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Paediatric Trauma for Orthopaedic Exams
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Paediatric Trauma for Orthopaedic Exams
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Language: EN.
Segment:0 .
OK good evening, everyone, and welcome to this teaching session, which is organized jointly by the FRCS mentor group and orthopedic Research UK. I'm Nicola Evans and I'll be running the session this evening in combination with the rest of the mentors.
We have two speakers for you this evening. We have Mr. Tom Crompton, who's a consultant, pediatric orthopedic surgeon at Brighton and Sussex. He undertook his fellowships in Westmead Children's Hospital in Sydney and at the Royal London hospital, and he's also the convener of the UK pediatric trauma course. We're then going to move on to Mr. Kyle James, who's a consultant at the Royal Alexandra Children's Hospital in Brighton, is a UK trained surgeon and has done two international fellowships in pediatric orthopedics.
He's worked as a mission surgeon in Malawi and was a consultant at the Royal London Hospital. He's experienced in pediatric and adult trauma, is a senior lecturer on the trauma master's program at Queen Mary university, and he's got 16 peer reviewed publications. So for this evening, we're going to do the upper limb trauma talk by Mr. Crompton. We've then got some new questions.
We will move on to lower limb trauma by Mr. James again with some new questions, and then we will move on to questions from the group. After that, we will do some viable practice, so we want to give priority to those people sitting the survivors in November and February. So if you can let Ruth or Abdullah know in the chat box when you're sitting the exam, and if you'd like to be considered for survivor and we will list them in order of priority and whoever raises their hand first.
If you missed any part of this lecture, don't worry. It will be recorded and it will be available on YouTube. The Viva sessions will not be recorded and we will release from our UK will send you out some feedback and we'd be grateful if you could fill that in for us so we can continue to improve. So without further ado, I will hand you over to Mr. Crompton for his talk of Allen trauma.
Thank you. good evening, everybody, thank you for that introduction. Hopefully, you can all hear me, ok? I won't introduce ourselves again by Carl and I are working here at The Royal Sussex County Hospital. The only major trauma center with a view of the sea. Currently, it looks like a bit of a building site, unfortunately, but that is the future. So I have a lot of trainees with me in the feedback from the exam is that I get the questions that people have asked every, every sitting and still common.
Things are common in superconductor. Fractures tend to be asked to almost everyone. So I'm most of the torque side of this evening. I'm going to go through supracondylar fractures. My aims of this are to give you a plan because I think the pediatric part of this Viva is a place where you should be aiming to get an eight. There's a limited number of things people will ask you about and very clear plans and guidelines that you can follow to really sort of impress the examiner.
I will come up in the vivas and we can discuss that then, but I want to get across in this sort of 15 minutes, I've got things that tend to trip people up regularly in the feedback I get from the exams. So the aims of this session are to give you a plan for theater for when you are asked a brief discussion about lateral versus crossed wires so you can decide.
And then what will always come up in the exam is the pink, pulseless hand, and I'm going to give you one safe, effective way of managing that guidelines. My experience and a bit of an evidence review. There is a I'm a health Warning with this. There's no incontrovertible evidence and everyone has their own opinion. But what you want in the exam is a clear, effective way of answering it.
So that's what this session is about. So we're not really talking about this. This may not project perfectly on your computers, but this a sort of Gartland one on displaced fracture. I couldn't really care if you treat that in a sling or a plaster or will do fine, you're not really going to get that in the exam. Again, not really contentious is your sort of Gartland to supracondylar fracture.
We can discuss that in the vyver. Beware, though, if you're going to be shown a picture in the exam of a apparently simple fracture. Excuse me with my video, kids often just beware if you haven't examined the rear story, you can see the wrist on the X-ray because as we'll see from the vivus, the question can go in a slightly different direction, but otherwise you'd manage that.
As with any superconductor fracture? What I want to spend a bit of time on is your plan for this because this is what you're going to get in the exam. It's pretty much always going to be 8 or 900 PM at NIPE when this child comes into your examination or into your hospital. And pretty much if the limb is ischemic, then that's an easy answer for you. If the limb is completely, well, profuse with a good pulse, that's an easy answer as well.
So we're going to spend a bit of time about talking about the pink pulseless hand. So when I ask this in the exam, you just want a clear guideline based, sensible approach to doing it, so you're going to document a neurovascular assessment. You're going to talk about the setup in theater, which I've got a slide for later on, where to put the image intensifier to make it sound like you've done this many times before, you can say whether you want an assistant or not, I suggest being able to do it solo in theater.
Oh, an old boss of mine used to say, you know, the reduction maneuver, a slight flexion and traction for the whole of the stairway to heaven, depending on where you live, it's just for a long time, you know, lifting the muscles relaxed to allow you to do that. And as I said, we're going to talk about Cuellar configuration. You need to be aware of the boast guidelines for Super fractures factories, they are guidelines, but they're pretty clear about having to have a documented assessment of limb perfusion, both pre and post op.
If the limb remains is scheming, there's no timelines given. But if after you're open or closed, reduction exploration of the brachial artery is required. And on that note, in the video, you need to have an idea of how you're going to approach your open reduction. Again, it doesn't really matter. It's opinion based, whether it's laterally medially or anteriorly, but you've got to have a plan.
And again, we can discuss that in some of the vyver cases. But most guidelines say NIPE time operating is not necessary unless urgent. Indication for surgery doesn't really give absolutes, but again, we can discuss that in a bit. And it also says if a media wire is used, a technique should be used to avoid injury to the ulnar nerve. If you look at the American guidelines actually and the American Academy of orthopedic surgeons, they just recommend lateral wires and go into a bit of that later.
They also say 2 millimeter wires should be used where possible. Just beware with the very young children. If you're seeing an X-ray of a might be unusual but a very young child, then you probably wouldn't jump in straight to saying 2 millimeter wires because it just doesn't sound like you've hung around the children's theaters too much. So we use a pro forma because we found that however much we try to persuade registrars to document clearly about the neurovascular status, it never happened.
Now we've introduced this pre and post op. Or I should say Kyle James introduced this pre and post op our documentation has become much better. And my recommendation for both the life actually in general, but also for the exam is to set up for supracondylar fractures like this and certainly for the offended super, super connally's or the flexion type injuries. If you have your C arm parallel to the table and the patient, it allows you to swing through for a lateral without having to flex up the elbow and for the particularly unstable injuries that you are struggling with.
That can make a world of a world of difference. And saying something like that in the exam, together with the other things you are saying will give you a will certainly give you a head start in aiming towards your towards your eight. So for the pink and pulseless hand, you can always find evidence to take you to take you down either track, to be honest, these are slightly old papers, but they're still useful.
So those guidelines are based on some of this is in whether you wait less than eight hours or more than eight hours. This is with Gartland offended supracondylar fractures with a pink pollster's hand that there wasn't shown to be any adverse outcome from waiting till the next morning. So in your exam, you can go down the both guidelines route and say there'll be first on the list the next morning, depending on the time of day.
Also, other papers have shown some quite significant vascular injuries with if the post doesn't return. So I think you're always on good ground depending on the time of NIPE. We're talking about to just say if you're competent and confident to just go to theater within reason sort of almost any time of night, so don't be pushed down one route or other. IOS guidelines say in the absence of any reliable evidence, open exploration of the antiquity of fossils should be performed in patients who have a pink, pulseless hand after reduction and pinning again, they don't give any timeline on that.
You might want to use a Doppler or obviously wait for things to warm up and wait a few minutes before diving into the anti-liberal fossa, but it's certainly something to be aware of. So again, people have different ideas of different surgeons, will have different ideas of what is in their practice. But I'd suggest in the exam. Just having a definitive idea of how you're going to treat it and you can back that up with evidence.
I've barely put a medial wire in years because of papers like this, so someone is injuring owner nerves. Obviously, we were the best surgeons in the world, so it's never us. But I think this is enough reason to try and treat supracondylar fractures with lateral wires. And if done well, there's no clinical difference in the outcome, only a sort of theoretical mechanical difference in the fixation.
So being aware of papers like that to back yourself up when you're in the exam can be very useful. So just a slight technical point, I think it's very useful to try and visualize what you're trying to do and you're doing two lateral wires and get two wires crossing the fracture site in either half of the humerus. Obviously, there's no concerns about crossing the capital or the olecranon fossa.
As long as you've got that decent spread at the fracture site, you'll have a good outcome and you can always use a third wire if you don't have. If you don't have the stability you desire. So the reason I set up, I set up all super condo factories in the same way with the CRM along parallel to the bed, just so the theater staff and everyone working with me gets used to it. And that's AI think that's a reasonable thing to do because particularly if you're presented with something like this in the exam reflection type of fracture, you want to just show that you're aware of the difficulty with reduction and pinning of these sort of fractures and just mentioning that you've set the patient up like that.
So you're able to swing through for a lateral without having to mess around. Positioning the arm would just fill me with confidence. If I was sat opposite you on that exam table to show me that you've been there and been there and done it. They're obviously pretty rare, but it's just useful as some of the very unstable extension type fractures as well.
It's always very useful. So I ask all our registrars and you should talk about this in the exam as well to the assessment of stability after you fix the fracture. I get a view in external and internal rotation, and if that's still slightly unstable, you can put a third wire in. I understand that, sir.
Not everyone, what everyone would do. You may put a media wire in and there's not a right or wrong there. It's about what you're used to doing and where you are trained, but it's perfectly reasonable to put a third wire in, if that's what you're confident doing. They might then move on to ask you about the complications, and it's best to talk about the sort of Mao union and deformity rather than a growth arrest in a supracondylar fractures that gives us that common gun stop deformity.
You need to be aware that that's mostly a cosmetic issue. If you're getting on to discussing that, you're doing incredibly well. And never forget the compartment syndrome with concurrent distal radius fractures. So that is my run through of supracondylar fractures. We're going to talk much more about the other injuries that come up commonly in upper limb trauma. I just think the best place to do that, to go through so many of them is in the survivors that we'll be doing in a little while after Kyle has had a chat to you.
So Thanks for listening. We're going to do questions at the end of Kyle's talk. Kyle James in just a SEC. So if you've got any burning questions for regarding superconductor fractures, just you'll have to wait just another few minutes. So thank you for listening. Thank you very much, Mr Compton.
