Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

It start. Okay. Hi, guys. I am Husham Ampara, the Med Ipath public relations team. Today, we've got to talk about Dr Rooster who will be doing a talk on orthopedic emergencies. Uh Just a quick one, today's uh talk is sponsored by the Royal College of Surgeons Edinburgh and it's one CPD our, by the MDU. It's sponsored on the hand over to doctor roster. Uh Thank you and Sam. Um, so today we're going to go through some orthopedic emergencies. Um I'm an orthopedic registrar, senior registrar Aunque. Um, coming towards the end of my raining. Now we're in Stanmore in London, which is very sunny today. I hope you're all. Well, where you are. So let them get through these, uh these slides in the next hour. So, first of all, what is an orthopedic and see why? What, what do you want to know from? I've split up this talk into three areas. One being infection to being trauma and three being spinal emergency within infection. We'll talk a little bit about native joint infections and septic arthritis. We'll talk about necrotizing fasciitis and we'll talk about flex a tendon sheath infection within trauma. We'll speak compartment syndrome, open fractures and actor dislocations with neuro vascular compromise. Yes. And then at the very end, if we have time will be spine, which I know that uh Mr Arnuity has finally already given a lecture on. So you should be very good at that. Move on. So, what is an orthopedic emergency? Well, these are the problems that if you don't get to them early and you escalate appropriately to your seniors can cause significant morbidity and mortality for your patient's. So these are the things that in the middle of the night, when your registrar is at home or your consultants at home, you need to pick up the phone and call your boss and say I've got this problem. You only need to mention the I this is a patient with hepatitis and fasciitis and the surgeon will wake up and be listening. So let's go through some of those problems tonight. So let's start with infection. So the first thing is skeptical. Now, this is where you have infection inside the joint. Now, normally a joint is completely sterile. There are no bugs inside the joint and when infection does get into the joint, which can be from a direct inoculation into the joint, or it could be from sepsis that the patient has like urinary infection or a chest infection that then spreads via the bloodstream and concede in the joint that is devastating for the joint, the joint. Normally, as I say, is completely sterile and in situations where there's a bug, it can destroy the cartilage in matters of ours. And therefore we need to get on with it quickly to open and wash it out. Now, the common bacteria, Buffalo coccus aureus, and that is the most common cause of septic arthritis. But there are other bugs which you need to be aware of. Gonorrhea is a sexually transmitted infection that kept, that is most commonly seen in young men. And the others are slightly more rare group, a strep and you might recognize E coli from urinary tract infections. Now, how does it normally present? Well, you'll get referred these all of the time from A and E, I've got a hot red, swollen, painful joint. Now, the joint, the, the main thing that you often find with these patient's not just hot red is they are, they will not allow you to joint passively. So when you've got to pick a hot red swollen joint and they will let you move it, your suspicion should be high and then you should be doing some uh an X ray and then some blood tests and some observations. Now, the blood tests you want are mainly in flickers in the form of ESR and CRP, but also a white count. There, there's very little you can do in terms of imaging for uh for septic joints because most of the time you can feel the joint. However, there are moments organized some more image would be in situation, I'm not quite sure or the joint is deep like a hip joint where you can't feel the joint. So if there's fluid in there, you won't necessarily be able to feel it. So you might organize an ultrasound scan to see if there's a collection of fluid there. But the gold standard to diagnose a joint infection is to get a needle and two aspirated the joint. And when you aspirated that joint, you must do it under sterile conditions and then send it off urgently for a gram stain. Once you sent that blood that, that aspirate off, then you can start the patient on antibiotics um and reduce their chances of getting septic next slide. So it's well, you know, if it's not a septic joint, which is the main thing you want to rule out. The other things that can cause painful, hot, swollen joints are gout where you get your a crystals inside the joint, you can get something called suit gout, which is another form of gout. But crystal gout, you can get reactive arthritis. You get a sign of itis of the joint or an inflamed joint following your arthritis or gastroenteritis. And then there's, you have patients