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Hello, everyone. Um, welcome to the, er, second session um that we have for our S AQ and S VA series. My name is Palmy. I'm the, the president of the University of Leicester Orthopedic Society. And with us today is David. David's kindly um, er, sorted out this series and is, uh, has created the slide. So ma massive thanks to him. Um, today's um, session is we have affiliated with bombs or Midlands, um, bombs to check them out already if you have, um, if you haven't, so they're, er, it's the British orthopedic Medical Student Association and, um, and they, they do events that are regional based in the whole of the Midlands. Um, and yeah, less, less university is part of them. So that's, there's, there's a rep from scrubs and from myself. So, yeah, come out, they've got some events coming soon. So, um, that will also be great. Um, ok. So without further ado, um, Dave, can you, so is it, it's all full screen on your end? Yeah. Yeah, it looks good. Yeah. Right. Um, we could, um, so, um, Dave, I, I'll hand it over to you and, uh, you can do the first uh couple of cases. Yeah. Perfect. Yeah. So, hi guys. Yeah, my name is David. I, my third year. So we're gonna be talking about some hip fractures. We're gonna do some SA Qs and then some SBA S. So I'll be doing the first two S AQ questions and we'll try to make it as interactive as we can. So if you guys wanna um put in the messages, you know, what, what, what the answers, what you think the answers are. That'd be great and we can, you know, have a good discussion. So, um yeah, start with the first case. So case one. So we've got an 87 year old female who presents to A&E after she fell over last night, she was found on the floor by a neighbor. There's pain in her left hip region which refers to her knee. She's also unable to weight bear. So the first question uh is, um, what are your initial investigations for this patient? Sorry. We got um, six half mark. So you can think of like six things in the initial investigations and put in a chat. What, what, what do you think we could do initially for this patient? Ok. Yep. Someone says um a PX ray of the hip. Yep, that's good. So definitely you want an X ray, that's good investigation for sure. You can also think a bit more general as well. So, um should we, should we move on so we can see the answers. Yeah, so we have a look. Yeah, so um so yeah if you click again as well. Yeah. Nice. Yeah, perfect. Yeah. No, that's all right. So yeah, so you got a few things. So initial investigation with anyone kind of presenting to A&E you want to do a full blood count. So someone said an X ray. Yeah, someone said E CG as well. Uh Pong I think it's cut out. Hello? Oh I think I think his incident must have cut out apologies for that. Let me go ahead contact him. Sorry about that guys. Oh or your back was that new or was that you? I'm not sure. Can you hear me? Ok. It sorry can we should we go back to the first question? Just cos I think you cut out there PG can you hear me? Ok. Mhm. Hello. Yes. Yes. Hello mate. You alright. You can you hear me? I can't hear you but uh can you I can't uh give me a second. Can you hear me? Ok, sorry can you go? Can you guys hear me? Uh yeah I can I can hear you now. Uh David. 00 perfect sorry I think. Yeah. Oh thanks guys. Yeah. Ok. Should we go back to the first question? Yeah, yeah, just go over them. Ok, perfect. So yeah, so um sorry about that guys. So um yeah, so full blood count x-ray um using knees coagulation screen because most likely this patient uh will need to go into theater. So you want to check for any um um for the coagulation screen group and save as well to get their um blood group and their antibodies as well. Um creatine kinase is important as well because you wanna check for rhabdomyolysis. Er because as in the sle it says that this elderly lady was found on the floor. So we don't know how long she would have been on the floor for. So we want to check for creatine kinase um due to a possible long line urine dipstick as well in case there's any kind of um especially in elderly patients that may have a uti a chest X ray as well in case of any other traumatic injury. Um and an E CG as well, which some people have said in chat, which is very good. Yeah, and yes, someone has ACR P as well, which is good. Yeah, you can definitely do ACR P as well. So those are all good investigations for this patient. Um So definitely think about the overall patient when they, they actually come present. And a and so that's great. Nice. Awesome. So um second question. So apart from examining the hip, what else can you do in terms of examination? So I think we've got someone who's already said a few things but anyone else got any ideas you wanna put in check? Neurovascular? Yeah, that's good. Yeah. Great and yeah, some someone said as well, pelvic and femur as well. So that's good as well. So um yeah, we can see the answers move forward. Ok, so yeah, so um people have said, yeah, so you wanna do an A at E approach? So yeah, check your airways, breathing circulation, disability exposure. Um and you wanna do a primary survey, look for other injuries. So that's as good. Someone said, yeah, look at the pelvis, the femur, so other fractures, head injuries, um neurovascular. So you have full, full neurological examination to check in for um ati A so they've had, you know, a possible stroke as well which could have caused the fall. Um cardiovascular examination is important as well. So looking for any murmurs that could have caused an arrhythmia and then leading to the syncope which have caused could have caused this um this fall as well. So, yeah, nice. Ok. So um a question question c so