Well, you need to try and recreate Bowman's angle. I just do that by physical examination, just examining the other limb to see what it is on that side. I don't try getting angular measurements out in theater, trying to recreate Bowman's angle. I would literally just examine the other good side. Hopefully they've not had a lateral or super Gondola fracture before. Otherwise, I'll just go with the normal for humans.
But no, I don't measure it the most. You need to take it into account. I don't. I don't tend to X-ray the other side either. Actually, I just do a clinical examination and recreate that on the injured side. I don't know what anyone else's thoughts are on that. I'd be interested. But Mr James.
Yeah, I don't use it practically. It's really an angle, it's what we use and follow up when we think we're trying to assess if it's going to go into various, I think normally you're just restoring the column and that's to me. And it's not really useful in the grade 3 in the pre-op op interop, you're using image guidance to check your reduction and Baumans we tend to only measure when we're following them up in Long term follow up.
Brent, thank you. And if you're ready with your presentation, thank you. Fantastic so guys, we're going to try and go through some of the lower limb fractures and discuss some of the things you need to think about in a virus situation. And so it'll help you to answer the question a bit better and try and flesh out some of the difficult controversies. So I'm going to talk about this first, because this frequently comes up in a visor.
The important thing is that we need to start talking about a slip to fifth status in terms of stable or unstable Lotus classification, and the stability is stability for the child weight bear. Now stable slips. There isn't much controversy when we come to management of a stable slip. But you need to understand that treatment might change depending on the severity of the slip.
How great the slip angle is, so mild slips we measure as less than 30 degrees of one third slipping. We will pin inside you a single inside your screw fixation. It's the accepted method of treatment, which has the best long term follow up. When you get onto a moderate slap between 30 and 60 degrees, unfortunately this leaves a bump, which can lead to impingement later and develop arthritis at a later age.
But still, the management of stable, moderate slips is still a fixation inside you with a single pin. Now, whether or not we go on to manage the bump later, either through our open means is still debated and we don't know if this changes the natural history of these slips. There's still some new methods using growing screws to see if the hip can remodel with growth, but we don't know whether or not this will be the answer.
So all you need to know for moderate slap, the child will have a bump, which can lead to impingement and can cause arthritis or label pathology in early adulthood. Now we'll severe slap to discuss a bit later on unstable slips, the biggest area of controversy, and for that reason, the management of unstable slips is trying to be centralized in the UK, so it tends to be managed mainly in pediatric centers because there's no consensus on when we should operate, should it be immediate or should be delayed after a period of traction.
What's the best way of operating it on this hip? We don't know whether we should try the serendipitous closed reduction mini open or a formal open with a done procedure or a surgical dislocation. What we do know is that unstable slopes have a high rate of AVM and even the rate of avian differs throughout the series. Systematic review shows between 10 and 60% So the avian rate differs and we don't know what causes avian.
Is it sinking or disruption of vessels at a time of the slip? Or is it pressure from the cirrhosis in the hip, reducing the blood supply? So when we talk about venue, you'll need to know about the middle and the deeper of middle femoral circumflex that supplies the PCS, so these are things that you need to talk about. Maybe around anatomy. But what isn't controversial is that we tend to do some sort of the fixation should be at least two screws when we try and fix these because they're unstable slips and one screw we can cause if we just fix it, one screw the slip can then continue to lose position in follow up.
So we tend to use two screws. They spoke to the trend is to do some mini open, at least to try and release the arthritis because we feel by releasing the hematoma or the him.I process, we may reduce the chance of avascular necrosis. So for the exam, you'll say these are rare injuries. Hi risk of avian, you're going to manage them in a pediatric center because of the controversies around it, and we will definitely use two screws and we'll try and drain the hematoma and we may do an open reduction depending on the skill level of a surgeon and the training.
Now, when we talk about severe slips, these are slips over 60 degrees. These are also a challenge to treat the chronic and they. Often they may have been going on for a long time and to assess them properly, we often have to do a CT to see whether or not the office is open because that will dictate what type of procedure will do. Now a 60 degree slip is quite severe angle, and even extra Kessler osteotomy is the limit to correction is around 60 degrees, so an extracapsular osteotomy will only correct up to 60 degrees.
And then we have to think of a lumpectomy to try and reduce the final. Um, bit of a bump. We can use surgical dislocation and. A sub capsule realignment if the emphasis is open. Now, when we talk about fixation and they might tell you about how you do it and the complications related to it.
So you need to know whether you're going to do it on traction or free hand and using the image intensifier, you need to be able to talk running this procedure. I know I personally do it freehand because I feel that's easier for me to get a good frog lateral in the stable slip and I can just keep the CRM in the app position.
Joint penetration with a screw can lead to epicondylitis if the screw is not out of the head, it can lead to poor stability and loss of fixation. If the screw comes to posterior, you can risk damaging the deep branch of medial epicondyle flex and increasing your risk of avian. If it's not in the entry or too low on the lateral entry point, you can increase the risk of developing a fracture. Measuring the slap angle, we tend to do to decide whether or not we should fix the other side a when we measure this, the posterior sloping angle of the contralateral hip.
This helps us to predict whether or not we should do a prophylactic pinning. So if you draw a line from the anterior to posterior margins of the Ephesus perpendicular line is drawn and then a line along the axis of the femoral neck. This slip angle, if it's over 14 degrees anatomically, is more associated with a subsequent slip in that hip and we have a number needed to treat of around 1.7. So that's something you can talk about as a decision making process regarding prophylactic pinning.
And remember, there's the bump that's unfortunately can lead to an impingement and arthritis later on. When the principles for dealing with Kessler neck of femur fractures are quite similar depending on how much neck we have, we might try and use two screws in an extra physical manner, whereas in a slip typifies this, you have to go across the crisis. The aim is to fuse the crisis.
Now I'm going to move on to femur fractures. And as Tom was alluding, that majority of pediatric trauma comes after school on a weekend or in holiday time. So this is when there tends to be registrars that running the on-call without consultant cover. And some people might be on leave. So you need to be able to know how you'll do the emergency management of many of these fractures.
The important thing about FEMA fractures is that they still have quite a high association in the under three with non-accidental injury and the highest risk is in on the one-year-old child that isn't walking with a FEMA fracture. Now, and the important thing when we think about non-accidental injury, these children often present late, they don't tend to arrive by an ambulance, and the history of the injuries usually does not support the fracture that you're seeing.
So they will want you to talk about the management, but remember, most of these children are coming in the evening, so don't forget to talk about pain relief, so because you're likely to manage them on the next available trauma lists in a planned way. So you need to talk about pain relief, whether or not you're going to use a femoral block and whether or not you need to use some sort of an overnight.
So there's quite a few guidelines on how to measure, manage FEMA fractures and for children under the age of six months. We use a Pavlik Harness simple to put on, and the fractures heal very well in a Pavlik Harness. You might need to talk around about how to put on a public harness, what the different straps do. And don't forget, you have to say you're going to investigate a child for potential non-accidental injury.
Between six months and 5 years, we go for an early hip Spiker. Now, once again on the three, we worry, is this a non-accidental injury? So discuss that. The decision making on whether or not we do an early hip schweickert or a hitchhiker after a period of traction depends on the stability of the fracture, and we look at the amount of shortening that happens in the femoral fracture.
If it can shorten more than three centuries then these are best managed with a short period of traction before putting on a spyker. Let me talk about speicher, you can use a single leg spike. I want to spike both limbs depending really on the size of the child, how and the smaller the child, the more of the contralateral leg you'll need to include.
Most important thing is about your position of the leg, how much flexion you have at a hip and knee is dependent on where the fracture is if it's in the proximal, middle, or distal third. And you also want to do a slight mold. To avoid any various very small union of the femur fracture, a very small union has a high risk of re fracture because of the eccentric loading of the femur.
A child between the age of 5 and 11. The management is either a flexible, intimidatory nail or some sort of open reduction and internal fixation, usually with a maple bridge plating. We decide what we do, depending on the fracture stability, so flexible nails. Tend to be used for fractures within the diaphysis of the bone.
So you can see these dotted lines showing the we're looking for a fracture within this kind of central area of the femur, so you can have a entry point, which is far enough to give you that stability, that tension. You want to talk about the hoop stresses that you'll develop with bending of preventing of the nail. So we look at the fracture location. We look at whether or not the fracture is length stable.
It's a very community of fractures will shorten even with a flexible nail, and then you can have failure of your fixation as a result. So the fracture pattern determines how much length stability there is in the femoral fracture and whether or not we can use a flexible nail. So fractures that are around the metaphyseal region or length unstable. We tend to use.
Maple plating rather than a flexible meal. Now the important thing is that there's a weight cut off of flexible kneeling. We say around 50 kilos. We would prefer not to use a flexible nail because we see failure of the flexible nail. We know that we can use a stainless steel nail, which is actually a bit stronger than titanium nail and still gives you the same hoop stresses.
Now, to figure out stainless steel nail is equivalent to a titanium nail of 0.5 millimeters. A bigger diameter. So you can use two smaller stainless steel nails. Is the isthmus is quite small to get more stability, more strength? The use of end caps are used for length on stable femoral fracture patterns. However, the end caps also cause soft tissue irritation to me and can result in early removal of the work because of soft tissue irritation.
Now, when we go to a more adolescent over the age of 11, we're moving on to locked intercept adultery nails with rock and country, and there are several different ones on the market. We use the PDA nail biter pediatrics because it has a reconstructed recon screw or a straightforward, interlocking screw for image fracture.
The important thing is that we're doing a lateral entry in the truck and offices, and this avoids damage to that medial circuit flex from an artery. And this minimizes the risk of avian. Now, when we took a look at the nie, some of the knee fractures that you'll be taught us to talk about is really the distal femur, as well as the ones that we would see commonly that might need a urgent treatment.
Now, the important thing is that there's the thermal neurovascular bundle is running behind this injury and there's a high risk of injury to the neurovascular structures with very displaced fractures. So it's important to state that you're going to do a neurovascular assessment. These are usually high energy mechanisms. And there may be associated ligaments, injuries, so. You might do an egawa or required to do an MRI after this injury to help with the management.
You can also talk about anatomy of the distal femur. Thisis because of its undulating pattern, and that is fact is more concave. Possibly there's a higher risk of growth disturbance. And this runs to around 50% of these injuries have growth disturbance. So how you manage it, it can be either with cross wires or if there's a large Thurston Holland fragment, as in this fracture, we can use screws to fix that.
