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Colleague uh Charlie Howe, uh ST six, East of England, uh and uh by Mr Ben Coma orthopedic consultant, knee surgeon at the Norfolk Arch, uh who will be talking about to build plateau fractures. Uh We'll start from the lower end up. So I'll be starting with ankle fractures today and uh then we'll build our way up to the knee. Hopefully, we can give you guys a five or 10 minute break for uh you know, a quick tea or toilet break or so on. Let me just put my presentation up and then we can get going. So we're um I'm going to start with fractures of the ankle joint and the learning objectives today is to understand the anatomy of the ankle joint and the surrounding structures, recognize the risk factors and uh the incidence of ankle fractures to identify the signs and symptoms of patients that you will see with injuries around the ankle joint. Uh select the appropriate modes of imaging that are needed and the correct views relevant to this injury to classify these injuries. So you can relay the information properly to your colleagues or your consultant, uh treat ankle fractures, both in the acute setting, when you see the patient in the emergency department and then definitively and how to follow them up, identify the possible complications that can happen with ankle fractures and how to best rehabilitate rehabilitate these patients. Um We'll start with the happy with the ankle joint. Ok. So to start the ankle joint is formed of various structures, there, we start with the bones and there are the muscles around it. There are ligaments that are holding the bones together. And then there are the neurovascular structures that run around the ankle joint that you have to be mindful of whenever you approach an ankle fracture or similar injuries around the ankle joint. So to start with, we have the bones. Ok. So the ankle joint is a modified hinge joint. Uh meaning it will move mainly from dorsiflexion to plantar flexion, dorsiflexion, meaning you're bringing your toe towards your shin, plantar flexion is the opposite way around. So when you bring your toes away from your shin, ok. The modification in the sin joint is that it doesn't move in this direction only, it also has limited amount of inversion and eversion, meaning you can bring your ankle slightly inwards. So your foot or the uh the sole of your foot is pointing towards the other leg or you can bring the foot outwards and e so it's pointing towards the outside of your body. Ok. Within a limit. Of course, this isn't the best it, it doesn't have the best range of movement. And the reason and we see most of the ankle fractures we have is because there is an exaggeration in these movements in terms of uh abduction or supination, uh sorry, a deduction, abduction or supination uh or inversion or on the uh other hand, e version or uh abduction or pronation. However, you want to describe it, the bones around the ankle joint are the tibia represented mainly by the medial malleolus. Ok. So that's the bit of bone on the inside of the, of the ankle joint, which you can see here. Ok. Medial malleus, this protrusion that you can feel on the medial side of your, of your ankle. And by the tibial plafond, the tibial plafond is the lower articular surface or the distal articular surface of the tibia, which articulates with the second bone that's involved in the uh uh in the ankle joint. And that's the talus, this wedge shaped uh bone which you can see uh looks like a box on x-rays, but it is more of a wedge and it also articulates with the fibula, the s the third component of the ankle joint from the bone point of view, which is on the outside of the ankle joint and that lateral bump that you can feel at the bottom of your leg. And uh it is represented, the fibula is mainly represented in the lateral malleolus. This lower protrusion, you could feel at the outside aspect of your leg, the lateral aspect of your leg. Ok. So the tibial fonda and the talus are broader anteriorly and wider laterally because of their wedge shape. And that's relevant when you're looking at x-rays of the foot, uh and the ankle depending on the position of the ankle joint. So if your, if your foot is in cous, uh then you, you will have a specific view of the ankle. If your uh foot is in neutral, you'll have a different view of the ankle. And if it's dorsiflexion, you'll have a different view of the ankle. You have to be mindful of that. When you're assessing the x-rays or assessing the patient uh based on these x-rays, looking at the lateral view, you have the tibia here and then overlapping with it. I don't know if you can see my cursor or not. I'll assume you can, this is the fibula there overlying, OK. And overlapping with the, with the tibia. Ok. And this is the talus, as you can see much more wedge shaped than the box shape you can see on the A P. So this is it OK? And again, it's broader, anteriorly wider laterally. OK. And then you have the rest of the f the foot, uh the bones of the foot, the Calcaneus, the cuboid, the navicular bone, all right, which articulate all articulate with the talus. Now, moving on to the muscles, you have the muscles of the anterior compartment, the posterior compartment and the lateral compartment of the uh of the leg. You have the perineal tendon tendons laterally. Uh These are the Peroneus longus and brevis that run along the posterior groove of the lateral malleus. You have the tibialis posterior tendon which is located posterior and inferior at the level of the medial malleus. And they have the tibialis anterior along with the extensor Hayes passing anterior to the ankle joint. So immediately here you can see the tibialis posterior running along with the flexor Hayes, uh along this tendon behind the medial malleolus. Anteriorly, you have tibialis anterior, you have extensor haus long, this running along the anterior aspect of the ankle joint and laterally, you have the peroneus longus and brevis muscles running behind basically behind the lateral mell. The reason this is relevant is you need to know where these tendons are, where the muscle bellies are and where the neurovascular structures are as well when you're approaching the ankle joint. So you avoid any injury to them and be able to identify any injury to injury to them that may have been caused by the ankle if you go exploring around the ankle joint. Ok. Next, you have ligaments. There are three ligament complexes that are important and the interosseous membrane. Ok? And destabilize the ankle joint. So you have the deltoid ligament medially, the deltoid ligament, it looks like a triangle. Ok? Delta Greek delta. So it looks like a triangle, that's the letter for it. And that's why it looks like that. So why it's described like that because it has this triangular shape, it's on the medial side, it's a very strong ligament. And that's why commonly you'll see fractures more commonly of, of the median maul. Then you will see tears of the deltoid, the m the ligament is stronger than the bone and it will cause it to fracture more likely than it. So, in itself, tearing, then you have a lateral ligament complex. And these extend from the fibula to the bones around the tibia. So the gout to the calcaneum and to the talus. And then you have the syndesmosis. The syndesmosis is a group of ligaments that together form the dis uh sort of stabilize the distal ra uh tibiofibular joint. OK. And these are the anterior, inferior tibiofibular ligament and then the posterior inferior tibiofibular ligament and the transverse ligaments. And they are around the lower end of the uh of the tibia and lower end of the fibula forming the distal tibiofibular joint. OK. Then you have an interosseous, the um the interosseous ligament or the interosseous membrane, which is a ligament that joins the two bones together, extending from the proximal aspect to the distal a aspect very similar to the intraosseous membrane that you have between the radius and the ulna. It holds the two bones together. And so it's important to be mindful of that because damage to the interosseous ligament