which specific radiographs will you order? So it's two marks. So can um can you guys think of any other? What specific um x-rays would you would you want to order? Yes. So um do you have a look at the answers? Yep. So yeah, so as people have said, oh, nice. So someone said the end of the chat, it's a ap, so you want that anterior, posterior um hip. So ideally you want that on a traction with traction, so you wanna pull it and to rotate that hip to see the um see what type of well fracture it could be. Um Someone said, yeah, x-ray of both hips. So that's good. You wanna do an ap pelvis as well and a lateral hip as well? And a cross table? Yeah, that's good. And also a full length femur which someone has said which someone said before. So you wanna also assess the femur too because there could be possible um possible. Yeah. Um fracture of the femur too. So yeah, so that's what a cross table lateral radiograph would look like. So you want to position supine and with the, with the injured leg flex at 90 degrees. Um Yeah. OK. So the pain film radiograph, radiographic imaging shows a hip fracture. So what is the diagnosis here? Ok. Yeah, I see. It's, it's and now days in Yep someone said neck of femur fracture of the left. Yeah. Neck of Yeah, neck of femur fracture of the left hip. Yeah, more specifically, yeah. Someone said intracapsular. Yeah, that's great. So I don't know if you guys can see that. Yeah, that clearly, but um you can see. Yeah, yeah, you can see it right there. Um So yeah, you, you always want to make sure you say which hip it is. So in this case, it's left hip intracapsular me a feia. Yeah. Great. And as well it's displaced as well because um you can see the there's a line which we'll talk about later, but um that line has been disrupted and you can see there's a bit of kind of overlay in that um left hip and the as well, the um the neck of the femur has been shortened as well. So that's a good indication that has been displaced too great. So, um question e what classification is used to classify intracapsular neck of feur fractures and describe each type? So it's four marks. Just think about what the name of the classification is. Yep, someone said Garden. Yeah, that's great. Garden classification. And can you um describe what each type would be? It's, it's Yeah. Ok. Yes. No, that's OK. So we can move. So we have a couple of answers. Yeah. So there's four types. Um So you've got, yeah, type one which is a partial fracture, non displaced. You've got type two which is a complete fracture. So it completely er cuts the neck of femur or if someone's, yeah, someone's put the, put in the chat not and it's good well done. Uh non er non displaced and then type three is a complete fracture, but it's partially displaced. And then um type four is a complete fracture, fully displaced. Yeah. So we can have a look at the picture here as you can see. Um So it's a kind of step wise manner. So that's important. They um they love this in orthopedics, this classification, the G classification um for neck A femur fractures. Yeah. Ok. So um and yeah, go should we go back to the X rays and see what people think? Which, which type of fracture this is? So um what do you guys think? What fracture do you think this is guys? So someone said type two. Yeah, possibly perfect. So um this would be a type three because it's a, so first it's a complete fracture and it's partially displaced. So you can see as I um as I said before, um it's been um it's tattoo, yeah, tattoos a good good thought cos it's a complete fracture but um it is displaced in this instance because of the shortening of that um neck of femur and also the overlay. But yeah, but yeah. Good, good, good. Um Good thought. Yeah. And um yeah. So question f what is the blood supply to the femoral head? And what is the significance here? So that's four marks. So what do you guys think you can name the um the blood supply? And why is that important in this patient here? Yeah. Yeah. Correct. Yeah. Yeah, great. So yeah, someone said femoral artery. Um Yeah, that's a good idea. I mean that is the branch, it branches off that artery, but we want to be a bit more specific. Yeah. Someone said medial circumflex artery which is, yeah, that's great. And an VN so a avascular necrosis and someone said retrograde supply. So that's good. Yeah. So, exactly. So Um um So yeah, so you've got that retrograde supply to that femoral head. So it means it goes from more, more distal to proximal. And um that's important because with that neck of femur fracture, it cuts off that blood supply with causing that avascular necrosis. Um So yeah, you've got 22 blood supply. So you've got that ligamentum teres uh which is, you know, much less important er, in an adult and in that medial circumflex femoral arteries. So, yeah, in the intracardial necro feur fracture, that medial circumflex artery is cut off and that's the main blood supply to that to the femoral head. And the ligament in teres artery is not sufficient enough to supply that head and that causes avascular necrosis. Great. Um So on visual inspection, how would the leg look? So what do you guys think when you, when the patient comes in to you, how would that leg typically look like? Great. Perfect. Yeah, well done. So. Shorten. Yep. Tony rotated and A B ducted so abducted. Um great and those are some reasons why it would look like that um with the muscle. So when it shortened that rectus for moris, the magnus and hams pulled that distal fracture upwards. Yep. So someone said, is it shortened? Yep, it is shortened. Um Yeah, it to irit it um not entirely rotators, it be externally rotated. Yeah. So not internally rotated and they, yeah, not, it will be externally