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Hello, everyone. Um Welcome to our um fourth session on knee fractures and um related conditions. Uh Can you guys hear me if you just pop it into the chat if you can hear me because we had some uh technical difficulties last week. Yeah. Can you hear me, dad? Yeah. Yeah. Can you hear? You should be all right. Wonderful. Ok. Uh So, yeah, my name is I'm the president of the um University of Leicester Orthopedic Society. Um, and we're doing this event in affiliation with B sir. Um and we're part of the Midlands um team. Uh Boster is a, the orthopedic um association relative to medical students. So, um yeah, check them out, doing some good things coming up. So, yeah, it's worthwhile, checking them out. And er, yeah, so this is the fourth session out of um we've got a couple left. Um, so let's get cracking. So the session today um is split into three questions, three SA Qs 10 marks each and then we've got five SBA at the end and, and joining me today um is David David's our, our third year student who's um kindly set up this, this, this um teaching series. So, yeah, let's let's begin uh over to you, David, right? Yeah, so solved the first case then. Um All right. Um Yeah, let's go. Thanks. Thanks. So, a 25 year old male presents to the emergency department following a four during a basketball game, he complains of severe pain and swelling in his left. And the on examination there was tenderness over the superior pole of the patella. You, so the first question is you suspect the patella fracture? What signs would you look for on examination? Mhm So if you guys want to, you know, put any ideas in the chat, that'd be great. Don't be afraid um to think about your kind of general investigations and a general examination of a of trauma, trauma patient. Yeah, it is. No. Should we should we will answer this spongy? Oh Have the has come up? Yeah. Yeah. Yeah. Come up. Yeah, great. So um yeah, so you want to, you know, maybe you might be able to see a palpable patella defect. Uh there might be significant he arthrosis. So um lots of kind of blood within the joints. Uh there might be bruising, swelling, pain um on examination, they might, they won't be able to perform a straight leg raise or weight bear uh on that leg because of the pain. Um also that they might have the inability to extend their knee against gravity because of how the quadriceps attach. Um and so on to the patella. Um So that could, that could, that could be gone with a, a knee extension. And you'd also want to look at other signs of trauma. So, um just because they've said they, they've got pain in their knee, they might have other trauma such as a hip fracture, they might have a knee dislocation, they might have head trauma, uh They might have uh a lower leg. So like a tibial fracture or a fibular fracture. So you'd also want to look for that as well. Um Yeah, great. So we move on to the next question. So um what investigation would you order? So what do you think would be the sort of go sign investigation for this patient now? Ok. Yeah, it is. So think about how would you, how could you diagnose um how can you be certain and diagnose the that this patient has a patella patella fracture? What um investigation would you do? Yeah. Nice. Yeah, great. Um So you have a x-ray sunset view? Yeah, that's good. Yeah. Can actually do that. Um Any other kind of views which you might want to do as well? Should we have a look at the uh the answers? So, um so yeah, so um you with any sort of fracture, whether that be an ankle fracture, a hip fracture, you always want two views. So you want an AP and a lateral view and a, a radiograph. So um an X ray and you can also do for this for a uh a patella fracture. You can also do an actual radiograph too. And um as someone's said Sunset View as well, you can, I think that's also called a Skyline view. So this can be done if it's inconclusive as well. But uh these sort of views are quite painful to do and be difficult to obtain. So, um it wouldn't be first line. Um And for um you can also do a CT scan as well if you want to look at uh more uh if you suspect any like kind of soft tissue damage or the fracture is coming to your as well. So you could um uh do a CT scan as well if, if you just stay necessary. Um Yeah, so we move on to the next question. So yeah, that's just what a skyline view of a normal knee looks like. So you can see on the right um the rest the knee on with a slight slight flexion. So that could be if someone's got, you know, lots of pain, they've got a patellar fracture that could be very painful already. So, um you, you don't want to move it uh too much to um you don't want to distress the patient. Um You can see it's quite a nice view on the left side of the patella and then you've got the um so it sort of Ben and you can see it's kind of the patella, you can see the joint space there. So it's a, it's a good view. Nice. So the next question, so the radiograph is shown above, what is the diagnosis to think about? Um you know which leg is, which leg is it? Is it the left or right? And then um it's the fracture. How would you describe the