can affect the stability of the ankle joint if compounded with a fracture or compounded with distal ligament rupture. Finally, there's the neurovascular structures around the ankle joint. You have the anterior tibial artery and the perineal nerve. You have the posterior tibial artery and tibial nerve running uh posterior to the medial malleolus. You have the superficial perineal nerve which crosses anteriorly over the fibula and you have the sual nerve which runs uh lateral uh basically or posture, lateral to the fibula. And you have to be mindful to where these uh neurovascular structures are. So when you're approaching the joint or you're approaching the uh the fractures around the joint that you don't damage them. So it's important to be mindful of where the muscles and the your vessel structures are anteriorly when you're creating your portals for ankle arthroscopy, for example. And medially, you have to be mindful when you're approaching the medial malleus and laterally, the lateral mellitus, obviously. So you have the superficial Peroneal nerve and the the ru nerve running laterally and are liable to damage there. The superficial peroneal nerve lies a little bit more proximal about 10 centimeters uh uh from the distal tip of the uh of the fibula. But you will often encounter it if you have a more proximal fracture that you're approaching. So this is in a nutshell, the anatomy of the ankle joint. Now, it's a common fracture. It's about 100 and 87 per 100,000 adults annually. And it's common in two groups, young active males like this uh Austrian footballer here where you can see that in his right foot. He has a sustained of at least a dislocation if not a fracture, dislocation of his ankle. And you have the elderly females. Uh, only last week I saw a patient who had an open fracture, not very dissimilar from this one, who was just getting up from the toilet basically and uh and broke her leg like this without even a twisting injury to it. Um Then there's the fracture types, there's malle fractures that are isolated. Uh These are very common. These are about 70%. Then you have 20% bi malleolar ankle fractures. So affecting two mali and then you have tri maar ankle fractures which are affecting all three of them. Ok. The risk factors are commonly male and young, young males are typically more uh more likely to do dangerous or uh stupid things and end up with fractures. Uh obesity is a, is a, is a, is very common because obesity indicates lack of activity, lower bone density and higher uh uh body weight. And that can cause more pressure on the small bones of the lower leg when uh somebody sustains a twisting injury or hyper uh inversion or inversion injury, smoking uh like uh se uh explained last week, uh affects the osteo uh class uh osteoblastic activity and can result in uh in increased risk of risk of ankle fractures as well. Alcohol consumption because again, it goes with the male, younger age doing stupid things, uh physical examination, uh in orthopedics, you have to look and you have to feel and you have to move. Ok, looking, what are we looking for? When we see patients, we look for a patient who's having difficulty or inability to ambulate just because the patient can weight, bear or can walk, does not exclude that they have a fracture. Maybe they have a stable fracture or an undisplaced one. You have to uh examine for that as well. Uh swelling and uh bruising around the ankle, joint tenderness, uh deformity with displaced fractures. So uh often you get patients with severe ankle fractures who have gross deformity. In the past, both guidelines was to reduce these fractures as soon as they walk in. Now, there's a change to both guidelines and uh you will attempt to get x-rays before reducing the fracture. As long as the x-rays do not delay your treatment for the patient. Uh soft tissue injuries you have to look for as well if there's any cuts, any bruises, uh any massive bruises, any blistering uh around the ankle. Ok. Next to have you, you have to feel and what you're feeling for is the neurovascular supply of the pa and the patient feel sensation in uh their foot mainly you what you're looking for is the, the perineal nerve around there. That's the most distal uh nerve supply in the first web space of the foot. Um And uh you could feel that what sensation you will ask the patient to wiggle your, their toes. Typically uh with hallux dorsiflexion being in. Uh the one means the sort of the main examination they do for uh motor function. Uh You're feeling for tenderness on palpation, you're feeling for crepitus around the fractures, fractures, release some air underneath the skin. And sometimes you can feel that uh you're palpating the proximal fibula for any fractures there. And we'll come to that a little bit later and explain that a little bit later as well. And then you're feeling for skin tenting, meaning the skin hinging on a on the fractured bone and causing maybe threatening of the skin. Uh which is something that you'll have to be mindful of because that's an indication for either a quick manipulation or if it's persistent for uh an urgent surgery. Finally, you have to move. And uh the main things you have to see is the patient can weight bear. And if there's any ankle range of movement, if it's obviously fractured, that there's gross deformity, I don't suggest you try to move the ankle very much unless you're moving it to reduce it. Um Next, we're going to look at the imaging that you are going to ask for for the patient. Ok. And the main thing you're going to ask for straight away when the patient comes in. If you're seeing them in the emergency department or if you're seen in the fracture clinic is uh plain radiographs. What you want to ask for is an A P A lateral and a morph view. OK. Uh The A P view uh essentially is just a foot up toe towards the ceiling uh x-ray. OK. And this is, it sounds very self-explanatory, but it's different because if you're looking at the A P view here on this, uh on this image on the far right, you can see that there's a lot of overlap between the fibula and the tibia, but there's also overlap, plenty of overlap between the fibula and the talus as well. Now, this is a good view if you're looking for fractures, but it's not a good view if you're assessing the stability of these fractures once they're been, once they've been done. So the natural position of the foot, if you're lying down with your feet up, essentially, or um or if you're walking the foot for most people tends to be in about 15 degrees of external rotation. OK. If you want to, if you want to get a proper view of the ankle joint itself in all directions, so you see all of the fibula, you see all of the distal tibia and the medial meus, you want to see all of the talus and you want to see the joint spaces around them, you have to go the opposite way, you have to go into internal rotation about 15 degrees. OK? So when A P view is toe up, your natural foot position is 15 degrees external rotation. And the best view for getting an x-ray is the opposite direction, it's 15 degrees of internal rotation. OK? And the last view you want to get is you want to get the lateral view of the ankle as well. So there are stress views that you can get. And the stress views are helpful in assessing the stability of the fracture such as dynamic stress view. We do these often in theater. When we're fixing ankles, we'll move the ankle joint around from side to side and see if the fracture is moving or if there's uh if there's displacement, uh if the talus is stable within the joint or not, we, we can do a manual stress view where uh these are usually done in the in the department. Uh These are departmental views where you stress the ankle and leave it in one position and then you get an x-ray. And finally, you can get gravity stress view where gravity does the work. And uh this uh will give you an idea whether the fracture is displacing or not as well. Similar to these views are weight bearing views and these are stress views put in the opposite direction. And uh they'll also give you an indication