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A fab. Um So my name is Caitlyn. I'm the Bump Syrup for Scotland. Thank you for coming along to our teaching series on some extra interpretation. Um Great if you've stuck with us throughout in our last couple of sessions. Um So this is session three. Um And Tina has kindly come along to teach um about hip and knee X ray interpretation and she's an S T seven um in the west of Scotland. So kind of covering Glasgow area and yeah, and she's kind of given up her time today to come and run this session. Um Yeah, so I'll hand over to Tina and we'll get going. Thanks Caitlin. Hello, everyone. Thanks for joining us this evening. It's an absolutely glorious evening in Glasgow. So, um special thanks for giving up your evening to come along. I hope it's useful and I'll try and make it as interactive and interesting as possible. And Laura limbs, obviously huge topic. I've tried to pick some important topics over and try and pick the most relevant ones for you guys, I guess. And the people to our next like Caitlin got the overview of tonight's session. I think the focus of these um uh webinars is to focus on extra interpretations. So hopefully put lots of x rays and images we can discuss and, and got some questions for you guys as well to keep it interactive and keep you from falling asleep. Hopefully, um hip fractures are sorry, Caitlin, I'm supposed to say. So if you can all scan the ventilator code, um the QR code or put the code into the website means that you can join in the interaction, interactive questions and things. And I'm also happy for it to be quite informal and interactive. So just if you have any questions as we go along, if you can, you can use your mic or the chat box and ask them as we go along. Um So yeah, the overview, hip fractures are kind of the bread and butter of trauma surgery. So I thought it would be a good place to start. Um Pick some interesting cases for fractures around the knee and then limping child in itself, we could probably talk about the whole day. There's so many different things to talk about in differentials and each topic is quite um there's a lot of knowledge for each one as well. So I've picked a couple of cases again, I think three cases we'll go through those. We can't obviously cover everything, lots of details. So hopefully a good overview of each of these kind of pathologies. Yeah. So if you start with the hip, I thought would cover some basic anatomy. Um just because it's pretty important for how we determine what classification we use and that determines our treatment for hip fractures as well. So I'm sure you're all quite familiar with the bony anatomy of the proximal female. Um After on these lines on to indicate basically what the cutoffs for how we classify hip fractures depending on where they are. And again, I'm sure you all know it's mainly inter capsule and extracapsular that we use. But these can be subdivided into the following as well. And the hip capsule inserts from the thermal neck just somewhere between the yellow and green lines there you can see. So, um that's important when you go on to talk about treatment options and blood supply, which we'll talk about in a second and subcapital and transcervical ones are your intracapsular ones. And then basicervical intertrochanteric and subtrochanteric are your extracapsular fractures. And the subtrochanteric, the cut off for being subtrochanteric rather than say a daft seal or femoral shaft fractures within five centimeters of the lesser trochanter. Yeah. And pelvic radiographs, I want to focus on the hip mainly. So I'll quickly and go through pelvic radiographs, but there's quite a lot to cover. So essentially, you want to look that the film is adequate. So you want both iliac crests in view, you want probably about the proximal third of, of Femara in view, you're looking for asymmetry, that's probably good place to start and it doesn't matter what you do, everyone's got their own system, but it's not your systematic that you don't miss anything. So, normally just kind of work from top to bottom looking for any asymmetry and obvious fractures, cortical disruptions, any break in anatomical lines which will cover anyway. Second, um, any obvious pathological lesion's. And I think if there's a separate talk that Davis gets, he's done a lesions already and it's recorded on medal. If you want to have a look later, some of your maybe they're um and then another tip I'd say is to look for more than one abnormality. So it's quite easy to look at something, find an abnormality and then stop looking. And with pelvic radiographs, there, there can be multiple pelvic fractures that can be other lesion's and, and a pathologic fracture. So, in this example, here, you can see that on the patient's left hip, there's a cortical breach basically in the super pyramis, a high super pubic ramus fracture or almost like a acetabular fracture. Um And that's easy spot. And I don't think there are any other abnormalities in this plain film, but you can get super pubic ramus fractures with post your cycle involvement or widening of the sacroiliac joints. So things like that just always look for everything else. Make sure you're being systematic pubic diastase is for the last thing to look for, which is basically the pubic synthesis widening. Um But that's a relatively uncommon type of fracture. Um, yeah. So if you focus on the hip, it's much the same. You're looking for a cemetery, you're being systematic. Um, did you want to change is not labor too much? I'm sure you all know the sort of common findings for osteoarthritis and joints and joint space, narrowing, osteophyte formation. Uh subchondral sclerosis and subchondral cis really are the main ones and also correlation I put there because it's not abnormal for me to look at an X ray. When someone rivers me a patient, I'll go speak to the patient, take a history and examine the patient and then I'll maybe I'll go back to the X ray if I find something else. So, you know, clinically, they actually tender posterially. I'll take a really good look at the sacroiliac joints. And so yeah, just make sure you're thinking of the patient as a whole, not just your X rays. Yeah, the next slide we'll talk with some anatomical lines. Um We'll go through each of these in a minute. But if you guys want to maybe drop a pin onto which you think gentles line is, it's quite an important line. We'll talk about hip fractures and pathologies. I'll give you a second and yeah, there's the, you think if you need it okay? I can see a couple of people have talked been three. Give you a bit more time on this one, I guess because you might be joining on that to me too. And yeah. So are they the answers? Caitlin? Yeah. And yeah. So you're right. The majority of you put it on the orange line, that centonze line, it goes along the inferior border of the thermal neck. Um And then for your border of the superior previous ramos and breaks on that line can indicate an inter capsule neck femur fracture if it's along the neck or obviously extracapsular, if it's further down and distill and super pubic ramus fractures, it's just a useful guide. Um It's not, you know, if, if there's an intact sentence line doesn't mean that there's no hip fracture. And if there's a broken gentles line doesn't necessarily mean it's definitely, you know, hip fractures pathology, you can get another pathology as well, things like uh dysplasia of the hip or just any abnormal bone um anatomy really. But I'm getting to look at for put the other lines in their respective colors there. So you're looking at anti your post, your ass tabular walls and acetabular roof is fairly self explanatory. You've got your Ileo issue line, which the blue line and that's looking at your poster acetabular column, your Elio picked any a line, it's red one and that's looking at your and your a several column. The yellow teardrop is basically um a bony ridge that represents the true floor of the acetabulum. And I think we've covered more MRI and then this is just quickly go over hip laterals. I think you have to look at a lot of um lateral radiograph to get your head around it and get, get experience interpreting which ones are abnormal. Um But if I can try and quickly, you know, you can't see my mouse. But basically the one on the left hand side is a normal hip lateral radiograph. And, and what you're seeing super early is anterior