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Paediatric Upper Limb Fractures For Postgraduate Orthopaedic Exams
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Paediatric Upper Limb Fractures For Postgraduate Orthopaedic Exams
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Invitation to present tonight, and I'm certain we will all learn from him. So myself, parents are now I'll be moderating the session. And with me, we have Sean hinari and Nicolette Evans and good evening and from auto TV team, we have our show tonight.
So this session, as usual, and we will start with the focused lecture at exam exit exam, mainly if our case focused. We will not go into much depth to cover everything, but we'll try to stay exam focused. Mr al-abadi has prepared excellent presentation, has big educational value and we can all enjoy it tonight.
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So without further ado, I will leave you with what you had. If you could share your screen, please. Yes hello, everyone, and good evening. I will just start sharing my screen. Today, we are going to talk about pediatric fractures starting with the upper lymph. I'll start my talk with a supracondylar fracture as other incidents, it's the extinction type of a fracture is the commonest, usually between 59 to 98% Sorry, 95% to 98% Flexion type is less common, though usually in children between 5 to seven years of age, equal incidence between male and female, and the usual mechanism is full on the off switch and more importantly, in 44 cases.
How to examine pediatric patients being playful, attitude sitting or kneeling forward in the setting of the analgesia and splinting is very important. And specifically, for the superconductor of fracture, we need to examine them on regular intervals, specifically before and after applying the splint. This has gotten classification, which which has classified them into three types.
One is on display structure. Type 2 is displaced within the steel cortex and typekit is completely displaced. There is another classification that you need to be aware of, which is the wheel welcomes modified by modification of Gotland that classify them into four types that one would be on display structure. So it's similar to that one that two was classified to type 2 and B A is that in fact, osteoporotic can be still within the axilo cortex.
But there is a angulation and rotation type III is again classified into and B A is possible medial displacement and be exposed to a lot of displacement. And type IV is displaced unstable, both in flexion and extension as well. As for the radiographs, it's important to do an AP view on a lot of you for the latter review, as you can see on the left hand side.
Sometimes the only finding that someone can see is in an displaced fracture is the loose in shadows here, which indicate fat pads, interior and exterior. The presence of steel fat blood is highly suggestive of contraction. The elbow is an integral fat. Bad sign can occur without a fracture. Actually, on the AP view, we can see the Bowman's angle here, which is the angle between the analysis of the lateral condyle and the humeral shaft.
The mean of this angle is about 72 degrees. The range is between 64 and 4 and 81. Another another line that we look at for on the lateral view is the AM line, and it's a line along the anterior humerus cortex that extends down to the capital and usually it intersects through the middle third of the capital. This is useful in determining the adequacy of fracture reduction during the surgery.
Um, as of the management, we can divide that into management in the emergency department and definitive management for the emergency department. Mainly, it's adequate pain relief with an above elbow slap applied in the position of comfort for a displaced, completely displaced fracture. A splint. Better to be near extension to avoid compression than the neurovascular bundle in front of the elbow Gartland classification does help us with the determining the line of management that we are going to undertake.
I just wanted to quickly, briefly mention, because this is one of the questions. How would you assess the neurovascular status in a child in pain? Very one should be playful. One should make sure that proper analgesia and implanting has been applied. We apply for the motor, for the motor examination, the rock, paper and scissor and OK approach, where the rock test, the median nerve purpose test, of systems, just the ulnar nerve and the OK is for the anterior obvious, obviously, and for the sensory examination we use the autonomous zone.
So part of the index finger is for the median nerve, part of the little fingers for the ulnar nerve and the door. Some of the first foot space for the radial nerve haven't done that. It's very important to a number 1 to commend that. And number two is to frequently recommend that specifically before and after applying a splint for most of the Centers. I would say that type I fractures with the positive fat pad sign would be conservatively treated in an above elbow cost 4, 3, 2 four weeks.
Elbow flexion to 90 degrees with neutral rotation. Uh, for the displaced fractures, one of the questions was an important question is the reduction technique. So how would you reduce the type 2 or type 3 fracture? So steps all longitudinal, then attraction first applied to the forearm to dislodge the fracture and gain the length and correct rotation.
Number two is if there is a practical design, which is button holding of the distal fragment. Through the prequels, we can apply what we've call the melting maneuver. So between the thumb and index, we can milk through the skin and try and push the distal fragment back into position. This shouldn't be tried more than 2 times anyway. Supposing that we obtained an acceptable reduction, then.
Most of the Centers would go for penning. Usually we do that using a CRM, whether we do that as a cross technique or a lot or through up to cave to cave hours laterally. We use the both guidelines to. To determine the thickness of the cave wires and the both guidelines phase two device, although this is not usually possible if the closed reduction technique has failed or cannot obtain a proper closed reduction, then we go for an open reduction.
We use the latter approach for middle displacement and the middle approach for a lot of displacement, and we use the anterior approach if there is vascular compromise. Now I have this flowchart for the Super fund structure associated with no pulse. So we sort of divide them into either pink and perfused hand or white and hand or the pink and perfused hand fraction is fracture is reduced as per the technique mentioned intent, whether up to you.
According to the center, working forward with a divergent lateral two pins or crossed wires, then make sure on the X-rays. This is the most important thing that there is no fracture gap because if there is a fracture gap, it means most probably that the neurovascular bundle has become trapped between the fracture fragments. If the fall by splinting in about 40 degrees of flexion with the neurovascular monitoring and vascular surgery early on so that they can make further decision and act fast accordingly in the case of a white and non perfused hand, then reduce the fracture planet and make sure still that there is no fracture gap.
If it becomes pink but pulseless, we can adopt the first pathway, which is the pink perfused and if not, should be explored first by vascular surgeon as well as monitor the compartment. Most probably there will be compartment decompression following a reperfusion procedure. One further point is for the medial side pain.
There is about 8% incidence of ulnar nerve injury due to tethering effect of the k-y and the cubital tunnel. If a medial pain is going to be inserted, then a small incision should be put and make sure that we can visualize and protect the nerve as we do that to avoid ulnar nerve injury during this process.
The next structure that I will talk about is the lateral epicondyle fracture, which is the second most common fracture. In children around the elbow, usually it's a fall from a height or an outstretched hand, and there is a theory of pull off or push fall off is due to all of the collateral ligament lateral collateral ligament attached to the lateral side push of is by the radial head.
Now it's often missed on the radiographs and an internal oblique elbow radiograph like the one I'm showing here will help us detect a called fracture, the latter by for the treatment. Non operative treatment can be done with minimal displacement, but close follow up is important. Particular reduction is the primary goal to articular surface article coverage reduction, as the complication is relatively common after these fractures.
You're North epicondyle structure is still we need to do an AP lateral and consider internal bleak views specifically standard around the area and cannot be seen on x-rays. Really, we need a CT scan or an MRI, but our program is a very useful tool that the surgeon can apply in surgery to make sure that the articular surface is intact and it's even proper MRI is MRI is more closely and will need sedation or the child to be asleep to do it.
So for the classification of the lateral condyle, we have two classifications, actually three, but I will concentrate on melosh, which is the first one to classify a letter from a fracture into type I and type Ii. Type one was going through the ossification center of the cochlea, so basically stable type 2 is medial to the ossification center.
The military doesn't really provide any treatment prognostic guidance, but the voice one, which was 2009, is now more. A frequently used, which is classified into five, one, two and 3 1 is less than 2 with the intact articular cartilage type 2 is between two to 4 with intact articular cartilage. And type III is more than four with disrupted articular cartilage.