of displacement or stability of the ankle joint. And these are especially important along with the gravity stress views to indicate whether there's any the syndesmotic rupture, for example, or ligamentous rupture around the ankle as well. Full length tibia radiographs are important to get if you have a uh fracture of the medial malleus or if you have syndesmotic rupture and you don't know where the uh whether there's a fracture on the, on the fibula or not, if you don't see a fracture in the fibula distally, usually the forces will have traveled upwards in this twisting motion that caused the ankle fracture and cause the fracture to, to, to occur higher up or more proximal in the fibula. And we'll, we'll describe that a little bit further later on. So these are the gravity stress views. And you can see here that in this gravity stress view, there is displacement of the ankle joint laterally towards the fibula. And these are the long uh tibial views. So you have a syndesmotic injury here. You have ligament rupture that's made clear by the increased space between the tibia and the fibula. The in the increased space between the tibia and the talus, it's called the medial clear space. We'll come to that a little bit later as well, but it also happens with this uh proximal fibular fracture. Then you can get CT scans. CT scans are indicated for tri maar ankle fractures. Um So these are a little bit more difficult to, to visualize. Well on x-ray, uh there's a lot more energy that is causing these fractures. And so getting a CT scan to be able to delineate the fracture lines and the forces that went through the ankle and create a proper operative plan is very important. And I think uh there was a study that showed that uh in 50% of the cases where AC T scan was done, Operative planning was the operative plan changed uh to match the injuries. As the CT scan describes them, you uh uh you also get them supination, abduction injuries to assess for the impaction of the tibial pla. So whether there's a tibial pla fracture, so an in more of an intraarticular fracture and whether the talus itself had sustained any articular cartilage injuries, the top of the talus, as well as any other joint uh has cartilage that's covering it and sometimes that can be damaged with a fracture and you'll have bits of that floating around in the joint. And so to be able to see that better, sometimes AC T scan can be helpful or an MRI scan. Obviously, um axial and sagittal views are usually the most uh useful to look for at the posterior mas. But also they're u usually what we use to look at all the ankle in general. Um And uh the findings uh will be the things you're looking for the size and the shape of the posterior malleus uh fragment uh like this image here. Uh You have two different patterns of fracture. One of them is a little bit of a, it's a, a sort of a horizontal split. This one is a more posterior horizontal split and your operative plans can vary according to where the fracture is as per the Mason malloy uh classification. Uh If you're, if it is it, the mas classification is a little bit more advanced and it's something that's worth looking into for the uh CT twos, for example, or interested in orthopedics. It'll learn your brown knee points. If I describe that, I think a little Trump most junior registrars definitely uh give you a leg up. Um And loose fragments are very important to identify if there's any loose fragments within the joint because you need to take those out. Anything that's floating in the joint will cause a lot of erosion and will cause a lot of damage to the joint surface and cause arthritis. And it's a good chance to take those out while you have an ankle fracture uh that you're fixing because everything is unstable and you can move it around rather than having to go in months later with the patient still in pain when you haven't identified the lo fragment that's causing all the ongoing pain that the patient is getting. Uh fracture, impaction is important as well to identify. So you can dis impact the fracture when you reduce it and the combi where you're going to have bone loss. So you choose the correct implant. Finally, MRI scans are important for soft tissue cartilaginous injuries, like deltoid uh ligament injury, syndesmotic ruptures, lateral ligament, uh complex injuries and then tendon damage. And uh like we said, chondral lesions of the talus and uh loose fragments in the joint that are cartilaginous. So these are your modes of imaging. Now come we come to the classification uh the different classifications of the ankle. The first one that's important is how to describe the fracture configuration. OK. In this instance, then it's it's location more than anything. So to start, we've got a medium malleus fractures. OK? Medium malleolus fractures are uh usually a vulg or shear fractures. An avulsion fracture as we described last week is a bit of ligament or bit bit of muscle that's pulling bone off with it. So it uh it, it doesn't rupture but the bone comes off with it. It's usually a transverse fracture like similar to the one we see here. OK? And then there's some A V there are some uh medium minus fractures that are shear fractures and these are vertical fractures and they're caused by impaction typically in hyper supination injuries or as uh log hand and classification would describe it, supination, auction injuries. The medial mellitus is a very distal part of the tibia and it typically has poor blood supply, especially in smokers, for example, or uh patients that have low mobility or vascular issues. It's at a higher risk of nonunion. It also has a thickened uh periosteum around it, which can become entrapped within the joint. We call that transposition of soft tissues in the fracture site. Ok. That's entrapment of any soft tissue that will block the bones healing because you don't have that bridge that, uh, that basically or you don't, you are unable to bridge the gap between the bones because there's something in there that's limiting as SEBI described last week. OK. Uh The options are you can treat this conservatively if uh you're not worried about those things. If the patient is young, if the fracture is stable, you can use the lag screw fixation principle. So you can just use screws that go from the bottom of the medial nous up into the tibia to hold it all together. OK? And we'll talk about the different modes of uh fixation in another session. What's a lag screw? What's compression, what's neutralization and so on. You can use an ant glide plate. So it's a plate that uh that's typically more used than vertical shear fractures. But it's uh basically a plate that will block this bit of bone that's broken from traveling upwards with the forces of the ankle or something called the tension band wire. Tension band wire is a construct that we will describe later as well, but have, please feel free to look into it. Uh because knowing how these uh different constructs work is very useful when you're in uh the operating theater. And it's a good way to have an idea of what's going on in theater if you're more junior. OK. Um And typically it's the medial approach that you use for a medial MS if it's isolated. OK. Now, uh next thing is the lateral malleus fractures, lateral mallus fractures are described, usually according to the we classification, we'll come to that a little bit later. And sometimes they're associated with syndesmotic rupture. If they're more proximal fractures, or they can cause tibula vulg fractures, uh such as the tial fragment or the that fragment, which will uh wag that fragment, which we'll describe later as well. Uh An important thing to look at is the taal angle. And essentially, it's a line that you draw across the ankle joint and then uh sorry across the long axis of the tibia. And then a line that you draw from the tip of the fibula to the tip, tip of the medial mallus. And it's an angle. Basically, you have to try to replicate that back to normal. Uh when you're uh reducing this fracture, it's not very a reliable way to, to know whether you're corrected the shorting