and post your and and in fear really is post ears that you're looking at the patient side on. And if you look at the femoral neck and if you were to draw two lines, thanks Caitlin. If you were to draw two lines along the femoral neck and then the middle of that draw lines straight up the femoral neck, it should intersect the center of the femoral head. So basically people talk about an ice cream scoop sitting on a cone. The femoral head should be in in the middle of the thermal neck. Whereas on the right hand side, if you can imagine those same lines, if you draw a line straight up thermal neck, it would end up anterior to the middle of thermal head. If I'm, if I make sense, you know, it's like the the next tilted this way. So that's an inter capsule fracture. And and yeah, so it's a displacement capital fracture. Yeah, I think these are tricky and you have to look at quite a few of these before you get used to them and your next likely statement. So I'm sure you've all seen this picture as prime example of trying to get two views and one that you can be really misleading and you can have a fairly, you know, benign looking a P pelvis and you look at both. It's and you say there's no fracture, but actually you need to get a good lateral and make sure that and you're not seeing a falsely reassuring view. Again, relate the clinical anatomy and classify the hip fracture because that totally changes our management and, and, and influence the surgical options. Um It's not uncommon for us to have a patient with a sore hip. You know, clinically, they've got reduced range of movement and pain and passive movement. They can't straight leg raise, but the X rays aren't really convincing. Um And in that case, we probably would recommend further imaging and MRI is probably the most sensitive, but they can be hard to get depending where you work. It can, there can be a delay and these patient's don't ideally don't want to delay them too long because if they do have a hip fracture, then you want to try and get them surgeries. And if possible. So quite often, in reality, we get CT scans and I thought I'd ask this question to the group and then we'll kind of work our way backwards into why it might be. So these are four different types of hip fractures. Um And if you want to try and think about why it might be that one of these is the highest risk of avascular necrosis with the femoral head. Yeah. And just when you've got enough votes, when Caitlyn, you can move onto the answer. So, a variety of cancer there, which is good and, and this is why I wanted to ask it first is see what your thoughts were and we can work our way backwards. So, and let's do the blood supply of the femoral head. And I would say um A is probably the most appropriate answer. I'm sure you could argue uh for the reason for other ones as well, but essentially is a displaced intracapsular fracture be is an international fracture as well. But I would say is less this place and that still has a risk of avian as well. So you're quite right and, and the C and D are extracapsular fractures and their risk of avascular necrosis is relatively low compared to two A and B. And we'll talk about why after this next question, which basically talks about the blood supply to the femoral head, five different options. And then um I've got a diagram explaining why, why a was the right answer basically. And to clarify, this is um arterial blood supply to thermal head in adults because it is slightly different in Children which will cover later as well. Nice. Yeah. So, and the next diagram, you can see that the medial and lateral circumflex arteries come off the profunda and they run right along the formal neck and purely and so purely. So you can imagine if there's a displaced intersectional fracture and then those vessels are gonna become kinked or torn. And, and basically, you're, you're, you've damaged the main blood supply to thermal head. You do get a little bit from the ligament ligamentum Terry's artery, which is a branch of the actuator artery. But, and, and adults that's not the main blood supply and that's pretty minimal blood supply from that really. Actually. So, and, and that's what influenced their decision in terms of uh surgical management, which we'll talk about later again. Yeah. So principles of hip fracture management, I just wanted to quickly talk about the epidemiology and hip fracture patients that we get um 76,000 hip fractures in the UK per year, which is the most recent that I could find. Um an average age is around 80. So I think I read is about 83 84. Um 25% of these patient's are admitted from nursing homes or care homes. And ultimately 10 to 20% who are admitted from home have to return these institutional cares and as well, 10% it's, it's not a benign injury. It can be a terminal injury for a lot of people and 10 people, 10% people die within a month and, and once they die within 12 months, I think that's a reflection of how frail and co morbid these patient's are. And, and as you can see, it's very common. So, and there's lots of different aspects of managing these patient's safely and well to try and reduce. And these thats really just want to see what you guys thought about different. I think we've got word cloud coming up next. If you just want to type in basically different aspects of managing patient hip fractures and the different considerations, basically. Um if you think about all these co morbid and frail patient's, I don't know if there's a lag, but I'm not seeing any words pop up. I don't know if Caitlin can provide some clues. She can type some in from the next slide. This is really good. Yeah, fluke balance, polypharmacy, pain, open versus closed is that fractures. You have the clinical assessment of fractures, infection, antibiotics. Really important. We get a lot of patients who come in already with concurrent infections, chest infections, urine infections and mental capacity. This was really good reason for the fall. Super important. Yep, patient choice, loving this guy. So this is kind of basically what I wanted to get at. You know, there's so many different aspects of their care and you guys are totally nailing it bone protection. Yeah. So there's immediate and sort of ongoing postoperative or basically post admission care. But yeah, these patient's need analgesia. They get lots of opiates because they're so sore, but that can push them into delirium, you know, constipation and then that can worsen the delirium, lots of other complications. So, and quite often, most places now I think in the UK are using regional blocks, we use fascia iliac a blocks in, in any. Um, and they're really effective. I've seen patient's, you know, when you, when you've given it, they literally sign relief in front of you within a couple of minutes. That can be really quick and effective and it reduces the opiate. Um Basically, the mind over puts the need and you know, improves their experience in general. Once they leave a knee, they get, you know, pushed along the trolley and a bump recorder up to the ward and a lift, they have to get pat side under the bed, it's really painful. So, allergies is really important. Um, fluid balance. Uh you don't want to pump them full of fluids and push them to failure, but you don't want to leave them fasting for theater and totally dry, acute kidney injuries. And all of these patient's already have a form of chronic kidney disease. Um, electrolyte disturbances really common for our patient's and again, anything that can delay surgery. So, and you know, if they come in their mission blood show a low potassium, we need to try and replace that safely. And so they're fit for surgery. Then I say I'm an anesthetic. The next day more and more. We're seeing those patient's on anti coagulation. And when I started a foundation, your, most of the patient's were on Warfarin. But now we're seeing more and more of the wax. So your pick span and adopt span, etcetera. And they've got special considerations in terms of can't really reverse them. You have to wait and that depends on the creatinine clearance, etcetera. So basically diabetic control, treating infection, correcting anemia is all to try and improve the patient's chance of success after surgery, but also delay and minimize the delayed surgery. Um People said the reason for fall, that's really important. So you always ask whether it was a mechanical fall or if there's any proceeding