Computer generated transcript

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

Uh paul you might be able to answer. Uh the majority of you are all medical students right uh yeah okay right, so he is just a few different definitions of certain fracture types that you might come across or you might hear so a green stick fractures and one's in pediatrics where only one side of the bone is broken. Uh Pathological practice tends to be associated with a week or a disease bone, so that's usually associate with cancers, oblique fractures. I just mentioned so it's an angle, transversus, horizontal spiral fractures are due to a twisting kind of force and uh it's something to consider when you're thinking about nonaccidental injuries in children, so let's get you guys thinking a bit more so look at this fracture. If anyone fancies it just right in the box or right in the chat and uh just try to describe that practice for me, what do you think it is what's broken and uh try to use any of the little words that I was trying to use to describe it as well, you know, let's see how you guys were describe this fracture. Mhm, I feel like all this can maybe belgian, uh I'm not sure if yes, if you would just say that they can't see it, you know does anyone want to have a stab at trying to does anyone have a travis stabbed trying to explain and describe this fracture pardon Good well done with the left hand distal radius transverse fracture, I like that YEP so well done in a identifying the bone, yes, it's the radius, be the location that it's a distance, it's near the distal end of it uh and uh yeah a transverse fracture I think that's quite appropriate, yeah I think that sounds that sounds quite appropriate, anyone want any bonus points and to know exact there's this type of type of fracture has a special name if anyone wants to give it a go, This is already is closed fracture, Yeah does anyone know what this this type of fracture might be called like it's we call it an eponymous name sometimes in in orthopedics, but dorsal ambulation yes, well done marium year you got it yeah This is a cold fracture, so you'll come across it. This is the classic one where they say it's a dinner for deformity, so if you are uh so yeah I described as a distal radius, dorsally displaced extra articular, uh so I see extra articular because articular is where that joint surfaces, it's just not there so it's a little bit before that, hence it's extra articular and this is a closed fracture. You can tell it's closed as well because you might be able to see on the lateral version that there's you see the soft tissue and you can tell that the bone is actually not protruding out of the soft tissue, so I can quite confidently say that this is a closed fracture and this is a calls fracture well done. I've got one or two more, this one's a little bit more trickier and something like this might you might feel stumped at first, but again give it to go first of all be quite impressed if someone can know what the bone is and then be how would you kind of describe this one. I know it looks pretty a bit of a mess, any takers anyone good we got someone said, communicated tibial shaft french yeah well done well bang on that's exactly how I would explain it, so something like this is very hard to explain to try to say exactly what fragment what what this and that I think it comes to a point where when even when we explain this fracture is just better to say that it's just commuted it's a fancy way of saying it smashed to bits which I think you can all realize, so I wrote it as a midshaft because it's in that's one way to explain it as well, so midshaft tibia multi fragmentary or community fracture and also, if you notice the fibula is also broken as well and that looks looks like a more of a transverse fracture through the fibula as well, next to it good what about this one guys nice yes humeral fracture midshaft spiral fracture, humerus fracture closed well done well done cume, well done hero rajiv you all got it bang on yet that's it spiral humeral fracture midshaft, well done, guys, good, and what about this one guys okay. I think I put up to two of the fracture, but I think what I'm trying to get at is I'll just actually show it oh, yeah fine. I've kind of shown it here. These are always tricky to these are always tricky to identify this. Here is a pathological fracture. They both look quite unusually what you'll see is transverse fractures. Don't tend to happen that frequently whenever bones break, they just don't tend to break as nicely as just a straight line. But when you think of pathological fractures, if you look at the bone quality wherever these are broken, you can kind of see the first one that is a distal femur. You can see a lot of this translucency. Bubbling kind of uh characteristics of that this of the uh of the proximal portion of the femur and that's showing that there's something going on in the bone. Similarly, if you look at the humerus on the other side where the shoulder x rays, you can see that there's a lot of lucency in the bone near it and that just shows that the bone is weakened uh and that usually could be indicate, indicative of something like a bit of cancer of osteopenia, sarcomas, uh like osteosarcoma, is that kind of thing and they can tend to cause these pathological kind of fractures, so immediate management of a closed fracture, what