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for having all right, guys. So this is a 24 year old young champ who's working in the garden. Um, got a scratch on the leg. As you can see, it's led to some erythema. There is some pain on the leg and he comes to you in a and e with the race temperature. What's going on through your mind as you see this picture? So there's a clinical photograph of the right leg of this 24 year old man. There seems to be a robust discoloration with a central part that it's slightly more dark. My worries are of infection, and I'm worried about this given, um, the how big This, uh, this area is from a recent infection. I'm worried about necrotizing fasciitis. Other differentials would be, um, a cellulitis or an abscess. Um, so my approach to this case would involve taking a more thorough clinical history, Um, and also doing clinical examination, looking for any signs of sepsis or a systemic inflammatory response. This is a surgical emergency. If this is the case, so I would be quite quick in doing my assessment. But I'd also make sure pick both biochemical and also radiographic, um, checks as well. Okay, biochemically I'm looking at blood test Specifically, um, a full blood count. A renal profile. Um, a lactate. A looking at the creatinine as well in the renal profile. Um, glucose level. Um, and, um, I'd also take off a blood culture as well. From the patient. X rays are important to look for any gas within the soft tissue. Um, and, uh, then I would I would move on to, um Did you do anything else apart from the biochemical and the radiological examination? Uh, so in clinical examination, obviously. So the history, the clinical examination be focused on marking the area, Um, and then also examining distantly to see if there's the neurological status of the limb. Anything else? Clinically. So taking a temperature, uh, taking the So Take the obs and keep an eye on them. Yeah. So this for as part of the systemic inflammatory response, I'll be taking the observations and calculating, um, as well, whether he has sepsis or severe sepsis. Or is it a shock? Okay. And in case there is sepsis, so let's just move. Aside from this necrotizing fasciitis scenario, if you are suspecting sepsis, What would your immediate interventions be? Um, so I would manage the patient in line with nice guidelines with sepsis. Um, and this would involve the sepsis. Six, Um, so sepsis, obviously, as a systemic inflammatory response, plus a source of infection. I would give the patient three things and take three things from the patient. Eee I would give the patient, um, antibiotics. They would get a catheter as well. To measure urine output. They would get antibody. Um, they would get fluids. Um, and then I would also take off some blood tests as well, including a blood culture, um, inflammatory markers. And, uh, I would take a blood gas as well looking at lactate. Okay, so there's three and three hours, just three and three hours. Yeah. Yeah. All right. So coming back to the scenario say, this is the area of erythema. You've marked it. The markers are raised. Is there any score you're aware of? So as part of that blood test I was doing, I was mentioning the profiles for the limerick score. Um, this gives us a positive predictive value for necrotizing fasciitis, but this is a clinical diagnosis. Um, but we cannot use this score as a definitive for what are the cutoffs for the school? Do you remember? Um, so it looks at a, uh So what I would do in clinical practice, actually is I always check this again. Um, and I always look on using a calculator, um, for the specific values. That's fair enough. So, clinically, you said you look for crepidness? Yes, as well as look for gas on X rays Isn't Yes. Yes, right. Anything else? Any other test you are a finger sleep test as well, which is making a nick in the skin and then putting a finger into the skin and seeing whether disorder fluid comes back. You reckon the patient would let you make a nick to use your skin is anesthetized because of the infection. So normally it's not paying and what leads to the anesthesia of the skin? Um, so it's because of the bacterial infection, which uh, may cause localized changes, making a more change in the acid based environment of the of the skin in the area. That is one because anything else. So the sodium blockade as well, which is one of the reasons why I think we'll discuss this later. Okay, Fair enough. You do a dishwater. You do this finger sweep test this water bus comes out. You're suspecting this is necrotizing fasciitis. As you rightly pointed out, this is a surgical emergency. What are your next steps? I would inform the anesthetist. Encore! I t u. This patient will need to go to the unit after, um, I would speak to the patient, obviously consent them and explain what's happening in the family. I take the patient of theatre. This is would you explain to the patient and explain that this is a significant infection that requires urgent operation to reduce the risk of it spreading and or him losing the limb or his life? So this is an emergency and we would need to take in the theater. Yeah, Yeah. Perfect. Okay. And what next? So in your in theaters now, everything is done, marked and consented on table. No worries. Okay, fine. So if he's anesthetized, then I would start with a debridement around the area. We know from gyn who Wong's work that there are several zones and the aim is to not just clear the central infected zone, but also the reactive zone around into normal tissue. I would go along fascial planes, Um and would you need to bribe into muscle? But I would go along factional planes until I reached normal tissue. And when I've done this in the past, Normally, even when you get to normal tissue, you're not entirely sure. And sometimes you have to wait 5, 10 minutes to see if the infection has spread beyond your reception margins in order to bring it further than that. Fair enough. And what after surgery. So once you represent, the patient gets admitted to intensive cane, they may need to come back two days later, but they'll need intensive organ. They may need intensive organ support and monitoring guys. We started early, so that's OK. Cheers. Okay, That's very good, Hem. Next question. So we're gonna do three questions back to back, and then we give the feedback. Who's taking the next one? I can do the next one. Okay, So, Henry, tell me what you see here. So this is a clinical photograph of a screw. A screw is a machine that we commonly use an orthopedics that converts a rotational force to a longitudinal force Yeah, there are a number of different components to the screw, so I'm going to point to various things and tell me what what they are. What are these things here? I can't see any point here on. I'll do that. Okay, fine. Or I taught me through the different parts of the screw. So the there is the head and the shaft and court and tip with regards to the head. There are different designs and various engagements with screwdrivers. They can have a locking type design whereby it locks into a plate. Then, with regards to the court and threads, there's differences largely between cancellous and cortical. Yes, what's the difference in the court and threads between cancellous and cortical Screw. So with a cancellous screw, there is a bigger ratio of the thread to the court. Are we a bigger thread, depth and also less threads? I eat a bigger pitch or lead. The main design is to increase the pullout strength. That's the how do you How can you increase the pullout strength of a screw so we can increase the pullout strength by two main mechanisms. One is bigger thread to court diameter. I e wider threads. Secondly, more threads. So there's a bigger interface or contact area with the bow. Okay. All right. So I'm just going to move on now. Can you tell me about some different modes or ways in which we can use screws? Yes. So screws can be either positional or connecting compression mode. They can also an example of YouTube loads. So with a compression, this is with a an interlocking or interfragmentary locking mode, which can either be through a proximal gliding whole or through a partially threaded screw design. What do we call that? Interfragmentary pressure. But what's that technique called? Where it glides through the near cortex and it fixes, like, right? Okay, good. Okay. So, yeah, and then where would you see a positional screw? A positional screw is, for example, when fixing it tailors with combination where we don't want any. Someone's my laptops keeps moving around. I don't know what's happening when we don't want any movement at the fracture site. No compression. I think my whole laptops crashing here. Something's going Okay, okay. Just, uh, you able to keep talking at all while that's Yeah, sorry. It's fine. Okay. So fine. So positional lag any other modes that you can know of and which screws can be used. And then locking screws as well as interlocking screws in bolts, as well as blocking screws with an intramedullary nail device and possibly even raft screws as means of support, usually periarticular. Can you show the next slide for me? Yeah, right. So I want you to try and explain this phenomenon. Hear from me, Henry? Um, yeah, on the left image in the middle image, the two different. The main difference here is that the left image is a locking screw whereby this screw locks into the plate. So it's a fixed angle device on the middle image. This is a just a normal screw that would normally rely on a compression or friction interface between the bone and the plate. The main difference is that with the image on the left, this fails as a whole. So the whole construct fails, whereas an image be this fails by pull out and toggle ing at the, uh, screw head plate interface. Just click the slide for me a second as another animation know, back, back. Sorry. Go back. So what? I want to ask you, Henry is if I told you the one in the middle was a non locking screw. Why has the apple become unstable like that? There's no contact between the plate and the apple, so it's It's free to move. There's There's no, uh, what's the key difference about the fit between a locking and non locking construct? Yeah, with a non locking. It relies on that plate bone interface and friction compression at that interface. Very good. And also, the angle at which you're putting the screw in, as you say, has to be absolutely right, doesn't it? In a non locking screw, It's fixed. Yeah. What? What has to contour well to the plate. Okay, what would happen if you added a second screw? And it was a non locking construct? Would it increase the stability in the middle image? Yeah. Um, yes, it would. But still, in two planes are still free to move. It would add an element of stability. But if there's still no contact between the apple in this case and the plate and there's still, uh, degrees of freedom of movement, Okay. Where is the weak point of the screw when you see. Screws break. Where does it tend to break? So they break up the locking screw, they break at the head plate interface. I e at the base of the screw. Not not. Tip. Let me. Okay, fine. Um, good. How are we for time there? Uh um 11. 6. I think we're nearly time. Yeah, that's good. Right? Let's move on to question. Okay. So I'll take this one. So, uh, keep this is a patient who basically was treated for a a a wrist fracture and has come back to see you in your fracture clinic. And they're complaining of pain in their left hand, which was treated. Okay, Perhaps it's a clinical photograph showing, um, the dorsal aspect of both hands on the left hand side, there is swelling shininess to the skin. Um, and a globalized erythematous Look to it. Given the history, my concerns are of possibly complex regional pain syndrome. Other differentials would be a mile united fracture or a non union causing discomfort or infection. What do you mean by complex regional pain syndrome? So complex regional pain syndrome or reflect osteodystrophy is a, um It's a phenomenon that occurs where there are trophic changes, amongst other things. Um, secondary to usually an insult, which may be surgery but may also be idiopathic. The way that we think about it is in terms of its diagnosis, where we use the Budapest criteria looking at, um, the severity of the pain, which is not in keeping with the original insult or the underlying pathology. In fact, there is no other, um, diagnosis that, uh, this is a diagnosis of exclusion, essentially, and also both sense both symptoms and signs looking at trophic sudomotor, um, motor or edematous And, um and, uh, neurotrophic factors as well. So specifically talking about shyness of the skin, um, increased warmth, pain on movement, and lack of swelling is sympathetic response within the skin. So we can take a combination of these to make the diagnosis. But as I say, it's usually a diagnosis of exclusion. How would you How would you? OK, find. So you look at those different areas Budapest criteria. What else would you do in assessing this patient? Um, so my assessment would start with the clinical history. I would find out more about the pain, find out whether they had, um, the pain never settled what the movement has been like in the wrist. Whether this has changed, I find out more about the the index operation that they've had if they had an operation at all. I'm not sure if you mentioned that, uh, no operation. So their management, it's likely that they were left immobilized for quite a while. Um, and this may be causing them to have discomfort, And, uh, the lack of movement has caused them to develop this condition. So that's quite a common scenario that we see whether they were given any medications. I even come and see at the time when they had the fracture. Um, so I take all of this in my clinical history. I'd also be looking for other medical problems as well. So diabetes or, um, signs of inflammatory arthropathy. And that's a smoking history. Occupation, hand dominance and functional assessment are also important. Okay, good. Anything else that you might want to do? So clinical examination, Um so, specifically, I've inspected I look at the Palmer aspect of the hands as well. I want to make sure that this wasn't an infection, so I'd be looking for any breaks in the skin I would also move on to looking at the, uh, the palpations. See if there's pain, and if it's localized, any specific joint over, it's a globalized, generalized pain. And if there's pain on stretching the fingers as well to rule out of compartments in them, I'd also move on to blood tests. And also, uh, imaging. So an x ray can you show the next slide, please? Yeah, tell me what you see here. Uh, so this is a pa and electoral radiograph centered at the right wrist, which is a generalized osteopenic looking reactions. Looking at the carpus, there seems to be a loss of differentiation between the the borders with some sclerosis. There are no fractures visible on this radiograph. So this would be in keeping with a with a disused osteopenia type picture and mirroring this or matching this with the clinical image. Um, it would it would make me more concerned about a complex regional pain syndrome. Is there any other investigations that you could do apart from radiographs? So we could also do a bone scan? Um, so looking at a bone scan, this would help us, um, in terms of looking for, um uh, tracer uptake, uh, to see whether this was hot or cold. Uh, and, um, this will also help us in terms of looking for any signs of infection as well, which may be able to tell the difference. This ideally be a 99 technician bone scan. But if we were worried about any other pathology, I didn't take a full clinic history where she's diabetic. And this could be a Charcot joint, For example, a neuropathic joint. Um, a white cell bone scan would help differentiate that. Okay, good. All right. So how are you going to treat this? Um, so this is a m d t. Approach. The patient needs physiotherapy. They need painkillers. So a pain specialist as well, and they need movement of the hand. Um, so that would be the non operative approach towards this case. Um, most of these patient's do get better, but it does take a while, and I set the patient's expectations from the outset. Um, it's very rare that we need to perform surgery, but, um, Sympathectomy is have been have been described. Where you where you denude a with the therapist. I would encourage them to do both movements passive and active. And also, mirror therapy has some evidence as well. Which places do sympathectomy is tend to work better in, uh, so neuropathic patient. So patient's have neurotropic signs. What do we call that type of C p. Crps. Um, so there are different types of crps. So this type one and type two type one with no specific nerve issue and type two with an identifiable nerve lesion that would be the type that would benefit or may benefit from sympathectomy. Yeah, so we call it causalgia. Don't we basically have two? Good. All right, so I'll start with my questions first. So I thought, Yeah, this was You did very well with this now, crps I put it in because it's come up in the last two exams. I didn't cover it on the last blitz, but the scenarios, they usually give it in. So they've had it. Somebody's dropped something on their foot. They show a swollen foot. Um, they showed somebody has been treated in the cast, so I thought straight away you brought in stuff from the Budapest criteria. You could even show higher order thinking. Say this is a clinical photograph which shows shiny appearance. That and you could talk about things from the Budapest criteria as part of your assessment. But I can't really fault that. To be honest, you you got into management. You got into sympathectomy. Remember the two types causalgia always mention that. Remember to exclude infection, I think. Did you say about infection? I can't know if you had taken fine. I can't really fault that. Um, Henry again, The screw one. You knew about the different art. So usually, um, the weak point in the screws, the runoff, which is a bit sort of between the head or the run out between the head and the neck. But you're quite right in a locking. The whole construct basically breaks as one. It's a single unit. So that picture of the apple, if you just go back to that heaven back three slides, I quite like this. I thought I saw it online basically, and I thought it's quite a good way of, sort of showing it from a different way, but basically quite right. So with a these are actually all pictures of non locking. They're not. There's actually road. Okay, None of these are locking. It's all non locking. So what they're showing you is if we put locking in straight, basically it will sit off the bone unless and then, as you tighten it, it will pull it the the bone to the plate or the apple to the thing. But if you get the angle wrong, it becomes a very unstable construct. Now, what I was going to show you is the the one below with a locking construct is slightly different because then locking it works in a fixed angle and it will actually fix the device. But the one on the top left must be a locking. Screw. Is it? Well, how else can the apple stay up if it's Yeah, you're right, actually. OK. Apologies. I think it refers to the centric and eccentric screw insertion Eccentric. Yeah, eccentric. The plate kind of moves on the bone and brings about compression, isn't it? With every screw, it's about 0.3. But the idea is, Henry is don't worry about any, but the idea is basically with a plate. If you don't contour the plate to the bone in a non locking system, it will actually displace it as you tighten the screw. Whereas in a locking construct, if you saw the point, I was I didn't ask the question very well. But if you add a second screw in, um, in a locking construct actually increases the stability or the rigidity of the construct. Uh, whereas in a non locking, if you don't have it well, contoured to the plate, adding a second screw will actually cause it to loosen it won't cause it to tighten up. It'll actually make it worse. So that's why we prevent the plate basically. Okay, Thank you. I get. And I can't Really. I mean, that's all seven there. You talked about cortical can sellers. You talked about the different modes. Polar lag. Uh, positional, uh, so that that's fine. Any any points there haven't at all. No, I think it was pretty good. Yeah. Talk about all the important things. Uh, you said was would the cancellous you were talking about the difference between the cortical cancellous? I didn't. I thought just say that again. What? You thought the difference was so I thought the ratio of court to thread diameter was is different with the cancellous, whereby the thread to court ratios increased e more threads or a bigger thread depth with the country you want to use as pitch, don't you? So the pitches finer in cortical? It's wider in Cancellous. Yeah. And that as well. Yeah. Yeah. Now that's remember to say that now, the thing about it is I always used to find this confusing, if you can. If we know that pullout strength is increased by outer to in Accord Avatar and decreasing the pitch, why does a cancellous screw? Why do we use that in more, uh, metaphyseal bone? Because cancellous has got wider pitch, hasn't it? So you think it would have reduced pullout strength? That's true. I don't know. Why does it have great? It's also about the number of threads into the cortex or into the bones. So with a cortical screw, Uh, because the pitches so smaller it requires more compact bones. The more the number of threads essentially in the cortex, the better the pullout strength. And that's what. But what I'm saying to him heaven is because you've got to find a pitch. You would think a cortical would have a greater pull out, don't you? And then the councilors So why don't we use a cancellous in metaphyseal bone? So in metaphyseal bone? Because Because it is softer, more, uh, less compact. So you need bigger sort of thread depth. So So you want to be. So the reason is because even though you've got a more coarser pitch, you've got a bigger outer to inner core diameter. So the overall effect is that actually can screw has a greater pull out strength. Yeah, just if they could. But I thought it's very good. Henry, do you want to go to your case? Heaven? Sure. Um so Okay, Yeah. You were fantastic from the outset. Well done. You jumped in straight on neck fascia, which is good, which is what I did in my exam. As soon as I, uh, saw this clinical big net and I said, Okay, Neck Fash. But you also mentioned about cellulitis, and you should talk about movements of the adjacent joints as well. Just in case this erythema is is quite midshaft. So you know, it's quite clear. But if it is around the joint talk about this because you guys have been on my course, you're all going to jump in with neck fast. But make sure you say, Look, my first diagnosis is a severe cellulitis. Have to check for a septic arthritis. But I want to be aware of an early neck flash as well. So you get it in your opium gambit and then, uh, yes. So you talked about marking the area you talked about? Remember the OBS? They are critical because, you know, you have to say that I'll take a history and then examine in my examination general examination, do the obs and then your bloods and radiologic markers, which you all, which you said very correctly, uh, with sepsis. I think the cells criteria now outdated. You have the Q so fast score you may want to look at. And I mentioned that in the exam as well. Um, and then, yeah, mentioned the risk score. You mentioned the elements, which is good. And you also talked about Wong and zones. So I think that was fantastic. So I mean, with Larry Neck, I won't remember any numbers, but what I would say is, if you score a low, if you get low score, which is basically less than six or five, essentially you still have a 50% risk of neck fashion. You said it's a clinical, which exactly said now, the last I would have probably asked you was about bugs and modes of neck flash. Yeah, so for the so therefore. Right, so one is polymicrobial too is group A. Strep three is grab negatives. Negatives. Fungal fungal. Yeah. True. Yeah, that was perfect. I thought, Yeah, I think you're both very, very good. And you're already sounding a lot better than you did. Even even on the course a couple of weeks ago. So Yeah, Henry, I thought you answered that question very well, actually. Thanks, guys. You guys have any other questions? Um, I was trying to give you screw from a different way. The apple. I'm trying to confuse you a little bit, but the apple was a bit It was I was looking at that thinking like, uh, you Did you answer that very well. You answered it very well. I just thought it was a nice analogy. Uh, so So if they do give you something like that cause they do shit like that in basic sights in the exam, they won't give you it straightforwardly. They might give it from a different way. Don't get go back to your principles. But you didn't. You did that very well, I thought. Yeah. Then they talk about screwed tips as well. I'm sure you guys are aware like a corkscrew tip and cancel a screws, which helps compact bone as the screw advances through the bone. So just bear that in mind. Yeah, uh, then you have the self relaying self tapping screws. And what is the reverse cutting and why do you use the reverse cutting tip? Tell us. No. So the cutting is during insertion. The reverse cutting threads sort of help you take the screw out at the time of screw removal. So obviously, bone grows around the screw and makes it more sort of, you know, impacted in the bone. If you have reverse cutting flutes, when you pull the thread out, it cuts out its