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All right guys. Can you just confirm whether or not what is it? All right then guys. Um, thank you for coming. Um, we're gonna talk about TNA today, so I've got Fareed here with me. Um, hi guys. My name is Fareed. I'm doing the slides with Scott as well. Um, we're just gonna talk about a couple of presentations which are pretty common, uh, especially for Sh OS in TN O. probably the two most common things that you will see. Um, so that femoral fragility fractures, uh AK A knots, er, and we'll just talk about how you classify them any sort of initial investigations and managements that you'll do, er, and then the sort of definitive surgical management after that, we'll talk about Cad Quina syndrome and go through the same sort of things and then at the end, we will talk about X ray interpretation for M sk x-rays, which, you know, as well has been important for, uh, TN O, placements is actually just really important for every placement that you're on. Um, almost every placement you'll have to interpret some sort of M SK x-ray at some point in time. So, it's useful to know how to do it. Um, I'm gonna hand over to Fareed to, to sort of talk you through the first case, uh, and give you a couple of minutes just to think about it. I think it would be really useful to write your answers down. Uh, if you can otherwise just think about them in your head. Um, and then we will go through the teaching and then repent the case at the end. Uh And you can think about how your answers might have changed at the end of the case. OK. So we have the first case. So as you guys can see, Maggie is a 87 year old female patient presenting with left hip pain, unable to mobilize after a fall while getting up from the bed to immobilize to the toilet. Uh She describes the symptoms of dizziness and um sort of closing vision prior to the fall. She had no loss of consciousness, no trauma to her head and she had a long life of roughly five hours before being found by her son. And you can see the past medical history. She is on Warfarin for her atrial fibrillation. She's on amLODIPine for hypertension and in terms of her social history, she lives alone and she immobilizes with her sticks and you can see the X ray on admission. So I'd like you guys to take a look and obviously have a guess and see what type of x-ray. It is. And, and if there's any fracture or not, and, uh, there's some questions now coming up. So the first question to ask yourself is, you know, what initial investigations might you want to consider aside from this x-ray? Uh, and how would you classify this fracture? And again, what is your initial management plan when you see this patient? Imagine yourself, you're an ho you get cold and bleeped about this from A&E and obviously, what's the most appropriate surgical management? So see, these are the things that you need to think about when you're presented with cases like this. So, um I'll give you guys one or two minutes just to, you know, think it through and then if anyone wants to have a go or have a crack, uh just you can answer in the chat. It's OK. Yes. Anyways, OK. That's fine. Now that you guys read the question, we'll just move on to the next slide and explain things. So neck of femur fracture. So the femoral head receives a blood supply from three arterial sources. Uh There's some nutrient arteries inside the bone and then the ligamentum terrace and the femoral circumflex arteries, they sort of encircle the femoral neck uh on top of the capsule, which is why most of the time that if you have a fracture, a hip fracture, uh uh specifically intracapsular fracture, it affects these arteries. And uh you, most times you'd have to replace the uh um the f the neck of the femur with a total hip replacement or a hemi arthroplasty. Um So, move over to the next slide. So it's, it's good to have a look at this picture to see, to help you classify whether or not it's intracapsular or extracapsular. That's the most important bit to recognize when looking at the neck, a feur fracture. So if you look at the blue line, obviously, uh anything inside the blue line is a intracapsular fracture. And what that means, basically, it's inside the hip joint. Uh So, um that's what intracapsular means. Obviously, it, it, it can be fractured at different regions, whether it's the subcapsule region, the transcervical region or the basic cervical region, I think at, at your stage and at your level, the most important thing to know that it falls within the intracapsular hip joint region. And then you have the extracapsular region uh which is outside the um um the blue region, which is basically the greater between the greater tranter of the femur, which is uh that over there, uh all the way to the lesser tranter, which is on the lower portion, sort of uh um a parallel line in between them. And then we have the subtrochanteric uh fractures, which is that red line below. Um So if you have a look there, that's the red light. So the three main things to know is recognize that there's a fracture. And then once you recognize that there is a fracture. What type of fracture is it, is it intracapsular? Is it inter intertrochanteric fracture or is it subtrochanteric fracture? Uh Those are the three main differences to know because that would affect your surgical management. Whether you do a um total hip replacement, whether you do a dynamic hip screw or whether you do an intramedullary nail. Um Yeah. So move on to the next. So we have a garden classification system uh to recognize the severity of the fracture. We have type one, which is an incomplete fracture line or impacted fracture. We have stage two which is the complete fracture line and it's not displaced. And then we have stage three, which is a complete fracture line with partial displacement. And then we have stage four, which is a complete fracture line with a complete displacement. So, so causes, so we need to think of the demographic on your patients on who usually has these fractures. And I'm sure Scott can um uh back me up on this and it's mainly elderly patients 65 years and older, low energy trauma. It's usually from a fall and then they're outstanding eye. They just have a fall, they trip. Um sometimes high energy trauma can cause uh neck of femur fractures in younger patients. But generally uh the patients that we see tend to be uh older patients. Um rarely we do see it in sort of patients who have a tumor or infection