An important point to talk about the latter is the blood supply, so it is supplied with the regulatory and security in the capital fossa. But the branch that goes to the lateral side on the latter does come from posterior knee. And for the treatment consideration is the degree of displacement that dictates the management most type 1 fractures with less than 2 millimeter displacement.
There will be intact medial cartilaginous articular surface, so a long arm cost, which is an above elbow cost or a splint with 60 to 90 degrees of flexion due to swelling, but very close follow up. So the first X-ray should be within the first week, probably out of the cost, and do an internal oblique view as well to make sure that there is no further displacement costing can go up to six weeks in for some cases to make sure that they're ideologically and clinically, the functions feel for type 2 fractures.
Most of the surgeons will aim to reduce them because those fractures have a very high complication rate, either per percutaneous or open percutaneous. The closed reduction is by push the fragment onto medially and using a divergent configuration, as we can see in this picture.
X-rays of this one here we're using screws. Now Using a screw provides more compression and a range of motion compared to the pins, which are less stuff as crew will need to be removed if it crosses devices. Most of type III fractures, those who which are displaced more than 4 millimeters or rotated will need often reduction through a lateral approach.
The interval here is between the triceps and the brake regardless, which are both supplied by the radial nerve aiming at reducing surgically anteriorly, avoiding posterior dissection and again can use either key wires or screws. A screw is preferred because it provides compression and early mobilization. Complications of the lateral condyle to the most common is the lateral overgrowth of the lateral 75% and as well as covetous Vargas, there will be some stiffness and nonunion.
And growth disturbance and the ulnar nerve claw palsy. Now, medial epicondyle fracture, I added that to the presentation, because quite common, this is the third common elbow injury or fracture, usually in boys 9 to 14 years old. And it's due to now becoming more due to athletic injuries.
It can be due to an abortion as we know that common flex corrosion arises from that, as well as the medial collateral ligament or due to direct trauma, or it is associated with elbow dislocation in 50% to 60% of cases. Now it can be encapsulated incarcerated if it is associated with elbow dislocation. The incidence of that is about 15% One important question is the fusion centers around the elbow, which we can.
There is a misnomer out there, which is the cry to see is the capital on which started one. Art is for the radial head, which is three years. An eye is the internal. The medial epicondyle, which is 5 and t, is for the traject 7 and/or lateral 9 and lateral epicondyle, which is 11. The loss to fuse is the medial epicondyle bas status.
It's the origin for the flexor-pronator mass, as well as the ulnar collateral ligament. To identify it, we need an AP lateral and axial view like this for you here because it's supposed to medial position wise, treatment usually can be non operative if it's not displaced. 5 and usually we fix with sorry, we keep them above elbow cast for 1 to three weeks and about 90 degrees of flexion or go for an open reduction internal fixation.
The technique for that, it's a medial approach centered on the medial epicondyle itself, visualizing the ulnar nerve patient. Once we identify the fracture, we can use either Coy Wire or a screw with the water to compress the fracture problem with the screw and washer is its more prominent, though, so it will need to be removed.
common complications, medial epicondyle fractures are non-union nerve injury, injuring the ulnar nerve can be something between 10 to 16% Neuroprotection is common. Uh, an important complication is missing an incarcerated medial epicondyle with an elbow dislocation and stiffness following operative management.
Fracture is next 4 to 10 years old, radial head dislocation plus proximal ulnar nerve fracture, this is the definition of a multi-year fracture. It can be associated with plastic deformation of the ulna classified usually by Bardot. So type 1 is a ulnar nerve angulation with until dislocation of the radial head and type 2 is a posterior ulnar angulation with posterior radial head dislocation.
Type 3 is lateral and type 4 is associated proximal radius fracture for the X-ray. Again, it's very important to look at both the elbow and the wrist joint and look at the line of the axis of the radius, which should be running through the lateral epicondyle of the humerus. So radial line is an important line to look at on the lateral view as well as don't forget to obtain for fracture treatment.
Non operative indicated in type 1 to 3 with radial head is stable following closed reduction reduction. Technique itself is traction and radial head that most probably and almost most of cases spontaneously reduced once the ulnar length is restored for a type 1 Baddoo.
Elbow flexion is the main reduction maneuver. Following reduction, thigh bone will be immobilized in 110 degrees of flexion pulse of a nation. The aim is to tighten the interosseous and brain and relax the biceps. Tendon type 2 should be in full extension to the posterior and related type III full extension with voguish molding of the cast. There is an indication for operative training or nailing of the ulna, which is tied 1 to 1 to 3 where the radial head is not stable following the reduction of the ulnar length is not stable to unable to maintain basically either the ulnar or the radial head in reduced position in an acute body type for in open fractures in older patients or if like adults, should be done.
Technique wise, usually uneven ligament reconstruction is almost never required as again. Once all the reduction of the ulnar is obtained, usually the radial head is reduced as well. Next is structured Vegas and ulnar nerve and media Sonoma is about 40% of all pediatric fractures. Males are more than females.
Usually is falls due, falls from height, sporting or playground falls, and it is associated with other injuries like floating elbow and 15% of the cases superconductor fracture, neuro neurologic injuries, median nerve and about 1% of the injuries. One of the important exam questions for the forces is the muscles, causing the deformity.
So the biceps flexo-pronator act on the proximal fragment to flex it consolidated while the NIPE of tennis and the promoter quadrantids work on the distal fragment to connect it and the brachial dials again actor the distal fragment to dorsiflex and readily deviated. So for the distal fragment, there will be pronation dorsiflexion radial deviation, while proximal fragment will be in a flexo-pronator position.
And x-rays we do. And lateral X-rays to visualize what the radiation Alma. Sometimes you can see only single bone fracture, but that will mean that there will be plastic deformation of the other bone because the ridges on one unit, it's like one joint and there is no fracture if there is no fracture. But doing this would be suggestive of a plastic deformation.
Another question that can be asked either in McHugh's or survivors is the rotational muscle alignment or X-ray. So basically, the bas status tuberosity should align to 180 degrees from the radial is Lloyd on the AP and the ulnar nerve. The paranoid should be 180 degrees on the lateral. And there should be some matching diameter of the proximal and distal fragment and matching the thickness of 46 proximal and distal fragment classification.
Can either be classified as incomplete or complete fracture. So greenstick fractures, Taurus plastic deformation, or we can classify it by the position of the fracture, proximal, middle or distant third, as well as by the direction of the deformity. So a Bowler or ebix dorsal button. Three, treatment, closed reduction and casting.
Uh, important, you know, the tolerance is the accepted, accepted ethic, formal alignment. So that depends on the age. So up to 10 years, we can accept an angle and angulation of less than 15 degrees and a rotation of about 45 degrees or up to 45 degrees and a binary a position, which is shortening of the two fragments about a centimeter or less. If the child is above 10 years or so from 10 years and above, the angle will be 10 degrees or less and the rotation will be 30 degrees or less with no opposition or shortening.
Once the child reaches to almost near to the growth authority, greater maturity around less than two years from a skeletal maturity. So no rotational regulation should be accepted 0 degrees and no binary opposition. So the number would be 10 years. Anything below you can accept 15 degrees of angulation, 45 degrees of rotation or less, and 1 centimeter less than 1 centimeter of shortening 10 years or above.
Then the angulation is less than 10 degrees and the rotation is less than 30 degrees. Bionicle position is non-zero. If there is less than two years of growth remaining, then don't accept any deformity and proceed to function or close. Reduce the usual closed production is done on analgesia for plastic deformation. It's a 3 point bending to counteract the bending deformity for Green leg fracture.
