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Perthes Disease for Orthopaedic Exams
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Perthes Disease for Orthopaedic Exams
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Segment:0 .
Is on everyone, ok? Hello, everyone. Thank you for coming back to us. We know that our November batch, you've already done the exam, so we just want to say congratulations. That's at least a relief that you've done the exams.
Hopefully we've passed. We're very confident you have. But we would just like to tell you, take it easy from the not watching this because you don't want anything to do. We're going to talk about a disease. We have KneeKG Walsh from who's recently passed exams as well. She's going to talk to us about this disease. Some of her talk is based on international standards, and of course, I would point it out as well.
Nikki, would you like to go ahead? Yeah, sure. One I'd also like to say that, you know, so my talk, I put my clothes in there, but I did work with Dr. David little, who is a very big pediatric surgeon in Australia, and he's done a lot of work on syfy and per faith and part of my talk is related to.
His recent evidence on if you are interested, I can give you the scientific evidence, you know? But you know, obviously we're looking at this as part of an exam. So we're going to try and focus on what you need to talk to about the exam. So my disclosures are that I looked at the.
Like how they perceive disease. I use a jailhouse article that was in 2010, which has got some really nice pictures. And if you want a copy of that and you don't have access to it, I do have access to it. And I can send that to you. And the other part is the book, which is the postgraduates guide to pediatrics, which is from this press, right?
Very good. It's very good. Summary what you need to look about. It's good. I love my pictures taken from that because I think it's important. No one is perfect disease, and the problem is that disease is kind of avascular necrosis of the. Admiral epimysium so ephemeral, had it tends to be more common between children between the age of 5 and seven, but 4 to 8 is also recognized.
And if you are in. The population that's over eight years old, you're probably likely to develop. Post traumatic arthritis, which may require surgery the goal of treatment is to try and minimize the head deformity and anemia of excretion that we may see in Perth's.
So the etiology. I think this is difficult because we don't know. We don't know what it causes. There's three series, so one is the anatomical theory, which in my opinion, I think makes the most sense. And you got the hydrostatic from the film series and you got other factors, right? So for me, the anatomical theory makes the most sense.
So you've got a blood supply to the femoral head, which changes as you grow. All right, so. The thing is that the contribution from the lateral femoral so circumflex artery. In important in developing so. So in the adults, it's not necessary.
Right? but in the early stages, the contribution of the lateral femoral artery, which is a branch of the profunda memories, is really important. So if you look at the rest of it right, I've put that in there in the table there, right near the consumers. But you've got to think about the lateral femoral cutaneous, and that's important in the next slide because want do to get per get Magnapussies in people, though delayed in their bone development.
So typically two years for women and two years for one year for men. So the point being that the controls the civic nucleus is not developing because they've got delayed bone age, but their cartilage is developing because you still got fading from the synovial fluid. So here's where the importance of the lateral femoral so complex comes into.
You know, union, because we're going to have that changeover, we're going to have a changeover from the latter pharmaceutical. And we've got femoral head that is a bit delayed in developing. So your swings between the bone and the college challenge is increased.
All right. So your medial some of the complex arteries, which should be dying off, right? Can't preach that, and your lateral flow affects arteries, which should be taken over. All right. I've not quite taken over because this area is too big for them to breach, right?
That's why you get her face or at least one of the reasons why you would think about it. Other other things, so I think I think what I've just told you is probably the main reason. Well, we need to know about other things. So one of them is hydrostatic pressure, the increase in pressure cause, which would cause a reduction, but supply from the latrines, Rossi's artery.
And from Felix theory, which is that kids with sickle cell and thalassemia do show an increase in. You know, maybe that maybe we don't know. We don't know, we a place that we can look up. So what are the five? So trauma, obviously attention deficit disorder susceptibility, mental growth, low birth weight, low say so.
Write the point of this is that if you have a patient that has 38 degrees, they have this increased area of college as opposed to playing. So if you have any of these other factors right, then it's going to promote.
More deficiency, so. So even so, as you've already said, if you've got a low if you're low birth weight, you still kind of go, then college grows. It's not as hard as bone, it's going to promote a problem, right? Right presentation. So you look like kids that come in.
Right? so most of them have a limb. All right. They might have some pain. They might need pain and. Once I have knee pain, I don't need pain because the femoral on the obturator nerve supplies both the hip and knee so they can have hip, all knee.
All right. So if you see a child that has knee pain, we need to look hip. All right. It might be activity related. It might be accused and it might be a symptom of minor trauma. What do you find your examination. So quote in the early stages, it might be normal, but in the later stages, we have limited range of motion, especially abduction and interpretation, because of the decimation of hammerhead.
They my evidence, they might be trained element positive. They might have muscle spasms or atrophy. Some days. They might have a level of discrepancy because of the collapse in termite. And you need to look at these kids and see, right? Do they look normal? Do they have any other features of developmental dysplasia?
Is it an isolated lower limb discrepancy or is it something else we need to look at? And I would say it needs to look at things like Thomas's test diet trimmed down test. We need to look at that do through an apparent leg length. An examination.
