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coming to the last lecture in our essential pedic Siris. Hope you found it useful. If you being here before you haven't. Then welcome to the very last one. Um, so this would be covering a lot of the content that we've done before. Just kind of testing and cement in your knowledge to help you with finals. Um, And as I mentioned in my other ones before my colleagues might mention, Well, the bomb says the whole point of us is that we're student lead society trying to bring together along the aspiring off towards in the whole of United Kingdom together on bringing together. I'm currently the secretary for bomb, sir. And I've been working with the London I know the chance. Well, um, yeah. So if you've attended more than 75% off the other serious cause, they're all individual Siris. Then you'll get an extra certificate, which I'm working on the spread, itching at the movement to send it out. So I'm actually feeling the metal feedback afterwards so you could get sick it. And so that all of a lecturer get his get on his back as well. Well, over teeth. I guess eso my month, Um, were the CT Tuesday in the northeast of England? Yeah, eso, uh, had a look through the previous slide. You can't miss lecture series and also the list that daily sent me of conditions, and I try to make it single best answer questions. They're all FDA is, so they'll be one of's most appropriate. Obviously, some conditions lend themselves better to F. B, A, C and others, so you'll find that probably these percent more trauma focus. But that's fine. It's still fairly relative to you guys on in terms of the information of question, take it face value, know and realize you want more information, but try and answer on basis of what the admission that's been given to you on do. If you have any questions about all means interrupt Andi, I'll basically do the question of you guys about a minute or so to answer it or think what you're on it would be, And then we'll give the answer and explanation. Okay, let's get started. So that's the first question. Spines one. So you got 74 year old female falls forward in around home with her chin hitting the coffee table she lands. There was a spider cord injury of some sort of the level C four. She has a history of chronic neck pain and hypertension. Which of the following options best describes the most likely neurologic deficit you'll find? Um, I can just read the chair out for you because I'm not sure if you're able to see it. So the guys with the answer in the chat, that's fine. Um, just give it a go if you don't know, because I probably won't know either. Hopefully on the spot. So I mean, what this to getting that? Uh, yeah, so no one's button answer and I I but see, but only the other. But what is it? They so do you How much you know about in complete spinal cord syndromes? Um, it's something you covered. I mean, I'm in my specialty year, so I've not done any like trauma pedic. I probably did some of it in first year that supported That's all right s. Oh, I remember vaguely this doctor, my second year medical school. Or have you guys seen this? So the way the spinal cord is organized. So this little page is the gray matter and then the white matter where you've got the you're on striking down, um, is organized quite specifically. So you've got the dorsal column, which is light touch appropriate section. You've got the quarter spinal tract, which is motor now, and you've got the spondylitis track, which is pain and temperatures sensations evil had, for example, the grounds of college syndrome. Where you get heavy section of this, you get ah, defect in produce section motor and, um, pain in temperature. So in complete spinal cord is basically where you've got part of this part of the strokes injured. We're not complete injury. For example, you got no function below a certain level. The most common one you'll see is something called Central Court Syndrome. And that's what this case is now. Central core syndrome essentially is where you've got hyperextension injury on the background of previous spinal stenosis, so hope you have a lot of facet joint arthropathy. They have hypertrophy of the government and play flight play by so usually quite narrow C spine's. They're quite protest. Central cord injuries and what you essentially get is quite characteristics. You get a motor deficit because that's more pronouncing that in the upper limit and loans because the motor neurons for the lower limb generally quite central and then so the upper limit quite central in the living room, kind of over the periphery. So that's what this case is here. And it's the most common Europe's incomplete deficit. You'll see. Um, just going to the other options. Loss of pain in temperature sensation Once I would like touch and most function. So it loss of paying temperature sensation on one side with light, touch and motor loss it is, and that's the brand Sicard syndrome. So I would be a heavy section the cord, so that will be half of this. Taken out. Ah, bilateral light touch proprioception. That's what's called a posterior cord syndrome because it just affects this structure in the back. That's quite rare on then. Bilateral motor deficits, bilateral muscle pain and temperature sensation that is an anti record syndrome. So you see that either the context of trauma so you've got something that's compressed this front half of the court or you got spinal cord a senior. So if you've got the anterior spinal artery thrombosis normalized and you'll get a ski, me which will cause this deficit. That's quite rare. And the young prognosis is quite pull. And then this one bilaterally. Medical science has cord quiet, which clear this case isn't so. 41 year old male is brought in by AMA is falling it road traffic incident. The trauma CT scan demonstrates unstable vertebral fracture. Urologic examination. So she's lost wrist extension, elbow extension and finger flexion, and there's no motor function in the lower limb. So what level do you think? The spinal cord injury that So this essentially testing. If you know you're my terms give, you want to read that and think Oh, and rest up. Uh, no one has answered that. Give you a few more seconds there. I'd get D so clothes see? So my terms you learn, you'll forget them in your finals. It's fair game to do, and you want to examine a month, you know, examine you may we'll get asked this question Well, expect at least know what you're doing to put context. I did my annual CS a couple years ago, and, you know, we have to practice this and revision cause. And then the the still day Oh 0.0 Each one was like, you know, hip flexion. Which one? What is it? And then we all blanks. So no issues. We're not knowing it. It's fine. The best revision to a life found is this because they won't see this but basically the Asian chart. So basically, it's it's a standard documentation for spinal cord injuries. And if you look it up, what it has is a very helpful diagram on the left Here showing you see if I being elbow flexes. C six elbow extensive C seven c six risk extensive C seven