fracture? Any ideas you can put in chat? Just got a few moments. Uh Should we re review uh review the answers? So this is a left. So, I mean, in the stem mode, he kind of says the patient has pain in the left knee, but um this would be the left, the left, uh the left knee and it's undisplaced and it's a transverse patella fracture. So um if you, if you could click on the, click on it again, uh Thanks, you can see where the arrow is. That's the um the transverse. So going from left to right, uh it's a frac uh patella fracture. So, on the superior kind of pole of the patella and it's undisplaced as well. Yeah, and that's on the lateral view as well. You can see. Great. So, um so this uh this is a bit of a kind of more difficult uh question. So what uh classification is used for patellar fractures? Does anyone have any ideas? Yeah, great. Someone said AO Foundation. Yeah, perfect. Yeah, very good. So, um that's correct. So, yeah, it's the AO foundation uh cation and it's pretty simple kind of uh the three main groups which you should be aware of is the. So um group one being the extra articular or avulsion fractures, uh two being partial articular fractures and three being complete articular fractures. And if you go into the next slide, there's a diagram which shows the sub subgroups within these uh classification within these kind of types as you can see. OK. Yeah. So um given the diagnosis, how would you manage the patients? So what do you guys think with this patient? What would you, what would you do? And the scenario? So, I think about um what type of fracture it is and how would you, how would you manage that? Should we uh review your answers? Yeah, nice. So, uh because it's undisplaced this fracture, you wouldn't, uh you wouldn't opt for surgical management. So you'd want to do conservative management and you would uh immobilize the knee in a hinged knee brace or a cylinder case in extension. So with uh the knee extended and you could do this for kind of. Yes, for six weeks. Um Yeah. And then uh the patient would be allowed to fully weight, bear as well. So that would get the patient um prevent any uh increased healing, prevent any muscle atrophy, prevent any chances of DVT. Um So uh in orthopedics, if it's undisplaced, most of the time, you can, you won't need surgery. Um And if it is displaced, then most of the time you would need some sort of surgery to fix that. So should move on to the next question and then go back. So that's um, what on the left side of the picture of the slide is a um hinge knee brace and then on the right side is a cylinder case. So, um I think more the hinge knee brace is more preferable over the cylinder case. Um either can be used. Um Looks pretty cool. It's pretty um Yeah, nice. So, um what type of bone is the patella? So, going back to osteology, bit of uh pre preclinical knowledge. I don't really know what type of bone the patella is. Yeah. Sesamoid. Yeah. Perfect. Great. Um Yeah, so that's right. So the patella is the biggest sesamoid bone. Um You've also got um two other, well, you've got one other uh sesame uh Sesame. Does anyone have any ideas what the other one is? It's smaller than the patella? Uh I can give you a clue it's found in the hands. So one of the, one of the bones in the hands is also a sesamoid bone. So it's also the um the p of form as well. So the p of form is also a Sesame bone. Um And, but yeah, that was just about osteology of the patella. Um And then yeah, so you've got the base of the superior. So, ii, when I first learned about this, you know, I got a bit confused because you think bases at the bottom but the the bases, the superior and then the apex, which is the pointy bit is um on the, on the inferior border. Great. So we move on to the next question. So um if the fracture was displaced, how would you treat the patient? So if it was displaced and the the fracture was, you know, not aligned properly, what would you, what treatment options can you do? Yeah, perfect. Yeah. So someone said or if so, yeah, that's great. So yeah, an orthopedics, if something's a place, this place you usually do an or if um and do you know specifically what sort of uh technique you could use? I thought that's OK. Should we uh reveal the answer? So, yeah, most commonly you do an open reduction, so you'd reduce it, you'd go into theater, you'd open up uh the, the uh the knee, you reduce the, the fracture and then you would internally fixate it. Um And then most commonly it would be used. Uh tension band wiring is most commonly used, but you can also do screw fixation as well. So that's just like cannulated screws. And in some cases, if the, if an or is not possible or it's not successful, then you can do a partial or total ectomy, which is where you just completely remove the patella. And, and if you look at the next slide you can see some, some pictures of these uh procedures. So on the left, you've got that tension band wiring. So you kind of put some kind of like K wires and then some tension bands to hold that fracture together, to out to heal uh in the meadow. You've got the, the uh screw fixation and then uh on the right and you can see there's no