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Uh Oh, good morning or wherever you are. Uh Thanks for giving me this opportunity um to present um uh this meeting. Um So just let me see if I can share the my secret. All right, can you all see my supreme uh es three kind general principle of fractures. Lovely doctor. Thank you. All right. So today we're going to talk about um general principles of fracture. So you see like what is the fracture, how to describe fractures? Um When you see it in x rays um and just general management of fractures. Um So basically what is a fracture? Um So a fracture is, is a break in the bone. So there's loss of the continuity of the bone. Um And there are uh some causes for the causes for the fracture. Um Not only is the trauma is the common cause for the fracture. A trauma can be different like as it could be a mechanical stress or loading or could be a mix of them. Um So it could be like loading or mechanical citrus, like when someone, for example, um playing football um and they have like um sudden loading on the leg and with the twisting injury as well. So that's can cause loading and stress at the same time and they can break the bone. Um other than the trauma, um there are sometimes the trauma can be minor to cause the fractures. Um And when there is a problem in the bone itself, such as like osteoporosis, where the bond mass is low and any low or like just mechanical assume stress uh can cause a fracture, not a major trauma. Um and some other diseases like Paget disease as well. And there is a formality in the bone itself. They are prone to fractures quite easily. Um And there are born tumor's as well. Um And the metastases for the in the bone. Um and some si like primary cancer can metastasis to the bones such like thyroid cancer, lung cancer, prostate original cancer. Thus, can it assesses to the bone and the bone becomes weaker and any um abnormal load or just simple trauma can lead to fracture. Um How do we classified fracture? Like we have, I know they're like an anatomy. Uh There are uh types of bones and like in the upper limb, for example, they're humerus and there are radius on joints, elbow risk, shoulder, and then there are certain classification for each of these fracture. But we are, we are talking about um like the fractures classification in general. Like how do you describe a fracture? Especially when you see it on the X rays. Um So basically, we can classify it according to the anatomy. Um So the location which is the affected bone like, for example, um is a TV, a bone for example, or is it like for example, a fema or humorous? Um And also if which side like is a proximal tibia, for example, or is it in the distal time? Um and also in the position. So we can, for example, divide especially the long bones um into um epiphanies is metaphase is and the offices. So you can see where the fracture is. Is it in the office? Is is it extending into the joint or not? Um Is the fracture in the meta faces or the fracture in the dye Afis is. So for example, we say like there is a fracture in a tibia and which side is, for example, the right side. So we say like there is a fracture in the right tibia in the dye Afis is and then you can describe it in the, well, the extent of the fracture, whether it is complete or incomplete. So complete, it means like the fracture is broken, the extended from one cortex to the another. Um and incomplete, which means there's a fracture or crack only in one cortex. Um And also there's we can classify the according to the orientation. Um So that's sometimes of the fracture that can cause like a transverse of fracture or in this oblique or spiral or sometimes it can have mixed up them. Um Let me see if I can show you um what I mean by transverse oblique spiral. Um I think I've got some pictures I need to go down in my presentation. Sorry. Mhm. There we go. Yeah, that's what I mean by transfers fracture. As you can see from the Dr Graeme Oblique where it is oblique spiral. Yeah. And the other types is commuted um where the fracture is into many pieces and avulsion of fracture, usually where um some soft tissue attached to the bone like tendon or the joint capsules or ligaments. And sometimes the the tendon, for example, can pull piece of the bone attached to and can cause a fracture which is called avulsion fracture. Okay. Um So transverse or oblique spiral commuted orimulsion. So let's go back to um to how to subscribe the fractures. Um So we talked about the anatomy or extend and orientation and then you have to check the displacement. So when you look at an X ray and you identify a fracture, you need to see if there is any displacement or not, especially like trauma and orthopedics um is a surgical specialty. So we immediately think whether we need to do a surgical intervention or not. So this can be