rotated. Um yeah, about this picture here. Yeah. And you can see it's also not that obvious it's abducted. But um yeah, uh it'll be internally externally irritated. Sorry, because of those of your Gaal muscles. So those your Gaal muscles will pull that um the uh the greatest cancer outwards if you think about it. So, yeah. Nice. Ok. So it, what is the definitive treatment option here? So sorry. Um After taking history from the patient, we find out that she is unable to walk independently and requires a Zimmer frame to mobilize. She was also slightly confused when you spoke to her. What is the definite treatment option? So what do you guys think? How would you treat this patient? Yeah, because we've got some, we've got some good ideas in the chat. Yeah. Hemiarthroplasty or if intramedullary nail. Yeah. Good thoughts. Yeah. So it's hip replacement and that's also another good thought. Yeah. So we want to look at the stem. So it's quite important. So um so after you've taken the, we find out she um so she's, she's quite elderly. She's not that fit before this accident. She couldn't really walk that well. So um we want to do a a hemi arthroplasty. So we would prefer to do a hemiarthroplasty over a total hip replacement. Um So we wouldn't want to really do an int artery nail in this instant because it's displaced. So if it wasn't displaced, then we could consider an intimate Gary nail, um, and a total hip replacement is a good idea as well. But, er, because of this patient, she's quite, you know, fragile, she's quite weak. Um, a total hip replacement takes longer than a hemi. So we'd rather choose that hemi arthroplasty. Um, and ideally you'd want to do with a spinal block because rather than a general anesthetic because it's less uh invasive of a spinal block, the patient's still awake so she can still uh breath wellness by itself. And it's not as um there's less side effects as well and it help aid in the patient's recovery POSTOP too. So, um if you look at the next slide, you can see here. So this is uh what a hemiarthroplasty is. So it's basically just the same as a total hip replacement, but we don't replace that acetabulum. So the bit which connects to the um pelvis. So that, that is still the patient's own hip um socket. Um And it's a less invasive, it's still quite invasive, obviously, but it's less invasive than a total hip replacement. And um it's not as favor, it's more favorable in this patient, a hemi rather than a total hip replacement. So, um we'd rather do a total hip replacement in a patient who's more medically fit before the accident, they were able to immobilize better. Um And they're not as, you know, confused or cognitively impaired and just a bit about um the way they do a hemi arthrosis. This lecture won't, we won't really talk too much about the exact procedure, but I can just briefly talk about it. So, you've got your, um, the femoral heads. So you can see in there in this, uh, radiograph, the bright white is what the prosthetic is. So, yeah, you've got a new femoral head and this, the stem which goes into that femoral, um, inside the femoral, like the medulla medullary canal. And you basically because the neck of the femur is broken, you just cut that out and yep, just like that and then you just replace it and you cut, you draw a hole into that femur, make sure you get a prosthetic which fits and then usually nowadays, orthopedic surgeons like to use cement. So you put mix some cement, you put that inside the canal and then you put the prosthetic inside the stem and um ensure that's a good fit with uh the patient. And yeah, that's a, that's a brief overview. Great. So does anyone have any questions for that first case we can talk about? And the and any questions and share? Can I have a great. So yeah, should we move on to uh case two? So a 30 year old male presents to A&E after a road traffic, road traffic accident, a radiograph shows a right intertrochanteric fracture on examination. What would you find? So, so you could describe, you know what it would look like, what would the patient complain of what s symptoms and signs this patient would have. So, someone's asked about the pins classification. Do you have any idea what that is? And I promise you, I'm not gonna lie. I've never, I've never come across that. No. No, me neither. No, I think that's more, um, some more specialized knowledge. Yes. So someone said pain, pain in the leg. Yeah, that's correct. Um, should we look at, we look at the answers? So, yeah, it'd be quite similar to a yeah, decreased range of movement. Yeah, that's great. So, um it would be quite similar. So intra in intratrochanteric, quite similar to a um neck of feur fracture. So it'll be short and exter rotated. As someone's correctly said, there'll be tenderness over the greatest tranter. Um There'll be pain with a log roll and axial load. So that means um when a patient's lying supine in the bed and you just roll the leg left and right, it'll be painful. Um And a low will be painful. So they won't be able to wait there uh on that leg. Um And when you ask them to perform a straight leg brace test, they won't be able to do that because of the fracture. Um Someone's also said you had decreased range of movement as well. That's correct. Yeah, you can also say that too. Yeah. Very good. Yeah. So the patient is complaining of pain. What uh analgesia options could you prescribe So you got three marks here. So what three, choices do you think? Oh, thanks for that. Yeah, that's good. So, yeah, so some morphine. Yeah. Great. Yeah. So an opioid 100% because they're gonna be screaming and paying this patient. I mean, um, the Tylenol. Yeah, that's good. Yeah. Yeah. Great. Yeah. So someone