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Paediatric Orthopaedic Spotters for Orthopaedic Exams
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Paediatric Orthopaedic Spotters for Orthopaedic Exams
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Language: EN.
Segment:0 .
Good evening, everyone, and welcome to this evening's session, which is a joint teaching webinar between the FRC mentor group and OK. My name is Nicky Evans and I will be your host for this evening. The rest of the faculty include Imogen and Hannah from our UK and my fellow mentors Sian Harney, David and Hassan.
This evening, we are delighted to welcome Mr. mark Latimer and Mr. David, who are both consultant orthopedic surgeons at Addenbrooke's Hospital. Mr Latimer graduated from both Oxford and Cambridge in 1997 and did his orthopedic specialist training on the East Anglia rotation and Cambridge. He was awarded the prestigious fellowship in Sydney and worked with Doctor David little, and earlier this year, he was awarded the certificate of excellence from the I want great care group.
So this evening's lecture will be more interactive than usual, so we will be having some case discussions with some teaching points and tips for the exam throughout the webinar. And for that reason, we'd ask for people to volunteer to have some viable practice with Mr. Latimer and Mr. budoff during the session. Now, this part of the session will be recorded, so if you don't want to be recorded, please let us know.
As always, we ask if you have any questions to put them in the chat and we will keep an eye on that. We'll ask any questions at the end of the session. Any participation, any participants who wish to stay on five practice. Please raise your hand and let Hannah and imagine know whether you want to be part of the webinar or whether you want to be the practice at the end or whether you want to do both, which is fantastic.
We do understand that putting yourself forward in this forum is really stressful, but we're all here to help. All of us have been through this and it is the best way to get that training that you need for the exam, particularly with regard to your technique. And you know, as we all know, having passed the exam and quite recently, we've had some positive feedback from people who've been in this group as a participant who also passed the exam in the last week.
So congratulations to them. And so this way of teaching does actually work. So our next course for the exam will be on Thursday, the 2nd of September, and there are participant and observer spaces available. You can book this via the UK website and it's on a Thursday, so you'll need to remember to book study leave early. We recommend our textbooks from our UK and ourselves, and without any further delay.
I am honored to hand over to Mr. Latimer. Thank you very much. Thank thank you very much. I will just share screen as I'm sharing screen. Please to enthusiastically put yourself forward for the case discussions because I can't emphasize what KneeKG said strongly enough that the way to learn is actually through to some degree, putting yourself to the test.
And that's what I would. I would really, really like everyone to do. It's this is nothing to do with proving one another to be sort of better or clever. It's all about working together to help you guys to achieve your goal, which for the purposes of this evening, I trust for, for all of us really is to pass the box and to proceed on in a career in orthopedics.
Let me again introduce myself, although KneeKG has already done that very flatteringly. My name is Mark Latimer. I'm a children's orthopedic surgeon, primarily, although I also do some adult work and I'm still on the adult trauma rota at Cambridge. So I have a fairly general practice. And my background in orthopedics is, as KneeKG said, is that I have no background in pediatric orthopedics was a fellowship year at the Children's Hospital in Sydney, with Professor David Little and Michael bellmore, which was a very, very intense experience for those of you who keep a careful look at it 850 cases in a year.
Some of you would say, I suspect that's not money in comparison to training in the UK. That's that's quite a lot. So one of the things that I want you to be confident about by the end of this evening's webinar is discriminating between those things which are friendly and benign and those things which have the potential to come and bite us.
I like this. I'm going to ask, is it Mr. Wylie, said Ahmad, who has his hand up. This is not the question you're expecting, but can you unmute yourself? I'll ask. I'll unmute you. Do you do you have any idea what sort of animal this might be?
Well, I think it's well. Yeah, so that's you're almost certainly right, it has a sort of certain cetacean profile to it. Would you be confident enough that it is a friendly dolphin to actually to jump in the sea and have a swim with it? You know, exactly, Yes. Well, most I wouldn't. As somebody who spent a year in Australia, although dorsal fins on the surface often are friendly Dolphins and it's good fun to swim with Dolphins every now and again, this is what the dorsal fin turns out to be.
It turns out to be something that's dangerous and comes to bite you. On Earth are we talking about Dolphins and sharks in an orthopedic lecture? Well, the answer is that one of the things that we need to learn together is how to do fairly quickly assess from what sometimes, particularly in children, are fairly subtle and fairly non-specific signs.
Whether or not what lies beneath the surface is something benign or something dangerous. So when I'm talking about Dolphins and sharks, I'm talking about the difference between, you know, a simple, notorious fracture of the wrist and something which actually turns out to be osteomyelitis or some sort of neoplastic process and discriminating between the 1 and the other is is, is particularly difficult, I think, in children because they so often can't tell us exactly what's going on.
The remit of the fox, essentially, is to identify those people who can demonstrate an ability to work competently at the level of a newly appointed consultant to be able to identify emergency presentations. Also to recognize your limitations and to know how and when to get help. And it really is as simple as that. It's not simple. It's challenging.
It's a big and and broad based knowledge that's required and also an ability to think and the reason I'm going to pass this one on. Well, no, actually, since you answered so beautifully. Well forgive me if I'm not pronouncing your name correctly. Do you have any idea who this might be? I'll ask you some proper orthopedic questions. I promise your own music again.
I am not sure, but this, I can say, is told, I don't know, I'm not sure. So I don't think I don't think anybody knows terribly well what either Aristotle or this chap looked like and they would. They were very nearly contemporaries. Anybody from the audience want to hazard a guess who this is. This is this is Socrates and Socrates, Socrates very famously, so Socrates may be regarded as one of the pioneers of teaching and what Socrates, after trying various methods of teaching established and then demonstrated, was that the best way to teach is not to tell people things, but to ask them questions.
And so that's what we're going to do today. Some of the cases will be very difficult. The fact that they're difficult doesn't mean that they should, in a sense, represent any more of a challenge to you than the ones which seem on the face of it to be more straightforward. If you're faced with the difficult case, it's not necessarily esoteric detail that's being requested of you.
What's being requested of you is an ability to think logically and to try to demonstrate the clarity of thought in terms of proceeding towards a diagnosis and a management plan. So I promise you some orthopedic questions. Here we are. So hopefully you can see some long standing films and you can see an X-ray of the distal for the wrist in a child who's actually 11 years old, and both sets of x-rays were taken at roughly the same time.
I think actually the response was slightly taken a year earlier, but it's the same child I'd like you to just to clearly explain to me, describe to me what you can see. The extremes before they start for arm showing bony growth from the ulnar nerve border of the radius. Yes, it's well demarcated was a very narrow zone of transition. There is no I can see also the radius looks this increased muscle.
It could be United or heal the fracture of the deficit fracture of the radius. OK, that's the proximal to the bone growth. Yes other lesions in the four arm in the X-rays of the standing films of Muslims. Attention just to this area. Here I can. I can certainly see this some bony skills arising from the radial border of the distal Alma.
Yeah, also. And so even on the forearm films, there's evidence that this may not be an isolated lesion, but it may be a condition in which multiple lesions Wally osteoporotic lesions arise now. And you correctly described what appears to be a lesion on the ulnar nerve border of the radius and the smaller lesion on the radial border of the ulnar.
He described what might have been a previous physical fracture, but we may come back to that in a second. Now Now have a look at the long leg films and tell me what you can see. In the films. What is difficult?
I see this bony growth from the proximal tibia like ostia control because the film is too small. I cannot see exactly. Yeah, you're absolutely right. What you're looking at here is to control multiple conditions. There's also some other things going on. If I draw your attention to a. I can see between the fibula and people on the left side. There is the fibula is short.
The short. This is approximately between the Civil and tibia. And I'm just also then going to draw your attention to the coronal alignment of the legs. Is there anything you'd like to comment about? So this the rule is not dropped down completely midline, but it's nearly nearly midline. Is there anything you would comment about the coronal alignment of both sides?
This is values alignment of at the level of the hip and also the knee, especially on the left side. So we have a condition here, which seems to be affecting multiple bones, which appears to be causing ostia controllers, and it may or may not be causing some slowing of the radius. Although I'm perfectly prepared to accept it might have been a previous fracture and maybe some slightly asymmetric volume.
Actually, I have the angles on, but the left leg was somewhat more about this than the right leg. So what do you think would tie all of those findings in together? What is this condition of the lesion? Most probably multiple resistances. And do you happen to know the inheritance pattern? It is not a formal, dominant inheritance due to a lesion affection one or two?
Very good. That's exactly right. So in autosomal dominant inherited patterns and there are two well defined genetic defects in the next one, the two genes just for a little bit of CDCS outside of the context of the are just for your interest. Actually, the Evelina hospital St Thomas is in London. This actually is further interrogating the different genetics and relating the different genetics, even between patients with multiple stages relating to the phenotype and trying, trying to actually better relate the genetic basis to the phenotype, not only in terms of the question of but to so that the tendency for to but actually some long explanation.
And what are the treatment principles here? The treatment principle here is to maintain the presence if you need deformities to maintain the ligaments. If it is this discrepancy, if there is any angular deformity and to follow up to, there's any possibility of malignant change which is remote should be considered during the follow up of this patient. You know, since you raise malignant transformation, you know how you would differentiate an austere syndrome undergoing malignant transformation from which you is benign?
From the history of this, in addition to in the size of the legion, if there is in recent onset of pain. Uh, second thing is the MRI. MRI of the lesion showing the size assessing the thickness of the article cup. If it's more than one centimeter with the possibility of malignant transformation, yes, it should be said that threshold centimeter lies to completely mature individuals.
But for the growth, pain or a cartilage cat greater than a centimeter in depth in a fully mature individuals indicates the likelihood or the possibility of bleeding vaccinations. As with everything in orthopedics, to some extent, the treatment goals that maximized function minimize pain. And that's the treatment not to take out every lesion, not by any means, but to take out those lesions, which are causing pain or those few questions that I need to make sure you maintain longer.
Thank you very much. I'm now going to hand onto if I make a repeat enough. And what's this condition? Have a look at. Hopefully, you can see a AP pelvis for Hips and frog lateral at the same.
I think I can be heard now it's my voice, so I can see egawa. Yeah, so I can see an ebb and flow and the position of immaturity and showing and a decrease of emphasis. Height and the left hip, I assume, with sine of fragmentation. And there is a radiological evidence of chemical weapons which responded to Percy's disease.
Yes OK. If I told you that this was a six-year-old boy. Indeed, that it was birthdays disease, firstly, how would you? And this was actually the first presentation of six-year-old boy with this disease. How would you counsel his parents? What what would you say to the boy and to his parents about how did you express to them what the condition is and how it's likely to be treated in the future?
So in my counseling of the parent of this child, I need to describe for them this problem as a problem which until now we don't have an exact cause for this problem. We actually understand there is a decrease of the blood supply to the growing part of the head of the femur. It can be sometimes just unilateral or affecting one side or affecting both sides.
It have. Let me ask you to pause them if this were bilateral and you brought up bilateral reality. And you're absolutely right. Both can be bilateral. But if actually in a six-year-old boy, you saw symmetrical hips looking like the left hip, what other conditions would you have to consider? Because at this dysplasia, especially if there is a terrible reflection.
Very good. So multiple Olympic seal displays here because of these hyper realism skeptic epicondylitis sickle cell disease. Um, a lot of difficult diagnosis, but the most common bilateral happened that terrible infection is epimysium dysplasia. Yes so one has to also then consider essentially the mucus polysaccharide season disease, which I think you're hinting at.
But but things like hunters and hurlers and central banks, et cetera. But yeah, that's absolutely correct. If it's unilateral, then the likelihood is that it's worth as we tend to get an MRI scan these days just to check because it's easy and it's sort of crosses the T's and dot the I's. And you said that it's a condition that we don't fully understand.