There's an hole fragment. next, adolescent typekit injury, we tend to see, is a abortion of the anterior typical cubicle, I mean, the table cubicle, sorry, this is an ACL abortion. And it's recommended that an MRI is probably the best way of assessing this injury because you're able to assess the soft tissue structures that can have additional injuries, you might have a meniscal tear at a time.
The treatment is a extra fries, your screw or a suture repair. Both are equally equal in terms of fixation strength. And it really depends on the size of fragment, whether or not you can use a screw or not. Proximal tibial fractures. The ones we tend to use a table cubicle, abortion fractures, and these can vary from very minor injuries to much more severe thoracic injuries.
And the important thing is this is a high energy injury can be associated with the articular injury to the meniscus and the meniscus as this fragment is pulled off with the patellar tendon. It takes quite a lot long, soft tissue sleeve of the Taliban muscle and cause quite a lot of bleeding into the anterior compartment and result in compartment syndrome. So it's quite important to be aware of compartment syndrome in this injury.
And we try and anatomically reduce this, because it's intra articular. And we also want to prevent a growth disturbance to the proximal tibial orifices. So there's a screw here in the business and one in the metathesis. You still have to follow this up because you can get late deformity of the proximal tibia with a recovery team developing.
That next most common injury is a slap of ocean, once again is an injury to the quadriceps mechanism. The child will have an ability to a straight razor can be quite subtle with a high riding patella and you might not see a little sleeve fracture. We remember this is an intra articular injury where the cartilage is separated and a small piece of the bone is attached to this.
So you once again might need to have an MRI to aid the diagnosis in a young child, but the management is a open reduction internal fixation, usually with a transasia suture repair. Now, if we move on to table fractures of sea timber fractures are still very common in children and they remodel very well. But with an isolated tibial fracture.
Whilst managing plus, you have to remember isolated tibial fractures can have this phenomenon of various drift due to the pull of muscles. So in the lower third, it starts to drift into various. So often the plaster will need wedging around a 2 to three week mark. When both are broken, it tends to drift into Vegas. So once again, the 10 to 14 days time, you might have to wedge a plaster to improve your alignment.
Couple of appointments named fractures in a very young child. You might have a toddler's fracture. This is a common reason for a undiagnosed injury in a limping child. And often you may need to repeat the X-ray in 10 to 14 days to see if there's any callus. Whether or not it needs treatment is still debated.
Many can just be given no immobilization. Some children need a small walking buetow temporary plus for two to four weeks. Cousins, fractures, fractures of the proximal tibia, which have this phenomenon of fungus overgrowth, so as it heals the leg, then develops a valgus deformity later on. When we follow up cousins fractures, we know that this fungus tends to correct in the majority of children within two years, if it doesn't, we can simply manage it with a guided growth procedure where we put something called an eight plate or a temporary visas plate on the middle side to allow the lateral side to keep going and going to reconnect the fungus.
Now, when we move onto ankle fractures, you'll see from this. The scruff that's depending on the age of the child will see different sorts of Harris fractures of the ankle, so the younger child we see tend to see this type I and type Ii fractures, sometimes the type 4 as they become more adolescent, you then see the pain fractures.
Now, the reason we're all behind this is how the distal tibial axis fuses and the Pfizer's thesis, so it starts just over the medial malleolus. It starts in a central area there. And then the medial malleolus fuses around 13. Then it progresses towards the lateral side, and the last area to fuse is the till our fracture area. So until our fracture tends to be in a slightly older adolescents because it's the last area to fuse in the distal TiVo crisis.
Depending on depending on the age of child, the stage of Pfizer closure, we get different tribe pain fracture patterns, so try playing fracture pattern is just because part of the face is fused. It goes through the weakest part, which is on fuse process. So the younger you are, the more chance of getting more fragments, the older you are. It tends to be just tell how.
Now, you might be asking about the long Hanson classification for adult ankle fractures, but also it's the same for children's fractures. And yes, describe it. And remember, it's the first thing supination is position of the foot. And the next term is which direction the foot moves or the limb moved. So supination inversion.
So it and then there was an inversion force, and you tend to get these sorts of Harris for fractures. Um, and these can actually have quite a high rate of growth in terms. The most common type we see is a supination plant affliction, where you have this physical fracture, often with a posterior thirst in Holland and a little bit of displacement. It's very low risk of any fazil closure here.
When you go to the Super external rotation. You see this fracture pattern where it starts off quite low on the lateral distal tibia and exit higher up. So looking at the angle of this fracture pattern will help you to know if it's a supination external rotation or pronation external rotation, which tends to have the first island on the lateral side where the surgeon hollands on the medial side.
And I've shown you the rates of physical disturbances with these injuries. The most common type is we see this supination plantar flexion injury, and you'll see there's a gapping at the front of the anterior aspect of the tibia. And this is due to the enfolding of the person. So if you're unable to reduce this closed, you don't force it.
You also need to do a small mini open reduction and fish out of your system and then reduce it. You may need to put the wire a single wire to hold it, or just a plaster to keep it stable. If there's a large Thurston hole and fragment, you might use a screw to fix it. So foot injuries, majority foot injuries heal very well in children, and most heal just with some immobilization and walking boots, I guess only a Jones fracture, remember, is potentially might take a bit longer to heal the child, but.
So we may just immobilize the foot between 4 to six weeks, but it's not the same as an adult fracture, there's much less risk of non-union. And if it does become a nonunion, it's quite easily managed with screw fixation. The only other foot fracture to remember is the Seymore fracture, which is an evolution of the nail bed out of the nail fold associated with a sort of Harris fracture of the distal phalanx.
So it's important to know that this is an open fracture and we need to do a nail bed repair and treat the child with some antibiotics to prevent any infection. OK, thank you very much, guys. Thank you. Thank you so much, so that was two very good lectures, and I'd suggest that the participants watch those lectures again because these questions do come up in survivors.
And you've just been presented with a perfect way to answer them. So thank you very much for that. We do have some questions. So we've got one from Melinda. The contour, I think I think Mr James answered this, but we'll just clarify it again. He said if a kid comes in the evening with a displaced supracondylar fracture with no vascular compromise but an anterior interosseous nerve palsy, would your advice be to operate overnight?
Can the anterior interosseous nerve palsy be due to neural ischemia or compartment syndrome? So, yeah, so just say isolated nerve injury tends to be a fracture at the time of the injury. And this year, I can't remember it is just a jpoa. There's a meta analysis of nerve injuries and supercontinent fractures showing all the long term natural history is that most of them resolved within nine months, not 4 to six weeks, but nine months for them to fully resolve.
I would just say that the caveats for nerve injuries is if there's nerve injuries with vascular compromise, this is usually indicative of a much more serious mechanism. And these are where if you're seeing a pulseless limb with a nerve injury, often this means there's much higher energy. And this is where you'll be talking to either vascular surgeons or your peripheral nerve injury unit.
And the peripheral nerve unit will need nerve conduction studies. If you have that mechanism and you're not doing an open reduction, you get the pulse back. You can refer them even before the four week stage, and they will see the child because some of these may be a damaged nerve. Tom just to add into that full for the exam, just what the question is going to be, just prepare your answer before the exam.
The exam is not the time to be thinking about the, you know, the exact right and wrong you can the nerve injury, the mild I-in palsy, it doesn't come into it in terms of the timing of your operation. If if the hand is white, you're going to operate at any time of NIPE. If the hand is pink, you're going to leave that to tomorrow if you follow both guidelines. There is a great.
The only gray area in between. You don't really need to get into in the exam. That's for your practice. When your consultant and I tend to, I'd go to theater almost any time of NIPE. If there's a nerve injury, even if it's a pink hand and it's post ulnar nerve injury, I'd almost certainly get a theater. But you're backed up by both guidelines to say leave to the first case on the list the next day, and I would just choose one of those options.
And no one's going to say you're wrong when it comes to the exam. Thank you. I've got a question from Daniel bullshit. And he's put our posterior into focal wires ever helpful. I think the majority we can reduce closed. I know there's a temptation for some people to use that wire to back to flick its back on.
But remember, the AI structures are there and you also need to make sure the blunt end. It's quite a risky technique, and it often caused quite a big scar to back the arm as you pull it down. I think if you're having difficulty to reduce the fracture, you might be thinking there's something within the fracture preventing this. And it's often the muscle is buttonholed through the muscle in front, and that's causing a block to reduction.
And you would be pulling quite a lot with the wire bending the wire to try and aid a reduction. And again, this will come up in the IVUS later on, but is also part of your practice. The exam is not the time to decide which way you're going to openly reduce, just decide before in your practice and in and for the exam and have a reason for it. So, you know, some people will always go either lateral or midi.
I tend to go anteriorly for the reason that Carl just said, you can always just it's not a huge approach. You can just push the bit of bone back through the brachial and that's your sort of operation done. And it makes it much easier for any vascular surgeon who's following you in. If if the hand remains pulseless, but there is no right or wrong. So it's difficult to tell you what to say, but you should come up with that plan before, because when I'm practicing vivas with a lot of registrars just before their exams, they tend to be thinking about that on the hoof, and that's not the time to be doing it.
Thank you. I've got a question from ATF, and I think Adele is asking the same question. Is there a difference in how the manipulation is performed compared with a flexion type fracture? Yes, so again, in your vibe, I'd really like you to describe to me what you're going to do, and I tend to take the registrars as most people through a sort of staged approach.
And before you've done each bit, this is for the extension type fractures. You're going to put traction with a bit of flexion until it looks OK on the app. And then you're going to do your reduction maneuver. Obviously, if you're flexing right up, that is just going to be that's just going to be going to completely displace your flexion type injury.
So the reduction maneuver is different. You don't they tend not to need so much traction because they're not displaced in the same way as the extension injuries. But going back to my talk, how I set them up, and it's not the only way of doing it, but having this see on parallel with your bed. And then you can just move with the C arm in a sort of taking a picture laterally.
You can just flex and extend the forearm until you get it in a perfect position for your first for your first wire. It was a colleague of Kyle James is at the London who told me that Matt Barrie and it's always served me well, so it is a different technique. Yeah, I agree, Yeah. There's not much manipulation. Make sure you see how can rotate intellectual because you can't really do any of the column views.