This attraction and direct pressure again on 3 point bending. Basically, if it's a volar angle, then we fix them inflammation. If it's a dorsal angle, then we fix them by nation. So basically traction and reverse the deformity and use the point technique. The costing will maintain the reduction.
Again, 3 point molding and interosseous small membrane molding to avoid loss of reduction. Keep a close eye and do X-rays. Very important to keep a close eye on our compartment syndrome. If there is excessive swelling, then you might think of by involving the cost to avoid this. If if the reduction technique of the closed reduction was outside the acceptable degrees of rotation and and shortening just mentioned earlier, then we can consider either continuous thinning or reduction internal fixation specifically for children above 13 years or badly severely displaced fracture, which is a relative indication.
Now for the distant radial or distressed fracture. Right so this story, destruction really has a fracture. This is about 31% of the fractures. The peak incidence of ages 11 to 12 years in girls and 13 to 14 years in boys, males more than females.
So rate is 1.5 voices involved about one third of the patients distal radius, fracture, pain, swelling and tenderness. Spontaneous movement is reduced very common with fall on outstretched hand AP and lateral. Very rarely that we need a CT scan to detect into a particular extension. Of the first type of fractures is the torso of the back and fractures.
This is my drawing here. So Torres is basically unique cortical in dental buckling of the cortex. This is compared to the greenstick fracture, which is a complete fracture on one cortex and plastic deformation or bending on the other. Taller structures are usually stable. We can treat that in a splint removal of splint, which which is important to reduce the health care cost and the burden on the family, usually very perverted function and return to sports earlier with the removal removable splint.
For greenstick fractures. And there is. There is a combined total cortical disruption with plastic deformation as per the previous drawing. If it's only pure bending forces, then the radius will break at the same level.
If there is rotational forces, then they will break at a different level when it's the same level. So when you reduce it, you reduce it using the 3 point fixation principle in a unilateral reduction. If it's different levels, then consider the direction of the apex. If its apex Voula, then reduce inflammation if it's apex door, suddenly reducing subordination.
Again, there is a debate whether the completed or not those who are with completing the fracture, it's for proper alignment and better colours, formation and fracture. The drawback is less structural stability fractures are common on most commonly fractured as well. There will be clinical and graphic deformity. Study studies has definitely shown that remodeling potential is good with both the radiation and no reduction has been attempted, even with no reduction has been attempted.
That's 2003 by 2 and Crawford 2012 and even blown in 1967. Barnett opposition can be accepted and patient age younger, usually than 10 years in the reduction we mold to maintain and maintain in a below elbow cost. We use the principles of the cost index, which is by choice for those who have or are not familiar with that.
So the cost index is defined as the measurement of the internal cost width on the lateral view and the internal cost width in the AP view. And this is expressed as a ratio and it would be OK as long as it's below one. And as the cars become more circular, so the lateral diameter approach approaches that the AP diameter and the cost index will be closer to 1 suspect as long as less that one.
It's good. There is good evidence that many, many displaced fracture in the metathesis treated by a simple splint similar to the buccal fracture. Still gives good functional and healing. Next, we talk about the metaphysical fracture when the fracture is not within the acceptable alignment with a closed reduction and again, the acceptable arrangement depends on age.
So those who are below 10 years, we accept less than 1 centimeter 15 to 20 degrees of angulation. Now we are in the metaphysical area and meditation of less than 40 45 degrees with the dorsal angulation of about 30 degrees. For those who are above 10 years, violent opposition is not acceptable. Angulation should be 10 degrees and specifically distal radius and ulna.
It should be less than 20 degrees, and for normal rotation, it's about 30 degrees. So the complication rates for the initial measurement with pain fixation appeared to be related to mainly to the potential loss of reduction, not depending. And there has been no change in the long term outcome. So that's why there is mounting evidence that simpler or simplified treatment of the distal rigor structure and currently we are running the EU and the UK the craft trial.
I know it's early, but there is some indication from early evidence that better results actually within the non operative arm are still running the trial. So don't say this now for the physeal fracture to go through its destroyed, the spices 90% of the growth happens in it. It has got a very good significant remodeling potential pure distal ulnar nerve. Their injuries are much less common, and it's most often associated with physical fractures of the distal radius.
One third of pediatric fractures occurring the distal radial vices usually consist of one can be certain enhanced type 2. You will know that due to normal X-rays and localized in the region, the distal radius half of those distal radial physical injuries will be associated with almost myeloid and physical injury of the ulnar nerve as well. If it's not displaced, then below elbows plant cost for about three, four weeks.
If it is displaced, then that five year fracture, then closed reduction. But this can cause risk of arrest even if there is residual angulation greater than 20 degrees. This will normalize subsequently as their Freiburg in 79 so the recommendation for reduction is according to the previous tolerances as we discussed it.
But basically avoid repeat. Repeated forcible and late attempts for zero risk may still occur, even if this had been because there has been enough compressive forces in danger, specifically in Slaughterhouse type 1. There is a very good and great potential of remodeling. Age at the time of the fracture has significant impact on the outcome. The closure of the distal radius plate occurs over a very short time, so less than one year.
So it's got something like a trampoline fracture. With this to reduce that, that's rare. But maybe worth mentioning. And I think that's the last fight, so we are doing fine, so Gagliardi fracture. Uh, the force here runs through the ulnar nerve side of the distal forearm with fracture of the distal radius and dislocation of the distribution a joint, it's frequently missed on the initial assessment.
But still there is good outcomes for at least for close treatment, even when recognized late as by the paper by April 2008. if we reduce the fracture of the radius accurately, then we expect the forearm to usually to fall in slap nation and reduction of the torn articular disc and ligaments, which will allow healing in their approximate position.
The triangle of cartilage is attached to the ulnar nerve deployed, and it can cause ulnar nerve third abortion. So if you see that, expect that the SEC has been injured with the terrible physical injury. So non-union workers, but this shouldn't be given a problem only if the patient has ongoing ulnar nerve sided chest pain after the structure of the distal radius then work out as a PT FCC.
I think that's it. For this part. And back to you for us. Brilliant, thank you very much. I look forward. Any questions from the audience? Yeah well, it's very, very comprehensive and focused. Lecture very thank you very much for the interest of time.
We will try to move on as quick as we can. There is one question came in across, which is very sensible question about what's the time span between fracture and manipulation? How long can you wait for before, you know? Well, I'm not sure. Are we talking about the Super popular fracture? No generally, with the physical fracture, with the physical fracture, the sooner the better as individuals in this law.
When is it? What is the timeline when you say manipulation now is going to cause more damage than good manipulation if it's delayed? Yeah what's the time frame for some? If it comes, I would say something more than a week, more than a week. And is that evidence or is it the experience bas status experience rather than evidence having gone through them preparing the slides?
I didn't really see any sort of like time. Every I mean, most of what's written in the literature say is chronic or delayed manipulation. But we don't know exactly the time span. Not not days. Not not like weeks. I couldn't see it, at least when I was preparing the lecture. Could I suggest that a test would be to take the back slap of the arm?
If it's mobile and painful, then it's easy to slip back into place if it's already solid. I think that's sensible. If it's still painful, it means Yes in mobile. It's not, I think, depends on the age of the child as well. Isn't the child of two years old might heal within a week or two? A child of 10 12 take longer. I think that's also another factor here.