way. It cuts its way out basically out of the bone, so it's easier to remove. That's the use for reverse cutting. Are there any situations where we still use double threaded screws, right? Yeah, I know what you're talking about. The double pitch, because I don't know any. I don't know. I've ever used a double pitch. No, I've never seen one. Actually, one question. I want to ask you guys because it was right. Henry, Why? Why do we use the counter thing? Yeah, So to have greater surface area or contact with the head and the bone and therefore avoid point, uh, loading. Yeah. Avoid the stress riser. Yeah. Okay. Now, the other thing as well is when you? Because I I gave a lecture in this other day. When you apply a lag screw. As you said, you have basically your glide hole, and then you have your thread whole or pilot hole in the far cortex. And the idea is, the thread whole fixes the glide whole will slide, but the head acts as a physical barrier. It stops it from keeping on sliding. So the reason why you have a counter thing is the head can sit in a lot deeper. Um, okay, So the next thing to say is, um if you over counter sink, what happens and well, you're at risk of you've lost the cortex or can lose the quota. So the whole point is remember I said the head acts as a physical obstruction to stop you from sliding any further. And that's why you get compression. Because the distal bit fixes the proximal bit slide. But the head acts as a physical block. If you over drill. Sorry. If you over the counter sink, you won't get the head acting as a physical barrier anymore. It will sink. And if you under counter sink, the head won't basically sink into the bone enough so you won't get the compression. So these are little tricks that they might ask You would counter things, I think in my exam. Okay, great. So we have one minute to move to the sex station if you start in room to move to room three. So, Hammond, are we in room eight? We are. We're going to room. What? Great. Thanks, guys. Fine. Thank you very much. Thanks, guys. OK, so great. The best room one. Okay, good acting. Should I start then? The next one? Yeah, go ahead. Yeah. Hey, guys. Nice to see you again. You too, again. Hello. Okay, So we're just trying to think I think we're there for a few things. Watching, uh, should we do do the same cases last time. Yeah, that simple, simple Henry's tend to go twice this time. Do you find what we'll do? You want to get started now so that you don't actually run out of time? Yeah, I'll start. Right. Um, India, Are you happy to put the share the power point? Yeah, sure. Do you want me to do it again, or do you wanna? How do you want to? I could ask questions this time around. That's fine. Okay. Yeah, No worries. Well, I'll start with, uh, we start with the case while and then it's just automatically kind of gone. So get a bit of a preview there, guys. Right, Right. Who's starting off? Yeah, I'll start. Yeah, right. Henry, uh, take a look at this, uh, image. Describe it to me and tell me what's going through your mind. So this is an ap radiograph of the right hip showing a bipolar cemented hemiarthroplasty in situ, uh, showing significant heterotopic ossification, causing what is likely to be complete ankylosis in, uh or ankylosis or fusion of the right hip. Uh, what? It's a chew. So H o is adverse bone formation in the soft tissues uh, in areas where bone should not be present. Okay, so it's extra skeletal, both for information. Okay, um, tell me a bit about who gets it, who's more likely to get it. So it's common in patient's who've had multiple injuries, brain injuries, significant local trauma or surgery burns as well as patient's who've had other systemic risk factors, such as bone forming conditions in the context of ankylosing spondylitis, for example, and also the biggest risk factors. Patient's who've previously had heterotopic ossification in other areas. So so you you're talking about some of the risk factors. How how do you want to manage this patient? So I take a full history as to when the surgery was done? Uh, when symptoms have progressed, how it limits their function. Other risk factors that we've mentioned there expect. What what are the symptoms you expecting? So not necessarily pain, but mainly limitation in range of movement and therefore function? Um, I would also like to know how this has progressed over time and ultimately whether it's become uh, whether it's plateaus or not, or whether it's become stable and also what their expectations of any intervention, maybe what they would what they would like and in terms of investigations, what what else would you do? So I would do a CT to see the extent of ankylosis or h O. And I would also do, uh, possibly even an MRI to look at the muscle bulk. If this is a chronic condition, with or without E m G, I would also like to do a bone scan to see if this is active or not. So possibly even a spect CT scan. Uh, and that would dictate my management. A blood test? Um, I think just preoperative bloods. I would rule out infection with CRP and white cell count. And I can't think of anything else that's relevant at this stage. How about alcohol? Four cities? Yes, with if if there's a suspicion of a metabolic bone disorder or budgets. Okay, So in terms of the definitive management patient's not happy. You did the hip. They want you to fix it. Okay, So I would, um, consent the patient appropriately, do the investigations that we've mentioned to make sure this is a mature phase of this broker for h O. And then proceed with you mean consent. The patient appropriately. So I would explain that this is likely to put well, high risk surgery in the first instance. Given that we've been in there before, the risk of nerve and vessel damage, I would explain that this can recur. I would also explain that we can't guarantee a long term good function for that reason and also the risk of perioperative fracture when we start to exercise this and defunction the possibly the surrounding musculature and in the chronic setting this may be, uh, in the context of week week AB doctors or surrounding musculature and therefore the risk of, um, reduce function, weakness and possibly even dislocation. And so I would I would mention all those things. Okay, so you've explained that what would you do for this patient? In terms of trying to reduce the risk of recurrence and in terms of trying to attack the risk of dislocation, I'm aware that we can give peri operative radiotherapy and also postoperative indomethacin. However, there's extremely limited evidence for this. Um, but I would discuss this with both the radiologists and the rheumatologists. Okay. And in terms of how do you manage to increase risk of dislocation? Um so various options here again discussing an MD t environment with a hip specialist with an interest in this. But the principles are to excise the heterotopic ossification and possibly revise this to a semi constrained total hip replacement. But this is not something that I have, uh, familiarity with. That's fine. Shall we, uh, shall we move to the next next one? Yep. We'll give feedback at the end. He's he's he's up. Now. I think, um, I think I'm up. So look at this clinical photograph and tell me what you see, and what do you think is causing it? This is a clinical photograph showing a lump over the patient's left shoulder. Um, this could be in keeping with any cause of a lump such as a soft tissue tumor, a lipoma, or it could also be related to the rotator cuff underneath. And this could be a Jesus sign with a rotator cuff arthropathy. So my my assessment of this patient would include a clinical history to find out more about about the lump and also about the patient's general health. Specifically, I'd want to know about any red flag symptoms, um, such as weight loss night sweats or any signs of, or any history of previous cancer. Um, I'd also be looking at the past medical history more extensively. Signs of diabetes. Um, and also the patient's hand dominance. What their function is like, what their job is, um, and how this is bothering them. I'd also move on to a clinical assessment to examine both the shoulder and also the overlying lump. Um, specifically, with a lump, I'd be looking to see whether it was firm, whether it was soft, whether it was cystic in nature, fixed the deeper structures. Um, whether it was transluminal, uh, and also, it was warmer any signs of sepsis or infection within the area and moved to a clinical assessment of the shoulder. Specifically, I'd also be a testing the rotator cuff during this, um, this examination and for any signs of glenohumeral arthritis or our cuff arthropathy, um, such as restricted range of movement. Um, following this, I'd move on to both blood tests and also, uh, imaging by way of plain radiographs. Uh, the blood tests and I do the blood test that I would do would be looking at infection markers. Uh, crp esr and also, um, a white Sorry. A full blood count and a renal profile. Um, I would also then move on to, uh, doing a obtaining a radiograph. What I'd specifically like would be an a p a gray, she and also an auxiliary view of the of the shoulder. And what I'd be looking for on these was any signs of superior migration of the humeral head. Any signs of, um, of arthritis and any glenoid or specifically annoyed edge loading on the auxiliary view. Okay, so if I tell you that the patient doesn't have any red flag signs, but he does have reduced range of motion. Um, around his shoulder. Uh, can we have the next image? What do you see? Um, tell me what you would do. So this is a T two weighted coronal slice of an MRI scan centered at the right. It looks like the right shoulder. So it's the It's the opposite shoulder to the one that we've just seen. Um, but what it does show is a cystic, um, fluid field. You don't you don't determine. Predetermine the images, but you're right. Okay. Uh, well, it looks like a cystic mass over the A, C J or in the in the super, uh, acromial space, which would be in keeping with a cuff arthropathy with the Giza sign or extra verse ation of glenohumeral joint, Um, uh, fluid synovial fluid into into the soft tissue area. So the way that I'd manage this patient would be by speaking with the patient about the diagnosis. I'd study these images in more detail, specifically looking at the rest of the rotator cuff. And then I'd find out more about the patient in terms of how functionally it's limiting them and what they're presenting complaint is and what they would like me to do. The options for management here will depend on more details on the patient. So his age, his occupation, medical history and whether they're fit for a procedure or not, I'm not sure. So this is He's a self employed builder. He doesn't wanna operation now, um, he just he basically just you know, you told him that it's nothing sinister. So he goes away, and then you're still there as a consultant, Uh, 10 years down the line and then he comes back, Uh, and then you see the next image in your clinic. Tell me what you see. So this is the left shoulder showing superior migration of the humeral head. Um, with a stabilization of the chromium, uh, memorization of the humeral head. And there's also we're at the glenohumeral joint. This would be a hamada four, maybe a five if that was aware of the head as well. Um, so my management options here would be non operative and operative. I asked the patient what they'd like me to do in terms of if they're still working and whether they want to temporize this with painkillers and joint injections, physiotherapy, whether they would want to consider having an operation at this point in time. The operative options for the patient, which I would discuss with them, um, would include joint arthroplasty. And, um, it would depend on on on what the patient wants at at that point in time. Uh, you said there are options and you said joint arthroplasty. What? What options are there? Uh, in terms of options, there are non operative and operative. We've spoken about the non operative options, the operative options. Um, would, uh it would depend on the patient and whether they're still functioning. Working the other option would be to do a nerve ablation or a super scapula nerve ablation for pain. Um, which, which is, uh, which we would do following a joint injection to check that into the super scapula nerve, uh, to check that it actually does anesthetist the area in terms of actual operative procedures. Given that he's lost the rotator cuff on that side, um, then a reverse shoulder arthroplasty would be, uh, would would be the option. He is still quite young for this procedure. Other options would be a fusion of the shoulder, something which I don't have much experience with. Wouldn't do myself. I discuss him with a shoulder specialist. In such a circumstance, there was some evidence for doing things such as If you didn't have severe arthritis, there would have been other options, such as, um, doing tendon transfers like, uh, like a trapdoor, side transfer or even a super superior capsule. Reconstruction gap was, Well, uh, let's go to the next case. Who's doing this one? Yep. Me? Yeah. Henry, describe the X ray to me. So ap radiograph of what looks like a left knee, uh, showing a small uh, anterolaterally fragment, perhaps consistent with a sigan fracture with it, which is path anomic of a an ACL rupture. I would like to assess the patient, take a history and examine appropriately. So this is a 24 year old semi professional footballer. Had a pivoting injury, uh, during a game on Saturday. He's got restricted range of motion because of pain selling. Um, tell me what you want to know. The history and what you'd expect to find in the examination. So history, any other significant medical problems and whether he's a smoker, which I presume not if he's a professional footballer, I'd also like to know about the injury itself. So whether it's swole up immediately and whether he was able to play on or not no, he is. The swelling was immediate. He couldn't play on straight away and whether he's had any other introvert or problems with this knee in the past. No previous problems, okay, and then I would proceed with examination, So I want to know if there's any other signs of injury elsewhere and whether he's closed neurovascular intact. But focusing on this knee, um, I would, uh, perform a Lachman's test I think it's probably gonna be too painful to do a pivot shift. But whatever the patient can tolerate as well as it says other ligaments of the knee, because this could be in context with a multi ligamentous injury. But ultimately, I'd like to scan this patient before you carry on in the examinations. Anything else you want to do? Um, I would assess his range of movement. Uh, Lackman, possibly a pivot shift test assess the surrounding ligaments. Uh, see if he can straight leg raise. So assess his extensor mechanism. And again, maybe difficult if he's acutely swollen or whether this is a new presentation. But McMurray's test and joint line tenderness for any possible meniscal involvement. Anything else? Um, I was still asking anything, which could affect what type of graph do you use? So his hamstring bulk his patella tendon to see if its intact and pain free nontender. So, when you were in doing your soft tissue knee clinics, did you ever routinely do base in school? Yes. Sorry. Baiting score as well. Yeah. Talked me through the base in school. So pain score is a score from 0 to 9, which is a crude measuring tool for hyper mobility. And the scores are too on the arm. So little finger extend beyond 90 degrees. Thumb, anterior to forearm. Can they touch the forearm as well as elbow beyond zero degrees I e. Hyper extend. So that's three on each side. And then whether they can touch the floor with their Pam's flat is one point and then hyper extension of both knees, which we probably couldn't reliably assess in this left knee. But we could get an idea of whether he's hyper Mobil or not. Yeah, and it's probably worth asking history, whether any family members parents have hyper mobility Ellis animals. Okay, so you've decided to operate on him? Uh, he's got no meniscal injury. Um, but before that, uh, can you show me the next image? What do you see here? So this is a, uh, MRI scan showing, uh, I think it's, uh no, it's a t one. M r. I t one MRI scan, uh, digital plane, uh, of the knee in question showing discontinuity of the, uh, fibers of the ACL. And I can't see any other significant injury, but I'd like to assess, Assess this in in full. You're You're correct. Usually, you know, you you use the t two images because you're looking for bone bruising as well. Um, So tell me about how to do an A C l reconstruction. So, um, this would be done by an ACL soft tissue specialist of which I'm not, But the principles of fixation, our graft choice, appropriate patient consent and in terms of the procedure itself, if we say, decide to do a hamstring, uh, reconstruction or two first, obtain or harvest the graft from the semi tendinosis and gracilis through an incision over the Pez anserinus insertion and isolation of those tendons and then with orthoscopic methods, uh, find the appropriate footprint for both the on the femoral side and the tibial to tibial side. And there are various means of fixation, but usually a button with suture at the femoral side and an interposition screw plus or minus staples at the femoral side with an appropriate jig. Um, yes. So So try and keep it open and just say is either happy Tre fixation or, um, suspensory. Okay. Because you you get too many variations and people get upset. If you say techniques, they don't use? Um, good, uh, feedback to them. Yeah, I think that was, uh I mean, I've examined you guys before. I think fantastic, I think. Keep doing what you're doing. Really? Um, you know, you come across very well. I like the pace of your your answers, Henry, to be honest, like I think you have a cross is very calm. So, you know, that kind of reassures you, Examiner, uh, to some degree. So I think your presentation style and exam technique, I think is very, very good. I like the way you kind of, you know, a bit like with the soft tissue stuff. You know, I'm not a soft tissue, Sergent, but the principles are, and it's focusing on the principles. You know, you're a day one consultant. You know, an expert in these kind of things. Um, well, unless you want to do soft tissue, knee surgery, of course. But, you know, you're focusing on the principles which I think is very, very good. Um, and you come across the safe and very calm, So I think I was very good. Uh, keeb? Likewise. Um uh, there was something. What was it that you said? There's one thing that you said there was a big, uh, like, uh, it was the opposite shoulder kind of thing, but, I mean, that was good. It was, as in, you know, you picked up on It's obviously very astute, but yeah, you don't want to, like, piss off the Examiner with something. So, um, you know, just just keep it, you know, just just focus on the image and, you know, kind of, uh, you know, everything that you said was very good. I don't think there's any problems with your technique or knowledge. I tried to since the UK thing last week. Henry and I have both been up in writing to for the week doing fibers. Uh, one of the things I worked on based on your feedback was to slow down with my speech. I think it was it was better this week than last week. I think it was fantastic. I could you know, it's just, you know, don't tag, because it was something that was gravity situation, wasn't it? I remember, you know, when I was talking to you about Newton's laws, you know, you know? Yeah, just yeah. You know, just just stick to, you know? Yeah, the basics basically. And, you know, on on on on what you're seeing And you describe the images. Yeah. You know, I think everything that you said was bang on I couldn't find any faults. Thank you. Easy sevens, I suppose. The only thing for the eight's you know, uh, it's difficult to get onto that with things like a c L. I mean, yeah, you want to be getting to the reconstruction issues? Um, so, yeah, graph choices, pros and cons of each. What you would do and why, Um, and any evidence for it, You know, you can do a There's an increasing trend to do, you know, extra articular kind of Tina DCIS. But, you know, you can say Oh, you know, if the patient's hyper Mobil, you know, grade to pivot shift and higher or there are, you know, extremely sporty. There's a more of a trend to do that, you know, things like that. I mean, the bell will go, you know, five minutes will run out by that stage, but, you know, it's just trying to get on to those high points clearly for you guys. You know, so sorry. What would you do if they're? If they're hyper Mobil, you'd be leaning towards more of a btv. No, no, no, no, no. Well, uh, you've been using alibi some people. Yeah, well, it's more, um, with regards to the hyper mobility and the pivot shift, the rotational instability, there's increased or recent evidence. So certainly, you know, in writing to where I'm working, a lot of guys are now doing, uh, like a lateral extra articular team DCIS. So it's just it's just to reduce that that lateral laxity that you get. And obviously you can do that in chronic ACL injuries because the capsule is lax laterally. Anyway, so you're trying to reduce that rotational instability, but for hyper mobile people And, uh, you know, uh, yeah, young, athletic people with a serious. That's what you could talk about. So that's it's get good, I think is the guy that did the paper. I think it's like a big review on it, but yeah, that's the kind of stuff that you want to start talking about. But but in principle what you're trying to say, Okay, firstly, you don't have to mention whether you you you're interested in that speciality. Just say, uh, based on principle, this is what I would do. But effectively, if someone has hyper laxity, they're high. They have a high likelihood of having a failure if you use their own graft. So that's the reasoning you use for saying I would use a allograft. You know, that's a safe answer, which more than most people could understand. The thing is, well, I I agree with in the in terms of, you know, leveraging DCIS for, you know, for basically rotational stability. But the problem is, you're not going to get asked by knee surgeon Lower limb. Uh, questions are predominantly by asked by specialties which aren't lower limb similar with, you know, apart from hands and Pete's, you normally don't ask us the questions which you are a specialist for, So the questions will be based on principle. Yeah, if you if it is that that kind of stuff. Only if you're pushing for those eights or the Gold Prizes kind of situation. If you want to start getting that kind of information as as seven saying, you know these guys won't have a clue about lateral extra articular tenodesis, but you know if you're if you're talking about it, assuming you know this patient has high, you know, because, you know, we want to know about the bait and scores and all that kind of stuff. How is it relevant? Well, it's relevant, that kind of stuff. You know, you it may change your management with either your graft options should and said or, you know, doing extra procedures. And if you're trying to get that higher level knowledge and you're aiming for those AIDS that that that's the kind of stuff. But yeah. Easy sevens, I would say. Easy sevens. Thanks, Cindy. Thanks. Indi. Knowledge, You guys. I mean, how do you think you know you? Are you happy with how things go? And I realized it was writing tongue that we met. Not not our our UK. Yeah, I know what you meant. I'm sorry about that. It's been a long week. I could imagine you've done even more, but yeah, you're doing the right thing as well. Keep practicing. Practicing, practicing. That's all it's about. Now, you know, you clearly got the knowledge. It's just refining those techniques and yeah. Yeah. Just remember you On balance, most people do get fives at some point in the exam. The whole point is that you want to get as many seven to compensate for that. On balance, the vast majority of UK train people will pass exam. The vast majority of people who fail are the ones who trained outside the UK That's just what the stats show. So if you just keep to the patient's you're talking, talking out. And if you also keep too having a balanced answer, you will pass. You might not get a gold medal you might not get, you know, 8 to 7, but you will pass. And ultimately, that's what most people going for this exam. One, um, in terms of Henry for your you clearly know your stuff for the for the ACL question. But small things like the bait. And it's worth just mentioning it because it just shows that you're thinking further up as well. Yeah, how does it influence your management? It's all about the management, isn't it? That that that's just going to get the higher marks? You know, history examination is like lower level stuff, how you know what you thought that's going to change what you do and then talking about you will get those top stuff. But thinking one step ahead, isn't it? And that's it. Easier said than done. You know, obviously, in the heat of the situation and getting, you know, you know, six questions bang, bang, bang. You know, it could be pretty stressful, obviously. So you know. But you've got to calm head about you, Henry. So, you know, keep, keep, keep going. Thank you know, most people say, if you passed day one, are you the clinical stuff? You've passed the whole exam, so just just make sure that you you rest the night before for the for the clinical. It's even though it's fewer stations. That is what will determine whether you pass whole