would you do any uh any thoughts amongst you, all, so, if someone's come in, they've got a fracture. They've broken the bone. What do you think should happen. What do you think we should we do is orthopedics is that a bulb signed uh is that bob sign that was that was the bulb sign yes, so the bulb sign is referring to the fact that it looks like a bulb, so it's like uh the humerus in that shoulder uh socket shape, yeah so that is what bulb sign is where good analgesia stabilizing the fracture, so back slab perfect stabilizing joints. That's the most important thing Yep, analgesia stabilize and reduce if you can bang on well done guys yep that's exactly the type of things they need to be doing so. The best ways to manage well the kind of exam answer that I would always give is as you get older when you get past medical school as well, then you start to realize something called a. T. L. S. It's just a way it's kind of your 80 assessment but just with a little bit more trauma spin to it, so you always go in you might the correct way of saying this is you always immobilize the c spine, just in case they've got a certain injury in the neck. Then you'll check their airway, breathing circulation, disability. Everything else so that's doing your classic 80. Following that you want to check to neuro vascular status after that, yes you're correct, immobilized. This can be done via a cast or a splint and like you guys mentioned as well, bring it back to a normal anatomy, so people get very scared about reducing joints and limbs and things of that nature. Effectively, once it's broke, you can't really make it much much worse, but what you can do is you can try to bring it back to what's a normal ish looking anatomy. If it's told if the bone is broken, the arms looking completely deformed, bring it back to what you think looks like normal and let's you that will probably be much better than where it where it is after the fracture has just occurred following that you've got your long term management as well, so for stable fractures. If it's in a good position, you could just let it heal in a cast 4 to 6 weeks is usually the rough guide guidance that we give for bones to heal. It takes about six weeks for a bone to heal. However, if the stable, if the positioning is unstable of that fracture, If it's you feel you put into a cast to help reduce the pain. The reason why we cast as well for pain relief is once it's in a cast, it can only move in one particular plane. The bones can't keep moving back and forward on top of each other, so that's very important for fracture management. That's what reduces that pain, but like I said if it's an unstable position or you feel like it's not the best positioning, then it will require orthopedic surgery. Some ways this can happen is em you, a which means manipulation under anesthesia, so you could put the patient to sleep or give them a regional anesthesia or spinal. These are usually the most common types of anesthetics that we give and you can just manipulate it just under that under the anesthetic and put into a position. Sometimes to stabilize it further, you might need a care wire, So this is essentially as as simple as the care. It means kerschner, so usually they come in different sizes, but usually the classically is like 1.6 millimeter or two millimeter wires and with the drill you fire it through and you would try to cross both you try to cross through the fracture site and that would then stabilize both the proximal and distal fragments of the fracture intramedullary nails similar to the wire, but this will be going down the shaft of the long bone so something like you can do it for tibias femurs, humerus is and then or if it's another term that you might come across. Uh If you ever, if you do an orthopedic placement. If you go on to the orthopedic ward or if fancy this acronym it simply means open reduction internal fixation. It sounds fancy, but all it means is that we're going to instead of clothes reduce, which is just trying to bend it into position without opening without making a cut open reduction means well actually make a cut and then internal fixation means we'll put some plates or screws uh to keep it in that position, and then with all these will still have it most likely healing in a cast and still waiting for to six weeks. It's just that you put it in a better position to allow it to heal correctly rather than suboptimally and here's just some examples of all those things that I've just described, so the first image shows these k wires and yes they do stick out of the skin and what tends to happen is after um after a few weeks usually about four weeks, when you notice that the fracture is stable, you re x ray in a clinic setting, you can just take out those wires. You don't need to go back to theater for them something more serious however, you've got this in the middle, you've got this image of this intramedullary nail. You'll put that down the canal and then you use some screws to fix it in place and that then stabilizes the nasty fracture, but that will stay in usually for usually for the rest of your life and similarly, I know the images of the best quality where you can see here uh some plates that we've used for the wrist and you put screws across these plates to hold in position. That's what you call your or if surgery, So when you talk about close fractures, you've got