What are you going to do, look at this kid. I'm going to make sure there's no. And then we look at strikes, I'm going to do a problems, right? I'm going to look out. Look, ferdie, age and. Slap capital has a better sense, right? But they are outside of all.
Great we're going to look at it anyway. All great. We're going to be looking for Percy's. They're looking at widening of the joint space. And the reason you get one of join space is because you get hypertrophy of. And the ligament in Terry slap, you going to see a smaller hit because it's not developing because it's got avian Christmastime slap kind of fracture, you might see that and flattening it eclipses on the.
Then that is going to give you the right, the most reliable thing is going to be in my life. So you need to consider septic arthritis in any of these things you need to consider. So unilateral. Processes you need to consider septic arthritis, you need to consider sickle cell disease, which will give you everything you need to consider something like an fairly granuloma.
You need to consider subscapularis now differential or bilateral. So typically. Whose agency does not give you the same findings at the same time. It may give you the face in one help and then maybe 12 months later, another hit. If you see bilateral purchases, you need to consider that multiple axilo disclosure.
But you will do you will do because per doesn't do both at the same time, even secondary to steroids or chemotherapy. It doesn't do it at the same time. So if you see bilateral purchases at the same time, you need to consider these little prognoses and the most common would be multiple axilo dysplasia.
So when you look in at Percy's, these are the several classification systems, right? So the first one is what options, which is based on radiographic changes and the really good changes are based on the fact that you've got a function of the bone fracture. The stage one is the initial undisclosed stage. Number two is the fragmentation stage.
Number 3 is ossification and number 4 is remodeling. So let's have a look at that. So in stage one. You got a sclerotic and aquatic stage, right? You've got bonus scheme here, which leached necrosis. The soffit nucleus is not growing because of avian, but the cartilage is growing. Right?
so you get one joint space and you get sclerosis of the nucleus. And this typically lasts between six 12 months. When you get the right, you're starting to get revascularization. So you get this uncoupling of bone formation and bone resorption just like pageants. But you get this, you get these fissures in the bone because the bone is reabsorption, but because it's uncoupled, you're not quite getting the reabsorption straight away.
This is the area where you're going to get a lot of deformity. You see something like this, which is reabsorption, right? Stage 3 is what are you getting baseload generation? It starts initially peripherally and it progressed essentially. So it goes post you turn to a lateral medium.
Right? so what you're seeing is the sclerotic area is being resolved and you're starting to see a little bit more of the femoral head. And again, these last six 24 months and the remodeling stage is when you get meaning of the bang bone it reabsorb. So the sclerotic and the.
And radiographic changes start to return to normal. You get a femoral head that looks almost normal. What it may have decimation, it may of some of the changes that we'll talk about. So so one of the things is at a large head, it's not like you might have a white sauna, which is Cox observer.
And as you get older, the remodeling phase is less good, so you diagnose Percy's in a. Roger Ailes is probably going to be a good outcome if you diagnose it in a 9 year old, it's going to be a less good outcome. On the other point, is the acetabular demoralization, so the acetabular probably remodels up until the age of seven or eight.
So if you got a young child, the acetabulum will remodel. If you're diagnosing per phase and a nine year old, the acetabulum probably won't remodel. So classification, there's three classification systems and there's probably four, actually. So what is cultural? Tony 971?
I've not touched on it. Sultan Thomas, 94, again, I'm not sure tonight the Herring classification of lateral pillar. This is probably the one that is most prognostic, so we will talk about that. And you need an Apple plus to competitive side and the next one is the silberberg, which is more of an A long term classification.
So the purpose of your exam know these exist, but you want to focus on the Herring, right? So here is the Herring. So the Herring is based on what I'm saying natural killer. So Herring top a. The lateral pillar is no. And having type B. Last week, I think to actually put the wrong link, healing type B is more than 50% of the lunch period is maintained on type C is less.
Done 50% of the National parenting, so ABC. Is that? You've lost your lateral pillar. And you've lost your central segment as well. So the point being that. B.c. may be worthy of treatment.
So poor science. Are the fact that if you're female, so Perth is 4 times more common in men and women, maybe a female? It's bad, right? If you're older? Yeah, that's bad. If you're fat.
Yeah, not close. If it's bilateral, I'd say it's probably not Perth Zs if it's same stage, but it's different stages. That's part as well. And stiffness and stiffness because, you know, how are we going to get over this? So let's look at some of the things, so what are things you come across in your exam this is culturelles head at risk signs.
And even though I've not gone through catterall classification. Because I don't think it's necessary. These are the head at risk kinds that think you probably should know. So one of them is gay sign. And what they say is it's a v-shape decency and their natural purposes was shown a SEC lateral cast calcification lateral to the purposes, which implies a loss of the lateral support, but lateral subluxation again similar.
Implies loss of support if it's more than three millimeters, we'd be concerned. Horizontal Doris played well. Generally, the growth plate is about 45 degrees, and if you have a horizontal growth plate, it kind of makes you think, well, is there a problem with the growth plates? You know, we'd have to look at that a bit further. And it's still very fraction of this chain.