symptoms. So, chest pain, shortness of breath, dizziness and that's commonly not just a simple trip, unfortunately. So you're, you're totally right. You have to find out why they've fallen, find any other injuries and be really thorough. Um Because again, once you've got hip, you know, an X ray showing a hip fracture is, is easy to not think about anything else, but quite often they have other injuries, you know, risk factors, shoulder fractures, dislocations, head injuries, especially if they're an anti coagulation, they might need CT head scan, etcetera. So that's really important. And an Ortho geriatric input has massively improved care for the patient. So we have specialist geriatric teams to look after repeated patient's and and all that needs to continue POSTOP as well, because they're relevant and then there's things like reducing DVTs PS, you want to get the mobilizing early. And when we talk about surgical treatment options, we'll talk about why we do certain things and early input from physios O T s and dieticians and false assessments and making sure they don't get pressure sores. Unfortunately, it's not. And I would say it's not uncommon but you know that they do happen and so really meticulous pressure cure for people who aren't very mobile and bone protection. And I think certainly where I work and I really get this, the uh bone density protection team, like basically come up to the word every morning and take a list of patients have been admitted and they get put the system where they get Dexa scans once you're discharged from etcetera. Okay. So the one labor, the point, basically there's loads of different things you have to think about with these patient and it's really important given they're so vulnerable and to look after them. Well, there's lots of guidance and all those things. If any of you are interested, please feel free to go to those links. They'll be on online on medal. And in terms of surgical management, this is the nice guidelines. Um some of the points are quite useful, some of them are less useful and they're quite vague. I think basically whatever operation we choose for the patient's, we want them to be able to fully wait very mobilized as soon as possible. Um This place intracapsular fractures because of the reasons we talked about where the blood supply could be disturbed and the recommendation is to offer replacement arthroplasty. So a total hip replacement or hemiarthroplasty, I think a total hip replacement, their guidance on who that would be appropriate for is slightly vague. It says about people who can walk independently or with a stick and do not have a condition or comparability that makes a procedure unsuitable. So it doesn't list any particular comorbidities or conditions. It kind of leaves up to the clinician. Um Essentially, it's about taking a really thorough functional history, past medical history and trying to decide which these patient's might benefit from a total hip replacement rather than a hemi arthroplasty. And as we caveat, it says, offer replacement arthroplasty for displaced inter capital hip fractures. But actually, if you have a very young patient, and there's again, there's not guidance in terms of uh an exact age cut off. But, you know, I would hope that if I fell and broke my hip in a cycling accident, NRT or something, and it was an international fracture, even if it's displaced. And we would think about basically doing open reduction. We'll try close reduction for us. So you can get an atomic production, otherwise, open reduction. And for younger patient's, we're still trying to fix it and preserve the natural formal head and younger patient's who without Corbett et cetera. Um But they do still have a risk of avian just lower than the elderly patients that we get. So, and it's not always that for displaced under capsule fractures, uh We'd always replace it when we talk about extra capsule fractures. And you've probably heard of these, I'm sure you have. So sliding hip screw dynamic hip screws and we use typically for intertrochanteric fractures and, and intramedullary nails for soccer talking terror fractures or particularly unstable looking intertrochanteric fractures. I think maybe I've got some cases next Caitlin doing. Oh yeah. So that's a quick summary. I made quite a few years ago and I actually have the nice and signed guidelines basically summarizes what we talked about combining the two guidelines because the nice guidelines at the time didn't really talk about and the younger patient's and displaced fractures. But that, that's basically what I explained uh prettier table if you wanna look at it later. Yes, our first case. Um It was a 78 year old gentleman who's had a mechanical fall. So no proceeding symptoms, it's an isolated injury. Um And he's complaining of left hip pain past medical history wise, high BP and prostate cancer. And you can see those radiotherapy clips there in his prostate actually. Um uh um The question is MCQ afterwards, I think if you guys can look at the x rays and see what surgical management you think will be most appropriate for this, the only other thing for people who have fractures with a history of malignancy is that yes, you want to make sure that you, when you're taking history, have they had any pain prior to their fall? So, you know, could this be a pathological fracture? They had a lytic lesion there perhaps. Um, and, and it could be useful to get full of humor, refused just to make sure they've not got any lytic lesions in there shaft or they're just a female party surgery. Yeah. So, um DHS seems to be the most popular answer. And uh is that yes, I don't know if you can see the correct answer there that comes up. But yeah, th s basically, and it's an intertrochanteric fracture. I know that actually it's quite small there. But, and yeah, basically it's an inter talking to a fracture without real extension past the sub doctor region. So this will be um yeah, would be a candidate for A D H S. I'll just take you quickly through DHS. I know that most of you don't need to know at this level anyway, specifically how to do TH S S but it's good to have an idea of how we do these. Um So the patient's positions on attraction table there, unaffected leg is putting that 90 degrees sort of away from and to let this extra machine in that big C is A C arm is an extra machine and the operating legs in the traction boot. Essentially, we use this guide and 135 degrees the sort of average angle, the thermal neck compared to the shaft of most people. So that's the, that's the normal DHS that we normally we use. But you can get different angles for different varying anatomy. Essentially use that guy to get the guide wire under X ray into the middle of femoral heck head on the A P and the lateral and then s obviously very simplified, but we put screw in and play in and usually four hold DHS. Well, that's what we use in Glasgow. Think Edinburgh sometimes use three whole DHS is, but essentially you're fixing the fracture, not too concerned about avian and femoral head because it's extracapsular. And so we fix it and hope that it heals and the majority of time it does and they can start weight bearing, um immediately POSTOP. So if they feel up to it, they can do it later that evening, next day. And that's the benefit of surgical management. Yeah, these are just some interruptive films. Um I don't know why I chose in this example years ago when I use his X rays because it's not very well reduced intertrochanteric fracture. But that's, that's basically what the DHS looks like in, in fluoroscopy and theater. I've just included a picture of a shortage Medullary nail at the bottom of the right, right side there on the screen because quite a lot of places in Europe mainly I think use these and serve THS is and I think in America as well, but it's quite controversial. But I just thought in case, you know, you think we always use DHS for these is not, some people would argue that you can use a short camera. Okay. So case too. And it's an 82 year old gentleman fall in the medical ward and left like that to be short and it's irritated has history of dementia can't give a clear history, but it's crying out in pain and currently on the medical ward with your oh sepsis. Um And if you look at the A P and I hope it's clear that basically we've got displaced international neck from a fracture. And if you look at the lateral is what we discussed