said, yeah. Morphine. Fer lot block. Yeah. Great. Yeah. So nerve block as well. Definitely. That would be traMADol. Yeah, definitely. Yes. And an NSAID. Yeah. Trip of the answers. So yeah, you wanna start off? Yeah, paracetamol. I mean that's quite basic. So just paracetamol and then the next step up would be an opioid. So morphine oxyCODONE. Um and then ideally because this patient's gonna be in lots of pain, a nerve block. So a fascia iliaca block would be um probably about the gold standards in this, in this patient. So um question c So what is the intertrochanteric line? So you could describe what, what this line is? Yeah. So someone said, oh your periods, morphine, I tr tr THS Yeah. And Abdula said, is this the same thing as I Yeah, I I'm not mistaken. That is. Yeah. Yeah. So great. Yeah. Yes. So someone said the line between the greater and cancer? Perfect. Yeah. So it's the um the line up on the anterior aspect of the proximal end of the femur. So extent between the greater cancer and the literature cancer. So perfect. Yeah, that's great. You can see in this diagram from teaching anatomy. There's that line there. Yeah. And this would still be, this would be classified as extra capsular as well. Um Question D So what is the definite treatment option for this patient? So what um what surgery do you think this this patient might need the world any others put in, put it in? Chat? Great. Yeah, I do. It says DHS. Yeah. Perfect. Yeah. So yeah. Dynamic hip screw. Yeah. So in this patient, because it's an intertrochanteric fracture, you would do a dynamic hip screw. Perfect. And if you look at the next slide, you can um there's a few steps on how um you perform a DHS. So um you see the fracture in that in the cic line and basically you um use your jaw. Yeah. Yeah. Um Someone said or if with iron ak a screw um I wouldn't say in this patient. So that's more than another fracture which we'll talk about later. So intertrochanteric, it would be ideally a DHS just like this. And you use. So basically you just insert a lag group which compresses the the fragments. So you still compared to like a um a hemi arthroplasty, you keep the the neck of feur and the femoral head. So you just use that lag screw to compress those two fractures together. So they can heal by itself. And then you use this side plate with a barrel as support. So it's sort of like, yeah, it is a internal, yeah. So it is an, or if so it's an open reduction. So you open up the patient, you reduce it in surgery and then you internally fixate it. So, that's right. Yeah. Tia, yeah. But um, more specifically it's called a DHS. So a dynamic hip screw and Yeah. Mm. Yeah, we can move on. I'd go over the, the steps but just because of time, time wise or move on. Um, question e the patient undergoes surgery. What are three short term, POSTOP complications? So, in all surgeries, you always got to think about POSTOP complications and as well, uh, whenever you consent, a patient for an operation, you'd always want to, um, discuss if there were possible complications as well as benefits, of course of the surgery. Ok. And also tia, yeah, you said can a screw. Yeah. So, um, yeah, that's with, er, im. Yeah. Nails. Yeah. Yeah. Sepsis. DVT fat embolism. Great. Yeah. Very good. Yeah. Yeah. Great. Perfect. Yeah. So, yeah, so pain bleeding infection or sepsis as well. Uh, leg length discrepancies. So, with any, um, hip surgery, it might, it's not going to be perfect. So they might have a bit of discrepancies in um, their legs, uh, DVT or fat embolism, which could cause a pe so a pulmonary embolism and also potential neurovascular damage as well. So that's important to discuss, um, that they might have damage to like the femoral nerve or their, the sciatic nerve, someone said POSTOP ileus. Yeah, that's great as well. Yeah. So that's a good general, uh, POSTOP complications. Yeah. Very good. Um, and question f was three, long term, POSTOP complications is more specific to fractures we're talking about. So, um, what do you think would be some long term complications of a hip, hip, uh, surgery? Yeah. Bleeding and pain. Yeah. You can also still get pain long term for sure. Yeah. Stiffness. Yeah. Uh, now Union. Non union. Yeah, that's good anesthetic complications. Um, that's a good thought. But I'd say that's more, um, more short term. Yeah. Leg length, discrepancy. Yeah. Yeah. Great. So, um, those are all very good answers. Yeah. So we've got um, much. Do you have a look at the answers? Hardware failure? Yep. So, joint dislocation. So that's more specific to a, um, a hemiarthroplasty. But, um, aseptic loosening. So you can get loosening of the, the hardware, um, peri prosthetic fracture. Um, so you can get a fracture lines due to the, due to the surgery and then deep infection and then joint infections as well. Yeah. Ok. So the next day after the surgery, the physiotherapist immobilizes the patient. Why is this important? Also? Got a thing about POSTOP um, POSTOP care. So why wouldn't it be important to immobilize this patient as soon as possible? Ok. Ok. Yeah. So should we have a look at some of the answers. So, uh, most importantly, it reduces the chances of developing a DVT. Um, because you're moving. So that prevents stasis. Yep. Great initial, yeah, DVT prevention, um, pneumonia as well to prevent pneumonia because, uh, lying down for a while, um, it can cause pneumonia, pressure sores as well. Um, and it increases blood supply to the joints so it aids in a faster healing tube. Um, yeah, great. Four days. POSTOP, the patient complains of a tender, hot and painful, right? C you suspect a DVT, you calculate it 22 level well score which comes back as three. What scan and blood tests are involved. So what would