that have osteoarthritis and they may just be having a flare or patient's can occasionally bleeding to their joints. And this is becoming certainly more of a common problem. Uh As we put more and more patient's on blood thinners for conditions such as a F or to reduce their risk of strokes. Now, how do we manage it? Well, we need to make sure that they're on us. So we must give IV antibiotics and we treat them just like you would or anything septic patient to your catheterized cultures, you'll give them fluids, you give them IV antibiotics. But ultimately, the management is to wash the joint out and you can either do that by making a big cut over the joint and going in um and seeing the joint itself or you can do it arthroscopically with a camera and flush the joint clean. After that, we'll start them on what we call empirical antibiotics, which is what the hospital have a have protocols and you start them on whatever the protocol is for septic joint until the culture has come back from microbiology. And they can tell you the exact antibiotic the patient requires. So how do you do an aspiration of a knee? Well, the easiest way to do it because the knee is quite a common joint. And most people would expect you to be able to get inside. You would place the patient on a couch, you'd consent them for the procedure. You would clean their knee with some chlorhexidine or some Betadine. And then with the knee in slight flexion, you just mark out the borders of the patella and then as written by one centimeter up one centimeter to the side of the patella and then join those dots up and go in at that point, you need to go in fairly shallow. You want to be above the femur, but that part, the joint capsule of a knee that's been that swollen with pass will go above the patella and that's going to be your best spot for trying to get a decent amount of fluid off for culture. But you must remember that if the patient has a prosthesis in I A total knee replacement, you mustn't do it in the A ND department that needs to be done in theater in really sterile conditions because infections inside with metal work are devastating and extremely difficult to treat and those should be done by somebody who does this regularly and in theater. Oh, so yeah, I mean, I've been through most of this, this is the method I'm happy to move on to the next slide. So once you take the fluid off, does it look like? Well, actually, inside a normal joint in your joint today, if you've not got any pain, there's only about 2 to 4 mills or fluid running around your knee. So it's very little fluid in a normie. Once you take out a large amount of fluid, you start to think there's some sort of pathology going on. Well, what does, what do the different things look like? Well, as you can probably get infection thick turbid yellow, green fluid it looks really mucky compared to a reactivation where it's clear yellow or cou an osteoarthritis where again, you'll just get a pale yellow fluid that comes out clearly. If you've got blood coming out, then you're thinking, is there bleeding into the knee for some reason? And why do people bleeding? Well, either blood thinners or they've got a fracture normally. Next. Okay. So we've been through the first bit, which is septic arthritis. Let's go through this question, which we're going to start a pole for. So please participate if possible. A 20 year old who's come in with painful, hot, swollen, left sternoclavicular joint, which is the joint up by the clavicle that attaches to the sternum. Um, he's got a temperature of 38.9. He's got a white count of 14,000 and his CRPS up, he reports using IV heroin. Now, he's at a three D CT. Um, uh, well, and there's, and there's a collection there. Now, you've done a joint aspirate and you, and, and that's staying positive for organisms. Which organism do you think is going to be the most likely organism to be uh isolated? Yeah. So that's correct. All of you got that right. It's only been three, response. Three, only three. Okay. Well, well, what have you now that I'll give you the answer company on 17. Keep going like no response. S okay. Not bad. Most people put Staph Aureus. I'd always go with Staph aureus if you're talking about infection, you'll ever asked a trauma meeting. It's generally staph aureus, know someone's putting a syria gonorrhea. It's possibility in a 20 year old man. Totally agree. But not in a patient's with, you're going to be staph aureus, you won't go wrong. Generally if you press staph aureus. Um, ok, next screen please. It's the next, uh, condition we're gonna talk about is necrotizing fasciitis. Now, you might not see many of these. I've probably seen about five in my 10 year career today in orthopedics. But when it does come around, you'll know about it. So, necrotizing fasciitis is a life threatening bacterial soft tissue infection that spreads along along the fascia which surrounds the muscles and this is what it looks like when you see it and it is, it's rapidly spreading. So, be