that may cause um you know, neck of femur fractures. Uh But the reason why it happened in older patients is obviously uh more common in in female patients because after the age of 5055 after menopause, uh they get a drop in estrogen which protects the bone. And obviously, now that they have a drop in estrogen, they're more prone to osteoporosis. Um uh long uh long term use of corticosteroids obviously can affect the bone density and increase your risk for osteoporosis, alcohol consumption because obviously, the patient is a bit um uh disoriented from alcohol and they may trip and fall over and um also infections. Uh te generally, patients who are older who get infections might be a bit delirious um and they might be more prone to tripping. So, yeah, I mean, this is basically what I mentioned. So, uh if they're over the age of 65 years in women and 75 years in men, uh as I mentioned with women, the reason why is because after menopause, they get a drop in estrogen and generally with old age as well with men, um your bone density tends to drop and you have a higher risk for osteoporosis. Um um So menopause, amenorrhea, smoking as well, excessive alcohol, physical inactivity. So things like weightlifting tends to help uh combat fractures. Um uh long term use of steroids, previous fractures, uh history of falls, poor nutrition and obviously low body mass as well can affect the dementia visual impairment, which increases your risks of falling and history of tumors. Although that's a bit more rare to. Oh, so I think generally speaking, like you're at increased risk of having a neck of femur fracture for two reasons either because your bones are more brittle. So that's the kind of things that Fareed mention like the osteoporosis or because you're more likely to fall. So that's history of falls and uh poor nutrition, dementia, things like that are things that are just linked to having more falls, basically. Yeah. And one of the things to mention before we move on to the symptoms is um if a patient falls and it's a new presentation, it's always good to investigate the cause of the falls. We'll we'll talk about it in the next slides, but things like infections uh do a full blood count, uh obviously assess their social mobility. Um But anyways, I'll, we'll talk about that later on in terms of symptoms. So obviously, you get pain in the hip or in the groin. Now, you might think that obviously, if you have a neck of femur fracture, the pain will be more towards, you know, your backside, but actually, it's more towards your groin. And sometimes you can get knee pain with no hip pain or groin pain and they can have a neck of femur fracture. I've seen a patient only had referred knee pain and turned out they had a neck of femur fracture, they bedbound. Uh And the reason for that is obviously the femoral nerve innervates the neck of, you know, the the hip joint, but also innervates the knee, the the knee portion as well. So you can have a fracture in the hip, but then get referred knee pain. So because of the similar innervation and things like unable to weight bear, uh obviously, it's going to be extremely painful, they're not going to be able to walk. Um and uh decreased or painful mobility of the affected hip. Uh Now, sometimes you might run into patients who are bed bound. So, um it's, it's good that you do a, a thorough investigation of the hip and not just rely on them, you know, being able to walk or not, especially if you're in, in the geriatric wards or, or patients who have very, very poor poor mobility as, as a baseline to begin with. And it's also worth noting that occasionally. So, I mean, today, we had a patient, for example, who was admitted, um who'd had a neck of feur fracture for six weeks, um and had been in a, a care home but had been sort of able to mobilize around. But because she had poor mobility anyway, uh didn't really notice that there was that fracture. Um she must have had a hell of a pain threshold. But, so this is the clinical frailty scale. Um Obviously, if they're very fit versus if they're sort of bad bound, severely frail. Uh This is important in terms of determining whether or not you would go for a hemiarthroplasty, which is a partial hip replacement versus uh total hip replacement. So, a total hip replacement, you'd give it to someone generally who is very fit, sort of well, asymptomatic um, is able to mobilize because the total hip replacement, you replace the acetabulum and the sort of uh the femur, the femoral head and that gives you sort of a lot of mobility to go on with your day to day life. Uh Whereas uh obviously, there's a, a risk that it may detach and um obviously, we'd have to revisit and do another surgery. But if you're severely frail or uh mo moderator flare, you go for a partial hip replacement because the normally their mobility is is they're not as mobile. So there's not a mu much movement and there's less risk of the hip joint detaching the new hip joints, um detaching, move on to the next slide. So when you examine a patient, first of all, you'll have a thorough history and once you get a history from them, obviously do it in the way you're taught with, you know, Socrates, um describing the pain, et cetera. Um So the affected leg is shortened normally and then externally rotated and abducted as you can see in the picture. And when you try to palpate the hip pain, they will generally be in tremendous pain and it will be very obvious. Um They can't perform a straight leg raise. Um And obviously, um, there's pain on gentle in uh internal and external rotation of the affected leg. So when you try to rotate the leg, you'll be in a lot of pain. Um So in some cases, you get a lot of bruising and swelling in some cases you don't. Um So generally you don't wanna rely on bruising and swelling whether or not you have a hip fracture. Uh So move on to the next slide. So investigations. So full blood count, e clotting creatine kinase. So you do a full blood count just to make sure they don't have any infection. Obviously, you'd add a CRP as well. Um because sometimes infection can lead to a fall. Um using the knees. If they have an AKI, you wanna make sure you rule that out because sometimes ak I can be a cause for the fall, maybe a contributing factor clotting because if this patient needs to go to surgery, it's really important to get clotting as well as a group and safe and uh uh creatine kinase as well. Obviously, if they had a fall with long lie, um