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University. And I'm also one of the educational research code leads. Um And this is our first sort of talk in our series where we're doing sort of an Ortho orthopedic teaching series run by medical students for medical students. Um And we hope this is this is helpful to sort of increase your knowledge and orthopedics and also sort of increase your knowledge in preparation for your exams as well. Um As a disclaimer, um these are made from our own notes in our own time. Um So if there's any inaccuracies or if you hear different things on placement from your supervisors, please just, you know, refer to what they say. Um So yeah, um our first talk today, this is an orthopedic emergencies. Um As an overview, we'll go through four main topics. So we'll go through compartment syndrome, septic arthritis, ask you myelitis and called your equina. If you've got any questions, please feel free to put them in the chat and then we can just go through them as we go along and if you've got time, we've got a little quiz at the end. Um And then we can use the chat for that as well. So to start off with, we'll go through compartment syndrome. Um this is very much an orthopedic emergency, it needs to be dealt with straight away as the impact of this can be sort of limb threatening. Um So as a definition, it's basically where there's a pressure increase within a confined compartment and this reaches a critical level and can ultimately result in nerve compression, nerve damage and also scania. Um and it can be limb threatening. Um So, the pathophysiology behind compartment syndrome, it mainly occurs following sort of high energy trauma and injuries or fractures. Um It can also be iatrogenic. So we can sort of cause this, it can be caused with type cast or splint. So when someone comes in with a fracture, you typically don't want to have a circumferential cast. Um you want to have a little bit of space in just to relieve that pressure. You can also get it in deep deep vein from basis as well. And um it's quite rare but it's really important to detect. Um So to go through the stages of come up compartment syndrome, basically what you initially get is fluid accumulation. Um So you've got a close pressure compartment, there's nowhere for this pressure to go to and you get an increase in the intra compartment of pressure. This will start to compress the veins inside the legs or the arms or whichever minute is. Um and this again causes further. Um increasing pressure and this then starts to cause nerve compressions. So you might find that your patient's come in with a sensory and, or a motor deficit. Um and Paris seizures as well. And then eventually this becomes so swollen in the pressure increases so much that basically you get a compromise of your arterial blood flow. And this is when you notice those vascular signs of limb ischemia. So you've got your pale, pulseless nous, perishing, perishing the cold and paralysis. And that's a mixture of vascular compromise and no compression. So, an overview of how it presents. Um the main thing here is just being aware that the patient is in severe pain. So if you remember anything from this, remember pain, um and this typically is disproportionate to the injury. So it will seem that they, you've touched loads of pain killers that then you've given them analgesia, you've tried to elevate it and this pain just won't go away and it seems to be increased relative to the injury that they've had. Another thing, you might find an examination is they get pain on passive stress stretch. So if you're stretching the leg passively, they'll find it even more painful. You might also find later features. So you're looking at your arterial insufficiency. So you've got pale or mottled skin, uh it's perishing, perishing, the cold lack of pulse is a paralysis and this is when it's really quite worrying at this point. Um in terms of investigation, it's very much a clinical diagnosis. Um and you basically need a high degree of suspicion. So a low threshold to think is this compartment syndrome, um some patient's might be unconscious and they might not be able to sort of talk to you. You might not be able to examine them effectively. In this case, you can do inter compartment or pressure monitoring, but this is the most reliable test, but it's quite invasive. And essentially you just put the pressure monitor into the compartment through the skin, through the muscles and that will be raised, you can also find an elevated CK level. So you're creating coyness on blood tests and this is a sign of sort of muscle damage and it's released when you get muscle damage. Um in terms of management, like I said, this is very much an emergency involve your senior, give them, make sure the limbs at a neutral level. So don't elevate it or lower it because that can cause further sort of fluid accumulation and in further increase the pressure. And if the hypoxic give them oxygen, make sure they've got vascular access and you need to give a fluid bolus and this will help increase the BP which increases profusion. Um if they've come in with a cast, make sure you take that cast off just to allow that pressure just reduce. And of course they're in extreme pain. So you need to give them IV analgesia in