aware if you see bully, you see some hemorrhaging or particular hemorrhage underneath the skin. Uh and you see some necrotic patches and this is somebody who's at risk. So let's go to the next screen. So what are the symptoms were the patient's? They come in? They've got severe pain. Often it's often on the legs or arms. They have high fever, they have chills, they have rigors, they're often tachycardic. And as I said, with the physical exam, you often see skin ballet, you see discoloration of the skin stem ick patches, swelling, gangrene thing called subcutaneous emphysema where get from gas producing organisms where if you feel the skin, it feels like bubbly okay. Next. Now, the best way to diagnose uh necrotizing fasciitis because it is a clinical diagnosis. There is no, there's not time to be scanning patient's there's no aspirate required. You have to make the call there. And then this is necrotizing fasciitis and the patient needs to go to theater. But we have this score ing system, which was introduced in the last few years called L Wryneck score NG. And it's a combination of your white cell count, your CRP, your hemoglobin, your serum sodium, your glucose, your serum creatinine. And if you get a score above six, then you're, you're thinking this is likely to be neck fash and therefore you make that diagnosis this as a as a surgeon and you take that patient theater. Let's go to the next screen, please. Now, what are the diet? What are the uh uh we, we classify the necrotizing fasciitis into polymer, which means more than one bug mono microbial, which means just one bugs involved. Whether there's a marine exposure is type three and fungal infections. Now, by far the most common organisms involved in this disease, it's polymicrobial type, one polymicrobial common, lots of organism or always more than one. And the treatment for this is get that patient to theater as soon as possible and remove all of the dead tissue. Can you get that done the better? Because this condition, it spreads extremely fast. And as it spreads and toxins get released by the bugs. BP drops, they need supporting and they will eventually collapse. If you don't debride them, often you need to take them back multiple times to continue to debride them because sometimes this infection is, but it hasn't quite declared itself. So you need to aggressively debride all of the dead tissue. Take all the skin off, take the fascia off, remove any muscle. Often you're not left with mark like being in the dissection to be honest, but these patient's again, need specific broad, anti broad spectrum antibiotics. So another MCQ, so this is a 41 year old diabetic. So high risk for neck fash, he's got a cut on his from a rusty metal yesterday. Now he's coming to the emergency department. He's got a CRP of 100 and 80. He's got a white count of 19. His glucose is 11. Creatinine is 1 50. His sodium is 1 20 and he's got a temperature of 38 5 and a heart rate of 1 10. Now, obviously, you're worried about this patient being septic until you do an L Rynex score and it's high. But which of these is needed to, to calculate a patient's L Rynex score. It's not sweet. Mhm These are quite questions. I don't expect everyone to be getting them right and they have come from uh Ortho bullets which is a uh orthopedic trainees. So they're, they're, they're tough, but you just getting used using this scoring system. And the fact that you've heard of it, time you get referred a patient with a red swollen egg by the medics saying we think it's neck fashion, not say litis. So the answers for this is actually hemoglobin. You do need hemoglobin. You don't need calcium, bicarb or calcium is see at CRP, you need no air saw. Okay. Next slide please. The next condition is called flex a tendon sheath infection. Now, this is where you get infection within the synovial sheath which surrounds the tendon going into the hand. You often see this in patient's that have been out gardening and then they've taken the thorn out, but the thorn has got some bugs on it and that's got inside this sheath um inside the hand. Next slide, please. Now again, this is another clinical diagnosis and this is why it's so important that you understand what these conditions are because it's not like other conditions that you can say are just get an MRI wait till the morning, this you have to make the diagnosis there. And because if they've got signs of inflect teeth infection and there's past inside that tendon sheath that needs to be drained. So we use these signs and they're called cann ovals signs and they're very useful. So does the patient have tenderness along the line of the tendon sheath? So you can just feel across the tendon by palpating and the patient will often jump off the chair. Do they have marked pain when you extend the digit like that? Do they have a fusiform swelling or a sausage finger? And is the finger held in a flexed posture to try to reduce the pressure inside the tendon sheath? If they've got some