to talk about open fractures as well. Uh I should have warned you a little bit that is a bit of a gruesome image either one on the left, but there is an ankle fracture as you can see the bone is popping out, but the reason I put this other image next to it with this finger that is also an open fracture, so this one is so the one on the left of the screen, that's an obvious open fracture. You can tell the bones poking out, but you should also know that that the one in the finger is also open to. I think I've got a little definition as well, so open fracture occurs when the skin overlying of fracture is broken and that allows for communication between the fracture and the external environment. This can be either big or small, but you should always be treating it with the same uh guidelines, which are both in very shortly on how to manage an open fracture, So we're talking about open fractures. These can be categorized by a certain classification system, which is known as the Osteo anderson classification system, and usually as you can see here if it's a grade one, it's got a very small puncture wound that there's not much tissue damage, grade to the tissue damage. The soft tissue damage around that fracture is getting much larger, grade three A is getting significantly larger, but it still doesn't need a skin graft of plastics input three B you're starting to need plastic surgery to get give us a hand and grade three C is the worst type and that's when you've actually got a vascular injury alongside your open fracture and that's when you're gonna be needing the vascular surgeons to help out and uh they're the most worrying types of injuries because you're losing blood supply and that's becoming less neurovascular intact and that's what a patient probably needs to go to theater as an emergency, So I know um I don't know if anyone's ever come across them, but for open fractures, a lot of the things are similar as you would for a closed fracture, but do you think there's any different things that we might do for open fractures that you might not due for a closed fracture. Again, you can write in the box, just any ideas that you might think of that we might that you might do too uh They might do differently for an open fracture. Antibiotics, tetanus, well done, good antibiotics, yep, tetanus yep, bang on well done guys, took me a while to get used to these things, anything else that comes to mind, So you give an antibiotic and tetanus. They're two very important things it's iv antibiotics as well and you'll think it's overkill sometimes and it depends on it depends on certain departments, people get very touchy, but uh the, if I'm teaching you properly the right, the correct, both guidelines are even for uh a small finger fracture. You should be giving it one dose of IV antibiotics, at least, do bryggman that's an interesting point and I'm going to talk about in a second uh prep for surgery to no food or drink, etcetera very good. They're all very good answers, guys. So immediate management for both guidelines always start off with your answer as a tls, I'll start off always with mobilizing the c spine because you don't know the extent of the injury, do you weigh two. We get that other way check the new vascular status now goes back to the point of uh debriding, So the guidelines state that if you can see some really obvious large visible debris, so if you see something like that like sewage or fecal contamination, so that's very obviously overtly not good in that wound, yeah you can take that out. Otherwise, we don't actively wash out, so you don't sit there and actually get saline like the first two images that I showed you they were quite clean looking fracture open fractures. There wasn't like covered in milk and dirt, so in that situation, All you do, is you just uh you wouldn't actually do much uh you wouldn't do anything to actually visit physically, debride or start to pull things out or start to clean it off you want to do that in a clean sterile theater set setting not on a dirty a any table. You'd always photograph okay, IV antibiotics in tetanus and then what we tend to do is you give us a stair line so because you put that on the area that needs uh that where the wound is and then you put your plastic cast around that area to immobilize it and treat it. Like you would any closed fracture and I kind of mentioned the bottom there depending on where it lands in this castillo Anderson classification uh You might need plastics input and vascular input if that's required long term management uh similar to a closed fracture, but this time, you're gonna also want to repair the soft tissue and as part of that that's when you'll do your debridement, so you will try to take back any sort of dirty looking tissue at that point uh and make sure it closes it well If it's not closing well, That's when you're gonna be talking to the most likely the plastic surgery team and they might be looking into skin grafting at this point as well or flats. It depends on what the injury is some people might debate this. If you've got a dirty infected wound and uh you're going to fix it is it appropriate to put metal work in there. At that time, I've had a, I've heard different sides of the argument. Some people think it's but it depends on probably how dirty the wound is how infected it is, um but you might want to delay putting that metal work