So changes in the seal part of the femur. So this actually shows us is gauges sign. I can see someone's taking a bite of the lateral femoral purposes. And if you look at the other side, you can see subluxation of the femoral head. Yeah so what are we trying to do with percy's? So we want to try and prevent deformation of the federal hate.
It's not always possible. We were trying to prevent oxidation, minimize enlargements. What about Frank gtl? Because what happens with the gti? I think I've put this further. But what happens is your capital growth plates stops. Growing and you get growth rate keeps growing. So you get this whole concept of GTA enlargement, right?
They're going to look at SEC. So we operate on them. Well, it depends on what their radiographic stage is and what their clinical symptoms are. So management, the management is always controversial, and I think you need to say that I think any survivor he needs to say, look, management of Perth is controversial, right? Inside, because.
What I'm about to say next. Is not a definite. It's a summary of what I've been told. But it's not necessarily what I do. I would always speak to. A pediatric place to decide on whether treatment is appropriate or not.
So this is just a summary, and I would say need to talk to someone else in pediatrics. But it's something to think about. So as I said, your management is going to be controversial. You range on to preserve the range of motion and maintain the coverage of hip, unlimited deformity. So let me change the weight bearing activities, so, you know, in the fragmentation stage, which is where most of which happens.
And possibly we should limit their weight bearing, probably on coaches. You know, maybe we should do that. I don't know of the evidence for this, but that's probably something I would consider questions. Same reason. Physio, right? You want to maintain their range of motion. Again, same reason limit their activity, maintain a range of motion.
Abduction, braces on faces. That's because they tend to form an adult deformity. So should we splint them in abduction pot broomstick carson? I don't know. There's a lot of evidence to convince that, but it's something we should consider containment and salvage.
Right, so weight bearing, we've got that. I don't think there's very much evidence to say that we should wait by them or not wait for them. I don't know, to be honest, bracing casting broomstick cast again, I'm not sure. I don't know. I don't know if we cast them in abduction and external rotation. Does that make a difference?
I don't know that there's very much evidence it does. Surgery is containment vessel salvage. So your containment surgery options are going to be a femoral osteotomy, a various extension of tenotomy, a shelf or redirection. And the best results are done in patients who are overweight with Herring B or c, because Herring and B are probably going to be OK with no treatment.
Herring C It's not going to make any difference. So the only time you have to act is the Herring being c, right? Does it make a difference? I don't know. Let's look at it, right? So containment, that's of it, containment, so your options are. Ephemeral, various osteotomy. Right so you put the hair up in various to put it back and the establishment.
Pepcid of progress. Yeah, you can do that, yeah, I can say I don't know what the evidence is for it. I worked in Sydney Children's Hospital. I never saw it, but it's there as an option. A proximal femoral artery hinge abduction. Well, the point of hinge abduction is that. Is that an abduction? It hinges on the chaplain.
So the point of doing a bogus osteotomy is to put the ship in a better position so they don't get injured. General public posture to me, yet bestial. Yeah you know. Yeah, it's fantastic. Well, it's a big operation, right? It's a big operation, is that really where you want to go? I think you need to talk to the family and the surgeons about that.
It's a terrible pub. so it's going to be a redirection. To me, it's going to involve three cuts in the pelvis and redirecting the shelf. Shelton loves talking about the pelvis. I think if that's necessary to salvage so Vargas intra operatively, so you got the hinge, abduction doesn't work.
So fast, is it going to stretch to this last one to go next? Can you put an extra X in the pelvis for next thing, if you strike the joint? I'm the short term results were quite good, but apparently the long term results in. After this is fusing the hip. So it's good in young patients you fusing to hip in a position that's slightly abducted and 30 degrees of flexion, maybe 15 degrees of external rotation.
And yes, that could work as far as pain relief goes, but if you look at that in a female patient. She can't go to the toilet, you know, so you may be looking at the next option, which is toilet placement. And yes, we understand doing it. Toilet placement in a patient in a 20s has its own problems. But it may be a better option than.
I'm on three days, so doing a hip replacement in a 20-year-old right, they're probably going to need to have a revision. They're probably going to use we're not going to use metal or metal anymore these days when you strike. All right. But they're going to need to have revision surgery at some stage.
So this is so hinge abduction, so in the normal hip, this way we are. Expectations, so even in hinge abduction, because you get enlargement of the femoral head and overgrowth of the gt, you get a hinge here, you're going to hinge on your abduction.
The so what we were concerned about. So you've got a young person who has purposes. What am I concerned about? It's about the rage. So is there a little bit older?
I'm more concerned about a femoral head defamation, and I'm more concerned about how severe the disease is. There's less option for remodeling in the older child. Right? I've never seen involvement my Ave the whole season involved. It's going to have a poor outcome. Right if seeing a child with a more progressive disease, then we have to look at the other options.
And then, you know, is the femoral head extruded? If it is, that's behind it was an older child. That's bad as well. We need to think about that. So and a kid under five. You know, this is going to be good, right? Kids under five. There's a lot of potential for remodeling. So do they have any privacy involvement notion of here?