thing or not. Six. Most people pass survivors. Well, that's interesting. It's only to do this week active. Yeah, that's the plan, isn't it? It's all the clinical shorts, and you don't neglect that stuff. Don't neglect that stuff. Are you seeing patient's now? We had a whole week, really or yeah, well, the last few days we've been seeing quite a lot of patient's. Yeah, just in the exam. In the intermediate. Still be patient's in the shorts. It'll still be, um, images or multimedia. Okay, just make sure you spend time physically examining a friend just to get slick at it. Yeah, for the for the shorts. If you have to do verbalize your exam. Just get used to verbalizing it. It's a sink manner. Yeah. So what we'll do on Wednesday? Thursday, Henry? Yeah. Yeah, Just describing tests, you know, get you That can be really awkward. So yeah, practice verbalizing how you do a Lachman's or you know, those kind of things quickly. Because, yeah, that's that's what it'll be in the short, Uh, we're going to thank you, guys. Thank you. Good luck, guys. All right. Yeah. Bye. Okay. Is it one ship? Uh, yeah. Yeah, yeah, yeah. Hello? Hello. Can you I think we just waiting for sway Sharp. I've examined both these. I've examined both these young but insurgents. So do you want to take them for two and then I'll take whoever is going to have one. Where's Henry? How is he? Okay. How are you guys doing this? Uh, I'm going to Henry's doing one this time. Okay, fine. So I'll take Henry for his for his one. Uh, is that all right? Yeah, that's good. Thank you. Where you want to start? You want me to start? If you can start, that would be great. Please. Okay. Cool. Thank you. Uh, how are you? Uh, is a 65 year old chap who's, uh, come to your clinic and he says, I got an ouchie hip. Uh, and you get this radiograph. What do you see? Uh, so this is an ap radiograph of the hips. Um, uh, for this gentleman, it shows that he has a right sided, um, collapsed femoral head with metal work in situ, indicative of a previous operation. Possibly cannulated screws. Um, I'd like to see an orthogonal view, but just based on this image, I can see that the hip is subluxed. There is a significant collapse of the femoral head with, um, with arthritis within the within the hip joint is aware of the acetabulum as well. Um, so given this is a clinical scenario, and he's in my clinic. I would start by taking a history from him specifically within the history. What I would like to know was about, um how long or what? What, When? When his index operation was and the reason for that operation, what's happened since I'd want to know more about his pain, about how this is bothering him. I'd also be thinking about the Oxford hip score in terms of his ability to get I/O of a car. Pain at night, stiffness ability to get up from the flat when he's sitting down for a while, Um, and also take a pain level to understand more about how this is impacting on his life. Take a medical history, finding out if he has diabetes or any significant medical issues that may complicate. Um uh, his his care. So cardiac issues or previous neurological issues, Um, take a medication history for any blood thinners. Uh, his allergy history, whether he's a smoker and if he still currently works. Okay, So he had this done 18 months ago. He had a full and he had these candidate hips cruise, uh, put in. Um, actually, he's in. He's functioning. Okay, Okay, He's got pain in there, and it's just, um it's extremely uncomfortable, but he's functioning, okay? And he can He can do all his activity, can do his activities, but he's He said it is painful. Um, okay, Well, what I would do is have clinically examine him to see whether he had a reduced range of movement has a reduced range of motion. Okay. And I would speak with the patient about the options for what we could do. The options would include, um, taking a, uh Well, this is a complex case, so I would discuss them with experienced hip colleagues within the unit. You are the experienced colleagues, thankfully, but the But the principles here are to follow the nice guidelines for hip arthritis, which would include painkillers, physiotherapy, injections. But this is quite an advanced case, and I think that crisis Sorry. Has he got arthritis? I think he has secondary osteoarthritis of the hips after following a femoral collapse. Possibly due to avascular necrosis following a hip fixation 18 months ago. So he does have a degree of subluxation, and he does have wearing of the superior acetabulum Arjun. So he does have secondary osteoarthritis following what I think is a b n of the hip. Okay. All right. So you follow the nice guidelines because I'm I'm somewhat able to cope with at the moment So what? You're what are the nice guidelines? You can give him some painful and senator physio. So painkillers, physios and injections are options, which I must present to the patient. Um, so I would tell him that there are non operative options available. Um, but I think that with the degree of collapse with the arthrosis that he has in the hip, other options would include surgical management. And if he was amenable and wanted to have an operation, I would explain you guys, it's up to you dot What do you think I should do? Um, so if he's functioning at the moment and he's managing the pain, then he doesn't necessarily need to have anything done as yet, but he's finding it very difficult and painful. Then it's reasonable to have an operation by way of, uh, performing a hip replacement. And this would you guys, why can't you just take the screws out if we took the screws out? The likelihood is that the head may continue to collapse. Um, and that, you know, would would not would not collapse. If you keep the screws in, it could continue to collapse as well that if the if the screws are kept in. But the issue is not so much to do with the screws. It's more to do with how the ball and the socket and explain to the patient the ball is collapsed. And taking the screws out would not stop the problem in terms of do you think having screwed metal work just in the joint rubbing over that happened. Not an issue. Um, no, I'm I think that it is an issue. But I explained to the patient that taking just the screws out is unlikely to solve his pain issues. Okay. All right. So he that, you know, you discussed with your hip colleague. Okay, fine. We're done there. Right? Have you got you again? One second. Sorry. Let's move. Slides. Okay, So you have this h here, lady who's coming to, uh, the emergency department. Uh, and she had this injury and the trauma chaps have seen her and said they're not sure whether what what they can do. So And they've asked your opinion. What do you see? Um, so this is an A p and a lateral radiograph center at the right knee. What I can see is a distal femoral fracture. Um, I can see there's mettle work more proximately with some form of an intra medullary stem. And I can see distally. The patient has also had metal work in way of some sort of plate and screws. I need to some further imaging of the bone and joint above and below. Uh, this this radiograph. So he's he's got a long stem. Uh, hip replacement, more proximately. And then she had this deformity correction Sherman Plate put in when she was a child, but it's not really troubled her. Um okay. Um so, uh, sorry. Can you tell me again, am I in the emergency department assessing her or No, no. She's been admitted to the ward, and they're wondering what their to do in the mastery opinion. Okay, I can see the significant joint arthrosis, which seems to be tricompartmental in nature as well. So in terms of what to do, that's the primary management and then the and the subsequent management. I need to know more about the patient in terms of a pre morbid function. More about her in terms of her medical history, whether she has helpers and carers, whether she's cognitively intact. I'd want to know more about the index operations, the timings of these as well. And I'd want to know more about the actual mechanism and the operation. I said to you without the other one was a child when she was a child and the hip replacement was done, done 10 years ago, and it's been trouble free. Um, she's had some recent mild cognitive decline, but otherwise it's independent and has carers that check on her just socially once a day. Any significant medical problems in terms of, um, diabetes, strokes, heart problems in the past? No, nothing. Okay, fine. And in terms of ambulating that you normally walk with independent, I said Okay. Um, so as such, this patient needs to be managed in line with the most guidelines for fragility fractures and also in terms of best practice plotlines or best practice tariff for fractures of the distal femur in elderly patient's um, this requires admission joint admission with an Ortho geriatrician. We need to pre optimize the patient, and the goals of management here are to try and allow the patient to weight bear sooner by providing them with some form of a construct that will allow them, um to to to ambulate they should be done within a timely manner. I e. Within 36 hours and they should be looked after post operatively by both geriatricians, orthopedic surgeons and therapy teams. And they should have a dietician assessment as well. So that would be the medical management of the patient and looking at her as a whole in terms of the actual options for what we can do. This is a complex case, and this is something that I would discuss with other colleagues within the department. The I have to think about the principles, the challenges and the strategies here in terms of what we can do. So the principles I've mentioned are to provide her with some form of a fixation or replacement that will allow her to ambulate. The challenges are that she has metal work more proximately, which I haven't imaged and metal work more distantly. Um, and she's likely to have soft tissue swelling. You've told me that this is a closed injury, that it's neurovascular intact and you've told me she's been admitted following an a. T. L s approach that there's been no other injuries So if we're focusing just on this knee, then our options are either to fix it or two. I think it would be difficult to perform some form of replacement, given that she has a long stem prosthesis, more proximately. Another option would be to to treat her in a cast. However, that would not allow her to ambulate. And it's likely she could defunction while she's an inpatient because she would require a prolonged period of about six weeks in a cast or so, why wouldn't you fix it? So you have what? The fixation. What would you do if you did fix it? Um, so I would get a CT scan in the first instance to assess this in more detail. Um, to understand the configuration, this is likely to be a, um a, uh intra articular uh, fracture. Um, it's quite common. It'd as well. You're likely to be an intraarticular fracture. Um, so fractures around the distal femur and the distal third of the femur can often propagate. Why do you say it's likely? Sorry. Could you say that you said often? Why do you think it's likely? Because there's a fracture in the metatarsal region which is extending distantly towards the joint. Okay. And usually usually these fractures may involve the condos. So I would routinely get a CT scan to further understand mammography. Okay, Henry. Right. So you've got a 62 year old gentleman who's otherwise fit and well, he presented to A and E with worsening back pain and unintentional weight loss for six months. He's got lower limb weakness and an unsteady gait for two weeks. What's going through your mind? So I'm concerned initially about possible coda Qana and would assess as such, but in the background of or on the background of you want to choose one thing that you're most concerned about Cancer cancer. Okay, so Okay, so if it is cancer, what sort of things would you want to be asking about? So, red flag symptoms, i e. We've meant you've mentioned weight loss, but lethargy also a history of cancer specifically with a male, any prostate symptoms, and then do a screen of the other cancers that can potentially metastasized to bones. So lung, kidney, thyroid and prostate, and any infective symptoms just to rule out any possible infective cause which can So so you You've thought about cancer. He has given you no history to suggest that he's been diagnosed or has any frank symptoms of any cancer. What would you do next? So again, a further history as to delineate the exact nature of the pain. But also neurology, looking at his red flag ball that you've got there moving on from history. Okay, so what you do, moving onto examination, I would assess his both upper and lower limbs or do a full Asia neurological assessment looking for any focal deficits or neurology. So you find on Eurasia assessment and, um and you document that on your Asia taht is that he has a sensory level of around about t 10 and he has no, um, power against gravity in his lower limbs in any of his myotomes. He's got reduced perianal sensation, but he does have a voluntary anal contraction. Okay, so he's an Asia be, I believe, and I would discuss this urgently with a metastatic spinal cord unit at the first available. Luckily you have got you are the regional spine unit, and you have got a, uh, a metastatic spinal cord nurse, but with an unidentified primary, they won't accept him. Okay, fine. So I would then proceed with my, uh, investigative work up, which is both biochemical and radiological. So biochemical. I'm looking at his ps A a bone screen, including a myeloma screen. But also, I'd like to do inflammatory markers, including E esR and CRP. To rule out any possible infection which may mimic this. I would also like to then perform radiological investigations. So, depending, is there anything else in your blood that you want? So you said myeloma screen PS a inflammatory markers and esr p s A. I wouldn't do any bone markers at this stage for cancer and bone screen, kidney function, thyroid function, and possibly a group and save if we're considering any operative intervention. Okay. And then radiological. Yeah, I would do, in the first instance a lumber, a pa and lateral x ray. But most importantly, I'd like to do an MRI scan extra going to show you it may show spondylolisthesis or degeneration Mation that. Is that one of your differentials? Um, no, but it could happen concomitantly and shows obvious, uh, collateral treatment as an acute problem, Or is that more of a degenerative elective issue? That can be dealt with later. Um, yeah, maybe more elective. I think I would still do if there was any delay to an MRI scan. That may sort of dictate management or early referral. So let's say you order the X ray, and you order the MRI scan. But whilst they've come to get him for the MRI scan, he's down in X ray. Yeah. Okay. Well, if it's going to delay, then I would just proceed straight with with an MRI scan. Okay, So here's your MRI scan, right? That's okay. Right? We'll move on charge. You want to, um, start with your feedback? Yeah. Hey, how do you think? How do you think they went then? Um, I thought it was okay. I mean, I wanted to do a bit better. I think you both get onto management, but I kind of stuck to my guns. I didn't think I was safe. I feel like I agree. I think that the flow of the kind of questioning and I felt like I answered the questions and told you what I would do as if I was the one consultant. I don't think I said anything that was horrendously off better. I don't think I did. I agree with that. Yes. I think you were a systematic. I think you're very clear. I think you're a nice manner about yourself. So that's good. I think a little bit is there's in the exam. You need to get your treatment marks in fairly quickly so you can buy yourself the the guidelines, all that sort of stuff. I think calling this I would managers according to our nice guidelines or osteoarthritis a bit of a stretch. That's clearly not what the guidelines are for a case like this, Right? So in this, you need to say, because in patients who this guy is gonna be symptomatic. But if he was, if he weren't, you would still advocate something with him because you're gonna trash his hip. Yeah, if you just leave him be and say, come and see me in six months, you'll see a disappearing hip and last have nots trash that you can't reconstruct. Yeah, really, to, uh, you know, you pass safely, but if you're gonna go to the higher marks, then it would be at some point you have to commit yeah, to a management plan. or if patient asked you. I said, Well, okay. Your options are that you've got collapsing from ahead. You've got prominent metal work. You will. This hip will deteriorate and could deteriorate significantly to a point whereby surgeries more difficult. But there's always the patient's choice. Whether you choose to have surgery or not. I would advocate surgical intervention because at the moment I think I can get a primary implant in, uh, and safely reconstructing to give him a stable joint. That's functional, right? If he came back to me in six months and the asked taverns trashed, then you're into really difficult territory. You need revision of all that sort of stuff. Do you see how it's a different conversation? Rather, rather than I use nice guidelines and I would give him some an injection because you're not inject this hit. Yeah. You're not gonna hesitate to have take some allergies here. Maybe it'll work. Maybe it won't work. Those guidelines are aren't for this? Yeah, right. Therefore, degenerative osteoarthritis patient has some grumbling or arthritis going on that you know, they can walk to the shots that they can't. This guy is gonna very rapidly. He's you know 18 months ago he's had an operation. It's failed his metal work in the joint. If even if he didn't want it, I would say for my own self. If I'm going to do this operation, tell him what? Let's take the screws out. Because at least the screws aren't because very quickly the screws was simply sitting somewhere in the eye Liam that you can't even get. And he's trashing the joint. So I think somewhere another. You know how to have a place whereby you have a discussion about surgery and it's It's the the the the the F. R. C s has got to be that you get to surgical decision making at some point another right, yeah, stuck in guideline land because that you'll be on that now. Now you need to be at the point where you're making decisions and management in the patient, right? So I think overall otherwise, that was correct. But I think you needed to have a further discussion. And if you're going to say a specialist colleague, I would almost after that, say, and if I were the hip expert, this would be my decision making because you can't sit behind that in the exam either, right? You can't say. Well, I refer to tertiary sentence. See how it goes Because they obviously going to say where you are. The tertiary center. It's just too easy for them. Right? Um so that was that one. The second one. Just with your language. Don't say there seems to be tricompartmental arthritis. It usually may happen. It would likely do this again. Stick by what you're saying. You can't say usually may go into the joint because it just sounds slightly lazy with your language, and it's difficult. You're in a stressful example situation. And I'm guilty of that as anybody. But, uh, you'd say I would be concerned that this may extend the joints. I would want some further imaging on the on that case. He said this is a difficult case to manage and then go through the pros and cons of each management plan. So what would What was the issue with fixing that fracture? I mean, she can't walk on it straight away. It's It's commuted. It's You'd have to spend loads. Those plated right? You've seen distant from refractures places, Have you? Yeah. Have stress rises if you don't make the plate go long enough. Yeah, so that's not the discussion over there, right? The issue with that is that she's got an almost ankle. Oh, yeah, and so that actually, if you fixed her, she'll be moving only at the level of the fracture. So her chances of union are low. And that's where you're if you're gonna ask her, understand the mechanics of how to manage that fracture that goes. Actually, we're fixing this fracture. She's so arthritic within her knee joint. Even if you fixed her well, she still might not heal because the only mobility she's getting is that is sort of Sue. There are throws through her fracture. So then it's like where you're looking at replacement options and those are massive in her instants. So this will need to go to a tertiary center, I would say in this instance that would probably get you enough to to seven stroke eight land because the other options would be you're looking at total FEMA distal femur, all that sort of stuff. That's because it's vogue with these distal femur fractures and elderly patient to do de fr, and there's increasing literature on it and they may or may. I don't want you to just discuss that option that you could do. I think the reason why I was hesitant to say that was because she's got a long stem hip replacement. Exactly. So it's important to say it it because that says to me that you're thinking about surgery rather than the dietician having reviewed her and the physios mobilizing her, that's what. Well and good and boast and boast and whatnot. They are important things to say, but they're kind of sitting at the ST 34 mark. Yeah, and they they're important to say Go. Okay, there are There are guidelines on this, according to boast and, uh, nice guidelines. And there's a tariff for these. I think this one This is probably one that you you need to get to theater fairly quickly and have a discussion because you can run around the those guidelines, but they don't really. They're not score ing opportunities. This that there there's there. There needs to do marks, but yeah, I know you need an issue. Initial review. I know she needs physio. I care about what you want to do. Turn to the surgery. Okay. But otherwise I think you had a very You're a systematic. You're very clear. And I did. I do think when you're oppressed, you stick to your guns and there's a real positive points. You have a nice manner away about yourself. You're calm and collected, so I think you're, you know, easily pass both those stations. But it's just when you're there, you go through if you have to the management options surgically and say why the pros and cons of each one? Okay. All right. Right. Henry, can you hear me? Yeah. Okay. So why were you hesitant to commit that? This is metastatic spine cord disease. Just in the past, we've always been told to sort of put infection and tumeric. Yeah, that's fine. But you you again didn't want to really say Well, he's got an intentional weight loss. He's a man in his sixties. And don't be afraid of saying that. I think this is what I'm most worried about his metastatic spine disease. But I want to also exclude infection, etcetera, saying that fine, You've asked all the questions I wanted to sort of hurry you up over the history and examination part so that we can actually get to the imaging. But you didn't you said just myeloma screen inflammatory markers. Ps A, an esr, and you didn't want to do anything else. So usually you need to do all the tumor markers. Send them off all at the same time. But most importantly, with these patient's is you need to do a bone profile. All right, you need to do liver function test to see because same as they the the primary site for metastases lung, followed by liver, followed by bones. So we need to establish whether they've had any metastases in the liver, because that may cause you to have derangements in your clotting profile. So you also need to do a clotting profile. But more importantly than all of that and what's going to kill this patient really quickly is the hypercalcemia. So you need to do your bone profile because if they're hypercalcemic, you need to treat that as a matter of emergency. That is the key bit here, where it's are you being safe or are you not? All right, so you cannot forget bone profile. Then we would have moved on to radiological X ray first. No, absolutely not. 100%. You do not get an X ray to look for something that's degenerative, that is. Well, whilst we wait to know because And I tried to say to you, Well, he could be an X ray whilst the MRI people are coming. No, X ray is absolutely no role here at all. You need to go for a straight away whole spine. MRI scan, Okay. And the whole spine MRI scan. There is a protocol for it. You should have a whole spine of tea one and then t two. And you should also have some stare. If you're really thinking about those infections to make sure that you go can differentiate between the two in your MRI scan, you want to know exactly where is the location of it? All right. And you then also want to find out. Is it involving just the canal? Is it extra dual? How much of the cord is it compressing? Where is it? Etcetera? All of these things. And then you need to do a CT, chest, abdomen and pelvis. All right. The CT is quite good because it will help you identify if there is a primary. And also it will help you differentiate whether this is a lytic lesion, whether it's a blastic lesion and therefore it will help you to identify whether this is something that is stable. It's not stable. And then you need to have moved on to ask about Takahashi score ing and the since scoring. Because that's where the real differentiating us to This is how I'm going to manage this patient. All right? That was very helpful. Thank you. You're welcome. Good luck. Thanks, guys. So we're moving on to one now. Yeah, um, just to let you know. 11. I'm going to need to