they might, might have elevated creatine kinase because of the um long lie because of the breakdown of muscle tissue and that as well can cause kidney damage. Uh ECG obviously, you need to have that before surgery um especially if uh it could be a cause of the fall, such as uh bradycardia or heart block may cause the fall. Uh lying and standing BP. Obviously, it may be, you might not be able to do that, obviously, because of the patients in pain. But that's something to consider after uh the patient's better vasovagal symptoms may cause the fall. Um In terms of x-rays, you wanna have ap and lateral hip view of the X ray because you might see it one view and, and then you might not see it in the other. It's always good practice uh to have both and as well, you can look at um it's good to have a full, full length from all X ray just to make sure there's no metastases any pathological fractures. Um So, MRI, this is we rarely use MRI for hip fractures unless uh uh obviously, you don't see any hip fracture in the x-rays, but you have a strong clinical sub um suspicion that there is a hip fracture. Um Again, uh CT is, is more if MRI is not available. Um And it sort of, you get a better look as well, but generally x-rays tend to do the trick and most of the time uh you can notice the fracture and we'll talk about it more on the X ray interpretation. Um So, initial management, uh you get referred to A&E by someone with a fracture. What do you do analgesia. Uh they're going to be in tremendous pain. Uh You, you can start with paracetamol and other weaker painkillers, but that doesn't usually do the trick. You probably need to give them something stronger. You first need to ask A&E to give them um, a, a nerve block for more nerve block to help with the pain and give them some opioids in the meantime, until they get the nerve block. Um So I try to get IV access uh T two Cannulas uh to give medication the regular meds and for any blood transfusions, if they need some um assess and manage complications to prevent delay in surgical management, this will be your, your infections, your A KS uh uh correcting the anemia or the hemoglobin. If their hemoglobin is quite low, you need to give them a blood transfusion before surgery. Uh generally, uh elderly patients are going to be comorbid that come in not all the time, but most of the time with a lot of complications. So you have to make sure you adjust them for surgery. And obviously it's good to get the Ortho geriatricians involved um as well to make sure they can take care of the medical aspect of the patients. Just say that as well for the assessed and managed complications. Er, ants are really funny about uh electrolyte imbalances. So any sort of hyponatremia or hypo hyperkalemia, they really like that to be fixed before they go to the theater OK. So, surgical management, um I didn't have a picture on this, but basically, uh the most important thing is urgent reduction and internal fixation followed by early immobilization. So, depending on what surgery they have, this is the bread and butter of orthopedics is if there's a fracture and there's a displacement, whether or not it's like a femur fracture or any other fracture in the body is to reduce it as soon as possible. Uh And sort of engage in early immobilization and physiotherapy. So in the case of neck of femur fracture, uh if it's intracapsular fracture, then you would have a, a total hip replacement assuming they're fit and well, or a hemi arthroplasty or partial hip replacement. Um If it's a, yeah, if it's a inter uh trochanteric fracture, then you would give a dynamic hip screw that's between the greater trochanter and the lower uh lesser trochanter, um which would reduce the fracture. And then you'd have a um if it's subtrochanteric, you would have um interim nail which would help reduce the fracture. And then obviously, it's good to engage in physiotherapy. And usually once patients have this type of procedure they're fit and well immobilizing assuming they don't have any comorbidities within, within a day or sometimes even within the same day. So we're going back to the case again. So hopefully, now that makes sense and you feel more confident to answer these questions in terms of uh what initial investigations might you consider aside from the chest X ray? And obviously, how would you classify this fracture? What's your initial management plan and what's the most appropriate surgical management? So if we have a look at this case, um in particular, um, so that's fine. So in the initial investigations, like you mentioned FP CSE LFT S ECG, um and how would you classify this fracture? It's a intracapsular neck of femur fracture. Gardner stage four. Usually uh practice. Now people don't use the Gardner stage uh fracture. But if you have a look here, it's within the hip joint, uh intracapsular fracture and it's uh displaced, completely displaced. Um OK. Uh So what's your initial management plan? So you would give a femoral nerve block, but in the meantime, you'd give some Oramorph as well. Uh You'd correct clotting assuming if they have. So this patient was on Warfarin. So the inr would probably raise their clotting would be um sort of high. So usually uh you'd give 5 mg IV, Vitamin K But as an, if you're not sure you can always call hematology, you get some advice and correct that dose. Uh Warfarin is a medication they don't like for surgery because it takes a while to reverse uh the patients to be on lower low molecular weight heparin. Uh But you're going to have to obviously reverse that. Um And obviously you'd give them some fluids, uh IV fluids as well. Uh So the appropriate surgical management for this patient is a hemi arthroplasty which is a partial hip replacements. Uh due to the fact that this patient's baseline mobility is sort of impaired. So one taking a history from the patient getting a good social history is really important. Assessing their baseline. Are they normally fit and well, do they walk around normally or do they use a walking stick or are they bedbound? In this case, the patient was using a walking stick and it has a fairly poor mobility. Uh, so they had a hemiarthroplasty stuff. Mm. Just hand over to Scott to talk about the second case, which is a very common case in orthopedics. You get looped about lots of time. Yeah, thanks for, uh, yeah. So we're gonna look at a case of called quina uh syndrome. Now, um, give me a sec the fee. So if we look through the case for a