One, two three. No, I wouldn't involve them. We just review, right? Is there under-5, but they have more significant changes? Might consider a brace. We're still not in the surgery stage because this kid's going to do well, right? On the 12th. Right?
OK. You're not doing well. So you've got a process, it's not an extrusion, but it's quite far in the disease. So keep an eye on it. Five, seven, you're in that middle bit. All right. You might consider might consider some surgery. Seven, 12.
Oh, God. You ring up and say. We're going to consider some surgery. Seven, 12. With a lot of changes, Yeah. Maybe containment is out of the question we might be able to salvage. Maybe go on the abduction.
What we need to think about that. So the silver classification depends on the controversy, and I've summarized this, so there's about five or six stages. But for me, I think, you know, we can put it into this way. So one or two is that it's spherical. Authorities authorized and developed. 3 and four. Yeah, you might get arthritis, typekit severe arthritis.
And that's what I would do. And you can look at my lecture notes to further identify this, but I think generally talking an example, this is what you would do. So for the purpose of the exam, I'm not described all the search clinics, but I can do this is very it's very controversial. And I would recommend that you say I would discuss this case with a pediatric orthopedic unit and you would say, right, OK, it's this stage.
I think but no treatment I might consider. You know, containment or salvage. But I would discuss it with an orthopedic unit, and I think that is a safe thing to say for your exam. This is the course that men who some are doing this year.
Welcome come and join us. And right. Minimization, thank you very much. So so far, we've discussed this Kashif is one of the mentors who has joined with us. I'm sure he's listening. It's just he's off camera at the moment. The couple of things, guys, just to remind you, yes, this is absolutely absolutely correct.
It is a controversial subject because we're not 100% sure about the exact treatment pathway. There is no doubt the majority of patients are just going to need observation when you need to intervene. This is one of the questions. And where and what intervention will you do? Is another question. So the approach to this is to develop a pathway in your head.
What are you going to do for a child that is young and has significant headwinds classification as in the sea? What are you going to do or with b.c.? What are you going to do with the Middle age as somewhere between 5 and eight? What are you going to do with that child on initial presentation? What are you going to do with each of these versions of the Herring classification, from ABC to a bbc?
And see how are you going to manage? And finally, the patient who is older and/or delayed presentation patient who has clinical symptoms and severity, which shows that the head is not encapsulated and not or is an engine, or there's already a tabula remodeling, which is causing problems for later on in life. So these are if you develop those scenarios in your head and have an answer for them, you don't have to be very accurate or very in-depth in your answer.
Just understand that each patient has a different pathway and how you're going to manage. Yes, the majority do just require observation. How frequent is your observation is often a question. They'll ask you what are you looking for? What are you waiting for in your observation? And what about your clinical examination? What's your clinical examination going to involve? So people always talk about the X-rays.
And what they're looking for. But clinical examination is also quite important, as mentioned by Nicky again. So you need to have a think about what are the clinical factors that would indicate that you need to consider an intervention or not. OK, before we go on to bigger questions, you go to any questions here.
Look, I think one, I think the treatment of trophée disease is very controversial, and I think that for most exam candidates, it would be enough to recognize the sages and what the possible complications could be. Yeah, having to explain the treatment because the treatment is very controversial.
The treatment principles is probably what they're going to look for. So I wouldn't say you need to know how to do each operation, but you do need to understand the principles of containment. And remember, treatment doesn't necessarily mean always surgery. So containment observation is also treatment. Yeah so so one of the cases I want to I'm going to present, but I've not done it is I had a four-year-old last week.
He presented with a limp. Right? no fever. No family history of anything presented with the link is for years old, so he's a little bit on the. You know, downside of pro face. But it did have some indication that his specific nucleus was not forming the right way it should be. So in that case, I would say we need to observe this child, right?
We are we know the prognosis is going to be good because he's young and fully observant. Absolutely correct. So the scenarios in this exam are not going to be straight away. Tell me about this. That's not the way they're going to ask this question. They're going to give you a case like that for your own child. Or usually it will come up as either limiting child or part of the differential diagnosis.
It's very important to keep on Percy's no matter what the age of the child is, because there are other diagnoses which are much more devastating if you miss them in the initial stages than if you outgrew them first, and then go to. Well, now we've excluded everything else. Let's think about process. Does that make sense? Well, one of the things I wanted to say it was very much apparent in the Australian training system doesn't seem to be that much in the UK training system is the fact that you can get bilateral lateral.
Now, normally you don't get bilateral per CS at the same stage, if it's truly per. You've got to think of multiple epiphyseal dysplasia. That was one of the things that came at really highly in my Australian exams, but maybe not so much. And absolutely right. And also the other way that we can ask. This is what you're seeing the patient after a diagnosis of criticism in age, and the mom now wants to know what the chances are for their child or what is perfect.
Mum wants to know what is birth, so you need to be able to explain the its etiology, its diagnosis, its risk of inheritance, which there is a connection with family history, but not necessarily an inherited risk and also the other factors associated with. So these are all conversations and also the prognosis for this child. And so on, and what might happen in their adulthood.
So these are all the way those questions can be brought up without actually talking about doing corrective surgery to maintain containment and things like that. OK, so it does come up in the exam. I do appreciate it is a controversial one.