It's quite unstable and rotate as soon as you try and do a column view. So try and swing it through to a lateral app. And it's often just a little bit of posture of force and flexion extension changing flexion extension to see the reduction. Thank you. OK I've got a question from Simon Adnan, he said. Is the Jones view helpful in confirming reduction in alignment?
I'm going to say I don't like the economist views or names, I it's not useful at all. I think just Colin views and stressed views are all I would use in assessing if you're talking about the final picture, in assessing the view. OK thank you. Emma has asked post-op epicondyle of fractures, are there any restrictions to what exercises you would advise them to avoid, depending on the fracture severity?
Yeah, obviously that's very different, depending on the severity. So, you know, they're going to be in plaster 4, 3, 2 four weeks and then until it's a, you know, for at least a month after that, they're going to be avoiding my user strap line is any activity that increases the risk of them falling.
And I try not to get into a bat and ball game with parents on that. It's up to them to decide how likely their kid is going to fall doing what. Because some people can ride a bike and some can't. So I'm not entirely sure. I'm not entirely sure of the question you asked. I mean, just, you know, normal range of movement exercises, perhaps supervised by a physio.
If it's a very severe fracture and they're very stiff, but most kids, it's normal. Playing activity is all they need to get back to normal. I think just Warning the parents say it takes longer, it's not six weeks, it'll be better. Every time is six months to nine months to return. Range of motion and you might lose some of the full extensions sometimes lost and that's normal for these things.
Yeah, thank you. And OK, so we've got a question from Mohammed Hassan. He said a child with an isolated posterior dislocation of the elbow, would you reduce it overnight? Would you be concerned about them developing condolences if it was left overnight? So the timing is difficult there, so obviously, if we're not talking about a new, vastly compromised arm, which it often isn't, actually then if you've got an obvious which will probably come up in the Viva as well, you're pre-empting.
But if you've got an obvious incarcerated piece of bone from the medial epicondyle, then you know, if we're talking about trying to reduce it in A&E, then I'd probably recommend not doing that. If it truly is a simple dislocation and you're in a safe place, a safe where they've got children's A&E with anesthetic back up and they can give sedation or give whatever you need to give, then you should reduce it as soon as possible.
Equally, if the child is comfortable in, it's 300 in the morning and you think there's a incarcerated bit of bone, then obviously that's not the right thing to do. So I'm going to Doc. I don't think I can give you an absolute clear answer on that because every situation would be slightly different. Just reduce it as soon as you can safely. But it wouldn't be unreasonable with a comfortable child neurovascular intact to leave to the first list on the morning.
I don't know whether you want to add. Absolutely that's I agree. Majority of these in pediatric Amy's where you have intranasal fentanyl and nox, we can do close reductions in A&E before needing to take the child to theater. Are you going to add to that caveat in the exam goes, you you're supposed to prove yourself as a level one consultant.
Do not do something unsafe. Exactly that's the main thing. So if you can't have a safe way of reducing this overnight, take it to theater. If it's in a safe way and they usually give you a reason why it's not safe, there's vascular going to theater with the AAA or something like that. Then refer or wait.
Advice from pediatric colleague or wait until the morning. Always the patient safety comes first. Absolutely, Yes. Thank you. We're now moving on to some lower limb questions, there's five of them. Just one more question to finish up the there were two questions, actually just to finish up the second row, the pink puzzle sound in terms of clarification on the exam.
After reducing inquiring and the hand is still pink and pulseless, it hasn't changed. What would you do in that scenario in the exam? Are you asking me or one of the sections, yeah, for everyone answering that, I and I think it's reasonable to say you try and get some. You'd obviously have spoken to the vascular surgeons beforehand, so they would usually be sat in the coffee room in real life.
And that's what you should say in the exam. So you'd ask them to come in and help you out assessing it. They may use a Doppler, and if they can get a very good sort of try physics signal, it's just cannot feel it with your sweaty gloved hands, then that's fine. If if it's a true if you cannot find a pulse on declaw with vascular assessment and it's been a few minutes, at least after you've done your reduction, then you're duty bound, I think, to do an approach and a repair together with the vascular surgeons.
Obviously, you would say you're doing that with the caveat that you've done a proper assessment with the hand in extension as opposed to the flexed position. So I'm saying this for the candidates. Yeah, no, no, that's perfect. And also wait a few more minutes to see if it comes back because spasm is the most common cause. So this is the information. These are the buzzwords they're looking for on the vivo table, guys.
OK so one I know you've answered this. You think it's safe for lateral wires, but the question is safer to use natural wires. But the question was about stability of cross wires versus lateral wires. If they ask me, that's an example. Yes so there's no doubt mechanically and a sort of lab when you've got a sore bone. People have done studies on it and there is more mechanical stability from doing crossed wires.
There has not been shown in large studies now that there's any clinical difference with lateral versus crossed wires. So I think that's what backs you up in the exam. But I'm not saying sometimes I do. These talks a lot and sometimes people think I'm entirely against media wise. That's not the case. I think it's just where you train and what you're used to doing as long as you're thinking about why you're doing it.
The key is to assess your stability at the end of your fixation, whatever you've done, because and if you need a meter wire safer to use as many open to make sure you're on the bone and not ulnar nerve. Yeah, yeah, OK, we'll move on to the lower limb part questions. So are you going to continue? So we've got Emma again. So she said, post-op neck, a femur fractures. What are your thoughts on weight bearing status and straight leg raising?
OK, so number one for let's talk about a slip typifies. Then first and then we'll talk about next femur, the slip sepsis on stable ones, we'll keep them non weight bearing. We look at the faces widening on the X-ray. The face is quite wide. Initially, within about six weeks, we see thisis narrows down. That means the fastest time to start to fuse and you can start weight bearing.
So stable slip. You may do a short period of non weight bearing until you see some stability with the Pfizer widening reducing. So that's usually between 4 and 6 weeks, and then you can start some weight bearing. Now for nexium, a fracture, if you're just using two screws, you'll on table your level of stability, sometimes in younger children, you have them in a spike as well.
So I would tend to keep them non weight bearing in the older child and with in a wheelchair. Yeah, wheelchair now non weight bearing. Until then, they can use range of motion and transfer on the other side. If they're very good, they can use crutch weight bearing on the unaffected limb. OK, thank you.
We've got sign on again. What would you be your landmarks for your entry point for the screw fixation in? So sit on that. Yeah, you need to be able to talk through how you do this on table. So we use image intensifier and often you put a guidewire in the AP view to make it, but the God wired into the center of the femoral head, the emphasis and you draw a line to mark the airplane.
It's not so much where you go in the lateral. The lateral is slightly anterior. And you want to get your entry point just in and. Into truck and truck ridge. So that's how you plan it. I guess you need to see it to be able to explain it. On on my talk, there was a little link to a YouTube video that we did for regional teaching that describes more in detail about thermal purposes.
So if you later, you'll get a PDF of this and you can go to that YouTube and you'll see how to do it. And they'll help you to talk it through. I think you can just draw it on a piece of paper in the exam that might be the easiest way. Hey, thank you. Got a question from David gudinski? He said, could you give him the reference for prophylactic pinning number needed to treat 1.7? So yeah, it's on to talk.
I haven't put it on this one for brevity, so click on that link. It's got all the references on this GIFE talk. There's been several papers. The latest one was from New Zealand. I can't remember that author, but that was in 2017, I believe. But it's on the scifi talk on there on the YouTube link. Axilo, OK, great, thank you. Barbara van Ibrahim was asked, what's the difference between neighborhood Amin axilo fractures?
What direction do you place your percutaneous screw medial collateral or lateral to medial? So you want to try and reduce the fragment, so you'll do an anterolateral approach, so it's lateral to medial. Thank you. And last question, I believe what size of elastic nail would you use in a femoral shaft fracture? OK, so it's a good question.
So we tend to look at the diameter of the isthmus, and it's one third of the diameter or times 0.4. And u minus one, but a third of the diameter because using two nails in the femur. But remember, the thermal diameter varies quite a lot with age. And on average is between 2.5 and 3. But you have to be sure because some femoral canal estimates are very narrow and you can't even get at 2.5 in.
And that's where you might go to a 2 millimeter stainless steel nail to increase your strength of your fixation. That's great. Thank you very much. So I think that concludes our questions, so we will move on to the mix. We'll take this moment to remind everybody that concise orthopedic provisionals is now available in the textbook written by the FRCS matters.
You can actually see it in my background. And we do recommend it as a textbook, not because we wrote it, but because it's based on the experience of pretty much all the mentors, most recent passed exams and the ones we've passed a couple of years ago. It's available in all online good bookstores, obviously. And I can see the majority of the answers now. So the vast majority of 2/3 of you got the correct answer, noting that a sort of tardy ulnar nerve claw palsy following decubitus Vegas deformity for this fracture would be the most common cube experience is much more commonly associated.
It's the sort of gun stock deformity seen after supracondylar fracture Mao union someone someone said Hatcher ossification. That is certainly possible, but not very common, and neither the last two. So ulnar nerve Posey is correct. And then you all. Quite rightly, I wasn't entirely sure of the level of everyone doing these webinars.
So 90% of your anatomy, which is fantastic. Fantastic news. The thumb index IP flexes because obviously the a'le'inn is the most commonly injured nerve. So well done. And I'll take this opportunity to thank our UK. And our excellent presenters, Kyle James for brilliant talks. The UK is the research charity which which is orthopedic Research UK.
They provide a lot of charity work in terms of age, in terms of research for orthopedic conditions, but also in terms of education. They are our partners in this webinar session today. So it was a 5050 result here on the first question. I'm just trying to demonstrate that this is actually a length stable fracture, so it's less than 2 centimeters shortening. So it has to be over $0.03 for us to want traction first so we can go for an immediate Schweiker and to treat a spinal fracture with two of shortening.
Remember, overgrowth is very common in femoral fractures, so centimeters is not a concern. It's the second fracture, so trying to just trying to fish out a bit more about your anatomy. So the distal femoral crisis is the one which has the most growth. It has a very undulating anatomical pattern. This is the highest risk of having a growth arrest.
Remember accounts for 70% of the growth of femur growth by a centimeter a year in adolescence, and about nearly 60% of the length of the leg is from the distal from offices. So it's very important to follow up all sorts of barriers to fractures of distal female officer. 24 OK. So I think we've finished the poll, so we're going to stop the recording and move on to the Viva sessions.