minute there, so it pretend you're a, a, an author S HL on call. Um, and you've been bleeped, er, about someone with back pain, er, which is, to be honest, probably the most frequent leep that you get, er, as an off sho, um, just because people are so concerned about called or equina. Um, that even if, if you know there's any sort of hint of, of it being potentially that then you'll, you'll be asked to go and review them. So, James is a 47 year old male presenting with New onset lumbar back pain over the last 24 hours. He initially noted the pain marks, listing, lifting at work, but it's progressed to 10 out of 10 severity of time with associated nausea, but no vomiting. He has difficulty walking and complains of shooting pains down the back of both of his legs. Additionally, he has felt like he needs to pass urine for the past five hours but has not been able to. his bowels are opening as normal, but he is unable to feel when he is wiping in terms of his past medical history. He's got type two diabetes and rheumatoid arthritis which mostly affects his hands. Uh, and his social history is, he works as a builder, uh, which explains why he was lifting as he was at work. If you just take a, a couple of minutes, write down your questions, uh, write down your answers, sorry, ideally, and then we'll come back to the questions at the end. Uh, and you can think about whether or not you want to change them. Um, but just go through the questions, uh, on the board that relating to the case before. Ok. Just give me one more minute. Ok. We'll come back to those questions at the end. Uh, at the end of talking about CHD Quina then, uh, and we'll think about whether or not we want to change our answers. So the first thing, uh, talk about CHD Quina is the, er, er, etiology. Um, so in terms of causes of CHR, by far, the most common is disc herniation, uh, commonly occurring at L5, S one and L4 and L5. Um, often times that's due to trauma. So it might be due to sort of twisting or heavy lifting. Er, but sometimes it's also just degenerative. So, particularly in older patients, it's just wear and tear over time, which has gradually led to the disc to wear down, er, and the pulps that's inside the disc is then able to bulge out er, and press on the corda requi the corda quina itself is uh the lower motor neurons that come off the end of the Conus medullaris. So that's the end of the spinal cord. So, corda quina is a lower motor neuron issue. It's the er lower motor neurons coming off that cord that get uh compressed in the spinal canal aside from disc herniation trauma is quite common. So, vertebral fractures that can uh press uh posteriorly onto the cord equina neoplasms, er, is also quite common that can be either primary within the spine or more likely metastatic. Um commonly renal um breast melanoma or metastasized to bone. Um and the spine's obviously a big area of bone that they, they often do metastasize to infection is less likely a cause of called a equina. Uh pots disease is TB of the spine, um which is quite rare to see, but it does happen. Um other things that can cause it again, even less common but chronic inflammatory disorders. So I spin for example, and iatrogenic. So, hematoma secondary to spinal anesthesias have been known to cause it in the past signs and symptoms. Um like I said, it is, it's a lower motor neuron issue. So you get that l classic lower motor neuron picture, uh reduced sensation weakness, um hypertonia. Um but you don't get any of the increased reflexes or ongoing plans or anything that you might expect to see in an op mood neural disorder, you also get back pain, which is just a mechanical pressing on the nerves, um and that is usually severe. So most of the time you see patients record a recliner and they'll come in, unable to walk really 10 out of 10 severe pain. Rarely. It happens that the, the symptoms aren't actually that severe and they, they are able to walk and come in. But normally you're more concerned if they've got this really, really severe back pain. Um, bladder and bowel dysfunction is quite common uh and impotence as well. And that's because of the er, parasympathetic nervous system, which, which comes with those nerve roots, which gets compressed. And most concerning is urinary retention. So, an inability to open up the bladder neck and release urine. So they go into urinary retention and that's pretty much it was the best, er, signer for Corina in terms of the examinations that you want to do, then you want to do a full lower limb neurological examination. Most hospitals will have a clerking pro performer. Uh That will take you for exactly what you want to do for somebody with called a equina. But if they don't, a lot of hospitals also use what's called an Asia chart. So an American Spinal Injury Association chart. Um and that's kind of everything that you've sort of learned really from a neuro examination. So it's full sort of sensitivity across uh all of the dermat homes. Um, you'll do muscle strength. So L2 hip flexors, L3, hip knee extension and go through your myotomes like that testing uh the power according to the MRC grading. So five out of five being full power, er, four out of five being some resistance. Three out of five being um some action with gravity removed, et cetera, et cetera. Uh you'll also test their reflexes and again, because it's a lower rating or an issue, you'll be looking for hyporeflexia, so, decreased reflex. Um and you will do er, certain tests as well. So straight leg ray is, is quite a common one. and normally this would be positive uh because you're stretching that sciatic nerve and it, it's worsening that pain that you'll get on doing that. Um, as well as doing that full lower limb neurological examination if you do find any signs of an upper motor neuron. So that might be uh upgoing plantars, hyperreflexia, hypertonia. Um then you would want to do an upper limb neuro examination as well. Cos again, that would suggest that actually, it's an upper motor neuron issue, which could suggest something compressing the spinal cord rather than just compressing the cord or equina. Uh more inferiorly, aside from the uh neurological exam, then you'll also want to do APR examination. Um And that is, that is required for all patients that have had that are query called a quina. And you're assessing for two things. The first one being uh anal tone. So after inserting your finger, you ask for them to bear down as hard as they can. And