They, so any upper limb injury in Children, we want to do what's called a full neurovascular assessment. So we want to check all the nerves are working. So median nerve, radial nerve, ulnar nerve, and also the anterior interosseous branch of the median nerve. So in Children, it's very easy to do this with a game of rock paper scissors. Um So that's something you will encounter a lot in A&E uh you work. So, and that's pretty much it. That's a bunch of sort of run through of all the common pediatric cases uh that you'd expect to see as a, as a foundation doctor, any questions at all? No, I would very much appreciate if you can just fill out this feedback form. It just helps me sort of guide future sessions and think about how I can make things better for you guys. Um Let me know if there's any questions or anything else you want to know about. But uh I think that's it. Thank you very much. Mister Biola. So, yeah, if everyone can um fill out um the feedback form, that would be great. And also, um I think we've also got a feedback form if possible. Um I, I'll see if I can, I'm just gonna send it out. And then after um you've completed both feedback forms, then we'll be able to send you a um confirmation like letter um to just show that you've attended the session, um um which would look good on, on your CV later on. So that would be great. Thank you very much for joining everybody and thank you very much um Mister Biola for um, no problem. Thank you for having me such a very insightful talk. I think it's very useful for um year fours and um your fives, especially because we've both got, um we'll both be tested on orthopedics. So, yeah, that would be great. Yeah, thank you very much. No problem. Thank you. Thank you. Thanks.