you, what scan and blood tests would be involved in investigating a DVT? Ok. So this is a more POSTOP um postop care, POSTOP management. Mhm Any ideas you can put in in the chart? Great. Yeah, DD and C TPA. Yeah, that's good Doppler. Yeah. All good. Um All good um suggestions, all good answers. Yeah. So in this patient, um you would want to do a a yeah, a Doppler ultrasound. So proximal leg vein ultrasound within four hours. And if that because the well score we've calculated is more than two. So it's quite likely this patient has a DVC. So we want to just do an ultrasound just to double confirm that. However, if that ultrasound comes back negative, we can do ad diamond test and if that comes back positive, we can be certain that that is a, a DVT and then treat a DVT. Um, if the well score was less than two, then we wouldn't be that suspicious of a DVT. But the C TPA is also good. Um, good, good thought. But, um, because a CTP is more for AP ES or pulmonary embolism, we're not really suspecting that at the moment because they don't have any signs of shortness of breath or chest pain at the moment, but are still good. Yeah. Good thought. Nice. Um um The next question. So the scan comes back positive. So you diagnose A DVT. So what treatment do you start? And for how long? So in orthopedics is not just fixing bones and mending bones, you've also got to, you know, think about POSTOP care too. Yep. Someone said Warfarin or low weight, low molecular weight. Heparin is a good two c good choices. Yeah. No, no molecular weight, Heparin and Bridge with Warfarin. That's good. Um I'm not sure how it is in different areas, but here we, we've so new literature suggests that using a DOAC is better now than Warfarin for DBC. So do you want to use either a Pix Aan or Raban? And Great Tia said for three months, it provoked them. So, yeah. So it's three months if it was provoked. So, exactly. So in this patient, because the patient's POSTOP it's provoked. So due to the surgery. So we want to give it a three months. However, if a patient comes in with a DVT and it's, there's no, um, underlying cause such as, you know, pregnancy surgery, um, uh, cancer, then that'll be unprovoked and you do that for six months. So, and this patient is provoked. So three months of a nice. All right. Thank you. Lovely. Thank you David. Um, yeah, so case three. so just for time, we might, we might be going a bit quick um on this, on this in these cases. But uh no worries for a 78 year old, uh, female presents to the GB, complaining of stiffness and generalized pain in her right hip. What other questions would you like to ask her from her history? So, let's jot them down in the chat. So at the moment, your differentials are probably quite broad. Um Yes, some of you guys might have already had your GP placements in third year. What would you ask? Uh, can you see the chat or should I let you know? Just, uh, yeah, I work, I work out how to do it. Yeah. Oh, cool, cool. No worries. So, it's always good to ask. Um So if there's pain, I usually just follow a squats or a Socrates method. Um, but things like onset. How long was it going on for? When's it worse? Is it worse in the morning or the night time? Is it, is there pain after resting? How has it affected their daily activities? Would they, would have they noticed any instability when they're walking, any locking or any catching sensations? Um Are they notice, notice their mobility, er, limiting uh, being limited? And are there any joints involved uh such as at the knee or the lower back? So these are common, good questions to ask in your history. Um, cos it provides you to funnel down your differential diagnoses. So you suspect, uh, osteoarthritis, how would you define osteoarthritis? This is a very common exam question and common in our OSK as well. Yeah, good. There was good some good options in the chat for the last question. Um, so osteoarthritis is a degenerative disorder arising from a breakdown of articular highline cartilage due to an imbalance in the wear and tear of the joint. So, patients commonly define osteoarthritis as wear and tear, but there is a bit more to it, uh, that we need to know of and it's actually due to the highline cartilage of mostly of weight bearing joints. So, what's the difference between primary and secondary osteoarthritis? Ok. So the, the chat, so those could be aware of the types of osteoarthritis. The, so primary osteoarthritis has come from an unknown cause. Um, secondary osteoarthritis has occurred due to identical cause such as potential previous trauma. So, they might have previous surgeries. Um, they might have had a previous infection in that joint. Uh, there might be joint abnormalities which can precipitate your weight bearing to be different in the hip, which can then bring on osteoarthritis in later life. So, it's a primary osteoarthritis. And the secondary, commonly we usually see, um, patients that have a, a primary one, but a lot of the times we do see secondary as well. So it's always good to be aware. So, uh, give me three points of how to, uh, briefly, um, explain the pathophysiology of osteoarthritis. So what actually happens? So, yeah, we were right on the last question we're done. Yes. So this is always a good question about any condition we get asked in an S AQ question. It's always a des describe the diagnosis you think and then tell me the pathophysiology. So for osteoarthritis, it's the articular cartilage that breaks down due to chondrocytes, producing less procto glycan and cartilage. So the cartilage then becomes eroded down down to the subchondral bone, um which people commonly say are bone on bone. Um Then there's remodeling of the subchondral bone leading to