you'll also test for perianal sensation. So using a uh neuro uh or testing around the anus to check that their sensation is intact on both sides. Um in terms of initial management, then analgesia always as patients are often in really quite severe pain and you'll probably give them paracetamol an opiate some form of neuropathic analgesia. So whether that's gabapentin, pregabalin, et cetera for that neuropathic pain that they get and diazePAM as well, which helps to release any sort of muscle spasms that can happen and relieve the pain from that. A pre and post void bladder scan is, is sort of the gold standard of bedside investigation. So again, that's the thing that's most specific for cada requiring is patients go into urinary retention. Um and anything over sort of 100 mils post void, er, would be significant and would raise your concerns for the patient having Cadarena. If they are in retention, then you'd want to catheterize the patient, er, and obviously do document the post void residual, whether or not they felt the insertion and the catheter tug. So that's just tugging on the catheter. Um, because again, if they aren't able to feel that, then that suggests there's a loss of perianal sensation, um, that saddle shaped anesthesia that you classically think about record a recliner, er, which again would raise your suspicion pre op bloods always just in case they need to go for an operation. So FB CSS clotting get an E CG er same reasons what Fred mentioned for enough uh particularly in cold require it is a medical emergency and you want them to go as soon as possible if it is. So you don't want anything to delay them going to theater. So really that's, that's from an anesthetics point of view, making sure that they're not anemic and if it is then correct it, making sure they've not got electrolyte abnormalities, any clotting abnormalities, uh or anything else like that, spinal patients don't get given any sort of VT prophylaxis. So no low molecular weight heparin. And the reason for that is because the risk of bleeding in spinal surgery is so much higher. Um because if you do get bleeding into that spinal canal, then it can cause compression, it can cause more issues, uh, and can also just make the surgery much more difficult, uh, with the, with the bleeding that can go on around there because it's such a well vascularized area. Still give them, er, Ted Stockings though. So you can still do mechanical prophylaxis. Just no chemoprophylaxis. Probably the most important point of any chordal caring is to get them an urgent MRI lumbosacral spine. Um, normally that would be get done and vetted pretty rapidly by the radiology department because they see coqui and they pretty much just put it through some, some um hospitals don't have overnight MRI S. In which case, you might need to transfer the a patient to a different hospital uh to make sure that that can happen as soon as possible. Uh Also make sure to keep the patient no by mouth. Um Again, just because you don't want anything to delay, then go into theater or cause any issues with that in terms of imaging. Then. So after you've got your MRI, it's usually the T two image which is the best to view the spinal cord. And the reason for that is that T two accentuates H2O. So it accentuates water and the CSF that's in the spinal cord, it is a fluid. So the CSF is what you can see that's really light on this image here and the little dark things that you can see they're the nerve roots. So you can see this is a nice normal canal with CSF all going around and the nerve roots coming down and no compression from any of the discs. On the axial image. It's somewhat more difficult to sort of visualize what is what. But again, this big dark section anteriorly is the vertebral body. And in the canal behind, you can see that you've got bright CSF and then the small dark nerve roots that are transversing down in the spinal canal. And you can see that here, there's no compression of that. Uh and all the, there's loads of C AF CSF surrounding loads of nerve roots. If we look at a compressed spinal image, then a spinal MRI you can see the, the CSF has been completely pushed away. So that suggests that there's a complete blockage at that part of the spine. And it's easier to see in the sagittal image. Um But in the axial image, you can see as well that where those arrows are pointing, that's normally where that CSS. So that's normally that lumen of the spinal canal. And the CSF there has been completely displaced by this disc bulge that is coming out at uh L4 L5. OK. Often times with cor a recliner is this obvious to see uh because you've got that complete blockage of the spinal canal, sometimes they can be more subtle. And then it's, it's a sort of spinal decision on whether or not they need to go to the theater urgently or whether it's something that can take a bit more time or be managed more conservatively. But certainly if you've got complete loss in the CSF in any area like this, then you want to get them to theater as soon as possible in terms of the management, then a, an urgent, urgent surgical decompression is really what's done. Er, and exactly what they do depends on the cause. Er, but most commonly you'll get a combination of a laminectomy. So that's removal of that bridging part of your vertebra. So the lamina goes from the body uh to, to the transverse process. Er er, and they'll take that away so that they can get access into the spinal cord. A discectomy is where a section of the disc is removed. So, particularly with prolapse disc, they'll do a laminectomy to give them access to the spinal cord and then take away that uh prolapse part of the disc just to relieve that compression on the spinal cord and often times they'll do a fusion as well. So that's effectively where they fuse two of the vertebrae together, often times they do it with a bone graft. So they'll take a part of bone maybe from the spinal cord or somewhere else. Put it between those two vertebrae and over time that will gradually fuse together and reducing that movement between the two between those two vertebrae means that the patient might have less mobility, especially in the spine um but it reduces the risk of any further compression or irritation or pain or any related symptoms that might come from that. Um Obviously, that's the treatment for the most common thing, which is a prolapsed disc. If it's an infection or a tumor or an abscess that's causing that compression