terms of this sort of definitive management, these patient's need to go for surgery and they'll have a fasciotomy performed, which is basically where they make skin incisions um within the planes and then they open them and that it's the pressure sort of go down. Um And decrease, there might be in a process because as we explained, you can get vascular compromise if that's the case you divide that. Um And then in terms of follow up reassess in about 1 to 2 days, um and then monitor the renal function. As we said, you can get elevated, creating kind of days and due to muscle injury, you can get rhabdomyolysis, which is basically a breakdown of the muscles and you get an increase of this compound called micro been. And that can cause damage such as kidney damage because it can accumulate in the kidneys. Um So as an overview, this might come up in your exam questions, the typical scenario would be that a patient sustained a fracture and it's immobilized in a car past, usually it's a confidential cast. And then a few hours later, they have severe pain, which isn't helping with analgesia, it doesn't go away. And um it seems out of proportion to the level of injury they've got and then on examination, they'd have pain on passive stretch. And that should make you think this is a compartment syndrome. This patient, you know, ultimately needs to go for a fasciotomy So that's compartment syndrome, just checking if there's any questions. Uh No questions. No fabulous. Okay. So we'll move on now to septic arthritis. So, septic arthritis is essentially an infection of the joint. And there's three main mechanisms by which joints can become infected. And so the first one is bacteremia. So essentially, if you've already got an infection, the bugs can go through the bloodstream and basically go into your joints. So sources of infection could be a cellulitis, a chest infection, a uti any sort of infection you can get and that spreads through the blood and goes into the joints. Um The second mechanism is direct inoculation. So this is it directly introduce the bacteria into the joint. So this could be from, for example, joint injection, it could be from intravenous drug use if they inject close to a joint. Um and then the third mechanism is adjacent osteomyelitis, which will also discuss. So essentially, if you've got an infection of your bone, it can then see its way in into the joint. Um and the further course quarter further infection, your risk factors as we discussed intravenous drug use, any penetrating trauma. So that would cause direct inoculation. Um increasing age, any pre existing joint disease, for example, rheumatoid arthritis along with similar lines, any immuno suppression. So the diabetes um and this just means they're less effective at fighting off infections. Um Similarly, in chronic renal failure, um and also prosthetic joints tend to be quite a nice environment for bugs to grow. So that's a further risk factor. Um in terms of the organisms that cause it, the most common one is staph aureus. And so if somebody comes in with septic arthritis, you typically expect to see staphylococcus aureus on sort of a culture. However, there are different ones depending on different backgrounds. So if a patient has gonorrhea, um they could get septic arthritis and then in sickle cell anemia, patient's, it's usually caused by salmonella, which is quite a common question that comes up in finals, you might see that on pass med. Um So in terms of how they present again, they'd have pain and usually you'll see a single, swollen joint because they've got an infection, you'd expect them to also have a fever. And the key thing here is they'll have an inability to wait there. So they'll come in with a fever, they'll complain of pain and a swollen leg joint and they won't be able to wait there on that joint. So, if you think a new joint, they'll say I can't stand up on it. I can't walk. This is really impacting me and, and as we've discussed, there'll be pain on movement and a red swollen, warm joint. Um, in terms of investigations, um, you want to take a lot of bloods, so you want to take, um, full blood count CRP and ESR to look for inflammatory markers, take a serum your rate to rule out something like, for example, gout because that can present quite similar in a single swollen joints. And of course, you want to take your blood cultures because patient's with septic arthritis as the name suggesting usually quite unwell. Um So you might need to activate your sepsis six if it's indicated. And you're worried that this patient septic um before giving antibiotics, it's really important that you, you take the blood cultures and aspirate the joint. Um And it's really important to note that sometimes you can get swollen red joints for other reasons. Um You don't want to inject into a joint until you've proven that it's not such arthritis because if you inject into a joint will basically cause further infection. And so make sure if you have any suspicion, this could be a septic arthritis. You do a joint aspiration and then you need to look for gram staining. So your culture, look at the leukocyte count and then you can also send it for a polarizing microscopy microscopy to rule out things like gout as you dig out. Um pain radiographs are also very helpful