based on the day displacement of the fracture. So types of displacement you can have is a rotation where there is a rotation. So when you break a bone And so they can divide the bone into two pieces, the proximal approximately the fracture and distal to the fracture. And one of the pieces can rotate against the other because of the actions of course of the muscles around the bone. Um So you can end up with a rotation deformity or rotational displacement. And you can see it on the uh when you come to the clinical examination, clinically, you can see it as deformity of the leg, like the, the leg may be rotated to the inside or to the outside, for example, or in the, the arm rotated to the inside or outside. Um And the other displacement type of displacement is angulations. Um So the angulations could be um anterior, posterior angulations or two, the size like medial or lateral angulations. Um As you can see it on the X ray if you want to describe it and then you can measure the angle, especially like certain fractures. Um We can measure the angle and whether we need to accept it as in like treating it conservatively or if the angle more than the accepted position, then we have to do like some sort of surgical intervention or even manipulation. So, angulations is another type of displacement. Um And then there is a translation um and that's where there is the, there is no angulations along the axis of the bone. Um But the, the bone moves translated to the side or to the front or back. But the overall access is in one line. Um So that's called translation. You can have a complete translation or incomplete translation. And sometimes you can even measure it like you say 50% translation or less than, for example, less than 50% or there is a complete 100% translation. Um And then there is another displacement is which is a language original displacement, which means like sometimes you can have shortening, especially like for example, if you have a complete translation, like 100% translation and then you know, especially the long bones where the much act on the bone itself. And when you break it, you can have like the muscle Axion and can cause shortening. So you pull one fragment into the other and you can see a deformity which in terms of shortening or sometimes you can have elongation Z or destruction. So instead of shortening, you can have an engage in again on because of the Axion of the muscles on the broken bone. So this is the type of displacement, rotation, angulations, translation or destruction in shortening or lengthening. Um And then as we said, like in the diagram, you can see there is uh in terms of fragmentation, whether there is only one line fracture, you can see or you can see multiple fragments, which me it means is a commuted fracture. Basically doesn't the medical term we call it in in orthopedics or trauma, we call it a commuted fracture. And that is the way you can see more than uh two pieces of fractures. Um And it's basically does is the commuted fracture. So you can have a segmental fracture. What I mean um is like example, if you take a fema um and you break it in more than two lines, for example, if you can have a break, for example, in the metaphase is and another break in the dioceses and that's called segmental fracture. And then you need to identify whether there is a soft tissue involvement or not. Um So, in other terms, it is a closed fracture or open fracture, close the fracture, that's when you have a fracture with the soft tissue intact and the skin is intact. Um um And there's no community communication between the fracture side and the outside world or open fracture. That's when there is a communication between the outside with the fracture. Open fracture can happen from out outside, in or inside out what it means by uh by that is like when you break upon. Um And especially when you have a displacement, some sort of displacement, like for example, there is angulations and there is like a spike of bone go through the soft tissue through the skin and it punctured the skin to the outside and that's from inside out or from outside. And that's when, for example, if it's a major trauma, especially in road traffic accidents or uh like I have a heavy metal cut like um you can have a cut through the skin and then it goes through the soft tissues and to the bone and break the bone. Um And that's from outside. Um And both of them is open a fracture, um treated the same as an open fracture treatment. Um um We're not gonna talk about this at the moment. Um But they both open the factors. Um And then there are in Children before the fusion of the physical plate. Um They have the pediatric fractures and usually the classified according. Um some common classifications is Salter Harris classifications for growth plate fractures. Um And that's an absolutely immature