patella there. So that's, it's been removed. Um And they can still, yeah, function normally without patella. We move on to the next question. So, um what are potential complications associated with patella fractures is if you have any ideas, what can it can be a complication? Arthritis? Yeah. Yeah. Very good. Yeah, I mean, um that's always a safe bet to say. So, um it can more specifically it be, you call it uh either secondary osteoarthritis or uh posttraumatic or uh posttraumatic arthritis. So, um with most, a lot of fractures, not just with, you know, fracture with um shoulder fractures, hip fractures, ankle fractures, there's always a, a high, there's always a chance of developing uh osteoarthritis. Any other um complications you can think of? Should we um have a look at the answers? So, yeah, you've got a secondary osteoarthritis. You've got um symptomatic hardware. So that's where, you know, the, the screws or the, the wiring can become um irritated, they can move so they can migrate, they could not work at all. Um They could come infected as well, which would require removal or revision surgery. That could be with any uh fracture as well. That could be bone malunion. So it doesn't um heal properly together. That could be nonunion. Uh There could be a chance of a patellar tendon rupture as well. Um And with most or with all surgeries, you can also, there's a chance of bleeding and infection and also as well. If the uh patient doesn't uh weight bear immobilize um early, they could develop a muscle atrophy as well. So that's just a few of the potential complications which can be associated with potential fractures. So as as uh before we move on to the next case, does any anyone have any questions about that? Feel free to put it in the shop? Yeah, great. So yeah, so we move on to the second case then. So um the second case, a 20 year old female presents to the emergency department with complaints of knee instability and swelling following a skiing accident. She reports hearing a pop in her knee at the time of injury and has been able unable to fully bear weight on the affected leg since then. So given the most likely diagnosis, what would you look for on a physical examination? So, does anyone have any ideas? Pop it in the chat? Swelling? Yeah. Great. Yeah, definitely. Yeah. Great. Yeah. Positive anterior draws and las and redness. Yeah, definitely. Yeah. All very good answers and yeah. Great. So, we have a look at the answers. Oh, so, yeah. So, yeah, positive Lachman's test, positive anterior drawer test, uh, knee swelling and redness as well. Um, quadriceps, avoidance gait. So you'd also want to, if they are able to kind of, uh, walk a little bit, you can see that they don't actually extend that knee and they will also, um, if it's, you know, very painful, be unable to wait there too. Um Yeah, and then you can see you. So the difference between these two tests, you've got the Lachmans where you um isolate that femur, so you bring you lift the leg up and then you uh pull the, the, the tibia and the fibula anteriorly and then the anterior drawer test where you um flex the knee, sit on the, um sit on the foot and then pull the, pull the lower leg, the tibia and the fibula towards you. And there shouldn't be uh much movement. So it should only be sort of five millimeters of movement. But um any increased movement could be a could be a sign of, would be a positive sign. So it's increased laxity in that, that movement. Ok. So, um what is the most common mechanism of an injury for an ACL injury? So it's the most common sort of uh cause how it, what movement would cause an a cell injury? Yeah, great. So it's almost twisting me. Definitely. Yeah. So, um yeah, I can have a answer. So, yeah, sudden twisting. Um and also like awkward landing so that it's, you know, it can be quite common in like basketball. Um, it's more common in sort of non contact sports, like football, basketball and netball, things like that where you jump and it lands or when you're kind of moving around a lot on your feet. So it's very common and yeah, skiing as well. Yeah. So you've got sort of that kind of movement. So you've got that media rotation of the, of your sort of hip and then with your foot being planted, it doesn't move with it and cause that ACL tear. So great. Um So um in most cases, you wouldn't, you know, you wouldn't, you do, this is quite very, you've got very high sus suspicion that this is a uh ACL injury. But what would be the gold standard imaging option for an ACL injury? So I don't have any ideas. Great. Yeah, MRI. So um perfect. Yeah. So an X ray, it only shows bones. So that would be a normal, you do you have a normal X ray? And I said there was other sort of um injuries associated with that ACL injury, but um an MRI would be the gold standard in confirming and diagnosing a ACL injury. Um Yeah, great. And then, so I could so could, so could you uh describe the origin and insertion of the ACL so bit of anatomy any ideas we have. So the origin would be the medial area of the lateral femoral condyle. So that's um so more superior. So do that and then they would cross anteriorly over the PCR and