elbow expenses, then finger flexes. See eight and then finger up doctors t one. So in this scenario, you got patient who has wrist extension? Elbow extension on day has lost finger flexion. So the highest deficit is a C six. Hence the answer S o elbow collections preserved. So that is C five. Um, it's got this diagram is definitely got. He's got the my terms of lower limits. Well, and if you look at the right side, it shows you where the most reliable place is to test each sensor dermato. So I definitely found a good revision tool for finals on do. Um, if you have, you can only 1 to 1 piece. You will have to know this, um so definitely want to have a look at it. It's just it's it's going easy to have a quick glance and just get the especially need moving on. Going to Stick With Spines 20 year old female presents today, anyway to day history of severe back pain. Bilateral lower limit Radiculopathy sounds like sciatica type pain Going down both legs after living a heavy box at work on questioning, she tells me she's leak small volumes of urine you are concerned about quarter quintessence room. What's the most likely cause of her symptoms in this case? Is it spondylolisthesis? Which is essentially think was in one your slides percent of the parts defect where you got this final, the total body will translate forward. And about the one below it, uh, quite often seen in younger people. A spinal fracture, malignant core compression along about this candy, a shin or infection or an abscess of some thought. The water common cause a quarter quinine is a sense of what the question is getting up. Okay, so the answer's date, um, so 2% of lumbar disk herniations will cause a quarter quinine. Well, it below L1. Um So the rest of these are all possible causes, but essentially just learned that that's the most common burn this one bit more surgical and away from the spines. Which people have people. A lot of weight. So you got 84 year old female presents to Anne. She's fooling around home, Home? She's complained of four month history of right groin pain as well Have passed markers includes hypertension, air, osteoporosis on a hater nya. That's the medications that he's on amlodipine warfarin and then Jordan Constant lines up result. So this is your X ray, and you're right. Your consultant ask you what is the most appropriate operative? Plus, because that question uh, no, no question. Yeah, So you send you what is the most appropriate surgical management for this fracture? I have looking again. So is it essentially a hemiarthroplasty be? And I am nail through the FEMA, see a dynamic keep school, which you may have seen, but essentially, it's a play inside about with the screw going up into the hip joint D you're gonna go a lot on replacing type proximal femur or C. Would you admit surfer attraction and just let it heal conservatively? What would you guys want to do? So the answer's date. This would be essentially, the reason is so it is it. Class is the neck of the femur fracture on D. You got into capsule fractures. I, which are above the Intrakota line anteriorly. So the neck, which why have me off last you off that young you consider trying to replace to fix it sent you your ward about a B N extra captive practice you would generally fixed now to auctions you've got available. Essentially are a dynamic keep screw or a nail. If you've got a fracture that extends below, the less it'll counter Ah, hips down and keeps cruise essentially useless because basically won't stop it collapsing into various see See this fragments pointing in words. If you've got a plate on top of that bone, that one that will just pull out it won't control those forces. So what you want is essentially taking theater. Realign the fracture with the traction table and you want to put a nail in through the bone to realign and then basically report screw up into the neck as well for that instability. Um, so that's what I was questioned getting out. So we have a bonus question. I'm not expecting this book in terms of her history that I gave you. Is there anything you'd be concerned about? In particular with this pattern having, And that's the history, you know, just give you a few seconds time to think about in Elena because it's a good empty Q. Actually, um, someone's just typing. Yep, the suspense, Um, and a typical from a fracture due to prolonged use of disphosphanates. Yeah, exactly. Well, So essentially, this is quite quite classic, cracked a pad, so send you what you get with a bisphosphonate fracture are. It's always in the stop traffic region. I blow Lester counter. It's transversus with the if a. Can you see how you've got a bit of a pointed edge on the lateral cortex? Essentially, that's called B King, so classic signs are a fractured that always involves a lot of cortex that has beak in the cortex and his transversing nature. The reason you get it is essentially what, how before, so it's working. You may know is they reduce osteo class activity, so you want to slow bone turnover, so you want to slow, but results in bone turnover is important for repairing microtrauma that, well, naturally get as we go about a day. So what could happen is you get microtrauma you don't have, but the bone turnover that is required to repair. It's essentially. What you get is that it's more crackle event. You propagate and then you'll have a full blown femoral fracture. Um, so, yes, you want to consider stopping the bisphosphonate use well, five years from entering acid. But yeah, that's what I was getting up there so well done. They don't heal very well. That's the other thing, um, reason to be aware off. Um, and they always needed. I am now cool. So this hopefully is more straightforward. A 19 year old female football, the land or quickly falling a tackle. Four hours later, she complains of swelling in her right knee and intimate it, locking on examination. You can put in the presence of infusion, and she's tending the medial joint line. What you concerned about So it's a meniscal injury is an ACL Rupture PLC injury which essentially a complex on the for a corner of the knee and I'll call fracture or a PCR. Roger. Um, there's two ways so far to eight and the age of correct. Yeah, so, messenger. It's classic, you know, in a delayed swelling tennis, the medial joint line. Think it made a meniscus, Um, and then obviously an awkward tackle on a good landing in football again. All things, um, would indicate that in this case is medial. Uh, you can get an eighth a lot of physical injury as well. And that's more commonly seen. The context of either an ACL acute rupture or someone with a C L deficient knee. Um, just something to be aware of. But I got another bonus question for this one. I mentioned that she has intermittent locking. Look, do you know anything about what kind of mystical tears can get and walk, particularly, would you be concerned about in the context of someone with was getting locking anyone typing on safe? When was that stopped? I'd be surprised to get right. There's no pressure on if you don't know it. Someone's just typing bucket handle tear. Yes, well, that on