Segment:0 .
Is on everyone, ok? Hello, everyone. Thank you for coming back to us. We know that our November batch, you've already done the exam, so we just want to say congratulations. That's at least a relief that you've done the exams.
Hopefully we've passed. We're very confident you have. But we would just like to tell you, take it easy from the not watching this because you don't want anything to do. We're going to talk about a disease. We have KneeKG Walsh from who's recently passed exams as well. She's going to talk to us about this disease. Some of her talk is based on international standards, and of course, I would point it out as well.
Nikki, would you like to go ahead? Yeah, sure. One I'd also like to say that, you know, so my talk, I put my clothes in there, but I did work with Dr. David little, who is a very big pediatric surgeon in Australia, and he's done a lot of work on syfy and per faith and part of my talk is related to.
His recent evidence on if you are interested, I can give you the scientific evidence, you know? But you know, obviously we're looking at this as part of an exam. So we're going to try and focus on what you need to talk to about the exam. So my disclosures are that I looked at the.
Like how they perceive disease. I use a jailhouse article that was in 2010, which has got some really nice pictures. And if you want a copy of that and you don't have access to it, I do have access to it. And I can send that to you. And the other part is the book, which is the postgraduates guide to pediatrics, which is from this press, right?
Very good. It's very good. Summary what you need to look about. It's good. I love my pictures taken from that because I think it's important. No one is perfect disease, and the problem is that disease is kind of avascular necrosis of the. Admiral epimysium so ephemeral, had it tends to be more common between children between the age of 5 and seven, but 4 to 8 is also recognized.
And if you are in. The population that's over eight years old, you're probably likely to develop. Post traumatic arthritis, which may require surgery the goal of treatment is to try and minimize the head deformity and anemia of excretion that we may see in Perth's.
So the etiology. I think this is difficult because we don't know. We don't know what it causes. There's three series, so one is the anatomical theory, which in my opinion, I think makes the most sense. And you got the hydrostatic from the film series and you got other factors, right? So for me, the anatomical theory makes the most sense.
So you've got a blood supply to the femoral head, which changes as you grow. All right, so. The thing is that the contribution from the lateral femoral so circumflex artery. In important in developing so. So in the adults, it's not necessary.
Right? but in the early stages, the contribution of the lateral femoral artery, which is a branch of the profunda memories, is really important. So if you look at the rest of it right, I've put that in there in the table there, right near the consumers. But you've got to think about the lateral femoral cutaneous, and that's important in the next slide because want do to get per get Magnapussies in people, though delayed in their bone development.
So typically two years for women and two years for one year for men. So the point being that the controls the civic nucleus is not developing because they've got delayed bone age, but their cartilage is developing because you still got fading from the synovial fluid. So here's where the importance of the lateral femoral so complex comes into.
You know, union, because we're going to have that changeover, we're going to have a changeover from the latter pharmaceutical. And we've got femoral head that is a bit delayed in developing. So your swings between the bone and the college challenge is increased.
All right. So your medial some of the complex arteries, which should be dying off, right? Can't preach that, and your lateral flow affects arteries, which should be taken over. All right. I've not quite taken over because this area is too big for them to breach, right?
That's why you get her face or at least one of the reasons why you would think about it. Other other things, so I think I think what I've just told you is probably the main reason. Well, we need to know about other things. So one of them is hydrostatic pressure, the increase in pressure cause, which would cause a reduction, but supply from the latrines, Rossi's artery.
And from Felix theory, which is that kids with sickle cell and thalassemia do show an increase in. You know, maybe that maybe we don't know. We don't know, we a place that we can look up. So what are the five? So trauma, obviously attention deficit disorder susceptibility, mental growth, low birth weight, low say so.
Write the point of this is that if you have a patient that has 38 degrees, they have this increased area of college as opposed to playing. So if you have any of these other factors right, then it's going to promote.
More deficiency, so. So even so, as you've already said, if you've got a low if you're low birth weight, you still kind of go, then college grows. It's not as hard as bone, it's going to promote a problem, right? Right presentation. So you look like kids that come in.
Right? so most of them have a limb. All right. They might have some pain. They might need pain and. Once I have knee pain, I don't need pain because the femoral on the obturator nerve supplies both the hip and knee so they can have hip, all knee.
All right. So if you see a child that has knee pain, we need to look hip. All right. It might be activity related. It might be accused and it might be a symptom of minor trauma. What do you find your examination. So quote in the early stages, it might be normal, but in the later stages, we have limited range of motion, especially abduction and interpretation, because of the decimation of hammerhead.
They my evidence, they might be trained element positive. They might have muscle spasms or atrophy. Some days. They might have a level of discrepancy because of the collapse in termite. And you need to look at these kids and see, right? Do they look normal? Do they have any other features of developmental dysplasia?
Is it an isolated lower limb discrepancy or is it something else we need to look at? And I would say it needs to look at things like Thomas's test diet trimmed down test. We need to look at that do through an apparent leg length. An examination.