insert anterior medial on the anterior medial aspect of the interchondral area on the tibial plateau. So you have a look at the uh next, next slide, you can have a look here. So you've got um on the left picture uh and you can see how the ACL comes from that uh that medial side of that lateral femoral condyle and then it inserts goes over the PCR and inserts and that uh on the tibia plateau and that intercon the arrows between the two, the two condyles and inserts anteriorly and a bit medially as well. So, um so a good way to remember this is putting your hands in your pockets. So if you put your hand in your pocket in, let's say your left pocket, then your left ACL will go in that direction. So from that lateral side to and inserts media. So that's a good way to remember. Um And then the PCR, so your posterior cruciate ligament will be the opposite. So it goes, it originates from the lateral aspect of that medial condyle and inserts uh quite posteriorly in that um intercondylar uh area on that tibial plateau. Great. So we uh we on. So um what other injuries commonly associated with ACL injuries. So I think you don't have any ideas. What, what are the injury is associated with an ACL tear or injury? Yep. Great. Yeah. So someone said medial meniscus and M CL. Yeah. Yeah, very good. So, yeah, so the most common would be a meniscal tear. So 50% of all ACL tears will also have a meniscal tear and the most common being the medial meniscus. Um We'll talk about the, the M CL as well in association with, with an ACL and medial meniscus tear later on. Um Yeah, definitely M CL uh could be, yeah, associated with ACL injuries as well. Definitely. And then um so what would be the immediate management of a suspected AC O there? So what uh what four things would you do if, let's say, yeah, this person was skiing and then um they collapsed. What would you, what would be the immediate management for that, for that, for the patient in that scenario? Any other? Yeah. Nice rice. Yeah, perfect. Yeah. So um yeah, you want to in that immediate management of a CTA, you want to do, you want to rest the, get the patient inside rest uh put ice, so reduce that sweating. So in um in a ACL tear or injury, that would be acute swelling. So it'll be, you know, really get swollen really quickly. So you'd want to put some ice compression as well and then elevate that leg as well. And then um obviously you can also give like an analgesia. So, pain relief too. Um, go to the next slide. So, what is the conservative treatment for an ACL test? So, um usually this is the most, um common initially in a patient. Yeah, physio, great. So, um, yeah, so you want to do rehabilitation, get physiotherapists involved. And um, I'm not sure if anyone here has a, has ever, you know, injured their ACL or got a friend or a mate who's injured there. But it's a very long uh recovery process involving a lot of people. So, um, yeah, initially, you would, you wouldn't acutely in an acute sets and you wouldn't, um, surgically manage, you wouldn't uh surgically fix the ACL, you'd want to first rehabilitate them and then improve their strength around that knee. So we kind of look at the, to the answers. So, yeah, rehabilitation and physical therapy focusing on, you know, range of mo motion and then progressing to quad hamstring hip AUC and core strengthening. And, um, if the patient eventually can, you know, they can wait there, uh, they can, you can get a quick pad knee splint just to protect, um, and support that knee. So we can, uh, should move on to the next slide and see. So that's what kind of typically looks like. Um, just when someone's recovering and then the next question. So what is the surgical treatment for ACL tear? Then? Any ideas? Ok. Yeah. Reconstruction. Yeah. Great. Well done. So, yeah, you'd want to um surgically reconstruct the ACL using a tendon or an artificial graft. And this is uh commonly done arthroscopically as well. So I can have a look at the answers. So, yeah. And so yeah, it's not performed acutely, but it's, it's done following a period of prehabilitation. So that's uh with this sort of conservative treatment first. So you do a few months of physiotherapy, strengthen that leg. Um strengthening. yeah, the muscles around out of the leg to support the knee. And then you would do do do uh surgical reconstruction. So yeah, it can be very, very long uh long recovery journey. And if you have a look at the next slides, you can have a look at some pictures. So you can see on the top that is uh some pictures of an arthroscopic um arthroscopic reconstruction of the right ACL using an autograph. So an autograph is when they sort of grow um that tissue that ligament using um another source from your body. So you most commonly be in the IAC crest, but they could also use your proximal tibia or your fibula or a rib and that they can use that and grow that uh ligament to then um fix that your, fix your, fix the ACL tear. And then on the picture on the diagram, on the right, you can see how um they use. So they use screws so they screw in sort of in that anterior aspect of the tibia. And then also on that lateral side of your uh your femur