file brilliant. Uh, yes. Oh, a bucket handle tear is essentially it's a type of the school tell where flatter meniscus elevates up. Now when you get lucky, what true locking is is an inability. Terminally extend the knee so they get to about here and then they can just look it out. So what happened that you got FLOPPINESS. Is that rates that raises up then that interposed between family condom to get plateau and they get walking? Um, so essentially, it's indicated quiet for a nerve agent repair. I'm seeing a really nice example is getting it. Find a 28 year old baby. Nothing, actually about the 20 year old kickboxer sustains this injury and compared to fight, hopefully can even see what the problem is. It which nervous most at risk and war still deficit. You'll find on examination. So give me a moment to take that extra end on they go there your options, tibial nerve weakness to the nerve injury, and we get in dorsiflexion of the ankle. Superficial pain and nerve and weakness of angle and plant affection. Tibial nerve and weakness, implant, deflection, comp panel nerve and weakness and put inversion and component of the weakness and ankle dorsiflexion. If you want to see the x ray again, just say so. Yeah. Could receive the X ray again, please. On when you really see the options, just let me know. Got it? But you, um well, we have a knee. You have any Okay? Yeah, I'm not sure. I'm gonna just pick. See, Because when in doubt, pixie Yeah, you know, they randomized a lot of where the answers are, so it doesn't actually work, is that thanks. That's not um yeah, it's e. So, um yeah, well done. So the common paraneal nerve winds around the neck of the fibula with head of fibula. Um, so while these type of member and straight down the the popliteal fossa the comparison of devices superficial on deeper No, the superficial brain Neil Nerve in a basal lot of compartments of 40 version on de de parent of innovation, Anti a compartment. So on the anterior compartment of like it can have contains the muscles that daughter flex the ankle. Hence you get foot drop if you can't. If you get a compounding of injury, Why in D is wrong is because inversions controlled by two muscles to be as anti area, which would be common apparently. But the tibial nerve, as I mentioned, is preserving that controls tubules posterior. So he would This patient would still have dorsiflexion as our inversion preserved. Um, yeah. When you see that it's a component of injury on foot drop is that your weight gets, um, again, as always, any questions Just stick in the chart and then just feel free to interrupt another one. Another anatomy being mean here. So the region marked in blue is supplied by which now which sensory nerve. So that's medial, by the way. So pictures there. This runs from just about the need to just underneath the medial malleolus be going and CS Ah, see? Yes. Seeing your strategy would would have Ah, no, it worked for you here a lot. So I went against and I put d so Oh, yeah. See, There you go. And that works what you think it is? Deep. So the shirt on Uh okay, So tibial nerve runs around the back and he wants me that you know so and that So the foot deep peril nerve that goes the first Web space as you probably will know the sciatic nerve is appear and doesn't have any scent. Two Bunches, the sure on there, which you guys put in if it is on the lateral side to the non weight bearing aspect off the foot on the plastic Support is innervated by this, Your Honor. And this is the seven. It's nerve. Um, the stuffiness never sent. It is just a continuation of formal Merck. And then it just goes all the way down the medial aspect. The leg, Um, just below the medial malleolus. Um, good. Um, so bit more. Do you see a 38 year old motor cyclists is involved in, uh, the roads out collision. This is the injury. I hope you can tell it's broken. You were called to see my overnight do significant increase in his pain, and that's not set up to about 20 mg of morphine. You examine him and you anytime you flex his big toe. He screams in pain. The leg feels tight on palpations, but the foot is warm. Welcome fused. Which of these options is the most appropriate? That management step. So take Take that in they go. So you've got a guy with a nasty break in a lot pain, but it's foot's warm or perfused, and he's had his or morphine. It's not helped. Do you want to go straight? To do a fast walk? To me you want to measure is in the compartment of pressures. You want a CT scan the limb. Do you want to overnight going taking theater just to fix the fracture? What would you want to? Just keep a close eye on him? If you must have to look at history, let me know we have three A's. He's having it yet proceeded to me. So his compartment syndrome Ah, so and it's a clinical diagnosis. So if you've got the clinical signs, which is except see, it's excessive pain on passive stretch, and that's not responsive to you analgesia. You probably got enough to make a diagnosis into compartment. Pressures are only useful in the context of uneducated patient. So you've got some, um, ethical. Try another one I to you. They can't tell you whether the pain you've got high and it's a special. You can stick a probe into your compartment legs and measure them to come out mental pressures, she just gotten it might be useful for planning on going to fix. The fracture was not in this case received with overdose conversation. That's not the fractures in the issue is the consequence of fracture you the soft tissue swelling around it on monitor closely. Well, you respond about that. So the absolutely perceived fasciotomy I'm glad no one got thrown by the dealing with WalMart use because a pale them or opposes them is extremely lay Sonika promises on paper ever happens. Um so compartment syndrome disease, the small vessels, whereas so actually pulses are often preserved capital for the sins of preserves that do not use us. Make a diagnosis and a lot. People do get that confused with acute ischemia, which is obviously where your pulses would go in early on. Um, so the key finding is that's a pain in outer portion with the clinic close signs on pain on passive stretches. Effective compartment. This diagram is from the post. Garland's just shows you where you make it a shot tonight. So this green dash landmarks out the borders, the tibia. So to decompress the to posterior compartment, you go. She sent me a medial to the tibia. And that's your incision on D for the anterior compartment, you go to centimeters lateral to the anterior, poor the tibia. And that's about side decision. And you can get to the to a lot of cramps leg. So it's called a two incision for compartment decompression, right? Pediatrics, an eight year old boy presents with an inability to wait there on the left leg. This is his X ray. Which of these tests will be most useful in this patient? Can you see the abnormality first and foremost, if anyone can You say so? Okay. And if you can see that Mountie What, you think it's most useful? Would you want to do an MRI? You want to end a craft? Screens, ultrasound, chromosome testing or what