in initially and put it in a later date after a course of antibiotics. If we felt that the wound itself is very dirty because the last thing you want is your metal work to get infected some complications of open fractures. Uh The infections that can happen to the wound osteomyelitis gangrene tetanus can happen. If you don't give the tetanus antibiotic and with all fractures as well, if it doesn't heal in the correct position, that's that's what mild union is called and nonunion is, if the bones just don't unite, if they don't conform that callus and they just start healing apart from one another, so moving on from practice a little bit even the compartment syndrome does cover it. Let's talk about compartment syndrome, so this is another very serious and can be a life a limb or a life threatening problem. It's compartment syndrome. Some of the reasons this can happen in context with orthopedics, crush injuries, so when you're damaging a lot of soft tissue imagine it just releases so much inflammation, it causes so much swelling, so even if sometimes the bone isn't broken especially when it is broken, You've caused so much uh soft tissue damage in that area. The inflammation is just tightening and tightening, especially a tight compartment such as as you can see in the image on the slide of that lower leg. You'll be surprised that open fractures are worse than closed fractures. You think to yourself that an open fracture the wound is, you think that oh I've got a wound that the pressure that's accumulating in that compartment, that's being released from this. Uh This open wound that I've got now reality is to get that open fracture you probably had much more significant trauma and impact in that in that compartment that that swelling will be too much more and that will cause an increased risk of compartment syndrome versus a closed fracture, which probably didn't have as much damage to the surrounding soft tissue okay. Other reasons for compartment syndrome. Turner case, if you've left them on for a long period of time, you've occluded and reduced that blood supply to the muscles again causing it to inflame constructive plaster casts in a similar way to turn a case and hematoma hematoma developing is causing increased pressure on the blood supply, reducing on the nerves on the muscles as well uh with increasing coagulopathy. Uh Yeah if uh I'm trying to get a if you've got that extra swelling happening is increasing the chances of you forming a clot as well in that area, so similar to the first time if you think someone's got compartment syndrome, what kind of symptoms do you think they'll start to tell you if they're on the board, or they presented to you what kind of things do you think they'll be saying to you that they, that they're going through at that time, well done marium yep that is the most important one it's actually quite as someone was saying this to me the other day, it's quite an archaic sign still in medicine that here we are and one of the key things is pain, pain, pain. If someone saying to her in absolute agonizing pain, chances are you need to start to think is it compartment syndrome is there anything else that you might think of the image that you guys just saw what else would make you a bit worried if you if if you saw a certain image, good pala, palace a very good one so you saw it in that limb. There, it starts to become a later signing compartment syndrome. But if you start, if you're starting to see uh if you're starting to see that a lower limb is losing its color. It's not looking pink and well perfused. I'd be worried anything else, yeah good and to be honest, I still think of that today about. Under. It's literally six p s, so you're talking about. Uh you've got me tested nurses. Pain, parasthesia pala, paralysis, perishing cold. I always forget one of them uh being promises paris easier, Persian called uh so we can remind me I've got the last one missing pissed off in crisis. It'll come to me there is 1/4 of pulseless, pulseless, so you're losing your blood supply as well, let's see what I wrote down, so yeah, severe pain out of proportion, that's the key indicator that it's out of proportion because even fractures will hurt, but this is just and it's usually with passive stretching, So yeah, so that's the key thing that if the compartments been, uh if you move it even a little bit and it's their agonisingly painful, I'd get that's when he's trying to get worried, it's tense to touch tight, shiny skin around it cause the compartments swelling, and then I brought five p s, but yes correct those six ps uh pain parasthesia parallel. AsUS post less pallor. These are all things that you should be thinking of. If someone starts to mention these kind of symptoms, then compartment symptoms should be on your radar and here is a little diagram which shows it goes into a bit more of the pathophysiology of compartment syndrome, but it is a cyclical problem where you start off with, let's start off with something like yes you've got a direct injury or you've got you've got direct injury that's causing the edema, that's the one that was talking to you about that leads to the increased part compartment pressure. With that increased pressure, you've got less blood flow, blood flow happening because you're compressing the arteries and the veins as well, that's leading to ischemia and that's causing worsening