as they can show sort of joint damage and other signs in terms of your management, essentially, this patient will need antibiotics because they've got an infection and they usually have quite a strong infection at this point. So the first two weeks, you tend to give it intravenously and commitment hospital. Um and then they'll have around 4 to 6 weeks, total of antibiotics. So the first few weeks you give it intravenously and then you give it already and then they can go home if they're well enough and sometimes as well, you might need to surgically irrigate. And the Bride um, in theater. So a few weeks ago I saw there was a young boy, he came up with septic arthritis of the elbow. Um, and we, I was in theater when that was washed out and then it just helps to sort of control the infection. Um And then typical exam scenario, usually they'll give a background history of an immunosuppressive disorder. They'll come in with a single red swollen joint and a fever. And then when you do a joint aspiration, they'll typically have a raised white cell count. And at that point, you should think is this septic arthritis, I need to, you know, take my blood cultures, take my blood, you know, form a joint aspiration and get a radiograph. So that's septic arthritis. I'll just check if there's any questions on that before we move on. Uh No questions. Ok. Great. So we'll move on to Osteomyelitis. So, on a similar theme, it's another infective theme, but this time, we're looking at the bone itself instead of the joint. Um So again, the most common organism is staph aureus. But again, really important to note that if a patient has sickle cell, anemia, salmonella is the predominant organism effective cause here. Um Again, there's different types of spread. So similar to such a qarth rightists, we've said this hematogenic Osteomyelitis iss so you can get it through the bloodstream and it will affect the bone. Um I saw a patient a few years ago with this and he ended up having osteomyelitis of the lumbar spine. Um and that was because he'd actually had an underlying chest infection and it just went around into the back and you can also get direct Osteomyelitis. So, again, any penetrating trauma, any intravenous drug use can increase your risk of introducing bacteria into the bone. And, and again, um if you're doing replacement, so, Pristiq prosthetics um can again increase that risk because you're introducing the potential for bugs to get into the bone, um and open fractures as well. So size and symptoms, again, a fever, this usually tends to be lower than in septic arthritis. So, septic arthritis, they usually have quite a high fever. Whereas an Osteomyelitis, it could be a bit more sort of subtle and low grade. They might also have nonspecific pain at the site of the infection. So they might just complain of generalized bone pains. Um you know, a history of a bit of bone pain, uh and then also the pain is sort of being tired and then you might find on examination that they do have a bit of redness and swelling and they will typically have a decreased range of motion in the effective segment. So again, your investigation is quite similar um to septic arthritis. You want to do your full blood count. So you can look at your white cells and you want to look at the CLP at the S are for your refractory markers. And again, you want to get an X ray of the affected area. Um so you tend to get an acute disease, osteopenia. So this is sort of like a softening of the bones and that occurs about a week after the onset of infection. You can also have evidence of bone destruction as well because if you think if you've got bugs in your bone, it's going to cause some level of disruption and damage to the bone. And then in terms of chronic disease, um you might find different things which is cavity formation. Um So the bone essentially becomes necrotic um and just collapses and it will leave cavities. And you can also find a site called intramuscular machinery scalloping, which is a sign that you can see on x rays. You might want to do an ultrasound as well, that's quite helpful in the acute cases of osteo my life. Um And you can look for any associated septic arthritis. As we said, you can get septic arthritis, common osteomyelitis because the infection migrates into the joint. Um You might also it might show collections, abscesses, um and again, adjacent joint infusions. Um The best quality of imaging is the MRI. So, so this can show sort of more clearly any signs of infection and those signs that we've said before, they just show up in better quality on an MRI. So if ever you're thinking about an effective cause um in a muscular scalito situation, you want to do blood and you want to do imaging and you always want in any patient, you want to rule out the choice that, you know, they could, they be septic. And if they're septic, you've managed accordingly. There is a classification here and this is just sort of a diagram to visualize the, the stages of damage and osteomyelitis. So it sort of creeps through and then eventually gets into the middle of the bone causes sort of cavities and collapse. Um in terms of management, again, you want to treat them with antibiotics. Um And again, it's quite a long course, you're looking at about six weeks for an acute