that femoral head is saying not in the middle of the neck and you, and you can see that it's shortened and that's why I typically with um with hip fractures, they, they're described as having the leg shortened the next shortage. And that's just the way that your your hip ligaments, right? That's where your leg goes. Um And hemiarthroplasty, these so these are typically performed on the lateral side. There are one or two surgeons I think in the region that too, it's a pain, but most of us will do on the lateral position. It's an anterolateral approach to the hip. Now just and it included a couple of different types of hemiarthroplasty cysts and the one in the mid one, the middle. So the left X ray is Thompson's Hemiarthroplasty, which is quite, quite old fashioned. Some places still use them, but I think mostly not now. And on the right side is an extra trauma stand, which is the standard that we use in Glasgow. So case 3, 78 year old, six month history of left thigh pain and is complaining of night pain, which I guess is a concerning symptom but no other red flags and she's getting a car and stumble to no real major fall or anything like that with sudden pain and left side and I'm unable to wait their history of a skipping heart disease, asthma and osteoporosis. Um and osteo process. If I got this history and looking at this fracture, I'd be thinking and I would say there's an atypical fracture. So it's subtrochanteric fracture within five centimeters to the less truck. Um But this has a typical appearance of an atypical fracture which will go over in a second. Anyone, I don't know if you can use your Yeah. So, uh I was gonna say if someone was taking my cough and shut up, it's probably quite difficult and it's basically osteo process, you'd be thinking are the um bisphosphonate treatment and that can be a common and drug that can cause his appearance in this fracture. And when this happens, it always goes into that position where the that fracture, approximal fracture fragment is abducted and slightly stop. You can see in the lateral. Um And the next question is basically why does that happen? You look at the greater trochanter and what attaches onto the greater trochanter trochanter? Which anatomical structure? Yeah. Nice. Yep. So it's your hip abductors that basically pull that fragment into abduction is your hip adductors A D doctors that pull the distal fragment in and then, and your hip flexor is your earliest. So it's attached to a lesser trochanter as well. So that's why the proximal fragment flexes up and it can be quite difficult to reduce. Um So quite often these need open reduction. Um nice. Most of you got abductors. So that's just the diagram explaining exactly why this happens. And it's, it's really typical appearance. And, but we are to that cortical be, can you see that little thickened bit of cortisone that's typical of atypical fractures and from this phosphinates. And it's Paradoxic, isn't it? Because bisphosphonates are people who have fractures. But basically, when you're on long term, because they inhibit osteoclasts function, they also inhibit one remodeling. And therefore, you can get sort of micro damage accumulating, you can get stress fractures of the femur. All right. Yeah. So, and this is the sort of immediate management in any for subtrochanteric or um femoral shaft fractures. This is called the Thomas splint. And it was initially described by Welsh physician. I think you used it to treat people with polio and TB and things. But essentially his nephew started using in British army and in the first World War and it saved, I think pre Thomas Splint, the lower limb fracture mortality in the battlefield was up to 80%. And, and then after this, it was about 16%. And it's obviously not all down to the Thomas Splint, but, you know, immobilizing a fracture and reduces blood loss as well as providing analgesia. So in the Femoral Shaft factory can lose about one liter to 1.5 liters of blood. And so it isn't uh isn't a benign injury. Um It's basically some sticky tape that goes on the side of the leg, bandage it up, get attached this. Um You can't see my mouth, sorry, you've got those sort of old style leather buckets at the top there, slightly more modern now. But basically they go into the groin and provide counter traction. And which is why I can't leave this on for too long because they can develop and pressure sores on their groin. It's not very pleasant. So you have to keep, keep an eye on them and then you put some weights at the bottom and to give the traction. So it's temporary mobilization until they get defensive surgery, which I think should be on the next slide. Um Typically we use intermodal a nailing and again, I've used a horrible example where the fracture isn't actually reduced. And I don't think this is one of mine. And so this, this is a problem because they're difficult to reduce. Sometimes they're not properly reduced. And you do have to open these up. And quite a lot of people actually advocate now that we should take the pathological bone away. So it's basically cut that bit of bone out, get compression across the fracture site and, and some people will, will use plates as well on the side uh to get extra compression. But the important thing is a sample reduction, get in and fixation with an interim Medullary device. And um sorry, I'm just gonna explain in case some, some of you aren't familiar with iron nails. Um It's similar to DHS and that we use X ray and a guide to put the guidewire up into the formal head and put it screws in and put, and we have a long guidewire down the femur as well and put the uh nail down the femur. And then um you need something still locking screws as well just to make sure that the stuff fragment is rotating where the nails are rotating in the bone. So they're still locking is important. Yeah, great. So, um I'm sorry, half past, I'll try and fly through some, some cases from the knee again. We'll talk about some basic anatomy first. Um I'm sure you're all familiar with the basic bony anatomy, which is on the next slide. Um You've got your media and your lateral collateral ligaments and your anterior cruciate and um post your cruciate ligaments. Um tibial tuberosity where your patella tendon attaches. Um We're just where that bracket shinbone is. Um The next slide you've obviously also got your, I mean, this guy um there, the medial natural mask are different for reasons which will cover in a second again as well. But if you guys want to choose, might be a really easy question. I don't know. But if you drop a pin onto the medial meniscus and we'll talk about why they're different, it's 50 50 isn't it? So it's a fairly even split. And yeah, so the next slide I think has maybe another diagram. Um Yeah. So your medial meniscus is actually you're more c shaped, larger meniscus. Um And your lateral one is more circular in shape and they're important because they help, basically transmit the force to your knee and they make your knee joint more congruent. Um And they also have a shock absorbers and they do have a function for stability as well, especially in ACL deficiently. They can become sort of primary stabilizers. And I think there's another slide next. Um If you look at the, yeah. So if you look at the bony anatomy again, so you've got large medial femoral condyle and this concave medial tibial plateau. And that's because more relative, you know, 60% of your body weight goes to the medial side of the knee or just medial to the middle of the knee. Um So that's, that's why I also your medial meniscus is larger to accommodate for this as well. Um lateral side, slightly less of 40% of your body weight and it does tend to have less dense bone. And that's why lateral tibial plateau fractures are more common. And if you look at the lateral extra views, that's, that's kind of just showing your medial and your lateral table plateaus, your lateral is convex and red and your medial is concave in orange. Yeah, next slide, please keep going. Which takes us unter fourth case, the 48 year old male is fit and well uh crossing the road petition hit by a car relatively low speed, but it's obviously still a significant force um on the lateral aspect of his left knee. So it's a significant valgus force and isolated injury. It's closed and it's got no neurovascular deficits. And hopefully, you can see on the ap that he's got a fracture of his tibial plateau. And