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Mike Doc. Hello. Can you guys hear me? Yeah. Yeah. Yeah. You that right. Yeah. Hi guys. My name is Jack and you guys can see my cursor and everything. Ok. I'm one of the I show in orthopedic and we are starting the teaching is about pediatrics, supracondylar fracture. And so, so the learning outcome is basically is mainly targeting the sho junior level. Uh and below is for so that we understand so that we will understand the basic osteology of a distal humerus and able to distinguish, distinguish the type of pediatric uh super fractures and able to manage it. So we don't, we are not panic over at night time. This one, two sides. It still, it still slight changing. Can I go back to see more or? Oh, good. It's ok. And so it is very common in, in the Children. It's uh it's usually a foot injury and it is commonly between five and seven years old, male equal to female. And then this is just a quick post about about the, the, the joint, the elbow joint you got laterally. You have a lateral epicondyle and then you have capitum trochlear media epicondyle radial head. Yeah, you have to, you have to come out of it. It doesn't work. Now, can you guys see it? Ok. Sorry, there's a bit of clinical issue but um fine. So you got a lateral down here, a bit of throat, clear media, epicondyle and radial head. So there are the time when it, it fuses together, but I don't know the ossification. So it shows on the X ray is a cri to. So um one year, one year old for the C 3579 and 11. So it's like a old number basically. And then you just go down with a cri to OK. And then this is just more structure in depth. So you got your around there, you got a brachial artery, it's running down there. This is just a 3d image of it, of, of an adult. This is an adult but it's similar similar. So you got a radio art artery, uh sorry brachial artery down there becomes nine and ra and nine radio artery down there. And then you have a nerve behind and then you have a, you have um you have this median nerve test, yeah, median nerve and then you have uh you have your right, you have your, you have a radial nerve around here over the lateral side of it. So those are the important structure when it comes to the injury so that we can assess the feature of neurovascular. But if there's any neurovascular deficit. So, clinical presentation is usually people coming with pain, refuse to move uh the elbow. You can see some growth deformity around here and then you see the swelling and chemosis probably crying because of the difficulty. Uh everyone's panic and nurse will be shouting, but don't worry. After this course, you will not be panicked. So you got a, you, you got some sort of um what, what they call is a brachialis or Parker sign it and it may present as a median nerve injury and uh or like brachial artery inju uh injury. In that case, you may feel like uh you may not feel the bra pulse and then it it is mainly because of the proximal fragment may have button hole through the brachial muscle. So it just pressing it, pushing it out, pushing things out a bit. Uh The clinical assessment here, I'm just going down with a a boost the boost of British or Orthopedic Association Center for Trauma Guideline. They say we need to make sure we have a clear documentation. It's very important on presentations. And right before the surgical management, if we are going down the surgical route. So make sure you, you mention the radial pulse, cap refill time. Make sure you mention the radial nerve functions, median nerve function, including the anterior dose nerve interior in dose nerve is the model branch of it. So you can say, oh, the patient can feel the median nerve, um me, median nerve, uh sensory sort of cutaneous sen sensation area, but you must make sure you may also mention the the motor functions and then outline also the outline of function. So on your neuro examination, make sure it is done before the maneuver before you reduce it. So, so you we can rule out the the injury was not due to iatrogenic, it's not caused by the reductions. Otherwise people always sus suspect that it's due to the reduction of man or maneuver. So, anterior inter nerve neurop. So in that case, patient may not flex the IP joint, interphalan or D I PJ because it in innervate the, the flexor digitorum profundus. So in that case, you will see if normal, you see a proper OK. But if it's, if it's not OK, you don't see the OK. And then if you, you can say you can say that loss of sensation over over the B aspect of the finger and then also the, the median nerve also innervates the anterior compartment of the forearm. So the flexion of the wrist will get affected and the radial nerve is basically unable to extend the wrist finger sometime fi in finger, it, it, it is not that accurate. M CPJ. Yes, but in D I PJ, extensions or P I PJ uh extension, it may be affected by the intrinsic nerve of the muscle. So, so make sure you tell the patient try to move their wrist. And then also a is a nerve is mainly innovating your, your, your interesting muscle of the hand. So finger abductions, abductions. So vascular vascular examinations, you, you may, you may encounter many situations when you feel, when you feel it, you either feel the pulse or you don't feel the pulse. If you don't feel the pulse, make sure you find some biphasic Doppler pulse to check whether if it is present or not present. And there are situation where if you can feel a warm pink and cold pale and the cap refill. If it's more than two seconds, it's very important to. This is just a schematic illustration of it. How, why when you, when we see the brachial is uh sign or like how the there's a, there's a potential problem if we mani uh if we manipulate or we try to reduce it because the brachial artery may get caught by the fracture fragment if you can see this and imaging. So this is where the, the CTO all the bones around there. So how are we going to evaluate it? Ba basically, it's just there are a few way of evaluating it. 11 is you can see the anterior humeral line in, in an older kids, it will tend to go at intersection anterior one third, middle, one third of the capital of the Children. If they are young, they will be just touching. Yeah. So if it's still presentations, it will be, it will be shift in front because U usually sometime during the flection or extensions, it, it will just off the line. The the anterior humera line may move anterior because of infection type injury and then it moves poster if it's in a type