of those signs there, you're thinking this is a flex, a tendon sheath infection and you're starting them on antibiotics and you're taking them urgently to theater or your bosses. And the management again is to open up the tendon sheath and wash it out. The way we tend to do that is we'll cut over here, which is the part of the tendon sheath and a cut at the very end of the finger, which is the end of the tendon sheath. And we, we put a cannula inside and we flush it and we'll irrigate it with lots and lots of fluids, do it until all of us comes out. Now, the problem is is that if you miss one and uh you don't wash it out, then the infection causes a lot of inflammation inside the system, which obviously as a finger, you need it to be perfectly smooth and to glide and you get adhesions in the finger and suddenly you've left someone with a finger that doesn't essentially work very well. And the morbidity from having a finger that doesn't work well in your hand is huge. So we've tried to get on, we get on with these as well. Next, please. Okay. Another MCQ 48 year old hairdresser pain and swelling in the ring finger for the last four days on examination. She's got generalized tenderness along the whole digit, passive extensions, painful. What would be your next step in management market is, you know, we're actually more people. We'll give you another 30 seconds for this one and then we'll move on and we've finished infection And those are the three main infections that you need to be aware of. If you're doing an orthopedic job and your uncle to be able to refer to your seniors. So, necrotizing fasciitis, septic arthritis in a joint and flex a tendon sheath infections. Okay. Good. Yeah, most people got that right. So yeah, open irrigation and debridement. Okay. So, trauma, which is the fun bit where we see patient's that have had horrendous injuries and broken bone. And the first thing we talk about is what we call open fractures. They used to be called compound fractures that we know fractures. And what does it mean the bone is out of the skin and is seeing the outside world which it should never do. So what is a fracture? First of all, but a fracture is not just a broken bone. And most people would say the fractures, a broken bone, but origin would say a fracture is a soft tissue injury, injury in the presence of a broken bone and open fractures are say, question to the outside world as you can see here, this is someone's tibia and it's come out through the medial aspect, occasion dri to cover the wound. And in tighty, there's a bone that's come out through the skin, but also there's a vascular injury and those are therefore uh extremely bad and often need some sort of bypass graft into uh vascular repair. So that's the Costello Anderson classification and for orthopedic wannabes, that is an essential classification to know next, please. So how do you treat them well, they often come in and you need to do a trauma call. So first there'll be a trauma call, there'll be lots of senior doctors there. And then as the orthopedic shou will start to manage the fracture itself. We have lots of good guidance for this, but essentially the patient needs immediate IV antibiotics and that should happen within the first hour uh of the injury. You don't pulling bits of grass out of the wound, just leave it well alone. Do not wash it in a and E just give them IV antibiotics, put them in a plaster and call your boss. Now, when do we need to get on with it? Well, it depends on the type of injury and where the injury happened. For example, if you've got an open tibial fracture and it happened in a farmyard where there's a um um where it's particularly dirty, then you need to get on with that straight away. Or if you've fallen off a boat as I've seen before and you've been hit by a rudder and, or the motor and that's open, sliced open your leg intentionally, marine bugs that also needs to be done urgently. Or of course, if you've got a vascular injury, etcetera, and the main problems are that we have with the open fractures is we have problems with infection. As you can imagine, this bone is not supposed to uh say hello to the outside world. Um And we like to keep them underneath, but clearly as it comes out in quite dirty injuries, you get infections of the bone which we call osteomyelitis and that's why we must give them antibiotics in a timely manner. Um Yeah, so 29 year old been in a road traffic accident. He's got an open fracture, his right tibia, the wound is one centimeter. There are no pulses distantly. What is his Costello Anderson score? Give you another 20 seconds for this one. 20. Okay. Good. So, yep. So patient, although he's only got a small wound one centimeter, which would make him a grade one. He doesn't have a pulse which means he's automatically into grade three. So he would actually be a three C. Um But made this question a little bit easier for you. Most of you got that right. That's good. Next slide, please. So the final thing that