you want to check is in front of Marcus? Um, there's no answers yet. There's an echo and a B. Okay, which one do you think I put? B? But that's because I have no idea. No, you're going to be so this is a soupy essentially. So this view is called a frog leg lateral. Always request in a child with pain. So what you can see is you look on the right side. You got the method, the femoral neck, the growth plate and then the head sitting nicely on it. Here, look at that. It's You can clearly see it slipped. You know they call. It was an ice cube on accounts, I know. Whatever. So it's a Sufi. The most common age for a Sufi is 12, 13 years old, and it's common whore. It's 12 13. They're overweight on they present with a limp. That's a dramatic If you get Sufi in someone who is prepubescent, it's very unusual. Need to investigate why, and one of the causes off the most common cause in that context will be some sort endocrinology, so hypopituitarism so hypothyroidism, growth hormone deficiency. Then whatever else opportunity around six secretes. But so you have to do an endocrine screening. All these patients an emery is useful if you're suspicious, but you've not quite got that characteristic slip yet on. What you're looking for is, since he's a demon in devices for blood count more useful if you got a you know, considering infection, chromosome testing can be useful. I mean, you ever written increased risk of down syndrome and turn a syndrome which is acceptable, as is the boy. And there's no kind of suspicion dust room, you know, probably less use of the endocrine sweet in this context. So this essentially just a grief over your Sufi? Um, just say it's adolescents because as we grow that basically FISA's becomes more virtually orientated, so it's just more prone to slipping. Um, you've also got basically a perichondrium around the slices, which also weakens as urine as you enter you teenage years again. You just moved from slip, and they're saying an atomical variations that make you more prone to it. Essentially, it's memory version, which space it from the femur, is twisted in words again. It just makes you can imagine if you missed was in with. It's just more prone to stress out. The price is, um and basically these are kind of pretty specific history knows how to destroy the growth hormone parathyroid hormone deficiency Have Thoreson um Consentyx three. Slight if you want. I have some just like anyone, so feel free. Distribute that. But since you what you get is the the the med. If isis, which is this part, goes anteriorly and externally rotate on the prices goes pastas. That's why you get the short and next time rotated leg in a Sufi. Right? Another. That's me. Um, question. So five year old female fell from her off the trampoline lining around straight home. This is the X ray shown when you try to examine, You know, she can't make an okay. Science can't do this. Which nervous? Most likely injured. I can just say when you're ready to move on. Um, we go to CNN, right? C is correct. Um, yeah. So the anterior interosseous. So this is this is super cannula. Fracture is the most common Albuquerque seen Children. And the anterior up into a snow was a branch of the median, actually, but it runs just in front. Um, where the spike is? I'm so busy, it's given off just after mean That passes through the ACL. And what's specific? It does it. It controls flex A policies longest. So some collection on FDP so flex it is from this. So this moments of flushing in the distal, uh, thanks with the happy J. So if you get them to make this sign and they can't do it, you're testing FBI on FTB. So you're testing. I am, um so yeah, it's a hand injury. Regular nervous, more involved in this extension Median nerve. Yes. And I mean, I put you got more specific answer here. Well, no nerve controls it tested by asking them to either abducted fingers. We can ask them to make a fingers cross eyed. So you test in the apartment or dorsal interests I and mostly patients nervous off the break of places and all that innovates part steps. Um so just learned that in a in a super common fracture A i n is the know, most risk. Um, that's just a simple fact. And he tested by a Okay, So remember, it's a a thing. A I am. So, um, what's the most common organisms course of organism that whilst in my lights and Children. And it's the most common cause of organism and most kind of skin and soft tissue infections Be good. Yes. Number saying that, but this is quite classic. MCQ um I didn't remember getting question after this in my finals in my written finals and comes up a swell in MRCs occasions. If you want to pursue green orthopedics as well. There's a 19 year old male presents with severe back pain worse at night, which is sponsored old to naproxen, which is is the most likely diagnosis. Um, got C and B, although I think could be a a swell be be Could be it could be probably it's big. So the classic stories enough That's a classic story story. Um, so basically in Australia is, um, uh is a tumor osteoblasts. So it's very similar to a nostril blastoma, which you may have heard of a century, the only the two to see if it's peaches are. It's smaller, so it's less than two centimeters and radiologically. It does look a bit different, which you don't need to know you don't need to get into. Essentially, it's common in young males for some reason that you minutes secretes. Prosecute this high level prostate cancer creation, which, um, which is why your response So welcome nonsteroidal. So if you get that kind of pain in the back approximately sponsor really well controlled, it's not. So that's essentially it. Um, so just learned that, and it's one of those things would execute. If you see, so includes and you just know what the answer is. And this is one of them, Um, just for the background. Essentially, it's a benign tumor. It's self limiting, so usually burns itself out on average of three years. But you can persist 3 to 5. The symptoms. Campuses talked about seven years. If you do need to operate on it, you sent to you It's an operation, just a cure it out. Um, but that's basically it. So I want to get this one. A 13 year old male is is normal fitting, well presented drugs on 70 or knee pain. He plays basketball appliances, exacerbated symptoms. What's the most likely diagnosis on this number is MRI. Just look good. Measure. We got the answer here. Um, I put see and no one else put an answer yet. Yeah. See, splatters. So essentially, the classic story is young male's normal, evolving jumping sports. Essentially, what you get is you've got you get basically besides the inflammation around the keep your keep your oxygen um, bruits basically inflammation on the table to cross. If isis So what? This MRI shows if you can see this is all dark, dark and then around 10 and you caught based on this area? Lights up. Um, you don't need a new diagnosis. MRI's of medical diagnosis But that's a very classic history. So, um, young male, roughly about puberty. Age, uh, Lasses jumping sports or general? Quite athletic. It's with anterior paints. Also, it's letters. Easy is empty coupon