What are you going to do, look at this kid. I'm going to make sure there's no. And then we look at strikes, I'm going to do a problems, right? I'm going to look out. Look, ferdie, age and. Slap capital has a better sense, right? But they are outside of all.
Great we're going to look at it anyway. All great. We're going to be looking for Percy's. They're looking at widening of the joint space. And the reason you get one of join space is because you get hypertrophy of. And the ligament in Terry slap, you going to see a smaller hit because it's not developing because it's got avian Christmastime slap kind of fracture, you might see that and flattening it eclipses on the.
Then that is going to give you the right, the most reliable thing is going to be in my life. So you need to consider septic arthritis in any of these things you need to consider. So unilateral. Processes you need to consider septic arthritis, you need to consider sickle cell disease, which will give you everything you need to consider something like an fairly granuloma.
You need to consider subscapularis now differential or bilateral. So typically. Whose agency does not give you the same findings at the same time. It may give you the face in one help and then maybe 12 months later, another hit. If you see bilateral purchases, you need to consider that multiple axilo disclosure.
But you will do you will do because per doesn't do both at the same time, even secondary to steroids or chemotherapy. It doesn't do it at the same time. So if you see bilateral purchases at the same time, you need to consider these little prognoses and the most common would be multiple axilo dysplasia.
So when you look in at Percy's, these are the several classification systems, right? So the first one is what options, which is based on radiographic changes and the really good changes are based on the fact that you've got a function of the bone fracture. The stage one is the initial undisclosed stage. Number two is the fragmentation stage.
Number 3 is ossification and number 4 is remodeling. So let's have a look at that. So in stage one. You got a sclerotic and aquatic stage, right? You've got bonus scheme here, which leached necrosis. The soffit nucleus is not growing because of avian, but the cartilage is growing. Right?
so you get one joint space and you get sclerosis of the nucleus. And this typically lasts between six 12 months. When you get the right, you're starting to get revascularization. So you get this uncoupling of bone formation and bone resorption just like pageants. But you get this, you get these fissures in the bone because the bone is reabsorption, but because it's uncoupled, you're not quite getting the reabsorption straight away.
This is the area where you're going to get a lot of deformity. You see something like this, which is reabsorption, right? Stage 3 is what are you getting baseload generation? It starts initially peripherally and it progressed essentially. So it goes post you turn to a lateral medium.
Right? so what you're seeing is the sclerotic area is being resolved and you're starting to see a little bit more of the femoral head. And again, these last six 24 months and the remodeling stage is when you get meaning of the bang bone it reabsorb. So the sclerotic and the.
And radiographic changes start to return to normal. You get a femoral head that looks almost normal. What it may have decimation, it may of some of the changes that we'll talk about. So so one of the things is at a large head, it's not like you might have a white sauna, which is Cox observer.
And as you get older, the remodeling phase is less good, so you diagnose Percy's in a. Roger Ailes is probably going to be a good outcome if you diagnose it in a 9 year old, it's going to be a less good outcome. On the other point, is the acetabular demoralization, so the acetabular probably remodels up until the age of seven or eight.
So if you got a young child, the acetabulum will remodel. If you're diagnosing per phase and a nine year old, the acetabulum probably won't remodel. So classification, there's three classification systems and there's probably four, actually. So what is cultural? Tony 971?
I've not touched on it. Sultan Thomas, 94, again, I'm not sure tonight the Herring classification of lateral pillar. This is probably the one that is most prognostic, so we will talk about that. And you need an Apple plus to competitive side and the next one is the silberberg, which is more of an A long term classification.
So the purpose of your exam know these exist, but you want to focus on the Herring, right? So here is the Herring. So the Herring is based on what I'm saying natural killer. So Herring top a. The lateral pillar is no. And having type B. Last week, I think to actually put the wrong link, healing type B is more than 50% of the lunch period is maintained on type C is less.
Done 50% of the National parenting, so ABC. Is that? You've lost your lateral pillar. And you've lost your central segment as well. So the point being that. B.c. may be worthy of treatment.
So poor science. Are the fact that if you're female, so Perth is 4 times more common in men and women, maybe a female? It's bad, right? If you're older? Yeah, that's bad. If you're fat.
Yeah, not close. If it's bilateral, I'd say it's probably not Perth Zs if it's same stage, but it's different stages. That's part as well. And stiffness and stiffness because, you know, how are we going to get over this? So let's look at some of the things, so what are things you come across in your exam this is culturelles head at risk signs.
And even though I've not gone through catterall classification. Because I don't think it's necessary. These are the head at risk kinds that think you probably should know. So one of them is gay sign. And what they say is it's a v-shape decency and their natural purposes was shown a SEC lateral cast calcification lateral to the purposes, which implies a loss of the lateral support, but lateral subluxation again similar.
Implies loss of support if it's more than three millimeters, we'd be concerned. Horizontal Doris played well. Generally, the growth plate is about 45 degrees, and if you have a horizontal growth plate, it kind of makes you think, well, is there a problem with the growth plates? You know, we'd have to look at that a bit further. And it's still very fraction of this chain.