abandon ship for about 15 to 20 minutes. That's fine. I'll take them through death by spine. Okay. Okay. I'll see you there. See it? Hello. Hi, guys. How you doing? Good. How are you? Keep that, Henry, is it? Yes. Great. Um, vanilla is my name. I'm, uh, post exam. Uh, Surjeet is a bit a bit more experience than I am, but, uh, just just a small But But, uh, just wanted to check with you guys will get started with the stations, so we kind of have time for feedback and everything. Whereabouts? Are you guys in terms of the questions? Who's going to Who's doing one or what are you doing? I'll go first. I'm going to. That's okay. We'll start with you, Henry. I'll ask you two questions, so I just have I just have some cases, uh, that we can go through here. Okay, So give me one second or what? Let me decide how mean we'll be into it. This doesn't let me kind of go through, um, doesn't let me go through open in a specific slide. Here we go. Okay. So tell me this. This is a 30 year old gentleman he presented to the emergency department after a fall off his bicycle. He was going downhill about 30 40 kilometers an hour, and he presents with this x ray. So tell me, what would you do for this case? So ap radiograph showing a significant injury to the distal uterus at the junction of the mid to distal third, showing a spiral type fracture and possibly combination. My initial concern is that this is a high energy injury and therefore adopt an A t. L s approach to rule out any other injuries, but specifically looking at this arm, I'm concerned there may be an open injury because some there is some compromise in the soft tissue over the distal lateral humeral border at the level of the skin. Um, and also assess the distal neurovascular status, but specifically the vasculature and the radial nerve. Okay, so you've assessed them. This is an isolated injury. There's no other injuries. He's very swollen in the arm. Okay, He's very sore. Um, but it is a closed injury. Um, when you assess him, he, uh he appears to not be able to extend his metacarpophalangeal joints. Okay, so I'm concerned of some, um, radial nerve involvement. If this was an open injury, I would refer directly to a peripheral nerve injury in it. However, I won't immediately in these circumstances. Initially, I'd give the patient some analgesia and splint in a position of comfort prior to further imaging in the form of a CT scan to linea eight, the fracture configuration. I'd also take a focus history as to whether he had any other significant medical problems which may complicate ongoing treatments, but but specifically diabetes and smoking, or my main concerns any young patient. Okay, so he's otherwise fit and, well, you decide to operate. Um, Well, I guess. Would you would you Definitely. We operate on this. Or I think in these circumstances, I'd have a discussion with the patient about pros and cons of surgery. But I would lean towards surgical management and this patient, given the area of the fracture, the degree of displacement and energy involved, but have a discussion and appropriately consent the patient for this. Okay, No problem. So, um, you've discussed the piano unit. Um, and you're you're about to have a discussion with the patient regarding the injury to his radial nerve. What would you tell the patient? So I would explain that it's a relatively common to have a radial nerve involvement with a fracture like this. A Holstein Lewis type fracture. The evidence by John John nudists and lead shows that we should treat the fracture and not necessarily the nerve injury it may resolve. And they do resolve in most circumstances. However, we would keep a close eye on this after a reduction and fixation and intraoperatively document the position of the nerve relative to the plate as well as the condition of the nerve in the area or zone of injury. Very good. Uh, you have decided initially not to operate on this patient. Okay, um, he has had an interval displacement of the fracture at six weeks. When do you decide whether you would operate or not? So we've Sorry. So we've gone for the non operative option, But what's happened? At six weeks, we've tended an operative, and the fracture is displaced on on your follow up X rays at six weeks. Okay, Uh, I would have a discussion with the patient and state that this isn't progressing as we would like it to with conservative means, and therefore, give him the option and discuss possible surgical intervention at this stage. Okay, You would fix it at that. At that point at the six week mark, I would discuss this with an upper limb specialist and an MD t environment, but I think, uh, I think I would consider it. Yes. Okay. Okay. Very good. So we've decided to fix this. You've documented the nerve. Um, it appeared intact at the time of the surgery. However, six months. Um, he's still no MCP joint extension. What would you do at this point? So I clinically assess him for an advancing tunnels I would arrange for e n g studies to be taking place. This is all in the context of a peripheral nerve injury referral. Uh, then look for the positive and negative prognostic features on his nerve conduction studies and e mg. Uh, at this point, he may require a number of procedures, depending on his clinical picture. So what are these positive features? So a polyphasic units are are good prognostic features, but sharp waves and fibrillations are negative prognostic features. Very good. I think we're just We're that that time is a bit off. So they do have time for one question. He has no signs of recovery. He's got negative features here of recovery of the nerd. What would you do? Um, the principles of this are a degree of, uh, no. Either nerve transfers or muscle transfers. Okay, Okay. Very good. So we're a time there, so we'll just get on to the next case, and then we'll get onto it because there's lots of lots to do with that question. Okay, moving on. Okay, So this is a another young person. Okay, So 25 year old guy was rushing to work at seven o'clock in the morning, Um, was overtaken under the car and I had a head on collision with an approaching vehicle. Okay, this is his presenting X ray an emergency department. So a p of the left hip showing a basicervical displaced fracture in this young patient is high energy. So I'd like to do an a t. L s approach looking for other injuries, including head injuries and possibly further imaging in the form of CT chest Abdul pelvis. But specifically, with this injury, I'd be concerned about an iptc lateral or concomitant radial or femoral shaft fracture and therefore, image as such. But look for any other open injuries and distal neurovascular status. Okay, Very good. So you've taken, you've taken your other X ray correctly, and you've identified that he's got an associated injury here. You've completed the rest of your chest assessment, and there appears to be no injuries there. Um, I just wanted to check. Um um you're Are you happy to uh, sorry about this. Uh, in terms of the emergency department, Are you going to do anything else or do you Do you feel that he's appropriately worked up? Um, so this should be worked up in a trauma setting, so he may require a transfer to a trauma unit that provided I am that unit. I would make sure he's appropriately resuscitated. May require blood products depending on his clinical picture and further Imogene with the CT, chest, abdomen, pelvis, uh, take a focused history. Rule out any other significant other medical problems. Diabetes, uh, other. And when How did you manage his patient? So can the country analgesia. I would put him in initially skin traction and then plan for definitive surgical treatment, um, with discussion with a experienced hip surgeon and with the M D T trauma team. But the principles of fixation or two fold. So his femur is a a priority in that it can cause bleeding further pain. But the neck of femur fracture is something that we should aim for anatomical reduction and a stable fixation, which allows early range of movement but not necessarily weight bearing to prevent the risk of ongoing or avascular necrosis. But when would you take them to theater? It depends on his clinical picture. So whether This is something we could do urgently, depending on his lactate. And if he's unwell, this would be a discussion with the, uh, anesthetic or I t u team. But the principles are to, uh, not necessarily early surgery, but appropriate reduction is shown to be better in terms of long term outcome. So if this was the middle of the night, I would be happy to wait to do this the following morning. Okay, Very good. And then in theater, tell me your sequence of events. How would you set the case up? What? What would your full approach be here? So be careful not to displace the proximal fracture any further. I know there are a number of ways to do this, but initially I wouldn't put the patient in traction. I would first with the knee bent, put a retrograde nail up, uh, with opening the fracture site and reducing this with hay grows. Once we've reduced this fracture, then we can think of doing Ledbetter's maneuver to try and reduce the proximal fracture, or even just traction on age fraction table. But at least we've stabilized the femoral fracture. At this point, we can fix proximately uh, with a I think this would be amenable to a d. H s, uh, and and the distal screws of the DHS can bypass the approximal element of the intramedullary nail. Okay, so you you you've tried, you have attempted your Ledbetter maneuver. It hasn't worked. You, you you do not have a good reduction. Well, first, tell me, how would you assess your quality of reduction? And then secondly, if you don't have it, what would you do? So quality of reduction would be off. Shenton is line. I would also look at a pa and lateral views to look at the normal contours of the femoral neck. I would if this fails with multiple attempts at Ledbetter's with traction on the traction table, Then I would consider doing an anterior approach to the hip to reduce this under direct vision, with or without a small third tubular, uh, plate on the medial calcar. How would you How would you put that plate along your cow car? One third, tubular. One third to bitter. Yeah. Yeah. One third tubular plate along the medial calcar in buttress mode and guidance. Um, okay, So buttress mode. And what What are you doing in regard to your screws? How are you putting those in? Um, yeah, I would put screws in both proximately and distantly to the fracture site and do this under a p guided, uh, image guidance. So you you you would put the screws to put you set up with, uh, from the near to the far cortexes It, um I don't necessarily need to go through the far cortex. No, Um, as long as there's a stable construct to buttress that medial neck fragment. Okay. Very good. We're just the time here. Sorry. We'll get to the third question, and and then we'll kind of go through the, uh, feedback. Then you have a slight They're Surjeet, or you want me to go for the next one either? Yeah, I'm happy today. Cool. A cube high. Hi there. You've got a 74 year old man. He's on a cycle, traveling at 20. Okay? And he falls off of the spike on some slippery road and you have an isolated ankle injury. He comes to a and e. How would you assess the patient initially? Um, so this patient needs to be assessed in an A T l s manner ensuring that there are no other injuries. Aside from the obvious ankle injury. Um, so this would involve activation of the trauma team, a trauma team leader and also various surgical and emergency medicine specialties. Um, we would do an 80 approach for the patient in the primary survey, with the goals being to preserve life and then them. And then the secondary survey following that. Yeah. So he's got an open, uh, ankle fracture with lacerations over the medial aspect. You get a X ray and the radiograph show. This will do the radiograph share. So it's a lateral. And ap radiograph centered at the right ankle, it shows a quite a severe open fracture. As you've told me, um, involving both the distal fibula and the Sindh asthma Asus and also the medial malleolus. There's likely to be an element of the posterior malleolus of the tibia as well. The taylor seems well preserved on the AP radiograph. I can't see it fully on the lateral. So my concerns here are here are that this is an open fracture. I would want to assess the soft tissue envelope would like to follow the both guidelines for open fracture management, including giving the patient antibiotics within an hour, as well as documenting the wound with a photograph and then sealing, removing any gross contamination and ceiling the wound with a sterile soap, gauze and a non impregnated dressing. This patient has an open fracture and needs to be transferred to a major trauma center. Once, um, once stabilized, I'd assess the neuro vascular status distal to the limb and document this as well would be an emergency First aid. Medicaid, uh, management be. Would you put him into a back slab? So this would be this would need to be reduced and placed into a back slab with repeat imaging to see whether, when you do that, the repeat imaging shows that it's still subluxed. Okay, um, in such a circumstance of the bone is still visible, and this is still an open fracture. Then the patient would need to be stabilized surgically with an external fixator. But there are few things we need to do prior to this. So the first is we need to speak with our plastic surgical colleagues. I'm assuming that we're at the MTC and have referred him across. Um, but it would be the case that we need to document our findings. Um, we would need to get give him the antibiotics and the tetanus prophylaxis as mentioned. And then, um, make sure that we've taken a sample history seen winnings Last eaten. Make sure he's not in any significant medications or blood thinners, Um, and also find out more about the circumstances. But I informed the anesthetist, Take them to theater and put an expects on in a Delta frame configuration. If you're putting an X six on, where would your pins be? Outside of the zone of injury and outside of the potential zona fixation. So I would go quite high up the tibia, actually, with 25 millimeter pins into the tibia and then one calcaneal pin, and I tend to do a pin into the, um into the first metatarsal to prevent Aquinas. Okay, this patient, You take two theatre and you decide the soft tissue envelope is amenable for primary fixation. There's a lacerations over the medial aspect. You take the patient to theater, and this is what his wound looks like once it's delivered out of the wound. The wounds had extensions approximately and distally, uh, you give it a really good wash? What would How would you fix this? What would you do? I'll go back to the original radiographs. So in terms of so the principles of their principles challenges, um, and strategies here. So my principles are the patient requires a stable ankle, um, and that would be achieved by reduction. Um, and also an x fix. The challenges are the open wound and also the combination that's present. I do the plastic surgeon because this patient is likely to require some form of skin grafting procedure of this extensive wound following the debridement. Um, and then also my my strategy is would be essentially to both stabilize, uh, the fracture. Get imaging. So span scan and plan for a definitive procedure once the soft tissue is amenable to primary closure, which we should aim for within 72 hours. As for both guidelines, so this patient is amenable to closure the wounds amenable to closure straightaway. How would you What would be the configuration of your fixation? Um, so there would need to be a lateral plate to get the fibula out to length. Um, and, uh, the I'd have to study the CT scan in more detail, um, to to really understand the tomography, but they would need to be worked to to stabilize the syndesmosis, possibly by by screws or tightropes. The posture malleolus may also need to be addressed. The medial side. Why would you Why would you use screws over tightropes? Um, so the evidence is mixed in the evidence is mixed in regards to this. Um so tight rope. Uh, yeah. Sorry about that. So we'll we'll get to that bit in a sec. So what I'll do is I'll just go back to the slide that we're talking about before. So, Henry, first of all, I thought you did. Really? Well, um, it's my mind you unequivocally would have passed on the day I pushed you hard because I thought you knew your stuff. So the reason I kept poking at you and badgering it was I wanted you to give me more information because I knew you had it. So I just wanted to get as much out of you as I could. And I thought you were really good. So going back to the distal humerus, he said, hosting loose. You said initially you're concerned about the, um, the radial nerve. You correctly said, Did you knew this paper? You know, I would have said, you know, definitely a seven or an eight on that, Uh, you know, I would have definitely just said in terms of, uh, any approach. Like, I think you are correct. You just kind of always go back to this can be managed operatively and not non operatively in terms of very specific things. Like I I would have an interest in a prelim prelim trauma and a lot of guys that would have spoken to about fixing these say at the interval period of about six weeks. You have a lot of early callus there. Uh, it's very hard to dissect out the nerve and you probably even though there's no great literature to show it. But a lot of guys will say I would not operate until they're at least that the 10 to 12 week mark, because that early callous actually makes it more difficult to isolate and dissect out the nerve. It's not a definite but if you say that it kind of it brings up, brings up that extra bit of knowledge that you can't even get in a book. So it's a very, very minor point. But from everything you said, you did really well. And then again when we said, how would you manage this again? It's the same thing that really she says reconstructive bladder. So I would, you know, assess that I would assess the neurovascular studies or a neurological studies. I would approach my ladder using either in your license. Initially, If that doesn't work, I would consider a nerve approximation ultimately. And then you say, Ultimately, I think in this patient, they would require, uh, tendon transfer, and then you would talk about your Jones tendon transfer. Okay? And that's kind of but I would have said you were definitely, you know, seven borderline eight. What? Everything you're giving me. I taught in that question, um, then moving on to the next guy. I thought you did. Really? Well, you didn't. You didn't dwell too much before. You told me, um, that you wanted to get an X ray of the femur. So you very early on didn't miss that injury and like, gave me confidence that you're thinking along all the right lines. I got a little stuttering there because I was trying to kind of, uh I was undecided whether I should push you on the, you know, to make him an unstable patient, to see if you would go down the down the line of trying to take him to theater, even though he's unstable. But then when you brought it back, you said, Look, I would check his lactate. I would check. So So you could, you know, you could say I would manage this patient according to head of values principles of early appropriate care. I would look like signposted literally, just as much as that. And you do really well the reason I was pushing you on on the on the fixation side of things, I thought that, um, I just couldn't hear you. Or maybe I didn't hear you say unicortical place. So that's why I was on the plate. Sometimes people have you'll. You'll find yourself in a scenario where the Examiner, the person examining you, has something on their mind, and they want you to say whatever's on their mind. So it was a bit of a tough question because I wanted you to tell me what was on my mind. But I want you to say I would use particle plate because you didn't want the screws to be in the way of your DHS screw, even though you know you wouldn't do it. But the guys like to hear the word unicortical plate. I don't know surgeons. If there's more, you can add to that. So, yeah, these are difficult fractures to fix. And Ledbetter mover manoeuvre is not going to work. But anyway, what you want to do is your your My considerations here is going to be Do I do an open reduction? So Smith Peterson approach and then with my implant placement, is that a lateral approach for a. D. H s? The important thing is regarding fixation here. You've got to restore your cow car and you do your anterior approach, and I often put a 2.7 millimeter footplate on. So it's locking, and you can use that to stabilize the, uh, the medial cow car. And it doesn't buttress on the medial aspect of the cow cart. It's actually anterior. That's what you've got to do. If you find it difficult to actually reduce it, you may need to do ex ex con construct. You can put a chance pin into the head and put a couple of pins unicortical into the proximal femur. Adjust it. Put on your X six, but it is completely reduced. Make sure the pins aren't going all the way. Bicortical the unicortical. And then you do your implant of choice. And I've done that before and what I've progressed on doing, even with fractures like this, what I've progressed on doing is I put the plate in, and even with a locked construct with that medial plate, once I've got my DHS in with a D rotation screw, for example, I take the plate off because even locked plates, the screws come loose. Then you got to go back in to actually fish out those screws. If you say that they know you've done it, they know that you're safe and you're way above eight. You're like at 10 because hardly anyone think one doesn't. Yeah, Henry, as I forgot to say to you when I was asking about quality of reduction, there's that Quinn tank video that he talks about trabecular lines and how you draw the trabecular lines. But the end of the video, he talks about how he says, your alignment and there are a couple of things you said centonze line, which you would then say I would look at my trabecular lines to see if my primary compressor group is aligned. And then the other thing that talks about is Lowell's Alignment Index Alignment Index. And that's off the trabecular lines as well as low as a line index is. Actually, it's this s shape that you get when you go in the lateral and the a p. It's the s shape that you get that that follows the actual cortical line. So if you say those things, they're kind of the extra things, especially like surge. It is, um, kind of, uh, I guess, a younger trauma surgeon. So he doesn't talk about the the traditional stuff he knows which way. It's a line. But the some of the older examiners that you find hanging around might ask, you know, might want you to say low as alignment Shenton is line my trabecular lines and then that kind of pads out your answer more nicely, and then we get your keeps, then bit as well, like you can switch this off. Uh, was that both of them? Oh, yeah. That was both yours. My one. Let me just come back. Okay. So, yeah, the teaching with this is you basically turn them to an Ortho plastic unit. Uh, this patient came in, uh, and because I had a small lacerations that was easily amenable, all I did was extend it. You've got to think about the structure at risk. Why is it not reducing? It may be because you've got interposition of your deltoid ligament, which I've never I've only read about, but it is actually the case here. The deltoid ligament was in, told us that it couldn't be reduced. And so all I've done and and the way that you approach this was absolutely good. Uh, you want a length stable construct. So if you use a If you use, uh, tightropes, you're making a tight rope whole, which is 2.5 meal, and you're putting a little cord through that. You're going to get some movement, and you may want to do, uh, 4.5 screws here. I've used multiple 3.5 screws, but these are four cortices and the reason for that is they often break here at the scene. Osmosis. And that way you've got easy access to take them out from the other side. But again, all you want is alignment of your fibula so that you control your limp and rotation. And that in itself could be difficult. If they test you about that, put a a Weber clamp on to the distal end of the fibula. Give it a pull. Take radiographs. Make sure that you've restored sort of that little Shenzhen's line near the, uh, distal end here. And what you can do is transfixed the end of the tibula You using ky into your tailor, which is what I did to keep my limp right. And then you just do the rest of it. And I put a couple of anchors, uh, well, actually, suit to this, but you can put anchors into your deltoid. But you answered it really well. Yeah, I thought I thought you both did very good at, say on the day. I certainly don't think there'd be any question to my mind that you would have passed both your stations. Do you have any questions? Yourselves from anything that's come up so far in your studies or you know how to approach anything. Mm. Not at the moment. We're just trying to do as much as we can. Uh, so the important the important thing is stay calm. You'll gain lots of mark on your trauma divers, uh, and start from the principles. If you need to and get through it, be safe. Uh, yeah. You'll be absolutely fine. So when you get shit like this, I'll just go through because we've got time. Are you happy with that? Just just to give you some stuff. Uh, if you get an amputation, think about amputations. What do you do regarding soft tissue coverage? Uh, nice. And buy it. The principles Are you gonna re