I think we'd be fair. In fact, first described, of course, 1912 Tabby and Percy's possibly by. There was a conference in 2012 in which that was the overwhelming consensus that we in 100 years there was not very much discovered about it. But what are the principles of treatment? What would you regard as your goal in treating this six-year-old lad over the next two or three subsequent years?
So according to the evidence based medicine, there is a long follow up series of Mr Harding regarding one of the classification of the person's disease regarding the management, and he, according to the letter classification, as the FA is the person who is the patient in the category, the most important predictive factor is the age of the patient. So according to his long series, which had been done, more than 39 pediatric orthopedic centers run by multiple surgeons and a lot of persons patients, they discovered that in a class and c, there is no any effect of the treatment plan, while in a B category in particular and in presence of the age less than eight.
There is no need for doing anything about it. The containment phase will be very effective to get a Fuller result. Better isn't as regarding the shape of the head, and they are avoiding any complication of disfiguring of the proximal feel. Yeah, I entirely agree with your description of Tony Herring's milestone paper. For me, it's some components of it are a little bit nihilistic.
We're very lucky in East Anglia to work alongside a chap called Tony catterall, who's retired now that used to work at Great Ormond Street in the Royal National orthopedic hospital. And he's a very great expert in Perth as prof. Little mountain in Sydney. I work with they would regard the principle of treatment as concentric containment. Basically, there's not very much you can do about femoral head collapse.
There's been lots of techniques described, but none of them are terribly effective if one was terribly effective with all doing it. But what you do want to achieve is concentric containment. So when the hip starts to swell up, you need to do something about it and a very easy next thing to do, which applies to quite a lot of heat related conditions.
If you want to hedge your bets and say something fairly neutral that can't be criticized is to do an Arthur grant, and I'm going to show you this picture and ask the yellow line on my screen. I don't know if that's on everyone else's skin, but this is an air of ground, and I'm a great fan when I'm training my trainees how to do all four grams that they inject a little bit of air before they inject any dye.
Because I'm not sure if this expression translates universally, but it avoids blotting once copybook. It avoids injecting a whole load of dye, which then obscures obscures the region before effectively getting it into the joint. Good OK, I am now going to move on, if I may, to hasten lightly Haitham. Would you be kind enough to unmute yourself?
OK Yes. OK this is a super tricky one, do you want to take on a super tricky one? So this is the sort of case where I'm not really looking for specific diagnoses. I'm looking for sort of broad brush categories. Ok? and importantly, a case she's five, because there aren't the normal, possibly the normal hints of skeletal development in terms of femoral, head and so forth on the X-rays.
So she's 5 and she's on the 1st percentile for height, i.e. if you line up 100 girls of her age, she would be one of the shortest in the hundreds on average. Describe what you see and tell me what broad category of condition you think this could. Who's actually of beliefs and posts blogs about females showing bilateral support?
And there is a decrease the Pacific Ocean is cooler than usual at this age and also the stellar distances shorten and this seems to be regarding the history. She seems to be syndromic. So maybe she's dysplasia, a type of congenital cookstove, Osiris type, serious congenital, developmental and acquired due to many causes like syndromic or dysplasia, or due to infection or in other causes, e.g. dysplasia.
Yeah, and you've described it beautifully. Actually, there is lots of error. There's delayed officiel or superstation. Yeah what sorts of. Displays and yet the pelvis not doesn't look completely normal, but the acetabular looks relatively well-formed. What what, what sort of dysplasia do you think this might be?
Mostly physical dysplasia. It's affecting the faces, mostly. So this could potentially be a multiple dysplasia. Yeah, it happens. It's not. It's dysplasia, but it could be me, either. What sort of thing? So what do you think are the principles of treatment in a condition that I'm willing to bet you never treated?
In fact, you may not have ever even encountered some dysplasia? Yeah, and that's not that's not the point. The point is, what are the orthopedic principles that we would apply to this for you and me both relatively unfamiliar? Yeah so the principle of treatment of correcting the course of virus and was dilatation proximal femoral osteotomy to still the neck shaft angle and also reduce the haytham line or angle and also restore the stable through this distance.
And also sometimes we need to achieve normal activation of the femur and to keep the physical vein more transverse to allow healing and avoid any more works very nicely expressed. And in fact, that is not the next step that I took, but it is the step that I took, as it were happening, leapfrogged from the next step. So this girl now has had bilateral Valukas still to me, but I'm going to take you back to what I said to Muhammad about it.
You can very, very rarely be criticized for doing so. And this, for me, is interesting, and it shows that actually, as you add up to the hip, the medial increases i.e. the subluxation as you add doctors across the legs. Actually, the here that it was improved. And that's why I was very confident to do about this. Thank you.
Let us move on to action one. And then after this next case, I think I'll hand over to the wonderful Mr. egawa today. It's ready. So, oh, Yeah. So this is a trust for you actually back into to be more, more familiar territory, so hopefully you can see again a frog lateral and an ape pelvis for Hips.
Would you like to describe what you consider? I a. The hi, can you hear me? I can. Thank you. Yeah so these are AP and a lateral radiographs of the screen you put in your video on.
I'd like to speak to people as close as possible to the concept of face to face carry on. I recognize it's not for everyone. So these are APM traject lateral radiographs of the skeletal image or patient. They're showing that, especially on the right hip, the clients line is passing above the prefaces. So this appears to be a case of a slip up of a moral epiphanies.
The left hip seems reasonably normal to me. Um, so actually, if I told you that this child had this, this is a 14-year-old boy. Is a real case. I have operated on a 14-year-old boy who actually had been limping on and off for six months, but he could walk out. How do you classify slipped up of rough seas in a way which both guides management and predicts prognosis?
So that would be either an acute or a chronic slap in this case, it's a chronic slap I can see on the radiographs that there's some calcification from Italy, which points that there's some attempt at callus formation. So this, as you said, has been going on for about six months. It's still beating which, which hints at the chronicity. That's not exactly what I asked, though. If if I may, I would like you to tell me what feature of this child's.
Presentation, clinical or radiographic? Actually, best predicts prognosis and guides management, so that would be based on a Lotus stability classification so stable versus unstable, depending on whether they were able to make it better or not. So this child can read better, so he would be classified into a stable slap, and that basically quantifies the risk of even if they're unable to bear weight.
Then there's a 47% chance of necrosis of the hip. Very good. So how would you manage this? A consultant on two to three months into the job and this child presents to the emergency department is frustrated that the GPs not properly examine the child. When you examine the child, the child has a pronounced limp walks with an externally rotated foot regression angle.
You actually put him up on the examination couch and flex the hip. It goes into sort of radical external rotation. That is to say, as you flex the hip flex the hip up on the left hand side. And you can touch the knee to the shoulder, flex the hip hop on the right hand side and the knee swings way out laterally. In fact, his heel comes across his.
What what are you, what are you going? How are you going to manage this challenge? So the principle here is to arrest the slap progression. So we want the slap to be at the place that it is now. Um, for that, ideally, this is best managed by a pediatric orthopedic surgeon who is adept at dealing with severe up of small.
But even if you are going to choose to phone a friend or transfer this patient and what measures are you going to Institute essentially immediately? Uh, so. I would how could you how could this how could you definitely make this young man's hit worse? So by adopting an acute reduction.
Peel-back no, so I don't think you would achieve anything by attempting an acute reduction because of the chronicity, because it is stuck. What the way you could make this child's hit worse would be to turn it from a stable hip into an unstable hip. so actually your duty, your responsibility as the diagnosing surgeon is to ensure that you minimize ideally eliminate that risk and that.
So first of all, you actually ask him to be non weight. Very simple as that. Now let us imagine that you are this time at the receiving hospital and that you are in the position of being at the receiving pediatric orthopedic surgeon. What what options are open to you? How would you how would you advise the parents?
How would you consent what would you actually do if you were not the man passing buck that the receiving the bulk, then not passing the baton, but receiving the baton? So I would opt for in-situ pinning of the right hip. But I would explain to the parents that the options essentially are to. Like I said, the principle is to arrest the slip progression and then deal with the deformity later. That would be in my hands, but there is also an option.
It is done very frequently in other centers to correct this deformity in one go and then bend the hip. Yes do you know? Do you know how that surgery is performed? You know, any of the eponymous operations described? So that would be a feather with Dan osteotomy, who? And what do you do with it in a dumb or osteotomy? So essentially, you're trying to reduce the neck back in line with the hypothesis that is with a that is making.
Making sure that you preserve the vascular title to the hip while doing that. So the word to bring into your explanation is cuneiform. You take out a wedge of metathesis. Very nicely answered I operation on this chart. And I did exactly what you suggested. First I did in situ pinning. And we will come back to fight another day, possibly, depending on what the Chinese.
But choose this in the future. Now I'm going to see if I may hand over to my colleague, Mr. egawa test, and I'm going to stop sharing now. Hi, everyone, and thank you, mark, so for those of you who don't know me, I'm a consultant, pediatric orthopedic surgeon between Broomfield hospital and Max hospital in Essex. So I think these sort of sessions is quite a lot of your head is now probably around 75% of you here for questions, and I really want everyone to get as much out of this as possible.
And I think to do that, what we're going to do is we're going to go through a sort of quick fire round of cases. So if everyone can get a sheet of paper and a pen, we're going to start and we're going to go through 30 different pediatric orthopedic cases in quick succession. And then we're going to go through the answers of them and give you the opportunity to ask any questions.
Because the issue with the farke's is you may not get the standard question that you expect to get. You may not get the parfaits, the spoofy, the clubfoot, the basic trauma, and therefore you need to be aware of the other things that can pop up and just stay calm and understand how to deal with them. OK, so if everyone has that, I'll start showing my screen and we'll move on.
OK it's so different, so I'm going to time this and we're going to spend 30 seconds per slide. OK, so there's not going to be much talking for the first 10 minutes or so, but then after that we'll be able to do whatever we need to do. If you have any questions, I'm very happy for you, just unmute and interrupt me, but we need to move on pretty swiftly to get through this in the timely manner.
So I'm going to put up the first question and we're going to start our 30 seconds now. So this is an X-ray chest of a near an eight. And there's three questions here. What do you think the diagnosis is? How would you manage it? And what other things can you consider it could be or you could be concerned about?
OK, so just three short words on their. And hope you've got those down, we're moving on. This is an X-ray again of a neonates. Can you identify or provide us with the diagnosis? And how you would subsequently manage this patient.
These are quite important things to recognize as a consultant, even in a decision house or anywhere, really. We'll move on. Here's an X-ray spine once again of a young child just four months old under my care currently. Can you provide me with the diagnosis for this patient? The cause for the diagnosis and how you would manage them.
In the very first instance. OK, we're moving on 30 seconds, we're going quick here. Axilo foot in a six-year-old boy presenting with pain, swelling, difficulty, weight bearing if we can have the diagnosis. And the subsequent management, how you would manage this patient in your fracture clinic if they came through the front door. There's only two here, so move on quicker to slightly more complex, one more obvious clinical picture and supported by X-rays in a unit again.
And we have the diagnosis, how you would manage this patient in the very first instance. And what further investigations or associations are in keeping with this clinical presentation? I can't see most of you, so I hope you're keeping up and writing down really quickly, we'll move on again. I think this may be reasonably similar to 1 you've seen before today, but if we can have the diagnosis of this patient, the inheritance patterns of the communication and the gene that is affected.
The next one will be pretty obvious, but it is once again in a young neonatal patient. What is the diagnosis? What would be your management knowing that this child is a brand new born neonatal child? And what are your further considerations, one of the most important things that you need to do when approaching this child in this clinical situation?