and then with those screws, they can anchor that new um new reconstructed ACL ligaments. ACL. Um So yeah, pretty, pretty cool stuff and that's it. Any questions for that case? Yeah, lovely. Uh Thank you very much David for those two great cases on the patella fractures and um ACL tear. So um case three is um a 65 year old female presents to the emergency department with right knee pain and swelling following a fall from a bicycle, she reports landing directly onto a flexed right knee on examination. There is tenderness and swelling over the proximal tibia with limited range of motion due to pain. Anterior draw and Lachman's test are negative. You suspect a tibial plateau fracture. What is the mechanism of action that can cause a tibial plateau fracture? Uh da if you uh just uh man the chat, if that's all right. Yeah, of course, no worries. Ok. So yeah, this this case is not, you know, it's quite unlikely that this will come up in a, in a an exam. But um it's just interesting to know about if you're interested in orthopedics. So, yeah, it's quite a common, a common uh trauma injury that you may have seen on your placement. Uh ACL S are probably the most likely question that can come up in exams. Um However, it's always good to have a, a good understanding about pathology that can happen in the knee, um especially if you want to pursue a career in surgery. So going through the answers. So it's um a valgus force causing a lateral tibial plateau fracture or a varus force causing a medial tibial plateau fracture. It's usually quite high energy causing an axial load uh and usually from low energy trauma such as falling off a bike, for example, like the patient did. So essentially, it's kind of a force coming in. Your knee is flexed, it's quite low energy going and the force is going downwards and it can cause a fracture in the tibial plateau, which is commonly the area of the tibia where um the articular surface can be as well. Um And we'll probably come on to that next soon. Um So what associated conditions or injuries would you be looking out for? So you're in A&E you think someone's, you know, so someone's fallen off a bike. Um You've, you've done your ACL tests are negative. What other injuries would you wanna kind of rule out or look out for? Just pop, pop, pop your thoughts into the chat. So primarily you, you want to kind of look for any, any, any other um bone, any other bone or other um ligamentous injuries um around the knee. So that can involve your lateral or medial meniscus. Um your ACL injuries like uh David just covered uh potential fibrillar head fractures which are quite important because they can cause um uh problems to your uh perineal nerve, which can cause symptoms such as foot drop. Um Compartment syndrome is a big one. and uh neurovascular injury as well. So it's always good to have a AAA broad understanding of knee pathology when you see someone with a trauma to the knee. So there's you can also, I didn't add but you can also, yeah, as it currently says, yeah, other fractures. So like a hip fracture, other head trauma. So you'd always want to like a kind of a holistic view on the patient and always, well, yeah, absolutely. Absolutely. Especially if you're, if especially in a trauma setting, you want to kind of do an A two E assessment before you kind of hone in on what, what is going wrong um from a burning perspective to kind of give that holistic approach to when you see a patient. Um So what classification is commonly used for tibial plateau fractures? So this is probably a bit more mainstream which more of you may have heard about. So, orthopedic loves classification systems and loves to classify things into different ways um to kind of make it a bit more logical to explain things. Um And it was, it's always good to kind of have a basic understanding. So I don't think there's anything in the chat. Um So someone said Weber um good, good thought. But um yeah, we Weber's close. Weber's in the ankle, which we covered last week. Um, but yeah, sure shaka classifications. Um, and there's, er, six types which I think, yeah, there you go. Um, so there's six type, we don't need to notice it at medical school level. It's more for core training, et cetera. But, um, but yeah, you wanna look at it. So you can see here there's a lateral tibial plateau fracture without a depression, depression basically means what you see in chats type two where the bone depresses downwards. Um Chats type three is usually more centralized. Um more of a compression fracture. Type four is medial um type five is bicondylar. So it's on both sides and type six is uh a tibial plateau fracture where the dye facil discontinue. So it's discontinued here. Um And you can see there's an associated fracture um in the tibial area as well. So, um it's always good to have a basic understanding of the, there's six types and it's a shas classification um for our level at medical school just to have a basic understanding of knee pathology. So based on what I've what the type, the six types I've just mentioned, um if someone in the chat um can mention what the radiograph here shows. So any time you describe a