changes such as sclerosis, osteocytes and cysts that form in there can be common and commonly seen on some radiographs as well. So, if you had some of these points, we could um that's a very good starting point, but it's always good to know the pathophysiology of conditions as it allows you to understand the treatment going forward as well. So far as we can see here, uh from an histological screen, um that there are some chondrocytes placed within the, within the articular of the bone, um, which shows that it's degrading within the matrix. So, this is just good, good to be aware of if anything. So, you've got this patient in a GP GB clinic and without referring them, let's just say to surgery. Um, what, what conservative management options would you, would you consider with someone with osteoarthritis? Yes. Yeah. Yeah. Like David said so. Yeah. Oh, it does affect other larger joints, but it also affects smaller ones. Yeah. And, yeah, also just to add, yeah. So, um, you don't always wanna do is go straight into surgery as well. So you always want to think about, uh, doing everything before surgery. Cos, surgeries are the last, last option. So conservative management wise, um, obviously weight loss cos obesity increases the amount of joint, uh, amount of weight going through the hips. So that'll always be good resting, uh, physiotherapy. So, giving strength based exercise plans to allow the pull of the muscles to be, um, significant enough to be able to not let the bone just hit each other. Um, you can give mobility agent of walking sticks, gutted frames, um, walking frames, et cetera. Um, but obviously this is more a bit further down the line. So also as a, as a GP, you then referred him to the orthopedic team. Um, what are the four signs, uh, you'll see on a radiograph in osteoarthritis? And this is a question that has come up because it came up in our exams when I was in third year. Yes. So there's, am there is a um a ammonic you can follow. Yes. Yes. So the monarch is loss. Um So loss of joint space. Um for l osteophyte formation which tends to form on the edges of the hip, you can see them on usually on the edges of the acetabulum. Um you can get subchondral sclerosis and subchondral cysts. Um So I remember it as lo ss um for rheumatoid, it's les S. Um So do uh check that out what the difference is between the two cos that can be a very good exam question to throw in as well. So we can see here. Um This is a very, so you should always compare left to right. So this is a right sided uh hip. You can see that there's a lot of joint space within the articular surfaces. Um You can see osteophytes be formed just there, everything slightly. Um And there are some cysts and sclerosis of the, of the femoral head itself. So it's always good to look at a, if you're ever on an orthopedic ward and there's someone that's um having a hip replacement, for example, do check out their pre and POSTOP X rays. So after a trial of conservative measurements and topical nsaids, the GP decides to describe an oral NSAID. What other medications should the GP prescribe So let's have a look at the chart. So PPI shot. Yeah. So PPI such as omeprazole as it prevents uh gastric, it prevents any gastric issues going on. Uh especially with stronger nsaids like naproxen, et cetera. So, hold on. That was a, so we've covered, um we call it intracapsular fracture. We've covered a er intratrochanteric, we've covered oa of the hip. So now the fourth case, a 45 year old male presents to A&E after a motorbike accident, he complains of severe right hip pain and an I and, and an inability to move his left. I um, to move his leg on examination, his right leg leg appears shortened, internally rotated and adopted. There is tenderness over the right hip joint and the patient is unable to actively move his right hip. What's the most likely diagnosis? So we went through the movements last time of uh the position that the hip usually goes in. What, what do you think this is gonna pop your options in the chat? Ok. So, yeah, so posterior hip dislocation. So this is something that you, if you're on ever on call, er, in the orthopedic team in Leicester, er, you might actually see and you might actually see uh, see what the treatment is, et cetera. So do go to your on call. I know it's a bit long sometimes to not go but um, do try to go to the, so this is a position. So it's shortened, er, internally rotated as you can see the, the legs going inwards as, as you can see from the feet. And it's ad so it's er coming towards the center of the body. So which type of hip dislocation is the most common? And why? Yeah. So like David said, so, yeah, hip hip fracture is usually externally rotated due to the pull of the gluteal muscles. Um and this is more internally rotated usually when it's posterior dislocation. So, yeah, posterior hip dislocation is the most uh common and why? Um it's because you know, the three ligaments that hold the hip in, in place, um and surround the capsule, the iliofemoral ligament, which is the anterior part is the strongest ligament. So that's not gonna really give. Um, so posterior ones usually give. So then that causes it there to be an internal rotation. So you've gotta kind of imagine it in 3d. It's like a shift. And so what would you do as your definitive treatment? Yeah. So it is posterior. That's right. Um But what would you, how would you treat this to urinate any? It's no, so you'd reduce, so you try to reduce it. Um So you, you, you can take them to theater, it's very uncommon to do these just under sedation. So you get, get them under general, um, you've close, close reduction. So you, you use traction, um, you then er pla place, put traction on the hip. Um, you