And I hope you'll keep me locked up, we're going to have scores of The doors at the end. Everyone can submit their scores, so next patient. Another trauma, slightly older child around 10 years old, had a twisting injury, can we have the diagnosis of this patient? How you would manage it in the first instance, it's come on your general trauma on call and what your concerns would be with regards to this fracture.
And this was a case that I was given in my fowlkes. OK something most of you would have seen before and stayed up all NIPE managing. But if we can have the obvious diagnosis, the classification and what this one would be. And again, how you would manage this, I'm sure the folks mentors can vyver you with regards to some of these more core critical topics.
Later done on. So here we have an AP pelvis in a 14-year-old runner presenting with right sided pain. If we can have the diagnosis. How you would manage this patient and what you may be concerned about or any further considerations? Anything, any other tests you would do anything else you would advise, et cetera.
This is a clinical test that I expect everyone to know and understand why it works. So can you name the test? I'm sure you've all done this. We've done it in foot and ankle rotations and pediatric rotations and neuromuscular patients. And then we'll talk about imaging. And what we are doing.
And image b, what are we looking for? What is the tight structure? What would you have to manage an image versus image be? Next, one clinical photo of a newborn with associated X-rays. This is a congenital deformity that we would see so diagnosis. The management of this patient and what your further considerations are for the future when looking after this patient, what would you advise the parents or explain to the parents would be an issue or potentially an issue in the future?
Next we have a clinical photo of a foot. I would say it has a particular shape to it. Especially with regards to the sole of the foot and associated X-ray. Hopefully helping you identify what the issue is. And are you aware of how these patients are managed?
30 seconds. Moving on. Again, a patient who presents with the below X ray, you can see the clinical picture of the limb in the foot with the associated long leg X-ray. Just give me the clear diagnosis that this child has and how you feel they should be managed.
Something slightly more complex with regards to this one, but if we have a pelvis and a child, obviously, so let's have a diagnosis, what is the important measurement that we would like to know about, which helps guide our clinical treatment of this child? What are the potential causes? And subsequently, the management that can be applied to address that. So full marks of this one, there's not many with full marks.
We're halfway through already is a clinical photo, the resolution and coloration of the X-ray is absolutely fine. This is what it appears like. I have not adjusted any shading on this. We have the diagnosis. The pathophysiology, what causes this condition? From a bone cellular level. And subsequently, what are the risks associated with this condition?
Next X. Right femur in a child who presents with pain was playing basketball. No problems, but presented with pain that then began to cause issues at NIPE time has an obvious swelling in the thigh. Can you tell me the underlying diagnosis, the radiological signs that we're looking for and how you would further investigate this child?
Then one not to be missed. X-ray of distal femur in the child's. Can you give me the obvious diagnosis? And then what arrow won an arrow to his pointed to, what is the name for? The two regions of Bowen affected. And what do we what's the appropriate nomenclature?
Clinical photos and wrist X-ray of a child with an obvious deformity. Pretty clear cut, who have the diagnosis. What the inheritance pattern is and what is the key anatomical structure that causes this deformity in the wrist? And me, myself and Mr. Latham have both recently managed a couple of patients with this condition.
I'm letting go in a few more seconds so you can scribble down and get on. Patient who presents with pain on the medial aspect of the foot. Can we have a diagnosis? A classification. And what your management would be. And this is a 9-year-old child, if that helps any of you.
It's a medial aspect of the foot that is painful. A five-year-old child presents with this X-ray walks waddles late presentation. What is the obvious diagnosis? Can you name five risk factors? Which you should all know about, this is a core topic and subsequently how you feel this patient should we manage understanding that they are five years old?
One to puzzle a few of you. What is this is an X-ray of A is in a 13-year-old. We can have a diagnosis. And if you can give me the eponymous name, that's a bonus point. They may have seen it may not have seen it. Don't worry, it's just there.
You don't need to know much about it. What is the name of the procedure and the approach that has been taken with the needle in this image here? What is the obvious pathology? And can you name what 1 and 2 are pointing at, and we'll talk about that. Just seven more to go.
But getting there quickly. Here we have your typical presentation in most hospitals, and a 12-year-old girl was walking and suddenly fell to the ground and had to present to the hospital. What is the what's the diagnosis in this radiograph? What are the anatomical associations, one of the things that we need to assess in this child, both clinically and logically?
And what is the name of the main ligament that is usually stretched or torn in this injury? And we have ATP and lateral of a five-year-old child who presents with a clinical deformity. These are the X-rays for them. Can you describe the deformity? There is a bowing of this tibia fibula.
So what is the underlying diagnosis and what are its associations? This is a 12-year-old child that presents with no trauma. There's no trauma associated with this presents with a. Prominence over the right upper chest.
If so, not understanding that there's no trauma can have a diagnosis, a cause, anatomical cause and management. How would you manage this patient? Back to something we're more familiar with. We have the name of this.
An issue. Please don't get distracted by the obvious. Have a close look at the X-ray. What is the diagnosis for this patient? It was a major trauma accident. How would you assess this child and what would be your management?
The coming down to the last three. I think this we've been through, but please just write down the obvious diagnosis. The risk factors associated for this to occur in a child. And I'll mention briefly the management that can be undertaken. Final two.
We're only 10 seconds behind where we planned. Significantly shorter leg. One bone predominantly affected. Diagnosis, how it can be classified. And subsequent management. And finally. X-ray and CT scan.
We have a diagnosis for the lesion. In the history, what is it typically improved with medication wise? And subsequently, how can we manage this patient? OK, everyone, happy. Let's all have a breather for 30 seconds. OK there was a lot to go across there and we'll start from the top in a few seconds.
Take away, take away your answers, keep a log of your scores, and then we'll get them put into the chat box. Again, I'll go through them relatively quickly, but if you have a question, if you can please unmute yourself and also or put something in the chat box, that would be really helpful just because I'm going to try and get the chat box up on my screen as well.
So we can have a look. OK, so we'll start from here. So number one, diagnosis is actually a clavicle fracture that was caused by birth. This was the same child who had an X-ray at three weeks, and you can see significant healing there. Management, conservative neonate, it will heal. And what are your other considerations?
Well, could it be a suit of arthritis of the clavicle and non-accidental injury if it was not an immediate birth injury? OK, next one. This is really important, and this is something that people tend to miss quite often, this is a seal separation. OK, this was a birth injury in this child. What do we mean by 5 syllable separation?
It's essentially a to Harris one fracture where if you go to this? This is the metamorphosis. Their purpose is still cartilaginous, you cannot see it and is actually reduced. This is not an elbow dislocation. And that's the most important thing to understand. This needs timely treatment. It is associated with non-accidental injury, so does need to be looked at.
And how do we do it? Normally we do a manipulation and arthrogram to confirm appropriate action and worry. OK next one, hopefully most of you got this diagnosis is congenital scoliosis. OK there's a young child, what is the cause in this case? There is a hemi vertebra that you can hopefully identify here, which is the apex of the curve. And this is obviously due to a failure of formation.
There is obviously a failure of segmentation as well that you need to be aware of. What do you do? Well, typically you would observe it and they can be excised later down the line. If it's not improving. And this defect forms is an issue with the formation of the Mason cable and lag during the 4 to six week of gestation.
So you can get a bar, which is a failure of segmentation, or you can get failure formation, which is how many vertebrate, just as in this case. And for this child, you can see they're actually got multi-level issues with them. We've sent this child off to Great Ormond Street. Six-year-old child, I think I said before the diagnosis. Cola's disease, a Avastin necrosis of the navicular common thing to see commonly seen in a fracture clinic, how do you manage it?
Essentially, non weight bearing and symptomatically management expectedly give them a cost if it's really severe. Most patients can get around on a boot, and it does improve over time. Number five, newborn child. This is a congenital knee dislocation usually caused by very tight quadriceps, tendon and subluxation of the hamstring, which then causes this extension moment. How do we manage it?
Cereal casting of the knee in gradual flexion. In fact, I probably have the same patient here. So this is the taric classification, which basically depends on how much passive protection they have. So it's either greater than 90 30 to 90 or less than 30, as you can see if it's quite severe. Management is cereal casting, and the association is with fx and protocols, so always get a scan.
The last patient I had with a congenital knee dislocation also had a graft three dislocated hip that we had to manage in a Pavlik Harness. Mark went through this one earlier, this is multiple hereditary axilo dosis, the most benign brain tumor. Inheritance patterns as autism were dominant. So it is quite common to see in families, of course, and it's the exact one, two gene.
OK, we don't need to go through this much anymore. Any questions? So far, please unmute, otherwise, I'll carry on in a few seconds. OK so obvious fracture said this was a. This is a neonatal femoral fracture. How do you manage it? Pavlik harness OK or with no treatment whatsoever.
This is the same child. When I saw them a year and a half time, the line completely healed, completely remodel. No leg Allen discrepancy. But you do need to look at the leg lengths as you follow these children up. Obviously, if you have a young child present with the femoral fracture, who is not a walking age, of course, non-accidental injury that needs to be investigated for child safeguarding.
And you must mention that when you see in the pediatric section any sort of fracture, you need to always mention the word safeguarding. It's very important. This is the case that I got given in my FRC us exam, this is a to Harris through fractured tibia with a high fibula fracture. What how do we fix it? Well, you can fix it just through manipulation.
You can hold it with a screw. You can hold it with a K while dealer's choice. But what is the concern? concern is this concern is a growth arrest that can happen and cause an angular deformity around the ankle. So the third mark for that was looking for growth deformity later down the line. Supercontinent fracture garden three.
How do you manage it depends on the mechanism of injury, but you need to approach the child with its practical abcs, assess their neurology, make sure you document individual nerves, including the Enter into ulnar nerve, which has gone in quite a few numbers must ensure there's a radial pass to document the perfusion of the hand. Obviously, child needs to go to theater anyway and choirs dealer's choice with what you do.
You know there's evidence for both lateral and medial choirs. If you want to start mentioning evidence, you can talk. We have our guidelines. Obviously, if you're doing in the UK to mention two wires can be lateral or cross. But if you're doing a medial side, then you must open and have a look to ensure you haven't penetrated the ulnar nerve to at least retract it.
This one here is a right neck of femur in a 15-year-old runner fracture across here. Obviously, the classic. Well, the classification is a delicate fracture and this is a delicate classification and that essentially is a transfer seal transfer vehicle basis if I call into truck and it's a slightly similar. But obviously, the Abn rates are quite significant when this transfer seal and it's associated with or without epicondylitis Allen, which essentially is a soofi, if you think about it that way.
But trans cervical also has is the most common one and also has a 30% risk of AVM. How do you fix it, kayleigh? Screws aspirate the joint of its hematoma, and other things need to be looking at is obviously could be a stress fracture, low vitamin D and things like that. Number 11, so this is a silver Scholes test. I feel like a lot of people don't tend to understand this. So with the knee straight, both the gastronomical and the Achilles tendon are tight.
OK, you have to connect the heel position. And if you've got tightness and you have that quietness, deformity that tip toe walker, if it improves with knee flexion, that means you have relaxed the gastric Solis in its entirety, and that means it. If you still have tightness with the knee flex, it is truly an Achilles tendon issue. Most I would say would be like b, where they're tight with improvement, with the knee flexion, which means you relax a gastric, which means it's a gastric minimus tightness and that's very common in neuromuscular disease.
The name of the test is silver gold. Sylvester s.h.I.e.l.d. OK, thank you. Thank you, Nicky, for that. Great this also allows you to then decide on how you treat it, because if it's an Achilles tendon issue alone, then you can do a percutaneous or tender Achilles lengthening as sort of shown here. Or if it's the gastric near-miss, which in most cases I found in my patient call, it is you can do a gastric near-miss recession, which is essentially lengthening what I tell the parents is the Shirt that sits around the muscles and allows it to stretch very, very useful.