shortening or not. But it's something that's described. What I think is more reliable is just being able to see the bone fragments. Well, if it's a not common, it's not a very common you to fracture and making sure that uh the fracture fragments key in well. And that will give you a good indication, especially if there's a posterior meus fracture that's involved with it as well. Having that uh reduce on its own or a median mallus fracture that reduces on its own. Well, after a lateral mellitus reduction is a very good indication that they've reduced this correctly. The treatment for isolated ank um the medial sorry, isolated lateral maus fractures is either nonoperative management if they're stable uh or nondisplaced versus plate fixation is typically what we use. Sometimes you can augment that with a lax screw or in uh in many cases, if it's an oblique fracture like this one, you can put in a lag screw to compress the fracture and then put a plate over it to neutralize. And again, we'll talk about these things in another session and we typically use the lateral approach or a post lateral approach to the uh to the fibula, to the distal fibula or to the lateral Mandle. Next up, we have the posterior metus fractures and these can be either articular or can be extraarticular. Um looking at them, you have to look at how much of the articular surface they're involving. That's the traditional way to think about it. If it's more than 25% you typically want to fix these. The classification is usually the melo classification. Again, that's a little bit more advanced. So for the CT to have a look at that. If you uh if you want to, I press your foot and ankle surgeon, uh what you can see typically on these, on the A P, you can see a double contour sign where the uh posterior magnus fragment superimposes on the x-rays. And you can see sort of a double contour or Misty mountain sign uh where you have what looks like uh a sharp fragment floating behind the tibia and it gives that appearance. And again, you can approach these, if you're going to fix them, either through the posture, medial approach or a posture lateral approach, then you have the syndesmotic rupture. As we described before. Syndesmotic rupture is sometimes associated with proximal fibular fracture, which is called the meal fracture. That's why you need your full tibial views. If you see this appearance on the ankle x-rays disappearance, you have is increased, medial clear space, increased tibu fibular, clear space and decreased tibiofibular overlap. In this image, there's no overlap between the tibia and the fibula altogether. And the way to treat this usually is either putting syndesmosis screws from the lateral uh sort of through the distal fibula into the tibia or using something called tightrope, which is again, basically a rope that goes from the lateral side to the medial side and you compress that or you tighten it and it holds the two of them together. Ok. Syndesmotic screws usually break and sometimes a lot of people will want to take them out around four months after they go in before they break, then you have your bimalleolar ankle fractures. These most of the time are unstable, but they could be stable. And if they're stable, you treat them nonoperatively. The best way to know whether they're stable or not is to get moras views. Ok. This like this one, this is a a good morar view where you can see the medial clear space and the superior, clear uh sorry, the superior, clear space around the ankle joint, you can get stress views and they will displace the fracture if the fracture is unstable and then you can basically choose how to fix them. Typically, you will just combine the uh construct you've used before. So for the medial mag, it would be a leg screws and for the lateral mall, it would be leg screw plus uh plate fixation. Then you have your trimalleolar ankle fractures where you have medial mallus fracture, lateral malleus fracture. And you can see here this m demo appearance behind. OK? Or you can see the double contour sign on the lateral side of the tibia there. And that's the posterior malleus fragment floating in the back. These are typically high energy you want to get CT scans uh for these to identify all of the stuff we talked about before. These are inherently unstable. And unless the patient is very decrepit or very unfit for surgery you will treat these with an operation, usually using open reduction, internal fixation or in some cases, limited cases of hindfoot. Now, and these have an increased incidence of syndesmosis, syndesmosis rupture that's associated with them. So in a lot of cases, you'll find people who will put in syndesmosis screws across the fr uh across the distal fibula into the distal tibia to restore that. And very briefly, the Weber classification is a classification of lateral malleus fractures. And according to the position of the fracture to the syn, to the syndesmosis. So the Weber A uh basically, it is a fracture of the fibula that's distal to the syndesmosis. Here's the syndesmosis, the fracture is below it. So it's usually a stable fracture and you leave that alone, you treat it conservatively typically in a boot, at least in my hospital, we put them in a boot for uh for up to six weeks and they mobilize fully weight bearing. Usually don't follow these patients up. Then you have the Weber Y you have Weber B fractures and these are at the level of the syndesmosis. And uh these fractures could be stable, could be unstable, get your stress views, get your morta views and assess them from that point of view. And uh basically, if you can see that they're unstable, usually there's an associated uh fracture or an associated ligament rupture that you will have to address. Finally, you've got the Weber C and the Weber C is proximal to the level of the syndesmosis. These are inherently unstable because they usually indicate that you have damaged the syndesmosis as well. And so we typically treat these surgically. We stress the syndesmosis in during the operation, check that it's stable. If it is, then we leave it alone. If not, then we put in some syndesmosis screws or tightrope to treat it. Ok. Then you've got some nerves such as the bosworth fracture dislocation where the fibula becomes trapped behind the tibia and it is irreducible. You have the curbs stone fracture where the fracture, the posterior uh malleus when you, when somebody trips forward. So when they plant or flex severely, they can evolve the posterior tibia. You have the little forth wax that fracture and the T lo Chappel fractures. It's basically when you uh damage the syndesmosis, but then you also a bulge a bit of bone with it. The le four def fibular fracture, the T lo shepherd fracture is a tibia. So T LO is tibia. LeFort is fibular. The complications that you could see with these fractures and fixations are the normal uh things that you could see with most injuries like nonunion, delayed union and maun uh you can see neurovascular injuries as we've described. So, be mindful of the structures when you're approaching the ankle irritation due to metal work can uh can be one especially in uh skinny patients who uh have di lateral plates and that will be an indication to take these out, especially if they're causing any muscle irritation or muscle damage, arthritis and stiffness because these typically are intraarticular fractures. And so, uh there's always that risk and you have to consult the patient for that as well when uh when you're consenting for the procedure, and finally, the thromboembolic events are very important to be mindful of. Most of these patients will be nonweight bearing for up for six weeks and you need to make sure you give them the appropriate VT prophylaxis. Uh unless they're fully weight bearing, like the Weber a fractures. That's it. Any questions. There are a couple of questions from the er Cha Kare. Um First one from Mark Cut and asking what our fracture B list is. So, fracture blisters are basically when you have a lot of swelling around the ankle. Uh and it's in a tight area like uh you know, the tight