Segment:0 .
OK good evening, everyone, and welcome to this teaching session, which is organized jointly by the FRCS mentor group and orthopedic Research UK. I'm Nicola Evans and I'll be running the session this evening in combination with the rest of the mentors.
We have two speakers for you this evening. We have Mr. Tom Crompton, who's a consultant, pediatric orthopedic surgeon at Brighton and Sussex. He undertook his fellowships in Westmead Children's Hospital in Sydney and at the Royal London hospital, and he's also the convener of the UK pediatric trauma course. We're then going to move on to Mr. Kyle James, who's a consultant at the Royal Alexandra Children's Hospital in Brighton, is a UK trained surgeon and has done two international fellowships in pediatric orthopedics.
He's worked as a mission surgeon in Malawi and was a consultant at the Royal London Hospital. He's experienced in pediatric and adult trauma, is a senior lecturer on the trauma master's program at Queen Mary university, and he's got 16 peer reviewed publications. So for this evening, we're going to do the upper limb trauma talk by Mr. Crompton. We've then got some new questions.
We will move on to lower limb trauma by Mr. James again with some new questions, and then we will move on to questions from the group. After that, we will do some viable practice, so we want to give priority to those people sitting the survivors in November and February. So if you can let Ruth or Abdullah know in the chat box when you're sitting the exam, and if you'd like to be considered for survivor and we will list them in order of priority and whoever raises their hand first.
If you missed any part of this lecture, don't worry. It will be recorded and it will be available on YouTube. The Viva sessions will not be recorded and we will release from our UK will send you out some feedback and we'd be grateful if you could fill that in for us so we can continue to improve. So without further ado, I will hand you over to Mr. Crompton for his talk of Allen trauma.
Thank you. good evening, everybody, thank you for that introduction. Hopefully, you can all hear me, ok? I won't introduce ourselves again by Carl and I are working here at The Royal Sussex County Hospital. The only major trauma center with a view of the sea. Currently, it looks like a bit of a building site, unfortunately, but that is the future. So I have a lot of trainees with me in the feedback from the exam is that I get the questions that people have asked every, every sitting and still common.
Things are common in superconductor. Fractures tend to be asked to almost everyone. So I'm most of the torque side of this evening. I'm going to go through supracondylar fractures. My aims of this are to give you a plan because I think the pediatric part of this Viva is a place where you should be aiming to get an eight. There's a limited number of things people will ask you about and very clear plans and guidelines that you can follow to really sort of impress the examiner.
I will come up in the vivas and we can discuss that then, but I want to get across in this sort of 15 minutes, I've got things that tend to trip people up regularly in the feedback I get from the exams. So the aims of this session are to give you a plan for theater for when you are asked a brief discussion about lateral versus crossed wires so you can decide.
And then what will always come up in the exam is the pink, pulseless hand, and I'm going to give you one safe, effective way of managing that guidelines. My experience and a bit of an evidence review. There is a I'm a health Warning with this. There's no incontrovertible evidence and everyone has their own opinion. But what you want in the exam is a clear, effective way of answering it.
So that's what this session is about. So we're not really talking about this. This may not project perfectly on your computers, but this a sort of Gartland one on displaced fracture. I couldn't really care if you treat that in a sling or a plaster or will do fine, you're not really going to get that in the exam. Again, not really contentious is your sort of Gartland to supracondylar fracture.
We can discuss that in the vyver. Beware, though, if you're going to be shown a picture in the exam of a apparently simple fracture. Excuse me with my video, kids often just beware if you haven't examined the rear story, you can see the wrist on the X-ray because as we'll see from the vivus, the question can go in a slightly different direction, but otherwise you'd manage that.
As with any superconductor fracture? What I want to spend a bit of time on is your plan for this because this is what you're going to get in the exam. It's pretty much always going to be 8 or 900 PM at NIPE when this child comes into your examination or into your hospital. And pretty much if the limb is ischemic, then that's an easy answer for you. If the limb is completely, well, profuse with a good pulse, that's an easy answer as well.
So we're going to spend a bit of time about talking about the pink pulseless hand. So when I ask this in the exam, you just want a clear guideline based, sensible approach to doing it, so you're going to document a neurovascular assessment. You're going to talk about the setup in theater, which I've got a slide for later on, where to put the image intensifier to make it sound like you've done this many times before, you can say whether you want an assistant or not, I suggest being able to do it solo in theater.
Oh, an old boss of mine used to say, you know, the reduction maneuver, a slight flexion and traction for the whole of the stairway to heaven, depending on where you live, it's just for a long time, you know, lifting the muscles relaxed to allow you to do that. And as I said, we're going to talk about Cuellar configuration. You need to be aware of the boast guidelines for Super fractures factories, they are guidelines, but they're pretty clear about having to have a documented assessment of limb perfusion, both pre and post op.
If the limb remains is scheming, there's no timelines given. But if after you're open or closed, reduction exploration of the brachial artery is required. And on that note, in the video, you need to have an idea of how you're going to approach your open reduction. Again, it doesn't really matter. It's opinion based, whether it's laterally medially or anteriorly, but you've got to have a plan.
And again, we can discuss that in some of the vyver cases. But most guidelines say NIPE time operating is not necessary unless urgent. Indication for surgery doesn't really give absolutes, but again, we can discuss that in a bit. And it also says if a media wire is used, a technique should be used to avoid injury to the ulnar nerve. If you look at the American guidelines actually and the American Academy of orthopedic surgeons, they just recommend lateral wires and go into a bit of that later.
They also say 2 millimeter wires should be used where possible. Just beware with the very young children. If you're seeing an X-ray of a might be unusual but a very young child, then you probably wouldn't jump in straight to saying 2 millimeter wires because it just doesn't sound like you've hung around the children's theaters too much. So we use a pro forma because we found that however much we try to persuade registrars to document clearly about the neurovascular status, it never happened.
Now we've introduced this pre and post op. Or I should say Kyle James introduced this pre and post op our documentation has become much better. And my recommendation for both the life actually in general, but also for the exam is to set up for supracondylar fractures like this and certainly for the offended super, super connally's or the flexion type injuries. If you have your C arm parallel to the table and the patient, it allows you to swing through for a lateral without having to flex up the elbow and for the particularly unstable injuries that you are struggling with.
That can make a world of a world of difference. And saying something like that in the exam, together with the other things you are saying will give you a will certainly give you a head start in aiming towards your towards your eight. So for the pink and pulseless hand, you can always find evidence to take you to take you down either track, to be honest, these are slightly old papers, but they're still useful.
So those guidelines are based on some of this is in whether you wait less than eight hours or more than eight hours. This is with Gartland offended supracondylar fractures with a pink pollster's hand that there wasn't shown to be any adverse outcome from waiting till the next morning. So in your exam, you can go down the both guidelines route and say there'll be first on the list the next morning, depending on the time of day.
Also, other papers have shown some quite significant vascular injuries with if the post doesn't return. So I think you're always on good ground depending on the time of NIPE. We're talking about to just say if you're competent and confident to just go to theater within reason sort of almost any time of night, so don't be pushed down one route or other. IOS guidelines say in the absence of any reliable evidence, open exploration of the antiquity of fossils should be performed in patients who have a pink, pulseless hand after reduction and pinning again, they don't give any timeline on that.
You might want to use a Doppler or obviously wait for things to warm up and wait a few minutes before diving into the anti-liberal fossa, but it's certainly something to be aware of. So again, people have different ideas of different surgeons, will have different ideas of what is in their practice. But I'd suggest in the exam. Just having a definitive idea of how you're going to treat it and you can back that up with evidence.
I've barely put a medial wire in years because of papers like this, so someone is injuring owner nerves. Obviously, we were the best surgeons in the world, so it's never us. But I think this is enough reason to try and treat supracondylar fractures with lateral wires. And if done well, there's no clinical difference in the outcome, only a sort of theoretical mechanical difference in the fixation.
So being aware of papers like that to back yourself up when you're in the exam can be very useful. So just a slight technical point, I think it's very useful to try and visualize what you're trying to do and you're doing two lateral wires and get two wires crossing the fracture site in either half of the humerus. Obviously, there's no concerns about crossing the capital or the olecranon fossa.
As long as you've got that decent spread at the fracture site, you'll have a good outcome and you can always use a third wire if you don't have. If you don't have the stability you desire. So the reason I set up, I set up all super condo factories in the same way with the CRM along parallel to the bed, just so the theater staff and everyone working with me gets used to it. And that's AI think that's a reasonable thing to do because particularly if you're presented with something like this in the exam reflection type of fracture, you want to just show that you're aware of the difficulty with reduction and pinning of these sort of fractures and just mentioning that you've set the patient up like that.
So you're able to swing through for a lateral without having to mess around. Positioning the arm would just fill me with confidence. If I was sat opposite you on that exam table to show me that you've been there and been there and done it. They're obviously pretty rare, but it's just useful as some of the very unstable extension type fractures as well.
It's always very useful. So I ask all our registrars and you should talk about this in the exam as well to the assessment of stability after you fix the fracture. I get a view in external and internal rotation, and if that's still slightly unstable, you can put a third wire in. I understand that, sir.
Not everyone, what everyone would do. You may put a media wire in and there's not a right or wrong there. It's about what you're used to doing and where you are trained, but it's perfectly reasonable to put a third wire in, if that's what you're confident doing. They might then move on to ask you about the complications, and it's best to talk about the sort of Mao union and deformity rather than a growth arrest in a supracondylar fractures that gives us that common gun stop deformity.
You need to be aware that that's mostly a cosmetic issue. If you're getting on to discussing that, you're doing incredibly well. And never forget the compartment syndrome with concurrent distal radius fractures. So that is my run through of supracondylar fractures. We're going to talk much more about the other injuries that come up commonly in upper limb trauma. I just think the best place to do that, to go through so many of them is in the survivors that we'll be doing in a little while after Kyle has had a chat to you.
So Thanks for listening. We're going to do questions at the end of Kyle's talk. Kyle James in just a SEC. So if you've got any burning questions for regarding superconductor fractures, just you'll have to wait just another few minutes. So thank you for listening. Thank you very much, Mr Compton.