radiograph, you wanna say this is an ap view of a uh of, of a I think so. Yeah, right, right sided um right side of the knee. Um and he obviously followed the congruity, cong cong congruity of the bone. Um um So obviously, you can see here there's a clear tubal plateau fracture. Uh Yeah. So yeah, it's, it's a, a right type one, obviously, it's lateral er as it's on the side of the fibula. So any time you get confused in an exam, you don't know what side it is, cos it happened to me in an exam. Um You just think you just look at the, obviously in, in that stressful exam setting, you can kind of get flustered. So always look at the fibula, the fibula is always lateral. Um So you'll always be able to see what side it is. Um Yeah, so it's a type one. So you do a neurovascular examination that shows common fibular nerve injury or I might have said the answer to this um what sensation and movement will be reduced or lost. So this is a good question to test your anatomy. Um uh Thinking about where the common peroneal nerve goes where it splits into. Um And that can kind of help your understanding of the uh sens motor and sensory innovations of those. No, so anyone that chop you can break. So the common perineal nerve it wraps around the head of the fibula. And yeah. Uh so yeah, you, as I said earlier, you can get foot drop um which is due to er innervation of the um extensor muscles such as uh the tibialis muscle. And as you can remember, the common, common er perineal nerve splits into your um deep and superficial branch. The deep one goes into your anterior compartment, your superficial branch goes into your lateral compartment. So your paraesthesia will be along the later aspect of the leg, the dorsum of the foot and the first web space. Um you'll also be unable to extend or either the foot, which is, which is the muscles um innervated in the lateral compartment, which are your um Peroneal er longus and Brevis. So, so yeah, basically, it's, it's good to know the uh the anatomy of, of that because that's a common question that can come up um especially just um trauma to the er head of the fibula. So I'd, I'd make a point that's quite important to learn. Uh Sorry PG Some, some, some people are saying that um the, the powerpoints on full screen, I'm not sure. Yeah, I mean, for me, for me, it's, for me, it is, but um I'm not sure. Is that better? Uh Sorry about that guys. Is it, is it fixed or is it still still kind of in the corner? Oh, it's back. Ok, great, thanks. Um So, yeah, so it's um yeah, so it's a foot drop and you get paraesthesia along the lateral part of the leg, the dorsum of the foot and the first web space. That's the important bit. So, as we said here, so your Longus and brevis of your. So the fibula is also used the, the word, the word peri perineum fibular um in is also the same thing. So some people call it fibularis long, some people call it perineal longus doesn't really matter. Um So those are the two muscles. So obviously, if those muscles aren't working, you won't be able to even up the foot because there won't be any pull. So if you think about muscles or think about like a pulley system makes it a bit easier to learn. Um, your deep branch of the perineal nerve will supply your anterior compartment muscles, which are your extensors. So you won't be able to lift the foot up and then this is your sensory branches of those. So your uh superficial supplies the um the dorsum of the foot and the deep branches supplies the um your first web space. Ok. So the orthopedic surgeon, uh orthopedic surgeon decides on a surgical treatment. There's no soft in soft tissue injury. What is the most likely operation to be? So, as most things in orthopedics, uh if it's an operation, if there's a fracture, it's likely to be um one of the very few things. Um So what do you think it's gonna be? So like, like usually open reduction, internal fixation, also known as an orif. So you basically want to restore the joint surface congruence and ensure joint stability. Um And this is quite important in those type two fractures. Um, where there's depression you wanna kind of actively lift. If you've ever seen a surgery, it's quite cool. You should go see it. They kind of lift it up and try to put a buttress plate on. Maybe I shouldn't say that. Um, they'll put, er, they'll, they'll, they'll fix it. Maybe it might be a later question. My bad. Um, yeah, you can also fill up gaps with, uh, like, like David said about bone grafts, er or bone bone substitutes. So, yeah, so here's a, this is what we call a buttress plate. Um And you can put that in, stick some screws in, this is usually done on X ray um supervision. Um So you wanna put some screws in uh sometimes a lock in and then you wanna, you wanna go by a cortical, so you wanna go through both cortexes. Um So sometimes in theater, you might see, you know, the surgeons going really hard on the cortex on and there's a massive give when the bone uh when the screw goes through here and then they'll reach the other cortex. So this will kind of improve the, the, the joint surface and this will obviously prevent complications long term. So what management would you give