person, which is basically a pediatric fractures, right? Um What do you expect to see like if someone came in with the trauma and uh you um uh concerned about fracture. Um clinically, of course, you see the patient come in pain. Um Usually they come like aided like they may be using crutches or cannot wait, bear. Um Maybe they come with a wheelchair or a stretcher trolley by ambulance crew because they are unable to weight, bear or move the limp uh the affected limb. Um So they come with pain. Sometimes you see redness um from the trauma uh swelling if because of the soft tissue injury around the fracture side. Uh and you can see maybe a deformity according like to if there is a deformity at the fracture side as we describe it earlier. If there is angulations, you will see a not possible deformity um of the limp affected. And as we said, if there is an open fracture, sometimes, um uh you can see a bone fragment um coming outside or penetrating the skin. Um if it is a closed injury, and if you feel the the fracture side, you may see like a gap or like a probable step off. Um that's from the fracture site or you feel a bone crepitus, especially if there is a combination at the fracture site, you feel like cricketers. Um And that's only if, I mean, usually we try not to press hard over the fracture side when we examine the patient. Unless, unless we are like 50 50 we don't know whether there is a fracture or not and we have to examine the patient for tenderness and then maybe you can uh feel uh crepitus on them, but usually it's very painful. Um Well, as I said, like, if there is um like if you see a noticeable deformity, um swelling and um usually you might suspect fracture, um even without uh touching it um and other concomitant, soft tissue injuries um as well like uh uh and also uh neuro vascular compromise. So you may see, for example, if there is a fracture um with the vascular injury, for example, you may see the limp distantly, it's like it becomes bell. Um So thus can give you a clue like what type of fracture, this and whether there is a vascular injury associated would be fracture, um clinically how to assess the patient. Um So assess for signs of fracture, as we said, um look, feel um we try not to move if you suspect a fracture because any movement can cause pain. Um But as I said, like if like some, if you suspect fracture but not 100% sure, maybe you can ask the patient to move the limp or the joints above and joint below to assess it. Uh Most important in any injuries, any limb injuries or fractures. Um You assess for the neurovascular uh compromise um and any associated complications of uh fracture or any major trauma, um like any like crush injuries, um basically can lead to a compartment syndrome. So you assess a neurovascular uh distal to the fracture by feeling the pulse is distally and examine the neurology, sensation not and sensation and motor. So you have to check for sensation and you have to check for the motor uh as well um as well as checking the pulses, um checking the uh the capillary refill, feel the limp, whether it's a warm, like just really, for example, if it's a fracture in the tibia or fema, you feel, for example, you look for the toes, see if the toes are pink, warm capillary refill, uh less than two seconds is fine or if not, like if there is no pulses. Um And the limp is spell capillary refill more than three seconds, uh up to five seconds and then you are become concerned about past color injury. Um And usually the the you can have in mind and with the compartment syndrome as well can have in mind, the six piece which is pain, especially pain on passive movement, as we said, like any fractures can goes pain. Um So any if you ask the patient to move the affected limb, it will be painful. Um But how to assess for compartment syndrome is usually is pain on passive movement rather than active movement. Um So it become more suspicious if passively is more painful than actively. So, are suspicious of compartment syndrome. Um And as we said that there is a vascular injury or there will be a pala or pulse nous, reduced and pulseless nous because of the absence of the peripheral pulses. Um patient may become uh parasthesia which is basically abnormal sensation or reduced sensation in the affected limb distal to the fracture. Um And, and then uh that's all basically, that's the signs of the compartment syndrome, which is like basically is a lead sign if we need to diagnose a compartment syndrome. Uh when you assess fractures, um we we need to um where we, we need to diagnose the compartment syndrome as early as possible because it is an um emergency condition. Um We don't need to um delay the management of compartment central um and delaying it that can lead to um parasthesia and eventually paralysis and that's where the muscles already died. Um