And you don't, then have to touch a tendon. Diagnosis, this is the posture and medial bow. What do you do with it? Nothing observe improves. But what are the further considerations? Leg length discrepancy 2 to 3 centimeters at skeletal maturity. So I just watch these. The most telltale sign is that you can essentially touch the dorsum of the foot up towards the shin.
Obviously, the apex of the boat is both posterior and medial. So whenever you see one of these funny bows, look at the apex. Where is it? It's at the back. It's on the inside of the posterior medial bone that will help you a lot when you get seen some of the more complex ones. And as you said, the leg length discrepancy is the one thing that we watch out for, and we have our very clever ways of guiding growth these days.
Diagnosis, this is a Persian slip, a foot or a rock, a bottom foot. Hopefully you could identify that the tolerance is almost vertical. And if you look at the line, if you draw between the taste and the first rate, it's completely non-linear. They're completely off. How do we manage this?
Typically with a reverse Ponseti casting method? So that would be the first onset to reverse Ponseti casting that essentially loosens up all the soft tissues. And then we do an open reduction and wiring of that. Muhammad's eyes? No, no. 12, no. 12 was poster and medial bow.
There is no other diagnosis. It's just posturing. Egawa so 13 traject vertical tails reversed Ponseti technique and open reduction casting. And this is the reduction you actually see. You're sitting yourself and you usually where you can do it. I do it retrograde like this and you can see I've gone through the base of the first metatarsal into the tennis and hold it in that way.
Diagnosis of this one. So to be pretty simple about it, look at the bow. So the bow here is again, medial. If we show you a lateral, it'll be anterior. This is the entry medial bow and this patient has missing Lateral Raise. OK, this is fibula, hemi Emilia. And the way you can remember it is, it's an intermediate bow. Mi familiar fibula media OK, and I'll tell you why, because on the next one, we'll have a look at something else.
These are some complex and more complicated cases. As you can see, you've got your ADA both the medial boats much more significant. There is a classification. I don't think you really need to know this, and obviously there are. You can either observe it and there there will be reconstruction options. This can also be associated with proximal femoral focal deficiency and absence of the ACL.
So I have a patient currently with very mild fibula, and Emilia basically has four toes. No significant other findings are just slightly shorter. Fibula has a ball and socket, ankle joint and an absent ACL, and we're actually managing his ACL because that's the big issue for them at the moment. Next, diagnosis, this is a congenital savara, it's bilateral, it's a problem with ossification femoral neck.
What it causes for this congenital development, it can be autosomal dominant. It could be acquired. It could be following trauma parfait Sufi. But you know, this is an obvious congenital severa. What line are we talking about? We're talking about the h-e angle Hildenbrand angle. As you can see, the Hildenbrand line, the axilo angle. If it's 45 degrees, it's likely to correct.
It's 45 to 60 watch and wait 60 degrees plus surgery. Typically, if a femoral neck is less than 110 degrees of angulation, as you can see here. And what I did for this one is I did a bilateral osteotomy. This 1 May have confused a few of you. This is osteoporosis. Ok? essentially, marble bone disease is caused by the pathophysiology a defective osteoclast resorption.
There are three genetics type and essentially there's inability to acidify the hardships. And there's a lack of ruffles border that I would say is the sort of magic phrase on your fix. Part one is the lack of Rafah border defective Oct class. You can't resolve the bone, so it just gets harder and harder and harder. Osteoblasts keep on working, laying down more bone, laying down more bone, and they can actually present with quite significant fractures.
And they. And because you get this other view, which is a bone within the bone, it can actually end up leading to anemia as the marrow is unable to produce hemoglobin. And you can also get increased risk of osteomyelitis again because of the stagnant blood flow. A very important case with this, I hope you pick this up. This is actually a Ewing's sarcoma. There's the onion skinning found of the period.
This was a 15-year-old NIPE pain able to walk that has pain with associated swelling swelling. Further investigation would be MRI scan. You see a significant tumor here and there large soft tissue components that it's hot on the PET scan and actually about 25% to 30% of them already have metastases on presentation. If you're doing the part one histology that you tend to find, the bullet is round blue cells or pseudo rosettes and treatment is chemo, limb salvage and then radiation.
So quite horrible things to have, but important to pick up. This is chronic osteomyelitis, that's the diagnosis, the metamorphosis, as the vessels make a sharp turn, basically happens in this area because this sluggish blood flow. One what is 1 1 is the question necrotic bone, which has been walled off from its own blood supply and two is the blood from a layer of new bone forming outside the existing osteomyelitis.
Chronic osteomyelitis the question is one interleukin 2. Apologies, the patient might have recently had this the mad lungs deformity. That's the diagnosis. Essentially, it can be a congenital disc, ndrosis of the distal radial firefighters on the volar side.
It's autosomal dominant. You get under explanation of all the tilts growth, the rest of that part and essentially the anatomical structure is the Vickers ligaments, ok? The Vickers ligament, which is a short radio lunaz ligament, and that's what you would release in this child. OK it's also the document, as I mentioned earlier, and it can be linked to a condition called very wild. This control stenosis, which is where they all get me and milk dwarfism.
This is actually the first painful on the media side, this is an accessory navicula, about 10% of pediatric population have them, 70% of them are bilateral. They're three different types type one, type two, type three, depending on if the bone is essentially a CSA void within the tendon, which causes pain to when a separate or three when it's just global enlargement procedure is a procedure which is basically open exercise and advance the type tibia on his posterior tendon on their.
OK last 10, I know we've gone through a lot already. Bilateral Nadh. This is totally logical risk factors. First born female breech, family history, last birth weight, oligo hydroponics, twin pregnancies take your own pick. OK, you need to know about the 9p screening that we have in this country. How would you treat it? Well, if you've got a child young enough, you can do a close adduction.
Unfortunately, in this child, there were five years old. As I mentioned, they needed what I call the full shebang, which is a femoral osteotomy shorten. That's a shortening de rotation osteotomy. They don't need a virus. You then do an open reduction and a pelvic osteotomy. And this is the child after they've had staged. This is one just to get you in the mix. For some, maybe even some of the faculty, this is disappearing bone syndrome, which is massive osteoporosis with proliferation and dilation lymphatic vessels.
Eponymous name is goram Stout syndrome Gordon syndrome don't need to know this for the exam. It was just in there as an extra what's happened here? Patella dislocation patellofemoral instability is very common and it's very complicated, so you need to understand what are the anatomical considerations. Well, has this child got patella, alta? Is it too high?
Is it sitting within the notch appropriately? Is the notch appropriately formed? That's chocolate dysplasia. Do they have abnormal version of their femur that can subsequently tilt the way that their distal femur is like, and therefore it slips out? You need to know about the TG distance hypermobility in these kids, and the main ligament was the MPFL fell MPFL ligament.
This child I had, they had a. It was patella Alta. So we did a tip top transfer for the child in addition to an MPFL MPFL reconstruction. Nearly there, 25 described the diagnosis, OK. Once again, let's look where the apex of the bones, its anterior and its lateral, it's an anterolateral boat. Ok? and two lateral bow is congenital sujoy versus the tibia Association's neurofibromatosis.
I won't take it more further than that. Here we go, there's lots of different things, there's a whole bunch of different things you can do to identify if it is neurofibromatosis a seven different types. Vast majority are like this. You need to be looking for cafe Au lait spots, et cetera.
OK this one, I said, was a traumatic and had been there for a long time. This is actually a congenital arthritis. The clavicle, if we were talking about a fracture, I'd be very keen to tell everyone, do not operate on them, they do heal by themselves. And this new papers in the bge to say it's us do that. Mohammed, 24, was patella from when stability. And we talked about that.
So here, congenital arthritis and essentially failure fusion between the lateral and medial ossification sensors of the clavicle and in caused what's the cause of this is essentially your subclavian artery. That essentially pulsates and stops it from fusing together. Failure fusion, you get extensive compression of the subclavian more, usually more on the right hand side unless the patient situs inverters, how would you treat it?
Well, you around the edges. You can imagine conservatively, but if worse comes to worse, you can fix it as like you would have fracture. Oh, yeah, we're coming up to. Oh, did I miss one? I may have missed one. Apologies to all of those. 23 As you said, sorry, I missed this, so go back to your scores.
23 This is an off the ground. The needles coming medial. So this is a supper doctor because you would go subadult to the medial approach. The diagnosis, obviously, what's number one? It's your dye pooling your medial dye pooling. Because the hip joint is actually empty too, is your rose thorn because there's caps the constriction due to the size tendon.
Thank you for making me do that. Let's go to 27 27. We'd already had a supercontinents, so we didn't make the same mistake. This is actually a floating elbow. As you can see, the child also has a wrist fracture and an elbow fracture. You have to be aware that there's a high risk of compartment syndrome.
You need to be very vigilant with your new examination. How would you manage it? Well, I tried both on the same day and got them sorted out. 28 severe Sufi as you can see, risk factors obesity, hypothyroidism, other hypogonadism, skeletal maturity, low vitamin D. There's some new things like acetabular retroversion that have been sighted with this. Obviously, you want to check if the blood flow is there for vascular.
How would you acutely do this? Well, this is as one of our colleagues mentioned earlier, which was an immediate modifier done osteotomy surgical, hip dislocation, identifying the slip, putting it back on nibbling off the Tufts is holding it on and then checking its vascular. I think if it's an acute severe slip, it would be completely reasonable to say I would either discuss my hip, young adult hip colleagues or my pediatric colleagues to perform an urgent reduction surgery dislocation reduction using the done method.
I think the fact that about that what the risks are, which is obviously AVM, that's up to you. Fine this is the gant's approach. This is a surgical dislocation. OK, we've taken it off the great uc-santa. So I'm just looking at the chart at the same time. Take it off. The great Eric Cantor flipped it over, essentially put a wire up the neck into hold that dislocated as one and any royal for traction for acute Sufi.
No, I think unless you're getting to it on the very first day and within the first six hours or 12 hours, that's the posh technique where you can do essentially a closed reduction and pinning. But the AVN rates are pretty high, so I think it'd be pretty safe. If you see this, that you would refer to a center that manages this regularly and you can also do it. As market said, you can do a direct anterior approach and do it essentially a sub cuneiform osteotomy.
That's essentially the fish, which is another one where you leave it in situ, you take out a bit from the neck. But I think this is a pretty standard answer for if I see us. That's what it looks like a following, and obviously we did the other side. This is a funny story. It's called a peg, a screw because this child was only 10 years old.
It's a growing screw. But I think, you know, contralateral pinning is a debate of its own last two. Here we have a significant shorter leg proximal femoral focal deficiency or congenital shortening of the femur, whichever one you want to talk about classification Aitken classification, which essentially allows you to say, is the femoral head present or absent and then describe how dysplastic the acetabulum is.
This is. How would you manage it? Well, most people would say lengthening, but if you're ever going to, I've never seen this procedure. But you know, the Van rotation, plus this is something we always wanted to see most. Now with growing nails, we wouldn't put nails in and bring them up. Final one sorry, it's taken a while.
It's the radial lesion surrounded by sclerotic bone tendonitis. What are we looking for? What are we looking for? This is a osteosarcoma, and the improvement happens with inside's ibuprofen. How do we treat it? Radio ablation, OK. If everyone wants to count up their stores and put them in the box, it'd be great.
But I hope that sort of made you quickly feel comfortable with a lot of things you may or may not have seen before may just be as helpful for those of you who are waiting to do the part. One of the exam as opposed to part two and I'm sure the folks mentors can further quiz you guys on some of the more common topics, but I hope you've now handled understand with that. Thanks very much.