edema uh and if you can go increasing the power and pressure, you're gonna also have those six p s happening as well and the only way to break the cycle is by having a fasciotomy. We can't seem to hear you right and I think you meet it yourself uh okay good, uh So there's an image literally, it's acute surgery you want to do it. Asap, If you think your compartment syndrome, don't waste time is the key thing that and you go there and you make these large co incisions and just let the let the compartment and breathe essentially the commonest ones that you come across is the lower leg and you were surprised to know uh that there are four compartments to that lower leg as I've tried to show in this diagram here, So you've got the anterior compartment, deep, posterior, posterior superficial, and the lateral compartments and uh yeah so there's a lot of chance for these these tightness to develop in these, these tights. These uh special sectioned off areas of muscle and that can really cause a lot of these compartment syndrome symptoms, so some of the complications of compartment syndrome to be wary of uh Volkmann scheme it contractions. This is because you have increased calcium uh as a result of uh increased calcium, also increased potassium because the muscle breakdown and that can cause the spasming of the muscles itself permanent nerve damage. Uh If you that if they're getting, if the nerve isn't receiving a good blood supply. Lemme ischemia, if you included the blood supply elite amputations, Unfortunately, if the but essentially the tissue is dying, then you might have the only chance is to take it off rhabdomyolysis, so again it goes down to the fact of your muscle death, increasing potassium, increasing myoglobin, myoglobin that's rhabdomyolysis. And then if you get in all these nasty toxins developing, If you've got so much muscle breakdown, you're gonna have renal failure as well. So very nasty problem is compartment syndrome and one that needs to be taken extremely seriously and you need to get on top of it as soon as possible dislocations right, so I've tried to just go through a few commoner dislocations in the next few slides, first one here shoulders, so you can see in the first image normal anatomy, but commonly you get anterior dislocations and that's usually 95% of people where their uh the uh of that do you know humeral joint, the humerus will anteriorly dislocate and then in about 2% you'll have a posterior dislocation and usually that tends to be associated with a seizure because that sort of trauma that once you're unfortunately maybe on the floor of fitting quite violently, that it's been found that that's a common association that we tend to have a posterior dislocation rather than anterior uh with dislocations. You've also got to be wary especially with shoulders that it can be associated with the fracture. You can have rotator cuff tears because to with for the socket too, for the uh for the humeral head to move out of its socket, it needs to take a lot of force and you've got that rotator cook, they're keeping it well, nice, and tight, uh but if it's if it's not, uh but therefore to get out of that position, the rotator cuff cantor well. This question, does anyone know what the muscles of the rotator cuff are good, good, yes, yes, yeah, so you've got super spin nature's infraspinatus, teres minor, and subscapularis good. Anytime you got dislocation, you're always going to try to reduce it, You can do it under local uh local or regional anesthesia. I'll give them usually something like gas in there, if it's in a and e sometimes and you can try to put it back into position and uh it might require surgery to put it back in. If the muscles around it are quite contracted intense and the person is not allowing you when the muscles seize up a little bit, then it gets a bit harder to do it under a local or regional anesthesia. At that time, you might want to take them to theater, put them under a general, give them a good muscle relaxant and that will help to pop it back in with a bit more ease. Here's knee dislocations is some so you'll come across your dislocations quite frequently. Uh. I myself did my own shoulder about three times playing rugby guys, uh but knee dislocations very serious problems. The reason being is you've got a high chance of causing damage to your property or artery and vein uh and definitely if your knees coming out of joint, this is the, this is different to patella dislocations, patella dislocations because it's but the patella is quite superficial. Uh It's not got that many blood supply to it or nerves. For that reason, it's not as damaging. Whereas if the knee comes out, that's a very big problem so I brought here, you will definitely need your ct angio to rule out any arterial ruptures. Uh However, you'll you will be rupturing a lot of your ligaments to get that joint, looking like that in that x ray, so acl damage, PcL, damage lateral collateral ligaments uh and you need to reduce it as soon as possible in theater, most likely most often next hip dislocations. Again a very serious problem especially if you've got a native hip. It's not as much problematic if it's uh if it's a prosthetic hip because the key problem is it's about the blood supply, dying the head of the head of the femur, guess its blood supply from that ligament and Terry's and you've just avulsed it out of position, so