Yeah, yeah, so I think that's probably why there is no hard evidence behind this, because I think it's quite complicated to not that I could see if anyone else have more sort of like literature experience. Let us know. So I think probably what exam answer, like I said, they'd probably be more on clinical grounds.
There is no exact number, but maybe on a clinical ground and clinical assessment of whether there is an established healing process has started. And or not? I think that's sensible if you remove the cost of the patient is still tender, should assume that is mobile still or you can try and reduce it. Yeah, there was one more question in the exam, if you ask, this is a week late and you are what would you do?
You will assess the patient, establish if there's any pain or discomfort with movement, but you will discuss this with the senior pediatric colleague. The reason why is pediatric colleague is the one that's going to deal with the complication later on. So you want to get their advice on what to do and then they say, OK, what would you do? And then you can decide whether you're going to need to go forward, do not trust me at a later stage or a corrective.
So it depends on what the injury is in terms of growth rate or its growth rate traject. I think that sense fun because, again, this is what the process of the Air Force is, so would do exactly like what you said. I will discuss that with the pediatric colleagues before doing or going further and then decide accordingly. Yeah, that's great. Thank you very much.
And one more question from AJ asked, which never injured in pll? I think I presume that positive lateral and medial superconductor humerus fractures. So I will. So the nerve, the nerve injured. So for the flexion type of fracture, it's usually ulnar nerve. Now for the extension type, it's usually the median nerve, commonly or most commonly is the anterior to OSHA's.
I'm going to answer a few questions asked me about distal radius and facial injuries. You have to remember that the ability for the bone to remodel is based on the range of motion and the direction of motion of the joints. So the majority of facial injuries are grossly dilated and there's a lot of movement in the wrist. So if you've missed the boat on a correction, as we've described, it's not necessarily the end of or a bad outcome for this child.
No, because there is still quite a significant correction left. Even if the child is close to the effusion, they will still be quite a significant correct correction. And then once they've finished going, let's say it's a 16 year old, they've got a year, maybe two years left in their growth or a 14-year-old year and two years left. Wait and see. And then you can do an osteotomy once, once the correction has stopped.
Was the remodeling stopped? Yeah, I think Sean kanata in 2003 has exactly written what you said is one of the lost points. So the greatest potential for remodeling is in the distal radius, and age and time of fracture has a significant impact on the outcome. So maybe this paper here, the Canada paper from 2003, might give some more shed some more light on this point.
Yeah, that's a good idea. I think it's a paper to have a look at, and it might give a little bit of backing and support for answers with this regard. I think that's probably definitely a level 8 kind of. Yeah, an answer. So that's a good one. That's brilliant. Thank you.
Thank you, guys. I think I'd like you to the cry tone. Yeah, I think that's very useful as well for the closure of the certification centers around the elbow. I think you guys can have a look at that as well. Again, later on, when you view the lectures I find for the interest of time will move on to the next part of.
This is the questions. Can you stop sharing? Yeah, that's fine. Can you see guys pull? No OK. How about now? Great so, guys, for all this watching. I'm not sure, so if all of you watching, I'm very sorry that the people who are live streaming are unable to see this.
This poll, this poll. The questions. There are three issues, please everyone who is attending. Please attempt to answer this. The answers will be anonymized, so we cannot identify who said what. So, OK, hold it. If you would like to go through the questions with us, please. All right.
So the first one was seven years old, who fell on a slide, fell off a slide. There is a fracture of the distal humerus. This is now will be or can be associated with a ground stop deformity because of one of the three options. Just let me get the options in front of me again. So the first option was Gartland type 2 with a lateral cortex impaction or guardian type 2 of the posterior lateral displacement of the fragment or government, up 3 with lateral intra articular involvement or garden type 2 with impaction of the medial cortex to the posterior medial displacement of the front.
And the right answer for this one is the medial cortex. Impaction and practice with medial cortex impaction tend to end up in a Mali United position and a Gulf stop deformity. And that's why it's recommended that for the four, most of those injuries to get X-rays of both hands in theater and make sure that you correct the Baumans angle to be similar on each side.
Unusual it's a very small union that causes this press. Good question, joy and question. So this was a hard question, this last one. It is, I think, only 27% answered correctly. Yeah, yeah, it was. But it's very important to look at the AP view, make sure that there is no medial cortex communication and interaction.
And if so, in your surgery, you need to look at major departments angle and try and sort of copy the other side to avoid the varus deformity. That's how you avoid it, and it's due to various reunion the most common. The second question is the most common complication of a lateral condyle fracture. Is it hubertus?
Whereas ulnar nerve claw palsy, which is tada ulnar nerve claw palsy osteonecrosis, occipital Volga or a lot of despair formation? The answer would be the lateral formation, which is the lateral protuberance that happens in about half of the cases. It's it has no functional disability and no surgical treatment is required. It was one question this past time that someone with the tada ulnar nerve we'll see.
Again, it's not the communists, the communists, actually the lateral spur formation. I think that's a wonderful question. I love this one valid because I think this is a very important skill in excuse. Yeah, it's not the one you hear a lot more about. Yeah, or the most significant read the question is the most common. And the most common come sometimes could be the most minor of the complications, not the one you all hear about and we have to deal with.
Yeah so please, guys, is a good example of how to actually read the question. Just asking you what's most common, not the most serious or most specifically for this exam, because you really need to do it fast? Yes, I think that's why some people come out of the M6 component of the exam thinking they've done well, but they actually have not really answered the correct question.
Here's the question, please. Is the elastic nails for the forearm? So whether a is radial entry at the fourth and fifth extensor compartment B diameter of the nail for each bone is 30% to 50% of diameter medullary canal proximal entry on the ulna or at the ulnar nerve ulnar nerve needs to be visualized indications field close reduction, re fracture, open fracture, lateral humeral fracture, unstable radial dislocation or all of the above.
So the answer is D actually were the indications are all the right things. The radial entry is not at the fourth and fifth extent, so you can either enter the radius, defer the first and second compartment between them, which is APL and CRL tendons or the second and third compartment is hip. That's if you are going three, but if you are going laterally, it's about two to 2 centimeters proximal to the distal radial bénéfices that's on the radius the diameter of the nail.
Put that one because they ask about the FEMA. It's about 30% to 40% But for the radius and ulna is different. Usually we use only one. So it's about 2/3 of the canal, 60% to 80% because actually both bones work as one bone with the interosseous membrane between them. So, um, so that one was wrong. It's not 30 50, it's about two thirds, or 60% to 80% and then there is a proximal injury of the ulnar, the ulnar nerve doesn't need to be visualized.
You go and you avoid the electron above offices and you will be away from the ulnar nerve. Indications are all right. Field growth reduction restructure, open fracture, axilo lateral humerus fracture, unstable radial dislocation. We use plates if it's severely comminuted. And microfracture or linked unstable fracture, all of the above is not because it's only one variant, only 9% for this one.
And do you think it's that difficult? I think to be honest, I don't think it's difficult, but when people. And I think it's a very good to demonstrate another skill in that time of stress. Yeah, Yeah. I think what you do in the exam as well in the exam, you get one and I have the maximum 1 and 1/2 minutes per question.
So but when people see all the above, they say that's the answer. Yeah and a lot of the time it is, but not every time. But that's why I specifically for this one, I went through all of them because you need to know the technique, even for you. If you do not. Normally you need to know where you're going and honestly where you're going.