I'll pass it back to you, mark.
Segment:0 .
Good evening, everyone, and welcome to this evening's session, which is a joint teaching webinar between the FRC mentor group and OK. My name is Nicky Evans and I will be your host for this evening. The rest of the faculty include Imogen and Hannah from our UK and my fellow mentors Sian Harney, David and Hassan.
This evening, we are delighted to welcome Mr. mark Latimer and Mr. David, who are both consultant orthopedic surgeons at Addenbrooke's Hospital. Mr Latimer graduated from both Oxford and Cambridge in 1997 and did his orthopedic specialist training on the East Anglia rotation and Cambridge. He was awarded the prestigious fellowship in Sydney and worked with Doctor David little, and earlier this year, he was awarded the certificate of excellence from the I want great care group.
So this evening's lecture will be more interactive than usual, so we will be having some case discussions with some teaching points and tips for the exam throughout the webinar. And for that reason, we'd ask for people to volunteer to have some viable practice with Mr. Latimer and Mr. budoff during the session. Now, this part of the session will be recorded, so if you don't want to be recorded, please let us know.
As always, we ask if you have any questions to put them in the chat and we will keep an eye on that. We'll ask any questions at the end of the session. Any participation, any participants who wish to stay on five practice. Please raise your hand and let Hannah and imagine know whether you want to be part of the webinar or whether you want to be the practice at the end or whether you want to do both, which is fantastic.
We do understand that putting yourself forward in this forum is really stressful, but we're all here to help. All of us have been through this and it is the best way to get that training that you need for the exam, particularly with regard to your technique. And you know, as we all know, having passed the exam and quite recently, we've had some positive feedback from people who've been in this group as a participant who also passed the exam in the last week.
So congratulations to them. And so this way of teaching does actually work. So our next course for the exam will be on Thursday, the 2nd of September, and there are participant and observer spaces available. You can book this via the UK website and it's on a Thursday, so you'll need to remember to book study leave early. We recommend our textbooks from our UK and ourselves, and without any further delay.
I am honored to hand over to Mr. Latimer. Thank you very much. Thank thank you very much. I will just share screen as I'm sharing screen. Please to enthusiastically put yourself forward for the case discussions because I can't emphasize what KneeKG said strongly enough that the way to learn is actually through to some degree, putting yourself to the test.
And that's what I would. I would really, really like everyone to do. It's this is nothing to do with proving one another to be sort of better or clever. It's all about working together to help you guys to achieve your goal, which for the purposes of this evening, I trust for, for all of us really is to pass the box and to proceed on in a career in orthopedics.
Let me again introduce myself, although KneeKG has already done that very flatteringly. My name is Mark Latimer. I'm a children's orthopedic surgeon, primarily, although I also do some adult work and I'm still on the adult trauma rota at Cambridge. So I have a fairly general practice. And my background in orthopedics is, as KneeKG said, is that I have no background in pediatric orthopedics was a fellowship year at the Children's Hospital in Sydney, with Professor David Little and Michael bellmore, which was a very, very intense experience for those of you who keep a careful look at it 850 cases in a year.
Some of you would say, I suspect that's not money in comparison to training in the UK. That's that's quite a lot. So one of the things that I want you to be confident about by the end of this evening's webinar is discriminating between those things which are friendly and benign and those things which have the potential to come and bite us.
I like this. I'm going to ask, is it Mr. Wylie, said Ahmad, who has his hand up. This is not the question you're expecting, but can you unmute yourself? I'll ask. I'll unmute you. Do you do you have any idea what sort of animal this might be?
Well, I think it's well. Yeah, so that's you're almost certainly right, it has a sort of certain cetacean profile to it. Would you be confident enough that it is a friendly dolphin to actually to jump in the sea and have a swim with it? You know, exactly, Yes. Well, most I wouldn't. As somebody who spent a year in Australia, although dorsal fins on the surface often are friendly Dolphins and it's good fun to swim with Dolphins every now and again, this is what the dorsal fin turns out to be.
It turns out to be something that's dangerous and comes to bite you. On Earth are we talking about Dolphins and sharks in an orthopedic lecture? Well, the answer is that one of the things that we need to learn together is how to do fairly quickly assess from what sometimes, particularly in children, are fairly subtle and fairly non-specific signs.
Whether or not what lies beneath the surface is something benign or something dangerous. So when I'm talking about Dolphins and sharks, I'm talking about the difference between, you know, a simple, notorious fracture of the wrist and something which actually turns out to be osteomyelitis or some sort of neoplastic process and discriminating between the 1 and the other is is, is particularly difficult, I think, in children because they so often can't tell us exactly what's going on.
The remit of the fox, essentially, is to identify those people who can demonstrate an ability to work competently at the level of a newly appointed consultant to be able to identify emergency presentations. Also to recognize your limitations and to know how and when to get help. And it really is as simple as that. It's not simple. It's challenging.
It's a big and and broad based knowledge that's required and also an ability to think and the reason I'm going to pass this one on. Well, no, actually, since you answered so beautifully. Well forgive me if I'm not pronouncing your name correctly. Do you have any idea who this might be? I'll ask you some proper orthopedic questions. I promise your own music again.
I am not sure, but this, I can say, is told, I don't know, I'm not sure. So I don't think I don't think anybody knows terribly well what either Aristotle or this chap looked like and they would. They were very nearly contemporaries. Anybody from the audience want to hazard a guess who this is. This is this is Socrates and Socrates, Socrates very famously, so Socrates may be regarded as one of the pioneers of teaching and what Socrates, after trying various methods of teaching established and then demonstrated, was that the best way to teach is not to tell people things, but to ask them questions.
And so that's what we're going to do today. Some of the cases will be very difficult. The fact that they're difficult doesn't mean that they should, in a sense, represent any more of a challenge to you than the ones which seem on the face of it to be more straightforward. If you're faced with the difficult case, it's not necessarily esoteric detail that's being requested of you.
What's being requested of you is an ability to think logically and to try to demonstrate the clarity of thought in terms of proceeding towards a diagnosis and a management plan. So I promise you some orthopedic questions. Here we are. So hopefully you can see some long standing films and you can see an X-ray of the distal for the wrist in a child who's actually 11 years old, and both sets of x-rays were taken at roughly the same time.
I think actually the response was slightly taken a year earlier, but it's the same child I'd like you to just to clearly explain to me, describe to me what you can see. The extremes before they start for arm showing bony growth from the ulnar nerve border of the radius. Yes, it's well demarcated was a very narrow zone of transition. There is no I can see also the radius looks this increased muscle.
It could be United or heal the fracture of the deficit fracture of the radius. OK, that's the proximal to the bone growth. Yes other lesions in the four arm in the X-rays of the standing films of Muslims. Attention just to this area. Here I can. I can certainly see this some bony skills arising from the radial border of the distal Alma.
Yeah, also. And so even on the forearm films, there's evidence that this may not be an isolated lesion, but it may be a condition in which multiple lesions Wally osteoporotic lesions arise now. And you correctly described what appears to be a lesion on the ulnar nerve border of the radius and the smaller lesion on the radial border of the ulnar.
He described what might have been a previous physical fracture, but we may come back to that in a second. Now Now have a look at the long leg films and tell me what you can see. In the films. What is difficult?
I see this bony growth from the proximal tibia like ostia control because the film is too small. I cannot see exactly. Yeah, you're absolutely right. What you're looking at here is to control multiple conditions. There's also some other things going on. If I draw your attention to a. I can see between the fibula and people on the left side. There is the fibula is short.
The short. This is approximately between the Civil and tibia. And I'm just also then going to draw your attention to the coronal alignment of the legs. Is there anything you'd like to comment about? So this the rule is not dropped down completely midline, but it's nearly nearly midline. Is there anything you would comment about the coronal alignment of both sides?
This is values alignment of at the level of the hip and also the knee, especially on the left side. So we have a condition here, which seems to be affecting multiple bones, which appears to be causing ostia controllers, and it may or may not be causing some slowing of the radius. Although I'm perfectly prepared to accept it might have been a previous fracture and maybe some slightly asymmetric volume.
Actually, I have the angles on, but the left leg was somewhat more about this than the right leg. So what do you think would tie all of those findings in together? What is this condition of the lesion? Most probably multiple resistances. And do you happen to know the inheritance pattern? It is not a formal, dominant inheritance due to a lesion affection one or two?
Very good. That's exactly right. So in autosomal dominant inherited patterns and there are two well defined genetic defects in the next one, the two genes just for a little bit of CDCS outside of the context of the are just for your interest. Actually, the Evelina hospital St Thomas is in London. This actually is further interrogating the different genetics and relating the different genetics, even between patients with multiple stages relating to the phenotype and trying, trying to actually better relate the genetic basis to the phenotype, not only in terms of the question of but to so that the tendency for to but actually some long explanation.
And what are the treatment principles here? The treatment principle here is to maintain the presence if you need deformities to maintain the ligaments. If it is this discrepancy, if there is any angular deformity and to follow up to, there's any possibility of malignant change which is remote should be considered during the follow up of this patient. You know, since you raise malignant transformation, you know how you would differentiate an austere syndrome undergoing malignant transformation from which you is benign?
From the history of this, in addition to in the size of the legion, if there is in recent onset of pain. Uh, second thing is the MRI. MRI of the lesion showing the size assessing the thickness of the article cup. If it's more than one centimeter with the possibility of malignant transformation, yes, it should be said that threshold centimeter lies to completely mature individuals.
But for the growth, pain or a cartilage cat greater than a centimeter in depth in a fully mature individuals indicates the likelihood or the possibility of bleeding vaccinations. As with everything in orthopedics, to some extent, the treatment goals that maximized function minimize pain. And that's the treatment not to take out every lesion, not by any means, but to take out those lesions, which are causing pain or those few questions that I need to make sure you maintain longer.
Thank you very much. I'm now going to hand onto if I make a repeat enough. And what's this condition? Have a look at. Hopefully, you can see a AP pelvis for Hips and frog lateral at the same.
I think I can be heard now it's my voice, so I can see egawa. Yeah, so I can see an ebb and flow and the position of immaturity and showing and a decrease of emphasis. Height and the left hip, I assume, with sine of fragmentation. And there is a radiological evidence of chemical weapons which responded to Percy's disease.
Yes OK. If I told you that this was a six-year-old boy. Indeed, that it was birthdays disease, firstly, how would you? And this was actually the first presentation of six-year-old boy with this disease. How would you counsel his parents? What what would you say to the boy and to his parents about how did you express to them what the condition is and how it's likely to be treated in the future?
So in my counseling of the parent of this child, I need to describe for them this problem as a problem which until now we don't have an exact cause for this problem. We actually understand there is a decrease of the blood supply to the growing part of the head of the femur. It can be sometimes just unilateral or affecting one side or affecting both sides.
It have. Let me ask you to pause them if this were bilateral and you brought up bilateral reality. And you're absolutely right. Both can be bilateral. But if actually in a six-year-old boy, you saw symmetrical hips looking like the left hip, what other conditions would you have to consider? Because at this dysplasia, especially if there is a terrible reflection.
Very good. So multiple Olympic seal displays here because of these hyper realism skeptic epicondylitis sickle cell disease. Um, a lot of difficult diagnosis, but the most common bilateral happened that terrible infection is epimysium dysplasia. Yes so one has to also then consider essentially the mucus polysaccharide season disease, which I think you're hinting at.
But but things like hunters and hurlers and central banks, et cetera. But yeah, that's absolutely correct. If it's unilateral, then the likelihood is that it's worth as we tend to get an MRI scan these days just to check because it's easy and it's sort of crosses the T's and dot the I's. And you said that it's a condition that we don't fully understand.
