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The Notes orthopedic teaching series. Uh And today we've been uh we've been joined um by Doctor Drummond who is an ST four registrar on festival po rotation in London. Uh and Doctor Doctor Jones who's an ST three registrar on the road London rotation. Um So thank you. Thanks a lot for being uh so charitable with your time. Um And yeah, that's crack on. Thank you or not. No. Yeah, we can, we can see it, we can see it. Yeah, perfect. Yeah. Yeah, we're in. Ok. Um So yeah, so I'm Izzy and Neil will take over shortly. Um So we're both registrars in London. Um And we're, we've been given the topic of orthopedic emergencies. So we're doing a whistle stop tour of the main topics um including a general trauma, patient, um open fractures, acute compartment syndrome, dislocations, neurovascular injuries, septic joints, and coral equina. So we're sort of running it at sort of a few cases, talking through some of our experiences and hopefully get some learning. Um Don't hesitate if you've got any questions, just let us know and we can answer them. Um as we go. Ok, so off you go now Yeah, perfect, thanks. Um The first thing I would say is um is that I've just thought of is, can you not take photos of some of these pictures? Cos a lot of these are from what me, me and I you've seen over the last two or three years at Rule London. Um And yeah, it shouldn't really be become in kind of anyone notes just for kind of patient identification purposes. Um And secondly, if you've got any questions, just shout at me, um flag me down and, and, and ask them during the talk cos it's probably best we get them ironed out during the talk, then wait till the end and have to go back. So I'm more than happy to be shouted out, put your hand up, do anything um just to stop us on the way through. Um So the first thing I'm gonna talk about is a really common, first of all, a really common ST three interview question. Um And also something that um I think a lot of medical students struggle to get some exposure to um and particularly in an orthopedic sense understanding where we fit in, in a kind of trauma called a trauma analysis situation. Um And exactly what we're looking for when we see the patients that come in. Um So in terms of a case to kick us off, um let's just imagine we've got a trauma call for a second. Um You're working at the Royal London. It's in a major trauma center. Um, they do trauma calls very well, day in day out, probably on average between five and, and 15. Um, a day. It's a young male that's been brought in, um, by the hem. So by the, the helicopter they've been in a road traffic accident about 50 miles an hour and as the patient arrives, um, you're handed over by the crew that they've got a heart rate of 100 and 20 beats for a minute. The BPS down at 85/56 the resp S are at 22 and a temperature of 36.4. So immediately, obviously, the whole trauma team are thinking that this is someone who's potentially in shock, um, next sliders and we're always thinking about these five things. Now, any of you who have done, who've been very keen as a medical student and either uh volunteered or participated in a uh ATL S courses will understand that these are the life threatening injuries. Now, in truth, these are normally dealt with prehospital, ok. The guys are so good on the chopper and the ambulances at seeing these things and identifying. Um, and at least giving a clue when they, when they hit the, the rhesus bay that these are the things that they're worried about. Um, as an orthopedic surgeon. Again, we won't particularly, I'm not gonna spend too long on this because it's not really our, our game Alright. At this point, we're letting the trauma team carry on with what they're doing with a patient who clearly, er, is potentially an extremist, particularly with a young patient that has um, er, parameters that are atypical. Ok. Now, in terms of ATL S, we're gonna follow our set pathway to try and pick up these, these, er, life threatening injuries or these immediately life threatening injuries. Um, so catastrophic bleeding comes to mind but then we go straight to airway and C spine protection. Er, and then B CDE as you probably will all have heard of. But again, ok, in, particularly in the Royal London Hospital, this isn't massively the orthopedic surgeons emphasis. Now this isn't to say that they don't have a place and when you're in sho you will be looking at these things and you will be examining them, of course, you will, but in terms of an orthopedic, er, thought process, ok. I want all of these things to be done and I want all of these things to be ticked off before I start thinking to myself. Ok. Is there anything underlying here that I need to be interested in? Ok. In truth, in actual truth, I know that all of these are gonna be done by the ED team and the general surgery team. Ok. And when that patient comes in, I'm thinking, can I see any limbs that are threatened? Can I see any injuries that are obvious for me? That I need to be thinking about. And that's the beauty of the trauma scenario. You've got every, every single person with a slightly different slant on what's going on. Your ed people are, are, are concentrating on keeping them alive. I'm thinking about, uh obviously keeping them alive. But what, what, what is it that I need to focus on in the future? Next slide is so you've got, you will, you, you know, sometimes you've got distracting injuries and I put this slide in. This is a case I had two weeks ago on the right hand side of a, a chap that had been um, under a train and auto amputated his right foot. That's a metatarsal. You can see the head of um, and these will be distracting. Now, in truth, in absolute truth, these aren't what's gonna kill you. Ok? Um, an auto amputated foot. Yeah, it's gonna bleed but you put, you put a tourniquet on that. It's not gonna, it's not gonna kill you. You will arrest the bleeding. Yes, they need to go to the theater. But is it gonna immediately kill you? No. Ok. Similarly, this is a on the left. We'll come back to this. I think it's later on in the talk as well. Um But if you've got a vascular injury in the femur, yeah, your femur is gonna swell up and you're gonna, and you're gonna lose a lot of blood, but that will tamper hard. Ok. Providing it's not open and again, it's unlikely to kill you given the measures that Ed can put in place. Now, next slide is so what we're really talking about when someone comes in in shock, particularly in the context of trauma is hypovolemic shock. OK. They're losing blood from somewhere. Um And there are other, other types of shock are available. Um But in, particularly in the context of trauma, this isn't what we're talking about. We're taught, we will always bang on about hypovolemic shock. Ok. So the the fluid is coming out. Um There is, there's not enough fluid left in the vascular. So it's, it's escaping from somewhere and you've heard of four and, and, and one more on the floor. Um And this very much, this picture very much encapsulates that point of view. Ok. So is this something in the thorax? Now, if it's something in the thorax again, ed will pick this up, your, your primary survey should pick this up. Um And particularly they do quite a lot of chest x rays on the recess bay if they worried about a Thora Thora thoracal injury, peritoneal cavity. Again, general surgery are here. Um We can get them through ATC CT scanner. Again, that isn't my focus particularly but retroperitoneal spaces. Ok. Retroperitoneal space and, and pelvic spaces, muscle or subcutaneous tissue. Yep, long, long bone fractures and external hemorrhage being the one on the floor. But again, the things that are gonna kill you are 12 and three normally. Ok. These are the things where you can lose massive amount of volumes of blood and no one understands why, um, the patient doesn't get better and you end up having to do something, which we'll talk about in a little bit next slide. So, in orthopedics, we're normally talking about pelvic fractures, ok. Patients that are hypovolemic that are shocked on the trauma rhesus bay, either as I've mentioned have long bone fractures, but the main, the main killer, the main thing that we're worried about is is this, is this a pelvic injury, is this a pelvic ring injury which is caused bleeding, which is bleeding into the pelvis, OK? Which is bleeding into that retroperitoneal space, it's bleeding into the intrapelvic space. And I put some CT images here of a patient that we had the other day, a young patient, 17 year old male come off a motorbike having hit a stationary car. This was about 3 a.m. got transferred from south end. Um And can you, you probably can't see my mouse, can you? No, no. Um On the top right image, uh you can see there's an acetabular fracture. Um And the top right image actually really nicely shows uh a displaced pubic symphysis. OK. So there's diastasis of there would be diastasis of the pubic symphysis have something not have happened, which I'll mention in a second on the, on the image next to that you've got an acetabular fracture, the image on the bottom left, you can see the propagation of the acetabular fracture. And the I put the um I put the, the um the scout imaging just to um just to prove to you how misleading these scout images can be. OK? They're not an X ray. And if you glanced at that X ray and if we had x-rayed him, perhaps it wouldn't have, it wouldn't have appeared quite as bad as it is on the CT. It's just something to bear in mind. Next slide is, and what are our actions gonna try and prevent? Ok, this patient's come in with a pelvis fracture or a suspected pelvis fracture at this point. Um And they've got the parameters as shown before. So what is the whole trauma team trying to avoid? Well, this is the, this is what's the triad of death or doom depending on which, which reference you look at. Um And this is what, what we're trying to, what it's what everything is trying to stop happening. And if it continues to happen, we have to have some sort of bailout, some sort of definitive management management that we turn to. So, coag coagulopathy. Well, if we're bleeding from somewhere and we're coagulopathic, we've lost clotting factors, we've lost fibrin, we've lost all of these things which help us seal off clots, then clearly, we're not gonna be able to clot and we're gonna carry on bleeding