on the coral equina, then it, it'll be a slightly different surgical management, but the general principle remains the same which is urgent surgical decompression. So, whatever it is that's pressing back on that nerve, you want to, to take that away, spinal surgery is really interesting to watch and I definitely would recommend that if anybody can, then you should go and watch it. Um especially, especially because uh it's actually easy to see what's going on because they use this microscope, um which accentuates the spinal cord and allows you to see exactly what they're doing. But as a student or, or even as a foundation doctor, it means that you can go in and watch it and see what's going on, what you're using and what you can in most surgeries. Um The general principles there are sort of what we spoke about. So on the left hand side, you can see the laminectomy. So the removal of that posterior section of the vertebra, er move away the spinal cord uh and the the nerve root, sorry. Uh And that allows you access to the nucleus pus. So that disc which you can then take away and relieve the compression. Ok. Going back to the case now, then I'll just give you a minute just to think about those questions and think about what might have changed. Um, and feel like, think about how confident you feel with those questions now that we've gone through it. Uh, and then we'll look at the answers just in a minute's time. Ok? I was looking through the answers then just very quickly. Um So the red flag symptoms for corda quina are bilateral sciatica, the saddle shaped anesthesia that we talked about and urinary retention if any patient presents with back pain and one of those three things, they will almost definitely get an MRI uh just to rule it out. Um And the reason that you only need one of them is that often times the the symptoms can be quite unspecific. Um So some patients can present with one but not the other. Um So if they have any one of those and back pain, then you definitely wanna get them an MRI just to rule it out. One thing to mention. Uh Obviously, with the back pain is sometimes patients can have back pain for six months, seven months, eight months. The the key difference if it's new onset back pain within two weeks, uh or if it's, if they had back pain for quite a long time, but if they have new symptoms like bilateral sciatica or sad anesthesia or any incontinence, that's new, uh, then you'd think more cardio cornea cos sometimes you get a lot of these referrals. Uh, so it's, it's good to know the s, er, specifics of the symptoms, which is why you need to get a good history, uh, about everything. Yeah. Sorry. No. Yeah, it's true. And often times you get referrals from, um, patients who are presented and they've got a long standing history of back pain and now they've got this new symptom which kind of complicate, complicates the thing a bit more. Um But yeah, in terms of the examination that you do, it's the lower limb neuro examination, looking for lower motor neuron signs and the pr exam that we mentioned looking for perianal sensation and tone. So that initial bedside investigation is the post void bladder scan is the most important thing to get. So the neurosurgeons who are often the ones that do these de debulking surgeries. Um we really uh really focus on that and if it's over 100 mils, then they will most definitely be concerned gold standard imaging MRI L spine always. Um and surgical management is that debulking that we spoke about. Um so removal of, of the bone in the disc or removal of the abscess or removal of whatever it is that's pressing on the spinal cord. Ok. So just quickly gonna go through uh M SK X ray interpretation, er quickly gonna talk about a sort of approach of how to do this how to approach um these X rays and then we'll look at some examples just quickly. So the first thing for an M SK er interpretation is the six Ws and this is really useful. Er, if a consultant asks you to present an X ray which happens quite a lot in trauma meetings, er then you always want to start going through these six things. Uh And the reason for that is because it's important to make sure that you check these things, but also it buys you some time to think about what is actually going on. Er So what is it? So the type of imaging which you so ap lateral, et cetera, what are you actually looking at? So the part of the body, which side, who is the patient? And when was it done? Um and running through those six things just kind of show that you've got an approach that you know what you're doing and it buys you time. So it's never bad to do them. The actual approach to looking at the X ray then is an A B C's approach. So just like um just like a chest X ray really, it's the same sort of idea. ABC S and now you're looking for alignment. So that's the alignment of joints, but also the alignment of the cortex. So making sure that there's no discontinuity in the cortex and any sort of misalignment or discontinuity er that you see at the joints or in the cortex suggests that there's some sort of issue be that a fracture dislocation or subluxation, which is basically just a partial dislocation, bone texture is the second thing. So that's looking for lucency when it's darker on the image. So a thinner bone or sclerosis, which is when it's lighter on the image and they can suggest things like osteoporosis but also things like tumors uh and just generally damage. So, osteoarthritis, for example, will cause that sclerosis around the joint. The third thing to look at is cartilage. So that's the joint space, uh abnormalities. So any sort of thickening or any sort of uh narrowing of the joint space, which often suggests osteoarthritis. And the fourth thing is soft tissue, which to be honest with you, I II think it's quite hard to make head of ts of uh maybe until you're looking at them every day that on a registrar role, um or a core trainee role, but often times you can get soft tissue damage, which you can pick up on an X ray, for example, effusions and they're really useful because if you see those effusions, it can suggest that maybe there's actually a an underlying bony pathology uh which you can't see on that x-. So if you see an effusion perhaps in the knee joint, for example, um then you're more likely to request further imaging for act or an MRI um just to have a look for whether or not there is actually any underlying bone damage that you can't see when describing fractures. Then