So changes in the seal part of the femur. So this actually shows us is gauges sign. I can see someone's taking a bite of the lateral femoral purposes. And if you look at the other side, you can see subluxation of the femoral head. Yeah so what are we trying to do with percy's? So we want to try and prevent deformation of the federal hate.
It's not always possible. We were trying to prevent oxidation, minimize enlargements. What about Frank gtl? Because what happens with the gti? I think I've put this further. But what happens is your capital growth plates stops. Growing and you get growth rate keeps growing. So you get this whole concept of GTA enlargement, right?
They're going to look at SEC. So we operate on them. Well, it depends on what their radiographic stage is and what their clinical symptoms are. So management, the management is always controversial, and I think you need to say that I think any survivor he needs to say, look, management of Perth is controversial, right? Inside, because.
What I'm about to say next. Is not a definite. It's a summary of what I've been told. But it's not necessarily what I do. I would always speak to. A pediatric place to decide on whether treatment is appropriate or not.
So this is just a summary, and I would say need to talk to someone else in pediatrics. But it's something to think about. So as I said, your management is going to be controversial. You range on to preserve the range of motion and maintain the coverage of hip, unlimited deformity. So let me change the weight bearing activities, so, you know, in the fragmentation stage, which is where most of which happens.
And possibly we should limit their weight bearing, probably on coaches. You know, maybe we should do that. I don't know of the evidence for this, but that's probably something I would consider questions. Same reason. Physio, right? You want to maintain their range of motion. Again, same reason limit their activity, maintain a range of motion.
Abduction, braces on faces. That's because they tend to form an adult deformity. So should we splint them in abduction pot broomstick carson? I don't know. There's a lot of evidence to convince that, but it's something we should consider containment and salvage.
Right, so weight bearing, we've got that. I don't think there's very much evidence to say that we should wait by them or not wait for them. I don't know, to be honest, bracing casting broomstick cast again, I'm not sure. I don't know. I don't know if we cast them in abduction and external rotation. Does that make a difference?
I don't know that there's very much evidence it does. Surgery is containment vessel salvage. So your containment surgery options are going to be a femoral osteotomy, a various extension of tenotomy, a shelf or redirection. And the best results are done in patients who are overweight with Herring B or c, because Herring and B are probably going to be OK with no treatment.
Herring C It's not going to make any difference. So the only time you have to act is the Herring being c, right? Does it make a difference? I don't know. Let's look at it, right? So containment, that's of it, containment, so your options are. Ephemeral, various osteotomy. Right so you put the hair up in various to put it back and the establishment.
Pepcid of progress. Yeah, you can do that, yeah, I can say I don't know what the evidence is for it. I worked in Sydney Children's Hospital. I never saw it, but it's there as an option. A proximal femoral artery hinge abduction. Well, the point of hinge abduction is that. Is that an abduction? It hinges on the chaplain.
So the point of doing a bogus osteotomy is to put the ship in a better position so they don't get injured. General public posture to me, yet bestial. Yeah you know. Yeah, it's fantastic. Well, it's a big operation, right? It's a big operation, is that really where you want to go? I think you need to talk to the family and the surgeons about that.
It's a terrible pub. so it's going to be a redirection. To me, it's going to involve three cuts in the pelvis and redirecting the shelf. Shelton loves talking about the pelvis. I think if that's necessary to salvage so Vargas intra operatively, so you got the hinge, abduction doesn't work.
So fast, is it going to stretch to this last one to go next? Can you put an extra X in the pelvis for next thing, if you strike the joint? I'm the short term results were quite good, but apparently the long term results in. After this is fusing the hip. So it's good in young patients you fusing to hip in a position that's slightly abducted and 30 degrees of flexion, maybe 15 degrees of external rotation.
And yes, that could work as far as pain relief goes, but if you look at that in a female patient. She can't go to the toilet, you know, so you may be looking at the next option, which is toilet placement. And yes, we understand doing it. Toilet placement in a patient in a 20s has its own problems. But it may be a better option than.
I'm on three days, so doing a hip replacement in a 20-year-old right, they're probably going to need to have a revision. They're probably going to use we're not going to use metal or metal anymore these days when you strike. All right. But they're going to need to have revision surgery at some stage.
So this is so hinge abduction, so in the normal hip, this way we are. Expectations, so even in hinge abduction, because you get enlargement of the femoral head and overgrowth of the gt, you get a hinge here, you're going to hinge on your abduction.
The so what we were concerned about. So you've got a young person who has purposes. What am I concerned about? It's about the rage. So is there a little bit older?
I'm more concerned about a femoral head defamation, and I'm more concerned about how severe the disease is. There's less option for remodeling in the older child. Right? I've never seen involvement my Ave the whole season involved. It's going to have a poor outcome. Right if seeing a child with a more progressive disease, then we have to look at the other options.
And then, you know, is the femoral head extruded? If it is, that's behind it was an older child. That's bad as well. We need to think about that. So and a kid under five. You know, this is going to be good, right? Kids under five. There's a lot of potential for remodeling. So do they have any privacy involvement notion of here?
One, two three. No, I wouldn't involve them. We just review, right? Is there under-5, but they have more significant changes? Might consider a brace. We're still not in the surgery stage because this kid's going to do well, right? On the 12th. Right?