and then the next question is, can you try and identify on the lateral where the fracture might be? You see any abnormalities? Yeah. So, so you put on the A P as well, which is, which is good. That is where that you can see that fracture line and splitting the lateral to be a plateau. And I've probably not made this actually big enough to, yeah, you could probably put it anywhere around the lateral and I probably accept your answer. But yeah, just where that boxes and, and I think I've included this extra in the next slide as well to explain. Yeah, remember we talked about the lateral too. So you can see on the ap that's a lateral tibial plateau fracture. And we said that the lateral tibial plateau is convex. Whereas if you look at the lateral film and they look pretty both concave to me and certainly there's a depressed fragment there. You can see it clear on the, on the CT slide below it. But essentially that convicts tibial plateau has been pushed down. So there's a depressed fragment. So you can see there's a split and a depression and that's part of the most common type of tibial plateau and use a Schatzker classification which you don't need to know in detail. But essentially the split depression, it's the most common type affecting the lateral tibial plateau. And this particular gentleman had it fixed with plate and screws and we'll talk a little bit more about to be plateaus in different ways, we can fix them. Um So yeah, typically it's a various or valgus force. So, Valgus typically struck, struck on the outside of their uh the knee commonwealth petition versus car and you can have a uh various producing four. So typically, you know, sports tackles into the inside of the knee and, but you you know, it can be a combination of these or axial loading or rotational as well. So, and, and most of the time actually, when you asked patient, what exactly happened, it's all a bit of a blur. So you can't and get exact mechanism. But, and it's important to try and understand the different injuries that might have occurred if you can get an accurate mechanism. Um Yeah, the next slide please. Caitlin and there is not uncommon to have lots of associated injuries, either soft tissue, other bone injuries around uh the knee meniscal injury is really common and I can't remember the exact figure, maybe up to 40% of certain types of tibial plateau fractures. Essentially, obviously, if you have a lateral tibial plateau fracture or more like to the lateral meniscus injury and vice versa and like mentis injury. So, medial lateral collateral, we talked about the various and valgus forces involved that can easily and enjoy your collateral ligaments. Um, an ACL injury particularly is quite common and they can occur also in combination with essentially any dislocation. So that extra at the bottom, there's there's a really bad example of the tibial plateau fracture, but essentially that's a dislocated knee. And that's pretty concerning if you think about the neuro vascular structures around the knee, you want to make sure that you're assessing the patient is looking at the soft tissues. Is there a significant crush injury? Is there any open fracture? And is there lots of swelling or the specific patient at risk of compartment syndrome and you want to feel for pulses and popularly refill. Distantly. Um need desiccation has a really high risk of vascular injury. Um And you need for further surgery, I've put their because quite often these patient's will develop the counter changes in North arthritis and they might need a new placement in the future. And just on that top, buy extra, I just wanted to show you as well. Sorry, Caitlin is. And so I don't know if you can see the fraction of the tibial plateau you can see, yeah, just just in the posterior cortex there. And sometimes it can be more subtle than that and you might not be able to see anything. But um I hope you can see that there's basically a fluid level and there's a big infusion. So if you look just over the patella, there's a stark, there's a fluid level just slightly do it. Yeah. So and that's basically a lipo hemarthrosis iss that's because you've got the tibial plateau fracture and bone marrow is escape from, from my intraosseous bone marrow, fat cells essentially and blood. So you get the dense blood that falls and the fat that rises and you get that fluid level. And that's, and if I see that, then I'm, you know, pretty happy there's a fracture somewhere and you need to find it. And if you can't see on plain films, you might need to get a CT scan schools of treatment. You want to try and restore the anatomy to, to what it was as best you can. It's not always possible, but you want to make um as conger and articular surface as possible. You want to restore joint stability. So that might involve treating leg mentis injuries as well. And you want to allow early injured movement. So they get, they don't get really stiff Stephanie's and you want to allow early weight bearing if possible. And sometimes if someone's got really a really nasty fracture, they've, you know, it's been a struggle to reduce and put back together and they've got really poor quality bone, then you might have to protect their weight bearing. But ideally we would get them weight bearing early because we know that actually loading bone helps healing and you want to try and get them back to as the same as any orthopedic injury. Really. You want to get these patient's back to their pre injury function and limit the, yeah, the effects of injury and their risk of arthritis afterwards. I think I got something that surgical aims next. Yeah. So same as kind, what we talked about. You want, you want to elevate any joint surface that's depressed and that might leave a defect essentially because you know that that bone's been punched down, you've lifted it back up. But there's, there's just basically for a year in the middle. So quite often you to use bone grafts and that can be from the patient. So toilet is bone grafts or, or you can use synthetic bone grafts, which is what you can see. I think in that middle X ray, you might have to do soft tissue repair. So miss school repairs or ligamentous ACL reconstructions, etcetera, you probably wouldn't do them at the same time. So someone had an ACL rupture and a tibial plateau fracture, then you probably fix the fracture come back for the see another day. Um Sometimes if the swelling's to, you know, if, if there's too much swelling, you can't really make an incision because you won't get that close again and you just have a place there and back at you, which would be a disaster. So, and you might need to put a temporary expects on which is the top right picture. That's a spanning external fixator with the knee, you can actually see there and they've had fasciotomy as well. So this patient's obviously had compartment syndrome and now external fixator applied and sometimes people do do prophylactic fasciotomy. So there are really high risk of, you know, things like the profusion injury. But in the trauma setting, we would probably reserve it for people who actually have compartment syndrome. And then the bottom right is um circular frames which you don't need to know lots about it, but just know that it's out there, it's an option and and that can be used as definitive fixation for tibial plateau fractures rather than the temporary X fix the top. Right. All righty. Um So case 5, 12 year old girl playing football and she had a twisting injury after being tackled and she's got really sore knee. Uh It was swollen immediately, she was unable to walk, she had to stop playing and it's an isolated injury. If you look at the A PN lateral, you can hopefully see that she's got a tibial spine fracture, no avulsion fracture. And, and I've got some options coming up next about what my, so basically, an avulsion fracture is a different structure is pulled that bit of bone off, right. So, and what structure might be responsible basically. Okay. It's pretty close any more votes, a deciding vote. Yeah, we'll go with A C L. Um So yeah, it is A C L and, and, and Children. It's because basically the bones weak at this stage. It typically happens at that age before things and sort of Aasif I completely. So the bone is weak and the ligamental structures are comparatively stronger. So they get avulsion fractures rather than ligamentous ruptures that adults would get. And another know, slide Caitlin. But