But we need to um detect compartment syndrome where before that. Um So that's why they put pain is the most important. And usually in orthopedic even we neglect. The other piece is pain, usually five piece or some people, they say six piece is pain, pain, pain, pain, pain. Yeah. Um So that's how you get most compartment syndrome. So basically assess neurovascular um with any associated limb injuries, um whether it's a minor injuries or major injuries, uss the neurovascular um and you document as well, like you document what uh what's your examination is. Uh um And also you check the neuro vascular um if you do some sort of intervention. So for example, on the management of the fractures, if you try to manipulate the limp or if you uh immobilize the limp in some sort of immobilization, whether it's a plaster cast or brace, uh anything you do or if you do manipulation to correct the deformity. Um and then you need to check the neurovascular uh status again and document as well. Um That's important as well, right? So once you identify um you examined, you assess the patient, um obviously, we didn't go like, you know, you take a history first and, and then the examination and assess the patient and then you need to confirm whether there is a fracture or not. Um So you asked for imaging. So the most common imaging we do is is basic X rays. Um So you ask for the X ray and usually you do um two views, two joints, especially in long bones, especially if the deficits of long bones. Um And in two times two occasions. Um So what we mean by that when you ask for an X ray, we need to at least two views. Um So most commonly is the A P views and the lateral views. And sometimes you can ask for special, special views, like sometimes, like for example, if uh show the injuries, you can ask for a why of you or sometimes you can ask for oblique view for other type of injuries. Um and the pelvis, um you ask for other special views for the pelvis. Um but uh always ask for at least two views. Um And uh I've got some, some X rays uh on my presentation. So we can have a look and see the difference. Why is two views is important um uh for the fractures. Um Also we image the two joints, joint above and joint below, especially in the long ones. Um because you may miss some other associated injuries um or, and it can guide us or help us when we decide for surgical option. Uh two times that means 22 occasions. Uh what it means by the like, for example, um you asked for an X ray you identify there is a fracture. You need, you need to place the affected the the broken limp in um in a plaster cast or you place it in um Siplin or you decided to do some sort of manipulation. Apologies, professor. I think your internet connection is quite low again. Oh, I'm sorry. Yes, the screen keeps him turning off and on. Oh, okay. So uh um is he okay now or? Yeah, and I was quite tough. Thank you very much. So I just want some elevated. Right. Um Sorry. Did you get the X rays? And yeah, lovely. Now we can see the, we can see the PDF correctly. Thank you very much. Uh sorry about that. Um Right. And then when you look at the X rays and basically you identify there is a fracture. Um And as we said, you describe with the fracture um as we talked earlier um as in like an atomic location alignment and whether it's a fracture, completing, complete or like if there is any sort of um displacement, um whether the joint is involved means is there is intra-articular uh fracture or not. Um And then um if you are still concerned, like if you couldn't see the fracture on the X ray and if you're still concerned about the fracture, you can ask for a CT or MRI um sometimes we do cities can for surgical planning as well as well. As the X ray, right? Um Unfortunately done to the screen turned black again. Uh Sorry. Uh Shall I stop sharing and sharing it again? I think right now we can see it. Oh, it's just try. Yes, because we can't see it anymore. So maybe if you can stop share in the share again, if that's going to be possible. It is. It's quite blank for us. Oh, sorry. Well done. No problem. Right To me. If I, oh, that's quite lovely. Doctor Mesic. If anyone cannot see in the chat, please, um update us. Thank you. All right, sorry about that. Um Right. Um So generally after assessment and um of the fracture and then you pay attention to wound care, especially if it's on an open fracture. Um And obviously, as we said, like a broken bone is usually painful. So you start getting patient's uh analgesia. Uh and then you pay attention to the fracture itself. Um So the basic of treatment is whether do we need an atomic reduction, especially if there is a joint involvement. Um Do we need to fix the fracture um surgically and we should do some sort of um immobilization and then the rehabilitation period comes after that. So, um basically that's