forever. Patella tendonitis is common jumpers, but it's more common in adults. So if you get the same story and someone is 40 then that's your answer. These are all common cause is, but in this case, it's just say, single best answer. It's most likely this. See right, a 41 year old epileptic presents with difficulty moving her shoulder, falling a siege on examination. You notice, Haram, it's internally, right? Cases like that, you can see me. I don't see myself. And then she's unable to extremely retain the shoulder. This is her reps, right? What's the most likely diagnosis We got? B. Yes, good. It's be so it's a possible told this location. So what you get in someone who is has a son answer off large spasm large muscles. Either their electrically electrocuted or they have seizures is you get basically co contraction of big, powerful muscles, like the latest MS Door sign that the pet major like terrorist major. All of which, in turn, a rotated shoulder. The only two months that external rotation other two are two other couples. Impersonators on terrorist minor. We can match in, you know, you pat your letter much more powerful. So that's why you get be, um, a posterior dislocation. It's very difficult to see on X ray and can be quite some time. It's often miss, but what your stent you looking for on the on APB, you is what's called a light bulb sign. So if you look at this, if I call the truck with the humeral head, what you got is a perfect so human, you know, shot, You've got perfectly spherical humiral head here. What you could actually see is the human head kind of bulging towards a clean oil. So it's a therapy. So it kind of shapes like that. So when you've got a context of someone with a perfect special human ahead on the AP view, that should bring alarm bells in this kitchen and kind of see is, well, the glenoid shadow. But, um, almost look like a city in front of the right is a which is another clue. But it's not like a sign that you want to look for. If there's any doubt you get in the real life, you know, like get CT. But essentially, that's what they mean. But if you hear like a sign, that's what they need sticking on shoulders. So this time the rugged play has been tackled. Oh, he's attempting, taking off. So you play, he comes to you and this is what he looks like. What's the most like the injury? Please don't say it's got D. Yes, so this is called squaring of the shoulder joints, so he's gone on to dislocation. So the call mechanism is abduction an external rotation. So you can imagine a replay doing a tackle easy coming like that, and then, if they're taken out or taking through them this shoulder, just go like that. So excited rotate and that tennis pop it will pop out the front. The clinic walk squaring means we see you see on his left side. He's got a nice kind of control the deltoid muscle because the humor had a sub locks forward. You've lost into the exhilarated, sitting somewhere in the axilla. You've lost that lovely contour you get in the deltoid muscle. What you got is a crummy in, and then it goes straight down so that that's what we mean when this is scaring in the shoulder joint. Fine back. Pedes. So which of these statements is true regarding developments? Hip dysplasia. How much you go by the way? A minute? Um, I think there's There's five of us. I've put a, but I don't know so much. But see, that's it. They don't put the no, they don't put the now. I said that because it's, uh so development of it. This way. There is actually a favorite topic impedes. It's topical with terms of screening, which they love. A medical school. So a bolus. So let's go through a bolus positive test is that bill to reduce it is located hip. Um, it's not true. So Apollo bolus test is C A B building to dislocate the hip. So what you do essentially no, only dislocated prostate. The way do you get the baby you flex any is up and then you apply it down with pressure on their knees. with the hip flex, and then you feel it click. Is it as a hip dislocates that supposed to bolus test? Um, so I have to change the options because I was having a difficult Let's go with this one. So that's what Boston it is. And then you can imagine what an ultra Lonnie's test is. You want to try and see now that hip you dislocated is reducible, so you want to send to the opposite bars. So rather than act up from the hips you want externally, rotate the hips and then you wanna push up and then you should feel quick as it reduces. That's an auto lining. Positive test. The way I remember is, like worst Lonnie out to the hips or the out and then get you want to push it back in. And if all this test is you're pushing out, Um, do you learn it, though, because those those two Did you love that in your pizza? What you want? It is fat game per MCQ, Um, when the child is when the babies newborn, those tests, like positive as they grow older and the other the hips or chronically out or sub locks. They tend to get soft tissue contractures on the 10. Just get bigger and more muscular anyway, so those tests are not likely positive. After three months, ultrasound is the primary modality. That's how you screen for it. So if you've got someone in your baby chicks, which may we'll do it some point. Ah, and you see that composite dollars test on insulin ease? You would then send it for a noticed on that since you you can find a diagnosis with he. So to do about six months, you can add to manage them in what's called a public harness. So essentially, this is it. What you want to do is you want to since checks the defect of Superior. So what you want to do is start posterior. So what you wanna do? Is it still retain the hips and keep him in that position? And you want to allow the ass tapping him to mold around the federal head and, um as it normally would? Um, so this is it's called an abduction brace or have the context in the UK After about six months, a child gets too big for this. You won't be able to keep them still or keeping position you want to. So then you have to attempt a close reduction in theater, and this is what this diagram is showing. So since you have taken healthy pump sleep and then they reduced the hip and then they're injecting dye into the joint to try and conflict firm the hips in the right place. Um, just for interest when you got people with you have grown up into half display, just having complete covered from head as they do in this state. They're basically in this x ray what you've got. Look at this side. Look how that's tabula. Um, covers most of femoral head in this case you seem or the family head is uncovered. Now, this is since you delayed a consequence off Ms dysplasia and what you get because you've got some some of the family had uncovered, you get abnormal contact. Pressure's on the family had that within the establish so they could hit them. So if you're seeing this, hasn't had a one, things you can do is called a periosteal. Stopped me where you basically make a cut in the pelvis and you reorient it's tapping. Um, so it's covering more of family head, and that's essential. That's done. Is that the pre op? That's post office. So