hypothermia, a lot of those clotting factors and a lot of the process that causes our clotting in the body is caused um by enzymes. And if the enzymes are cold, they don't work as well. We carry on bleeding, a metabolic acidosis, a metabolic acidosis, similar sort of vein stops, enzyme working and also gives us uh a pointer uh and gives us a lead as to how well we're perfusing our tissues in terms of lactate. Next slide, please. So these are our goals. We're gonna try and not do anything that we don't need to do. Um And, and we're gonna try and control that bleeding again. We know where the bleeding has come from. We suspect where the bleeding has come from. We think we've got a pelvis fracture. We're gonna try and somehow do things which stop that or promote hemostasis and restore perfusion. So all of these things are in aid of reversing or limiting that triad of doing that. I previously mentioned. Next five, please. Yeah. So, so what we're gonna do what you as the orthopedic surgeon? Ok. So they turn around to me and they say nil we think we, we think this is a pelvis fracture. Ok? They've, they've come in, we've, we've cleared the chest, we've cleared the abdomen, there's no pain there. The patient might be semiconscious or even sometimes tubed. Um But there's a lot of swelling around the pelvis. There may or may be even external signs that there's a pelvis injury and this patient's, er, parameters aren't improving, there's no other injuries, there's no distracting injuries. So, what are we gonna do? Well, the first thing is to say that we should have given tranexamic acid and in reality, this is given prehospital, um, and then we give her for 1 g and then we normally give another gram on arrival. If we're worried about that they're bleeding, you might have heard about the crash two trial. Don't worry if you haven't. Um, it's quite hard to know which level to pitch in my talk at the moment. I mean, just come through interviews. Um, but essentially, um TX A has been proven to improve outcomes in those trauma patients which are bleeding. Um, they should have a pelvic binder. Now, a pelvic binder is a hemostatic agent. Um A lot of people think it's an orthopedic kind of reduction tool for pelvic fractures. Ok? It's not, it's actually to control bleeding. Um, a lot of studies they did some studies on cadavers where they put the pelvic binder on and they, they, they, er, measured the intrapelvic pressure, ok? If you've got a CVP, so central venous pressure, so your blood return. In fact, I might come onto this in a sec. Yeah, I'll come onto this in a sec. You're gonna put a pelvic binder on to try and stop the bleeding. Ok? Er, you're gonna initiate a transfusion protocol. Hospitals are very good at this. Now, they will get e blood to you very quickly. Um in order to, to administer that normally through what's called a Belmont administrator. But the point is it goes through something that keeps it warm. Ok. So you're pump, pumping blood into this patient. That's not just fluid because blood has clotting factors and all the other goodness that's gonna keep you clotting. But you're gonna give the transfusion protocol and you're gonna give it warm so that you don't end up with a hypothalmic patient. And the other thing to mention is you're gonna control BP. Now, this used to be called permissive hypotension. Um The only reason I say that is, it gives you a good idea of what we're doing nowadays, it's called damage control resuscitation, which essentially means your top end. So you're anesthetist is keeping your BP about 90 systolic. It's not maintainable. Ok? Because your kidney perfusion is, is inadequate long term at that pressure. But for the two hours that you need to obviously save that patient's life, it's adequate and clearly, as I said, as I mentioned, you're gonna keep them warm because all of these things are trying to avoid that triad of doom and then you're gonna monitor them. Well, obviously, you're gonna monitor the hemodynamic status and the response to any fluids that you're giving, you're gonna monitor the temperature lactate massive indicator and used widely across er, resource um as a marker of perfusion. Ok. Not perfusing your tissues, anaerobic respiration lactate goes up. Um It's a, it's a really good marker of how well you're getting on and we'll often take serial lactates having given transfusions to see if we're winning and to see how, how the patient is progressing. Your lactate goes 23456. You're not getting a grip of the situation. Your lactate goes from 4 to 2 in an hour time. OK. Fine. We might be winning and we don't need to do anything drastic. Next scan, next um slide. No, you just got a question. Sorry. Yeah. Um Hello. Yeah. Um I just wanted to ask, how would you balance promote hemostasis with preventing an embolism from happening? How do you balance, say that again? Promoting hemostasis? Well. Oh OK. OK. So, so over clotting. Uh Yes. Yeah. Yeah. Yeah. OK. So normally in hypovolemic patients particularly shocked hyperemic hypovolemic trauma. Um they are by definition uh clotting factor and enzyme deficient. OK. So you're, you're coming from a position of relative deficiency. How do you not swing the other way? Well, there's a, the main thing that they use in research at the moment. OK. Fir first things first, the the point is to the goal of all of this is to save the patient's life. OK. So if you throw off an embolus, having done that, then actually that's accepted as a as a risk of doing what we're doing to save that patient's life. Ok. So that's the first thing. So, first of all, you can't completely control it. But the, but the emphasis is on obviously keeping the pe person with a pulse. Yeah. The second thing is, um, there's a, um, there's a test now that, that's in the MTC s called ROM which stands for is, um, it's so it's ii can't remember what it actually sounds for, but it measures, it measures the amount of clotting you can do. And so basically, basically what it does, right is it puts your blood, imagine your blood in a little beaker. And then it has what looks like a, a lollipop stick. OK? And it, it's, it turns a lollipop stick in the beaker of blood and how quickly your blood clots affects how much that lollipop stick is deflected out of the normal circle. That makes sense. Yeah. So if you've got, if your blood thickens in 30 seconds, OK, then on your Rotem graph, it prints you out, chart your graph will look a certain way. OK? Depending on when your blood thickened, how thick it got. And whether it stayed thick, your blood will in a normal person's blood, it will clearly thicken and stay thick because you form the clot and you've maintained the clot in people that are enzyme deficient and clotting factor deficient. You may have someone who takes much, much, much, much longer the clo uh But then the clot's maintained, OK, which is kind of ok. Now, the coag coagulopathy that we wanna, uh, avoid in trauma is one, it's called, um, it's called the Puffer Fish of death just because it, what it looks like on the graph and basically what you have is blood which clots and clots a little bit and kind of carries on and carries on. But then think, uh, I've not got enough stuff, I've not got enough fibrin, I've not got enough factors. I don't have enough um of all of those things and it basically just disintegrates again. Ok. So in that blood, you're never gonna form a clot. Now, how does this help us in terms of making sure we don't over coagulate? Clearly, it gives us an indication, right? If someone's, if someone's suddenly gone from, from not doing any of that to, to normal blood, then we can stop our transfusion. Ok? We can stop our replacement and we can make make sure that we're getting source control and we're doing all of the things here to try and make sure that we're stopping the bleeding. Yeah. Does that make sense? Is that, that does? Thank you so much. But the it tells you what um different um elements of the blood that you still need. So if it's, if it's this type of graft, you can give more fibrinogen. If it's this type of graft, you need more platelets and things like that. So then you can, you can work out what they still need to, to make sure that they uh resuscitate it in the right way. Yeah, it's quite impressive when you see you. It's good uh roten uh or something, something um Thromboelastometry just to let you know. Thank you. It's gotta be rotational or something or other, something like that. Yeah. Yeah, it might even be ro rotation anyway. Um So again, go, so coming back to a pelvic patient, you've done all of the things I've mentioned. Um and they're inos and normally OK, nine times out of 10, they will get better having done all of these things. OK? And that's because nine times out of 10 90% of pelvic bleeding is venous. So it's from the venous plexus that lies just anterior to the sacrum. And as I nearly started saying earlier, but I thought I'd say it now because it makes slightly more sense. Your pelvic binder can exert a, go back your pelvic binder can exert a, an intrapelvic pressure of about 20 mg millimeters of mercury. Now, your CVP range is, I mean, this is going back a few years, but I think CVP is around 13 to 15. So if you raise your intrapelvic pressure to about 20 you're gonna tampon on whatever p whatever venous ooze is going on. Yeah. Um We all know that venous oozing is also not as um not as high pressured, not as swift and therefore, if you form a clot, if you get to a point at which you can form a clot and this is another reason for keeping your systolic BP at 90. The chances of you blowing off that clot are much lower in the venous system. Ok. Um Cool. So what if you've done all of that and the, your patient's still bleeding? So you're now looking at an arterial bleed, you've got an arterial bleed on your hands and the mainstay of treatment is pelvic packing or angiographic embolization. And you can go to either you sorry, you can go to pelvic packing if you don't have act scan. If you've got a patient that is just really, you know, on the verge, you can't even get them through a scanner. They will go for pelvic packing if you've got them through a scanner and you've got them through ATC T scan. And that's a totally, um that's a totally clinician led judgment call, ok? Um It's not my judgment call to make, it's my bosses, judgment call to make. Ok. So all of the ed bosses, not