I think we'd be fair. In fact, first described, of course, 1912 Tabby and Percy's possibly by. There was a conference in 2012 in which that was the overwhelming consensus that we in 100 years there was not very much discovered about it. But what are the principles of treatment? What would you regard as your goal in treating this six-year-old lad over the next two or three subsequent years?
So according to the evidence based medicine, there is a long follow up series of Mr Harding regarding one of the classification of the person's disease regarding the management, and he, according to the letter classification, as the FA is the person who is the patient in the category, the most important predictive factor is the age of the patient. So according to his long series, which had been done, more than 39 pediatric orthopedic centers run by multiple surgeons and a lot of persons patients, they discovered that in a class and c, there is no any effect of the treatment plan, while in a B category in particular and in presence of the age less than eight.
There is no need for doing anything about it. The containment phase will be very effective to get a Fuller result. Better isn't as regarding the shape of the head, and they are avoiding any complication of disfiguring of the proximal feel. Yeah, I entirely agree with your description of Tony Herring's milestone paper. For me, it's some components of it are a little bit nihilistic.
We're very lucky in East Anglia to work alongside a chap called Tony catterall, who's retired now that used to work at Great Ormond Street in the Royal National orthopedic hospital. And he's a very great expert in Perth as prof. Little mountain in Sydney. I work with they would regard the principle of treatment as concentric containment. Basically, there's not very much you can do about femoral head collapse.
There's been lots of techniques described, but none of them are terribly effective if one was terribly effective with all doing it. But what you do want to achieve is concentric containment. So when the hip starts to swell up, you need to do something about it and a very easy next thing to do, which applies to quite a lot of heat related conditions.
If you want to hedge your bets and say something fairly neutral that can't be criticized is to do an Arthur grant, and I'm going to show you this picture and ask the yellow line on my screen. I don't know if that's on everyone else's skin, but this is an air of ground, and I'm a great fan when I'm training my trainees how to do all four grams that they inject a little bit of air before they inject any dye.
Because I'm not sure if this expression translates universally, but it avoids blotting once copybook. It avoids injecting a whole load of dye, which then obscures obscures the region before effectively getting it into the joint. Good OK, I am now going to move on, if I may, to hasten lightly Haitham. Would you be kind enough to unmute yourself?
OK Yes. OK this is a super tricky one, do you want to take on a super tricky one? So this is the sort of case where I'm not really looking for specific diagnoses. I'm looking for sort of broad brush categories. Ok? and importantly, a case she's five, because there aren't the normal, possibly the normal hints of skeletal development in terms of femoral, head and so forth on the X-rays.
So she's 5 and she's on the 1st percentile for height, i.e. if you line up 100 girls of her age, she would be one of the shortest in the hundreds on average. Describe what you see and tell me what broad category of condition you think this could. Who's actually of beliefs and posts blogs about females showing bilateral support?
And there is a decrease the Pacific Ocean is cooler than usual at this age and also the stellar distances shorten and this seems to be regarding the history. She seems to be syndromic. So maybe she's dysplasia, a type of congenital cookstove, Osiris type, serious congenital, developmental and acquired due to many causes like syndromic or dysplasia, or due to infection or in other causes, e.g. dysplasia.
Yeah, and you've described it beautifully. Actually, there is lots of error. There's delayed officiel or superstation. Yeah what sorts of. Displays and yet the pelvis not doesn't look completely normal, but the acetabular looks relatively well-formed. What what, what sort of dysplasia do you think this might be?
Mostly physical dysplasia. It's affecting the faces, mostly. So this could potentially be a multiple dysplasia. Yeah, it happens. It's not. It's dysplasia, but it could be me, either. What sort of thing? So what do you think are the principles of treatment in a condition that I'm willing to bet you never treated?
In fact, you may not have ever even encountered some dysplasia? Yeah, and that's not that's not the point. The point is, what are the orthopedic principles that we would apply to this for you and me both relatively unfamiliar? Yeah so the principle of treatment of correcting the course of virus and was dilatation proximal femoral osteotomy to still the neck shaft angle and also reduce the haytham line or angle and also restore the stable through this distance.
And also sometimes we need to achieve normal activation of the femur and to keep the physical vein more transverse to allow healing and avoid any more works very nicely expressed. And in fact, that is not the next step that I took, but it is the step that I took, as it were happening, leapfrogged from the next step. So this girl now has had bilateral Valukas still to me, but I'm going to take you back to what I said to Muhammad about it.
You can very, very rarely be criticized for doing so. And this, for me, is interesting, and it shows that actually, as you add up to the hip, the medial increases i.e. the subluxation as you add doctors across the legs. Actually, the here that it was improved. And that's why I was very confident to do about this. Thank you.
Let us move on to action one. And then after this next case, I think I'll hand over to the wonderful Mr. egawa today. It's ready. So, oh, Yeah. So this is a trust for you actually back into to be more, more familiar territory, so hopefully you can see again a frog lateral and an ape pelvis for Hips.
Would you like to describe what you consider? I a. The hi, can you hear me? I can. Thank you. Yeah so these are AP and a lateral radiographs of the screen you put in your video on.
I'd like to speak to people as close as possible to the concept of face to face carry on. I recognize it's not for everyone. So these are APM traject lateral radiographs of the skeletal image or patient. They're showing that, especially on the right hip, the clients line is passing above the prefaces. So this appears to be a case of a slip up of a moral epiphanies.
The left hip seems reasonably normal to me. Um, so actually, if I told you that this child had this, this is a 14-year-old boy. Is a real case. I have operated on a 14-year-old boy who actually had been limping on and off for six months, but he could walk out. How do you classify slipped up of rough seas in a way which both guides management and predicts prognosis?
So that would be either an acute or a chronic slap in this case, it's a chronic slap I can see on the radiographs that there's some calcification from Italy, which points that there's some attempt at callus formation. So this, as you said, has been going on for about six months. It's still beating which, which hints at the chronicity. That's not exactly what I asked, though. If if I may, I would like you to tell me what feature of this child's.
Presentation, clinical or radiographic? Actually, best predicts prognosis and guides management, so that would be based on a Lotus stability classification so stable versus unstable, depending on whether they were able to make it better or not. So this child can read better, so he would be classified into a stable slap, and that basically quantifies the risk of even if they're unable to bear weight.
Then there's a 47% chance of necrosis of the hip. Very good. So how would you manage this? A consultant on two to three months into the job and this child presents to the emergency department is frustrated that the GPs not properly examine the child. When you examine the child, the child has a pronounced limp walks with an externally rotated foot regression angle.
You actually put him up on the examination couch and flex the hip. It goes into sort of radical external rotation. That is to say, as you flex the hip flex the hip up on the left hand side. And you can touch the knee to the shoulder, flex the hip hop on the right hand side and the knee swings way out laterally. In fact, his heel comes across his.
What what are you, what are you going? How are you going to manage this challenge? So the principle here is to arrest the slap progression. So we want the slap to be at the place that it is now. Um, for that, ideally, this is best managed by a pediatric orthopedic surgeon who is adept at dealing with severe up of small.
But even if you are going to choose to phone a friend or transfer this patient and what measures are you going to Institute essentially immediately? Uh, so. I would how could you how could this how could you definitely make this young man's hit worse? So by adopting an acute reduction.
Peel-back no, so I don't think you would achieve anything by attempting an acute reduction because of the chronicity, because it is stuck. What the way you could make this child's hit worse would be to turn it from a stable hip into an unstable hip. so actually your duty, your responsibility as the diagnosing surgeon is to ensure that you minimize ideally eliminate that risk and that.
So first of all, you actually ask him to be non weight. Very simple as that. Now let us imagine that you are this time at the receiving hospital and that you are in the position of being at the receiving pediatric orthopedic surgeon. What what options are open to you? How would you how would you advise the parents?
How would you consent what would you actually do if you were not the man passing buck that the receiving the bulk, then not passing the baton, but receiving the baton? So I would opt for in-situ pinning of the right hip. But I would explain to the parents that the options essentially are to. Like I said, the principle is to arrest the slip progression and then deal with the deformity later. That would be in my hands, but there is also an option.
It is done very frequently in other centers to correct this deformity in one go and then bend the hip. Yes do you know? Do you know how that surgery is performed? You know, any of the eponymous operations described? So that would be a feather with Dan osteotomy, who? And what do you do with it in a dumb or osteotomy? So essentially, you're trying to reduce the neck back in line with the hypothesis that is with a that is making.
Making sure that you preserve the vascular title to the hip while doing that. So the word to bring into your explanation is cuneiform. You take out a wedge of metathesis. Very nicely answered I operation on this chart. And I did exactly what you suggested. First I did in situ pinning. And we will come back to fight another day, possibly, depending on what the Chinese.
But choose this in the future. Now I'm going to see if I may hand over to my colleague, Mr. egawa test, and I'm going to stop sharing now. Hi, everyone, and thank you, mark, so for those of you who don't know me, I'm a consultant, pediatric orthopedic surgeon between Broomfield hospital and Max hospital in Essex. So I think these sort of sessions is quite a lot of your head is now probably around 75% of you here for questions, and I really want everyone to get as much out of this as possible.
And I think to do that, what we're going to do is we're going to go through a sort of quick fire round of cases. So if everyone can get a sheet of paper and a pen, we're going to start and we're going to go through 30 different pediatric orthopedic cases in quick succession. And then we're going to go through the answers of them and give you the opportunity to ask any questions.
Because the issue with the farke's is you may not get the standard question that you expect to get. You may not get the parfaits, the spoofy, the clubfoot, the basic trauma, and therefore you need to be aware of the other things that can pop up and just stay calm and understand how to deal with them. OK, so if everyone has that, I'll start showing my screen and we'll move on.
OK it's so different, so I'm going to time this and we're going to spend 30 seconds per slide. OK, so there's not going to be much talking for the first 10 minutes or so, but then after that we'll be able to do whatever we need to do. If you have any questions, I'm very happy for you, just unmute and interrupt me, but we need to move on pretty swiftly to get through this in the timely manner.
So I'm going to put up the first question and we're going to start our 30 seconds now. So this is an X-ray chest of a near an eight. And there's three questions here. What do you think the diagnosis is? How would you manage it? And what other things can you consider it could be or you could be concerned about?
OK, so just three short words on their. And hope you've got those down, we're moving on. This is an X-ray again of a neonates. Can you identify or provide us with the diagnosis? And how you would subsequently manage this patient.
These are quite important things to recognize as a consultant, even in a decision house or anywhere, really. We'll move on. Here's an X-ray spine once again of a young child just four months old under my care currently. Can you provide me with the diagnosis for this patient? The cause for the diagnosis and how you would manage them.
In the very first instance. OK, we're moving on 30 seconds, we're going quick here. Axilo foot in a six-year-old boy presenting with pain, swelling, difficulty, weight bearing if we can have the diagnosis. And the subsequent management, how you would manage this patient in your fracture clinic if they came through the front door. There's only two here, so move on quicker to slightly more complex, one more obvious clinical picture and supported by X-rays in a unit again.
And we have the diagnosis, how you would manage this patient in the very first instance. And what further investigations or associations are in keeping with this clinical presentation? I can't see most of you, so I hope you're keeping up and writing down really quickly, we'll move on again. I think this may be reasonably similar to 1 you've seen before today, but if we can have the diagnosis of this patient, the inheritance patterns of the communication and the gene that is affected.
The next one will be pretty obvious, but it is once again in a young neonatal patient. What is the diagnosis? What would be your management knowing that this child is a brand new born neonatal child? And what are your further considerations, one of the most important things that you need to do when approaching this child in this clinical situation?