And approximately, do I need to visualize the ulnar nerve medicolegal, you know, as long as you are away from the offices. It's an indication that you need to get them right when to use the plate, severe communication, severe displacement, basically length on a stable fracture. Otherwise, it's both the plates and elastic nails do the same, but the operative time for the elastic nerves is much shorter.
Yeah, thank you very much. Wonderful questions. Now we'll move on for the interest of time. We immediately to the vital questions.
Segment:0 .
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So without further ado, I will leave you with what you had. If you could share your screen, please. Yes hello, everyone, and good evening. I will just start sharing my screen. Today, we are going to talk about pediatric fractures starting with the upper lymph. I'll start my talk with a supracondylar fracture as other incidents, it's the extinction type of a fracture is the commonest, usually between 59 to 98% Sorry, 95% to 98% Flexion type is less common, though usually in children between 5 to seven years of age, equal incidence between male and female, and the usual mechanism is full on the off switch and more importantly, in 44 cases.
How to examine pediatric patients being playful, attitude sitting or kneeling forward in the setting of the analgesia and splinting is very important. And specifically, for the superconductor of fracture, we need to examine them on regular intervals, specifically before and after applying the splint. This has gotten classification, which which has classified them into three types.
One is on display structure. Type 2 is displaced within the steel cortex and typekit is completely displaced. There is another classification that you need to be aware of, which is the wheel welcomes modified by modification of Gotland that classify them into four types that one would be on display structure. So it's similar to that one that two was classified to type 2 and B A is that in fact, osteoporotic can be still within the axilo cortex.
But there is a angulation and rotation type III is again classified into and B A is possible medial displacement and be exposed to a lot of displacement. And type IV is displaced unstable, both in flexion and extension as well. As for the radiographs, it's important to do an AP view on a lot of you for the latter review, as you can see on the left hand side.
Sometimes the only finding that someone can see is in an displaced fracture is the loose in shadows here, which indicate fat pads, interior and exterior. The presence of steel fat blood is highly suggestive of contraction. The elbow is an integral fat. Bad sign can occur without a fracture. Actually, on the AP view, we can see the Bowman's angle here, which is the angle between the analysis of the lateral condyle and the humeral shaft.
The mean of this angle is about 72 degrees. The range is between 64 and 4 and 81. Another another line that we look at for on the lateral view is the AM line, and it's a line along the anterior humerus cortex that extends down to the capital and usually it intersects through the middle third of the capital. This is useful in determining the adequacy of fracture reduction during the surgery.
Um, as of the management, we can divide that into management in the emergency department and definitive management for the emergency department. Mainly, it's adequate pain relief with an above elbow slap applied in the position of comfort for a displaced, completely displaced fracture. A splint. Better to be near extension to avoid compression than the neurovascular bundle in front of the elbow Gartland classification does help us with the determining the line of management that we are going to undertake.
I just wanted to quickly, briefly mention, because this is one of the questions. How would you assess the neurovascular status in a child in pain? Very one should be playful. One should make sure that proper analgesia and implanting has been applied. We apply for the motor, for the motor examination, the rock, paper and scissor and OK approach, where the rock test, the median nerve purpose test, of systems, just the ulnar nerve and the OK is for the anterior obvious, obviously, and for the sensory examination we use the autonomous zone.
So part of the index finger is for the median nerve, part of the little fingers for the ulnar nerve and the door. Some of the first foot space for the radial nerve haven't done that. It's very important to a number 1 to commend that. And number two is to frequently recommend that specifically before and after applying a splint for most of the Centers. I would say that type I fractures with the positive fat pad sign would be conservatively treated in an above elbow cost 4, 3, 2 four weeks.
Elbow flexion to 90 degrees with neutral rotation. Uh, for the displaced fractures, one of the questions was an important question is the reduction technique. So how would you reduce the type 2 or type 3 fracture? So steps all longitudinal, then attraction first applied to the forearm to dislodge the fracture and gain the length and correct rotation.
Number two is if there is a practical design, which is button holding of the distal fragment. Through the prequels, we can apply what we've call the melting maneuver. So between the thumb and index, we can milk through the skin and try and push the distal fragment back into position. This shouldn't be tried more than 2 times anyway. Supposing that we obtained an acceptable reduction, then.
Most of the Centers would go for penning. Usually we do that using a CRM, whether we do that as a cross technique or a lot or through up to cave to cave hours laterally. We use the both guidelines to. To determine the thickness of the cave wires and the both guidelines phase two device, although this is not usually possible if the closed reduction technique has failed or cannot obtain a proper closed reduction, then we go for an open reduction.
We use the latter approach for middle displacement and the middle approach for a lot of displacement, and we use the anterior approach if there is vascular compromise. Now I have this flowchart for the Super fund structure associated with no pulse. So we sort of divide them into either pink and perfused hand or white and hand or the pink and perfused hand fraction is fracture is reduced as per the technique mentioned intent, whether up to you.
According to the center, working forward with a divergent lateral two pins or crossed wires, then make sure on the X-rays. This is the most important thing that there is no fracture gap because if there is a fracture gap, it means most probably that the neurovascular bundle has become trapped between the fracture fragments. If the fall by splinting in about 40 degrees of flexion with the neurovascular monitoring and vascular surgery early on so that they can make further decision and act fast accordingly in the case of a white and non perfused hand, then reduce the fracture planet and make sure still that there is no fracture gap.
If it becomes pink but pulseless, we can adopt the first pathway, which is the pink perfused and if not, should be explored first by vascular surgeon as well as monitor the compartment. Most probably there will be compartment decompression following a reperfusion procedure. One further point is for the medial side pain.
There is about 8% incidence of ulnar nerve injury due to tethering effect of the k-y and the cubital tunnel. If a medial pain is going to be inserted, then a small incision should be put and make sure that we can visualize and protect the nerve as we do that to avoid ulnar nerve injury during this process.
The next structure that I will talk about is the lateral epicondyle fracture, which is the second most common fracture. In children around the elbow, usually it's a fall from a height or an outstretched hand, and there is a theory of pull off or push fall off is due to all of the collateral ligament lateral collateral ligament attached to the lateral side push of is by the radial head.
Now it's often missed on the radiographs and an internal oblique elbow radiograph like the one I'm showing here will help us detect a called fracture, the latter by for the treatment. Non operative treatment can be done with minimal displacement, but close follow up is important. Particular reduction is the primary goal to articular surface article coverage reduction, as the complication is relatively common after these fractures.
You're North epicondyle structure is still we need to do an AP lateral and consider internal bleak views specifically standard around the area and cannot be seen on x-rays. Really, we need a CT scan or an MRI, but our program is a very useful tool that the surgeon can apply in surgery to make sure that the articular surface is intact and it's even proper MRI is MRI is more closely and will need sedation or the child to be asleep to do it.
So for the classification of the lateral condyle, we have two classifications, actually three, but I will concentrate on melosh, which is the first one to classify a letter from a fracture into type I and type Ii. Type one was going through the ossification center of the cochlea, so basically stable type 2 is medial to the ossification center.
The military doesn't really provide any treatment prognostic guidance, but the voice one, which was 2009, is now more. A frequently used, which is classified into five, one, two and 3 1 is less than 2 with the intact articular cartilage type 2 is between two to 4 with intact articular cartilage. And type III is more than four with disrupted articular cartilage.
An important point to talk about the latter is the blood supply, so it is supplied with the regulatory and security in the capital fossa. But the branch that goes to the lateral side on the latter does come from posterior knee. And for the treatment consideration is the degree of displacement that dictates the management most type 1 fractures with less than 2 millimeter displacement.