infection. And then obviously, it's always important, really important to check for allergies because if the penicillin allergic, you'd go for Clindamycin instead of three clocks, asylum in terms of surgery, um it's not always indicated. So a lot of the time Osteomyelitis just responds to antibiotics alone. Um And that's what you need to do for the patient. However, if they're dead bone or significant damage to the bone, you might need to perform surgery. Um And that would just allow them to restore their functioning and the mobility of the affected area. And of course, you should immobilize the limb during treatment and your comorbidities addressed. And again, if you think that septic act on that, um, so that's Osteomyelitis. Um, and we'll move on to Corded Equina Syndrome. Next, I'll just double check again if there's any questions. Uh, fabulous. Now we'll move on to Corded Equina Syndrome. This is again, quite a popular exam topic. So, from my personal experience, I have this in my written papers and I had a Noski station on this. Um, so it's really, really important that, you know, the signs, of course equina syndrome. Again, it's quite rare, but it's a very debilitating condition if, if it goes unnoticed. So it's really important to be aware of it. So the corner rick whiner is a bundle of lower motor neurons and this is inferior to the spinal cord. So, as we can see, we've got the codes Medearis and then the cord require will come off that um, it has a lot of functions. So it can provide both sensory and motor function to the lower limbs, motor function to the anal sphincter and parasympathetic innovation to the bladder. And if you understand the anatomy and physiology of the cord require an er, you'll understand why patient's have quite a unique presentation when they present Recorder Queen syndrome. Um, quarter of quite a syndrome is essentially any compression of this quarter recliner. And there's different ways that compression can happen. So for example, a disc herniation, which is most common. So you might find these patient's say, oh, a few weeks ago or a few days ago, I actually tripped and I hurt my back and there's trauma. So any fracture or subluxation, which is like a partial dislocation, neoplasm. So this is really important. So if anyone has a history of cancer that quite typically will metastasize to the bone. So, thyroid cancer, breast, lung renal and prostate or your big five, that have a higher risk of metastasizing into bone. If you get a tumor in your bone and it keeps growing, it can compress the cord recliner, any sort of infection. So disc itis infection of those discs or pots disease, which is a complication of tuberculosis. Um any chronic spinal information such as an closing spondylitis, which is not a new disorder, whether vertebrae essentially fuse, um and I intragenic as well. So say if you've given someone spinal anesthesia and you cause a large hematoma and this can actually compress onto the cord recliner. So the clinical presentation is quite unique for cordial acquirer. So it's really important when you're taking a history of anyone with back pain, you always screen for red flags. And when you're screening for red flags, it is mainly cordial quieter alongside other things. So if a corner rick whiner, um they will get reduced, lower limb sensation and in particular saddle anesthesia. So this means that the perianal area will become numb essentially. And a really easy way to screen for this is when you're taking a history from a patient, asked them when you go to the toilet and wipe yourself, can you feel it? Um, and essentially is the only, only caused by called, required in most cases. And that's what you're worried about if they, if they have saddle anesthesia and bladder and bowel dysfunction. So they might, uh, complain of incontinence. They might say, well, I'm actually just really not able to get to the toilet on time. You know, I'm soiling myself and they might complain the other way with the bladder. So they have urinary retention if a patient has called recliner and they have urinary retention, this is actually the worst sign that can have. So at this point, it's indicative that this damage is irreversible. And so urinary retention is quite a very bad sign to have alongside this. They can get, you know, alongside sensory disturbances, they can get motor disturbances. So they might say, oh, and my legs are really weak. I'm not able to sort of get myself around. I've really been struggling to walk and again, so they're back pain. So pain is quite a common theme today and in men, they might have impotence as well. So again, on examination, you want to look at the perianal area, you can assess anal tone on P R. However, it's important to note the guidelines have recently changed that not everyone requires a pr exam. If you're worried about poured equina, I'd recommend to get more information. Just look this up is it only changed over the past few weeks. Another important sign is that they get hyporeflexia. So when you're assessing a patient with called rick Wina, you basically want to assess their sensation, um their motor function and the reflexes and you'll find that because it's a lower motor neuron issue, they'll have reduced reflexes or absolute reflexes alongside weakness, low