all of them, obviously, sorry, but the Ed boss, the orthopedic consultant, the general surgeon will say, look, this is, this person is too extremist, they're going to theater. But the two main mode again, I don't think I've ever seen that happen. Um because normally we can, we can normalize them through or we can resuscitate them well enough with our, with the, the previous outline um, and we can get them through a scanner. So you've got them through a scanner and you've got your blush, you've got where they're bleeding from. And the choice between pelvic packing if you've got a scan is largely institutional. Ok. It's quite, um, it's quite place specific. And here the Rule London, we do quite a lot of angiographic embolization with, er, in comparison to pelvic packing. And that's because we have the resources, we have the people that are keen about it. Um And we have the labs that are readily available and quite well kitted out um pelvic packing. Actually, I'll talk about that in a sec um embolization can be selective or nonselective. OK. So you can either embolize specifically the um inferior gluteal artery, OK. Or you can be nonselective uh and you can embolize the internal iliac artery clearly selective um is better for the patient and better for long term. Um But nonselective, you know, if necessary uh needs to happen, particularly if you've got um a fracture that that's, that's rod with multiple branches of, of the internal um next slide. So, pelvic packing and this is just to give you an idea of the kind of space that I'm talking about on the left hand side is, is an image of the, that's the peritoneum being held up. Um This is a cadaver. Um But then if you reflect the peritoneum in this middle image that all of that space under there is the, is the pelvic brim. So that's actually the, that's the iliac crest you can see right in the middle, the kind of white structure and all of that space can fill with blood. And that's why. And if you imagine that pushes the peritoneum up, peritoneum's relatively um relatively mobile, particularly at the back ie the retroperitoneal space. And you could just fill that with loads and loads of blood without realizing um next slide. And this is just a very quick flow diagram to recap what we've just discussed. So if we start at a, at the top, someone come, I just realized I've got a theater ha on, sorry. Um look like some kind of um Grey's anatomy, whatever we um the, if you, if we start at the top with a OK, you've got a trauma evaluation, you'll get an X ray, you'll get a scan if you can. Um But all of those things I've talked about will, will, will be initiated and if you've got a hemody dyn er hemodynamically stable patient, um you can get them through the scanner, you can get them into CT. And if there's no pelvic blush, you can get them upstairs and you can discuss them with your pelvic surgeon in the morning as to how you're gonna manage them if they are hemodynamically um stable, but you can see a blot on the CT, then that's a conversation with the um with particularly the um, interventional radiologist to see if there's that, it's something that they're interested in and they wanna go after. Normally, if you've got a fairly well patient and it's a very minor blush, they'll sit on it. But if it's anything major, they may well go in and stabilize it. Um, a non hemodynamically stable patient, um, where you're gonna initiate that transfusion protocol and do all the things I've talked about. Um, I want you to ignore for the time being pelvic stabilization because no one goes straight to the theater. Um But what they do go for as I've, as I've mentioned is about is um is pelvic packing um or to er angiography and embolization? All right. Um Does anyone have any quest? I think that's the last slide on this bit. Yeah. Go, go to the neck. Is it last line? I think it is. Last question quickly. Yeah, definitely. You, you said it pelvic stabilization. So sorry if this is um bringing it back round to pelvic stabilization. Yeah. The role of like an external fixator in pelvic injuries. Would you do that at the same time as, as peritoneal packing or is that something that's not really involved in acute trauma? Yeah. It's a good question. And actually um I recently did some interviews of uses for some of some of the reg jobs here and a lot. They use it a lot in the Middle East. OK. The Middle East are still fascinated by, by, by pelvic external fixators. We honestly, they've, they've not done one in three years have been here, ok. We just don't use them that, that much in the UK. And that's because they bring with them, um, a real morbidity risk, ok? You're firing screws into it into big structures and they've got to be big pins. Um, and secondly, invariably you, you get in the, you get in the way of, of someone who's trying to do the pelvic packing, OK? Um And they take time to put on time that you just don't have in this scenario. So, the thinking now particularly in the UK is that, um as I say, we've come well away from external fixation. Um and you either pack against a um binder. So when they go for packing, I didn't mention that when they go for packing the binder stays on because if you've got an un unstable pelvic ring fracture and you start lobbing massive, you know, er, swabs into the pelvic cavity, all you do is just, is just spread the pelvis wider and wider and wider and wider and wider and you don't get any hemostasis or any uh tampered artifact at all. Um So you either pack against the, er, a binder and then either rook within 24 hours or establish a source of bleeding intraoperatively and, and solve it. Um or you go straight to embolization the, the, the, the way the, when, when you would need an X fix is if there's a, an open wound or something like that where you put the pelvic binder, the pelvic binder is a lot more efficient than an X fix. Cos the XVI you're only fixing in two places in one dimension. So there's, it's not actually that stable. Um So that's, that's a pelvic binder actually hugs, hugs the whole um pelvis together. So it's, yeah, it, that is the tampon effect. So actually it works a lot better than an X fix. And what we, we end up actually trying to take them to theater probably within 24 hours to check out where it's still bleeding after we've packed a pelvis to see if it's still bleeding. And that's when we can start thinking about something more stable, like er actually fixing it with an orif or um a plate or something like that to the stability. And these fact they like these are, these are urgent cases, right? So they will go back to theater within 24 48 hours at which point if they've stopped bleeding and everyone's happy, then your pelvic surgeon will definitively fix it because that's what's best. Um It's not, you know, it doesn't have the advantage that say lower limb external fixators have in that you can temporize a situation, you know, let soft tissues settle or declare because, well, that's irrelevant. Ok, you just need to fix it and get them closed. Sure. Well, Thank you. Cool, cool. So I'm in charge of case two and this is actually one of my patients also from the Royal London from a few years ago. Um So this is a 23 year old. This is actually a male ii finally found the images today. Um And they got in a fight and they were hit with a metal bar and then dragged through their back garden. Um So this was the injury on presentation and I found out that all that dirt in that wound was actually dog feces. OK. So that was act scan. We don't actually have any X rays from when they first came in. So from here, we made the decision. This was at three o'clock in the morning, we need to take them straight to theater because poo in a wound is obviously not great. So we took them straight to theater. We did a wash out and debridement. So this is the debridement. Um After we've spent about 45 minutes to an hour trying to clear out all of that rubbish and to stabilize the fracture, we decided to put an X fix on. This is not the X fix we put on because I don't have any images of that, but that's similar to what we would have done. And then this is the intra op images to make sure that the fracturable nicely reduced from there. Um The next plan for these kind of injuries open fractures is to work out how we're gonna stabilize this more, um permanently. Um Now this ended up, there's, we ended up taking this back to theater after 48 hours for a further wash out because we knew there was gonna be more dirt inside. And so from that, we ended up doing, I think over 20 operations on this, this guy. So the one on the left is, um, we, he's still in an X fix there, but we've ended up actually taking out half that bone because most of the bone had died. But all it was contaminated with this feces. So we had to remove all the dead bone. We had to remove all the dirty bone and removed all the um bad tissues around that area as well. And we had to do that about five times before we thought it was gonna be good enough to actually, we, we're back to healthy tissue and healthy bone. So in the middle here, you see, there's this, there's a little um stick and this um block and that's a cement um spacer which has got antibiotic, antibiotics in it. And that meant we could actually close the wound over the top, but actually keep it all sterile inside. So after that, we, we knew we weren't gonna have to be, we weren't gonna be able to put a plate on this because of um chance of infection. We weren't gonna be able to put a, a nail down the middle of the femur, uh, sorry, er, Tibia, um, which was how we would normally fix this if it was a closed injury. Um, so we ended up speaking to our limb recon team who put on a special circular frame and you might have seen these in some of your clinics, I'm not sure if you would have seen them, um, or you might have seen them uh, with people on the, on the street, they often like showing these off. Um So a circular frame is, it is a sort of a mode of external fixator. Um But we can um manipulate the bone at the same time and we can use it to grow new bone. So if you see here that this is the cement space is still here, but they've put a um they've done an osteotomy here down here, which is basically breaking the bone and then bit by bit, they move this bit of real bone slowly up and up and up and behind it is left new fresh bone. So we're actually growing the bone newly from this