you can call compartment syndrome. Now there's when the pressure within the leg, within that fascial compartment is abnormally elevated. Now, it most commonly affects the lower leg, but it can affect any area of the body, which is coaches, all of the muscles essentially. And when does it most commonly occur? Well, it most commonly occurs when you have injuries to the leg. And therefore, as a consequence of the injury, you get a lot of information, you get a lot of bleeding and that blood has nowhere to escape and it sits inside the leg and the pressure builds up and that can occur from fractures of the bone can occur from crush injuries. Are you being run over by Laurie? It can occur because we put on tight cast. So, um idiopathic or it can occur from burns where you get constriction. Next slide, please. So how does it happen? Well, there's a cascade of events. You get some local trauma and you get the destruction within the compartment and that leads to some bleeding and some edema and that leads to increase in the interstitial pressure. If you remember that from medical school days and that pressure increase means that the blood coming in, uh the blood coming out, the veins generally, which can be compressed are now collapsed. And therefore the blood coming in by the arteries doesn't come back out by the veins and then suddenly you've got a build up of pressure and the blood is not coming in and the blood blood is not coming out and that causes some ischemia to the myoneural ischemia. And therefore, the patient's often present with, um, and if they've got so far on the line that they've got no pulse, then you're in a really bad situation. So that's why we want to get on top of these early to try to release the pressure. Next, please. So how do they present? They present with pain? And you can look through lots of textbooks and look for findings like parasthesia where they've got a bit of numbness or paralysis or they've got no pulses in the foot, but this is too late and we need to find these patient's before they get to that stage. Because once they get to the stage where they've got no pulse and the muscles starting to die, we can't bring it back. So we need to get onto it early. And the way you get onto it early is you recognize that the mechanism of injury that they've had puts them at high risk. For example, a young guy who comes off his motorbike and breaks his tibia and comes into your A and E department. You, you're not going to send him home on the same day because you think this is a energy injury. There's gonna be a lot of information in that leg and the pressure might go up to, you're going to want to monitor him. And the way that you examine these patient's is you look pain on passive stretching of the muscle compartment. So you passively try and stretch the muscle in the, in the involved compartment that's under pressure and they scream out in pain. And when I, when you say pain, this makes men cry. When I've seen it, there are men crying and you've given them 304 100 mg of morphine and they're still crying there in that much pain. This is exquisitely painful. And when you see it, you know, but we get referred these all the time from the medics with patient's that are in pain in their leg and 99% of the time it isn't. But the safe thing to do is get an orthopedic review and let us see it and make a, make a decision for you next. So how do you manage it? Well, again, this is why we're discussing it tonight because this is a clinical diagnosis. So you will make that decision yourself. And if you say this page compartment syndrome, that's fine. You take them to theater and you decompressive. If you're unsure, you can use these special devices. But trying to find one in your hospital is probably extremely difficult and I've certainly never found one in the hospitals. I've worked the last 10 years. If you, then you have to measure that it will give you a pressure reading. And then you need to compare that to the diastolic pressure of the patient. And if that compartment pressure that you're measuring is within 30 millimeters of mercury of the diastolic pressure of the patient, then you're thinking this is compartment syndrome or if the absolute pressure on the gauge that you're measuring is above 30. Again, you're thinking this is compartment syndrome just confirms your fault, your your thoughts. But to be honest with you, if you think in apartment syndrome get someone to see it and I would happily open up someone's leg without this. And most people were too because we can't frankly find them most of the time. What do you do? You open up the leg, you unzip the compartment, you do long incisions, you take down the skin, you go into the compartment, you open up the fascia and you leave the leg open to allow the pressure to settle. It's a bit like when you have patient this with head injuries and you do a borehole, it shouldn't. Well, thank you. It's a bit like put a catheter in a with urinary retention. They'll love you