to the patient POSTOP? You're the f one on the ward. Um You've got their note from that op note. How would you kind of tell the patient? So, so postoperatively, they likely to be in a hinge knee brace, um, and it'll be fitted usually in theater and they may have, they may be able to do some, er, passive range of motion but it'll be limited. Um, although be non wa this all depends on the surgeon's preference. Some surgeons are lesser, a bit more active in terms of getting people up and going. Some are not, um, and per surgeon's preference and usually just follow the up note, um, typically 8 to 12 weeks. And if you, as David said, um, hinge knee brace, um, if you ever look at the size of them, they've got these circular bits which you can, um, which usually the, the, all the, all the surgeons will set, all the physios will set and they'll allow a certain degree of movement. So there might be 30 degree for a few weeks and up it to like 60 then up it to 100 and 20 that prevents, um, flexion, um, excessive flexion. So that will help, um, a slow, progressive, um, rehab. Ok. So, unfortunately, the patient develops posttraumatic osteoarthritis later in life. I assume what the four cardinal signs you'll see on a radiograph. And now this is a good question because it came up in my third year exams last year. So we'll wait till someone pops in the chat. So I can see a lot of joint space. Good osteophytes. Good. Two more. Yes. So the acronym is, um, loss. So, like rightly said in the chat, loss of joint space, osteophytes, subchondral cysts and subchondral sclerosis uh for rheumatoid arthritis. The acronym is less. Um So do look it up. Um cos that's quite important. It's good to know the differentiation between the two for exams. So here we can see um a um an ap view of the left knee. Um Here you can see that there's a loss of joint space here and this is usually um medial compartment, arthritis, osteoarthritis. You might see that a lot of people tend to get to this stage may end up needing a um surgical intervention. Um, osteophytes form as the bone is growing, but it tends to grow outwards. There's some sclerosed bone and there may be some cysts, but there's not any here. So, um, yeah, so if someone gets to this stage treatments, usually physio um in arthritis, obviously, but then they might need a partial knee replacement, uh or a full knee replacement. So, um, yeah, good. It's good to know the management options of osteoarthritis. So that's our three Sa Qs. We're gonna go through five SBA S now. Um Just jot down the um, the letter in the chat. Um So 14 year old male presents to the clinic with anterior knee pain that's worsened with physical activity. He's a avid soccer player and has recently experienced a growth spurt on examination. There is localized tenderness and swelling over the tibial tuberosity. He reports no history of trauma to the knee, which of the following is the most likely diagnosis. So, tendonitis, meniscal tear, osgood splatter disease. P FJ, pain or chondromalacia patella. Pop your letters in the chat. Oh, let me see. A few CS is about right. Yeah, Oscar's latter's disease. So, Oscar's latter is usually seen in, er, sporty teenagers, usually when they're having a growth spurt. Um, it's usually pain and tenderness over the tibial tuberosity, um can be caused by trauma. Um It's usually treated with just ice rest elevation and usually nsaids surgery barely use and it usually improves as they get older. There. You can see femur patella tibia and that tibial tuo and you can see that little bony growth there. Good. Hold on question. 2, 19 year old female presents to the clinic with anterior knee pain that worsens with prolonged sitting and climbing stairs. She reports a history of recurrent knee injuries and participates in high impact exercises on examination. There is tenderness along with medial and lateral board along the medial and lateral borders of the patella crepitus is noted with passive knee extension and flexion, which of the following is the most likely diagnosis. Patella tendonitis, meniscal tear, Oscar scatters disease P FJ pain syndrome, chondromalacia patellae. Hard question. So let's break the question down. She's 19. She's worse when she's been sitting for too long or climbing stairs. Uh She has a history of current injuries, has high impact exercises and there's tenderness on, on either side of the patella, it's on crepitus. So what do you think? So, the answer is chondromalacia patellae and we'll go into that. So it's basically softening of the cartilage of the patella. Uh It's common in teenage girls. Um and it's usually pain when walking up and down the stairs and arises from prolonged sitting as well, usually responds well from physio. So as you can see here, there's inflammation posterior to the patella. So that can, that, that's usually softening of that cartilage behind it. That's chondromalacia, malacia, softening. Chondro is cartilage. So question three, 35 year old male presents at the clinic with lateral uh knee pain that's worse when running and descending the stairs. He described a sharp stabbing pain along the outside of his knee and began gradually