fresh bit of bone and we join this bit up to here. So you see here, we've, we've removed the cement spacer and it's slowly slowly getting distracted up this way. So we're slowly growing the bone, there's a bit of callus there which shows a bit of bone now bring that to there. And this is the final result which was taken, I think last in the last um year. So this has taken 22 years to grow. So we've taken off the uh the um the circular frame and you can see that this is now all solid bone. We ended up having to do a um I think we did this on purpose just so that um we could lengthen the um the bone, but that is, you can walk on that now and it's a pretty solid bone, ok? So this is obviously an open fracture and an open fracture is an injury where the fractured bone um is exposed to the external environment. Um which means that there's a higher chance of getting bacteria into there, ok. So it's, it is a orthopedic emergency and it does need treatment urgently. Um These are often high, high energy injuries as you can imagine and you need a lot of energy to try and get to break a bone in the first place, but to displace it enough to push it through the skin. Um It's often high energy especially in young patients. So we classify open fractures with the Gillo Anderson classification. You don't need to know it at your level. But um we it's 1 to 3 type one, sort of very small puncture wounds, type two are slightly bigger wounds um but doesn't, but the vascular supply is ok. Um And you know, we're likely to be able to close the skin directly um type three is where there's a, there's a bigger trauma, there might be some contamination and the bone, the, the periosteum is how the bone gets um its blood supply and it means that the blood supply is might have been disrupted. So there might be some dead bone in there. Uh Three B is where we're gonna get the plastics team involved because um the there's too much soft tissue injury and type three C is where there's an arterial injury. So we're gonna have to get the vascular supply. So as you can imagine, these kind of injuries need to go to a major trauma center where you have all those specialties and we will work together to treat um these patients. So the main, the, the biggest um impact with um open fractures is giving antibiotics within the first hour. So here we've got, we've got to fight the bacteria as soon as possible. And nowadays, especially in London, they do give the antibiotics with the hens team or with the paramedics. Um So actually the infection rate has significantly improved. Um Second of all, we're the, it's mainly the long bones that we're concerned about about. So it's the um the forearm bones, the humerus, femur tibia and fibula are the ones that we really get worried about. And those are the ones that need to go to the trauma centers in A&E itself. Um It's the orthopedics team to, to um manage these and we have to make sure there's no big debris in there so often they've been, there's a car crash or someone's cycled into a, a ditch or something like that. So they're quite nasty, dirty injuries. So we have to clear anything. Uh, big, so big. Um, er, bits of concrete. I've, I've pulled, um, grass mud, all sorts, you name it. Um, yeah, out of, er, wounds, we always take photos of these, which is why there are so many photos around and that's because once we've dressed it, we don't want to keep undressing it. So we can, but from those photos, we can make a management plan. So we, we get the plastic team involved and they can then work out where they're gonna get, whether they think they can close the skin directly or whether they're gonna have to manipulate some other skin, whether it's a flap from a, er, a close area or whether they're gonna have to make af, er, bring a flap. So a mus cutaneous flap from somewhere else. So they can take, there's different areas in the body where we take flaps from, to cover the, the skin, we always dress it with saline. So it goes and that, so it doesn't dry out. Um, and then it is a fracture so we have to reduce it and immobilize it and this is always harder when there's lots of blood around, um, because everything gets a bit slippery. Um, so you it is, it's hard, it's a lot harder to do, um, reductions with open fractures, but they do need to be done. Um, and then they're treated in a back slab. These are the kind of injuries that always need to get escalated early to your bosses, your registrars. Um, because these are ones that might need to go to the theater, er, quicker, but they're also more likely to have a neurovascular injury, which we're gonna cover later. So the ones that need to go straight to theater are the ones with that fallen in the water. So we've had a guy that, um, got run. He, I think he was on a tractor lawnmower by the edge of a river. He managed to f, er, capsize the tractor lawnmower, er, break his leg open fracture and fell into the, um, the Thames. Um, and as you know, the Thames is not very, er, clean. So he had to go straight to theater, then we had sewage farm yard. So they all need to go straight. Then we've got the high energy injuries. So the road traffic accidents, the cycling accidents, er, falling from a heart la large height. Um, they all need to go to theater within the 1st 12 hours. Um, we always have to communicate with the plastics team because we need to, ideally close all these wounds within 72 hours. That is the, that's our, the main aim of, um, the treatment and once that's closed, then it reduces the chance of infection. Um So once we've done the A&E management, the next plan is how do we fix these? And it really does depend on the fracture pattern. The type of patient um cos if they're a smoker, if they're old frail, they've got poor vascular supply. So then we normally end up doing like an angiogram um similar to some of the images you've already seen to work out whether they do have a good blood supply and whether we can use their local blood supply to make sure that we've got coverage of the bone. Um So, um here, as you can see, we've got an open fracture here. It's a nasty fracture. So initially, here it was stabilized with an X fix. Um We try and keep these X fixes out of the way of um where we're gonna f er permanently fix it. So, um so yeah, so we kept sort of the construct away from the zone of injury and then what's happened? Why, why did it have an X fix is just to explain why that had an X fix first. So, so first of all, we need to stabilize it, but we also need to. So what we do is um we stabilize it and then we can scan it. So then we can work out where all the fractures are, how we're gonna fix it orthopedically. But then we can also get the plastics team involved to work out. And the, that's when we do the angiogram to work out what vessels and um blood supplies we've got available so that we can cover the soft uh the bone such as here. So here we've got medial gastrocnemius flap covering the bone. So at least the bone doesn't get infected because chronic osteomyelitis in the, in the tibia is a bad, bad ending to this. And we don't want to put fixation in a wound that's open, right? So, so there's no point you, you don't wanna put a tibial nail or put a plate and screws or anything in a wound. Yeah. Or, or on a bone, sorry, and then leave the wound open. Ok? Bugs love metal. They'll stick to it like glue. So there's absolutely no value in putting metal in something and leaving the wounds open. Ok? So in that scenario, if you can't close the wounds and plastic say, no, we, we don't have time to do a flap because they take 10 billion hours. Cos they whack their microscope out and fanny around for ages. Um Then we'll put an X fix on it. We'll cover the wound, we'll put a vac dressing on it, which is a neg negative pressure dressing that sits on top of the wound and come back to it another day. Ok? But there's no value input in any metalwork near that whatsoever. That's gonna stay in there forever because it will just get infected. Yeah. So we, we can easily treat soft tissue infections but treating bone infections is a lot harder. So we don't mind that the local the the skin gets infected, but we need to try and cover that bone as soon as possible. So, as you can see here, this was fixed with a plate. Um and this is the outcome. So actually, it's not bad considering what it looked like initially and then this is what the um the circular frames are like um that I described earlier. So here we've got an open fracture over here, but there was no good blood supply to this area. So they've used a flap from the other side and they've put a star where the blood supply where one of the perforating arteries is on the other side. So then they're gonna plumb that in to the other side if that makes. So, yeah. So basically we work, work with the plastics team with a vascular team to work out how to fix these kind of fractures, um complications with open fractures, wound infections. A bad one as, as we I've said, um once the, once the bacteria gets into the bone, it's bad times we end up having to chop out all of that bone. And as you can see here, there's osteomyelitis all the way down this, er oops, sorry. Um all the way down that um tibia. Um So it, and it's very hard to manage. Um So most of that will have to be excised and then from there you end up having either amputations, um, or, or different types of, um, um, oh, I can't even think of the word now. Um, prosthesis. Let's leave it like that. Um, the other things, if it becomes infected, you can get non unions, male unions. Um, so that's what we try. That's why we want the antibiotics to be given within the hour. We need the debridement to happen as soon as possible. And we need that bone to be covered within the 1st 72 hours to prevent all of this from happening. OK. Um Just so here are some other pictures of other complications. Um This is a chronic sinus. I think this is, is, this is, this is one of yours Neil, isn't it? Yeah. Yeah. So that's a chronic sinus in a tibia that was fixed as an iron nail. Um This patient went to theater about four days after having come in just because of the pressures. So we did an so this is what I this is what I was alluding to, right. Infection settles in the bone. It's an open fracture or rather bacteria colonize the bone because it's an open fracture and it sits there for four days. We then come along, we debride. Yeah. OK. We debride