OK. You're not doing well. So you've got a process, it's not an extrusion, but it's quite far in the disease. So keep an eye on it. Five, seven, you're in that middle bit. All right. You might consider might consider some surgery. Seven, 12.
Oh, God. You ring up and say. We're going to consider some surgery. Seven, 12. With a lot of changes, Yeah. Maybe containment is out of the question we might be able to salvage. Maybe go on the abduction.
What we need to think about that. So the silver classification depends on the controversy, and I've summarized this, so there's about five or six stages. But for me, I think, you know, we can put it into this way. So one or two is that it's spherical. Authorities authorized and developed. 3 and four. Yeah, you might get arthritis, typekit severe arthritis.
And that's what I would do. And you can look at my lecture notes to further identify this, but I think generally talking an example, this is what you would do. So for the purpose of the exam, I'm not described all the search clinics, but I can do this is very it's very controversial. And I would recommend that you say I would discuss this case with a pediatric orthopedic unit and you would say, right, OK, it's this stage.
I think but no treatment I might consider. You know, containment or salvage. But I would discuss it with an orthopedic unit, and I think that is a safe thing to say for your exam. This is the course that men who some are doing this year.
Welcome come and join us. And right. Minimization, thank you very much. So so far, we've discussed this Kashif is one of the mentors who has joined with us. I'm sure he's listening. It's just he's off camera at the moment. The couple of things, guys, just to remind you, yes, this is absolutely absolutely correct.
It is a controversial subject because we're not 100% sure about the exact treatment pathway. There is no doubt the majority of patients are just going to need observation when you need to intervene. This is one of the questions. And where and what intervention will you do? Is another question. So the approach to this is to develop a pathway in your head.
What are you going to do for a child that is young and has significant headwinds classification as in the sea? What are you going to do or with b.c.? What are you going to do with the Middle age as somewhere between 5 and eight? What are you going to do with that child on initial presentation? What are you going to do with each of these versions of the Herring classification, from ABC to a bbc?
And see how are you going to manage? And finally, the patient who is older and/or delayed presentation patient who has clinical symptoms and severity, which shows that the head is not encapsulated and not or is an engine, or there's already a tabula remodeling, which is causing problems for later on in life. So these are if you develop those scenarios in your head and have an answer for them, you don't have to be very accurate or very in-depth in your answer.
Just understand that each patient has a different pathway and how you're going to manage. Yes, the majority do just require observation. How frequent is your observation is often a question. They'll ask you what are you looking for? What are you waiting for in your observation? And what about your clinical examination? What's your clinical examination going to involve? So people always talk about the X-rays.
And what they're looking for. But clinical examination is also quite important, as mentioned by Nicky again. So you need to have a think about what are the clinical factors that would indicate that you need to consider an intervention or not. OK, before we go on to bigger questions, you go to any questions here.
Look, I think one, I think the treatment of trophée disease is very controversial, and I think that for most exam candidates, it would be enough to recognize the sages and what the possible complications could be. Yeah, having to explain the treatment because the treatment is very controversial.
The treatment principles is probably what they're going to look for. So I wouldn't say you need to know how to do each operation, but you do need to understand the principles of containment. And remember, treatment doesn't necessarily mean always surgery. So containment observation is also treatment. Yeah so so one of the cases I want to I'm going to present, but I've not done it is I had a four-year-old last week.
He presented with a limp. Right? no fever. No family history of anything presented with the link is for years old, so he's a little bit on the. You know, downside of pro face. But it did have some indication that his specific nucleus was not forming the right way it should be. So in that case, I would say we need to observe this child, right?
We are we know the prognosis is going to be good because he's young and fully observant. Absolutely correct. So the scenarios in this exam are not going to be straight away. Tell me about this. That's not the way they're going to ask this question. They're going to give you a case like that for your own child. Or usually it will come up as either limiting child or part of the differential diagnosis.
It's very important to keep on Percy's no matter what the age of the child is, because there are other diagnoses which are much more devastating if you miss them in the initial stages than if you outgrew them first, and then go to. Well, now we've excluded everything else. Let's think about process. Does that make sense? Well, one of the things I wanted to say it was very much apparent in the Australian training system doesn't seem to be that much in the UK training system is the fact that you can get bilateral lateral.
Now, normally you don't get bilateral per CS at the same stage, if it's truly per. You've got to think of multiple epiphyseal dysplasia. That was one of the things that came at really highly in my Australian exams, but maybe not so much. And absolutely right. And also the other way that we can ask. This is what you're seeing the patient after a diagnosis of criticism in age, and the mom now wants to know what the chances are for their child or what is perfect.
Mum wants to know what is birth, so you need to be able to explain the its etiology, its diagnosis, its risk of inheritance, which there is a connection with family history, but not necessarily an inherited risk and also the other factors associated with. So these are all conversations and also the prognosis for this child. And so on, and what might happen in their adulthood.
So these are all the way those questions can be brought up without actually talking about doing corrective surgery to maintain containment and things like that. OK, so it does come up in the exam. I do appreciate it is a controversial one.
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