Well, you need to try and recreate Bowman's angle. I just do that by physical examination, just examining the other limb to see what it is on that side. I don't try getting angular measurements out in theater, trying to recreate Bowman's angle. I would literally just examine the other good side. Hopefully they've not had a lateral or super Gondola fracture before. Otherwise, I'll just go with the normal for humans.
But no, I don't measure it the most. You need to take it into account. I don't. I don't tend to X-ray the other side either. Actually, I just do a clinical examination and recreate that on the injured side. I don't know what anyone else's thoughts are on that. I'd be interested. But Mr James.
Yeah, I don't use it practically. It's really an angle, it's what we use and follow up when we think we're trying to assess if it's going to go into various, I think normally you're just restoring the column and that's to me. And it's not really useful in the grade 3 in the pre-op op interop, you're using image guidance to check your reduction and Baumans we tend to only measure when we're following them up in Long term follow up.
Brent, thank you. And if you're ready with your presentation, thank you. Fantastic so guys, we're going to try and go through some of the lower limb fractures and discuss some of the things you need to think about in a virus situation. And so it'll help you to answer the question a bit better and try and flesh out some of the difficult controversies. So I'm going to talk about this first, because this frequently comes up in a visor.
The important thing is that we need to start talking about a slip to fifth status in terms of stable or unstable Lotus classification, and the stability is stability for the child weight bear. Now stable slips. There isn't much controversy when we come to management of a stable slip. But you need to understand that treatment might change depending on the severity of the slip.
How great the slip angle is, so mild slips we measure as less than 30 degrees of one third slipping. We will pin inside you a single inside your screw fixation. It's the accepted method of treatment, which has the best long term follow up. When you get onto a moderate slap between 30 and 60 degrees, unfortunately this leaves a bump, which can lead to impingement later and develop arthritis at a later age.
But still, the management of stable, moderate slips is still a fixation inside you with a single pin. Now, whether or not we go on to manage the bump later, either through our open means is still debated and we don't know if this changes the natural history of these slips. There's still some new methods using growing screws to see if the hip can remodel with growth, but we don't know whether or not this will be the answer.
So all you need to know for moderate slap, the child will have a bump, which can lead to impingement and can cause arthritis or label pathology in early adulthood. Now we'll severe slap to discuss a bit later on unstable slips, the biggest area of controversy, and for that reason, the management of unstable slips is trying to be centralized in the UK, so it tends to be managed mainly in pediatric centers because there's no consensus on when we should operate, should it be immediate or should be delayed after a period of traction.
What's the best way of operating it on this hip? We don't know whether we should try the serendipitous closed reduction mini open or a formal open with a done procedure or a surgical dislocation. What we do know is that unstable slopes have a high rate of AVM and even the rate of avian differs throughout the series. Systematic review shows between 10 and 60% So the avian rate differs and we don't know what causes avian.
Is it sinking or disruption of vessels at a time of the slip? Or is it pressure from the cirrhosis in the hip, reducing the blood supply? So when we talk about venue, you'll need to know about the middle and the deeper of middle femoral circumflex that supplies the PCS, so these are things that you need to talk about. Maybe around anatomy. But what isn't controversial is that we tend to do some sort of the fixation should be at least two screws when we try and fix these because they're unstable slips and one screw we can cause if we just fix it, one screw the slip can then continue to lose position in follow up.
So we tend to use two screws. They spoke to the trend is to do some mini open, at least to try and release the arthritis because we feel by releasing the hematoma or the him.I process, we may reduce the chance of avascular necrosis. So for the exam, you'll say these are rare injuries. Hi risk of avian, you're going to manage them in a pediatric center because of the controversies around it, and we will definitely use two screws and we'll try and drain the hematoma and we may do an open reduction depending on the skill level of a surgeon and the training.
Now, when we talk about severe slips, these are slips over 60 degrees. These are also a challenge to treat the chronic and they. Often they may have been going on for a long time and to assess them properly, we often have to do a CT to see whether or not the office is open because that will dictate what type of procedure will do. Now a 60 degree slip is quite severe angle, and even extra Kessler osteotomy is the limit to correction is around 60 degrees, so an extracapsular osteotomy will only correct up to 60 degrees.
And then we have to think of a lumpectomy to try and reduce the final. Um, bit of a bump. We can use surgical dislocation and. A sub capsule realignment if the emphasis is open. Now, when we talk about fixation and they might tell you about how you do it and the complications related to it.
So you need to know whether you're going to do it on traction or free hand and using the image intensifier, you need to be able to talk running this procedure. I know I personally do it freehand because I feel that's easier for me to get a good frog lateral in the stable slip and I can just keep the CRM in the app position.
Joint penetration with a screw can lead to epicondylitis if the screw is not out of the head, it can lead to poor stability and loss of fixation. If the screw comes to posterior, you can risk damaging the deep branch of medial epicondyle flex and increasing your risk of avian. If it's not in the entry or too low on the lateral entry point, you can increase the risk of developing a fracture. Measuring the slap angle, we tend to do to decide whether or not we should fix the other side a when we measure this, the posterior sloping angle of the contralateral hip.
This helps us to predict whether or not we should do a prophylactic pinning. So if you draw a line from the anterior to posterior margins of the Ephesus perpendicular line is drawn and then a line along the axis of the femoral neck. This slip angle, if it's over 14 degrees anatomically, is more associated with a subsequent slip in that hip and we have a number needed to treat of around 1.7. So that's something you can talk about as a decision making process regarding prophylactic pinning.
And remember, there's the bump that's unfortunately can lead to an impingement and arthritis later on. When the principles for dealing with Kessler neck of femur fractures are quite similar depending on how much neck we have, we might try and use two screws in an extra physical manner, whereas in a slip typifies this, you have to go across the crisis. The aim is to fuse the crisis.
Now I'm going to move on to femur fractures. And as Tom was alluding, that majority of pediatric trauma comes after school on a weekend or in holiday time. So this is when there tends to be registrars that running the on-call without consultant cover. And some people might be on leave. So you need to be able to know how you'll do the emergency management of many of these fractures.
The important thing about FEMA fractures is that they still have quite a high association in the under three with non-accidental injury and the highest risk is in on the one-year-old child that isn't walking with a FEMA fracture. Now, and the important thing when we think about non-accidental injury, these children often present late, they don't tend to arrive by an ambulance, and the history of the injuries usually does not support the fracture that you're seeing.
So they will want you to talk about the management, but remember, most of these children are coming in the evening, so don't forget to talk about pain relief, so because you're likely to manage them on the next available trauma lists in a planned way. So you need to talk about pain relief, whether or not you're going to use a femoral block and whether or not you need to use some sort of an overnight.
So there's quite a few guidelines on how to measure, manage FEMA fractures and for children under the age of six months. We use a Pavlik Harness simple to put on, and the fractures heal very well in a Pavlik Harness. You might need to talk around about how to put on a public harness, what the different straps do. And don't forget, you have to say you're going to investigate a child for potential non-accidental injury.
Between six months and 5 years, we go for an early hip Spiker. Now, once again on the three, we worry, is this a non-accidental injury? So discuss that. The decision making on whether or not we do an early hip schweickert or a hitchhiker after a period of traction depends on the stability of the fracture, and we look at the amount of shortening that happens in the femoral fracture.
If it can shorten more than three centuries then these are best managed with a short period of traction before putting on a spyker. Let me talk about speicher, you can use a single leg spike. I want to spike both limbs depending really on the size of the child, how and the smaller the child, the more of the contralateral leg you'll need to include.
Most important thing is about your position of the leg, how much flexion you have at a hip and knee is dependent on where the fracture is if it's in the proximal, middle, or distal third. And you also want to do a slight mold. To avoid any various very small union of the femur fracture, a very small union has a high risk of re fracture because of the eccentric loading of the femur.
A child between the age of 5 and 11. The management is either a flexible, intimidatory nail or some sort of open reduction and internal fixation, usually with a maple bridge plating. We decide what we do, depending on the fracture stability, so flexible nails. Tend to be used for fractures within the diaphysis of the bone.
So you can see these dotted lines showing the we're looking for a fracture within this kind of central area of the femur, so you can have a entry point, which is far enough to give you that stability, that tension. You want to talk about the hoop stresses that you'll develop with bending of preventing of the nail. So we look at the fracture location. We look at whether or not the fracture is length stable.
It's a very community of fractures will shorten even with a flexible nail, and then you can have failure of your fixation as a result. So the fracture pattern determines how much length stability there is in the femoral fracture and whether or not we can use a flexible nail. So fractures that are around the metaphyseal region or length unstable. We tend to use.
Maple plating rather than a flexible meal. Now the important thing is that there's a weight cut off of flexible kneeling. We say around 50 kilos. We would prefer not to use a flexible nail because we see failure of the flexible nail. We know that we can use a stainless steel nail, which is actually a bit stronger than titanium nail and still gives you the same hoop stresses.
Now, to figure out stainless steel nail is equivalent to a titanium nail of 0.5 millimeters. A bigger diameter. So you can use two smaller stainless steel nails. Is the isthmus is quite small to get more stability, more strength? The use of end caps are used for length on stable femoral fracture patterns. However, the end caps also cause soft tissue irritation to me and can result in early removal of the work because of soft tissue irritation.
Now, when we go to a more adolescent over the age of 11, we're moving on to locked intercept adultery nails with rock and country, and there are several different ones on the market. We use the PDA nail biter pediatrics because it has a reconstructed recon screw or a straightforward, interlocking screw for image fracture.
The important thing is that we're doing a lateral entry in the truck and offices, and this avoids damage to that medial circuit flex from an artery. And this minimizes the risk of avian. Now, when we took a look at the nie, some of the knee fractures that you'll be taught us to talk about is really the distal femur, as well as the ones that we would see commonly that might need a urgent treatment.
Now, the important thing is that there's the thermal neurovascular bundle is running behind this injury and there's a high risk of injury to the neurovascular structures with very displaced fractures. So it's important to state that you're going to do a neurovascular assessment. These are usually high energy mechanisms. And there may be associated ligaments, injuries, so. You might do an egawa or required to do an MRI after this injury to help with the management.
You can also talk about anatomy of the distal femur. Thisis because of its undulating pattern, and that is fact is more concave. Possibly there's a higher risk of growth disturbance. And this runs to around 50% of these injuries have growth disturbance. So how you manage it, it can be either with cross wires or if there's a large Thurston Holland fragment, as in this fracture, we can use screws to fix that.