the wound and we wash it, but we'll never be really rid of all that bacteria cos it's taking so long So then we go and put an iron nail down it. OK. So an intra meu fixation, uh we close the wounds, we say no, it looks great. But actually what we've done is driven a rod through a colonized area. The rod has picked up all the bacteria and then six months down the line, what happens is the bacteria have gotta get out somewhere. Um The they form a hole in the bone and then they eventually make their way to the skin and it presents like this. Um So as it as is is saying, right, the priority in all of these is antibiotics on board, early debridement, early theater um and early coverage um and judicious use and appropriate use of definitive management as and when you can. Yeah. Um Here's another sinus um basically from another uh I am now from the thing. Similar story. Yeah. And then this is completely broke open um skin. Um again, so all the the metal work is going to have to come out, they're going to have to have chronic uh antibiotics for a long time. We may might end up taking that um bone out and then we might end up having to do that bone transport. So regrowing that bone similar to that first case I've showed you and then just, just a another some other images I have from my phone. So this is someone that had an open fracture. Some of them are really obvious as you can see it, but some of them are less obvious. So all small wounds like that. If they're bleeding, if you think they're open, we treat them as an open until proven otherwise. Because the antibiotics is the most crucial bit of all this management for the open fractures. So, antibiotics within an hour and then get them to a major trauma center so they can have the plastics input, they can have the vascular input if needed. Ok. Any questions for ach and fractures, if you had, if you had a, a diabetic patient or say someone who had like burns on their leg and they had a sort of fracture at the same time and you weren't sure if it had pierced your skin because they already have like ulcers or, you know, bad blood supply to the area. Would you still treat it as an open fracture until proved otherwise, an open fracture until proven otherwise. So I've, I from other hospitals that you can't see the wound yourself. So I've been referred to patients at the Royal London where there's, we've got all the tools to fix it um than them sitting in another hospital, they won't be operated on for a whole week. And that's, that's when the long term problems happen. Um because the main, even if we might not be able to fix the fractures for these diabetic feet, but as long as we close the skin, that's the most crucial bit to get rid of that bacteria. We, there's always operations we can do further down the line. But the main problem is that skin getting the infection and that's what we need to prevent. Yeah, the, the complication is, is way too risky. Right. If you, if you think it might be open and you've had a look at it in resource, it's bleeding a bit. And you've got, as you, as you've described an at risk diabetic patient who would do pretty poorly with an infected open open fracture. Anyway, there's absolutely nothing wrong with saying to everyone. I'm not sure whether this is open. We're treating it as an open fracture because it needs an operation anyway. Right. It needs to go to the theater anyway. It's a tibial fracture. Um Whether you push for that in the, in the 1st 48 hours before because it was a low energy open fracture. It doesn't really matter as long as what you don't do is say no, I think it was ok. And then six days down the line when we finally come to do it, they've got an Osteomyelitic foot. Yeah. So it, it is totally acceptable. And I did one on Sunday that was, that came in. Registrar said, I think it's an open fracture. We took off the cast. We had a proper look. It wasn't, it was closed, but it was a, there was a graze on the anterior aspect of the shin. Um and we nailed it but that's totally fine. Like no one's jumping up and down saying you got it wrong. It's like, well, it was bleeding and it looked like it might have been. So we've treated it and we've done, we've done the proper thing. Yeah. Yeah, we, we, we'll never turn down an open fracture and we don't mind people that if it's not, we can always send them back your way basically. Ok. Next case. Oh yeah, this is me. Uh So the next case is a 45 year old chap. Um, so let's imagine he's a construction worker. Um, so a relatively young patient and his legs been run over by a car. So you're already thinking cross injury, you're already thinking high energy. He's got a bit of hypertension and we've taken him to theater today. Er, it was a closed injury and we've put down this, er, intimate now, as you can see on the right side with the POSTOP radiographs and let's imagine you're on call and you get a call from the nurses and the nurses say this guy's got loads of pain in his leg, he's not settling. Um I'm slightly concerned about him and you're the night registrar and it's 11 p.m. Yeah, that's all. So you're already thinking this could be compartment syndrome. Ok? Any, any patient who has had, er, any long bone fracture who has had intra internal fixation or an intramedullary device or has had a high energy mechanism. You'll, you'll have to be so aware of compartment syndrome. You're gonna hear it. If you want to do orthoped, you're gonna hear it. O on and on and on and on for the next however long. But it's because it's important and it's because we need to catch it and we need to be alive to it. Now, what is the definition now is, I'm sorry, I'm gonna disagree with your definition here. I tried to change it earlier but I've got a better up upgraded one. Ok. The point of compartment syndrome. And what I want you to take away from this is that the the myofascial compartment pressure raises to such a level that capillary perfusion is impaired. Ok? The capillaries shut down. It's not about your, your veins or your arteries. If your artery is shut down, you have missed the boat. Ok? The legs dead because arterial pressure is such that it will carry on going even when you've got the beginnings of compartment syndrome. Ok. But your capillaries, yeah, your one cell thick capillaries in the soft tissues aren't gonna withstand the increase in pressure. Ok. So you the definition is that you have increased faal myofascial compartment pressure such that capillary pressure is impaired, which decreases oxygen supply to the tissues, which creates ischemia in the tissues. Ok. So what cause? Yeah, cool. So what causes it? What cross injuries? Circumferential burns can cause it? Ok? Because of the amount of swelling. And there's a good diagram, we'll show you in a second, which shows you exactly the pathophysiology process fractures. 75%. We see it a lot. Um, and particularly in those young patients with, with high energy mechanisms, use of tourniquets or constricted breath dressings. So, tourniquet is particularly pertinent in prolonged surgery that that's been under tourniquet. Um, and yeah, putting a, putting a plastic cast on after a, after a difficult surgery that's gonna have swelling can cause a compartment syndrome because it's not only er a kind of er self or rather kind of um de novo increase in pressure within the leg, but you can have external pressure with uh onto the leg which can, again, can cause, can cause it. Um and then hematoma. Ok. So pa patients with coagulopathy patients that um patients who are on anticoagulants, um hematomas within the myofascial compartments can raise it such that you have a compartment syndrome. Yeah, I have seen that as well just to let you know. Yeah. Yeah. Yeah. Um and this is quite a nice diagram. So if we start on the left hand side with the trauma, um and we look at arterial inclusion, arterial spasm for that, I would change that to um capillary occlusion and capillary spasm. Ok. Again, if you've got artery occlusion, you've missed the boat. Ok. The, the, you may as well not open it up because it's all gonna be dead. Um, which in turn causes muscle ischemia. You get histamine, release your, in your capillary, permeability, permeability increases. Ok. So they collapsed. But they're still, they're still opening, they're still letting fluids through, they're letting, they're still letting molecules through from the blood that's already in them. You end up with venous occlusion, um, venous, um, uh venous stasis and intramuscular edema. Ok. So the whole thing, ok. And this is why it's associated with high energy trauma um and more severe injuries because it's just swelling, it's the body's response to any trauma. This is OK, increased permeability, loads of swelling, loads of molecules and, and um reactive factors and and um and I can't remember the name of it now but being thrown at cytokines, being thrown at the limb. Ok? Causing all this compression, causing this raising compartment pressure um and giving you the, the clothes and the capillus that I talk about. Yeah. So it's all about pain. Ok? It's all about pain. And you in, in, in assessing that patient that I mentioned before, you will be assessing how that pain is progressing. Is it crescendoing? Is it, has it been the same for the last six hours? What pain relief they've been having? Have they had some Oramorph have they had opiate analgesia? Um and, and then clinical examination. So they're the two things I wanna know right from your nurse when you arrive on the ward and they think they've got a compartment syndrome is what analgesia have they had? And I've seen it before. They'll say they've had 5 mg and they've had 10 mg and they've had 10 and they've had 10. And it literally like you can see the crescendo in pain relief. Uh And um and how long has it come on for? OK. How's it, how's it, how's it progressed? And is it crescendo? So is there pain in passive stretch? Now, this is because the whole muscle, this is because there is ischemia. OK. Where there is ischemia. If you then stretch all those muscle fibers, they're not gonna be happy about it. Have they got tight compartments? Is the, is the myofascial pressure within there? Can you feel that it's that it's tight and, and that is a thing? OK? Some people will tell you it's not, but I promise you it is OK? And have they got tight shiny skin? Um And then you're looking at your, your other examinations, which