then externally rotate it. So you kind of do the opposite movements essentially to kind of get it back into place. But if it doesn't reduce, then you've actually gotta open, reduce it. If that, if closed reduction doesn't work, and it'll need quite intense physiotherapy and rest to kind of let, let the, let the muscles heal. So we'll see a closed reduction here. Um So we won't dwell too much on this, but just remember um that there is a closed, the way the closed reduction does happen. So what are three complications of a posterior hip dislocation? So, think about the structures that are in and around that area. Yes. So we'll look at, we'll have a look at the chat. Yeah. So, hey, they say sciatic nerve injury sounds, sounds very plausible. So, yeah, you get can get sciatic or femoral nerve injury. Um You can get potential VN of the hip. Um It can precipitate osteoarthritis because the, the, the joint is out of place and getting it back in can then cause um trauma to the actual, the head. Um And it can actually cause recurrent dislocation. So, um you do need a lot of strengthening physiotherapy. You may have to enforce hip precautions. So the patients are not bending down too far, et cetera to make sure that they don't currently dislocate, making sure that the occupational therapist has seen their heights of their bed, their toilet at home, et cetera. So that's all very useful. So describe the signs and symptoms. Um the patient might experience with sciatic nerve injury. So, here you've got to think of um to distribution of the sciatic nerve, the, the functions of the sciatic nerve. So, have a look, let's uh pop down a few. Um, ok, a few signs and symptoms of sciatic nerve injury. So, yeah, you'll be, there's a, there's a motor motor function, so you'll get muscular atrophy of the muscles that the sciatic nerve innervates. Um, so cos it splits, remember into the common perineal and the tibial nerve. Um, so you'll get, um, weakness in hip extension and abduction and abduction, knee flexion, plantar, flexion, dorsi flexion and can even lead to a foot drop. You'll get paresthesia along the, um, sciatic nerve distribution and you can also get, uh, shooting pain. Um, it's commonly seen in sciatica down the back of the leg and thigh. So it's always good to know about the sciatic nerves. The biggest nerve in the, er, it's the biggest orthopedic nerve that, um, is managed. Um, and it's quite, if you've never seen it in a cadaver or in, on placement, it is bigger than you think. So, you've got to actually retract it out of the way, um, to, to, to make sure you don't injure it. So, we've got five S PA S in. So we usually, we're on time so we'll, we'll, we'll work through these, I'll do the first two and then we'll do the last three. So what anatomic landmark is crucial for assessing the integrity of the hip joint in radio, graphic imaging. So just pop down uh your um what, what letter you think it is? So, Ka thinks B OK. OK. So there's a, there's a discrepancy in our, in our chat. So let's have a look. So it is shen's line. So on er, systems like pacs, you can actually draw a she's line or ask one of the RS to help you draw it. Um So it's it and that this will show displacement um if there is any displacement. Um that's what um wasn't the case one. So, so you should always draw this Shenton line. Um It's very, very useful. So a 78 year old uh presents to the emergency department after falling at home, he complains of severe pain in his right hip and difficulty weight bearing on that leg. Physical examination reveals tenderness over the right hip and limited range of motion. X ray confirms a fracture of the proximal femur with displacement. What is the most appropriate treatment? So the treatment of hip fractures can be a bit confusing. Um And I'll tell you the way I can't remember them, but so let's have a look in the chart. So yeah, so there is be here, but the answer is c so proximal femur, so the fracture is gonna be around here. Um And then you can use cable ties or it's like a cable tie to compress the fragment. Um And then, then you can stick a, a nail down from the top of the GT down all the way. And then you can put a cannulated screw across like a DHS um to actually compress that proximal fragment, quite a painful operation. Um And the outcomes can be quite challenging depending on the patient's age, but it is one of the best ways to treat it. So, for neck of femur fractures, sorry, I remember them is sorry, just to interrupt. It's a, it's meant to be a subtrochanteric fracture. So that's why it's proximal femur. So it's a subtrochanteric fracture. So uh I didn't put that in it to make it, it's just to make it a bit more difficult. But yeah, it's a so subic. So that's below your intertrochanteric line and you'd use an iron nail. So, yeah. Yeah. Yeah, we could. So, yeah, the way I remember it is um if it's intracapsular, if they're active, then I'll do a total hip if they're not active. Um probably a hemi if it's a intertrochanteric fracture, most likely a DHS. Um And like um and like um David just said, er for a subtrochanteric fracture which will be around here. You do a interdomal nail. So I'll, I'll hand it over to uh David um who will do the last three. And our session. Yep. So um nice. So, thank you. Thank you, your apologies. So the next question is what of the following best defines the subch area of the femur? So, um someone's sort of mentioned it in the chat, but what do you, what does everyone else think? Yep. Deep. Perfect. Yeah, it's deep. So, um extends from the lesser cancer to five centimeters below it. So it's not um, yeah, not the greatest, it's not the, it's not the greatest of the lesser cancer. Yeah, great. Um As