there's, there's three things that you wanna look at. The first thing is where is the fracture? So normally you split the bone into thirds, if it's a long bone proximal being closest to the body, middle being sort of midshaft and distal and is it intra articular or not? So you can see at the bottom there, there's an example of a distal radial fracture. And on the left hand side, it's intraarticular. So the fracture is going into that wrist joint, whereas on the right hand side, it is extra articular. So it's a a fracture across the bone on the end of the bone. So a distal fracture, but it's not going into that wrist joint. And that's really important for the final management uh of these things because if it's going into the joint, then you need to make sure that as the bone heals, it doesn't form a callus or, or any sort of offshoots that are gonna mess with the function of that joint. The second thing is the type of fracture. So is it complete or incomplete? Which basically means does it go all the way through the bone or is it just a partial fracture? Partial fractures? So where it just goes partly through the bone are much more common in Children. Uh So green stick fractures, for example, is a common uh fracture that you see in Children just because their bones are more bendy. Is it open or is it closed? Open fractures are just ones that pop out of the skin? Um And they're just more of an emergency just because of the risk of infection, closed fractures are where it's still closed within the skin. So still aseptic. The third one is the fracture pattern and there's just certain types of fracture pattern that you see. So transverse straight across the bone, oblique is quite common where it goes diagonally across the bone. Spiral fractures are from twisting injuries. Uh and comminuted fractures are where there's multiple fragments in the bone. So I'd say that those four are probably your most common types of fracture pattern that you will see. And the third thing then is any displacement of the um of the fragment. So you always describe this in terms of the distal fragment. So the one furthest away from the body and you might see just displacement or translation. So that's movement of the bone either medially laterally posteriorly or anteriorly. Um And you usually describe that in terms of the width of the bone. So if you see that the bone has displaced halfway across from the proximal pa er proximal fragment, then you would say that there's been a 50% translation. Uh So 50% of the bone is still overlapping with the proximal fragment, but 50% is now removed away from the proximal fragment angulation is just uh effectively a change of access of the bone. And you usually describe that in terms of dorsal or palmar uh varus or valgus or radial or ulnar. Um So basically the deviation away from the normal axis, er and what you do there depends on whether it's in the wrist. So dorsal palmer uh in the leg, varus vuls and in the ankle, varus vuls er and in the forearm, it's radial ulnar. So just which way it's bent away from the normal axis and rotation er often found is quite difficult to appreciate on an X ray. Uh But that's just described in terms of uh percentage of rotation, um an angle of rotation, sorry. So there are the three things there that we talked about. So when describing a fracture, you're gonna do, where is the fracture? So whereabouts in the body? First of all? Er but whereabouts on the bone? And does the fracture go into the joint? Secondly, what type of fracture is it? So is it complete or incomplete, open or closed? And the pattern? And then thirdly any kind of displacement, so any kind of translation angulation shortening er that you might see er is something that you might wanna comment on? OK. Just got a few examples. Now, then for the last 10 minutes, I think if we just go through them reasonably quickly, um If you are feeling super confident, then put something in the chat otherwise just think about it in your own head and then we can go for the answer and think about how you might describe that fracture. So the first three that we've got are a bit more easy to see. Um So I think particularly about how you describe those fractures. And then the last three are a bit harder to see. So it's a bit more of a um a bit more difficult there to see what's happening, but just try and see if you can see what's going on. OK. So I'll give you 30 seconds or so to think about how you would describe this fracture. OK. So hopefully, most of you can see the fracture on that one. But just in case you can't, it is this bit across here and I would say that's in the proximal third of the femur. So the femur on the left hand side, which is handily marked by the radiograph. Uh and that is a spiral fracture and you can see that that is a spiral fraction because of the patterns. So you've got the sharp end here and the sharp end at the top. And it's been a general twisting motion that has pulled this bone away from the proximal fragment. You could say in this case that it's been shortened. So this is quite common in, in uh spinal fractures because you get the action of the muscles uh more superiorly pulling on the frag, the distal fragment. So you get the shortening. Um And I would say it's been laterally displaced by about 75%. So that is to say that only 25% roughly a quarter of the distal fragment sits in line with the proximal fragment. So the 75% of the bone that is actually slid out of place in place with the proximal fragment. Question two. Then again, hopefully, most of you can see the fracture. Uh but just think about how you might describe that. Yes. OK. So if we think where we are first, then, so we are in the humerus on the left hand side and we are in the proximal third again of the humerus, but we are extra articular. So there's no spread of that fracture into the joint space. So proximal third of the left humerus, extra articular, no spread into the uh joint space. I would say that it is a complete fracture. So there's no fragments, no none left joint to the proximal fragment that's completely associated. It is a comminuted fracture because there are multiple fragments and in comminuted fractures, often times it's hard to describe any sort of displacement um because you've got so many fractures. But here it doesn't actually look like the main segment is particularly angulated, rotated or displaced. It's just been split into multiple fragments in that section. OK. Thinking about