tone. That's when you're thinking this could be called rick whiner. The gold standard investigation is any patient that you think might have called required. It needs an urgent MRI scan. So if you're in the G P surgery, you need to immediately admit them to hospital and they need to get an MRI within 24 hours. Um And the management is mainly surgical. So they needed urgent decompression, the spine. This will then just relieve that pressure and then whatever is causing get you can respect. So for example, if there's a malignancy that might respect that at the time, um or they might do that at a later date or with other measures, such radio or chemotherapy, the only time you wouldn't have surgical intervention is if you're looking at someone who's perhaps nearing end of life, or you think the risks of surgery to, to great in that situation, you'd treat them with radio or chemotherapy and that will help sort of relieve the symptoms. So Cordray quinoa is spinal cord compression are quite similar, but they're also different. And I think this is something that often comes up in exams. Um and it took me ages to sort of understand the difference until I saw just a simple table like this. So a quarter equina is a lower motor neuron issue. Whereas a spinal cord compression is an upper motor neuron issue. And if you remember that you'll be able to work out where abouts this lesion is so called require presents with lower back pain, autonomic involvement because as we saw earlier, it has parasympathetic innovation to the bowel and bladder. So they'd have constipation or incontinence. So they might be constipated or they're swelling themselves and urinary retention is that late sign. Um They also have century since we are motor disturbance in a lower motor neuron pattern. So they'll have reduced sensation, reduced power, reduced reflexes and reduced tone. Whereas the spinal cord compressions and upper motor neuron issue, it can present upper back pain. So like thoracic back pain or again, lower back pain. But the difference here is that your reflexes and your tone will be different. So they'll have increased tone, hyper reflex. Yeah, I sort of have increased reflexes and they'll have a babinski sign or an extensive plan to response. So basically when you stroke the bottom of their foot, naturally, people flex their toes. In this situation, they'd extend their toes. And that's an upper motor neuron sign. You can also get something called clonus where essentially, if you bring, for example, in the lower limb, you can dorsiflex and avert the foot very quickly and you'll get like a tapping, um and it'll tap over five times and that's called clonus. Um So to summarize quarter recliners, lower motor neuron, spinal cord compressions, upper motor neuron, and they present quite similarly. So they both present with back pain, autonomic involvement and sensory motor disturbance. But the difference is the reflexes and the tone essentially. So as long as you know, the difference between upper and lower motor neuron, you can rule it out. However, both of these are emergencies. So if it's whether it's a spinal cord compression or a compression of the accord, a recliner, they need to go immediately for an urgent MRI and they'll probably need surgical reception. Um So that's sort of the end of my presentation just take the time. So if everyone's happy, we can have a quick quiz. But has anyone got any questions? First of all, before we do the quiz? Okay. Uh If there's any questions at the moment, Emily, uh fine. So I think it's just four or five questions, just a quick quiz. Um and it would just give you a practice of what kind of questions you might expect. So, do you question one, a 25 year old man is admitted to a and E after fracturing his tibia, a football match fractures reduced and immobilized in circumferential cast a day, a day later, he's got severe pain despite taking maximum pain relief on the wards. So the question is, what is the most likely diagnosis if you just want to pop your answers in the chat and, and then we can read out sort of what the most common answer is and then look at that answer on the next slide. So I'll give sort of 20 seconds or so. Well, sorry guys, I think um, the chats been enabled for everyone to type into now. Uh So you'll be able to put in your answer. Yeah, I mean, that's working now and they've got a couple of people saying a yeah. So fabulous. Yes, the answer is compartment syndrome. So, as you can see here, um, they've got pain, pain, pain, pain, essentially. Uh My arrows have gone sq But yeah, if we, if we look at the stem, um, he's been in a circumferential cast which is going to build up pressure and he's got severe pain despite taking maximal pain relief. So this very much seems like disproportionate to what's happened because his fracture has been reduced. It's been immobilized. You'd expect the pain to start getting better, but it's getting worse. Um So yeah, we would activate our management in him and he'd probably need, you know, ultimately need the fasciotomy. So, question to 75 year old woman is a bit of hospital with an extremely painful red, swollen knee. She has a past medical history of rheumatoid arthritis and takes methotrexate. You suspect this could be septic arthritis. Which of the following is