can you see how the family head is more covered by that stuff? Um, in this x ray? Um, so So that's one of the consequence of Ms dysplasia. This one, I think, is a hard one. But it is again 10. See? Fair game. So 52 year old female is brought into any after being involved in road traffic. Collision are observations are his followers Which of these injuries would like to explain these promises? So you've got someone who's got low heart rate is hypertensive. Do you think he has attention? Hemothorax would have the same variety. Five vertebral fracture and open book pelvis. Back to essentially is, um, basically, the pelvis opens up around the front and you'll take that section or epidural hematoma. What, you think, um, I've put c and another D. So I'm not sure no one else for Nancy. Yeah, fine. You want to give it a couple seconds or DPP is No, No. Um, I think people might just not know it. Honest. I think it did. come upon your slides. But have you heard of Urogenic shock? Someone's put be? Yes, Yes, We'll look good. That's it. Be so, um essentially, this person has a trauma and they've got low BP. They're shocked. That's in controversial, right? What would you expect in the context of someone with a low BP? I'll tell you, a high heart rate again makes sense, right? You You know, you're trying to maintain pretty profusion you put put his dropped your heart stuff coming faster in this case. What? You notice that this patient hasn't got a high heart rate, so their BP is low, but the heart is also have not got that compensated tachycardia. So what that suggests is that got an issue with the sympathetic drive and what you can get in spinal cord in in a spine. Fractures that are above t six is something called neurogenic shot because of cervical sympathetic chain runs down down from the cervical spine, t six. So injury at that six or above can take out the service sympathetic chain. So you lose your synthetic drives, you get what's called Urogenic shock. So you get low BP but you don't get the compensated tachycardia and that's so when you see that you know. And then that's injury said it's a spiell into above t six just quickly types of shots because it is something that is relevant. So you got four times a shock broadly so and it makes sense when you think about it. So the most common one you'll see is hemorrhagic. So loss of blood Well, you can also get shock due to the heart and ability to pump sufficient sufficiently. So you got lots of cardio contractility. So you see that in arrhythmias, So B f e t well, my card I see sent you information of the heart muscle. You can get shocked you to obstruction of the half outflow. And that's why attention your thorax cause you to be shocked because the heart simply can't just pump load up out out the purple circulation and then you get shocked which is scented you to what's called loss of peripheral vascular system. So you get a massive basic dilation of all you perform vessels. So essentially you get massive drop in blood pressure because pressure related to how how strict the best of all. And that's what happened in septic shock or anaphylactic shock. You get this. Massive is dilation. So you just get this mask, This something dropping pressure. Um, which is interesting is wife example fluid resuscitation Doesn't, isn't It is not as effective in anaphylactic shock as it would be in here, right in shock. And you're a cardiogenic shock doesn't count it as a former distributive. Shocked because you lose a sympathetic dry tell you vessels relax. So you get this, um, a drop in blood pressure from that reason, but on my accepting shock, you don't get a heart a high heart rate to compensate. Um, so Well, did we ever got that? So which of these does not form parts of the package of care for major hemorrhage? So is it fresh frozen plasma trying examine Cassidy calcium chloride? I be cryoprecipitates on my fanatic acid, and I think they talked about major hemorrhaging. When your slides, um, we have we correct? Yes. Methalonic acid. So methadone guys, a nonsteroidal think the only time I've seen it used his painful periods and obstetrics, but this takes me way back to my medical student days. Yeah, so fresh frozen plasma. Very important. Any major emergency station. So essentially, it's just the plasma blood. Tranexamic acid is big nowadays, so essentially, what? Trying to get? It's an anti footprint literate. So it started out as a drug to control him, period. But what it does, it's actually stops the breakdown of fiber and and within the blood clot. So now any patient, a major trauma automatically gets tranexamic acid a standard. Um, so it's definitely forten Cryoprecipitates is a complex off clotting practice that again you need to give calcium chloride. So if some calcium is actually a cofactor in the clotting cascade, so in the context of a hemorrhage, if you've got someone low counts, um, you do need to replace it. Otherwise they won't be able to form the clotting factors. So again, um, so that's why it's important. Yeah, well done, you guys. So again, I think the fact is, well, the thing which of these systems is used to class for a long bone open practice is it Schatzker cost you Anderson, Lage Hanson and send Alonzo or National classification System. Yeah, be correct. It's being Yeah. Stevenson shot skirts for tibial plateau fractures lager. Hansen's for ankle fractures. This is for C spine fractures or C two fractures, and this I just made up. Um, so this is a customer and see classic A systems. Essentially, the key thing is, any open fraction needs to be taken. The theater to be debrided the and the way it's works. Type one type two a distinguished based on size. So less than one centimeters a type one and type two is less is great than one centimeter and then three where it gets big computer. Essentially, what you've got is a more extensive wound, with some loss of the layer periosteum lay offs around the bone. Um, and then as you get the highest age is a three B. You basically lost so much skin and soft tissue that you can't close it primarily. See Colin. Just take the attention issues about together and what makes it see any sort. Vascular injury, in the context of know, practically automatic, makes its we see. So let's send you distinctly different data. All right, pull. Your thing was squeamish. So a 64 year old farmer has a full at work staying open fracture. He's got this very large wound. Um, and there's lot of contamination in it. He turns up 80 11 PM What's the appropriate management plan? So, do you want to take him to theater straight away the bride and fix a fracture? Definitively. You want to give a good clean a any antibiotics and then take it in the morning? You want to take 1/5 straight away debrided and do what's called a temporary stabilization. So basically, you put in extent of fixator on the fractures to hold the bones in place, but temporarily be you want to wash it in in any and then perform the defensive close in the morning. And he Do you want to take it fetoprotein and get plastic surgery to take a flap on it. What's the most appropriate? Um, we've