you can see here, that's less cancer and below that. And so um going back to question two, the subtrochanteric fractures in that area and you would use. Yeah, a intramedullary nail. Great. Perfect. So um question number four, a 68 year old woman with a history of osteoarthritis presents to her orthopedic surgeon complaining of severe pain and stiffness in her hip. She reports the pain has been getting progressively worse over the past few years, limiting her ability to walk and performing daily activities. Physical examination review reveals restricted range of mo motion in her right hip with significant tenderness, X rays show advanced degenerative changes in the hip joint with significant joint space narrowing and osteo formation, which of the following intervention is most likely to perform long term relief and improve her mo her mobility, right. So what do you guys think? So, corticosteroid injections, physical therapy and exercise, uh arthroscopic hip surgery or a total hip replacement? Yep. Indeed, great. Yeah, indeed. So um it's important. So all of these can be used to treat osteoarthritis, which is what this uh lady has. Um But for the definitive long term treatment, it would be a total hip replacement. Yeah. Ok, perfect. And um finally question five, a 45 year old man is admitted to the emergency department following a fall from a ladder. He complains of severe pain in his right hip and is unable to bear weight on that side. The examination reveals a shortened and externally rotated right lower limb and an X ray confirms a undisplaced inju capsular neck orf feur fracture. What surgical intervention would be most suitable for this patient's fracture? So, a hemiarthroplasty A B internal fixation, C total hip replacement or D intramedullary nail. Ok. See. Ok. That's a good thought. Yeah. See, yeah, not good thought. Um So in this patient, yeah, you can definitely do c however, because it's er undisplaced. Yeah. So some to, yeah, someone said candidate screws. Yeah. So that's internal fixation. So that's what candidate screws are. Um So because it's undisplaced and this patient's relatively young. I mean, we don't know much about um whether he's, you know, mobilizers usually, but we can assume that because you know, he likes he climb, he's climbing a ladder. So we can assume that he's quite mobile. Um We want to do a internal fixation. So uh we can see a diagram, a picture here of what it looks like. So it's basically just some can screws and you just drill it into um the, the neck of femur neck of the femur and the femoral head. So there's no need to replace the a femoral head towards uh um Neco Feur at this point in time. Great. Yep. So that's all all questions. So thank you for your time and for joining us today. If you could scan that QR Code, we can send you guys the um the slides of the answers as well. And it would also, you know, we'd really appreciate it as well for uh to help us improve this teaching series as well. If it doesn't work, I'll put a link in the chat as well, so you guys can use that and we're going to send out the, the slides. Yeah, lovely. Thank you very much guys. Um It be, be really good to get feedback. Um So we can improve each sessions. We've got um I wanna say another 3 to 4 sessions going um sorry. Uh four more. Yeah, 44 more. Yeah. So I think um, so we'll do a session just after Easter. Um and uh we'll go through some more er, content and I, if er, correct me if I'm wrong David, but I think it's on ankle fractures. Is that right? Um The next one is, yes. Yeah. Ankle. Yeah. Yeah. So um what we'll do is we'll uh yeah, we'll do a session next in about two weeks time we'll post on Instagram follow us. Um if you haven't already. Um and if any of you guys wanna do a future teaching series or have a, have an idea for an event, just reach out to us on our Instagram page. And uh yeah, we'll sort something out. Um and it, it's great to, to, to um so can you repeat the options for hip fractures? So, uh yeah, so for hip f er, for neck or femur fractures, um you can do, er, so there's, there's quite a few options. Um depends on the fracture is uh if we go to. Yes, my one second that was a really good um schematic here. So there's a neck or femur fracture if it's intracapsular and they're active. Um I uh it's very reasonable for the hip replacement if they're young if they're not so active and they're quite, I do a hemi, if it's in the intratrochanteric area, it's useful to do a DHS um which is a dynamic hip screw with plate and screws if it is in the subtrochanteric area. Um It is useful to do a um uh I am a nail um and a hand hit screw. Um if it's non displaced intracapsular fracture, then you, it can also, you can also use a cannulated um three cannulated screws just to the head itself. So it, it is quite confusing to go through it all. Um However, um teach me surgery has a really good schematic. So um I don't II use that. I was gonna say I can t, if you put, if you fill out the form, I'll, we'll be able to get your email, we can send you a diagram. Um If you like of a good table of all the options for hip fraction and we can send that to everyone as well if you guys like to lovely stuff just to make it nice and clear. Well, thank you. Thank you very much for attending. Um Have you got any closing remarks? Uh David? No, that's all. Yeah. Um just in two weeks time. So uh next month, the ninth of April, we'll be doing another session. So um yeah, yeah, definitely come join us for that and thank you for your time. Lovely. Thank you. Thank you very much guys. Uh lovely to meet you all and uh we'll touch base again in two weeks time. Yeah, great. Wonderful. Thank you. See, I'm gonna stop sharing now, David. Um.