of course you will do are things which you may have heard of from vascular colleagues in terms of the five ps of ischemia. So you're gonna assess for these, OK? You're gonna assess the pain, you're gonna assess whether they've got some numbness, whether there's any neural involvement. If it, if there's such, if there's so much compression that the nerves involved, um if there's so much compression that they can't move their muscles because of the nerve involvement is the repulse and their pallor again, I can't emphasize this enough if you've got a leg which has pallor no pulse and is paralyzed, you've missed the boat, it's so far gone. Ok? That you almost may as well not open it up. Um Which I'm not gonna get into cos there are some nuances regarding kind of delayed onset and delayed presentation compartment syndrome, but just realize that it's all about pain. Ok. Yeah. Excellent. But any of those other ones is basically too late. So even pulse is almost too late. So you need to get that that. Yeah. Um and investigations wise in a in a in a in an awake patient. Ok. Who can give you history who has all of the or some of the risk factors involved, you can make a clinical diagnosis. It's only really when you come to the Moribund patient or the patient who is tubed on ICU that you need to think about investigating. Um and you do go by intercompartmental pressures and um I've done this recently on on itu actually there's a good, I think it's made by striker. There's a striker compartment monitor. Not, yeah, I have no, I have no uh I have no um I have, I have no uh what's the word? Um nothing to, nothing to declare. Um and you plug it into a green needle and you put the green needle into the compartment and it'll give you a reading. Um and as alluded to here. Um Anything other than 30 I think it's actually in the both guidelines, anything, anything crudely over 40 is diagnostic of a compartment syndrome. Um And then they also talk in the most guidelines about a delta P and A delta P is your diastolic pressure minus your compartment pressure. And if you've got, if your pressures are nearing or less than 30 ok. So your compartment pressure has risen to and this is why it's all about capillaries, right? Um If your compartment pressure has risen to such a degree that the difference between your diastolic and your compartment pressure is less than 30. And again, it's diagnostic of compartment syndrome and you should be escalating that appropriately and that patient should go to the theater within the hour for um fasciotomies, which brings us nicely next on to the next slide. So, what are you gonna do for it? Well, um again, we're gonna focus on acute compartment syndrome. You've got about af and, and in any ischemic limb you have about a four hour window. Ok. You've got a four hour window, 4 to 6 hours, but really four hours to get that patient to theater and revascular things or do an intervention to make sure that the, that the, that the limb is salvaged and early treatment is the key, both guidelines, these patients should go within the hour of diagnosis. Um But there's some things you can do first like remove er circumferential dressing and bandage, bandages. Um But if that doesn't work and your boss is on the way in, then they're going to go to the theater. All right. Um And they're gonna have fasciotomies next slide and these are the fasciotomy lines that we used again from the BO guidelines. Um We use the subcutaneous border um for that lateral incision, er and then the medial border for the medial incision and it's two centimeters on, on the lateral side and 1.5 centimeters on the medial side. Um and you dissect down and you release the compartments individually and and systematically assess for how the muscle viability is underneath. Um and and leave them open next comp complications, what we're trying to avoid. Well, Volkman ischemic contractures are, are contractures, mainly kind of the, the eponymous name is from the upper limb. Um But you can have contractures of any way you can have contractures of the anterior compartment of the lower leg. Um following a compartment syndrome that killed off um you know, tib and er sorry. Um Yeah, anterior yeah, tib. Um and some of the other muscles um and permanent nerve damage, limb ischemia. And then obviously at the other end is things that amputation. We very rarely see amputation, but it can happen er rhabdomyolysis from from if there's lots of muscles involved, you can see it when you go in, OK, the muscles bulge and they'll either be black and reactive to the diathermy or it won't and those that aren't need, um, debridement, any questions about compartment syndrome? No. So we're gonna move on now. Um, we've got a 30 year old, uh, gentleman who's got shoulder pain after a rugby tackle and he's holding his arm against his chest. So, with all, er, orthopedic examinations, as you know, there's a look, feel move and as you can see here there is squaring off of his right shoulder. So this side's nice and curved, this side looks quite angulated. Um, see that there's um missing going on, the typical er, feature of a shoulder dislocation. So we're gonna quickly run through some shou er some dislocations. So a dislocation is displacement of a bone joint from their normal position. So basically the articular surfaces of two sides of the joint are not paired together. So you're not gonna get a nice movement management for, for dislocations is get the X ray to confirm it's out of position and where it's out of position, put it back in position. And you always need to check the neurovascular status before or after and that's the same with fractures as well. You always need to check the neurovascular status before and after and I'm gonna go through um that shortly. Um But also you need to know your anatomy. So here the, this is a shoulder, you can see that this sho um this shoulder's come out anteriorly. You do need two views. So, but II know this one's out. Um, and you can, you need to know what you're looking for. This one's posteriorly, this is the light bulb sign. So you can see sort of the ice cream on top or the golf ball on top of the golf tee. Um, this way you can see the whole, um, humeral head. So you need to get good at looking at these x rays and this is a normal x-ray. So this is what you should be looking for. So you can tell that it's out. Ok, shoulder dislocations, it is the most common joint to dislocate. Most of them come out anteriorly after falling over or ex uh externally rotating such as in, in a rugby tackle. The posterior ones are typically from an e um electrocution or from seizure. And uh I have actually seen bilateral um posterior shoulder dislocations after someone's seized. Um So you do, taking a good history is important to get those, those kind of details. Um It's often associated with the fractures, uh rotator cuff tears, um and neurovascular injuries. Um As you can see here when the, when the um humeral head does pop out, the glenoid pushes into the um posterior aspect of the humeral head. So that's known as a hill sacs lesion and then equally the humeral head is chipping away here at the glenoid. Um So you can get a either a labeled tear which is a bank heart lesion or you can get a bony bank heart which is where there's a fracture as well or an avulsion um of the bone. So you often get lab tears, you get um ligament injuries, tendon injuries, everything with uh dislocations, um shoulder dislocations. Majority of the time if they, if they are properly sedated can just be uh traction, countertraction. Um There are lots of different techniques and this one tends to work for me. The old method is, or is it cocker? No, is it coccus? No? Yeah, but no one uses cockers. No one uses it cos it causes fractures. Um, but that's uh it's often taught at med school but that's not used anymore in practice. Um, quickly moving on to knee dislocations. This is often a dashboard injury. So you often see it in car accidents like this. You can see it in, er, rugby injuries, um, sort of a twisting mechanism landing directly onto your knee or tackling kind of, er, injuries most of the time. Um, it's or anteriorly. Um, sometimes it goes laterally, rarely it goes medially. Um, and uh knee dislocations are bad because if you can uh remember any of your anatomy, you've got all your neurovascular um structures directly behind er, your knee. So you've got your popliteal artery and vein and then you've also got your nerves that come around. So such as the common perineal nerve, which I think most people should know where it comes around the head of the fibula. So those can all eas very easily get injured. Um So, perineal in er nerves are um injured in 20 to 40% of knee dislocations. And then you've got to think about all your ligaments. So your ACL S often go, your PCL S go and then your collateral ligaments as well. Um Here, you can have a sort of gives you an idea of where all the ligaments are and how easily they are ruptured. So, if it goes medially, then you're rupturing your lateral collaterals and it goes laterally, you're gonna rupture your medial collateral uh medial collateral ligaments anteriorly, you're gonna uh pull off your ACL posterior dislocation, it's gonna pull off your PCL and this is where your popal artery goes very close down the back of your um uh knee. So that is often ruptured. Um And so with all knee dislocations, you need to get an angiogram. Um because even if they've got pulses, they might have something called an intimal tear, um which might need um some vascular input. So that is, it's just quite important to know. So with knee dislocations, it is again, traction, countertraction and then knowing which way the knee is dislocated. So you can put it back into the, the er right way. This only really works if they're properly sedated. So you do need to get a good A&E um consultant or anesthetist to give you proper sedation for er, dislocations. And that's the same with shoulder dis medications as well. Um, yeah, so reduce the urgent, um, er, angiogram to assess for vascular injury. And then with all, um, injuries with orthopedics, you need to stabilize it for shoulders, you put them in a, um, collar and cuff for knees, you need to put them in either a, um, a cricket pad splint, which is, um, a removable splint which isolates the thigh as well as the, but most of the time I put them in a s, as