gonna be It's C. So with these open fractures washing out in and he is not indicated so essentially, if you've got an open fracture that's contaminated, it needs to go theater. You can remove any big contaminants. Got pieces of, you know, seen leaves stuck in there where you can read that anybody If we have a formal washout, it needs to be done the operating theater. And if this contaminated needs to go immediately, If it's high and you fracture, we're not, obviously, obviously contaminate musical than 12 hours. And if they're old school frail skin and it could go within 24 hours, that was I was getting out with that. Now you don't want to put any metal work within the body if you can't close the wound because your metal where we get infected. Which is why, um, option A on D uh option deal room. So what you essentially would we do in these situations is we'll take it. Theater get. We'll give you a good wash, get rid of all any dead or necrotic tissue. Well, then, obviously unbelievable bone ends and clean and the bride and wash the bone and what you would then do you put a temporary dressing on top, and then you put what's called the external fixated. See basic stick pins before active pins after and basically and some connecting rods and hold back the bone in place. Until then, you can speak to plastic surgery colleagues and the naked come in and you basically work with them. You do definitive fixation on and they will reconstruct stopped issues either through a skin graft or a flat. So that's what would happen. This context normally, to keep messages that if it's contaminated, open your theater straight away. And don't put definitive metal working unless you can close the wound. Yeah, they said just the post God last right under the hip fracture. So a 31 year old male is fitting. Well, sustains this neck appear fracture. Your boss asked you how you would you like to manage it? So using the information, that's that. What would you want to do for? Do you have announce it? Um, Yep. So we've got a B and a Well, then, well, then it's b I went to be so you're very right and said so let's talk about Okay, so this is intracapsular getting a fracture. So you're concerned about a BM? Which in a displaced into counseling already you've got about 30% risk. You've also got about 40% risk of non union. So if you've got someone who is old that you sent, you got 70% risk of this fracture, not healing in some form or another. All right, that's a B n or don't you? Which is why in the LD population of 65 we just we just replace it. There's no point, and I'm keeping in trying to fix it and present the hip and hip place. Nowadays. That's what you could outcome, that you would just do that. And basically you decide between the Hemi. Arthroplasty is a half a hip or a total hip, based on their functional outcomes over there, very good for their age, that playing golf or whatever it is that people do each want to try and do a total hip. If you just need to get them open walking, you do a hemiarthroplasty. This guy said You want your average is fitting. Well, your average hip replacement probably last up 30 years before you basically need to be revised because of where, um, usually over. So if you replace this man's here, you essentially condemning him to a revision in the sixties, it's finally 70 because they're living will probably outlive them. So if you've got someone sitting well, you want to give him every single chance to preserve his native hip. So hence you go for a candidate, scoop it fixation. We try and fix it. Essentially, it's just basically, take the fracture. You realign it on a traction table and sent you placed three screws, Turn left a cortex into the hip, and you need to keep them non weight back in six weeks. Um, because it's not a stable fixation. So you want and sure give the burnt up to here before you load it. Um, So, um well, then you said B, but that's that was my Russian out? Yeah, more than me. So yeah, the break of places was a bug bear of mine in my medical school years. I hated it, but and it's very complex, but so I don't want to get this wrong, but which of these is not a brand to the posterior called the break of plexus? Okay, um, I've put see anyone is answered, but I really can't remember. That's time is the So the posterior on interosseous now is a branch of the range in there. So all your wrist extensors is these muscles and the muscles on the extent of platform that spot p i n. So it's a brand new region of not the break a plexus directly. The rest are all positive branches. So the radial nerve on the examine of the two you should know. Um, so this is a complex diet, and what you want to know is essentially these five and the so you won't know posterior court gives off exhilarate. You'll never lateral cord gives off the most contagious media gets off the ulnar and then immediate takes a branch of the lateral and medial court. If you just learned that very basic schematic, then you you let enough for finals. Um, these two were a bit mean with fractal dorsal nerve in a vase. Latest Ms Door sign on the subscapular of invasive scapula eyes, but that you come off the record. So that was why they were correct. Um, yeah. Um, regular practice. Enjoy. Okay. Ramos of the end. You'll be glad to know. So 52 year old female presents with pain have foot on further questions. She describes the pain between being between the 3rd and 4th toes and worse when she wears high heels. Based on this history, what's the most likely diagnosis? Do you think she's got plant fasciitis? Um, mtp joints, osteoarthritis, a mortar? You're on Fridays. Disease or a stress fracture? This is one of those empty Q things where, like, it just won't thinking. This just gives it away, I hope. Anyway, um, got be any No, no, guys, all isn't at me. No, it's not a is it. So So I'll see a day. See when in doubt. See? Yeah, you're right. Yeah, More neuroma. So essentially a mortar zero basically is a Basically, it's it's swelling or pain, That swelling off the planter nerves a sense you book what you wanted for the person. Excuse what you want to get, get get it is, uh, pain was when they went high heels pain between the third apoptosis. That's what it must come in because And she did you have him on is your demographic. So all these three things if you see the any of those things clock the answer in the constant foot pain. Um, but essentially, it's they think it's due to my control around the nerves. So that's why example, you know, high heels. I don't know what the hell, but you know, if you've got back for a box of the end toes get squeezed on that cause irritation of the nerve over a long period of time. Which is why you tend to get this. Ah, and females, um, plants. Fasciitis is actually trying to paint us worse in the morning. Um, arthritis is always a possibility, but I say this aspects of his give it away or point was more neuroma. Freiburg's ease is essentially a bath in a Christoph the second metatarsal head. So I so so don't place the pain. Stress fracture again is a very reasonable answer. It's possibility. So I don't blame you guys for