um the orthopedic line of management um reduce hold and rehabilitate. Um that's for the fractures um treatment, as we said, like whether it's a conservative or um surgical, uh um it depends on the type of fracture on the displacement on the medical condition of the patient. Um conservative fracture, um usually if the fracture is stable, um we manage conservatively. Um But again, we may do some sort of uh reduction or manipulation. Um Not surgical manipulation is just um in access, an emergency manipulation. Um And we immobilize with the cast or splint and then rehabilitate patient after um pediatric fractures, usually most uh most of it, they end up with the conservative management uh surgical uh management. Um if there is open from structures or if the fracture is unstable, like for example, if we, if there is, for example, uh all alignment or discipline ointment at the fracture site, um we manipulated um where we still cannot control the displacement. Um We need to take the patient to theater um to a surgical stabilization. Um And as we said, if there is a severe displacement, especially a rotational deformity, um irritation deformity can be missed like even if you place the arm in a play faster or a cast or, but still there might be a rotational deformity. Um And sometimes the rotational deformity um is difficult to correct on conservative uh uh management. So we have to do surgical uh intervention. Um And as I said, uh inadequate manual and then we have to do a surgical intervention. Um Surgery involves anatomical reduction of the fracture and holding it in some sort of fixation and immobilization. Um uh the fixation um could be external fixation, for example. Um That's like when you see like someone with the pins um and um bars like outside, that's called external fixator um or internal fixation. That's when we opened the fracture site. Um we reduce the fracture and we hold it with the plate or screws or wires. Um And that's called open reduction, internal fixation, right? Um That's basically the management. Um So I have uh diagrams and x rays. Um We've seen this one. that's to show you like what type of fractures, transverse or oblique spiral. Um And then we have like to see some X rays so to familiarize yourself with it. So as you can see in so professor, I think you just cut off. All right. OK. Sorry. Yeah. Um Can you hear me now? Yes, we can hear in our lovely, okay, sorry about that. Um Right. As you can see like uh an uh x ray picture uh a um uh the fracture is if you want to describe it, um I'm sure this is a thing is a femur. Um It's in the distilled, the offices. Um And you can see the fracture is a transverse fracture and if you want to, you can say displacement, you can see there is a complete is a complete fracture, is a complete it uh displacement. Um uh And there is angulations as well. Yeah, and you see there is an overlap between the two fragments of the bond. Um And that means there is a shortening as well. Um And picture be you see the type of fracture is uh uh and uh applique fracture as in opposite to the transfers. This is a public. Um And in see uh it looks as an oblique maybe a spiral because there is a spike at the back. Um And you can see the type of the this is in picture, see you can see there is a translation but it's in complete translation. So you can see the uh the distal part moved immediately and there is no 100% contact between the 22 edges of the at the broken side. Um So it could be like um maybe about 30% uh like the edge is touching each other. So we'll say like maybe and doctor sorry, but this week the screen just keeps on turning black and white, just it turns off black and then comes back to the lecture. I don't know what seems to be the problem. Apologies, everyone we're just facing and some technical issues if you can just bear with us for a couple minutes. No apologies, everyone. Um The doctor's just gonna join right now. There's some technical issues, just bear with us for a couple more minutes. Thank you very much for your patience for the meantime, while the professors joining, does any, can you just fill out the survey that I've put in the chat? Thank you. Very much, which basically is, which basically is the shaft. Um And it is a spiral fracture and you see there are a couple of um multiple pieces and other line as well. So it is commuted is completely translated and also it is angulated. Yeah. Um And possibly there is some shortening because there is an overlap as well. Um And moving to picture e um again, you can see the uh multiple fragments, multiple lines of fracture. Um So this is a commuted and as well as the picture in F is a commuted fracture. And if you move to G you can see there is a fracture at more than one side um which is basically, it's called a segmental fracture. So this is a segmental fracture hedge