implant? Reconstruct? What are you going to do? He's had the tip of it taken off here. The consideration is really your flex and extent attendance. You can put him through a tunnel and actually get it to heal up within two weeks. So that's like, two weeks of their position. If you get dodgy, X rays like you probably won't. But let me just find something like that. If you get something completely bizarre. Uh, don't worry about that. Just go through the principles of faith Orthopedics. You get your teams of vascular guys pelvic guys involved, get a CT angiogram and then think about do I Do I are my options to redo this? Or do I want to reconstruct this using a calcar replacing total hip or a proximal femur? Uh, and other issues. I'll just quickly go for peri prosthetic fracture with a soft tissue injury. Think about what are your other methods of fixation regarding soft tissue injury. This patient had a total knee that I had enough RadiSys. So always get further imaging. Look at the joint blow. Look at the joint above Difficult question. But find out about your implants and what you can do is actually just stick an implant that's slightly longer. And that way you can fix it. It's just thinking a little bit outside the box. But if as long as you have the safe principles, you'll pass. And trauma is an easy way. Easy one to get lots of extra marks on. Yeah, for sure, certainly for my conversation with the examiners, um, kind of post exam in the lead up to the exam tends to be a station that people don't do as well on as the other stations is what they say is it's It's traditionally a station that people score poorly in. But if you follow the principles like Surjeet said, even if you don't arrive at the answer of, I will do an exchange nailing for the fusion nail. If you're following save principles, you will get a great mark. You really well and and And once you build on and build the complexity as you go along but you do your basics well, I think you'll do great. Yeah. Cool. Thank you very much. Very much. Guys, that was very helpful. That was very helpful. Thank you. Yeah. Good luck. Thank you. I think we're you pass the exam. Um, do you prefer to be called Dan or not? Really, Or whichever you prefer, Dan? Actually, a lot of Irish people can't pronounce the Nilo. So Dan is kind of what What most people call me. Um uh I passed this in November. Just gone. Uh, congratulations. Yeah, and I was I was kind of I was actually studying with a guy who ended up winning the medal. Um, so it was just kind of he he would always pushed me very hard and, like we would have pushed each other very hard. And you figure out over time it's really the technique that that's the most important bit. It's not. It's not just, you know, let me learn off loads of cases like and now at the same time, his knowledge was unbelievable. But, like, as we were quizzing each other and preparing, we we kind of found the more I think the more questions you ask people is actually just as much you're learning as it is when you're talking. So like recognizing, you know, recognizing this is what the Examiner wants and and going step buys on it. I I thought it was very important. I I'm sorry about the slides earlier, by the way, uh, problem uploaded the slides that that re she gave us, and I was kind of like I realized it was only after uploaded all of them. I realized there wasn't as much trauma, and But I have I have kind of the classic scenario ones now, so it's not just yeah, I just have some different ones because I just come across different cases and it's just keep me, Keep the interesting. Yeah, of course. You know, the ones the ones I had are the ones that myself and, um, the other guys used when we were preparing based on the last four years, and our old people coming back to us, saying this is what came up. My so they're kind of like, you know, as re she called them the 90% is the ones that come up a lot. So I thought that they were ones that, you know, you're nearly guaranteed to have 11 or more of on the day. Oh, I can I completely agree area and the ones that you've gone through, the one I just get bored because I've gone through many of them. Your level. It probably is a degree of boredom for sure, I I just think it's good for them to think, actually, if they go back to principles, they can answer anything. Doesn't matter what comes up. They they've got to not be scared, because that's what I was. I was scared at the time I did the exam. Uh, and I was absolutely frightened of it and you don't need to be. You just need to be prepared and come on the day big time, big time. And actually, I got I got I. I asked for my exam transcripts to kind of see, you know, what I actually ended up doing is I took down. I was going back to Ireland, literally from the exam center. I had to get a taxi straight to the airport, and I remember like, You know, while I'm sitting down, I might as well write down all my thoughts about what I was asked and how I thought each question went. And when I got the class scripts, it was It was interesting to see that kind of what was going on in your head and then contrasting it to what the Examiner wrote down. And every time you know, it's it's kind of like it's kind of like what one of the guys told me. It's kind of like a dance in a bar, like, you know, if you're both not stepping on each other's toes, everything's flowing Absolutely every time like that. I nearly got eights and every question that that went like that. But when you when you get to that public where he's like No, no, come back, come back and explain yourself. As soon as you have one scenario that goes like that automatically, you know, the eight is out of reach. You're now you're now only be at a seven, but still at the same time, I think passing some of that information back to people who are just kinda about to do the exam. I I just wanted to be as helpful as I could, I guess. Yeah, Yeah. No, I totally agree. Perfect. I think you and I have to switch over to breakout session one. Uh, and then we We started in five minutes, I think. Okay, I'll see him. One. Yeah. Uh, how are you There? Yeah. Cool. I got to share it if you want, but, um all right, guys, who wants to go first? Uh, I think it's my goal. Isn't Henry? Yeah. Are you alternating, or is one person doing all of them alternating? So I'm going to this time, and then we'll do one. Okay. Okay. Strong work. Uh, all right, cool. Right on the belt. Uh, say this is a 30 year old woman who's falling out trail running and has a painful swollen foot. Please describe the X rays. Uh, so there's a A P and a oblique view of the left foot, which shows, um, a fracture at the level of the second metatarsal in the mid foot. Um, there is, uh, from combination at that area as well. Shortening of the second Ray. Um, I'm looking specifically at the Liz Frank complex, and sometimes this can be associated with an injury at that level. Um, and the alignment seems fairly well preserved. Actually, I'd like to know this is what What what alignments are you talking about so specifically, I'm looking for a flex sign. In the first instance on the a P. I'm looking at the alignment of flexo uh, indicating advancement or an Advil, an avulsion of the bone from the from the list blank ligament, which connects the medial cuneiform to the base of the second metatarsal. Um, I can't see that from these images, but what I can see, I'm also looking at the alignment of the second Ray i e. The medial border of the second Ray and the medial border of the middle cuneiform on the AP view and on the lateral looking at the alignment of the fourth Ray and the Cuboid, which also seems fairly well aligned. Do we have a lateral view? And this is a weight bearing. But you said something about what this is non weight bearing. Why would a weight bearing change? It's a dynamic process of Liz Frank or mid foot instability. So it's on weight bearing on physiological loading. It may show displacement, and that would be significant. So when you examine this lady, she's got bruising on the sole of the foot and there is some displacement on the X rays. What would you do next? Um, so this is highly suggestive of a Liz Frank ligament, and as such, the patient will in the most department. We need to do an 80 less approach, ensuring this is an isolated injury. This is an isolated injury. You just follow the trail running. She's got some scrapes, but otherwise she's OK. So assuming that's the case, I would look at the soft tissue envelope around the mid foot. These can get swollen very quickly, and I would provide the patient with a splint in a position of comfort and reimage the foot. I get further imaging in way of a CT scan. The reason why I would do that to look for any combination, Um, and also look at the alignment of the arch and, uh, any fractures elsewhere within the ms with this frank ligament complex. So when you get the CT scan it like you described, there's the old healing fracture. She's a runner and she's a bit underweight, But there is displacement of the base of the second on the middle kun air form. There's no other obvious fracture spin around this area. How would this change your management? Um so sorry. Say that again. This displacement at the yeah, displacement of the base of the second on the middle kun air form. So it's dorsally displaced. I see. Um, so as such, this is a list frank injury and in the young well, in any patient who's amenable to surgery, we should stabilize the mid foot. We have to do that at a time where the soft tissues would allow us to do that so often these injuries can be quite swollen for a week to two weeks. But I would aim to speak with the patient about the options of a surgical fixation to recreate the medial arch and stabilize this fragment. Yeah, and what would be the consequence if she said, I don't want surgery? I just want to get running as soon as I can. Um, well, it's unlikely that she'll be able to function as well as she did before hand because of the instability Arthrosis would form within the joint. And she may have chronic instability and pain in the mid foot, and that can transfer to other joints. So you've convinced her now to have surgery. What, what surgery you're going to offer her? Um, so in in my hands and the experience that I have, I tend to do, uh, my principles are essentially to look at the the middle the, um, sorry. The media, the middle and the lateral columns of the foot, the middle and the medial columns with stable fixation and the lateral column. If involved is usually with K wire because it's a flexible column and that's what I would aim to do is study the images in more detail. But I've experienced in using a locking compression plate like a diamond plate to achieve compression across the front ligament and stabilize four corners of that plate. Um, there are other configurations that have been described, such as arthrodesis, which is the alternative, and that would be bypassing us through between the joint services. Is that arthrodesis? What else do you have to do to get arthrodesis? You prepare the joint services and then completely. Okay, So what would be the benefit and risk? What's the pros and cons of arthrodesis versus fixation in this kind of injury pattern you found, um, so arthrodesis would provide a stable, um, construct, which would heal it would stabilize the mid foot. Um, it would not require removal of the of the screw later on. Um, but the down or the cons would be that you can get adjacent joint disease in terms of arthritis because of the stiffness and up to date. And you know any evidence about this? The codes these paper in Australia looks at this, uh, so cozy. Compares both arthritis is versus, uh, fixation. Uh, and some of the ligamentous or in practice, um, so codes these paper, I believe, was in, um was in fractures, actually. Yeah, So do you think this is a fracture? Ligamentous injury sounds more like a ligamentous injury. But I would say, What do you think, James? Colder paper looking at elite athletes with ligamentous injury. Um, so I've not I've not read Koehler's paper. I'll have to read that again. Don't worry about that, Harry. Do you want to do the next one? And you want me to do this one? Uh, yeah. That's 55 minutes on my timer. But we're not on the screen yet. Yeah, I'm not sure if you started a bit early, Maybe, but that's okay. Um, so we can move onto the next one is Henry. Yeah. Yeah. Can you hear me? Yep. OK, so, Henry, this is a 53 year old lady she's been, um, doing, uh, putting the Christmas tree lights up on the house, and she's fallen off the ladder. Okay, So, um, tell me how you're going to manage this in your District General Hospital. So this is kind of photographs showing the I believe, uh, lateral aspect of the distal tibia at the level of the ankle showing an open injury, uh, possibly in context with a fracture. I'd adopt an A T. L s approach to this, Really? Not any other injuries, but specifically looking at the distal neurovascular status of this. So tell me which Which nerves are you going to test? Uh, sorry. There's something blocking the screen. I don't know whether this is front or so it looks like the lateral side. So I look at Cyril Nerve as well as the, uh, posterior tibial artery as well. Okay, so, um, you, uh, look at the wound and you, um, notice that there's a bit of bone in there. Okay, so this should be dealt with by both guidelines are e at a center that has orthopedic and plastic input. I didn't have trouble. You're in a D G. H. Um, they don't have plastics. Um, So what are you going to do? Yeah, So I would treat initially as per the those guidelines in that I would give appropriate algesia antibiotics, photograph the wound, remove any, uh, gross debris and dress appropriate with the saline smoke calls, and give tetanus if needed. But I would discuss this with a major trauma center, um, for their advice and whether they would like to transfer across immediately. Okay, so you discuss it with them, and they say, you know, we'd really love to help you out, but unfortunately, we don't have any beds. So, um, if you could do the first initial management and then, um, once bed is ready, we'll transfer the patient across. Okay, so in the first instance, I'd like to get X rays to see if there's any underlying bony injury and then X rays. Matt, you're on mute, Matt. Oh, yeah. So this shows a an ap and lateral of this limb showing a significantly common ated, uh, distal tibia fracture of both the tibia and fibula with some valgus angulations fracture at the ankle. So my management at this stage, other than management of open injury, would be to reduce this under conscious and safe sedation in a and E and place in a position of comfort my principles at this stage, or to take a focused history, rule out other injuries, but determine whether this lady had has any other significant injuries or sorry past medical history, including diabetes and smoking, and then, uh, consent er appropriately for ongoing surgical treatment, which would be the form of, uh, an initial debridement with external fixation. Okay, so tell me about the initial debridement. So, um, I wouldn't put a tourniquet on initially. I have it on in situ, but not inflated. I would extend the boundaries of the wound as necessary to gain access to the bony fragments and Bonin's. And how would you extend them so approximately and distantly, Um, avoiding the any sort of acute angles of any skin flaps. So in an s shape, type incision and then isolate the bone ends. Remove any debris, uh, debride any necrotic or nonviable tissue and curate the bone canals carefully prior to an image guided and ct. Sorry. Image guided and external fixation. Okay, so, um, you put your external fixator on and it's a bit wobbly. How are you going to stabilize it? So the number of ways we can increase the rigidity of this construct So more bars, more pins, cross-linking bars and pins, thicker bars and pins, and near near far, far complex the bars closer to the skin reduce the fracture as well as possible. And I think that's it. Okay. Um, so you've, uh you've put your external fixators in, uh, next slide, all right. Okay. What do you think? So three D reconstruction showing the fractures that we've mentioned has been relatively well reduced. There's quite a big anterolaterally fragment. I'm not sure if this is intra-articular or not. I would study the films appropriately. Okay, Next five minutes. A key. So this is a 25 year old gentleman who's been brought in to the hospital with following a road traffic collision on a motorbike. Speed, please tell me what you see. Uh, so this is an AP radiograph centered at the left femur showing the hip joint with an intra capsular, um, neck, femur fracture, small amount of combination. Um, I'd like to see a view of the entire femur and also take an 80 s approach, ruling out other injuries within the body. Because this is high energy. So following an HLS approach, seeing this is an isolated injury. This new film shows a common it fracture in the in the mid shaft of the femur, which happens in around 10% of cases. So I would examine the limb from the soft tissues, take a distant neurovascular assessment, looking for the pulse, and also looking at the the nerve status of the sciatic nerve and as the comparing you comparing your nerve and tibial nerve, which are part of that, my approach to this case would be guided by a T. L s stabilizing the patient physiologically so, the patient the patient's been stabilized in the emergency department has now been transferred to the orthopedic ward. Friday night, eight o'clock. You're the consultant on call what you want to do. Um So is the patient's stable? Yeah, a couple of bags of blood in recess, and they put him in a Thomas pinpoint. I see. So this patient should really be referred to a major trauma center if it's a high energy injury and there any other injuries, But, uh, regardless, assuming I'm that center, uh, then this pain I would take the patient out of the Thomas splint and place them into skin traction. Um, as this is kind of on the skin. Um, if the patient is stable, uh, then this is something that I wouldn't take the theater in the middle of the night, but something which I would like to do on a planned orthopedic list the next day. Something this is a, uh this is a very complex case. And what we know is that the quality of the reduction at the level of the hip is is very important and perhaps more important than the specific timing of the intervention. So if I didn't have an orthopedic be trained, skilled staff overnight, I wouldn't take this. The theater overnight of the patient was stable. My principles, challenges and strategies of managing this case the next morning would involve obtaining both anatomical reduction at the, um, femoral neck. Um, to an an fixation of that, um, and also you're gonna are you going to do? Are you going to do the neck? You're going to do the neck fracture first? No. So the way that I've approached this in the past and the way that I would do this is by by stabilizing the fracture distantly first, and the way I would do that would be by having a patient supine. I normally use a wedge underneath the knee, and I do a retrograde femoral nail. I do a nail which goes up towards the metaphyseal region of the femur, Um, and then, having stabilized the long bone, I try to get a closed reduction. I move the patient into attraction table and I try to get a closed reduction. Um, how might you get the closed reduction? Do you know anything? Ledbetter's maneuver? I try that once. The way I do that is by flexing the knee, providing actually attraction, abduction, internal rotation, and then go into a position of abduction, external rotation and extension. Try that once. I don't find that it actually works that often. So my backup is via a dual approach, which is an anterior Smith Peterson approach and also a lateral approach as well. The anti arrhythmic to be the same approach is to get anatomical reduction in stabilization with a third tubular plate, Um, in buttress mode. And once I have that reduction, I would do a lateral DHS. I usually use a six hole in the scenario so that I can cross the retrograde nail to avoid a stress riser. Okay, so unfortunately, um, this guy has done really well, but he has come to you three down the line with pain in the left groin, and he's starting to develop a the end of his femoral head. Why would he be getting a the end of his femoral head. Um, so the blood supply to the FEMA femoral head is a retrograde blood supply, which is likely been disrupted at the time of the initial injury. Um, and as such, the patient has unfortunately developed a complication from his initial trauma, the goals of management we patient led and surgeon lead. So specifically finding out what he's finding difficult the amount of arthrosis and if any prominent metal work is causing damage at the articular surface, and then we would go through a complex regional MDT discussion given that the patient's young but the principles we would be providing with a pain free, stable and mobile joint to allow him to function and that maybe by way of either of either a hip replacement had removing the metal work. Um, but how would you do any other things in the in the work up before you took into MDT? Uh, yeah. So blood tests, X rays and, yeah, spect ct, MRI, MRI, CT, uh, aspirated where we rule out infection. Actually, you were flying. I've not got to that point with anyone. I was just rolling with it because you were flying. That was really good from both of you guys. Very impressed. I like the way to come to this. Correct. And then we didn't have to ask you too many questions because you said neurovascular status. You went on and you told us the neurovascular status is going to do. Just make sure if you mentioned the cereal nerve and the posture is tibial artery there on either side of the foot. So why would you do you know? I mean, because you're supposed to tibial artery and then two on a and I was like, uh, yes, should, but also the tibial nerve as well, too, like the medium lateral plantar notes. But that's just me being pedantic. But it's nice that you guys gone to that that you described in your vascular assessment. Instead of just saying your vascular assessment, you describe what you're finding? Yes, it's very nice. We talked about some evidence in terms of, uh, list injury. We talked about managing the polyp traumatized patient and checking them out to the D. D. H. Realizing that it shouldn't be done in the D. J. H doesn't mean that the surgeons can't do it, but certainly it's high energy injury, and you describe the fracture path in Wales. In the Darvocet, it's a short, slightly transverse fracture. It's very vertical neck fracture, so you know all the high risk that a B M and then Henry in terms of your stuff tissue to bribe into little things. Just add in, try and debride towards the fasciotomy lines, because that's what keeps you safe in terms of the plastic surgery reconstructions. Whenever you're doing tibial debridement, you can even just bring it down as a T and then take it onto the fasciotomy line because that you're trying to show that you know you need to preserve the perforators and you do that in conjunction with plastics colleagues. And then you do that in a superficial circumferential, you know, skin fat Flasher, working your way down into out, deliver the bone. It's like you said the breed of it or the devitalized tissue. And then, you know we could then start talking about the articular cartilage falls out or there's a big bony defect. How do you feel the defect? What do you do? Do acutely shorten? Oh, you, you know, hold them out to length and try and transport them down or or all those sort of the recon techniques. But that's boring. That's because you guys done so. You've been gone six quickly describing your X rays, management of the case, getting to your sevens and towards you talking about the research today. I was very impressive about you, HBR. Yeah, I I thought you were both very good. Um, I think you've got the exam next week, haven't you? So, um, you're here already? Um, I would say, um I think, um, some of your techniques were really good in terms of, you know, Um um, I would do this, Um, in my experience, this doesn't work. However, um, that would be my first step. And my back up is to move on to this. I thought that was a very nice way of expressing it. Because what the examiners are looking for is they're looking for your decision making. Yeah, they want to know that. You know, if this is a difficult scenario, you will recognize this difficult scenario. You will speak to your colleagues if appropriate. Yeah, because they want to know that you're a team player, and also you will have steps that you will go through. So if it's if it's not opening, uh, if it's not being reduced closed, then you're going to move on to open. And, um, you know, you've got your plan A You've got your plan B. You've got your plan, C. Yeah. Um, at the end of the day, this this, um, fiber session, it's, you know, it's two hours of kind of intense, you know, um, answering questions and things. You'll come out and you will be exhausted. Okay, Um, the best advice that someone gave me was, You know, you've got to be like a lien for two hours. Go in there and you really have to roar. You know, just show them your knowledge, and then at the end of it, have an app or whatever. Yeah, And don't don't be afraid if they're battering you with questions that often means you're doing well because they want to rush you through to get those many marks is you can't especially in complex cases when there is so much to talk about. So if you get battered with questions, just go with it. Some