cast that gets put on in the emergency department, you can end up with basically the fracture. Uh the, the swelling coming out of the skin into this, into a blister essentially. And uh these are at a higher risk of infection. So you have to be mindful of that when you're seeing the patient, uh not just in the emergency department, but afterwards as well, whether there are any blisters formed around the ankle because of the swelling because they'd have to adjust your incisions around the ankle to avoid getting those blisters, sometimes they're unavoidable and you'll have to go through them. Ok. Uh, yeah, that's cool. Um, the other question we've got is, uh, please advise on contraindications to MRI with respect to metal work. So I, from my experience, uh, I think there's no problem with MRI, uh, uh, for the metalwork that we use, uh, in orthopedics generally. Uh, because most of it I think is MRI safe. I mean, uh, you always have to declare these to the radiology department. And if there's any issue, they alert you that, that whether this is not safe. But in most cases, I think the metalwork that we use is MRI safe. Am I wrong in saying that Charlie? No, I think I agree. Basically, most of the modern implants are MRI compatible and most of the modern MRI scans can accomplish it too. And also it's more, more of a case when you've got metal in more delicate areas like your brain or your heart, which are a bit more of a problem, aren't they? So most of the time in regards to like normal fixation for bones, etcetera, you can, you can MRI them, they'll give artifact, but there's a lot of good metal artifact reduction sequences they can do now. So you can still get good images and still see what infection things with the MRI is very, very good. Yeah. The other thing to mention is a lot of the implants we use particularly in trauma are Titanium based and, uh, Titanium is not basically affected by the MRI magnetic fields. So, which is why they're quite compatible with stilt performing MRI S. Even in patients we've operated on. Yeah. But even like steal implants that we use are usually not a problem, uh, for these patients. Yeah. So, yeah, that's any other questions. Uh, that seems to be it for now. Anyone else? Thank you. If you have any questions, send them in the chat and we'll get to them later. Um Charlie, you, uh you're going to talk about uh tibial shaft fractures. Is that correct? Um Yup, that's what I've thrown something together about very quickly just now. Thank you. All right. So, yeah, you can start, right. Can anyone see that on the screen? Yeah, I reason I couldn't hear you for ages cream. So I thought I lost you all. But. Right. Yeah. So, yeah, I'm Charlie Howe. I'm one of the se Sixes in the region. Um I haven't used it yet before but if you've used slide it before, have a go at going onto there and typing that number in. You just follow the website on your phone and there might be a few interactive bits and pieces to have a go at. Uh, there should be one already up and running that you can type anything into and then I can just see if it's working and then we'll move along. There'll be a few little random questions and bits and pieces to try and keep it mark. Interesting as we go along. So, once I see anyone put anything in how long we know it's working, uh, no results, no one broken anything ever. I, someone's put something. Yeah, we can see it. Yeah, I was just checking up, working up and running. So, um, I had a quick peak just out of interest at the core training. Sort of what, what do they expect on the curriculum side point of view for, er, trauma and orthopedics, which basically I pull these random things from, but essentially it comes down to, er, knowing some, some basics and being able to be involved in a trauma meeting, er, and, er, and be able to deal with some of the, you know, acutely unwell and some of the complications you get with trauma. So nothing too, er much you to have nothing, no surprises there, I'm sure. So we'll run straight into you. What kind of mechanisms do we think we tend to get, you know, tibial shaft fractures from? And obviously it tends to be two main groups. There's high energy which, er, this hopefully will share us something they probably would call that high energy and a very, very narrowness. Er, miraculously, I believe the guy who came off his bike didn't actually manage to get any significant injuries by some miracle, but Valentin Rossi has broken his leg a couple of times here. Tibia. Um, but yeah, there, of course the other, other, other group, apart from high energy is low energy, simple falls, twists, er, you know, normal sporting activities and such and they, they are sort of slightly different. So, um, you know, you guys might be on call, er, fairly soon and, oh dear, you, what made you use this Apple if you work at North? No, you get these lovely bleeps going off on your phone when you hold the, er, on call bit and that you call down 28 year old male high speed motorcycle accident, suspected fracture and things kind of cool. So if you go to your slide, I move it on. What are you gonna do? And let's see, people break their metatarsals, radius, hexes, clavicle. It's called com all common stuff. Er, right. So if you can enter free text, I believe you can type whatever you like. So what things are you thinking about? What are you gonna go do? Assess, think about anything at all and we'll see what, what we come up with as, as some options and you've got, I don't know, a minute or so. Yeah, you can go see them. That's good. A s principles. I like it. Yeah, so always start with those, those bits. Um, let's say that we've done your A LS uh uh primary survey, everything's absolutely fine miraculously and it's just that he's got some, you know, pain and an obvious injury. To his leg. So now what about just the leg? Mhm. Typing, typing, typing or everyone's just gonna do a TLS primary survey finish. Don't worry about the leg. Ignore that. Uh huh. Analgesia. Consider open fracture. Absolutely. Yeah. Thinking about getting some imaging. Yeah. Consider the A CT. If he's stable and given the, given the mechanism of injury, it's not a bad idea and your A state is very good. All right. So we'll move along a little bit. But yeah, so because we'll come over some of these things, but these are the things you want to be able to have in your mind. A really clear thing about everything you need to do, want to do. And especially when you come to sort of discussing things like cases like this in interview situations, you want to be able to reel off. Um, you know, have it very clear in your mind, all the various different bits you might do. So let's go back and see. So we've done that a bit. So, yeah, one of the, if you're just looking at the leg and about shafts, we really need to think about the soft tissues. Ok? Even if there is an, obviously it's underlying break, um, the soft tissues covering it matter quite significantly. And this isn't, obviously a young person was on a motorbike, but it is a significant lower limb injury. Um, and that soft tissue management is going to be key to doing anything and dealing with everything that's underneath. Um, so this wasn't the one associated with this actual, um, x-ray, but here you go, you got some, they having to do some xrays for you, not in any pla or anything. Um, here is one of the fractures we've got, um, but you're absolutely right. You've got to do all the primary work and think about, not just maybe the obvious bits but, um, everywhere else and first things up because people who are involved in high energy injuries get other injuries as well. So this was one of the first cases I had when I pitched up my most recent job. Um I think it was a 16 year old or something like that to come off a, a bike of some description. Um This was the same side two injuries. So you got to, you know, you got involved with those things. So the things I would point out high energy injury is always going to breach it. A TLS trauma team involved, you know, dealing with life and limb, threatening things early off. Um Usually if you basically