There's an hole fragment. next, adolescent typekit injury, we tend to see, is a abortion of the anterior typical cubicle, I mean, the table cubicle, sorry, this is an ACL abortion. And it's recommended that an MRI is probably the best way of assessing this injury because you're able to assess the soft tissue structures that can have additional injuries, you might have a meniscal tear at a time.
The treatment is a extra fries, your screw or a suture repair. Both are equally equal in terms of fixation strength. And it really depends on the size of fragment, whether or not you can use a screw or not. Proximal tibial fractures. The ones we tend to use a table cubicle, abortion fractures, and these can vary from very minor injuries to much more severe thoracic injuries.
And the important thing is this is a high energy injury can be associated with the articular injury to the meniscus and the meniscus as this fragment is pulled off with the patellar tendon. It takes quite a lot long, soft tissue sleeve of the Taliban muscle and cause quite a lot of bleeding into the anterior compartment and result in compartment syndrome. So it's quite important to be aware of compartment syndrome in this injury.
And we try and anatomically reduce this, because it's intra articular. And we also want to prevent a growth disturbance to the proximal tibial orifices. So there's a screw here in the business and one in the metathesis. You still have to follow this up because you can get late deformity of the proximal tibia with a recovery team developing.
That next most common injury is a slap of ocean, once again is an injury to the quadriceps mechanism. The child will have an ability to a straight razor can be quite subtle with a high riding patella and you might not see a little sleeve fracture. We remember this is an intra articular injury where the cartilage is separated and a small piece of the bone is attached to this.
So you once again might need to have an MRI to aid the diagnosis in a young child, but the management is a open reduction internal fixation, usually with a transasia suture repair. Now, if we move on to table fractures of sea timber fractures are still very common in children and they remodel very well. But with an isolated tibial fracture.
Whilst managing plus, you have to remember isolated tibial fractures can have this phenomenon of various drift due to the pull of muscles. So in the lower third, it starts to drift into various. So often the plaster will need wedging around a 2 to three week mark. When both are broken, it tends to drift into Vegas. So once again, the 10 to 14 days time, you might have to wedge a plaster to improve your alignment.
Couple of appointments named fractures in a very young child. You might have a toddler's fracture. This is a common reason for a undiagnosed injury in a limping child. And often you may need to repeat the X-ray in 10 to 14 days to see if there's any callus. Whether or not it needs treatment is still debated.
Many can just be given no immobilization. Some children need a small walking buetow temporary plus for two to four weeks. Cousins, fractures, fractures of the proximal tibia, which have this phenomenon of fungus overgrowth, so as it heals the leg, then develops a valgus deformity later on. When we follow up cousins fractures, we know that this fungus tends to correct in the majority of children within two years, if it doesn't, we can simply manage it with a guided growth procedure where we put something called an eight plate or a temporary visas plate on the middle side to allow the lateral side to keep going and going to reconnect the fungus.
Now, when we move onto ankle fractures, you'll see from this. The scruff that's depending on the age of the child will see different sorts of Harris fractures of the ankle, so the younger child we see tend to see this type I and type Ii fractures, sometimes the type 4 as they become more adolescent, you then see the pain fractures.
Now, the reason we're all behind this is how the distal tibial axis fuses and the Pfizer's thesis, so it starts just over the medial malleolus. It starts in a central area there. And then the medial malleolus fuses around 13. Then it progresses towards the lateral side, and the last area to fuse is the till our fracture area. So until our fracture tends to be in a slightly older adolescents because it's the last area to fuse in the distal TiVo crisis.
Depending on depending on the age of child, the stage of Pfizer closure, we get different tribe pain fracture patterns, so try playing fracture pattern is just because part of the face is fused. It goes through the weakest part, which is on fuse process. So the younger you are, the more chance of getting more fragments, the older you are. It tends to be just tell how.
Now, you might be asking about the long Hanson classification for adult ankle fractures, but also it's the same for children's fractures. And yes, describe it. And remember, it's the first thing supination is position of the foot. And the next term is which direction the foot moves or the limb moved. So supination inversion.
So it and then there was an inversion force, and you tend to get these sorts of Harris for fractures. Um, and these can actually have quite a high rate of growth in terms. The most common type we see is a supination plant affliction, where you have this physical fracture, often with a posterior thirst in Holland and a little bit of displacement. It's very low risk of any fazil closure here.
When you go to the Super external rotation. You see this fracture pattern where it starts off quite low on the lateral distal tibia and exit higher up. So looking at the angle of this fracture pattern will help you to know if it's a supination external rotation or pronation external rotation, which tends to have the first island on the lateral side where the surgeon hollands on the medial side.
And I've shown you the rates of physical disturbances with these injuries. The most common type is we see this supination plantar flexion injury, and you'll see there's a gapping at the front of the anterior aspect of the tibia. And this is due to the enfolding of the person. So if you're unable to reduce this closed, you don't force it.
You also need to do a small mini open reduction and fish out of your system and then reduce it. You may need to put the wire a single wire to hold it, or just a plaster to keep it stable. If there's a large Thurston hole and fragment, you might use a screw to fix it. So foot injuries, majority foot injuries heal very well in children, and most heal just with some immobilization and walking boots, I guess only a Jones fracture, remember, is potentially might take a bit longer to heal the child, but.
So we may just immobilize the foot between 4 to six weeks, but it's not the same as an adult fracture, there's much less risk of non-union. And if it does become a nonunion, it's quite easily managed with screw fixation. The only other foot fracture to remember is the Seymore fracture, which is an evolution of the nail bed out of the nail fold associated with a sort of Harris fracture of the distal phalanx.
So it's important to know that this is an open fracture and we need to do a nail bed repair and treat the child with some antibiotics to prevent any infection. OK, thank you very much, guys. Thank you. Thank you so much, so that was two very good lectures, and I'd suggest that the participants watch those lectures again because these questions do come up in survivors.
And you've just been presented with a perfect way to answer them. So thank you very much for that. We do have some questions. So we've got one from Melinda. The contour, I think I think Mr James answered this, but we'll just clarify it again. He said if a kid comes in the evening with a displaced supracondylar fracture with no vascular compromise but an anterior interosseous nerve palsy, would your advice be to operate overnight?
Can the anterior interosseous nerve palsy be due to neural ischemia or compartment syndrome? So, yeah, so just say isolated nerve injury tends to be a fracture at the time of the injury. And this year, I can't remember it is just a jpoa. There's a meta analysis of nerve injuries and supercontinent fractures showing all the long term natural history is that most of them resolved within nine months, not 4 to six weeks, but nine months for them to fully resolve.
I would just say that the caveats for nerve injuries is if there's nerve injuries with vascular compromise, this is usually indicative of a much more serious mechanism. And these are where if you're seeing a pulseless limb with a nerve injury, often this means there's much higher energy. And this is where you'll be talking to either vascular surgeons or your peripheral nerve injury unit.
And the peripheral nerve unit will need nerve conduction studies. If you have that mechanism and you're not doing an open reduction, you get the pulse back. You can refer them even before the four week stage, and they will see the child because some of these may be a damaged nerve. Tom just to add into that full for the exam, just what the question is going to be, just prepare your answer before the exam.
The exam is not the time to be thinking about the, you know, the exact right and wrong you can the nerve injury, the mild I-in palsy, it doesn't come into it in terms of the timing of your operation. If if the hand is white, you're going to operate at any time of NIPE. If the hand is pink, you're going to leave that to tomorrow if you follow both guidelines. There is a great.
The only gray area in between. You don't really need to get into in the exam. That's for your practice. When your consultant and I tend to, I'd go to theater almost any time of NIPE. If there's a nerve injury, even if it's a pink hand and it's post ulnar nerve injury, I'd almost certainly get a theater. But you're backed up by both guidelines to say leave to the first case on the list the next day, and I would just choose one of those options.
And no one's going to say you're wrong when it comes to the exam. Thank you. I've got a question from Daniel bullshit. And he's put our posterior into focal wires ever helpful. I think the majority we can reduce closed. I know there's a temptation for some people to use that wire to back to flick its back on.
But remember, the AI structures are there and you also need to make sure the blunt end. It's quite a risky technique, and it often caused quite a big scar to back the arm as you pull it down. I think if you're having difficulty to reduce the fracture, you might be thinking there's something within the fracture preventing this. And it's often the muscle is buttonholed through the muscle in front, and that's causing a block to reduction.
And you would be pulling quite a lot with the wire bending the wire to try and aid a reduction. And again, this will come up in the IVUS later on, but is also part of your practice. The exam is not the time to decide which way you're going to openly reduce, just decide before in your practice and in and for the exam and have a reason for it. So, you know, some people will always go either lateral or midi.
I tend to go anteriorly for the reason that Carl just said, you can always just it's not a huge approach. You can just push the bit of bone back through the brachial and that's your sort of operation done. And it makes it much easier for any vascular surgeon who's following you in. If if the hand remains pulseless, but there is no right or wrong. So it's difficult to tell you what to say, but you should come up with that plan before, because when I'm practicing vivas with a lot of registrars just before their exams, they tend to be thinking about that on the hoof, and that's not the time to be doing it.
Thank you. I've got a question from ATF, and I think Adele is asking the same question. Is there a difference in how the manipulation is performed compared with a flexion type fracture? Yes, so again, in your vibe, I'd really like you to describe to me what you're going to do, and I tend to take the registrars as most people through a sort of staged approach.
And before you've done each bit, this is for the extension type fractures. You're going to put traction with a bit of flexion until it looks OK on the app. And then you're going to do your reduction maneuver. Obviously, if you're flexing right up, that is just going to be that's just going to be going to completely displace your flexion type injury.
So the reduction maneuver is different. You don't they tend not to need so much traction because they're not displaced in the same way as the extension injuries. But going back to my talk, how I set them up, and it's not the only way of doing it, but having this see on parallel with your bed. And then you can just move with the C arm in a sort of taking a picture laterally.
You can just flex and extend the forearm until you get it in a perfect position for your first for your first wire. It was a colleague of Kyle James is at the London who told me that Matt Barrie and it's always served me well, so it is a different technique. Yeah, I agree, Yeah. There's not much manipulation. Make sure you see how can rotate intellectual because you can't really do any of the column views.