correct. So, do we act fast, start antibiotics immediately? Uh Do we administer steroid injections due to her history of rheumatoid arthritis? Do we wait for the blood results before commencing antibiotics? Do we take blood cultures and then start our antibiotics or do we advise her to book an urgent appointment with the G P discharge her? Because we're a busy department, we'll give you sort of 20 seconds and then we can uh go to the next slide. Okay. Okay. Have you got any answers to answers of the so far? Yeah, brilliant. So as we said, you need to take your blood cultures before starting your antibiotics because essentially if you start your antibiotics first, it can give sort of like a false results. So if it already starts treating the infection and then you take the cultures, it might sort of underplay the severity of the infection also what it's responsive to. So, yeah, always take your blood cultures first, do your bloods via at it and then immediately afterwards, start your antibiotics um in keeping with your local trust guidelines. So typically you'll use a broad spectrum antibiotic. Wait for the culture to come back and then once you know, it's sensitivity, you'd narrow it down to sort of a more effective um antibiotic and that will also sort of try and reduce your antibiotic resistance. And as we can see here, you'd also aspirated before you had to biotics for the same reason. Um Typically in rheumatoid arthritis, you can give steroid injections which help. So make sure if a patient comes in with rheumatoid arthritis, they usually have sort of bilateral joint, swelling and pain if it's unilateral or if they're presented with a fever or any other signs that make you suspicious, don't give the steroid injection until you've aspirated and assessed per septic arthritis best because I know I heard a case when I was on placement and G P surgery and they actually just thought, oh, this lady's come in with a flare up of rheumatoid arthritis gave the steroid injection, it turns actually have septic arthritis. Um and it made things significantly worse. So, you know, make sure as your in your future practice always just be suspicious and be safe. Uh So question three, which one of the following would you not expect to see in Cordoba equina syndrome? So, lower limb weakness, lower back pain, positive Babinski sign, perianal anesthesia, or reduced lower limb reflexes. Have we got any answers before we go to the next slide? No answers for this question. Okay. So I'll go to the next slide and then do explanation. So you would not expect to see a positive Babinski sign. So this is also known as an extensive plantar response or reflex. So make sure in your knowledge, exams, you're making sure you're reading the question properly because it would be quite easy to not see the knot here. Um And that often is quite a common exam mistake that people make um so called required. A syndrome is a lower motor neuron um issue. So we see all of the other features, so weakness, lower back pain because they've got a compression perianal anesthesia, which is very specific to called equina syndrome and reduced reflexes. So, reduced reflexes is a lower motor neuron sign. A babinski sign is a positive and upper motor neuron signs. So we wouldn't see that in Korea equina. And instead we see that in spinal cord compression. And then, like I said, essentially, what, what this sign is is that you'll run sort of a stick or something up the sole of someone's foot and you will expect them to flex their toes. Um If they extend it, that's an abnormal signs suggestive of a, of an upper motor neuron region. So this could be a spinal cord compression acutely. It could be something like multiple sclerosis. And you can also find it in hepatic and capital opathy. Um If your patient's, if you can't assess a liver flap, you can do that, in fact, not very orthopedics, but learning long nonetheless. Um So our next question is, which of the following is the most concerning feature of cord require syndrome. Um So is it perianal anesthesia? Is it constipation, severe back pain, urinary retention or lower limb weakness or paralysis? Look? Right. Uh So we've got three answers. Yeah. Perfect. Yeah. So I'm not really sure of the pathophysiology behind it. If anyone knows you can put in the chat, but essentially this is a really late sign. So this is a very worrying sign. If they get to this point, it's suggestive that the damage that's been done is likely to be irreversible. Whereas if you catch it early, you can normally reverse the symptoms that they have. Um this just comes up quite commonly on past med and it can come up in your knowledge papers as well, which is why I wanted to include it. So, yeah, urinary retention is your most concerning feature because you're worried that at this point is so reversible. And so that is the end of my presentation. Thank you everyone so much for um coming along and listening today. Um If you've got any questions, um please feel free to pop it in the chat. We do have we're running a weekly series now. So if you tune, if you enjoyed this and you want to take some future talks, then another one of our reps will be doing a talk next week, please make sure you check the Instagram page for updates and yeah, have a good evening and hopefully see