picking it. Whoever picked it, uh, again, it's just with the single best out of context. It just points to all points towards motor the aroma. This is a difficult one, but wrong. So the answer. So 24 year old one falls off a horse and presents the right foot pain. This is what her X ray looks like on the right and her foot. It's like on the left. This is a question which injuries demonstrated here. Um, so I'll go back in a second. It it's a mid foot spray. Is it? Mid foot sprain is a Lisfranc injury. Is there a particular fracture. Is there a sub Taylor joint dislocation or is it an ankle sprain? I've gone with B. Beautiful. Yes. Well, don't be so this frank injury. So the key point here, and it's for your finals. And even when you're practicing, if you're in any or you're working orthopedics plant, a bruising on the foot is a bad sign. If you've got planted breezing, you've done something quite severe unless proven until proven otherwise. So never ignore it, even if even he even the whole story or the everything else was quiet. Knock us if you see that, be worried. What a Lisfranc injury is is basically disruption of what's called a lisfranc ligament. So between the task is and metatarsal, you got these ligaments complex that preserve the architecture's put. So this, frankly, is ligament runs between this bone, which is the media clear from the second metatarsal. And then so you've actually no connection between the 1st and 2nd Intelsat's. So if that ligament goes off this complex with the ligaments go, basically, you risk losing the normal architecture the foot. So it's quite a serious injury, and how you look for it is you want to see if there's a gap between the first metatarsal on the second metatarsal, which in this case there is normally they should be bit of an overlap, as you can see the limit tassels. Um, sometimes you can get is a disruption, but you don't see there's an X ray. But so what you can do is what's called a weight bearing film you get put weight on, and then you see that stress that causes the gap to widen. Um, and also what you want to check that you want to check that Media said a lot of for the metatarsal aligns with this bone. Then you clear for me and you want to check that this bone the medial aspect of the second battle lines with the middle chemical, which you can see it doesn't is a step here again. That's something to consider. Well done. These are often missed any any. Um, so, um, that's what you guys got it right? Okay, seconds. Last question a 50 year old man presents with tingling and little finger. On examination, you notice some wasting hypothermia, remnants and Roman science Positive. You're able to recreate symptoms when you flex is out. What? What's the most likely diagnosis? Um, someone's put carpal tunnel, but I I think it's cubital tunnel. Yeah, correct. It's keeping it. So it's an only nerve compression of the Q books on which, which is essentially behind the meal. It becomes so just going through the signs quickly. So wasting happens, you know, evidence. So again, innovate by the Oh, no. Yes. So it's like in a copy. When you get with the non muscles and cubital tunnel syndrome, you can't waste of helps in your muscles from inside. So this is something that you know. You may get an examination in your finals. Um, and you know something? You they might ask you about books sent you a promise. Sinuses. You get them. Teo, can you get up? So what you want want to do is you want to test the abduction of thumb, so they built to bring some of this position sense. You get peace of people at that and stop you pulling it out. And the using a doctor Positive talking some stop it. Which is only no. If they're from inside positive in the camp, live on that boat. Probably can't do that what the little start, cheat and flex that thumb so they'll use F p l. It's a flexible slow because it's innovative. Different know, remember the area. So that's from inside. So if they're able to keep it there peeping that some strength, then it's normal. And if they start flex that thumb because they come, they can't use their doctors than they're supposed to. So sign of it on a nerve injury. Um, the re other reasonable option. And this would have been a C a. Particular the and because see, it doesn't have a that part of the hands, because that's where the only comes from. Um, but the difference here is that when I said that you can re create the symptoms by flexing their elbow. Um, when you flex your elbow, you're putting the on the nerve on stretch so you will worsen the symptoms. Which won't happen. And if you've got just compression of the spinal, a nerve root of C eight. So that wasn't sick with each other last one guys, and then we'll free um, a 40 year old female who's a keen tennis player, presents with pain on the raid last week. The wrist. There's no obvious swelling on examination, but you find that fourth on a deviation. So this But this is very painful. Which of these the most likely diagnosis, huh? I've got. See? Yes. When in doubt, See? Kind of exactly as thick weapons do you have to? You're synovitis all the side misplotted. Uh uh. Yeah. So dangling the pain is a, uh, swelling or swelling of the nerves. But it's not in this case, Copter syndrome. Glad he didn't get it. So dick opens is basically essentially the extent the most the tendons of the extensive is off the hand are ranging two compartments. The first compartment contains the extent of policies brevis on abductor polls longest. And it could become inflamed you to overuse various reasons. And that's what's called equivalency Inside, right? So is information about first compartment to get pain over the the the first extensive apartment. What you get is a pain in forced on a deviation. So the way test for is ask him to tuck that thumb into their hand like this. I can see that on. Then you asked him to continue it with your hand. You force the 100 on deviation. And if it's posted, though literally screaming pain. Uh, and that's called Single Stein's test. Um, says diagnostic for this, um, the most CMC joint arthritis is extremely comments, the most common joints in the body effect of arthritis. So it's basically tries to base of thumb. Uh, in second syndrome is like the equivalent, but with the equivalence effects. The first compartment. This is basically disease in second department. Um, so you don't need to know about it. It's not particularly common, but this one is you. You'll come across. I'm sure some point on get it. It may be them secure finals. So that's all I could come up with. Um, that's coming. Hope over there would just the right level bopping us to if you could. A scan is QR code end up seeing a lot of people for sure. The guys that boom so will really appreciate it. Yeah, um and I want to put the link in the chat guy so you can easily just click that as well if you happen to be watching on your phone or something. But then also, you get a certificate yourself, so make sure to fill out. Okay, um, thank you very much for giving that talks very good. Clearly needs to revision before next year, but least I have a whole year.