this next one, then maybe it's slightly more difficult to see where the fracture is, but again, have a think about how you might describe it. Yeah. OK. Then, so again, first of all, thinking about where we are, I'm not quite sure on whether we're on the left or the right here, but we're certainly in the distal third of the uh humerus. And again, we are extra articular. So the actual articular surface is this section down here. Where are these? Um you've got the electron on fossa. Um And it's above that. So this is a supracondylar fracture. This is a common fracture that you see in Children and it's between the medial and the lateral condyle of the humerus. I would say that it is a complete fracture. So the segment of bone has been completely removed from the proximal segment. Um It is a linear um sorry, it's a transverse fracture. So going sort of perpendicular to the bone straight across it. And I would say that it is posteriorly displaced. So always talking about the distal fragment. So here you're talking about the section that still joins the r normal and it's been posteriorly displaced as compared to the proximal fragment. It's these ones are a little more difficult than to describe. Uh and to see. So we'll just move on to have a look at three of those, but just have a look at them. See if you can see the fracture. I appreciate some of the images as well. It may be a little bit difficult to see here, but think about what the fracture shows and, and how you might describe it. OK. So we're looking at the left hip and again, we're in the proximal third of the femur and we're intra in intracapsular at this point. So this is the thinking back to what Fareed mentioned earlier about the neck of fractures because we are more proximal than the greater and lesser tant. If we imagine a line drawn between those, we are intracapsular. So we are intra articular um and it is displaced, it's not completely displaced, but I would say that that is a complete fracture with some displacement. So there's some movement of the head on the distal er on the more distal fragment femur. One thing that's useful to think about when uh looking at uh femoral x-rays. So neck or feur x-rays er is something called Shenton line. So if you look on the right hand side and then you can see the green line which shows the line around the pelvis and going round down the uh the head of the femur. And you can see that it's a nice smooth line that doesn't get unbroken if you can't trace that land round smoothly. So for example, on the left hand side here, then you know that there's been some sort of fracture with the displacement of the fragment. So on the left hand side here, you can see that and you can see this, this on the left image is the one that we just looked at as an example. And you can see that if you're tracing that line round from the pelvis and try and go down the femur to the left lesser Trachaner. You can see that there's a, a joint out and that's where you've had that, that uh femoral fracture. OK. A shen's line is something that's really useful when assessing those neck of feur fractures. This one's quite hard to see, but I'll leave you with it. Um Just for 20 seconds or so and think about where the fracture is. And again, think about how you might describe it. OK? Look at the answer for that one then so handily highlighted in red, but if I just go back for a second, you can see that it's on the fifth meso er the 5th, 5th metacarpal, sorry. Uh And you can see that it's in the middle third. So the shaft, the mid shaft of the left fifth metacarpal, it is an oblique fracture. So going diagonally across the bone, it is minimally displaced. Um which basically means, you know, it's mostly in line, there's not much translation, not much rotation. Um but there is some lengthening of that joint, which is why you can see that space between it. OK. This one then is very subtle and really quite hard to see. But just again, have a look, think about where you can see a fracture if you can see a fracture and how you might describe that fracture. OK. Again, handly handly highlighted there and made uh made more obvious. So it's in uh it's where is it? It's in the proximal third of the tibia. Um On the left hand side, it through to the joint space. OK. Um It is a oblique fracture. So, again, going up in a diagonal pattern, uh closed assumably because it, it, it's in the skin. Uh and it, it is com it is complete. So you can see that it's going through both ends with the ifa down at the bottom, uh it's going straight through the bone on both sides. Uh And yeah, it's pretty undisplaced, which is why it's so hard to see uh on the initial image. So there's not much translation, not much shortening or lengthening of that bone. It's pretty well in place. OK? Have a look at this one, then this is probably the hardest one and think about if you can see a fracture and where you can see a fracture on this er elbow image, I'm pretty sure this is the last one. OK. Just moving on in the interest of time then. So I appreciate this is a difficult one. And it looks like there could be multiple fractures um or around the elbow really as particularly in the electron on here. So this posterior bit of the humerus, it does look like a flake coming off. But what this actually is, is a normal X ray for a 10 year old child. So as the bones develop, there's certain ossification centers that form. So that's centers where the bones turn from um turn into solid bone and, and that happens in certain centers at certain ages. So they're turning from er being a more flimsy version of bone into the solid calcified bone that, that we see in adults. Uh and that's effectively what you're seeing here. So you get these different go growth plates effectively. Um So the capitellum, the radial head, the internal and the lateral epicondyle. So you can see in this pa in this patient, actually, the lateral epicondyle hasn't yet started to form um the trochlear uh also for me here uh and the electron on. So there's a bit here posteriorly. So even though you can see these gaps in bones, um it's not that there's a fracture there, it's just that these parts haven't yet calcified, but they will do over time. OK. Thank you for coming guys. Um If you could uh just please pop some feedback. So there's a QR code there and I will also just copy a link into the chat. Um Any questions, just pop them in the chat and I can answer them. But otherwise, thank you very much for coming.