again, is a transverse fracture. Uh Right musab if you move to the next uh please. Yeah. Right. So if you look at the first, uh if you try to solve the shot, um if you move, if you look at the first two X rays, um you can see like um on the one on the left, it's I think it's an ap view. Um you can see the uh fracture in the radius and the ulna as well and this is transverse a fracture. Um You can see overall alignment is not bad actually. Um That's why we need another view, which is basically, it's like as you said, a pa and lateral. But if you look at the lateral, you see how bad the fracture is. Um So that's why his two views is important uh to detect the deformity and the displacement of the fracture. Um And also you can see from the x rays, uh the swelling and the soft tissue and you can see the arm is so swollen. Um And also you can see the deformity. Um So, so from the X ray, you can actually uh say a lot about the fracture itself. And you remember when I talked about the open fracture from in out. So you see if you look at the lateral X ray and you can see that spike, the distal part of the radio, you can see there is a spike very close to the skin. Um and that can penetrate the skin and lead to an open fracture. So this is a type of fracture if I'm not sure if it is open fracture or not. But um if it is an open fracture, that would be in out fracture because of this spike of the bone penetrate uh the skin. Um and on the other X ray, that's the, we can see this is a plate and screws fixation. Um So basically, it's a surgical intervention. Patient was taken to theater, they put the plate, they reduce the fracture and they hold it immobilize it and with the plate and sea cruise. Um and then the rehabilitation period comes after that. Um Right. Um Musaab. Can we move to the, on that side of that? Thank you. Um Right. This is um an X ray just to show you like uh the. So not sure if you can, obviously you can see it. Um There is a lucent area in the bone. Um And that's basically represent um a bony metastases, that's how it looks on the X rays and that can cause uh or can weaken the bone and any simple trauma can lead to a fracture. Um The, the um picture be which is basically a ct scan of the same patient. And you can see the thinning of the cortices because of the erosions because of the uh tumor. Um And the patient had a surgery basically is um what they've done is just a replacement. So they removed the bone uh with the tumor and they put a metal one. Um Can we move to the another slide, please? Yeah, thank you. Um Again, this is to show you um uh the importance of uh asking for two views on the X ray. So if you look at the one in the left, um there is some, some degree of angulations maybe. Um but sometimes we can accept some degree of angulations, especially in Children because they can heal quite quickly and also the remodeling. Um they can remodel um uh quite good. So with some uh sort out, we accept um some degree of angulations, especially in Children, but as we said, like if you look at the A P and the one on the right side, which is lateral, you see how bad the fracture is. Um So you see the degree of angulations. Um So this is why it is important to look for more than one of you. Um If you move to the other slide, please. Thank you. Um That's basically just to show you like uh it's um an oblique fracture. Uh You can see it on both ap and lateral. Um And the one below you can see patient is I think is treated non operatively. And you can see there is um like a whitish circle around the fracture site which is basically that's a callus formation. It means the bone is started to heal. Um Can we move to the next slide, please? Um All right. So if you look at the this X ray, you see the it is a fema. Um And you can see the uh the shape of the female itself is abnormal and, and the, the look of it is abnormal. They can, you cannot identify which one is the cortex, which is the middle a and there is lots of like um white and lucent area. Um So that's basically is um is a patient with the Paget's disease. This is how you see it on the X ray. And you can see there is a fracture um because the bone is, is uh very weak and any sort of trauma, even minor trauma can lead to a fracture. Um Next slide, yeah, that's another uh fracture in the tibia and the fibula. Um And you can see the overall alignment is along the axis is fine in the A P but, and the laterally, you can see there is some sort of angulations. Uh So again, that's why you look for a pa and lateral views. Um because if you look at the A P only say like, oh maybe overall alignment is fine. However, there is a displacement, you can see there is a translation and also there is shortening as you can see because there is overlap in the bone as well um as well as the ambulation. So this patient needs um surgical intervention. And