There will be intact medial cartilaginous articular surface, so a long arm cost, which is an above elbow cost or a splint with 60 to 90 degrees of flexion due to swelling, but very close follow up. So the first X-ray should be within the first week, probably out of the cost, and do an internal oblique view as well to make sure that there is no further displacement costing can go up to six weeks in for some cases to make sure that they're ideologically and clinically, the functions feel for type 2 fractures.
Most of the surgeons will aim to reduce them because those fractures have a very high complication rate, either per percutaneous or open percutaneous. The closed reduction is by push the fragment onto medially and using a divergent configuration, as we can see in this picture.
X-rays of this one here we're using screws. Now Using a screw provides more compression and a range of motion compared to the pins, which are less stuff as crew will need to be removed if it crosses devices. Most of type III fractures, those who which are displaced more than 4 millimeters or rotated will need often reduction through a lateral approach.
The interval here is between the triceps and the brake regardless, which are both supplied by the radial nerve aiming at reducing surgically anteriorly, avoiding posterior dissection and again can use either key wires or screws. A screw is preferred because it provides compression and early mobilization. Complications of the lateral condyle to the most common is the lateral overgrowth of the lateral 75% and as well as covetous Vargas, there will be some stiffness and nonunion.
And growth disturbance and the ulnar nerve claw palsy. Now, medial epicondyle fracture, I added that to the presentation, because quite common, this is the third common elbow injury or fracture, usually in boys 9 to 14 years old. And it's due to now becoming more due to athletic injuries.
It can be due to an abortion as we know that common flex corrosion arises from that, as well as the medial collateral ligament or due to direct trauma, or it is associated with elbow dislocation in 50% to 60% of cases. Now it can be encapsulated incarcerated if it is associated with elbow dislocation. The incidence of that is about 15% One important question is the fusion centers around the elbow, which we can.
There is a misnomer out there, which is the cry to see is the capital on which started one. Art is for the radial head, which is three years. An eye is the internal. The medial epicondyle, which is 5 and t, is for the traject 7 and/or lateral 9 and lateral epicondyle, which is 11. The loss to fuse is the medial epicondyle bas status.
It's the origin for the flexor-pronator mass, as well as the ulnar collateral ligament. To identify it, we need an AP lateral and axial view like this for you here because it's supposed to medial position wise, treatment usually can be non operative if it's not displaced. 5 and usually we fix with sorry, we keep them above elbow cast for 1 to three weeks and about 90 degrees of flexion or go for an open reduction internal fixation.
The technique for that, it's a medial approach centered on the medial epicondyle itself, visualizing the ulnar nerve patient. Once we identify the fracture, we can use either Coy Wire or a screw with the water to compress the fracture problem with the screw and washer is its more prominent, though, so it will need to be removed.
common complications, medial epicondyle fractures are non-union nerve injury, injuring the ulnar nerve can be something between 10 to 16% Neuroprotection is common. Uh, an important complication is missing an incarcerated medial epicondyle with an elbow dislocation and stiffness following operative management.
Fracture is next 4 to 10 years old, radial head dislocation plus proximal ulnar nerve fracture, this is the definition of a multi-year fracture. It can be associated with plastic deformation of the ulna classified usually by Bardot. So type 1 is a ulnar nerve angulation with until dislocation of the radial head and type 2 is a posterior ulnar angulation with posterior radial head dislocation.
Type 3 is lateral and type 4 is associated proximal radius fracture for the X-ray. Again, it's very important to look at both the elbow and the wrist joint and look at the line of the axis of the radius, which should be running through the lateral epicondyle of the humerus. So radial line is an important line to look at on the lateral view as well as don't forget to obtain for fracture treatment.
Non operative indicated in type 1 to 3 with radial head is stable following closed reduction reduction. Technique itself is traction and radial head that most probably and almost most of cases spontaneously reduced once the ulnar length is restored for a type 1 Baddoo.
Elbow flexion is the main reduction maneuver. Following reduction, thigh bone will be immobilized in 110 degrees of flexion pulse of a nation. The aim is to tighten the interosseous and brain and relax the biceps. Tendon type 2 should be in full extension to the posterior and related type III full extension with voguish molding of the cast. There is an indication for operative training or nailing of the ulna, which is tied 1 to 1 to 3 where the radial head is not stable following the reduction of the ulnar length is not stable to unable to maintain basically either the ulnar or the radial head in reduced position in an acute body type for in open fractures in older patients or if like adults, should be done.
Technique wise, usually uneven ligament reconstruction is almost never required as again. Once all the reduction of the ulnar is obtained, usually the radial head is reduced as well. Next is structured Vegas and ulnar nerve and media Sonoma is about 40% of all pediatric fractures. Males are more than females.
Usually is falls due, falls from height, sporting or playground falls, and it is associated with other injuries like floating elbow and 15% of the cases superconductor fracture, neuro neurologic injuries, median nerve and about 1% of the injuries. One of the important exam questions for the forces is the muscles, causing the deformity.
So the biceps flexo-pronator act on the proximal fragment to flex it consolidated while the NIPE of tennis and the promoter quadrantids work on the distal fragment to connect it and the brachial dials again actor the distal fragment to dorsiflex and readily deviated. So for the distal fragment, there will be pronation dorsiflexion radial deviation, while proximal fragment will be in a flexo-pronator position.
And x-rays we do. And lateral X-rays to visualize what the radiation Alma. Sometimes you can see only single bone fracture, but that will mean that there will be plastic deformation of the other bone because the ridges on one unit, it's like one joint and there is no fracture if there is no fracture. But doing this would be suggestive of a plastic deformation.
Another question that can be asked either in McHugh's or survivors is the rotational muscle alignment or X-ray. So basically, the bas status tuberosity should align to 180 degrees from the radial is Lloyd on the AP and the ulnar nerve. The paranoid should be 180 degrees on the lateral. And there should be some matching diameter of the proximal and distal fragment and matching the thickness of 46 proximal and distal fragment classification.
Can either be classified as incomplete or complete fracture. So greenstick fractures, Taurus plastic deformation, or we can classify it by the position of the fracture, proximal, middle or distant third, as well as by the direction of the deformity. So a Bowler or ebix dorsal button. Three, treatment, closed reduction and casting.
Uh, important, you know, the tolerance is the accepted, accepted ethic, formal alignment. So that depends on the age. So up to 10 years, we can accept an angle and angulation of less than 15 degrees and a rotation of about 45 degrees or up to 45 degrees and a binary a position, which is shortening of the two fragments about a centimeter or less. If the child is above 10 years or so from 10 years and above, the angle will be 10 degrees or less and the rotation will be 30 degrees or less with no opposition or shortening.
Once the child reaches to almost near to the growth authority, greater maturity around less than two years from a skeletal maturity. So no rotational regulation should be accepted 0 degrees and no binary opposition. So the number would be 10 years. Anything below you can accept 15 degrees of angulation, 45 degrees of rotation or less, and 1 centimeter less than 1 centimeter of shortening 10 years or above.
Then the angulation is less than 10 degrees and the rotation is less than 30 degrees. Bionicle position is non-zero. If there is less than two years of growth remaining, then don't accept any deformity and proceed to function or close. Reduce the usual closed production is done on analgesia for plastic deformation. It's a 3 point bending to counteract the bending deformity for Green leg fracture.
This attraction and direct pressure again on 3 point bending. Basically, if it's a volar angle, then we fix them inflammation. If it's a dorsal angle, then we fix them by nation. So basically traction and reverse the deformity and use the point technique. The costing will maintain the reduction.