yeah, um there's different ways to fix is um if it's minimally displaced or you can get it reduced close without surgery, you can actually split them an extension in a cast and let it heal up. But if you need surgical treatment. And there's lots of other different ways you can treat them. You can use future and sort of tight rope structures which top top right, you can put futures through the ACL and then drill a hole and, and bring the structure of the bone. Um You can use it your anchors where you put plastic anchors into the bone and against each other ACL down or you can use screw fixation and just depends on the size of fragment as well. Sometimes you have to get CT scans to see if the fragments um communicated or assess the size of the fragment um to see what surgical option would be best. Quite a lot of these patient's unfortunately, even with surgical treatment, going to have a cl laxity and it's not uncommon, I think it's up to 25% that actually need a CLB construction later in life anyway. But um yeah, just a quick example of ACL ruptures quite often, they have an infusion on X ray, but um not necessarily like, okay, I'm arthros iss and they can often have normal X rays essentially. So I just wanted to point out a couple of different extra features you can get um they're on the left called a psa gone fracture. It's essentially another avulsion fracture, the antral lateral ligament. And people say that's basically pathognomic for an ACL rupture associated with 75 to 100% is the figure I found and then the deep sock is saying, which I haven't really come across that much clinically, but it's um it's what people say. So it's basically a impaction fracture of the lateral femoral condo because you've got this anterior translation of the tibia because your A C L O S E C has gone um treatment. Um Not all people with ACL ruptures need surgery and you can especially sort of low demand patient's or people who aren't, you know, do lots of pivoting sports, etcetera. You can, they've got A C L and targeted physiotherapy, which is quite effective. So you can go down the conservative route and or Optivar reconstruction, especially for higher level athletes or younger, very, very active patient's. Um You can reconstruct the ACL uh the one, the technique that I've seen most often, everyone does it differently. Literally every knee surgeon even in the same department and have a lot of different techniques. But the technique that I've seen most often is using hamstring graft and you basically drill tunnels through the tibia and femur and recreate and where the A cell would be using either shit, drank or screws or, or Endobutton, things like that. There's lots of different ways to do it but, and you use a hamstring graft or you can get an autograph. So achilles tendon or, or some other um tendon allograft and use that as well. Great. So, um I think we're doing okay for time limping child again is a huge topic. So I've just picked three sort of main topic. So hopefully you're, I'm sure their topics you've covered in your own medical schools and Pete's already. So, hopefully just a refresher. Um, first one I've chosen as a 14 year old boy with 44 month history of progressive growing pain, limp, worse than last week following and stumble during peace. So, not like a fall or proper trauma wasn't tackled, etcetera, but we stumble and he's had more pain and he's overweight but otherwise no significant past medical history or family history. Um, that's relevant and I think there's a workload coming up if you can just share out some differentials or what you think is the most likely differential birth, Asia. That's good. Sophie any others D D H. So the three main main pathologies around the hip and in Children, um, so we can kind of go through each of those, I suppose. So I think it'll be less likely to be DTH just because patient's 14 years old, obviously development till dysplasia starts quite early on. So I think it'd be quite rare for, for someone to be picked up at 14. And although you can get it, you can get adult dysplasia as well or quite mild dysplasia. So it's not completely impossible, but I think it's probably less likely and Perthes again tends to be in a slightly younger age group, but it is more common in boys and sort of heavier Children as well sometimes. So it's not unreasonable and there's always exceptions. So, yeah, it's a differential for sure. Um, but this, this child has a slipped upper formal antithesis. Um, if you can click on the side of abnormality, I don't think I said in the first language side was over. Um, again, it's 50 50. But if you drop a pin to whichever side you think the pathology is affecting and then we can go through. Why? Well, going laughed. Yeah, that's fair, isn't it? Oh, one. Right. So, yeah, the, the next slide I've drawn basically Klein's line and it's a, it's quite an easy way to have a quick look. Um, and it can be quite useful for even the subtle ones as well. You draw a line around along the superior border of uh border of the femoral neck and the line should intersect. So it should go through the up if Asus and you can see on the left hand side, the red line, it probably just goes, but not as much as the other side. So that's abnormal. And that's cultural 1000 sign when it doesn't intersect, people can do it on the frog frog lateral as well. And yeah, they're the next side, there's, there's loads of different extra signs and I think there's another side coming up that we'll go through. But Sophie and it's relatively rare and you'll see it more often if you obviously work in the peat center because that's where they generally get referred to. Um, general age is around sort of 12 to 15. I don't know why. I don't think anyone knows why. But the left side is more commonly affected than the right. Um, but it can affect both hips and quite a high percentage of people. And we'll talk about the risk factors for that in a second as well. I don't know why they're seasonal variation. And apparently there is, I don't know if they're the nicer weather, some more sort of injuries, precipitating acute and chronic Sophie's. I don't know. Um Next flight, please. Caitlin. Yeah. So basically, again, we don't really know why some people get Sophie and some don't, but the risk factors are anything that puts basically increased force through devices, um or anything that makes devices we can abnormal. So these are some of the, you know, it's quite exhaustive list, but if you look at them and if it's abnormal anatomy and, and obesity is the main factor. So quite often these Children are a bit heavier um renal failure. So renal osteodystrophy and endocrine disorders. So it's important that when you get any child dystrophy that you do full biochemical screen um for all those things, basically. So, you know, bone profile TFTs, uh growth hormone lot. Yeah, for the PT team are quite useful and they help us with those as well. Um Next slide please. And it's commonly very vague symptoms um, sometimes they don't have that much pain, uh, and they complain of limping or just not feeling right, but discomfort and really often actually, um, they complain of knee pain. So, um, when I worked in Pete's Ortho, 66 months ago, we had a child had been seen by three different, um, orthopedic surgeons, including consultants, had their knee x rayed MRI and actually one of the registrar, um, and thought they would extra his hip because they thought you had some clinical signs and he had a really bad, slipped up for federal purposes and have been missed for a really long time. So it's really important when we say, examine the joint above and below and it does work and uh just take a really thorough history and examination. Um quite often they'll say, oh, there's a, a trip or minor trauma basically, but it's, it's kind of a red herring. It might be something that's going on for a bit longer and that's kind of precipitated or made it worse. And, and it's important to differentiate which of these patient's are stable and unstable. And that comes from this guy called loader who described it basically, and it's stable as any child who can weightbear. Um Actually, his initial paper doesn't say weight bear, that's a mistake. It's basically ambulate or mobilize with crutches or without, whereas unstable, they just can't there too sore, they can't move and it's important because unstable. Um Sophie's have a much worse prognosis and