I think it's the license license slide again, just to show you like it's just basically is um uh an oblique fracture at the diet offices or the shaft of the tibia. Um I hope now you can at least like identify the fractures on the x rays. Um um And you describe it um and how to manage the fractures. Um Just um this, this is like a short talk is just general principles just to give you an idea about the fractures. Um I hope you enjoy it and I hope you get benefit of it. Uh Thank you for very much for the, for listening. Um Back to your mess up. Thank you. Very much doctor for your amazing lecture. And if it is any questions for the doctor, we've got a couple minutes. Okay. Wants to ask, ask, you know, I think everyone quite understood the lecture. Such an amazing lecture. Thank you very much doctor. Yeah. Sorry. One person, yes, please. Sorry. How do you know if pages disease from the X ray? I'm sorry, say it again. How do I recognize like pages disease from the from an X ray? Yeah, if you look at this slide, can we, can we go back please most up to the? Uh Yeah. Um Okay. Can you see it? No, no, not this one. The Yeah, that one, this one. Yeah, you can see uh first of all the abnormal shape of the bone itself. Um you can see this is uh like not the shape, the usual shape of the fema. Uh No, not this one. Sorry. What's up? Uh the one below one. Yeah, that one. Yeah. Yeah. So first of all, it's abnormal shape of the bone itself. Um If you look at the normal fema, uh this is not a normal fema and also usually in, in a normal bones, you can identify the, the cortices um with the middle of a inside um and in the proximal and distal like in the proximal femur especially like you see the tropically arrangements. Um I mean, sorry, I can't like show you like because I can't draw like um what the tropically. But if you search for the tropically, you see like the tropically arrangements in the bond. Um But here like there is no like there is no marking like um the, yeah, I can't see like the cortex, I can't see which is the cortex which is the medulla. Um And you can see like there is white area and there is a black area and yeah, that's the classic picture of budgets uh on the a few seat on x rays. Thank you. All right, thank you. Um There's one part one, someone said in the chair, professor that we need a quiz for this lecture. Think everyone loved the lecture, right? Ok. Maybe we can arrange something later. Like what type of the quiz like x rays and uh like something like that or x rays. Yes. Yeah. Okay. Yeah. Yeah. Maybe in the future we can arrange something about it. Yeah. Yeah, that's lovely. And there's also one more question says do fact fractures cause swelling. Yes. Yeah. It's when, when you, when you break a bone you uh they bleed inside. And also if the trauma is like a major trauma, you can have a soft tissue injury as well around the fracture, um maybe muscular injuries and soft tissue injuries. Um So all like they can bleed and they you have swelling uh around the fracture site. Yes, lovely. Well, I think there's no more questions here doctor. Um sorry, there's one more last one. Where do I, so I said, where do I find uh Ashy Amati in the compartment syndrome? Sorry. Um Say it again. Where do um where, where do I, where do I do the fascia to me in the compartment syndrome? Where, where do you do? Okay. So it's, it's basically is um uh is a clinical decision. So if you think clinically the patient has a compartment syndrome, um you um you do a fissure to me. Um So as we said, like you follow this five piece, but as I said, some people they rely only in pain and the clinical suspicion. Um So for example, if the patient um I had a trauma especially in the limb um where there is a compartment like in the forum or the lower leg. Um So, um so there is a highly suspicion of uh compartment syndrome. Um And if there is lots of swelling and if you put the plaster cast and that's plastic cost again, can um constrict the swelling um with the clinically if there is an increasing pain. Um So it's a clinical decision. Um you can still measure the compartment pressure. Um But usually it's a clinical decision whether you need to take the patient for fasciotomy as well, say, like if it's uh like highly suspicious of compartment, um you take the patient to theater for fasciotomy rather than you leave it um till, till late, like and then the consequences will be uh, disasters. Is that okay or uh, um, I don't see no more comments here, so I think, I think everyone's asked what they wanted. Thank you very much, Doctor for this amazing lecture and I thank everyone for attending and um, hopefully see you next week on Tuesday. Please do check the schedules for the next lectures and thank you very much, Doctor. Okay. Thank you very much. Thanks for everyone here. Thank you. Goodbye. Bye bye.