examiners will let you talk. Some will bath you questions and you'll soon realize that. But just run with it. I think you both have got really good techniques and excellent knowledge. Yeah, and there will be something that you don't, um you don't recognize straight off because, you know, there's lots of things that we've practiced and you would have gone through and stuff, but in the exam, there will definitely be something that you're you've never seen before. And you'll suddenly be like, Whoa. But all you need to do is just be calm and go back to your principles. Okay? Describe the x ray or whatever you see. Um, if there's something you know about it and say it and then, you know, go back to principles. Um, am I dealing with the bony bit? Am I dealing with the soft tissue bit? You know, um, do I need help? Yeah. Yeah, because I had a in one of my short cases, I had a rectus femoris test. Okay. Approximal rectus pharmacy. Clinical photo of a lump in the proximal thigh. Until, really, I was like, what on earth is this? And this is a consultant from my region that I'd never worked with, but I knew was a bit of a bit of a hawk, and he just battered me with questions about how am I going to deal with the scarring and do I lengthen the muscle? And I was like, Mate, I've never done this in my life. I have no idea. Yeah, And you can be You can be completely honest and say, Look, I haven't deal dealt with this before, but my principles of management would be this. Um, I've not read that paper, but, um you know, um, this other paper that I've read shows this Yeah, you've got to, you know, be honest. Yeah, that's these guys getting towards the, you know, the high sevens and eights because they're debating literature. That and that's when you know you're flying. And, you know, I had one in June patrons and it got towards discussing the cord study. And I was always kind of pointless because you can't give Latinate anymore. So, you know, hopefully there's a few things you know, that things like in hands you're going to get at some point, do patrons you're gonna get at some point rheumatoid, and you're going to get, you know, come up in the last week. Just how much basic samples? Probably because certainly I was appreciate that time. And I read some of Richie's watched all these videos while I was stuck isolating my room in Glasgow because I sat the first covid exam and thankfully, MRI came up. Thankfully, X ray came up and I watched the videos that morning because I couldn't sleep, you know, just to give Richie a little plug there as well. But this last week, Yeah. Look after yourself. Make sure you get plenty of sleep if you can. And I'm sure you're both going to smash it. Good luck, guys. Thank you. Smash it, guys. Where are we going next? Hurry. Eight. Uh, we have done eight. So we are on 29. Is there a nine or a back to one? Back to one? Yeah. Strong work. Cheers, guys. All right. Yeah. What's the thing? Isn't there something about if you have a muscle injury to stop it, Skowron, you put them for either a couple of days. I've known you. The FEMA remember reading that in the Miller. You flex the knee, don't you? You flex the hip. I thought if they've got erectus tear flex the hip. I thought it expects the need to stretch out the codes so it doesn't score contractors. I mean, mhm. Yeah, it was an effort review on it. It's for abortions. Something about a muscle tear. Specifically, though, isn't there quadriceps? I mean, I've done this before in the context of a kid like avulsion injuries, prophesy, revulsion, injuries. But it's something like a displaced by more than a centimeter. You may consider doing something that's a prophecy of adoptions, rather than But you don't really do anything for kids, do you? With a avulsion. Approximately significant. Yeah, and this is significantly displaced. But even then, that's based on Level four. Evidence. Yeah, should have quoted McGill at all. And, uh, yeah, quadriceps contusion. There's a north of bullets on. It's the, uh, mobilization at 100 and 20 degrees. A flexion that's the out of the knee. OK, using an ace wrap or hinged knee brace. And that's for 24 to 48 hours. Yeah, kind of by bit out, aren't we? Risk of myositis ossificans. Do you get them in the medicine or anything? Um, doesn't mention it here. Physical therapy therapy Monitor for a compartment syndrome. Mhm. Your turn to go twice. Yeah. Uh oh, God. Did you sleep well last night? I did. I honestly I could have slept for another couple hours this morning. So naked. You? Yeah, I probably can slate longer. It's just when you've been away. When you get back to your proper bed, it's sort of You really go for it, don't you? In the sleep. Yeah. I mean, I got to sleep at about 11. Uh, all right, guys. Hello. You get your your one on this one. Yeah. Um, what cases you want to do? Uh, I'll do the ones that I have, And then the next one, I'll take some from yours, so Yeah. Okay. Yeah. Sorry. OK, so who's going first? Yeah, I'll go first. That's okay. Yeah. Henry, this patient comes to you, um, you know, after having had an injury a long time ago to his, uh, left ring finger, Um, he he sort of, um he he didn't have any treatment at the time, so it might have been like, uh, two years ago, so but now it's bothering him. So describe what you see and tell me how you would assess and manage this patient. So clinical photograph of the door, some of this patient's left hand showing a ulnar deviation of the digit at the level of the A proximal interphalangeal joint. Uh, and possibly some, uh, flexion type deformity at the D. I. P. J. There is no evidence of surrounding joint swelling, redness, erythema or anything to suggest a rheumatological condition, and I can't see any evidence of previous surgery or scars. So in terms of my history, you've told me quite a lot. I want to know exactly what the injury was. I know that he didn't have any treatment at the time, but I'd like to know if there was any evidence to suggest he may have had infection or an open injury. And then I also want to know about him in general. So does he smoke? Does he have does? Is there any other significant medical problems, but also his job, his hobbies and whether this is his dominant hand or not? He's, uh, it's It's not his dominant hand, but he is a manual worker, Okay? And any significant medical problems in smoking know you were asking a rheumatoid, no rheumatoid arthritis. No other medical problems is fit and well, okay, so I would assess this patient's hand and focus my examination on this p i p joint. So assess his range of movement, whether he's got pain through it or whether it's just at extremes. This is his rotational profile, But there's again some ulnar deviation at the P I. P joint. I also want to look at the D I p joint for possible fixed flexion and his range of movement here and whether this is painful on examination or tender, um, and assess his distal neurovascular status as well as do a digital Allen's test. Okay, his distant your of escalated status is fine. His digital Ellence test is fine. Um, you know, so this finger doesn't actually flex anymore at the p I p join. Um, So what would you like to do next? I'd like to get X rays in the first instance. So an AP and lateral of his ring finger. So this shows his an ap of his hand showing an obvious, uh, ulnar deviation of his, uh, p I P joint with destruction at the approximal element of, um P to, uh with no obvious anything to suggest any other inflammatory arthropathies or change changes elsewhere. So this would be consistent with a previous injury. Uh, and then I have a discussion with him about what? His expectations are regarding treatment, and and it discussed various surgical options with him. Okay, Before we go on to the management, is there something in your history that you, uh, sorry in your examination that you might want to see about this finger? Uh, yeah. So I'm looking at his, um, collateral ligaments. Uh, his range of movement. Um, that's fine. So let's go on to management. How would you manage this? So this is a relatively complex problem. Should be dealt with primarily by hand surgeon who's experienced and comfortable with this, but the principles of any intervention or a joint decision. And in this circumstance, the idea is to preserve function and prevent pain, uh, and ate him with his ongoing hobbies activities. I know he's a manual laborer. So, uh, conservative treatments or non operative treatments would involve analgesia splinting of the finger, possibly injection therapy, albeit temporizing, and then more surgical treatments. And this is not something I'm personally familiar with, but uh, the option of a P I p joint fusion would would certainly be an option. Okay. Um, so he he didn't I mean, because it's been so long. One of the things is the finger is not really correctable. So splinting doesn't really help him. Uh, you know, his fingers getting in the way and he try injection. It didn't work so very quickly. If you're going to fuse it, how will refuse it? Dorsal approach. Careful of the neurovascular bundle. Retract the nerve or the extensor, uh, apparatus, uh, and excise the joint ends perpendicular to mechanical axis fixed with either wires or a compression screw. Okay. And what what degree do you fix it at As straight as possible. I know it's only partially correctable, but with bony cuts, this may be correctable. Okay, I'll just show you. Yeah, that's what we did. Okay. All right. Um, that's fine. Let's move on to the next question. Uh, yeah. So is it, Uh, keep who's answering high. Um, so I'll keep Can you? So this patient is 60 years old? The patient just had different surgery. You did a surgery. Um, and then, um, there's a problem with this finger at the moment. Once the tunic a has to come down. Um, So can you describe this picture for me and tell me how you manage this patient? Um, so this is a clinical photograph. Palmer aspect of the hand. Um, there is a Bruno like incision over the, um over the volar aspect of the fifth finger in Flexes owns two. And, um, I can see that the finger is still held in a flex position and it's slightly bluish in color, making me concerned about the vascularity of the finger, especially in the immediate post operative period. There are some pitting pitting as well in consistent with you Putin's, which is present. I'd like to see the dorsal aspect of the finger, but my concerns are in the post operative period that they may have been a neuro vascular injury to the finger in terms of my approached. What I would like to do in the in the recovery bay is number one. Assess the finger, see if there's any sensation. Distantly, I'd also like to do a capillary refill and feel the temperature of the finger as well. I'd remove any splints that are causing the finger too, that are wrapped around the finger to help improve the vascularity. And I also put the hand in a dependent position to try and increase the amount of blood flow to that area. You mean what do you mean by dependent? Low the level of the heart. Um, I would also provide some warm, um, warm solution to the areas that with warm wraps to try and encourage some blood blood flow to the area. And I would also put a saturation probe over the tip of the finger to monitor throughout to see whether there's any changes. My concern is high. I would like to re examine the finger at intervals of about 5 to 10 minutes to see whether it improves my interventions. What is your concern? You say your concern is high of of the vascularity to the finger e necrosis of the soft tissue and subsequent, uh, so the finger is quite warm. Um, and the capillary refill is about four seconds or so. Okay. Very sluggish. So tell me what? You've told me what you would do. So tell me what could have happened in this situation? So the patient likely had a fasciectomy or fasciotomy. Um, sorry. Fasciectomy of the cords. Uh, and looking at where the incisions go past the MCP J, it's likely there was a spiral cord. And as we know that does usually involve the neurovascular bundle. But also be concerned about the abductor digital Minami cord as well, which sometimes can be involved with the vasculature. So my concerns is that the neurovascular bundle has been disrupted with this operation. Is there anything else that you think might have made this finger more prone to having a neuro vascular injury? Um, the finger is likely to have been severely flexed, maybe a to be on a four before the operation. And now we're we've we've essentially released that and we're stretching the the soft tissue and the neurovascular structures. Okay, what's it to be on A For So to be on a is a grading system for Egyptians contractures, and it looks at the severity of the of the contracture and can help guide management. So we're looking at a flexion contraction of above 100 and 35 degrees, which would make it the most severe classification on the to be on a grading system. so that would obviously be a pre operative assessment. But there is a higher rate of neuro vascular injury if we're making a large correction, and is that 100 35 degrees of which joint M CPJ? Okay, um, so anything else you think that could have caused a more risk? So surgical intervention, Nitra genic injury. Um, patient, maybe a smoker. So, patient factors smoker, diabetes, etcetera poor vascularity, or perhaps not performing and digital islands test before the operation. It could also be a revision procedure as well. Which increases the risk. Yeah, fine. So you, uh, intra operatively. Is there anything that would affect your decision of whether you monitor the finger or whether you open the finger again? Is there anything that would affect your decision? Yes. So the patient does not improve if it continues to be dusky and the cat refill continues to be, um, prolonged. Then I would consider re exploring. Plus, I would have to refer this obviously to a plastic surgeon who can do micro vascular repair with microscopes. But that would be the principle here is to look for improvement. And if it fails, then re operation and microvascular repair would be indicated. Okay. Thank you. Are we going back to Henry? No, thanks. Yeah. Mhm. Okay. Henry, this is a 52 year old who came off their bike. Um, they were seen in any and then sent back, and then the patient return because of pain. Um, can you look at the X ray? Tell me what you see and then tell me how you take this forward. So there's a p a radiograph of this patient centered at the level of the risk. Um, I can see that there's some disruption of the distal Gallas lines and possibly some squaring of the lunate, which may be consistent with a per lunate or Perrilloux. Nate dislocation. Uh, given this patient had a relatively high, uh, degree of injury, I would adopt an A T. L s approach. Rule out other injuries or open injuries, but specifically with his hand. Assess his median nerve function. And it also like to get lateral x rays of the wrist. Okay. Um, so in terms of assessment, this is the only injury. Um, do you? How would you assess the neuro vascular status so I'd assess all nerves in the hand but specifically with the median nerve. Uh, I would assess the function distal to put the possible site of pathology e distal to the corporal tunnel. Uh, whereby I would look at his APB, the musculature of the thenar eminence and the sensation in the autonomous zone, which is the index filmer fingertip on the Palmer side. Um, so you said about X rays of the risk. Do you want the other view? Yeah. Natural. Yeah. So this shows a Mayfield three type Perrilloux. Nate dislocation, uh, which shows subluxation of the distal corporal row. And? And the corpus is flexed, or the unit has flexed forward. Okay, um, if I take you back to this x ray, can you tell me? Sorry, it's just, uh, this x ray. Can you tell me about the the two arcs of injury that potentially has can happen to here? And which arc do you think has been injured? So there's a primary and secondary arc. Uh, I believe the primary arc goes through the skateboard, whereas the secondary goes through the surrounding ligament structure. So I would classify this as a secondary arc injury which passes through, uh, under the skate void. and around the surrounding ligaments and a Mayfield type configuration from lateral to medial and ultimately complete, uh, subluxation of the lunate. Okay, Um, would you So how would you manage this patient then? So, yeah, real other injuries assessing median nerve. And then try and reduce this. I would have one attempt at reducing in a safe setting with controlled sedation in A and e using the Tavernier Methods. So traction Contra traction. I would put volar, uh, pressure on the area of the lunate. Um, and then, with extension of the risk, try and hook the remaining corpus over the, uh, flu Nate, preventing it from subluxing, which with anterior pressure and then re x ray reassess the neurovascular status. But ultimately, this may require an open procedure. Okay, Um, so you try and do that. So how long will you give this sustained traction for? Um, as long as possible. But a good five minutes, I think is reasonable. And this can be aided with Chinese finger traps. Okay. Uh, so you tried in any It doesn't work. Um, the so and the patient when you assess, the patient initially had median nerve symptoms. Okay, so, um What would you do next? So I would explain to the patient diagnosis Consent them appropriately for an open reduction but not definitive stabilisation. I would take them to theater. Mark consented. Arm board. Quick. Rhodesia. I would do an extended carpal tunnel type approach. Careful to isolate the median nerve and take it radial wide. Usually, the dissection has been done with the dislocated lunate. Isolate the lunate and possibly with kor joystick type method. It reduced the flu. Nate into it's appropriate position. I would use also finger traps, inter operative Lee and image guidance to aid this. Um, and then this patient will ultimately require a definitive usually for a dorsal approach. Stabilization by a hand surgeon. Fine. Um, I think Andrew to you for feedback. Okay. Uh, well done, guys. So if we go back to first, which is the P I p. J. So, Henry, well described, uh, you You talked about a couple of important negatives, which is really good to do on your first assessment. Whether that's a picture you're given or an X ray. Um, you know, you mentioned there's no sign of rheumatoid or anything that sort of other reasons to have a have a deformity. Um, so that was really good. Um, you did a good sort of. So do the focus. So you want to focus exam on the P I p. J. And the full function assessment in the hand? That's quite a nice thing in hands to just say that that sort of gets you out of a bit of trouble in terms of trying to remember all those grips and and things like that. So I think Kayla tried to push you on your your assessment of P I p j. A bit. So you're wanting to see, Is it is it a fixed deformity? Um, and range of motion, which which he said, um, uh, the X ray was well described. Um, you mentioned how it sort of post traumatic thing. You could say there's evidence of some post traumatic arthrosis there as well. Um uh, you mentioned earlier there was a complex problem. Always good to say. You can see that the severity of it. But you didn't skip a beat and went on to talk about principles. Which is exactly what you should do. Don't Don't sound like you just don't want to do any of the operations because you're not a specialist in everything in the exam. Um, but you obviously you're not. So you said it should be a hand surgeon. However, the pencils with it, And that's how it how it should be. You had good goals. Um, you want to talk about your function versus pain? Um, obviously, because of the deformity, injections aren't going to be a real option if it's affecting him functionally. And it's not just a pain problem, then you're going to need to get on and do something which you did Careful with saying I'm not just careful with saying I'm not familiar with Just don't want them to jump on. Know what you've you've never seen this or you just do what? Do what you did before, which would say, you know, best number, experience, experience, hand surgeon, complex problem, uh, principles would be, um so yeah, fusion. Quite reasonable. Um, uh, if there was time, you might get asked why. Why not replacement? And that's because it's a fixed deformity with clear problem. Clear issues with the collateral ligaments. Um, and also manual worker. So, um, most people would fuse this. Um So he tried to get you get get you to when she was talking about I think you realize when you saw the x ray of what was done when she meant what sort of what angle? Straight as possible When the Corona plane. Yes. Um, but, uh, the answer for that is sort of, I think traditionally, it was 30 to 40 degrees for the for the ring finger. But the other way to put it is that you discussed with patient in terms of what their what? Their goals are what they what they want. Uh, you know, they're looking for more grip where they're looking for more. Something straighter, but generally 30 to 40 degrees. Um, it's reasonable. So, yeah, dorsal can go Viola the compression plates. There are special little devices, various ways. You can fix it, but yeah. You want to, uh, take off the set? The ANC set the angle correctly and fuse it there, But I thought you wanted I thought you answered that well, Especially if you're not, uh, surgeon. You did well to go through, go through principles for it. Uh, Kilo. Anything you wanted to add? Uh, no, I think You know, um, it's quite happy with the the your answering of that. And I think, and Andras told about what? Certain things that will miss and how you can improve it. So, yeah, nothing else to that. Yeah. Good. Um, so next one was, uh it was the Dupuytren's, wasn't you? Clearly, um, you clearly had a lot of knowledge about this. Answered it answered. It's quite comprehensively. Um, and it sounded like you. Maybe you've seen it before, which is not the case for everything in the exam. Um, so you you raised early concern. Uh, you talked about, um, your assessment in terms of temperature, capillary refill, digital. Um, did you mention about digital islands? That's something that you could do to see if there's any evidence is one side or the other. You took the splint off, went dependent and warmth. That's probe was a nice was a nice touch as well. You need pushing a bit on the differential. So you're quite good at sort of managing quite rightly on that initial management, but needed a bit of pushing in terms of sort of why I sort of actual surgical, You know, someone. Have you have you cut the the artery, or is it just a spasm? Or is it, um, as you then got onto a attraction injury When you when you've opened it up, so to describe it. Well, once you've been pushed a little bit, Got to be on a in. But be careful. It's to be on. Uh, is the is the total of all the joints? Uh, total angle between between them. So just careful with that. Uh, I thought you did well. Uh, the station could go on to talking if it's a problem. If things don't come back, the other things you can try is, uh uh, You can give a little calcium channel blocker, um, and or g t n patches, things like that. People do use, Um uh, Beveren, um uh, a thing to to try and reduce spasm. Uh, and then getting onto choice of revascularization versus terminal ization is, uh, something. But but but no, I thought you did really well on that, um, and then moving on to the Perrilloux. Nate. So, um, nice. Nice description, Gilula. Um, you said squaring of the looney and people already talked about triangular flu, Nate, but Maybe that's another way of describing it. But 80 less you mentioned, um, good neurovascular scription, sort of full. So maybe, say you do a full neuro vascular assessment with focus on the medium nerve. I think initially you just said I'll examine the median nerve. So it's it's that balance with sort of. Of course, you want to get on with the median nerve. You know, you clearly you know what's going on, and that's what you're going to talk about. Um and, uh, but if you say you do a full Norvasc assessment with focus on, I think that's quite a nice way of showing like, yeah, I'm gonna say suspension fully. But this is a pair Alluna, and I'm interested in the median nerve. Um, so describe what you do for the median nerve. Really? Well, did you ask, ask for the orthogonal view, or did you just give it to you? I wasn't sure I asked you Did good. Well done. Um, described Mayfield Well, um, I think this time you didn't do important negative, which I thought you're going to do, which you did really well with the hand earlier, but saying there's no because I think you You seem to know this pretty well. So saying whether there's no scaphoid fracture or stay styloid fracture is is it gonna re recommend in your in your whatever you get given again at the beginning give a couple of important negatives. It shows higher order thinking it makes it makes the Examiner relax and go. Oh, God, they know this. I can I can stop listening. And then you might get away with saying something stupid. Uh, so the arcs, I learned them as great. Yeah, it's greater and lesser. This is Yeah. So sedation and stay Verney a good, really good said about you want to reassess the nerve and stuff afterwards? I thought you very methodical. You've got everything out whilst also not sounding like you were talking quickly, which is good. I've said this to a few people, and I don't know whether it's true or not, but I wonder if we should be careful saying Chinese finger traps. Nowadays, it sounds like something that Twitter would blow up about. Uh, but But just maybe, finger traps is a safer terminology. Careful