And I hope you'll keep me locked up, we're going to have scores of The doors at the end. Everyone can submit their scores, so next patient. Another trauma, slightly older child around 10 years old, had a twisting injury, can we have the diagnosis of this patient? How you would manage it in the first instance, it's come on your general trauma on call and what your concerns would be with regards to this fracture.
And this was a case that I was given in my fowlkes. OK something most of you would have seen before and stayed up all NIPE managing. But if we can have the obvious diagnosis, the classification and what this one would be. And again, how you would manage this, I'm sure the folks mentors can vyver you with regards to some of these more core critical topics.
Later done on. So here we have an AP pelvis in a 14-year-old runner presenting with right sided pain. If we can have the diagnosis. How you would manage this patient and what you may be concerned about or any further considerations? Anything, any other tests you would do anything else you would advise, et cetera.
This is a clinical test that I expect everyone to know and understand why it works. So can you name the test? I'm sure you've all done this. We've done it in foot and ankle rotations and pediatric rotations and neuromuscular patients. And then we'll talk about imaging. And what we are doing.
And image b, what are we looking for? What is the tight structure? What would you have to manage an image versus image be? Next, one clinical photo of a newborn with associated X-rays. This is a congenital deformity that we would see so diagnosis. The management of this patient and what your further considerations are for the future when looking after this patient, what would you advise the parents or explain to the parents would be an issue or potentially an issue in the future?
Next we have a clinical photo of a foot. I would say it has a particular shape to it. Especially with regards to the sole of the foot and associated X-ray. Hopefully helping you identify what the issue is. And are you aware of how these patients are managed?
30 seconds. Moving on. Again, a patient who presents with the below X ray, you can see the clinical picture of the limb in the foot with the associated long leg X-ray. Just give me the clear diagnosis that this child has and how you feel they should be managed.
Something slightly more complex with regards to this one, but if we have a pelvis and a child, obviously, so let's have a diagnosis, what is the important measurement that we would like to know about, which helps guide our clinical treatment of this child? What are the potential causes? And subsequently, the management that can be applied to address that. So full marks of this one, there's not many with full marks.
We're halfway through already is a clinical photo, the resolution and coloration of the X-ray is absolutely fine. This is what it appears like. I have not adjusted any shading on this. We have the diagnosis. The pathophysiology, what causes this condition? From a bone cellular level. And subsequently, what are the risks associated with this condition?
Next X. Right femur in a child who presents with pain was playing basketball. No problems, but presented with pain that then began to cause issues at NIPE time has an obvious swelling in the thigh. Can you tell me the underlying diagnosis, the radiological signs that we're looking for and how you would further investigate this child?
Then one not to be missed. X-ray of distal femur in the child's. Can you give me the obvious diagnosis? And then what arrow won an arrow to his pointed to, what is the name for? The two regions of Bowen affected. And what do we what's the appropriate nomenclature?
Clinical photos and wrist X-ray of a child with an obvious deformity. Pretty clear cut, who have the diagnosis. What the inheritance pattern is and what is the key anatomical structure that causes this deformity in the wrist? And me, myself and Mr. Latham have both recently managed a couple of patients with this condition.
I'm letting go in a few more seconds so you can scribble down and get on. Patient who presents with pain on the medial aspect of the foot. Can we have a diagnosis? A classification. And what your management would be. And this is a 9-year-old child, if that helps any of you.
It's a medial aspect of the foot that is painful. A five-year-old child presents with this X-ray walks waddles late presentation. What is the obvious diagnosis? Can you name five risk factors? Which you should all know about, this is a core topic and subsequently how you feel this patient should we manage understanding that they are five years old?
One to puzzle a few of you. What is this is an X-ray of A is in a 13-year-old. We can have a diagnosis. And if you can give me the eponymous name, that's a bonus point. They may have seen it may not have seen it. Don't worry, it's just there.
You don't need to know much about it. What is the name of the procedure and the approach that has been taken with the needle in this image here? What is the obvious pathology? And can you name what 1 and 2 are pointing at, and we'll talk about that. Just seven more to go.
But getting there quickly. Here we have your typical presentation in most hospitals, and a 12-year-old girl was walking and suddenly fell to the ground and had to present to the hospital. What is the what's the diagnosis in this radiograph? What are the anatomical associations, one of the things that we need to assess in this child, both clinically and logically?
And what is the name of the main ligament that is usually stretched or torn in this injury? And we have ATP and lateral of a five-year-old child who presents with a clinical deformity. These are the X-rays for them. Can you describe the deformity? There is a bowing of this tibia fibula.
So what is the underlying diagnosis and what are its associations? This is a 12-year-old child that presents with no trauma. There's no trauma associated with this presents with a. Prominence over the right upper chest.
If so, not understanding that there's no trauma can have a diagnosis, a cause, anatomical cause and management. How would you manage this patient? Back to something we're more familiar with. We have the name of this.
An issue. Please don't get distracted by the obvious. Have a close look at the X-ray. What is the diagnosis for this patient? It was a major trauma accident. How would you assess this child and what would be your management?
The coming down to the last three. I think this we've been through, but please just write down the obvious diagnosis. The risk factors associated for this to occur in a child. And I'll mention briefly the management that can be undertaken. Final two.
We're only 10 seconds behind where we planned. Significantly shorter leg. One bone predominantly affected. Diagnosis, how it can be classified. And subsequent management. And finally. X-ray and CT scan.
We have a diagnosis for the lesion. In the history, what is it typically improved with medication wise? And subsequently, how can we manage this patient? OK, everyone, happy. Let's all have a breather for 30 seconds. OK there was a lot to go across there and we'll start from the top in a few seconds.
Take away, take away your answers, keep a log of your scores, and then we'll get them put into the chat box. Again, I'll go through them relatively quickly, but if you have a question, if you can please unmute yourself and also or put something in the chat box, that would be really helpful just because I'm going to try and get the chat box up on my screen as well.
So we can have a look. OK, so we'll start from here. So number one, diagnosis is actually a clavicle fracture that was caused by birth. This was the same child who had an X-ray at three weeks, and you can see significant healing there. Management, conservative neonate, it will heal. And what are your other considerations?
Well, could it be a suit of arthritis of the clavicle and non-accidental injury if it was not an immediate birth injury? OK, next one. This is really important, and this is something that people tend to miss quite often, this is a seal separation. OK, this was a birth injury in this child. What do we mean by 5 syllable separation?
It's essentially a to Harris one fracture where if you go to this? This is the metamorphosis. Their purpose is still cartilaginous, you cannot see it and is actually reduced. This is not an elbow dislocation. And that's the most important thing to understand. This needs timely treatment. It is associated with non-accidental injury, so does need to be looked at.
And how do we do it? Normally we do a manipulation and arthrogram to confirm appropriate action and worry. OK next one, hopefully most of you got this diagnosis is congenital scoliosis. OK there's a young child, what is the cause in this case? There is a hemi vertebra that you can hopefully identify here, which is the apex of the curve. And this is obviously due to a failure of formation.
There is obviously a failure of segmentation as well that you need to be aware of. What do you do? Well, typically you would observe it and they can be excised later down the line. If it's not improving. And this defect forms is an issue with the formation of the Mason cable and lag during the 4 to six week of gestation.
So you can get a bar, which is a failure of segmentation, or you can get failure formation, which is how many vertebrate, just as in this case. And for this child, you can see they're actually got multi-level issues with them. We've sent this child off to Great Ormond Street. Six-year-old child, I think I said before the diagnosis. Cola's disease, a Avastin necrosis of the navicular common thing to see commonly seen in a fracture clinic, how do you manage it?
Essentially, non weight bearing and symptomatically management expectedly give them a cost if it's really severe. Most patients can get around on a boot, and it does improve over time. Number five, newborn child. This is a congenital knee dislocation usually caused by very tight quadriceps, tendon and subluxation of the hamstring, which then causes this extension moment. How do we manage it?
Cereal casting of the knee in gradual flexion. In fact, I probably have the same patient here. So this is the taric classification, which basically depends on how much passive protection they have. So it's either greater than 90 30 to 90 or less than 30, as you can see if it's quite severe. Management is cereal casting, and the association is with fx and protocols, so always get a scan.
The last patient I had with a congenital knee dislocation also had a graft three dislocated hip that we had to manage in a Pavlik Harness. Mark went through this one earlier, this is multiple hereditary axilo dosis, the most benign brain tumor. Inheritance patterns as autism were dominant. So it is quite common to see in families, of course, and it's the exact one, two gene.
OK, we don't need to go through this much anymore. Any questions? So far, please unmute, otherwise, I'll carry on in a few seconds. OK so obvious fracture said this was a. This is a neonatal femoral fracture. How do you manage it? Pavlik harness OK or with no treatment whatsoever.
This is the same child. When I saw them a year and a half time, the line completely healed, completely remodel. No leg Allen discrepancy. But you do need to look at the leg lengths as you follow these children up. Obviously, if you have a young child present with the femoral fracture, who is not a walking age, of course, non-accidental injury that needs to be investigated for child safeguarding.
And you must mention that when you see in the pediatric section any sort of fracture, you need to always mention the word safeguarding. It's very important. This is the case that I got given in my FRC us exam, this is a to Harris through fractured tibia with a high fibula fracture. What how do we fix it? Well, you can fix it just through manipulation.
You can hold it with a screw. You can hold it with a K while dealer's choice. But what is the concern? concern is this concern is a growth arrest that can happen and cause an angular deformity around the ankle. So the third mark for that was looking for growth deformity later down the line. Supercontinent fracture garden three.
How do you manage it depends on the mechanism of injury, but you need to approach the child with its practical abcs, assess their neurology, make sure you document individual nerves, including the Enter into ulnar nerve, which has gone in quite a few numbers must ensure there's a radial pass to document the perfusion of the hand. Obviously, child needs to go to theater anyway and choirs dealer's choice with what you do.
You know there's evidence for both lateral and medial choirs. If you want to start mentioning evidence, you can talk. We have our guidelines. Obviously, if you're doing in the UK to mention two wires can be lateral or cross. But if you're doing a medial side, then you must open and have a look to ensure you haven't penetrated the ulnar nerve to at least retract it.
This one here is a right neck of femur in a 15-year-old runner fracture across here. Obviously, the classic. Well, the classification is a delicate fracture and this is a delicate classification and that essentially is a transfer seal transfer vehicle basis if I call into truck and it's a slightly similar. But obviously, the Abn rates are quite significant when this transfer seal and it's associated with or without epicondylitis Allen, which essentially is a soofi, if you think about it that way.
But trans cervical also has is the most common one and also has a 30% risk of AVM. How do you fix it, kayleigh? Screws aspirate the joint of its hematoma, and other things need to be looking at is obviously could be a stress fracture, low vitamin D and things like that. Number 11, so this is a silver Scholes test. I feel like a lot of people don't tend to understand this. So with the knee straight, both the gastronomical and the Achilles tendon are tight.
OK, you have to connect the heel position. And if you've got tightness and you have that quietness, deformity that tip toe walker, if it improves with knee flexion, that means you have relaxed the gastric Solis in its entirety, and that means it. If you still have tightness with the knee flex, it is truly an Achilles tendon issue. Most I would say would be like b, where they're tight with improvement, with the knee flexion, which means you relax a gastric, which means it's a gastric minimus tightness and that's very common in neuromuscular disease.
The name of the test is silver gold. Sylvester s.h.I.e.l.d. OK, thank you. Thank you, Nicky, for that. Great this also allows you to then decide on how you treat it, because if it's an Achilles tendon issue alone, then you can do a percutaneous or tender Achilles lengthening as sort of shown here. Or if it's the gastric near-miss, which in most cases I found in my patient call, it is you can do a gastric near-miss recession, which is essentially lengthening what I tell the parents is the Shirt that sits around the muscles and allows it to stretch very, very useful.