It's quite unstable and rotate as soon as you try and do a column view. So try and swing it through to a lateral app. And it's often just a little bit of posture of force and flexion extension changing flexion extension to see the reduction. Thank you. OK I've got a question from Simon Adnan, he said. Is the Jones view helpful in confirming reduction in alignment?
I'm going to say I don't like the economist views or names, I it's not useful at all. I think just Colin views and stressed views are all I would use in assessing if you're talking about the final picture, in assessing the view. OK thank you. Emma has asked post-op epicondyle of fractures, are there any restrictions to what exercises you would advise them to avoid, depending on the fracture severity?
Yeah, obviously that's very different, depending on the severity. So, you know, they're going to be in plaster 4, 3, 2 four weeks and then until it's a, you know, for at least a month after that, they're going to be avoiding my user strap line is any activity that increases the risk of them falling.
And I try not to get into a bat and ball game with parents on that. It's up to them to decide how likely their kid is going to fall doing what. Because some people can ride a bike and some can't. So I'm not entirely sure. I'm not entirely sure of the question you asked. I mean, just, you know, normal range of movement exercises, perhaps supervised by a physio.
If it's a very severe fracture and they're very stiff, but most kids, it's normal. Playing activity is all they need to get back to normal. I think just Warning the parents say it takes longer, it's not six weeks, it'll be better. Every time is six months to nine months to return. Range of motion and you might lose some of the full extensions sometimes lost and that's normal for these things.
Yeah, thank you. And OK, so we've got a question from Mohammed Hassan. He said a child with an isolated posterior dislocation of the elbow, would you reduce it overnight? Would you be concerned about them developing condolences if it was left overnight? So the timing is difficult there, so obviously, if we're not talking about a new, vastly compromised arm, which it often isn't, actually then if you've got an obvious which will probably come up in the Viva as well, you're pre-empting.
But if you've got an obvious incarcerated piece of bone from the medial epicondyle, then you know, if we're talking about trying to reduce it in A&E, then I'd probably recommend not doing that. If it truly is a simple dislocation and you're in a safe place, a safe where they've got children's A&E with anesthetic back up and they can give sedation or give whatever you need to give, then you should reduce it as soon as possible.
Equally, if the child is comfortable in, it's 300 in the morning and you think there's a incarcerated bit of bone, then obviously that's not the right thing to do. So I'm going to Doc. I don't think I can give you an absolute clear answer on that because every situation would be slightly different. Just reduce it as soon as you can safely. But it wouldn't be unreasonable with a comfortable child neurovascular intact to leave to the first list on the morning.
I don't know whether you want to add. Absolutely that's I agree. Majority of these in pediatric Amy's where you have intranasal fentanyl and nox, we can do close reductions in A&E before needing to take the child to theater. Are you going to add to that caveat in the exam goes, you you're supposed to prove yourself as a level one consultant.
Do not do something unsafe. Exactly that's the main thing. So if you can't have a safe way of reducing this overnight, take it to theater. If it's in a safe way and they usually give you a reason why it's not safe, there's vascular going to theater with the AAA or something like that. Then refer or wait.
Advice from pediatric colleague or wait until the morning. Always the patient safety comes first. Absolutely, Yes. Thank you. We're now moving on to some lower limb questions, there's five of them. Just one more question to finish up the there were two questions, actually just to finish up the second row, the pink puzzle sound in terms of clarification on the exam.
After reducing inquiring and the hand is still pink and pulseless, it hasn't changed. What would you do in that scenario in the exam? Are you asking me or one of the sections, yeah, for everyone answering that, I and I think it's reasonable to say you try and get some. You'd obviously have spoken to the vascular surgeons beforehand, so they would usually be sat in the coffee room in real life.
And that's what you should say in the exam. So you'd ask them to come in and help you out assessing it. They may use a Doppler, and if they can get a very good sort of try physics signal, it's just cannot feel it with your sweaty gloved hands, then that's fine. If if it's a true if you cannot find a pulse on declaw with vascular assessment and it's been a few minutes, at least after you've done your reduction, then you're duty bound, I think, to do an approach and a repair together with the vascular surgeons.
Obviously, you would say you're doing that with the caveat that you've done a proper assessment with the hand in extension as opposed to the flexed position. So I'm saying this for the candidates. Yeah, no, no, that's perfect. And also wait a few more minutes to see if it comes back because spasm is the most common cause. So this is the information. These are the buzzwords they're looking for on the vivo table, guys.
OK so one I know you've answered this. You think it's safe for lateral wires, but the question is safer to use natural wires. But the question was about stability of cross wires versus lateral wires. If they ask me, that's an example. Yes so there's no doubt mechanically and a sort of lab when you've got a sore bone. People have done studies on it and there is more mechanical stability from doing crossed wires.
There has not been shown in large studies now that there's any clinical difference with lateral versus crossed wires. So I think that's what backs you up in the exam. But I'm not saying sometimes I do. These talks a lot and sometimes people think I'm entirely against media wise. That's not the case. I think it's just where you train and what you're used to doing as long as you're thinking about why you're doing it.
The key is to assess your stability at the end of your fixation, whatever you've done, because and if you need a meter wire safer to use as many open to make sure you're on the bone and not ulnar nerve. Yeah, yeah, OK, we'll move on to the lower limb part questions. So are you going to continue? So we've got Emma again. So she said, post-op neck, a femur fractures. What are your thoughts on weight bearing status and straight leg raising?
OK, so number one for let's talk about a slip typifies. Then first and then we'll talk about next femur, the slip sepsis on stable ones, we'll keep them non weight bearing. We look at the faces widening on the X-ray. The face is quite wide. Initially, within about six weeks, we see thisis narrows down. That means the fastest time to start to fuse and you can start weight bearing.
So stable slip. You may do a short period of non weight bearing until you see some stability with the Pfizer widening reducing. So that's usually between 4 and 6 weeks, and then you can start some weight bearing. Now for nexium, a fracture, if you're just using two screws, you'll on table your level of stability, sometimes in younger children, you have them in a spike as well.
So I would tend to keep them non weight bearing in the older child and with in a wheelchair. Yeah, wheelchair now non weight bearing. Until then, they can use range of motion and transfer on the other side. If they're very good, they can use crutch weight bearing on the unaffected limb. OK, thank you.
We've got sign on again. What would you be your landmarks for your entry point for the screw fixation in? So sit on that. Yeah, you need to be able to talk through how you do this on table. So we use image intensifier and often you put a guidewire in the AP view to make it, but the God wired into the center of the femoral head, the emphasis and you draw a line to mark the airplane.
It's not so much where you go in the lateral. The lateral is slightly anterior. And you want to get your entry point just in and. Into truck and truck ridge. So that's how you plan it. I guess you need to see it to be able to explain it. On on my talk, there was a little link to a YouTube video that we did for regional teaching that describes more in detail about thermal purposes.
So if you later, you'll get a PDF of this and you can go to that YouTube and you'll see how to do it. And they'll help you to talk it through. I think you can just draw it on a piece of paper in the exam that might be the easiest way. Hey, thank you. Got a question from David gudinski? He said, could you give him the reference for prophylactic pinning number needed to treat 1.7? So yeah, it's on to talk.
I haven't put it on this one for brevity, so click on that link. It's got all the references on this GIFE talk. There's been several papers. The latest one was from New Zealand. I can't remember that author, but that was in 2017, I believe. But it's on the scifi talk on there on the YouTube link. Axilo, OK, great, thank you. Barbara van Ibrahim was asked, what's the difference between neighborhood Amin axilo fractures?
What direction do you place your percutaneous screw medial collateral or lateral to medial? So you want to try and reduce the fragment, so you'll do an anterolateral approach, so it's lateral to medial. Thank you. And last question, I believe what size of elastic nail would you use in a femoral shaft fracture? OK, so it's a good question.
So we tend to look at the diameter of the isthmus, and it's one third of the diameter or times 0.4. And u minus one, but a third of the diameter because using two nails in the femur. But remember, the thermal diameter varies quite a lot with age. And on average is between 2.5 and 3. But you have to be sure because some femoral canal estimates are very narrow and you can't even get at 2.5 in.
And that's where you might go to a 2 millimeter stainless steel nail to increase your strength of your fixation. That's great. Thank you very much. So I think that concludes our questions, so we will move on to the mix. We'll take this moment to remind everybody that concise orthopedic provisionals is now available in the textbook written by the FRCS matters.
You can actually see it in my background. And we do recommend it as a textbook, not because we wrote it, but because it's based on the experience of pretty much all the mentors, most recent passed exams and the ones we've passed a couple of years ago. It's available in all online good bookstores, obviously. And I can see the majority of the answers now. So the vast majority of 2/3 of you got the correct answer, noting that a sort of tardy ulnar nerve claw palsy following decubitus Vegas deformity for this fracture would be the most common cube experience is much more commonly associated.
It's the sort of gun stock deformity seen after supracondylar fracture Mao union someone someone said Hatcher ossification. That is certainly possible, but not very common, and neither the last two. So ulnar nerve Posey is correct. And then you all. Quite rightly, I wasn't entirely sure of the level of everyone doing these webinars.
So 90% of your anatomy, which is fantastic. Fantastic news. The thumb index IP flexes because obviously the a'le'inn is the most commonly injured nerve. So well done. And I'll take this opportunity to thank our UK. And our excellent presenters, Kyle James for brilliant talks. The UK is the research charity which which is orthopedic Research UK.
They provide a lot of charity work in terms of age, in terms of research for orthopedic conditions, but also in terms of education. They are our partners in this webinar session today. So it was a 5050 result here on the first question. I'm just trying to demonstrate that this is actually a length stable fracture, so it's less than 2 centimeters shortening. So it has to be over $0.03 for us to want traction first so we can go for an immediate Schweiker and to treat a spinal fracture with two of shortening.
Remember, overgrowth is very common in femoral fractures, so centimeters is not a concern. It's the second fracture, so trying to just trying to fish out a bit more about your anatomy. So the distal femoral crisis is the one which has the most growth. It has a very undulating anatomical pattern. This is the highest risk of having a growth arrest.
Remember accounts for 70% of the growth of femur growth by a centimeter a year in adolescence, and about nearly 60% of the length of the leg is from the distal from offices. So it's very important to follow up all sorts of barriers to fractures of distal female officer. 24 OK. So I think we've finished the poll, so we're going to stop the recording and move on to the Viva sessions.
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