come in that strong, whatever you're doing and then if that is ok, then you can be dealing with the the underlying thing. So you got tibial fracture as suspected, you need to assess and document in your vascular status. And if they, because if they haven't got vascular um supply, you need to be addressing and dealing with that and, and uh, uh, you know, sooner rather than later. Um, and it's really key on all these things that document really clearly what the, um, you know, neurological status is, um, from the get go because when something doesn't work later down the line, was it from the original injury? Has it happened later? Have things changed? So, um, kind of getting that all really clear in your head is the key soft tissues are, you know, absolutely key for limb injuries. Um, you know, it's really a soft tissue injury complicated by a bony injury. At the same time. If they're open, need antibiotics, tetanus cover, you gonna photograph any wounds cover them. Then with uh sterile gauze Rey dressing, realign, splint the limb. And if there isn't any, if there's a problem with some of the vascular supply, once you've done that, often it can improve, especially if there's some malalignment. So you reassess all after that, always going to be a risk of compartment syndrome. You need to keep an eye on those, um, and then work them up because most of these are going to be off to be operative cases. So you need your, your bloods, your gasses, um imaging and care for, keep them start. And then part of all that, a secondary survey and thinking about other injuries and things and reassessing as you go along. That's a standard thing for kind of anything but er, you know, tibial shaft, tibial shaft injuries can be quite high energy and so this is all quite key. Um, of course, your other option is, oh no, you just got bleeped again and some other lady tripped over the stairs, uh, twisted a bit and she's got pain in her leg as well and her x-rays, er, even though she's had a much lower injury, she's got, er, this, um, fracture pattern instead. Um, but you're still going to sort of assess them in a tier way. And then we have to think about, well, ok, if they've got the shar fracture, what are we actually going to do about it? Um, various options, there are some principles of treatment that can help guide us. One is as we've already talked about manage the soft tissues because it doesn't really matter what you do to the bone. If the soft tissue envelope is poor and terrible, you, it's all going to fail and break down and, and, you know, looking at losing a leg in the long run. So you have to think about those as the first thing, principles on the bone side, you ideally need to be restoring the correct limb length, the alignment and the rotation, um, and whatever you're doing is trying to end up with something that's stable to therefore allow early weight bearing. Um, and also ideally allow some early knee and ankle range of motion. So those joints aren't overly affected as well. Um, there is classifications, um, basically it ao for everything and we, but we don't often tend to talk about them. We just tend to talk about what kind of, you know, pattern of fracture you can see um we just described in the x-rays, but there are certain ones that are associated with certain mechanisms of injury. Um but you can look into that in more detail if you like. Um basically just it's a way of categorizing them, I think mostly for research points of view. So, back to slide. Um, this, this lady or a similar injury, low energy, the soft tissue, but it's fine. I've got no other injuries. Can you treat them conservatively or non operatively? And what, er, you know, what criteria might there be in order to do that? So, move that along. Here we go. Next, here we go quiz. And you've only got about 10 seconds to answer each of these. So you have to zip through them. Yeah, you have to just stick your name or, or anything in you like. Yeah, just to, just to see that it's up and running. Uh, let's see, hemorrhoid. We got involved. We've got 17. So we'll wait for a, a few others. Uh, so someone's called bone, someone, one's called age. I like it. Mhm. Mhm. Oh, se B yes, you better get them. All right, se B, no pressure right now. They stopped. Oh, running out of time. Oh, I love it. 100%. Fabulous. Uh, next one. There we go. That's a bit unfair. Oh, age answer the quickest. Is that right? You nice. All right. A bit more split. But yeah, so this, this is all just taken off of, uh, there will be some, something around somewhere but out of, uh, bullets or Millers or something like that as a generic sort of thing. Essentially you can't, you can't accept too much angulation. So they're suggesting five degrees or so. Uh, obviously that does vary. But, oh, hello, Matt. Matt at the top said, but you know what to be seen? Oh dear. I was typing the answers. I didn't realize there was a pole. My bad. What about Valgus trick? Same again. So they, so, so the, the textbook says, and it's all about pro and, and yeah, sage to plane and the answer is, yeah, less than 10. So you can, because it's in the plane of joint motion. You can, you can get away with a bit more. Um, and obviously sometimes people's natural tibial slopes vary a fair bit. Um, so, yeah, so you, you can accept a bit more but usually at most of the time you need it to be fairly reasonable, which is why it's quite small numbers. Ok. So you can, I don't wanna accept significant, um, deformity. So overall is that, er, is that all of them may well be, maybe the s come out top? Oh, yeah, one more left left. How much cortical apposition how much of the bone ends need to really be in contact. You got a butterfly fragment or something. And the answer in theory, um I must have clicked on the wrong one. It's not 1% that's gonna be a skew the results, but at least 50%. Right, you'll have at least half of it in contact. Um So unfortunately, I've screwed that up by clicking the wrong one at the end. There you go. Well, then, so uh oh, I'll come back to that one in a minute. So we go back to this one. Can we say non operative for this? Um Well, actually, if you look at it, isn't it? So it's not really shortened, it's probably not a shortened you much, but there isn't much in terms of cordial apposition. There's a big butterfly fragment involving quite a lot of that and it is tipping, isn't it? Um Some a it looks pretty straight on the, on the flexion extension essential on the lateral. But um that's just about potential options about leaving it in cast. Um which are options. However, we have good options in terms of for young fit or not even young, but, you know, to allow early weight bearing with some operative interventions. Um Obviously, the other reasons why you might not want to do op intervention if you've got poor host with lots of risk factors. Um and maybe they've got really poor mobility. And so the benefits of doing optic fixation are not as great and the risks are higher. But so we've got this. So we might think about offering operations. Um So the main main options, you can divide things that down into. You can use some intramedullary fixation, some extra medulla, internal fixation plate and screws um or external fixation. And that can either be a temporary sort of mono lateral biplanar X fix or you can obviously do definitive um stable external fixation with a circular frame like a TSF or a Zaro. Um But primarily, obviously, most of the time which you may have come across as we often do intramedullary fixation when we can do when it's er um when indicated. Um and then there are different ways of obviously doing that. Now, in this case, we gave you some in interactive images of doing this case, you can do different approaches. So you, you can do this is supra uh sorry. Yeah, supra patella. OK. So you come above the uh through the quads tendon underneath the patella, which means you're going straight through the knee joint, but then it gets you right nicely down onto your entry point, which is basically around about here and lining up nicely with the shaft and between the spines