as it has persisted over several weeks. On examination. There's tenderness over the lateral femoral condyle and pain is reproduced with palpation or flexion and extension of the knee joint. Which of the following is most likely trochanteric bursitis, ITB syndrome, patella, stress fracture, tibial plateau fracture, and a lateral meniscal tear. So I would just pop it in a chat. What you think? Don't worry if you, if you're not sure anyone wanna had your guess. Yeah. So it's ITB uh down syndrome. The ITB is a, it's a band that extends up from your, um your hip travels down a very fibrous structure, inserts into the lateral portion of your um your knee. Um It's usually a couple of centimeters of tenderness above common in runners. Basically, you need to change your activities and you can refer to your physio. So, yeah, it's all well done if you've got that. So which of the following is part of the unhappy triad, lateral collateral ligament, lateral meniscal tear, posterior cruciate ligament, uh medial meniscal tear and patellar tendon rupture. So this is, so the sign says d looks good to me. So yeah, you're on abu is your ACL medial meniscus and your medial collateral ligament. Final question for today. 45 year old female presents to the clinic with pain and swelling over the anterior aspect of her knee. She reports a history of repetitive kneeling at work and gardening activities on examination. There's localized tenderness and swelling over the patella tendon and the area is warm to touch, passive flexion and extension of the of the knee joint exacerbate the pain, which of the following is most likely meniscal tear, rheumatoid arthritis, infrapatellar bursitis, prepatellar bursitis or good Slatter disease. So I think this, this is in the second year work or first year M SK content. Um I remember this from the Belbin days. So what do you think? What do you think's happening and you want the shot? So, yeah, it's pre patella bursitis. So these are common in uh in people that are usually like um domestic cleaners that usually get on all fours. Um common historically, um and it's usually pain just, just posterior to the um to the patella when, when the knee is flexed, but it usually is generalized tenderness. So, yeah. So it knows housemaid's knee or carpet, there's knee, it's characterized by inflammation of the bursa. Um, so commonly treated with nsaids, symptomatic relief can give physio uh but usually it does settle over time. So, yeah. Thank you very much guys. Um Hope you enjoyed today's session. Um uh Yeah, as David said, it's a bit of a harsh question, but yeah, yeah, I agree. Um, but that's all right. Um So yeah, there's a, there's a QR code there. Um If you, it would be great if you can give your feedback. Um, what would be the way to slide? Yeah. Yeah. So I'll, I'll leave you the answer to that question though. Oh yeah. So yeah, if you just, if you could fill out the feedback form, that'd be great. And then, um, you, you have to put your email address in there and then I can send the slides. So, yeah, I'm glad you found it useful. But um, yeah, be more than happy to. Yeah. Yeah, we'll send out the slides of all the answers. Yeah. Thank you. Thank you everyone for joining as well. Um Our next er, session will be in two weeks and it'll be quite a good one on pediatric fractures and, and conditions. So, uh a lot more, a lot more stuff. So yeah, um definitely will be interesting and high yield stuff. So that would be, yeah, in two week time, same time, same day. And yeah, if you can fill out, fill out that form, uh let me know if it's not working, I could put a link in the chat if you can't scan it. So just let me know if you want a link in the chat and then um yeah, and also the feedback helps us improve these sessions and helps us uh improve. Yeah, with what we're doing, right, what we're doing, right. So, yeah, we would really appreciate, yeah. Yeah, and thank you for your time coming. Yeah, and thank you PG as well and worries. Thanks for the slides, David. Really good and really informative, three really good cases. Um And uh yeah, so the anatomy is quite important. Um And yeah, so yeah, if you give us our, your feedback and we'll hopefully incorporate that into our next two sessions, er, that we've got left for this series. Um, and I appreciate your commitment towards exams coming as well. So we've got pediatrics, as David Rightly said, and then there's one on spines which will be four weeks from now. So, yeah, same place. Um, so um it's good to see you all. Um, and if you, if you wanna do any sessions um in the next coming weeks or months, just DM us on Instagram. Um I'm more than happy to let you guys lead as well as this is your society just as much as it is our. Um So yeah, um there is, is the link working guys. Yeah. Should I be? I'm getting some responses. Should be working. Yeah. Thank you very much guys. Um Yeah. Um uh if, if everything's all good and we can call it a day, David. Yeah, perfect. Yeah, thank you. Yeah, great. Thank you, everyone. Yeah, see you, see you all next in about two weeks time uh for pediatric uh orthopedic. Thanks guys. Thank you. Thank you. Thanks.