Again, 3 point molding and interosseous small membrane molding to avoid loss of reduction. Keep a close eye and do X-rays. Very important to keep a close eye on our compartment syndrome. If there is excessive swelling, then you might think of by involving the cost to avoid this. If if the reduction technique of the closed reduction was outside the acceptable degrees of rotation and and shortening just mentioned earlier, then we can consider either continuous thinning or reduction internal fixation specifically for children above 13 years or badly severely displaced fracture, which is a relative indication.
Now for the distant radial or distressed fracture. Right so this story, destruction really has a fracture. This is about 31% of the fractures. The peak incidence of ages 11 to 12 years in girls and 13 to 14 years in boys, males more than females.
So rate is 1.5 voices involved about one third of the patients distal radius, fracture, pain, swelling and tenderness. Spontaneous movement is reduced very common with fall on outstretched hand AP and lateral. Very rarely that we need a CT scan to detect into a particular extension. Of the first type of fractures is the torso of the back and fractures.
This is my drawing here. So Torres is basically unique cortical in dental buckling of the cortex. This is compared to the greenstick fracture, which is a complete fracture on one cortex and plastic deformation or bending on the other. Taller structures are usually stable. We can treat that in a splint removal of splint, which which is important to reduce the health care cost and the burden on the family, usually very perverted function and return to sports earlier with the removal removable splint.
For greenstick fractures. And there is. There is a combined total cortical disruption with plastic deformation as per the previous drawing. If it's only pure bending forces, then the radius will break at the same level.
If there is rotational forces, then they will break at a different level when it's the same level. So when you reduce it, you reduce it using the 3 point fixation principle in a unilateral reduction. If it's different levels, then consider the direction of the apex. If its apex Voula, then reduce inflammation if it's apex door, suddenly reducing subordination.
Again, there is a debate whether the completed or not those who are with completing the fracture, it's for proper alignment and better colours, formation and fracture. The drawback is less structural stability fractures are common on most commonly fractured as well. There will be clinical and graphic deformity. Study studies has definitely shown that remodeling potential is good with both the radiation and no reduction has been attempted, even with no reduction has been attempted.
That's 2003 by 2 and Crawford 2012 and even blown in 1967. Barnett opposition can be accepted and patient age younger, usually than 10 years in the reduction we mold to maintain and maintain in a below elbow cost. We use the principles of the cost index, which is by choice for those who have or are not familiar with that.
So the cost index is defined as the measurement of the internal cost width on the lateral view and the internal cost width in the AP view. And this is expressed as a ratio and it would be OK as long as it's below one. And as the cars become more circular, so the lateral diameter approach approaches that the AP diameter and the cost index will be closer to 1 suspect as long as less that one.
It's good. There is good evidence that many, many displaced fracture in the metathesis treated by a simple splint similar to the buccal fracture. Still gives good functional and healing. Next, we talk about the metaphysical fracture when the fracture is not within the acceptable alignment with a closed reduction and again, the acceptable arrangement depends on age.
So those who are below 10 years, we accept less than 1 centimeter 15 to 20 degrees of angulation. Now we are in the metaphysical area and meditation of less than 40 45 degrees with the dorsal angulation of about 30 degrees. For those who are above 10 years, violent opposition is not acceptable. Angulation should be 10 degrees and specifically distal radius and ulna.
It should be less than 20 degrees, and for normal rotation, it's about 30 degrees. So the complication rates for the initial measurement with pain fixation appeared to be related to mainly to the potential loss of reduction, not depending. And there has been no change in the long term outcome. So that's why there is mounting evidence that simpler or simplified treatment of the distal rigor structure and currently we are running the EU and the UK the craft trial.
I know it's early, but there is some indication from early evidence that better results actually within the non operative arm are still running the trial. So don't say this now for the physeal fracture to go through its destroyed, the spices 90% of the growth happens in it. It has got a very good significant remodeling potential pure distal ulnar nerve. Their injuries are much less common, and it's most often associated with physical fractures of the distal radius.
One third of pediatric fractures occurring the distal radial vices usually consist of one can be certain enhanced type 2. You will know that due to normal X-rays and localized in the region, the distal radius half of those distal radial physical injuries will be associated with almost myeloid and physical injury of the ulnar nerve as well. If it's not displaced, then below elbows plant cost for about three, four weeks.
If it is displaced, then that five year fracture, then closed reduction. But this can cause risk of arrest even if there is residual angulation greater than 20 degrees. This will normalize subsequently as their Freiburg in 79 so the recommendation for reduction is according to the previous tolerances as we discussed it.
But basically avoid repeat. Repeated forcible and late attempts for zero risk may still occur, even if this had been because there has been enough compressive forces in danger, specifically in Slaughterhouse type 1. There is a very good and great potential of remodeling. Age at the time of the fracture has significant impact on the outcome. The closure of the distal radius plate occurs over a very short time, so less than one year.
So it's got something like a trampoline fracture. With this to reduce that, that's rare. But maybe worth mentioning. And I think that's the last fight, so we are doing fine, so Gagliardi fracture. Uh, the force here runs through the ulnar nerve side of the distal forearm with fracture of the distal radius and dislocation of the distribution a joint, it's frequently missed on the initial assessment.
But still there is good outcomes for at least for close treatment, even when recognized late as by the paper by April 2008. if we reduce the fracture of the radius accurately, then we expect the forearm to usually to fall in slap nation and reduction of the torn articular disc and ligaments, which will allow healing in their approximate position.
The triangle of cartilage is attached to the ulnar nerve deployed, and it can cause ulnar nerve third abortion. So if you see that, expect that the SEC has been injured with the terrible physical injury. So non-union workers, but this shouldn't be given a problem only if the patient has ongoing ulnar nerve sided chest pain after the structure of the distal radius then work out as a PT FCC.
I think that's it. For this part. And back to you for us. Brilliant, thank you very much. I look forward. Any questions from the audience? Yeah well, it's very, very comprehensive and focused. Lecture very thank you very much for the interest of time.
We will try to move on as quick as we can. There is one question came in across, which is very sensible question about what's the time span between fracture and manipulation? How long can you wait for before, you know? Well, I'm not sure. Are we talking about the Super popular fracture? No generally, with the physical fracture, with the physical fracture, the sooner the better as individuals in this law.
When is it? What is the timeline when you say manipulation now is going to cause more damage than good manipulation if it's delayed? Yeah what's the time frame for some? If it comes, I would say something more than a week, more than a week. And is that evidence or is it the experience bas status experience rather than evidence having gone through them preparing the slides?
I didn't really see any sort of like time. Every I mean, most of what's written in the literature say is chronic or delayed manipulation. But we don't know exactly the time span. Not not days. Not not like weeks. I couldn't see it, at least when I was preparing the lecture. Could I suggest that a test would be to take the back slap of the arm?
If it's mobile and painful, then it's easy to slip back into place if it's already solid. I think that's sensible. If it's still painful, it means Yes in mobile. It's not, I think, depends on the age of the child as well. Isn't the child of two years old might heal within a week or two? A child of 10 12 take longer. I think that's also another factor here.
Yeah, yeah, so I think that's probably why there is no hard evidence behind this, because I think it's quite complicated to not that I could see if anyone else have more sort of like literature experience. Let us know. So I think probably what exam answer, like I said, they'd probably be more on clinical grounds.