what you want to do is quickly get back in position because the more it loses its blood supply, the more time is out, the more time that femoral that femoral head is going to die and that's they're going to increase the chance of you needing a hip replacement. Usually, these dislocations happen because they're high energy injuries. Uh if usually they dislocate posteriorly and that's when you notice that the limb itself is shortened and internally rotated, that's the most common presentation of a hip dislocation and uh if it does dislocate posteriorly, the biggest nerve that is in the posterior compartment of the leg is the sciatic nerve and that can be damaged as well and you've got a high chance of developing osteoarthritis afterwards. Because effectively, if you if that bone is dying, it's going to cause more pain, it's gonna be a a weakened bone and hence it's going to be more increased risk of having osteoarthritic changes. Right, I can't remember my own slides if this is the the last condition or the second to last but a very common problem for orthopedic surgery, and this is again like fractures, but there's a special type of fracture is our bread and butter we see every single day you'll have at least one or two cases and it's it's all the time it's on, it's on our operating lists always and if you have any sort of interest in orthopedics, having your head wrapped around a little bit about neck, the femur fractures is very important, so I'll try to give away of a whistle stop tour about it, Cause I always found this a bit confusing if you've ever covered it in your own medical school uh So let's go through a little bit first and most important part is to get your understanding of the different parts of the femur. So if we look at the diagram on the side, you can the way you can break down hip fracture. It can either be intracapsular or extracapsular. If it is intracapsular, you can see over there in the diagram image that that will cover the neck and the head of the femur itself and you can break that down into it being a subcapital fracture and you can see where the lions in the diagrams color there or it could be transcervical or basicervical, Those are fancy terms just meaning that one's just below the head in the middle of the neck, just near the base of the neck and they're all they all refer to an intracapsular fracture. Next you have an intertrochanteric fracture uh that's just between the, that is the oblique line between the greater trochanter and the lesser trochanter, and then beyond that, if you're getting a fracture that is then called an extra capsule fracture and that's when it can either be per trochanteric or it can be subtrochanteric neck of femur fractures are very common, especially in the older population. Osteoporotic bones when they fall, they fortunately break this joint. This uh this particular bone. The presentation here is it will be shortened and externally rotated. This is therefore different to your your hip dislocation, which tends to be shortened and internally rotated. Uh You should check for any other injuries because they just had a fall. If they've had that much impact to break the bone, have the broken anywhere else and usually is a fairly frail population that get this injury, so so, if you call that uh yeah go on, I'll go through it anyway, so management again, as always, if you take anything home from this little lecture, you'll learn a little bit about a t. L. S. That you tend to start anything off. If anyone asks you how would you manage something. If you don't want to say a tls, you'd always start instead of giving your answer is saying oh ad, manage a fracture by putting a cast over it, you just get into the habit of trying to say I would manage this patient by first of all doing an HIV assessment and then doing a cast. It just makes you sound a lot more slicker a lot more like you understand that you're seeing the patient as a whole because that's how you approach any patient you do it quite naturally by making sure it's usually it's quite obvious that the airway is okay. The breathing is okay, but it's nice to get into that rhythm of doing your a. T. L. S. Or a two E. Approach. When you see a patient, you make sure that your vascular intact for these patient because they're frail and they're gonna need to go to theater. You would get an e. C. G. To rule out why they had that fall most often ct head. If they bang, their head, check some basic bloods, do a group, and save chest x ray because this will be things to optimize them for theater, get them ready for theater. Uh. If they're getting uh if they've got any other medical problems, sometimes they've got heart failure, they've got a chest infection going on, just try your best to get the medical team involved as soon as possible, so then they can optimize the patient, so they have the best odds when they go to theater, you're trying to operate in the 1st 24 hours, that's the guideline that the entire country ties to follow and that's what trusts get paid for if the patient is operated after they had that broken bone when they've hit any, they need to have the operation 24 hours, so it's a quite quick turnaround. Actually, blood thinners are always an issue that's for any surgery and then you want to get them a nerve block as soon as possible, so then they can't feel that pain of that fracture while they're waiting for