you can see here, it's a cast that goes above the knee so they can't bend the knee. Um, they're really uncomfortable, um, but you need to stop any movement. Um, and then later on, uh, you can either you can do, um, immediate fixation, um, and, or you can leave them for a bit longer to everything's stiffen up and then you get an MRI scan before going in to do arthroscopy, um, and fixing it later. Ok? If there's, if there is a vascular injury, then you'll go and put an X fix on it. Um, so that the, er, vascular team then can fix the vascular injury and then they can stay on the, um, X fix until you have a more definitive management for them moving on to hips. Again, they tend to be uh, road traffic accidents and again, dashboard injuries. So if you can imagine your knee against a dashboard and it pushes your, um, your femoral head out the back, um often high energy in young patients. Um So in posteriorly, posteriorly dislocated hips, you're gonna be shortened and internally rotated. Anterior hips are gonna be shortened and externally rotated. And they might even be flexing their, their um leg that these are also associated with ace tablet fractures and often need a CT scan. Uh definitely afterwards to see if there's any bits um of the acetin inside the hip joint or if there's an acetabular fracture. But sometimes we've actually got them beforehand as well. If we know if you can see there's a big f er fragment of the acetin um broken off that we, we know that it might not be able to be reduced back cos the acetable is not there to hold it in place. So it might just carry on dislocating if that's the case, you can leave them in um skin traction, which just pulls them into a better position so that it's less painful for them with all dislocations. As I said, you need to be aware of your anatomy and what structures can be injured um around the area. So this is the back of your, this is like the, your bum. Um You can see if the uh femoral head here comes up back backwards. So posteriorly, it's gonna press on this big nerve, which is your sciatic nerve. So the necia nerve supplies all your leg below the knee basically. So you're not gonna get much movement below the knee, you're not gonna get any movement in your ankle. Um, so this is why you need to know your examinations. Well, so when you're examining, you know what to look for and why you're looking for it and what's, if you find something wrong, why it's wrong? Ok. Again, the anterior aspect, you've got all your, um, your arter arterial supplies, you've got your femoral artery, um, which can also be, this can be evolved off. So you might end up um losing your blood supply to your femoral head. So which why you might end up with BN of the femoral head? Ok. Hip dislocations. Again, you need a lot of sedation cos your, your muscle, your gluteal muscles are strong and your abductors are really strong. So everything is pulling against you. Um So you need, you need a, you need, you need to go to the gym occasionally I have to say, and these can be hard to get back in. You need someone pushing really hard down on the aci especially on this side and then someone pulling up uh to the ceiling. Um Yeah, they can be a bit of a struggle sometimes leading slowly on to vascular injuries. Um This is why I keep talking about the vascular injuries. You need to know, you do need to know your basic anatomy and that is they, it relates to your fractures, but it also relates to your dislocation. So you need to know roughly what might have been injured. So, in the upper limb, you need to know that you've got your um your brachial artery that divides into uh your radial and your ulnar. Um So if you fracture your, your midshaft of your humerus, what could be injured again, your forearm, what is gonna be injured? And again, your nerves, you need to know where your nerves apply, but also how to examine your nerves. Cos you need to know they get injured before you reduce a fracture or before you reduce a um dislocation and then you re examine them afterwards because if you have reduced it, you've reduced it well, but you might have caught a nerve in there, then you know, actually your, your maneuver has injured it and that needs to go to the theater sooner rather than later. This is just the lower limit. So again, you need to know roughly where your vascular supply is, roughly where your, your nerve supply is. Ok. So looking at this, you can sort of guess that this is, this is the um top of your foot. So you know, your, your, you could, this is where you feel for a pulse normally. So this is your um dorsalis pedis is gonna be around here. So it's likely that that might have been injured around this area because especially if the toe looks a bit bit pale. I'm not sure if that's what you're going for. On this one, Neil, but equally, you know, you've got lots of tendons running along here, which are gonna extend your toes. So you need to work out whether actually you've done a tendon in here, the main branches of your nerves would have already bra branched off, but some of the smaller branches might have also been injured. Ok. So you need to think about that with all your injuries. Um Again, supracondylar injuries are very common in kids. Um The most common injury is something of your anterior interosseous nerve, which is a branch of your median nerve, uh which as you can see here runs very close um to the supracondylar. And again, the radial nerve can easily be injured as well as your brachial artery. As we've seen this, we've seen this image earlier, but segmental fractures can come very close to your uh this is your artery. Um So your er profunda femoris artery can easily be er disrupted. Um So you, you do need to have a good i idea of your anatomy and if you can get the basics of your anatomy, just the main structures at med at med school, it really makes a big impact. Um So it's easier to learn later on. And the amount of times I've learned the pathways for these is ridiculous, but you need to keep, keep going through them. Ok. Learn them. Now, learn them again as af one, learn them again for CT training, learn them again for reg interviews. You're just gonna keep going over and over and, and over another one ankle fractures. You've got, I think five nerves passing over the ankle and you've got two big arteries passing over there. You need to check all of them are working before and after. Ok, again, some, you know, some are gonna be more obvious than others. Um, but as it, yeah, you need to know how to examine and you need to know how to examine in kids as well because actually kids get scared. So for me, when I examine a kid, I always do it on their good side first, make it a game and then go onto their bad side. So they know I'm not going to try and hurt them if I can help it. Um, and just getting at small movements are good enough. Ok? Um, and I'm gonna say this now it's my pet peeve. If someone just puts neurovascular intact, I really hate that cos actually that doesn't stand up in a, in a, in court, you need to say specifically which nerves you've c er, checked and which ones, um, you are, are working and if they're not working, you can just say I wasn't able to examine due to pain just so that if, if after the operation or after you've produced it, it's still the same, you know, that you might not have caused the injury, it might have just been there from the accident itself. Ok. Um So yeah, no documenting NVI please. Um Again, this one, it's probably more obvious, but yeah, it's probably gone through one of the arteries, there's four on there. Um But if you know, ulnar artery, sorry, ulnar artery. Thank you. Well done, you know, um but you know, in your hand, you've got your radial supply and you've got your ulnar supply. So actually this hand might still be well perfused, but you need to know you're anatomy to know that. And it was um again, this is your uh older size. Oh Yeah, just put this in because that's the ulnar nerve. Lovely. So you can see just next to the bone being trapped. So you need to make sure that it doesn't get trapped when you reduce. Ok. So yeah. So, neurovascular injuries are associated with fractures, always checked before and afterwards. And of causes are often fractures, dislocations, penetrating in trauma. So that can be a direct slice through the um through the uh and II and uh thromboses can cause neurovascular injuries. Um and then compartment syndrome. But equally, we can cause neurovascular injuries by putting on a cast too tight or at the or at the site that the um this is a common perineal nerve coming around the uh head of the fibula. If we put the cast at the exact height, it comes around, then it can cause pressure on the um common perinal nerve and it can cause a neurapraxia. So it's, you need to be aware of it even when doing this. Ok. Um, again, we've, we've done a bit of this. So vascular injuries, you look for pain, paraesthesia, uh paralysis, pulses, impala um look for that cold, um, cyanotic armer leg arm and it's actually something I do when the trauma team are doing their trbi, I'm actually looking at all peripheries. So I'm looking at the hands. Do they look the normal color? Yes, they do. Good looking at the feet. And I'm always looking to see if actually they are wiggling their toes, if they are moving or not. And if they aren't, then it's either there gonna be pain in that um, leg which might be a fracture, it could be dislocated or it could be something higher up like a spinal injury. So it's something you can do. You can check the pulses whilst everyone else on the trauma team is checking the airway, they're checking the breathing. So you could, you could get an idea of what injuries they've already got. Um So vascular in GS get help early escalate it early, get imaging. Um And then call the boss. Um, if no improvement, then ve yeah, so if it hasn't been reduced, then reduced, it, then you might get an improvement um in the vascular supply. So then the pulse might come back. If it still hasn't, then it needs to go for an operation Ok. And then, er, closed injuries often don't have a, just a nerve, it might be a neuropraxia rather than actual nerve, um, laceration and 90% will recover in four months. So often we don't, if, if they've got a nerve, if they've got a nerve injury and it's a closed injury, we won't go, uh, finding that nerve unless it's a chronic problem, open