when you were operate, you said about getting the dislocated lunate when you went in the front so that in this case it's apparently not illuminate. So the loonie isn't dislocated, But you describe the extended carpal tunnel. Well, uh, you went down and you're going to you're going to release the nerve and that you're going to reduce it and describe that that you weren't going to go in the back. Um, but that that's what they were going to need. We've we've said a couple of times, people, uh, I would like a a wire or two if my lower limb colleagues are happy doing it to heal A wouldn't. So, you know, you're you're you're perfectly valid either way. So, um, just either plaster it or wire it at the end. I think that's about it. Anything you wanted to add in ca he'll, uh, no, I think, um, I think you know, all these three would have been passing. You know, your the squaring of the lunate that you're talking about. What does re she says? She says, Piece of pie, right? Yeah. It should be more trapezius than it looks. More triangular when it's Yeah, it's a triangular lunate or piece of python is the classic description. Yeah, but these are minor details. You recognize the injury? I thought you both answered. Well, you're both for both of you. Your technique was good. You got lots. You You didn't just sound like you're trying to really quickly, really quickly and everything out, but also got everything out, Henry. Say, did you say 80 else, By the way? I did. Yeah. Yeah. Everyone. Is that so? Yeah. For your trauma. Anything traumatic? Especially high energy. Just quickly. Not 80 less. You know, it's not going to be. There's a point for it. Uh, yeah. Full assessment of the neurovascular structures and the soft tissue envelope with a particular focus on. Because then that gives you You're not going to miss that. It's open. You're not going to miss a nerve injury. It's a nice little sort of global thing to get you through those initial marks and on to where you want to be, Which is talking about management because it's you guys didn't do this. But a lot of people dwell on stuff at the beginning and and therefore don't have time, but well done. Good luck. Thank you very much. Thank you very much. Right, Where are we going next? I guess we're going to know 10. Is there a nine or 10? Let me just I think we might be going back round to one, maybe one. Okay, let's bring up our thingy. Yeah, Back to one round to one. Hello? Hello? Nothing. I think that I am brilliant. Uh, So did you want to go or No. Joe is not here. She's in previous group. She's gone out. No, no, no. I'm sorry. I was looking at my partner, which is Joe. I get started. Okay. Okay. Hello again. Hi. Nice to see you again. Right. So this is a 13 year old lad who's, um, come in with knee pain. Um, they've had three month history. They've had physiotherapy. And then finally, somebody examine their hips and those sensibly today hip X ray. So can you have a little look at these X rays? I would like you to tell me what pertinent points in the history and examination are going to change or affect your management. Okay, Um, so this is an a p and a lateral view. Looking at the pelvis in this, um skeletally mature child showing a slipped capital femoral epiphysis on the left hand side. In terms of the image, the key points are that climb lines, um, climb line is broken on the left hand side, but preserved on the right. Um, there is some metaphysical cysts that I can see. The patient seems to have a large body habitus, and on the lateral view, I can see that the cervix angle, which I could formally measure, would be higher compared to the other side. And I could formally measure where that's mild, moderate or severe e less than 30 degrees, 30 to 50 or more than 50 degrees described to me Not you're not going to draw it on yourself. But could you describe to me how you do yourself, wick? So it's a perpendicular line across the Fyssas and then a line down the femoral perfus iss and the and an angle off that, and you compare that to the contralateral side. So you minus that off the contralateral, though you minus contralateral side off that when you look at a degree difference between the two. If both are affected, you use 100 and 35 as the as the normal value 135 if both sides are affected. But if not, then it would be compared to the contralateral side. Okay, So what do you think The angle is on on this left hand side? Just eyeballing it, eyeballing it. This is a moderate or severe. Okay, if I tell you that it's 85 the Contrave actual side has 11 degrees of posterior, it's like, um so then that would be, uh it would be above 50 then. So it would be a severe. Okay, continue. Um, so from the history answering your initial question, what's concerning is the time frame. So it's been three months, so it's likely this was going to be a possibly an acute on chronic or a chronic Skippy. I'd also want to know about the weight bearing status of the child i e. If it was stable or unstable according to the load of classification. So he's able to walk even with the help of a parent in the emergency department. Um, to that the relevance is in terms of the subsequent risk of avascular necrosis. So if you have a stable hip, there's a much lower rate of avascular necrosis in the original load of paper. Um, shows maybe as low as zero as compared to if you have a If you do have an unstable um, Skippy. So the management asked across the strait be an unstable um, so I forget the exact figure, but it is much higher. Um, so the management, this child, this is a complex problem and requires discussion with the pediatric orthopedic unit. Um, given the time frame and that this is not an acute slip, and it sounds like chronic slip, so I'd refer it onwards. But the principles of management would be to get further imaging. So I want imaging of the knee as well as the rest of the femur. And also an MRI scan of the left hips specifically looking for, um, any, uh, metaphysical cysts within, um, looking for any acute changes. I hyperintensity on the background of a chronic slip. Um, and also, um, I would want to see whether there was any other vocal issues around the joint as well. Such as an infusion or or any evidence that this could be an acute on a chronic. Okay, so So, um, sorry. Just so you're looking for metastasis cysts. What would they tell you? Um, so that would suggest to me that this is a chronic, Um, this is a chronic slip and that the Fyssas has has had time to adapt or try to adapt, adapt to a to a slip. It would tell me that there would be some disruption within the fi CS layers as well. And it would also be concerning, obviously, uh, because it may indicate that the there might be a potential of a growth disturbance or, um, or problems with the Fyssas. And what would How would that impact what you would do about it? Um, so it would help in terms of the onward management. Uh, so, uh, in terms of the onward management, we're looking at the risk of osteonecrosis the risk of growth arrest and also what we would do in terms of whether this would be amenable to a primary fixation or if this requires, you know, in a in a specialist center, some form of a an osteotomy, um, to to realign the hip. And I think that you know, it's useful information to have it will also help with the bus assessing the vascularity the MRI scan would help. And assessing the vascularity of the head of the stage as well. Um, would it, uh, it may do it. May it may help us in terms of seeing whether or not there is, um, you know, the three month interval whether there is a low signal intensity on the t one scan or whether there's high signal intensity. Okay, um and then, um, you were So you're saying you're going to use whether it whether there's, um, the pen as to whether you pin in sight you or whether you, um, performer, an open procedure. Just take me through that. So, what's, uh, bearing in mind? I take on board what you said, which is the specialist unit. But just if you you're at that specialist unit what? What would be the decision making process for that? Um, so the decision making I missed the first part of your question. Sorry, because it kind of did it crack out. Sorry. My apologies. That's not my Internet can be a bit dodgy. Um, so baring your mind and I take on board what you're saying. It's going to be a specialist center, but what's the decision making process between pinning inside you or doing an open procedure for this case. She said that, um, you do knee ephemeral x rays. Um, and obviously that's, uh, MRI scan. Um what, uh, what of those is going to make your decision with regards to how you treat this? So severity. So the principles here, I think, would be the severity of the deformity, the vascularity of the head you've got, you know, the severity deformity because you've just told me it's a severe slip. Yes. Um, and then also the likelihood of so the severity links to impingement. So that would be one of the reasons why you may look at doing an osteotomy, um, and in terms of the vascularity of the head, um, you may not want to do a procedure that may cause you to reduce the head and lose the blood supply. Stop there. Um, if we go to the next side, Joe, did you want to? Sure. So, Henry, um, so you're asked to see this, uh, newborn regarding deformities in the lower limbs? Um, can you talk me through what you can see here? Oh, Henry, you're muted. Yeah. Clinical photograph of the newborn of both feet and side by side and then looking at the plantar aspect of the right foot, showing an obvious and quite severe, relatively symmetrical club foot type deformity. So I would proceed with my history and examination. At this stage, the history is to whether there's any family history or syndromic features. Uh, I would also ask if there's any hip problems that have been picked up during any initial screening and whether there any intra uterine problems such as oligo, Hydramine, ia's or any issues during the birth itself. Um, I would then proceed with an examination. So again, assess the hips, perform ortolan, ease and borrows test. There may be associated um D D H deformity assess the patient as a whole look for any obvious syndromic features or spinal problems. But focusing on the feet in question. Uh, I would just observe the actual deformity and whether it's consistent with a congenital tail. Oh, various deformity as well as the distal neurovascular status. Okay, fine. Um, so if you're talking to the parents about these deformities, you don't pick up anything else on the on your assessment of the patient. What are you going to talk. How you gonna explain these deformities and talk them through what you're gonna do next? I'll explain that this is a relatively recognized problem. Roughly one in 1000 births have this. Uh, there's some association with family history, but it's a treatable condition. Uh, most of these patient's with cereal casting in upon settee type method do resolve, and very few require a more serious, longer term operation. Okay. And what would be if you were explaining the pon CT method to them? What would you How would you describe the stages? So I'd say that there is a once a week change of X ray or change of plaster. It will be bilateral. In this circumstance, it's above knee. I would say that Don't be alarmed that the first or second cast might actually make the deformity look worse. But over time, we will regularly review change the cast, and that will dictate, uh, further treatment. But it's usually about six or eight weeks of treatment, I believe. Okay, can you just talk me through how you would do the correction with those casts? Uh, yes. So the first one would be to correct the first Rays, Super Nation or dorsiflexion of the first race. So I would lift the first Ray. And that's why the foot can actually look more supinated and then progressively correct from that point on. But it's important that the tailor is the fulcrum in this. So I would then after the first rate, correct the, uh ab deduction. Or so the a deduction by a bee ducting the forfeit and then correct the various. That's a composite movement of both those two together. And then, finally, the acquaintance deformity and I would explain that roughly 90% of these cases require a, uh, Achilles tenotomy of some description. Okay, fine. And in terms of the if you were talking them through the long term sequela of this or the the outcome is what would you What would you say again? Explain. 10% require an operation. Sometimes there's some dynamic deformity, which may again require an operation, and there is a degree of recurrence. But with the boots and bars, this is dose dependent. So it's really important they comply with the prescribed, um, advice and and also, um, explained that this is perhaps a more severe form because it's bilateral and therefore perhaps a slightly light, likely or higher likelihood of recurrence. Okay. And in terms of the risks of of having this treatment and also having this deformity longer term, what can they be? Um, I don't know the exact numbers. I know there is some element of long term dysfunction, but I can't quantify that, Okay. And just going back a few steps. So let's say that in your initial assessment of the patient, you actually find that there's evidence of spina bifida in this child. Would that change your management? Um, I think the principles are the same, but again, this would be managed by a subspecialists environment and it with an M D. T involvement. Know that with associated pathology such as spina bifida, there's, uh, it's It's a more difficult to treat and therefore might not be successful with poinsettia. But I believe that we should still proceed with the conservative measures, uh, through the use of pain. Ct. Okay. And if the pon settee? If it Rikers after your after your treatment with upon CT method. Um, what would you do then? In the case of spina bifida? Uh, let's say in a in a child without I would determine whether there is what the compliance was like with the Dennis Brown boots and bars, because that may have been an issue. But there's always the possibility in the first instance of returning to, uh on CT again and going through the necessary correction in a step wise approach and encourage good compliance with the, uh, the the boots and bars. Okay. And if it's if it Rikers again after 22 attempts upon CT, then it would require possibly I'm not familiar with this, but a surgical release of some descriptions of soft tissue and bony corrective procedures. We're good. Thank you. Right. J do you want to carry on? What? Um, any preference, uh, should do the elbow. Yeah. Okay. Uh, so this is a five year old child who's been brought up to clinic by the parents because they've been complaining of some aching pain in that in that right elbow. And it seems it seems to be more of a problem after they went away on a sort of activities weekend. Um, you've got these radiographs. The child's in clinic. What's your approach? And and can you tell me what you can see. Okay, so this is a series of radiographs looking at the right elbow, which shows a dislocated radial head on the lateral film. Um, there is a loss of the radio capital line, both lateral and AP film at level the elbow. There's a full length lateral x ray showing, uh, no fractures in the distal forum or in the ulnar. Um, So my concern here is that this patient has a dislocated Radiohead in the context of them being away. Um, this is not something which is an acute presentation. And my approach to this case would involve, um, taking a thorough history, ruling out any concerns for N A I, um, but also, uh, then assessing the limb in question, ensuring that it's neurovascular intact. Um, and assessing the pain levels of the child the Yep. Sorry. Um, So the principles here are two number one, um, to assess the child and ensure that they're paying free. So, in the interim, from the clinic setting, if they are in significant discomfort, you can rest the women and above elbow cast. Um, but this will require reduction and the difficulty here The challenge here is is likely to be a degree of plastic deformity of the of the ulnar, which would make primary reduction difficult to achieve and, if achieved with or possibly convey some instability. I e. The Radiohead would re dislocate unless we do something, um, to address that plastic deformity. So I would explain this to the parents. I would explain the diagnosis, and I explained the management plan. And what I would like to do is, I would like to take the patient in a planned fashion to theater on an urgent basis, and I'd like to perform a reduction of the, um of the radial head. And when I've done this before, we usually have to try to counteract the plastic deformity of the ulnar, which is quite difficult if it's been, um, a prolonged period of time. So the steps of management then would be to try and address the plastic deformity at the level of the ulnar by way of performing an osteotomy, which would be an extension type osteotomy to the ulnar, to recreate the bow of the ulnar to allow reduction of the radial head. Um, so that's that's what I've seen done before. Uh, in in these chronic settings. Okay, Okay. And, uh, in terms of the osteotomy of the ulnar What? What kind of osteotomy would you perform? So it would be an osteotomy in the proximal ulnar distal to the joint? Um, um, it would be a dorsal opening where Jost iata me, which can be fixed with a with a with a small plate with three screw fixations on either side. So this could be anything from a recon plate to a to a third tubular plate, but something to create that bow. What's important is to ensure that the Radiohead is reduced on both the AP and the lateral and the dynamic screen after reduction. As sometimes there can be soft tissue into position. I e. The annual ligament can prevent reduction. If the Radiohead does not reduce after the osteotomy, I would recheck the osteotomy to ensure that adequate, um, recreation of the bow to contract that plastic deformity has occurred. Okay. And what approach would you use? Surgical approach. Um, if the if you did need to address the radial head didn't go back in once you've performed your ostrich me? You're happy with the the osteotomy. Um So when I've done this before, it's been through a radial, um, through a lateral approach to the radius. And what I've done is a e d. C split, um, approach in order to access the annular ligament. Being aware of the pasta interosseous nerve having having examined to that undocumented pride and after the operation. Okay, so does that mean you're what you're saying is you have 22 separate incisions, one for the owner and then a separate, so I'd raise a flap. So the patient is usually position supine with the right amount of an arm board, and I do a posterior approach for the elbow, and then I'd open up a flat, which will allow me access to the radio or the lateral aspect of the elbow. Um, so I've done that twice before, and it's worked quite well. They don't tend to get skin problems afterwards. Um, but that would be my approach to this case. Okay. Very good. Um, and what would you What would you counsel the parents as to the the risks of surgery, So the risks would include, um, injury to nerves. So the pasta interosseous nerve and we do have to do a lateral approach. The risk of stiffness as well, Because we're doing work around the elbow growth disturbance is obviously an issue. Failure of reduction of the radius head or or needing to go back in if the radial head does not does not is unstable. Subsequently in clinic, um, and, uh, also issues with, um, with deformity angle it differentiation. Possibly also compartment syndrome as well. Very good. Thank you very much. Uh, feedback on that, uh, that was excellent. Active that last case. I think it's obvious that you've done this before. Um, and this is a tricky case, uh, for a few people to to get to, um So I think your presentation was at a good pace. I think your, uh, the way that you convey the information was confident. And like I said, it's evident that you've done it before. Um, the only thing I would very, very minor point is that the the owner here has actually had a chance to essentially remodel. So you're not necessarily trying to recreate recreate the normal anatomy of the proximal honor in terms of the bow, you're you're you're actually going to probably make it look more more abnormal when you do your doors opening wedge. Um uh, but other. I mean, that's a minor point. Clearly, clearly you've done those before and clearly, um, I think you would have done very well in that station. Thank you. Yeah, just with that posterior approach, you probably I mean, I did avoid for them, and I think what you're describing is you're going a little bit more posture, but you're still doing avoid Is that fair to say? Not really avoid. So I'm not opening up, postural you between anconeus and the ulnar. So when I've done it before, we've gone. You've broken up are soft tissue flaps with the skin and the and the fat. And then come more lateral in order to make a separate incision, which is kind of about, like a Kaplan, but acting CDC split. Okay, to access the knee ligament. Yeah. Okay, fine. I mean, there's there's lots of different tipping to get your second flap, I suppose, but we don't. We don't go into the bone. We just stay above the muscles. Yeah, lots of ways is going to cap, so, no, your principles are great, so yeah, no I have no concerns about that whatsoever. Um, it's probably worth getting pictures of the other arm just so that you can sort of say what the normal anatomy is. Uh, we would have given you pictures of the injury that occurred originally. So you could say, probably wasn't anti Geo, just sort of badly imaged. Um, good. But no, that was very, very good. I didn't have any concerns. So when you're saying when I've done them before, which always is people in my experience, usually what what experience you have that That's fine. As long as you can back it up. That's absolutely fine. Um, and, um yeah. Sorry. Jo. Jonathan, Back to Henry about the next. Uh, yes. So, uh, club foot, point of view. Yeah. So I think that was again good. I think your presentation was confident You clearly had a good knowledge of the subject. And you've seen these before? Um, no. The pon ct technique. Very well. Um, in terms of the additional thing you could mention in your assessment is your Pariani score. I don't think I can't remember if you I don't think you mentioned it. So that's the only thing you can add into your assessment of the patient. Obviously, if you're going to mention it, then the next question is going to be or potentially going to be. How would you score this foot? So if you if you're going to say, you need to be able to back that up. But, uh, I think you went through uh, yeah, Like I said, you went through the treatment very well. I guess, Um, there's a few things you can mention in terms of the longer term implications of having had a club for or other surgeries that might be required later down the line. So things like dynamic Super Nation is an issue that might need surgical treatment. Um, I don't know. How long would you agree with that? Yeah. I mean, there's about a 30% recurrence rate. Um, so, you know, you've got to warn them of that. And, uh, there's a paper. I think a brace would did one just not that long ago with Yale and demonstrate sort of saying that, um that there is a constant that, um and there's this one from America saying that they were doing tendon transfers about 45%. I think Certainly 30 to 40% do need something because of the weakness of perineals. So you know, you whilst the outcomes are excellent, Um, actually, a fair number. Do need further management or some sort of surgical intervention. Um, so about a third or more. What about long term? Is there anything? Uh, so they they have a flat top tailors often. Um, and, uh And so, um and, uh, uh, longer term ankle stiffness is a thing. Um, and as I say, the soft tissue so needing to be on a sentir attendant transfer is very common. That one in three. I would quote if I was quoting it, but as I say, it could be up to, um, you know, uh, four out of four out of 40% ish. Um uh, but, uh, long term notes and results are excellent. So it's just being aware that sometimes people take it as once they've done their quantity. Course they've got through the boots as well as their their gold. They're not, but and they have a functioning foot which will will work for them of life. But they made shorter legs getting a perennials, a weaker, smaller for it, etcetera. Um, so But I thought I thought you're very good. I think some of your terminology. And it's in some form with Nicholas Tenotomy. I think it's just ridiculous tenotomy because I don't think many would would do anything other than what was the spina bifida. Is there any difference with treatment? If there's an associated syndrome or no, it's just exactly as you said. It's just they can be more likely to be recalcitrant, Um, and And therefore, um, that they might need longer casting. They might seem we might see recurrence. You might be thinking about splinting during the daytime with the boots of us at night. So just changing that treatment. So, you know, if you've got that muscular imbalance that you might need to a f o them during the daytime. Um, but no, I thought I thought you're both excellent with with those two with the with the skiff e. I could have done a lot better with that. Actually, you know, the thing is, your knowledge is great is really, really good, but I think you've got so tangled up in telling me about minutiae of, you know, um you want to be a period, and this is really eight grade stuff is, you know, if you've got some to facil