they have a higher risk of avian. Um patient's will quite often have their legs short, external rotated and then ask them to flex their hip hop, they will um external rotate. And that's just because of the way that the metaphysis has slipped um anteriorly and external rotators compared to the prosthesis. Um Your next slide, please Caitlin. These are all some of the other signs that people talk about for Sophie and you don't need to know all of these are quite specific bottom, right? It's called Southwick angle and I can still barely get my head around it. But um if we talk about quickly, but I've still blanche sign of steel. That's because the purpose is sort of slipped posterially and there's overlap. So you're getting that sort of um more sclerotic looking view of the femoral neck. Um S sign is kind of like, you know, the Santon's line, but it goes around the pegasys and you can see it's broken on the left side and keeping her sign is um is where basically the bottom of the femoral meta facist doesn't overlap with the acetabulum because it's, it's displaced. But yeah, just because it's extra interpretation. I thought it just include these things for those if you're interested and come back and look at it. But there's lots of different X ray findings for SUFI. Um Our aims are to try and stop the slip from worsening. Our aim isn't usually to get it back to where it should be. Um, so unless it's very specific situations and usually that's very acute. So, you know, there's been no problems whatsoever. They've been running around as normal healthy Children and then they've had a fall and 20 for history, you know, within 24 is very short history. If it's very acute and, and sometimes they will try and reduce it, but more often it's just pinning in situ try and get that Fyssas too close so that it doesn't slip any further. Um And to minimize complications of surgery. So avian and condolences when we were putting the screws and there's some X rays coming up later to show you how we treat these. But basically you put the screw into the neck, into the, into the EPA thesis. And if you were to basically go into the hip joint by accident, um you can cause control icis and the guest of your pain and uh basically the Janta changes eventually. Um Yeah, next slide, please. Yeah. So that's a picture of one screws we use um again, controversial regarding one or two screws and most, most places I think use one screw. Now, there is a risk that if you use two screws or if you have lots of girls that putting in screws and drilling, you can cause paper cited fractures. And I did see a case of that where basically, um they fractured where the screws come in. Um, which is why it's important to try and differentiate the patient's who are likely to have the other side slip. So, and again, it's a very controversial topic but because some people, uh, say that they're at risk of slipping on the other side, they would prophylactically sleep in the other side as well before it slips. And so we try and gauge who's the highest risk of doing that. And that's probably the overweight Children and you know, very overweight or they have endocrine disorders or if they're very young when it happens, that puts them in the higher risk category as well. So you might want to pin the other side prophylactically. Um But you know, we've talked about complications and it's not just purpose peri prosthetic fractures. So you don't want to do it unnecessarily if, if they are not high risk. So it's just trying to find those individuals who would benefit from surgery. Great. Um K seven. So we're almost getting their promises. Eight year old boy refer about G P mom and teachers have noticed the limp and not particularly complaining of pain. Um Obviously he's had a radiograph which is quite abnormal past medical history wise, breach and low birth weight. Um You can see that left side, the vices is all fragmented. It's not normal, it's really reduced in height. And I don't think I've put a question for this one just cause I thought we'd be running out of time, but essentially this, this is Perthes disease. Um Is there another cycle in? Yeah. And again, we don't know exactly why this happens. But as uh idiopathic avascular of courses of the Hep if Asus and there's lots of different theories as to why might be mostly to do with the blood supply. So, um whether while the chilled, you know, the change from pediatric two adult blood supply and causes a degree of ischemia or anything that increases the inter capsule pressure within the hip. It was in the femoral head. So things like translate synovitis, we're getting infusion um or if they've had infection essentially. So we don't know exactly why I'm sure some people have different causes, but these are proposed series. Um it does affect boys more commonly. Um And it's a slightly younger age group that we talked about than SUFI. Um bilateral is uncommon. Um Well, less common than in SUFI. Um And even if you have bilateral disease, um they're never in Perthes at the same stage. So we talked about four different stages of birthdays. And again, you don't have to know this in detail, but infarction, fragmentation, Riaz Vacation and remodeling. And basically, if you have two hips involved, they should never be the same stage. And if they are, then you're probably looking at something else. And yeah, they have like multiple epiphyseal dysplasia. So if you have two identical looking hips are really Perthes, then it's probably not Perthes. Um, yeah, next slide, please kill him. Uh, I think we talked about this. So there's not always a pain that can be quite often a painless limp. It could be weeks and months. So diagnosis can be delayed and usually, unfortunately quite stiff or they can be stiff. So, and we want to try and prevent that. Um, if they've, has been going on for a few weeks or months and we'll even less active, less able to do things and they can get muscle atrophy. And if it's quite severe and you've got quite severe collapse of the epiphysis and you can have a like like discrepancy as well. Um So we talked about those different stages, the in the initial infarction stage, the X rays can be normal. But if they're quite symptomatic, then it might be worth getting an MRI to see if there's any early changes. And that will tell you basically whether there's increased the Dhiman, the pegasys and whether the other hips affected as well. And this example, you can see that the X rays look normal on the other side, but gradually later on, he develops the pressures with other side as well in five months time. Yeah, next slide, please. Caitlin. Um This is a really busy slide, sorry, but I had this slide from earlier. So I it's a good summary. So I've included it but, and it's a really controversial topic in terms of parties management. We we still don't really know exactly what's best for each patient. So you have to kind of go with evidence that we have and lateral pillar classifications that you don't need to know A B and C and what the term is each but basically is mild, be as moderate c is quite severe in terms of collapse of the lateral aspect of the epithets iss and the ones who are mild universalism to do well. So they don't need surgery. You get the physiotherapy to try and do stiffness and sort of and supervising neglect. So not doing too much activity when it's in the fragmentation phase, etcetera, and the ones that are severe, they seem to do badly regardless of treatment. So we probably don't operate on those either. And it's the ones in the middle who are kind of lateral pillar, classic Asian be sort of moderate disease that we're not quite sure. And who would definitely benefit from surgery? It seems that some of them do and the surgical options. I've put some pictures on the next slide. There's lots of different things that's quite complex and you don't need to know about this, but just not be interesting to look, look at some X rays. And the one that very left is a theorizing thermal osteotomy. So essentially you want to try and contain the femoral head within that's tabula um to try and make it remodel and as normally as possible. So you're cutting the female essentially and making it more various to try and get it more contained within this tabula. Um And you're facing with a plate and that gets feel so well that will fill in and he'll in that position. And middle one I think is a salt or osteotomy. So the next to