forever. The only problem is is that we leave these wounds open and often the patient's need skin grafts afterwards. So, and, and they, and they also often need to come back for a further operation to check to see if there's any more dead muscle that needs to be removed and what you get if you get neglected compartment syndrome. Well, you can get renal failure because the muscle breaks down and that can cause rhabdomyolysis and you can get long term necrotic muscle and that becomes scarred. As you can see in this hand, this is a patient that's had uh an injury in the beram. And now the tendons and the muscles have all contracted um due to scarring and that obviously leads to significant more stability and loss of function. So another MCQ 35 year old comes into A and E she's had a car accident leg was pinned up 30 minutes. Which of the is the most accurate way to diagnose compartment syndrome. So we'll give you a minute for this one. It's quite an easy one, a relatively easy, okay. So the correct answer would be see. So if you take the patient diastolic pressure and it's let's say 70 the patient's pressure inside the compartment is 50 you take those away, then that will be 20 that will be worrying. So you want it to be less than 30. I see that some people put surgeons palpations in the leg. Now, that is a good way of diagnosing. Definitely, it says the most accurate way to diagnose. Now, the most accurate way would be to do the actual compartment pressure, which gives you a specific number but not necessarily the way you have to do it. So the answer would be seen, okay. So now we're going to talk about fractures with neuro vascular compromise. Now, the most common one of these that you'll see is this one which is a supracondylar injury, which is an elbow fracture in a child. We see these all the time in the summer and as orthopedic surgeons, um they raise our anxiety levels significantly because they're often associated vascular compromise, which means the blood vessels or blood supply to the hand and the and the nerve supply to the hand can be damaged and cannot be working. And therefore, we need to address that urgently. Now, the principles are, if you've got a pulseless deformed limb, then you should realign it. And that, that makes sense to me. I mean, if you have a patient that comes in and they've got no pulse in their foot because their legs point in the wrong way. First thing you want to do is point the leg in the correct direction because that may well be just the vessels slightly kinked and that's always what we'll tend to do. You don't allow patient's to have deformed legs by significantly deformed part of basic management, paramedics should straighten legs and put them into a splint and you have to do a timely neurological and vascular examination. Now that involves examining each nerve that passes over that fracture site specifically and you must document specifically how that nerve is working. So, and after you do any reduction movement, whether you put a shoulder back in or or an ankle fracture dislocation, you need to repeat the examination afterwards because sometimes you can reduce fractures and actually get the nerve or the vessel trapped inside at the fracture site when you do it. And therefore you would want to know about that and not just pat yourself on the back once you've reduced it. So let's move on. As I say, supracondylar fractures, their elbow fractures seen in Children and they most commonly occur between five and seven and they occur when patient's fall onto their hand, whether they're doing um falling from a climbing frame or a bike or doing a cart. Will they happen? Um And, and as I say, this is one of the commonest fractures that you will see in your A and E department that presents on presentation with no pulse in the hand, which is clearly worry moving on. So with supracondylar injuries, you have to think about the nerves that are going over the front of the elbow. And the most common injury in terms of a nerve injury is the anterior and tear osseous nerve, which is a branch of the median nerve and that runs over the front of the elbow. And as you can imagine when injury like that, it gets kinked over the fracture site and the anterior intraosseous nerve and labels you to do the okay sign, okay. So you always ask the patient, can they do this come down the other injuries that you'll see? You'll be a radial nerve palsy. So the patient will have a wrist drop. You might see an owner, nerve palsy where they have a clot house, don't. Um, and they'll see is, do they have vascular compromise? I do they have no radial. Sometimes the patient's can have a pulse but they've got a white hand and, or a slow blue cap refill. So something's happening but you might still be at it. Now, the bo A which is at the British Orthopaedic Association have guidelines for all of these emergencies and they come on these amazing one sheet of a four and it tells you exactly how to manage emergencies in orthopedics. And it's a