the surgery, so, depending on where the bone is broken that depends on the type of management, you'll give for neck of femur fractures, so I'll try to, I'll try to break it down as simply as i can and hopefully this sticks in your mind, so focusing fueling on those intracapsular fractures. If the patient is young, that's when you will try to use just a cannulated screw, so you just try so you're hoping that it's not significantly displaced and you just put screw across the neck of the femur and that will hold it in place, so it's kind of like what you do if you've got uh If you got these k wires that was talking to you about at the beginning of this uh this talk uh. The reason behind that is because your old uh sorry, because you're young you what you want to do is you want to keep your normal bone in place for as long as possible. The reason behind that is is when you started two hip replacements, hip replacements only last 10 to 15 years before they start to feel worn out and causing you excessive pain, you need to get a revision hip surgery so if you had if you had a very traumatic incident and uh you were young enough to then break your hip. It's better off, let's say if you imagine you were 20 or 30 years old, If you had a hip replacement come 35 40 years old, you're gonna be saying right, I'm in pain again, doctor I need to get my hip replaced. What's gonna happen, then you do the 10 years later. Again, I need replacing again. I need replacing it's a very big problem, so you want to try to keep that bone there for as long as possible, you're on natural bone, however, for a lot of these patient's though they are older, so for that reason. Uh If they are independent and mobile, we'll say right, we'll give you a total hip replacement that means we'll also change that's a tabular component, so if you can see on this diagram here, we change the cup and also you'll have uh and you also have this the stem and the ball, so you change both the ball and the socket because you're active and mobile, you might wear your cup out whereas if you're old and frail and unfortunately you're not very active anymore, you don't need to change you don't need to put that extra acetabular component. You just do a hemiarthroplasty and that's just replacing the ball and leaving in its normal socket before I go on, does anyone know because I think I might just give you the answer straightaway, can anyone think of other ways we might so for the extra cups of hip fractures. What are other methods that we might use to treat those. This was intracapsular, anyone want to shout it out or write it in the box how we might treat an extra capsule hip fracture. Good good. I am neil is a very good option and I'll go on to that in a second dhs well done, they are the two main options so good right, so here it is so here's the first one of the two, it's acting up a little bit for me, so this this one is particularly for an intertrochanteric fracture and that's when you use this dynamic hip screw uh As you can see this, that's what the first images showing they're essentially when you put that screwing position and you use a plate at the side, and you use the schools to keep it secure against the shaft of the femur. Uh The way this works is it uses a dynamic compression system that the more you put weight on it, the more you use that hip, the more it allows for that fracture that intertrochanteric line two compact within it within itself and therefore allow for the bone to heal. However, if the boat fracture is a bit lower down and it's not just intertrochanteric, it's subtrochanteric that's when you'd be looking at using this intramedullary nail to keep it all in one position. I think this is the last condition guys septic joint, another thing that constantly comes up to orthopedics uh um and it's something that we have to take very seriously again another serious problem, Orthopedic surgery, so septic joint essentially it's an inflammation of synovial membrane with purulent infusion into that joint capsule and if it stays there for long enough, it can start to erode away the articular cartilage. Usually, it involves a single joint, uh The general bacteria that is most commonly associated with a septic joint can include staph aureus, streptococcus, or gonorrhea, and uh sometimes the causes for septic joint, they can vary quite a bit. Actually so one can be a direct invasion, which means has the person had a recent nick or a cut in that area, have they brush their their knee or their joint. Uh Next to some nettles or they had a bee sting maybe uh or they've had a cut there, which is allowing for uh something dirty to enter spreading from a source of infection so like an abscess in nearby, and it's spreading into that joint or is it a distant infection spread. So sometimes so if you got chest infection uh sometimes they can spread very nicely into the joint. Uh The reason why septic joints tend to occur is that synovial fluid is full of rich proteins and a lot of glucose and a lot of nutrients and bugs bugs love that, so that's why they love to just camp out there and they go they travel through the bloodstream and they'll say right, this is the perfect place for me to sit down and set up camp and grow and multiply, and that's why you get these septic joints, so looking at the type of joints that are affected as that image showed at first knee is one of the most