fractures, nerve injuries, more, um, more likely to be complete. So that might need to be explored at um the time of debridement and repair. And then the reasons we would go for early exploration, er, for the nerve is if it's an open fracture or if we are an or if, and we're gonna open up the skin anyway, then we would go and fight, try and find that nerve. Um if there's a vascular injury, um or if the nerve is er damaged after we've manipulated it or if we've manipulated a um a dislocation and then this is what I said, you need to know roughly what could be injured. Um This is just a useful table to know about. So, new dislocations, as we described as popliteal artery and vein, um supracondylar uh of AFA femur, there's a femoral artery, er scos of the arm brachial artery. So these are just useful things to know um similar with er, nerves, you know, your f you know where they are. So, you know, roughly what nerve to check for and then going back to Neil or has he gone? I so I will stop. I'm here. Don't worry, I'm conscious of, I'm conscious of time. Abraham. How long do we have? Um I think the aim is usually an hour. Um you guys have been really generous with your time. Um Neil can't stop talking. That's no. Yeah. No, that's all right. Uh I'll w I'll whizz through septic joint and then we've um and then we'll probably call it a day. Is that alright? Yeah, perfect, perfect. Um So yeah, let's talk about septic joints. Um And as a case example, we've got a 56 year old chap who comes in with a swollen and hot knee, um having had uh an insect bite last week and he's type two diabetic. He's got hypertension and some hypercholesterolemia. Next. So we're worried about aseptic arthritis as the orthopedic on call. Ok. It's defined as an inflammation within that joint of the sinovial membrane um with or without a purulent effusion into the capsule. So it's filled, filled with pus. Um And the problem with pus is that all of the studies show that it erodes cartilage, ok? It eats away cartilage and it's normally one of the joints. Um and it's usually bacterial. Ok? You don't find many other causes. There's some weird and wonderful kind of s ti causes, but by and large it's bacterial and it's normally next slider. It's normally been caused um, by us doing something too the joint or by something else or an external factor having done something to the joint. So normally penetrating wounds, injections and arthroscopy. Your big three. Ok. In kids, it's slightly more um, hematogenous. Um, or it could be direct spread from something like a bone abscess. Next slide. So by and large, we see it mostly in knees. Um And then we see it in hips and then we see it in the upper limb. Um, the knee is the, the, the most common mainly because of the, uh, the blood flow around the knee which slows down a, around the knee which allows the hematogenous spread, um, to be all the more uh prevalent. Er, but also because it, it's readily available and we fall on our knees, we a brace on knees, it's open to intake bites and things like that. Um, like perhaps the way that, that, that the rest of us isn't particularly things like hips and the upper limb next side. So, what are our risk factors? Well, anyone who's immunocompromised. So our diabetic patients are IVD used immunosuppressed, um, as well as our elderly patients and those that have inflammatory arthropathy and those that have had a prosthetic joint. Yeah. Um, how does it come about? Well, it's always rapid onset. Ok. Um, or nine times out of 10, it's rapid onset if it's not a funny bug. Um, it will be something that's come about over the last 24 48 hours, um, they have swelling, they have warmth, they have erythema, they are all the markers of infection. Um, and the, probably the, the kind of biggest differentiator for me when I examine someone is whether they have decreased range of motion and whether they can put weight on it. So if you've got a, if you've got a knee full of pus, you won't want to move it an inch, you'll, you'll almost punch me when I put my hand on it and you certainly won't be walking around the department. Ok. These patients get unwell, they have raised inflammatory markers. They have, um, they have off parameters. Um, and once you've seen a few you'll start to pick up the pattern of. Yeah. Ok. This really, this actually could be quite septic as opposed to this is probably arthritic or this is probably, um, another pathology like gout or something similar. So, what do we do? Well, we aspirate the knee. Now it's important to mention that you don't go through, er, cellulitic skin because there's a, there's a risk that you see the infection into the joint but you need to try at least to get some fluid out of there. So you can send it to the lab and the lab will do a gram stain and tell you whether there's gram positive cocci there and they'll do full on, er, they'll do more detailed microscopy after that to look for the specific bug. Er, and to pick up bugs that they hadn't initially found on gram stain before giving any antibiotics. Um, hopefully you would have got your aspirate unless they're, um, septic and unwell. In which case you need to get the antibiotics on board early. Um, and as mentioned before, your differentials are something like, um, a crystal arthropathy. So, a gout or a pseudo gout, something rheumatological, um, something noninflammatory and degenerative like osteoarthritis or traumatic. So, a history of trauma is a real key in this and, and things like gout are really hard to distinguish because they can still have raised white cells, they can still have raised CRP, still got a restricted range of movement. So it's only on the cultures, you can really actually tell whether it's gout or not. And without the, if you had taken it uh after the antibiotics, then you might get a negative culture. So you're actually treating completely the wrong thing. Yeah. So what do we do when it's confirmed? Um Septic arthritis? Um Well, by and large, we wash these out in theater. Ok. Very few are managed medically alone. And there's normally a reason behind that whether you've got a, a highly comorbid patient or there's other reasons. Um But by and large, they have IV antibiotics and we wash them out in theater or arthroscopically. Um We obviously give them an analgesia. Um and we try and keep the weight off it um until we've on the washout but after the washout, if they feel they can walk, they can walk and it's a good way of monitoring how well they're doing as to how well they're putting weight through the limb because anyone that's had a wash out and then stops putting weight through the limb having done. So for two or three days likely is heading for another washout and likely that the, the infection hasn't fully cleared yet. Next one. So what sort of complications? Why do we do it? Well, as I'd mentioned previously, the the has a there's a famous orthopedic like meme that says like time is cartilage. Ok? It destroys the cartilage, it destroys the joint. Um and particularly in kids, this can, this can damage the growth plate. Um but it also basically leads to early onset osteo osteo um arthritis. You can in rare cases get osteomyelitis and other and other and other problems. Uh and clearly sepsis and death is is is one end of the spectrum. However, it's not to be sniffed at, but I have seen patients die particularly obviously your elderly more um at risk patients, but I have genuinely seen patients die from from that before. I currently and we had one last week that dies from this and we've also got one currently who's too unwell to have a wash out and so is likely to die from it as well. So it is, it is, it is a killer. So yeah, it is, um, something that needs to be picked up early and needs a wash out as early as possible. Unfortunately, both of these, they, they, the, the washout was delayed too much or they presented too late and that's why they've got to the, um, to level of unwellness. Yeah. Cool. Um, well, thanks very much iron. Any questions before we leave you to your evening? I had a quick question about, um, er, neurovascular sort of, er, status, especially when you're putting a cast on if you're on call and it's like late at night or even if you're busy only are you always doing a back slab to prevent this or are you, is there still situations where you do a full cast? Especially now that the casting is getting better? Um, near, nearly always. I just do a back cl it's sometimes on kids. If it's a both bone forearm and I know there's not gonna be too much swelling, then, then I'm, but even then I safety net, like nobody's business to the parents to be like if the pain improves, you need to come straight back. Uh, sorry, if the pain worsens, you need to come straight back. But most of the time you've got to think that there's a fra once a fracture happens, there's gonna be bleeding into that area. So then the, the area needs to swell and the backside allows that swelling to happen if it is completely. Um, if you're going completely around for the cast. Then there is no room for, for that swelling and that's compartment syndrome. II agree by like for, for your level and basically up until the level of a of ast 45. Yes, put a back slab on anything. No one will ever have a go at. You put in a back slab on anything. There are some certain nuances as you start to look at particularly pediatric fractures, which you would you save the patient a trip back to your clinic if you just whack AAA forecast on it then, but again, no one's gonna take you off for putting a baab on the great any, any other questions, anyone? All right, I think that's it. Thanks. Thank you. Um Doctor Drummond and Doctor Jones. Uh I really appreciate it. Um If everyone else who's attended today can uh just fill the feedback form for um for your certificates. Um And yeah, that, that's about it. Thanks a lot. Uh Thanks for being so generous with your time as well. Not really. No problem. No problem. Hope you enjoyed it. Hope to see you soon. We will. Yeah. All right. Thank you. Thanks a lot. Bye. Perfect. I have a question. Um Obviously we've got the recording of the session. Um So the thing, obviously we won't share it without your permission. But um in terms of the photos that you have on it, um what's the best way to sort of go about, um, like we don't have to distribute it obviously if it has confidential information on. Um, yeah. Um, good question.