bit advanced for most shos but one aspiring to be an orthopedic surgeon and as an sho should know these guidance guidelines inside out and they will come up time and time again, interviews and exams in the future. As I said before, a documented assessment of the limb must be performed on presentation and immediately before surgical treatment, it needs to include the status of the radial pulse, the cap refill time and the individual function of the radial median and on pair of injury regard, whether they've got newer vascular compromise in daylight hours. If it's you're doing, thinking about doing nighttime operating, then that's only if the patient has urgent indications. Now, urgent indications would be no radial pulse, clinical signs of impaired perfusion of the hand. If they've got an open injury, either boat has come outside the skin or there's any evidence that the skin over the front of the elbow is compromised. Um The vast majority of these vascular impairments where you've got no radial pulse come back once you've reduced the fracture in theater. So which nerve is the most common uh which nerve injury is the most common after a supracondylar humerus got if time uh go over time. Uh okay, very good. So some people got fooled by median nerve and anterior intraosseous nerve being there. Yes. The anterior interosseous nerve is the correct answer, but that is a branch of the median nerve. So technically, they're both right, but the more right is a and there you'll often find this in exam papers, they'll do this to you. Um And they're looking for the best answer and there may be two answers there that are opposed. Correct. Okay. Moving on, please. Okay. This topic you covered last week with Mr Arnoldi, but we'll quickly go over it again. So Corder equina syndrome, you'll see countless referrals from A and E with patient's with back pain, as you can imagine. And they'll say we're worried about corduroy equina. Well, what is the cord requires this horse's tail, these nerves that's below the spinal cord, but inside the canal. Now, the spinal cord ends at about L1 L2. And after that, all of these nerve roots sit inside and it looks like a horse's tail. Now, these nerves at the very bottom of the spine, they provide sensation to the perineum, the uh the bladder and the rectum and they supply motor sensation to the limbs, anal and urethral sphincters. They also supply fibers to the bladder and rectum, parasympathetic fibers. So, when you think about how, if there's something that's compressing these, what it's going to affect, you know what it's going to effect because you know what those nerves supply. Now, this is a surgical emergency because the nerve roots are compressed and therefore no longer supplying your bladder, your legs, your anal sphincter. And if you get a delay in diagnosis, in getting to this injury, the nerves do not like being under perfused. And if they're compressed for a certain period, you will never be able to bring those nerves back to life for them to do their normal function. So therefore, we, if we do, I suspect that patient may have called a recliner, we must escalate early to seniors for them to review and to organize the appropriate investigations. So you can see here in this picture, this patient's got a large disc and it's completely obliterating that spinal canal where the roots are traveling. Next slide, please. Now you have to remember what your red flags are for back pain. So, if you've got patient's that are under 18 or over 50 patient's with patient's with risk factors for uh if they've got fevers or thinking about an infective process, they have recent weight loss, thinking more tumor. Um, but the main things that you will think about for corre Aquinnah are, do they have bilateral leg weakness or sciatica? Do they have a loss of uh, um urinary control? Do they have any fecal incontinence? And those are the main things? So, bilateral sciatica, uh fecal incontinence, urine, any of those symptoms, even if you've only got one, they're getting scanned because you, you need to do an MRI scan on these patient's because even if you only pick up one in 1000 the cost of those 999 MRI is that are all negative, then the costs it'll be if you miss a corner and that patient who is paralyzed never walks again and requires care for their bladder, they're back uh your neuro rehab for the rest of their life. So we crack on and we get MRI is for anyone with bilateral sciatica fecal or urinary incontinence moving on, please. So as I said again, these are the red flags for quarter equina, which we've discussed already. Okay. Next. So why do people get this obliteration of their nerve roots? Well, they have herniated discs and that's by far the most common reason, use those nerves. You can have an infection and an abscess that compresses the nerves. You could have trauma and a fracture where the broken bone breaks off that causes uh reduced space there and compression around those nerves. You could have a blood clot or