essentially um on, on the A P. And the thing with NAING is always get the entry point right? Because if you did it wrong, it means that the whole case doesn't go quite so well, it dictates about your um your alignment, especially like if you have a proximal fracture, you know, that's absolutely key on what you do at the, at the top. Um So that's the way you have to get it right once you've got the entry point, correct. So we talk about supra patella, you can also therefore do in patella or you can even do a kind of um a sort of lateral to the patella um option and things as well because when you, if you're in for a patella, you tend to have to flex the knee a fair bit in order to get this entry point. Um and, and sometimes that's can be difficult for some fracture patterns and things. So there are various ways around, but I'm personally quite a fan of supra p patella. Um This here is a blocking polar screw, er just to help to make sure that the nail doesn't end up over here to drive it across and to, to help with it getting the right alignment. So we throw the guide wire down you then ream or you don't have to ream over um tends to be slightly quicker time to union if you ream. Um but overall at the end of the day, if you wait long enough that it will tend to unite, um and then it all look distally and so to it, there we go postop nice alignment even though that's not posing there. It's just partly because how it all keyed in but you can look at the joint lines, top and bottom and overall it looks pretty good. It looks better than it was before. And then you can obviously allow that early weight bearing straight away. So. Oh yeah, another sliding. So you're gonna do a consent form maybe when you're on who we said. Oh, we think we got to have an operative fixation, er, interim done every nail. That's what we think you're gonna have. Uh We're gonna offer you what things might you need to put on a consent form. And obviously there are generic things that we're gonna come across whatever, but maybe think about more specific things that you might have to co remember to write for a tibial shaft or for it. I mean, tibial nail compare, compare compared to just all your general orthopedic stuff. Is there anything specific you can mention just for tibial nailing? So, yeah, a few people say compartment syndrome, which is absolutely correct. Um There is a higher incidence um and it's something you definitely need to be mentioned with these injuries, there's a risk of it straight away. Um And there's a risk of it postoperatively as well. It was a 20 year old lady. I remember teeing up from the on call when and had her nailing and unfortunately, she was in absolute agony in the, in the recovery room. Um And the consultant spent a few hours with her there and then she was not settling. So we took her back and fasciotomy her. Uh what else have we got in there? So, yeah, common things like infection, bleeding, injury, nerves and blood vessels. They're all very generic, aren't they? Um Non union. Ok. So there is a risk of non union specifically if you leave a gap, the tibia as well takes ages to heal um mal union or, you know, it's also key. So more proximal fractures are much more prone to it, much more prone to falling into um valgus and, and um apex anterior. So it's sort of a, you know, with a, a flexion deformity essentially. So often you can use if you know how to follow the screws and things to help to correct for that and to prevent it from happening. And anterior knee pain very good. Someone's got that one too. So that's very common um for young back. So, yeah, non union, male union infection. OK, is uh which we obviously all talked about, but it's that can be a cause of why things don't go into your night. And especially if obviously, things are open up syndrome. And anterior knee pain is a very common thing, you know, 50% of people or so, um can have some anterior knee pain and, and again, another half of them or so will get better if you remove the nail. Um Most of the time things will settle predominantly after, after quite a while. So it's just something you have to tell them about. Um, and actually if you've got someone who is on their knees a lot for their job, it's really important to make them know about that. And if you've got another option, actually, if it's a plat fracture or actually their alignment is really not too bad and you could potentially just run with the cast. If they were happy to be non weight bearing and have the timing cast, then, you know, it may be something they decide they would prefer not to have a really sore knee that limits them doing their work in the long run. So these are all things you have to sort of remember and talk to people about. So we right, er, different cases. So here's a more distal fracture. Um, anyone want to speak up over medal and, and point out anything they can see that is we haven't seen already and something to, else to consider. I haven't got a sli for this one. So you need a, we need a willing volunteer or you can put it in the chat. Mhm. Oh, there you go. Given in the game right now. So, the, the spiral distal tibial fractures. I don't know if you can see it on the x-rays coming down towards the joint. Yeah, you can see it on this one too coming down undisplaced poster mo. So CTS can be helpful. If you can't see them of often for the spiral distal tibia ones, you can find them on CT. Um, and the views show. And if you sometimes nail these, um without really knowing or thinking about it, you can blow these apart and then you've gone from an undisplaced ankle fracture to a displaced one. So often with the c with this, a view, you can think about potentially putting a percutaneous screw to hold that and keep it where it is and then you can go ahead and nail it or you, sometimes you can also very carefully do it and incorporate you knowing that you're locking screws will go through and grab it and stuff as well. So, um, always have a look, especially with these dis more distal ones, have a look for the ankle fracture because most of the time they'll be there. Um What are you going to do in this case? Um He's previously had a tibial shaft fracture was treated conservatively, but he's got some mal union. Er, I think he wasn't really aware of it. And er, essentially, and then he had another simple fall twisting on a of a boat or something, but a very simple fracture, there is some extension coming down this way. Um But can you nail that? Probably not. So then, uh you have to think about doing something else. So the options, therefore, yeah, either try and get a decent alignment in a cast but actually again, you want something maybe to be weight bearing on the options of doing a plate. Um, again, you're leaving a stress Arisa and, and again, it's, the plates are on the soft tissues. It can be upsetting, but some of the trials do show in the long run, there's not any dramatic differences, um, or you can use an external fixator to control things and that can help to also incorporate in with the sort of malalignment of various things. You got long legs. So this chat that's what he ended up doing. He had a ring fixator on and then you can basically with these x-rays dial things in to use these, this is called a TSF to help correct things and realign stuff to allow things heal and you can, although it's uncomfortable, you can, these are strong enough to walk on. So though you have to be on for a while while it all heals up. You can get up and about and you can get on with things. Um, once your pain settles what's different in this case, can you go straight ahead and do a normal in dully nail? Nobody said anything yet. Char I'll let you know if somebody pipes in. Oh yeah, go on, then go for it because otherwise I can't keep an eye on it. Nobody's, nobody's, er, brave enough to speak out loud, but I never ab normal on these things either. And, uh, yeah. What child so we have to be aware of putting screws through the growth plate and, uh, after distraction. Yeah. So little, little kids, um, you can put flexible nails in and usually they, they, and supplement them