Plenary session Module 1.4: promote understanding of modeling capacity Warm up cases: reevaluation of current treatment and knowledge Editors: Theddy Slongo, CH / Jon Dwyer, UK Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case! AOT Course—Managing Pediatric Musculoskeletal Injuries AOTrauma Pediatric Education Taskforce

Case 1 11-year-old boy, small stature; X-ray 6 weeks post injury! What will you recommend the parents? Wait and see, I am completely convinced that it will remodel within 6 months re-manipulation and some kind of fixation Wait and see but advise the parents there might be a requirement for future corrective osteotomy Faculty note: The purpose of this session: stimulate audience participation, revisit principles of growth and modelling Positive modeling factors: Age (growth remaining 5 years or more) Segment Location (rapidly growing physis) Modeling in the plane of deformity Note; the next slide asks for these responses  Discuss if the strategy was correct

Case 1 11-year-old boy, small stature; X-ray 6 weeks post injury! 6 weeks post injury 12 weeks 15 months Faculty note: The purpose of this session: stimulate audience participation, revisit principles of growth and modelling Positive modeling factors: Age (growth remaining 5 years or more) Segment Location (rapidly growing physis) Modeling in the plane of deformity Note; the next slide asks for these responses  Discuss if the strategy was correct

Why did this deformity correct so well? Case 1 11-year-old boy, small stature; X-ray 6 weeks post injury! At 15 months Why did this deformity correct so well? What are the important factors that influence the ability for modeling? Faculty note: Positive modeling factors: Age (growth remaining 5 years or more) Segment Location (rapidly growing physis) Modeling in the plane of joint motion

Case 2 What do you say to the parents next morning? 11-year-old boy, normal stature; injury film; no nerve injury Treatment; plaster cast splint, no active reduction What do you say to the parents next morning? This is a simple fracture; at this level we expect full modeling We should reduce and fix this fracture Wait and see but advise the parents there might be a requirement for future corrective osteotomy Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case! modeling factors: Age (growth remaining 5 years or more) Segment Location Modeling in the plane of joint motion Pediatric

Case 1 11-year-old boy, small stature; X-ray 6 weeks post injury! Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case! Why modeling is different? modeling factors: Age (growth remaining 5 years or more) Segment Location Modeling in the plane of joint motion the majority of axis realignment occures at the epiphysis ( only 25% in the diaphysis) 8 weeks post injury 12 weeks

Case 1 11-year-old boy, small stature; X-ray 6 weeks post injury! 27 months Would you recommend the same management? Yes No Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case! Why modeling is different? modeling factors: Age (growth remaining 5 years or more) Segment Location Modeling in the plane of joint motion the majority of axis realignment occures at the epiphysis ( only 25% in the diaphysis)

Case 3 2-year-old girl, normal stature; injury film; no other lesions Treatment; over head traction no active reduction What will you recommend? This is a simple fracture; at this level we expect full modeling We should reduce and fix this fracture Wait and see but advise the parents there might be a requirement for future corrective osteotomy Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case! modeling factors: Age (growth remaining 5 years or more) Segment Location Modeling in the plane of joint motion the majority of axis realignment occures at the epiphysis ( only 25% in the diaphysis) 

Case 3 2-year-old girl, normal stature; injury film; no other lesions Treatment; over head traction no active reduction 4 weeks post injury What will you recommend now? This healing is satisfactory The patient is now free to mobilize Continuing immobilization for 2 more weeks Wait and see but advise the parents there might be a requirement for future corrective osteotomy Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case! modeling factors: Age (growth remaining 5 years or more) Segment Location Modeling in the plane of joint motion the majority of axis realignment occures at the epiphysis ( only 25% in the diaphysis) 

Case 3 2-year-old girl, normal stature; injury film; no other lesions Treatment; over head traction no active reduction Follow up: 3 months  1 year Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case! Why modeling is different? modeling factors: Age (growth remaining 5 years or more) Segment Location Modeling in the plane of joint motion  Discuss how to manage rotation

Summary Good remodeling potential in a 2y old Case 3 Good remodeling potential in a 2y old Can accept some angulation and translation Should maintain proper rotation Slight shortening is acceptable in this age group Faculty note: Give a short summary of this case why we see such a good modeling and referring to the lecture about modeling

Case 4 10-year-old boy, fall from a tree What will you recommend? This is a simple fracture; at this level we expect full modeling We should reduce and fix this fracture Wait and see but advise the parents there might be a requirement for future corrective osteotomy Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case!  Why modeling is different?

Case 4 10-year-old boy, fall from a tree Are you happy with this? Faculty note: The purpose of this session is to reevaluate the existing knowledge of the important principles of managing fractures in children as compared to adults at the end of the module. Ask the participants to revote. Compare the initial voting with the new voting You have now a short time to discuss the case!  Why modeling is different? This is a metaphyseal fracture close to a slow growing physis Discuss which plane must be perfect reduced Advice: the sagittal offset greater than varus/valgus Rotation doesn't models Be aware of combinations of angulation with rotation Medial- lateral view Anterior-posterior view Lateral –medial view

Case 4 10-year-old boy, fall from a tree Faculty note: This is an example of a deformity that cannot completely model Be aware of combinations of angulation with rotation