injury. So bowman angle is another way of evaluating it. So you find a, you find the, you find your cap and you draw a line with your, with the anterior anterior humera line. You find an angle, the angle is between 64 to 81 angle. You always compare to the opposite side to make sure it's not to make sure they are similar because it varies between so more than 10, 5 or 10 degree variation, which is kind of accepted. Yeah, it's constant abnormal. Also, by the way, there is a posterior side where you see the shadow here, it's also indicating some fracture. And then broadly speaking, these are, these are when we, when it comes to classifications, they are extension type where the, where the distal fragment goes post theory and also flexion type. This is where it's speaking. But there's another classification is called a gland classification. There is a type one, it's not not so not displaced. Type two, you get a bit of displacement, you can move to one of the side, but the posterior cortex still attach because the bones are kind of probably green type of a thing. And then type three is talking about, there may be some rotational deformity and then type four is basically complete disruption. So when you have type one, type two is the attached. Type three, type three is attached but it down into two di two, set of um dimensions four is all, this is the treatment. So type one, it can be immobilized 3 to 4 weeks. And then we, we have first week or one week x-ray interval just to make sure it doesn't move too much. Type 234, when it surgery, it just depends on the urgency. So um this is the complication if it doesn't get treated well, it it's called cubitus of virus elbow. So you see a big be of elbow after it is quite late, very late. So treatment nonop you can do it with a long cast arm with less than 90 degree elbow flexion for type one, type two with specific precautions. When, when, when we can see humor is still is one thing, minimal swelling that's known the me side is still in 10, ok. You can do it for three weeks, keep it on three weeks. You can see in pressure clinic and then we repeat x in 11 week in between operative is what is what they call either close reduction or open reduction, close reduction. Many for type two and three. And it usually used on a flection type. And media column is usually uh when the media is uh is co and if they are warm and perfuse well, without neuro def, you know, you don't have to rush too much. You can wait overnight, you can admit them overnight time just to keep observations in case and an urgent or to do not wait situation. So this the the picture behind should be at at the front but now I can't edit because this is hospital computer, sorry. And so so in this, in this case, uh the do not waste situation, you may, what you may see is pulseless but well well produced pen, you may see a pink but you can feel the pulse. This is something that you have to worry when when there is a sensory enough deficit, excessive swelling is you know, when the swelling is very big or you can see a brachial sign sign is what I mentioned earlier. You know, when when there is a sis at the front, if you can see this emos you see a dim, you may see a button, you may feel the fragment at the front at the aspect of the of the upper arm. And because of the of the bone pregnant out. Basically, that is when you need to worry, a floating elbow is when there's two part of fracture. So sometimes when you are doing like whatever night shift or something, you may get a super fracture. And also patient also have some uh forearm fracture like arm fracture. So you may not connect it, make sure you connect to link basically the elbow, the elbow is floating. This is something quite urgent. This is for type three fractures. And what are we going to do? A flow shot? You know, you have a with ent pulse but with adequate perfusion, you go down the road of reduce fracture and clean for temperature and observe the color and make sure the color is nice. You can ait overnight for observation, elbow in relaxed position, do not hyperflex the positions if it's powerless and in the extremity and it's not and tell. And you, you, you try to reduce, reduce the fracture and thin it if it goes back to pink and but again, you go back to observation. If it remains the, then you probably need to explore the artery break three. So emergency vascular explorations or C RPP means uh for if you have a pulses and why if it uh like P per and that lost power after you do something that's when you try to do a Bachelor declarations or plus minus the exploration when you have a fracture, obviously, when you have a close reduction and PP A white hand that is unable to be reduced, all the de is remaining. So those uh the slide show was basically uh designed or I made it according to what I mean, I guided by this um standards for practice and then some and, and then what, what they usually say is that uh the sur the surgical manager management usually is done in daytime, nighttime operation is not necessary unless there are indications it's quite debatable. Sometimes surgeons say yes, sometimes they say no. The best thing to do is as an level and then surgical management should be provided urgently if there is an ra sign of impact perfusion of the. So it may look nasty, but as long as it doesn't take the sign, you still can come down a bit compose yourself, but try not to panic even if you see this because we know what to do next. You have to escalate at a level to this is just a longer sort of uh this is just a full standard. I don't think I have to, I need to go through it just on the online. Yeah. And thank you so much. This is my presentation. Any questions uh uh any questions? OK. One, you know, hi doctor. You're welcome. Bye. OK. Yes, you're welcome. Yeah. Is that long sleep? Oh, that's what what we mentioned here. Uh It's a long arm cast is your plan. So with cast with less than 90 degree flection, if it's a type one, type two with the, with the criteria as we mentioned here. So if the anterior humeral is still the with the minimal swelling and there is no combination as in uh any question next. So the key point is don't panic and then we can go down with a boost guideline if the pulse is ok. If the nurse is functioning fine, we got t it and if panic with the rash, this is the answer. Bye. Any more questions guys? All good. Thank you so much. And there is a feedback form for the attendance and once you finish your feedback form, you get an attendance and certificate. Thank you so much guys.