changes and it's not as much cyst, but it's more that you've got extra to muscle bone or signs of fusion. If your if your slip is starting to fuse, just leave it. You don't have to do anything exactly because you'll take out the blood supply if you do a cuneiform. If you try to open, reduce it, Um, so that's irrelevant to they're being They're being changes. Um, MRI can't definitively tell you whether there's a blood supply or not. You get em it irrespective. They're doing pet MRI s now, and there's been quite a lot coming through. I'm sure you've seen it in the literature. Um, so there's a lot more about blood supply. You know their Sydney Group is still are doing are still doing the, uh, monitoring vascular chair. There's There is an awful lot about what image it will tell us whether there's blood supply or not. The problem is, do we really want to know there's there's blood supply before we go and take it out when we do work in air form. That's yeah, Exactly. Yeah, with the controversy with with yourself, wick and something about it. But you have a sign. You did you out five. And I don't know what you meant by 100 35 because that sounds like you're talking about the next shaft angle. And I don't think you meant that. No, I meant if they have skivvies on both sides and you use a reference value of 135 but what's what's 100 and 35 I think. Do you mean 13.5? Uh, no, no, 100 and 35 degrees. And then you minus off. Whatever the So when you get your I probably haven't described this well enough. Sorry. Know, Or at least, uh, at least I don't understand what you're because 135 doesn't fit with the angles that I'm thinking of. So if unless you're thinking of it against the perpendicular, Um, but yeah, yeah, brilliant. Thank you. Know Well, well, very well done. As in I think you're just overthinking it because I think your knowledge is good. Thank you very much. OK, Best of luck, guys. Yeah, well, No, it's cheers. Thank you. Mm. Hello, Henry. And keep. Yes. Hi. Uh, So who's doing to? He's doing one Henry's doing to this time. Okay, So, Henry, we're going to do your two straight off, just back to back, and then we'll do a key. We'll do the third one. Just it saves. Switching over. Okay. Right. We're ready. Last one last one of the last one in the morning, right? OK, tell me. We can see Harry Henry Meted, Meted Meted. Yeah, ap radiograph of two different hips on the left hand side of the screen, we have a cemented, uh, Charlie Total hip replacement with some wires or under greater trochanteric area. It's cemented both in terms of the femur and the acetabular component. And then on the other side of the screen, we have a tapered, polished stem type design with cement again, both femoral and acetabular. Uh, besides. Okay, So, um, tell me about the stems and how they're different now. A Charlie is a close shape design whereby there is a, uh, in theory, no movement at the prosthesis cement interface and no substance, uh, in, uh, in contrast to the tapered design where there is a polished double or triple tapered design in a cement mantle whereby there is controlled subsidence, uh, and movement at the cement processes interface, which relies on, uh, continual whoop stresses. And And those are the main. The main difference is what's the hoop stress? So hoop stress is a circumferential uh, stress, which will stabilize the implant. Okay, good. Okay, let's focus on one on the left. Uh, I'm just going to get you to focus on the lesser trochanter to tell me what you can see there. So I can't see much of the lesser country. Yeah. Okay. So what do you think's going on there? So this could be a result of, um uh, What's the word I'm looking for stress. You near or where it's been offloaded. So what? What did you say? Stress. I said stress. Relaxation. But it's not. It's, um, forgotten the name. OK, shielding stress shielding. Yeah. Okay. So talk me through. What stress shielding is stress shielding is with this implant in particular. As we load the implant, it is the proximal part of the bone is bypass in terms of forced transfer, and it's distantly loaded. So by wolf slaw. Uh, the remodeling of the bone is reduced in that proximate element, and therefore we don't get the normal turnover and bone formation. So I'm not going to ask you a hard question. Why do you Why does this composite beam low distantly and not approximately when you said it's all bonded together was a mismatch. I believe there's a mismatch because as the implant load through cantilever bending, there is movement proximately and less movement distantly. And think about what you just said to me. So you said the statement never moves. Uh um uh, yeah. Sorry. The as it's loaded, it's usually well fixed distantly. And there's cantilever bending so by grooms, modes of failure. That's a So you say that every Charlie cantilever bends? Uh, that's the force that goes through. It doesn't necessarily fail through cantilever bending, but that's the okay. We'll come back to that, Henry. Okay, um, let's focus on the greatest cancer you can see. Why is there? Tell me about those. Why do you think they're They're so this could be as a result of intra operative iatrogenic injury. It could be from an extended truck and Terek Osteotomy for access or could be a POSTOP injury whereby there's been retraction or injury to the greater trochanter. If I said to you, Charlie did, for 10 years, did a truck and Terry Osteotomy on everyone, why do you think he did it? Um, I don't know. Okay, so Charlie's hip replacement is called well, used to be called a what? Low friction or three plastic. Okay, so what are these principles of his low friction arthroplasty? So he's used a smaller femoral head in the region of 22 millimeters with a large poly insert. Therefore, the radius at the head to the poly is, and the ratio is small and therefore, that reduces the torque stress at the acetabular bone interface and reduces the sheer stress at that point. Okay, Um, any other principles of his low friction arthroplasty um he also talks about medialize ing the acetabulum relative to the offset of the femur. So reducing the joint reaction force. Okay, uh, and any other ways of reducing the joint reaction force, um, in terms of the implant know. But there's lots of other means and methods in terms of the materials used, the patient's weight and okay, we'll be able to, uh, was that the t Right. So we're on two a week now. Um, So, um, you've done lots of hips and knees. Tell me, is there a difference between the poly in the hip and the knee? Yes, there is a difference between the polyethylene and the hip and the knee and that, um, they are loaded in different ways. So a polyethylene within the knee, um, is because of the higher point loading. Um uh, unless conformity at the knee, we want a stronger polyethylene. So it's high molecular weight polyethylene as compared to the polyethylene in the hip, where there's a more conformed design between the head and the polyethylene, whereby we want to reduce where, as that is, the mode of failure, um, in the hip and thereby it's a, uh, it's a, uh, highly cross linked polyethylene. Okay, so you talk. You said, Where what are the types of where in the hip that you typically get so you can have volumetric wear and you can also have linear wear as well. And there's the classic little more people, really. But what generates that? What's the types of where that you know, not modes, types. Um, so where it can be adhesive abrasive. Um, you can also have chemical wear. So galvanic corrosion or pitting corrosion. Typically, when we're talking about Polly wear? Yes. Pipe. Where are we talking about? In the hip. Well, with a hard on soft bearing, we're thinking about asperity. So we're thinking of either adhesive wear or abrasive wear. Perfect. And in the knee. What type of where are we talking about thinking about linear type. Where with? Subsurface delamination. Perfect. Okay, so now that you know those two things, tell me, how do you think the manufacturing process varies? So the two police, it varies at several stages within the manufacture. So when we think about our highly cross linked polyethylene, we're thinking about the, um, how we heat the polyethylene, for example, Um, we think about the scavengers, such as vitamin E, which may be added to the polyethylene, and also the irradiation and the level of the radiation in sterilization process. Okay, so, uh, so let's just talk me through a standard steps of polyp manufacturer. What are they? So polyethylene is initially ethylene gas. Um, it undergoes, uh, something called the Ziegler process, where, by either additional compensation, Um, it creates the polyethylene um powder, which is then shaped either through direct compression molding, um, or by a machining with sheet compression molding or ramble extrusion. Obviously, the sheet compression molding and Rambo extrusion machining does create more. Asperity is in direct compression. Molding is a smoother surface, which has a lower number of asperity ease. So if you were going to pick one for the hip, what method would use direct compression molding? It is how it's more expensive, but it's a better so in in the knee it it actually shouldn't make a difference either way. Um, OK, good. OK, next one. So moving on, we then look at the process of heating the polyethylene, um, to what's the heating doing? So that will increase. So it's either by a kneeling the polyethylene or by by melting it. But that will increase the the strength of the polyethylene but can increase the number of free radicals so that I'm going to ask you again. So where where are the free radicals? Where do the free radicals come from? Um, so the free radicals come from, um, a change within the chemical process as the polyethylene is heated. So there are different bonds that are created, which, which will create scavenger oxidative processes as well, so oxygen can cause issues in terms of free radicals. So you want to do this in an inert environment for that reason? Okay, so the free radicals are generated by your cross linking That's what generates the free radicals. Okay? Between the chemicals. Okay, so what's the difference between the kneeling and melting? Um, so kneeling is, is heating it to about two thirds of its, uh, it's boiling temperature, whilst, uh, melting is obviously going above the, uh, the melting temperature. Okay, so what What's the advantage of melting Upali? Um, So if you melt Upali, you, um, can change the structural properties of the polyethylene good. Or for the work for the better, or for the worse for the worse. Okay, So why do Why do we consider melting then? Um, it can change the It can change the number of, um, uh, free radicals within the polyethylene. So you melt and you can reduce the number of free radicals. Correct. So if you were going to pick a hip Hollywood, you kneel or melt. Uh, so with the hip poly, I would want to, uh, Neil, uh, I want to melt the melted to increase its structural properties. Uh, vitamin e in as well to reduce the free radicals. Okay, we'll stop there. Okay. Uh, we're back to Henry, aren't we? Okay. It's my favorite X ray, by the way. Right. So this is an ap and lateral radiograph of a, uh, femur with a fixed angle. Construct it with screws, proximately and distantly, with a, uh, black bolt as well as screws in the proximal tibia. The plate has broken, which means that it has reached its endurance limit. And this can be for a number of reasons. And usually, in these circumstances, it's a race between the metal work failing and the bone healing and the bone. It may or may not heal because of a number of factors that I would assess for in this circumstance. Okay, so the murder failure is endurance limits, so it's reached its endurance limit. So what's that called, um, fatigue failure. Good. Excellent. Okay. I need to hear you say those words. Okay. So talk me through these multiple factors that you think of caused the fatigue failure. So, um, we can talk about the stress versus number of cycles on the stress strain or stress cycle curve. So that line represents the point at which it fails. I e. With high stress. It will fail with a no low low number of cycles and vice versa. We talk about an arbitrary limit of 10 million cycles where that's roughly 10 years of 1000 cycles per year with gait, and we usually put implants in or in the context of hip and knee arthroplasty. Specifically hip. We should have an implant that acts below the endurance limit. E so specific to this scenario. Why do you think this? So because the bone hasn't healed. Therefore, the implant is weight bearing and therefore taking more of the strain over a longer period of time. Okay, I like the word straight. What straight strain change in length versus original length. Uh, and how do we, uh, what is the ideal Australian environment percentage? So with fracture healing, there is an optimum strain. But for primary bone healing without colors, that's less than 2% by parents theory. So what are the things that influence Australian violent. What can we do to improve or just Australia? A. You broke up a little bit there. But there are surgical factors, the things that we can do as well as things that will occur naturally. So with secondary bone healing, we have the natural process of inflammation bleeding soft and hard colors, which will naturally stabilize the fragment. Okay, so, surgery wise, how can you so surgery. We can use a combination of tools, so plates into medullary nails, intermit, fragmentary screws, compression plates, X fixes casts, all of which give varying degrees of stability. So in this situation, with a plating, So what? What could what do you think this plating was done? Well or badly, I would say there's a large working length of this now. So a big between the distal most lag screw in the proximal proximal screws, and therefore a high degree of strain and low stability. So where's the working length of this plate? Between the lag screw at the knee and then the distal most screw of all the proximal screws. Okay, we'll come back to that. Okay. Closest to the fracture site. Okay, So what mode is this? play being used in this is being used in bridging mode. Okay, um so talk me through how bridging mode works. So it's relative stability at the fracture site. There's no true interfragmentary compression. It's likely to result in a strain environment greater than 2%. Therefore, we would have secondary bone healing and callous formation in theory or otherwise, progress to a non union. Okay, um, just look at this plate and tell me, do you think this is a locking plate or a non locking plate? Looks like a non locking plate to me, but there's a fixed angle construct at the distal end. Okay, so now that you think is a non locking plate is a bridging plate, a load bearing device or a low share in device. In this circumstance, it's a load share ing if it's non locking approximately. But I don't know what those proximal screws are. Okay, we'll stop that. Okay, Right. So, um, we'll start with the one we just did. So this is quite difficult question, but it it pushes your limits on understanding, right? So fatigue failure. Say it straight off. It's very important to say fatigue failure. You talked about the S a curve, which is great, but basically we then go into Title's of why this has failed. So there are three Title's for any fracture, right? That is the implant, the fracture itself and the patient. Okay, so the implant factors here are This is a non locking plate with a really long working length. Now, working length is the screw that is loaded with the weight of the implant. When they put weight through it right, that's what we're talking about in bridging mode in the locking plate. That is the nearest screw either side of the fracture because they're locking. So it's an internal exits. Force comes down, up the screw across the plate down and a crowd so it's they load bearing device when it starts. This is a non locking screw device, which means that every single screw in the top is being loaded because it doesn't bypass the fracture. So load share device. So the working length of this plate goes all the way to the top. Screw that top screw is taking weight. Does that make sense in a locking plate? None of those screws, beyond that first locking screw, are taking any weight. The weight is between those two locking screws. Okay, so this is a load share ing device, not a load bearing device. Okay, so this is essentially a spanning plate. Okay, so we talk about working length, we talk about straight environment, so we want to make that straight environment as as as close to 2 to 5% as we want. Therefore, in a more fragmented fracture, we want to bring those screws closer together. Because if we keep them far apart, then there's so much bend in that plate that will have too much straight. So we bring the screws closer together because it's more fragmented, the more less fragmented it is, the further squeezing away we go because we don't want it to become so stiff that we create a non union when we go into primary bone healing territory. Right. So we talked about screw position, working length, adjusting strange environment, Australia. Environment is also adjusted by messing around with the fracture. If you got a fracture that's completely displaced, the malaligned, the amount of force going through it is enormous. Whereas if you've got a well aligned in, uh, bone, then you're gonna have less force going through that implant. Therefore, we've got easier to judge our strain environment. Does that make sense? That's why you go for anatomical reduction. And that's why the S N curve is so important, Right? Because s and Curve is here. There's the endurance limit. Our plate will always fail at some point in a fracture, so we need to reduce the force as much as possible. So we get as many cycles as possible before it breaks on that curve. So if we've got a malaligned mall reduced big gap are force going through our place up here. Therefore, we only get so many cycles before it breaks. Whereas we're right down here. We're only getting 10 Newtons instead of 1000 Newtons. We'll get a million cycles out of it, OK, That's the whole point of the S N curve. Minimize the amount of force, get more cycles, gives you more time for that plate before it fails. Get union uh, fracture factors. We kind of slightly missed it. It's high energy, right? So it's segmental. It's a really common native fracture. So we're talking about periosteal stripping. Vascularity may even been open. Okay, So those are the fracture factors, and then the patient factors is always the most important one that we forget. Infection? Is it infected? And then we talk about stuff that we can't really control. They're a smoker, that diabetic, the INR is suppressed. They've got bone, poor, bone quality, etcetera, etcetera. So if you stick to those three title's implant factors, uh, fracture factors and pay and patient factors, then you'll get those things. You'll think about what you need to do. So the 7 to 8 is then going. I'm worried about infection and worry about dead bone. So if you look at that lateral, you can see there's some sclerotic bone there, and then we're into how you're going to revise this. You're going to have to debride. You might have a hole. How you're going to deal with that segmental bone loss We go into masculine it and we go onto bone transport type things. That's your seven and eight. Okay, type questions. Um, the other one that we did. So, uh, poly. So the poly question is all about it. Okay. Is that at the bottom corner? Okay. It's a mixture between amorphous and crystalline so the crystalline bit gives you your mechanical strength. Your amorphous bit gives you your wear resistance in the hip. It's all about where, because the mechanical strength is not relevant, it's a very, uh, you know, constrained, Uh, and the forces are even so there's no mechanical loading, so we compromise a mechanical strength and push for where, whereas in the knee we've got to get mechanical strength. So we've got to get a balance. So we go for more crystal initi. So that first step of additional Peru monetization Ziegler process allows you to adjust that percentage of crystalline versus amorphous so more crystalline means ultra high molecular weight. So it's more densely packed lines of polymer, so it's tighter and thicker, and it's more dense. Okay, um, the next step, then generally, is the irradiation. So the irradiation is both sterilization and cross linking. It's a byproduct, right of the sterilization process. As you hit the chain with gamma radiation, one of those eight pluses gets knocked off, and therefore you got a free iron that's sitting there and another one gets knocked off and those two suddenly connect. That's your crosslink. But what you created is an H plus that's floating around with an electron that's unmatched. UNP aired. That's your free radical, and it has to find something. So if it's in an oxygen environment, it buys the oxygen and it goes straight into the poly and damages it and oxidizes it. So we want. So we do it in an inner environment, so there's nothing for that free radical to bond to. But as soon as we put it in the body, guess what? There's lots of oxygen. They're so there's free radicals and blood oxygen start damaging the poly. So we therefore got to find a way of reducing those number of free radicals. So that's either melting or a kneeling. Melting, as you said, kills them all. So therefore, in a hip, the poly is always white. OK, bright white. There's because there's no scavengers in there at all. They've all been melted. All the free radicals are gone and it goes in in the knee. We can't afford to melt because we've gone from solid to liquid, so the whole Polly structure will get affected if we melt it. So we want to keep that mechanical strength. So we are Neil as a result of a kneeling. We're left with that problem, which is we've left a few free radicals behind, and we don't want those causing the poly to oxidize in the knee. So therefore we add a scavenger, which typically is vitamin E or nitrous oxide. Which is why Polly's in the knee are less white and usually yellow discolored because that's the scavenger within the poly. We're happy with that. Yeah, OK, so that's Poly. And then the last one. Charlie, um, so they're never going to ask you to draw a free body diagram these days. OK, so unfortunately, from our point of view, it's It's much more like questions, I asking, asking about the basic principles. So stress shielding in a composite beam there is. The whole point is, it's composite. It's a mixture of materials, so when you load a composite beam, it will go preferentially through the stiffer part of the beam. So at the top there's more material. There's more metal, so the stiffer part is the hip replacement. As it goes down, the metal starts to narrow and therefore there's less material. And so the four starts to share itself with the remainder of the femur. Okay, so in an Exeter, when you draw the forces, every arrow is equal because it's subsiding. Control and all circumferential forces are identical in the Charlie. As you load, there's no force at the top, and as you go down, the arrows get bigger and bigger and bigger is there's less metal, less metal, less metal bone takes more bone, takes more, which is why you get stressed shielding. So it's a modulates mismatch between the bone and the stem at the top. Okay, so all the force goes preferentially through the stem. And then, as you said, you talk about wolves law and it resolving with the GT. It's about the whole principle of joint reaction force. We want to reduce joint for reaction force so we medialize the cup and we lateralize and distal eyes the trick conta, thereby increasing the lever arm or are doctors. By improving that, we reduce our joint reaction force, which means less wear at the hip. Everyone happy with that longer lever are means less force required to do the same job, therefore, less joint reaction force. So those are your principles from Charlie Medialize, the Cup That's why you can see the Mexican hat on the media side breached the medial wall. Almost create a soft spot that your consultants don't want you to do now. Alright. They made you go through the media wall. They put the Mexican hat on and then cement into it. So you go as medial as you dare, and then you push the trochanter as far down and as far lateral as you can to lengthen that lever on. So you're increasing it at both ends, moving the fulcrum that way, moving the lever on that way. So you've got a massive, massive lever ARB for your abductors, which means your abductor force goes down and therefore you're drawing actual force goes down. We happy with that? Um, small head needs less linear where, uh, small head needs more linear where less volumetric Where? Um So the problem is that his Polly's were crap, so he wanted as little Polly wear as debris as possible, because otherwise it loosens stem. All right, so that's why we went for linear where where these days are Polly's brilliant. So we go for bigger heads and we use the advantage of not dislocating and having a better jump distance. Okay, so we use that. So that's why we use bigger heads. Because our Polly's better. We don't We don't care about volumetric where it doesn't generate that much particles. You guys happy with that? Yeah. Thank you very much. Your sort of three classics. Any questions on those That was useful. Thank you. Very useful. Thank you. All right. Well done, guys. Okay, thanks. All the best. Thanks, Henry. What time do we come back from your lunch, Harry? Yeah, 20 past one. It says we should be back here. All right, mate. See you then. See? Yeah. All right.