with a cast and, and, um, they will not do too bad and, you know, they'll often be right with not walking but as adolescents, but they've still got their growth plates open, um, are a bit trickier. They're a bit bigger, little bit heavier. You know, the nails are just not as good and strong. So, um, they're not the easiest things to manage, but the current boss, because I'm working MP, he tends to put nails in and supplement them just with a TSF to help one get the alignment good. And I do if you get it all keyed in, but actually, again, to allow them to weight, bear on it sooner rather than later. So they can get on with life and things and this obviously helps control the rotation a lot more and makes it a lot more stable for that fracture type. But then because he puts his argument with the nails in is that you can then remove the frame earlier. Er, and it keeps, you know, there's some extra rigidity from it so that, so that it gets rid of the frame for a little bit sooner. So after eight weeks or so, things are looking like uniting fairly well, the frame then comes off, keep the nails and sit, you carry on walking and, and you obviously screen it in theater at the same time and then it all unites up. So that's different options. But something that you have to consider something different, er, if they've got feces. So this is back to the first case. Um So this was an open injury, uh high energy. So uh this is just for a bit of interest. So if you've got open injuries, when they go to the theater open, we will probably have a separate talk on open fractures, but essentially, they need wound excision, debridement of all the unhealthy tissue and non viable bone. You can see these, these fragments, et cetera here. You know, they, they, they don't incorporate in, especially if things are open, you get infection there that will just lead to chronic osteomyelitis and, and everything. Um you know, badness in the long run. So this is post debridement. Um And I don't know if anyone can see, but obviously, you got a few little clips around and the soft tissue looking different. So you'd end up having a free flap to cover the soft tissue defect. The bones all been resected back to healthy bleeding bone still a bit short, which you can see with the fibula and, and spanned currently with an X fixed while that settles in the flat matures. Um But then you know, how are, how is going to be dealt with this? This defect because that's the four centimeters at least. Um, you don't want to have a four centimeter shorter leg if you try and you know, bring that together. So you got to do something else. There are various options, but just a quick for interest. There's something else you can do with the frame having worked on one of these jobs. So there's a, a deliberate what we call Cortico or osteotomy up the top. And then this is a bone transport frame that's going to move this bit of bone down to there to dock those two bits together so they can then heal. And what you'll see what happens at that site is as you distract it away, slowly infills with, with new bone and then that matures up. So this is, you know, that's now turning not quite all the, all the way there yet, but as you can see is becoming solid, um bone that will be able to be walked on and used in, in the long run. Um And then this, but this bit always takes a bit longer to heal, but that's going to be compress together until that heals. Then you can't take the rest off. But anyway, so there you go. And obviously you can see how she had a femoral nail for that fe fracture as well. So tying it all together, another one, a high speed injury motorcycle, it's come off. Actually, this one's closed. What are you gonna do same as it was before. So, um, and this is, you know, segmental fracture as well, high energy bad injuries or soft tissues, although not open. Um, so you got to run to the same bit of standard stuff. A ts things all on neas sta is think about the soft tissues, splint, everything, um, and work them up for theater. In this case, obviously, if you think about principles, overall treatment got to think about those soft tissues. So are we just going to go ahead and slice it open, do a plate big open reductions that just, you know, it will lead to badness if you do that. Um You got to think about the principles of getting the right limb length, alignment, rotation for them. And you got to think about what's going to be a stable fixation option to allow them to rehab. Um And ideally something therefore, that can allow motion. And if you have, you know, if they've got a stable injury, we put them in pla that where you go above knee usually to start with. So that's not going to allow any of this, but you can convert them up if they got a stable injury. And um undisplaced, for example, to a what's called a Sao um cast, which is basically allows weight bearing partially through your patella tendon. Um And that allows knee motion and allows a bit earlier weight bearing when you've got tibial shaft fractures that you can undisplaced. Um, Bob. In this case, he needs an X fix to help to splint things while the soft tissues settle. And then you can plan some definitive fixation of what you're going to do to actually regain those that limb length alignment and rotation. And look, he's also got an ankle fracture at the same time. So that will need to be addressed too, right? Any questions shove in the chat or speak up. Uh Hopefully that was useful. Um There you go. I'm just waiting to see if there's any questions that are coming. If not, then mister K a quick question with the he do the tens nail tibia and then the frame, he did the nails first and the frame. Yes. Um Because you wouldn't want to be struggling to put your wires down what you already put a pin, you know what um half this, for example. So from what I remember, I think you tend to, if you can get your reduction ex that get, get your wi down. Um because that can be tricky enough anyway sometimes, right? Um And then, and then basically, then, then, then the cool and is the reason you use half pins at the top rather than just crossing wire. Well, so yeah, that's just, you know, so you, you work some framers who have very good principles but and they adhere very, you know, tightly to them, but there are multiple ways of putting on a stable frame and also Children that are lighter and um and you have different healing potential and and things that are not having to last two years difference. So that all comes down to a yeah, nitty gritty and finer details, for sure. Cool, cool. So you got any questions? Thank you very much. All the questions are all just a little bit I think around from the talk. But yeah, thank you. I'll stop sharing. Thank you. So, next we have Mister Kwanza, uh consultant at NH and uh uh knee surgeon. We can see you. Thank you very much for joining me. Thank you for clarifying that for me. Uh I'll just uh share my slides. Hello, everyone. How are you? How you guys all doing? Uh They, they don't go because of the metal set up but they'll can you? Oh, really? Oh, you've muted them deliberately. Have you? I didn't deliberately mute them. That's how this thing works. And um I'm trying to share my um slides, but I can't see the that button that you showed me. Kareem. It's not in the middle at the bottom. It's like a square with an arrow pointing up, but it depends on the make of that. Mm Maybe you weren't give him permission. Oh, I do wonder. So. Can you please allow Mr Konz to share the slides? No, no, in a nutshell. Uh So I'm looking on even on my more options. It doesn't give me any options to do that. So what you showed me cream is not, is not coming up with that. Have you um did you click on an invite link to follow through? Yeah, I think so. Should I log out and do it again? Just er, well, that's how I got on your email. I'll try that hospital email. Was it? Yeah. Yeah, I'll, I'll, I'll go and log into that again. Thanks. Thanks. Ok. How about you guys? Take a five-minute break and we will reconvene at 8 20. Anybody needs uh or needs a cup of tea and uh then we will reconvene.