commonest ones that 50% children's hips are very susceptible, 25% wrists septic joints and then you have shoulders, ankles, and elbows, give the next mixture that they can become septic effectively. Any joint which has a sino beall membrane can become infected, but knee is usually the most commonest mainly because it's the largest synovial joint that we have in the body. If your risk factors that increase your likelihood of a septic joint include if you have a prosthetic joint there, you've had recent operation. If you have rheumatoid arthritis, your old diabetic use, iv, your IV drug user immune suppressed you have and as such you might have some like Hiv or aids or you have sickle cell disease as well and some of the common symptoms that needs tend to present with things like a rapid onset. It feels it's very painful, it's swollen, it's warm, it's red to look at uh you've got to increase range of motion. These are common symptoms that tend to come to us or when I'm here taking the referral on the phone, I would here and that would make me suspicious of the septic joint. The ways to diagnose a septic joint and the most important thing is aspiration so that previous slide showed it but essentially you'll be sticking a needle in a sterile environment into that synovial into that infusion infused area and you take out a small sample and that can then be tested uh for microscopy to see if what is actually growing in that region and usually blood tests are very important as well, So you have an accompaniment of a high white cell, high Crp, so these are your inflammatory markers and associate fever as well maybe with a septic joint. The reason why this is a very popular referral, especially from the community to orthopedics, is because there's a lot of different differentials for a septic joint, so things like gout, pseudogout, osteoarthritis, flare up, rheumatoid arthritis, flare up another type of inflammatory arthropathy or a fracture could all kind of mimic a septic joint as well, and lastly the treatment for these is get your IV antibiotics in wash out. The joint gives ronald easier and if needed, if it's too painful, you can even put it in a little splint for the time time being as that joint heals and the infection settles down. Sometimes, these joints need multiple washouts and that's it that was a bit of a whistle stop tour throughout most and all of orthopedic surgery with some commoner conditions and some more serious ones as well. I hope you all found it quite interesting and we're able to take something away from it uh It's quite impressive that you're all here at six PM on a tuesday night. About thank you for listening if there are any questions then fire them away. If there's anything you want to ask me in particular to these slides or just in general about orthopedics, you're more than welcome to otherwise, if you can do the qr code and try to give some feedback for myself for this little talk that we very appreciate, thank you. Thank you very much ran, that was really good. I'm sure I talk on behalf of everyone here that that was really comprehensive. Um yeah really thorough again just to underline what Reagan said, Please do complete the feedback because you know, It's it's important for around as well who's putting the time to make these slides and you know it helps with this professional development and such and you know it also helps bima, with sort of how we deliver our talks and how we design that and stuff, so yeah, it will let you take one or two minutes and then you can get your certificate, which will get emailed automatically to you guys, but if you got any questions for doctors to get, please do far away, thank you very much paul uh well, I was going to say as well just to tell you for the next time. Next lecture, I'll be doing on thursday. That's quite primarily focused on histories and examinations and especially the m. S. K exams. Uh. I'll try to go through them in a quick, quick fire way. I don't know exactly what levels of levels you. All you all are at, but if you've all gotta Noski, coming up or you've got some sort of uh MSK exams to go through, then we can try to go through those quite well uh the different joints in the body and hopefully you find that useful uh so please do join in and uh it'll be quick fire and we'll go through quite a few of those examinations for you and you might find that useful, but no thank you for all your comments as well to see in the in the box world for your kind words, guys. Um yeah, uh you can more than welcome to ask paul as well uh to provide my details of my email address as well. If anyone wants to fire a question later on if it's anything even regarding a career in orthopedics or getting into orthopedic surgery or that kind of thing more than welcome to happy to answer any questions guys well. If that's it, then it was nice speaking to you, we'll just leave this on for a few more minutes, just what everyone does the feedback and then I'll close it down once most people have left well. Thank you for your for your organizing as well, Paul, Very appreciate it, yeah no worries, thanks for coming in last minute, but um yeah I really appreciate it cool. I think that's most people gone um I'll see you on thursday around. Um Any other thing is, I'll send you feedback for this now. Um If you've got any other c. S. T. S, who he's gone okay, that's fine all right