our pelvic osteotomy. So it's kind of mind blowing what these guys can do and they cut, cut the pelvis in various different places. You can do triple osteotomy knees or just one. And because when, when the Children are younger, the cartilaginous um joints are still quite mobile. So they can basically change the shape of the pelvis and cover the family head more and, and then as a salvage option on the very right you can use and things like curiosity ostomies and that's where you're not using the true acetabulum to cover the femoral head. But you basically move things along to provide almost like a pseudo acetabulum. So they've just moved that sort of bit of ileum to make, make the femoral head more contained. Um But yeah, there's an interesting x rays to look at. You don't need to know them in detail and I'm sorry, this X ray is such poor quality. Um This isn't a three year old, is the last case. Um Three year old I'm willing to wait. There is a month's notice that they're holding their leg up and not want to walk around as normal the last 24 hours. Um holding in that flex and abductor dexter rotated position and refusing to walk basically Perec ciel slightly tachycardic and borderline low BP for their age, I would say. Um Yeah, I think there's an MCQ is they're coming up. Oh, no, sorry. So I need to say first, basically that and on the left hand side against a horrible X ray. I'm sorry. But I hope you'll believe me when I say that there's an increased distance from the left and the taxes on the thermal neck or the, or the thermal head to the teardrop. And so that's a hip effusion and you'd be pretty concerned with this history and those numbers that this child has septic arthritis. Um And I think the next antique you is basically in this age group, three year old with a hip static arthritis. What do you think the most likely organism is uh just, you know, that actually was coming up, it came up, it was fine on the slides. I can why I don't know what happened. I'm sure I'm sure with my fault, I've got a clear version if you want me to show it. But no, it's fine. It's fine. You guys can giggle uh pediatric hippie fusion and you'll find that I'm sure. Um Yeah. So most of you saying staff for is um that's, that's correct. So, um generally is the most common organism in that age group. I've got a table in the next slide of thing that shows different organisms and different sort of patient groups and their age groups and the group B strep. I think some of you are saying is, is common in the pet population but tends to be more in the new needs. Um Yeah, that side will be there in middle if you want to look again, but it's on auto Blitz anyway. So kind of features. Uh it usually is acute onset. So if you have a child is limping and it's been a bit sore for 34 weeks, it's probably less like to be septic arthritis. You want to exclude it, but it's normally more acute than that visit. Bacterial have arthritis. You'd expect them to be more unwell if it was going on for three weeks, I think. And they usually do have systemic symptoms. So fever, general, you know, peru appetite, not eating off their food or vomiting rigors and limping obviously refused to bear weight. And obviously, no Neitz can't really tell you. So if you've got a, a baby that's really unsettled, irritable, um not feeding, etcetera, then you have to exclude septic are threat as well. If, if every time you move them or mom says I cuddle them, they keep crying out in pain, etcetera, then um and it's hard to say which hip is. So sometimes you have to investigate both. Um You're looking at for obvious signs of sepsis and, and you can feel warmth from the hip joint even, um and tenderness pain and they hold their hip in that typical position because it's basically the position that maximizes your capsular volume. You've got an infusion or possum that hip, then it's, it's the most comfortable position for them and you do have to rely adjacent involvement. So if you've got hip septic arthritis, always examine the knee exam in the spine and you can get multifocal septic arthritis. Um Yeah, I think I want to talk about Cockers criteria. So it's probably something to um to know uh it's kind of slightly updated now, but it is useful. I think there's a modified caucus criteria including CRP as well. But essentially, if you have all four of these features and there's a study that suggests you got 99 probability of having septic arthritis and even having three these pretty high and 93%. So, and it's a good tool to try and help you decide. But basically, if you've got clinical suspicion, then even with someone with Cockers, one, you've got to investigate them properly. Um Imaging, we've talked about the radiographs. Um You do want it for bony changes as well because they can get osteomyelitis so it can become current. Um Obviously, minuses bone changes take to, you know, they tend to take a while. So I've never seen any X ray changes of osteo mellitus with the septic arthritis. But guess look out for it, um ultrasounds can be useful, but they can't really tell between puss or an infusion typically. So I might tell you there's an infusion but that could be from something else like translate Santa Vitis um neonics again, like I said, you might need to up send both hips if you're not sure because they're just crying. And so every time you move them and MRI is probably more useful. And if you're concerned about osteomyelitis, and it can sometimes be quite difficult to differentiate whether someone's got a proximal femoral Osteomyelitis or a septic uh septic hip. Um But the next time we talk about treatment, septic arthritis is a surgical emergency. So the infective enzymes can be really destructive to cartilage really quickly and obviously, in kids, that's so important. So if there's any diet, e I don't think you'd be criticized for um if you have a suspicious septic arthritis washing out of that hip and if it turns out the Osteomyelitis and it's probably okay. Um If you have time, they're not seriously unwell and your clinical suspicion is lower, then you can try and get MRI um to see if it's osteomyelitis. Yes. So, surgical washout intravenous antibiotics and um that age group that we talked about in the different organisms and for different patient groups that can guide your empirical antibiotic treatment. Um And yeah, those are the complications. It's pretty detrimental. You know, it's pretty devastating to a child if you get any of those. Um, so that's why it's a surgical emergency. Yeah. So, I'm sorry that we've covered so much so quickly and I hope it's been useful. We've tried to cover some basic clinical anatomy and why that's relevant to the management of lower limb injuries. Tried to focus on extra interpretation of the various injuries we discussed and some differentials, differentials of the limping child with such a huge topic. So, I'm sorry, we haven't gone into some other things. I did want to cover D D H as well, but we're already over time. So um and yet just to say, actually interpretation takes time and practice and experience and you just keep getting better and better if you have any questions or things weren't clear. Um I think Caitlin, you can share my email address if anyone wants email me. Um If you have any general questions about Korea's orthopedics or working in Glasgow, etcetera, I'm happy for you to email as well. Um Yeah, I can just pop it in the chat there. Yeah. And do you guys have any questions? I was just any questions? I can't actually see any of your videos. So I'm sorry, I feel like I'm just talking to myself a bit but um I hope that was useful and you feel free to email me if you have any questions. Yeah, perfect. I'm interesting. Thank you. Um Some of that's about getting access to the slide. Um I will share those, um, at the end along with the recording of this session. Um, and yeah, if you can fill out the feedback form, you'll get a certificate after that. Um, and if you do think of any questions, me and Tina will stay on for the next five minutes or so. And, but yeah, if, if not then have a good night and thank you very much for coming. Um, we've got one more session left on Tuesday, um, which is covering foot and ankle. Um, so we'll keep that in your calendars. Mhm. No fashion if you think. No, I think we're all good. Okay. We'll, um, we'll call it there and, yeah, have a good evening everyone and, yeah, we'll hopefully see you Tuesday.