And you don't, then have to touch a tendon. Diagnosis, this is the posture and medial bow. What do you do with it? Nothing observe improves. But what are the further considerations? Leg length discrepancy 2 to 3 centimeters at skeletal maturity. So I just watch these. The most telltale sign is that you can essentially touch the dorsum of the foot up towards the shin.
Obviously, the apex of the boat is both posterior and medial. So whenever you see one of these funny bows, look at the apex. Where is it? It's at the back. It's on the inside of the posterior medial bone that will help you a lot when you get seen some of the more complex ones. And as you said, the leg length discrepancy is the one thing that we watch out for, and we have our very clever ways of guiding growth these days.
Diagnosis, this is a Persian slip, a foot or a rock, a bottom foot. Hopefully you could identify that the tolerance is almost vertical. And if you look at the line, if you draw between the taste and the first rate, it's completely non-linear. They're completely off. How do we manage this?
Typically with a reverse Ponseti casting method? So that would be the first onset to reverse Ponseti casting that essentially loosens up all the soft tissues. And then we do an open reduction and wiring of that. Muhammad's eyes? No, no. 12, no. 12 was poster and medial bow.
There is no other diagnosis. It's just posturing. Egawa so 13 traject vertical tails reversed Ponseti technique and open reduction casting. And this is the reduction you actually see. You're sitting yourself and you usually where you can do it. I do it retrograde like this and you can see I've gone through the base of the first metatarsal into the tennis and hold it in that way.
Diagnosis of this one. So to be pretty simple about it, look at the bow. So the bow here is again, medial. If we show you a lateral, it'll be anterior. This is the entry medial bow and this patient has missing Lateral Raise. OK, this is fibula, hemi Emilia. And the way you can remember it is, it's an intermediate bow. Mi familiar fibula media OK, and I'll tell you why, because on the next one, we'll have a look at something else.
These are some complex and more complicated cases. As you can see, you've got your ADA both the medial boats much more significant. There is a classification. I don't think you really need to know this, and obviously there are. You can either observe it and there there will be reconstruction options. This can also be associated with proximal femoral focal deficiency and absence of the ACL.
So I have a patient currently with very mild fibula, and Emilia basically has four toes. No significant other findings are just slightly shorter. Fibula has a ball and socket, ankle joint and an absent ACL, and we're actually managing his ACL because that's the big issue for them at the moment. Next, diagnosis, this is a congenital savara, it's bilateral, it's a problem with ossification femoral neck.
What it causes for this congenital development, it can be autosomal dominant. It could be acquired. It could be following trauma parfait Sufi. But you know, this is an obvious congenital severa. What line are we talking about? We're talking about the h-e angle Hildenbrand angle. As you can see, the Hildenbrand line, the axilo angle. If it's 45 degrees, it's likely to correct.
It's 45 to 60 watch and wait 60 degrees plus surgery. Typically, if a femoral neck is less than 110 degrees of angulation, as you can see here. And what I did for this one is I did a bilateral osteotomy. This 1 May have confused a few of you. This is osteoporosis. Ok? essentially, marble bone disease is caused by the pathophysiology a defective osteoclast resorption.
There are three genetics type and essentially there's inability to acidify the hardships. And there's a lack of ruffles border that I would say is the sort of magic phrase on your fix. Part one is the lack of Rafah border defective Oct class. You can't resolve the bone, so it just gets harder and harder and harder. Osteoblasts keep on working, laying down more bone, laying down more bone, and they can actually present with quite significant fractures.
And they. And because you get this other view, which is a bone within the bone, it can actually end up leading to anemia as the marrow is unable to produce hemoglobin. And you can also get increased risk of osteomyelitis again because of the stagnant blood flow. A very important case with this, I hope you pick this up. This is actually a Ewing's sarcoma. There's the onion skinning found of the period.
This was a 15-year-old NIPE pain able to walk that has pain with associated swelling swelling. Further investigation would be MRI scan. You see a significant tumor here and there large soft tissue components that it's hot on the PET scan and actually about 25% to 30% of them already have metastases on presentation. If you're doing the part one histology that you tend to find, the bullet is round blue cells or pseudo rosettes and treatment is chemo, limb salvage and then radiation.
So quite horrible things to have, but important to pick up. This is chronic osteomyelitis, that's the diagnosis, the metamorphosis, as the vessels make a sharp turn, basically happens in this area because this sluggish blood flow. One what is 1 1 is the question necrotic bone, which has been walled off from its own blood supply and two is the blood from a layer of new bone forming outside the existing osteomyelitis.
Chronic osteomyelitis the question is one interleukin 2. Apologies, the patient might have recently had this the mad lungs deformity. That's the diagnosis. Essentially, it can be a congenital disc, ndrosis of the distal radial firefighters on the volar side.
It's autosomal dominant. You get under explanation of all the tilts growth, the rest of that part and essentially the anatomical structure is the Vickers ligaments, ok? The Vickers ligament, which is a short radio lunaz ligament, and that's what you would release in this child. OK it's also the document, as I mentioned earlier, and it can be linked to a condition called very wild. This control stenosis, which is where they all get me and milk dwarfism.
This is actually the first painful on the media side, this is an accessory navicula, about 10% of pediatric population have them, 70% of them are bilateral. They're three different types type one, type two, type three, depending on if the bone is essentially a CSA void within the tendon, which causes pain to when a separate or three when it's just global enlargement procedure is a procedure which is basically open exercise and advance the type tibia on his posterior tendon on their.
OK last 10, I know we've gone through a lot already. Bilateral Nadh. This is totally logical risk factors. First born female breech, family history, last birth weight, oligo hydroponics, twin pregnancies take your own pick. OK, you need to know about the 9p screening that we have in this country. How would you treat it? Well, if you've got a child young enough, you can do a close adduction.
Unfortunately, in this child, there were five years old. As I mentioned, they needed what I call the full shebang, which is a femoral osteotomy shorten. That's a shortening de rotation osteotomy. They don't need a virus. You then do an open reduction and a pelvic osteotomy. And this is the child after they've had staged. This is one just to get you in the mix. For some, maybe even some of the faculty, this is disappearing bone syndrome, which is massive osteoporosis with proliferation and dilation lymphatic vessels.
Eponymous name is goram Stout syndrome Gordon syndrome don't need to know this for the exam. It was just in there as an extra what's happened here? Patella dislocation patellofemoral instability is very common and it's very complicated, so you need to understand what are the anatomical considerations. Well, has this child got patella, alta? Is it too high?
Is it sitting within the notch appropriately? Is the notch appropriately formed? That's chocolate dysplasia. Do they have abnormal version of their femur that can subsequently tilt the way that their distal femur is like, and therefore it slips out? You need to know about the TG distance hypermobility in these kids, and the main ligament was the MPFL fell MPFL ligament.
This child I had, they had a. It was patella Alta. So we did a tip top transfer for the child in addition to an MPFL MPFL reconstruction. Nearly there, 25 described the diagnosis, OK. Once again, let's look where the apex of the bones, its anterior and its lateral, it's an anterolateral boat. Ok? and two lateral bow is congenital sujoy versus the tibia Association's neurofibromatosis.
I won't take it more further than that. Here we go, there's lots of different things, there's a whole bunch of different things you can do to identify if it is neurofibromatosis a seven different types. Vast majority are like this. You need to be looking for cafe Au lait spots, et cetera.
OK this one, I said, was a traumatic and had been there for a long time. This is actually a congenital arthritis. The clavicle, if we were talking about a fracture, I'd be very keen to tell everyone, do not operate on them, they do heal by themselves. And this new papers in the bge to say it's us do that. Mohammed, 24, was patella from when stability. And we talked about that.
So here, congenital arthritis and essentially failure fusion between the lateral and medial ossification sensors of the clavicle and in caused what's the cause of this is essentially your subclavian artery. That essentially pulsates and stops it from fusing together. Failure fusion, you get extensive compression of the subclavian more, usually more on the right hand side unless the patient situs inverters, how would you treat it?
Well, you around the edges. You can imagine conservatively, but if worse comes to worse, you can fix it as like you would have fracture. Oh, yeah, we're coming up to. Oh, did I miss one? I may have missed one. Apologies to all of those. 23 As you said, sorry, I missed this, so go back to your scores.
23 This is an off the ground. The needles coming medial. So this is a supper doctor because you would go subadult to the medial approach. The diagnosis, obviously, what's number one? It's your dye pooling your medial dye pooling. Because the hip joint is actually empty too, is your rose thorn because there's caps the constriction due to the size tendon.
Thank you for making me do that. Let's go to 27 27. We'd already had a supercontinents, so we didn't make the same mistake. This is actually a floating elbow. As you can see, the child also has a wrist fracture and an elbow fracture. You have to be aware that there's a high risk of compartment syndrome.
You need to be very vigilant with your new examination. How would you manage it? Well, I tried both on the same day and got them sorted out. 28 severe Sufi as you can see, risk factors obesity, hypothyroidism, other hypogonadism, skeletal maturity, low vitamin D. There's some new things like acetabular retroversion that have been sighted with this. Obviously, you want to check if the blood flow is there for vascular.
How would you acutely do this? Well, this is as one of our colleagues mentioned earlier, which was an immediate modifier done osteotomy surgical, hip dislocation, identifying the slip, putting it back on nibbling off the Tufts is holding it on and then checking its vascular. I think if it's an acute severe slip, it would be completely reasonable to say I would either discuss my hip, young adult hip colleagues or my pediatric colleagues to perform an urgent reduction surgery dislocation reduction using the done method.
I think the fact that about that what the risks are, which is obviously AVM, that's up to you. Fine this is the gant's approach. This is a surgical dislocation. OK, we've taken it off the great uc-santa. So I'm just looking at the chart at the same time. Take it off. The great Eric Cantor flipped it over, essentially put a wire up the neck into hold that dislocated as one and any royal for traction for acute Sufi.
No, I think unless you're getting to it on the very first day and within the first six hours or 12 hours, that's the posh technique where you can do essentially a closed reduction and pinning. But the AVN rates are pretty high, so I think it'd be pretty safe. If you see this, that you would refer to a center that manages this regularly and you can also do it. As market said, you can do a direct anterior approach and do it essentially a sub cuneiform osteotomy.
That's essentially the fish, which is another one where you leave it in situ, you take out a bit from the neck. But I think this is a pretty standard answer for if I see us. That's what it looks like a following, and obviously we did the other side. This is a funny story. It's called a peg, a screw because this child was only 10 years old.
It's a growing screw. But I think, you know, contralateral pinning is a debate of its own last two. Here we have a significant shorter leg proximal femoral focal deficiency or congenital shortening of the femur, whichever one you want to talk about classification Aitken classification, which essentially allows you to say, is the femoral head present or absent and then describe how dysplastic the acetabulum is.
This is. How would you manage it? Well, most people would say lengthening, but if you're ever going to, I've never seen this procedure. But you know, the Van rotation, plus this is something we always wanted to see most. Now with growing nails, we wouldn't put nails in and bring them up. Final one sorry, it's taken a while.
It's the radial lesion surrounded by sclerotic bone tendonitis. What are we looking for? What are we looking for? This is a osteosarcoma, and the improvement happens with inside's ibuprofen. How do we treat it? Radio ablation, OK. If everyone wants to count up their stores and put them in the box, it'd be great.
But I hope that sort of made you quickly feel comfortable with a lot of things you may or may not have seen before may just be as helpful for those of you who are waiting to do the part. One of the exam as opposed to part two and I'm sure the folks mentors can further quiz you guys on some of the more common topics, but I hope you've now handled understand with that. Thanks very much.
I'll pass it back to you, mark.
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