a hematoma. You can have what we call a spondylolisthesis where it's where one virtual body moves forward on the other compressing the cord. Normally from either osteoarthritis or from trauma, you can have, uh, or you can have just generalized arthritis in those small joints at the back and big cysts which form, which can compress, um, and compromise that canal. Next, please. And what do we need to do, as I said before, look for the red flags if they've got any go on to do your full neurological assessment. And that has to be motor sensory reflexes and a pr which scan. Now most nurse, yeah, and you'll be able to ask that to post void. Not a bladder scan has to be post void. So you ask the patient and then afterwards you do a scan and see how much urine is in their bladder. A normal person when they avoid, they will have very little urine in their bladder if they try to avoid it fully right for you. And I, we would have 5 10 mils in your bladder maximum. After the avoided. If you find that after the patient's voided, they've still got more than 100 mils in their bloody bladder. You need to start worrying, think about ordering an urgent MRI scan. Now, once you've done the MRI scan, you would keep the patient near by mouth. And if that patient have quarter equina, which is can be an MRI with compression of these nerves. They need urgent decompression of their lumber spine to relieve the pressure on those nerves. Even with early surgery, patient's can still be left with bladder bowel and sexual dysfunction. So we need to get on with this as soon as you diagnose it. Let's go to the next five, please. So this is the final m secure of the night. 32 back pain, saddle anesthesia. After lifting a heavy object, MRI shows he's got a very large L4 L5 disk. When you look at this, which of the following most accurately list the additional symptoms or physical exam findings, this patient will have from most common to lease common. So can you see this, uh they can hear the cancer simply something. So the answer to this is a and because most of these patient's, they'll come in with leg pain, the bhaskar, then they'll head into urinary retention because the bladder is not now being innovated. So it'll start filling up and then it fills up to such a point that no longer hold the urine and then you become continent. So when patient's go into retention, so they may not. So you may speak to patient and say, okay, we'll have you wet yourself and they'll some wet myself. But the question is, are you able to p because if they're going to retention, the next step is going to be, they're going to be incontinent. If you leave this for long enough. Okay. Very good. That's the end of my presentation, some of these topics maybe a bit difficult to understand. Um, and that's completely understandable but these, this is the lecture that I give to all of my, uh, shos when they're covering the night when I'm on call. And I think it's absolutely essential that if you're going to take on a post as an sho in orthopedics that you must know about these and this will come up time and time again in any exams you're going to take. And thank you very much. Firstly, thank you Doctor Rosseter for today. Thanks. Um So there any questions that people look like to ask? Oh, yeah. Um If there's no questions, um we can sign off then. Sure. So guys, thanks for two. Thank you doctor Roster for today and Jerome. Uh huh. Can you hear me now? Yeah, it's okay. Don't worry, not to worry. Um So thanks for everyone. Everyone has been attending. It's been uh we had a great lecture and we've been hearing everything. Um Again, our lectures are sponsored by the ND. You and our lectures are COPD approved. So you will get one hours for the CPD points upon completion of uh upon completion of the lecture, the feedback forms. Uh So please do uh they will be set down automatically at seven o'clock o'clock. Uh Yeah, thank you. Actually, we have some questions here. Uh Questions, questions. Would you like to. So, yeah, I can see your question here. Yassin. Um, so no, is the answer you'll just see pass inside the joint. I have no idea what organism it will be. You're, you're, you're always going to guess that it's probably staph aureus, but you can't tell the fluids. It all looks the same. It just looks super mucky. You wouldn't be able to tell like, you know, if someone's got a urinary tract infection and you take a urine sample, you can't tell which bug it is based on what the urine looks like. Uh I think the lecture, Hassan Khan, the lecture will be available. Yeah, it's recorded. Yeah. So the lecturers were recorded and you'll be able to uh be able to watch it all over again. Um Yeah, and that's it guys just a quick before we do end this next lectures on cardiology emergencies on the 28. It's at 6 p.m. This net, but Dr Sunil Nadar is the lead consultant in cardiology. It's also sponsored by the MDU and CPD, approved by the Royal College of Surgeons. So hopefully go see you on the 28th at 6 p.m. shop.