There is no exact number, but maybe on a clinical ground and clinical assessment of whether there is an established healing process has started. And or not? I think that's sensible if you remove the cost of the patient is still tender, should assume that is mobile still or you can try and reduce it. Yeah, there was one more question in the exam, if you ask, this is a week late and you are what would you do?
You will assess the patient, establish if there's any pain or discomfort with movement, but you will discuss this with the senior pediatric colleague. The reason why is pediatric colleague is the one that's going to deal with the complication later on. So you want to get their advice on what to do and then they say, OK, what would you do? And then you can decide whether you're going to need to go forward, do not trust me at a later stage or a corrective.
So it depends on what the injury is in terms of growth rate or its growth rate traject. I think that sense fun because, again, this is what the process of the Air Force is, so would do exactly like what you said. I will discuss that with the pediatric colleagues before doing or going further and then decide accordingly. Yeah, that's great. Thank you very much.
And one more question from AJ asked, which never injured in pll? I think I presume that positive lateral and medial superconductor humerus fractures. So I will. So the nerve, the nerve injured. So for the flexion type of fracture, it's usually ulnar nerve. Now for the extension type, it's usually the median nerve, commonly or most commonly is the anterior to OSHA's.
I'm going to answer a few questions asked me about distal radius and facial injuries. You have to remember that the ability for the bone to remodel is based on the range of motion and the direction of motion of the joints. So the majority of facial injuries are grossly dilated and there's a lot of movement in the wrist. So if you've missed the boat on a correction, as we've described, it's not necessarily the end of or a bad outcome for this child.
No, because there is still quite a significant correction left. Even if the child is close to the effusion, they will still be quite a significant correct correction. And then once they've finished going, let's say it's a 16 year old, they've got a year, maybe two years left in their growth or a 14-year-old year and two years left. Wait and see. And then you can do an osteotomy once, once the correction has stopped.
Was the remodeling stopped? Yeah, I think Sean kanata in 2003 has exactly written what you said is one of the lost points. So the greatest potential for remodeling is in the distal radius, and age and time of fracture has a significant impact on the outcome. So maybe this paper here, the Canada paper from 2003, might give some more shed some more light on this point.
Yeah, that's a good idea. I think it's a paper to have a look at, and it might give a little bit of backing and support for answers with this regard. I think that's probably definitely a level 8 kind of. Yeah, an answer. So that's a good one. That's brilliant. Thank you.
Thank you, guys. I think I'd like you to the cry tone. Yeah, I think that's very useful as well for the closure of the certification centers around the elbow. I think you guys can have a look at that as well. Again, later on, when you view the lectures I find for the interest of time will move on to the next part of.
This is the questions. Can you stop sharing? Yeah, that's fine. Can you see guys pull? No OK. How about now? Great so, guys, for all this watching. I'm not sure, so if all of you watching, I'm very sorry that the people who are live streaming are unable to see this.
This poll, this poll. The questions. There are three issues, please everyone who is attending. Please attempt to answer this. The answers will be anonymized, so we cannot identify who said what. So, OK, hold it. If you would like to go through the questions with us, please. All right.
So the first one was seven years old, who fell on a slide, fell off a slide. There is a fracture of the distal humerus. This is now will be or can be associated with a ground stop deformity because of one of the three options. Just let me get the options in front of me again. So the first option was Gartland type 2 with a lateral cortex impaction or guardian type 2 of the posterior lateral displacement of the fragment or government, up 3 with lateral intra articular involvement or garden type 2 with impaction of the medial cortex to the posterior medial displacement of the front.
And the right answer for this one is the medial cortex. Impaction and practice with medial cortex impaction tend to end up in a Mali United position and a Gulf stop deformity. And that's why it's recommended that for the four, most of those injuries to get X-rays of both hands in theater and make sure that you correct the Baumans angle to be similar on each side.
Unusual it's a very small union that causes this press. Good question, joy and question. So this was a hard question, this last one. It is, I think, only 27% answered correctly. Yeah, yeah, it was. But it's very important to look at the AP view, make sure that there is no medial cortex communication and interaction.
And if so, in your surgery, you need to look at major departments angle and try and sort of copy the other side to avoid the varus deformity. That's how you avoid it, and it's due to various reunion the most common. The second question is the most common complication of a lateral condyle fracture. Is it hubertus?
Whereas ulnar nerve claw palsy, which is tada ulnar nerve claw palsy osteonecrosis, occipital Volga or a lot of despair formation? The answer would be the lateral formation, which is the lateral protuberance that happens in about half of the cases. It's it has no functional disability and no surgical treatment is required. It was one question this past time that someone with the tada ulnar nerve we'll see.
Again, it's not the communists, the communists, actually the lateral spur formation. I think that's a wonderful question. I love this one valid because I think this is a very important skill in excuse. Yeah, it's not the one you hear a lot more about. Yeah, or the most significant read the question is the most common. And the most common come sometimes could be the most minor of the complications, not the one you all hear about and we have to deal with.
Yeah so please, guys, is a good example of how to actually read the question. Just asking you what's most common, not the most serious or most specifically for this exam, because you really need to do it fast? Yes, I think that's why some people come out of the M6 component of the exam thinking they've done well, but they actually have not really answered the correct question.
Here's the question, please. Is the elastic nails for the forearm? So whether a is radial entry at the fourth and fifth extensor compartment B diameter of the nail for each bone is 30% to 50% of diameter medullary canal proximal entry on the ulna or at the ulnar nerve ulnar nerve needs to be visualized indications field close reduction, re fracture, open fracture, lateral humeral fracture, unstable radial dislocation or all of the above.
So the answer is D actually were the indications are all the right things. The radial entry is not at the fourth and fifth extent, so you can either enter the radius, defer the first and second compartment between them, which is APL and CRL tendons or the second and third compartment is hip. That's if you are going three, but if you are going laterally, it's about two to 2 centimeters proximal to the distal radial bénéfices that's on the radius the diameter of the nail.
Put that one because they ask about the FEMA. It's about 30% to 40% But for the radius and ulna is different. Usually we use only one. So it's about 2/3 of the canal, 60% to 80% because actually both bones work as one bone with the interosseous membrane between them. So, um, so that one was wrong. It's not 30 50, it's about two thirds, or 60% to 80% and then there is a proximal injury of the ulnar, the ulnar nerve doesn't need to be visualized.
You go and you avoid the electron above offices and you will be away from the ulnar nerve. Indications are all right. Field growth reduction restructure, open fracture, axilo lateral humerus fracture, unstable radial dislocation. We use plates if it's severely comminuted. And microfracture or linked unstable fracture, all of the above is not because it's only one variant, only 9% for this one.
And do you think it's that difficult? I think to be honest, I don't think it's difficult, but when people. And I think it's a very good to demonstrate another skill in that time of stress. Yeah, Yeah. I think what you do in the exam as well in the exam, you get one and I have the maximum 1 and 1/2 minutes per question.
So but when people see all the above, they say that's the answer. Yeah and a lot of the time it is, but not every time. But that's why I specifically for this one, I went through all of them because you need to know the technique, even for you. If you do not. Normally you need to know where you're going and honestly where you're going.
And approximately, do I need to visualize the ulnar nerve medicolegal, you know, as long as you are away from the offices. It's an indication that you need to get them right when to use the plate, severe communication, severe displacement, basically length on a stable fracture. Otherwise, it's both the plates and elastic nails do the same, but the operative time for the elastic nerves is much shorter.
Yeah, thank you very much. Wonderful questions. Now we'll move on for the interest of time. We immediately to the vital questions.
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