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With life. Ok. Hi, good afternoon from UK. Good morning. Good evening. Good night. Maybe from wherever you are. Welcome again to, uh, today's talk. Uh, for those who attended my last week's talk on upper limb fractures. Uh, there'll be a bit of a reputation, uh, of the generic discussion. But, uh, then we'll move on to the lower limb, common lower limb fractures. Again, those who've done emergency medicine, uh, or doing it or those who've done orthopedics, you, you, it will be, things will be seeming familiar, but whatever we'll discuss, I'll discuss, it will be from the emergency department perspective. Ok. So here we go. Uh, feel free to ask questions, uh, uh, again at the end and it will be interactive like I do, I ask questions and would welcome you to put your answers in the chat box. Ok. So what we'll do, we've got an hour, uh, we'll go through like we did before. These are for people who didn't attend the last, uh, talk, uh, and are new to this one and we will go through some classification of fractures just a bit of revision. For those who already know, then we'll talk about initial assessment. This is initial assessment uh from life and limb threatening point of view because a fracture of the lower limb can be a limb threat or a life threat. And if that's the case, your fracture management becomes secondary, your primary objective is to save the life of the patient. And the way you do it is by initial assessment, um which we'll come to you in a minute, then we'll go through very quickly give you a safe system of assessing an X ray of a limb on an x-ray. You know, a system. If you have a system that's fine. This is a sorry I use uh and I teach as well and then we'll spend major time over going through some lower limb fractures in order from hip down to the toes as much as we can do. Remember, it's a quite a lot of fractures and dislocations. We can't cover everything. Uh We'll go to the common ones. Um We'll have a bit of a presentation and management from the emergency department perspective and then we'll summarize it and leave you to ask questions, right? Ok. So um, fractures, what is it? A fracture is a broken bone as the layman or a patient will tell you they don't come and say I've got a fracture doctor. I've, I think I've got a broken bone. Yeah. Now it's a bone broken into two pieces. Yeah, due to a mechanism of injury. Now, sometimes the injury could be serious, sometimes it could be trivial. And if like for older pe people, older patients, a trivial trivial injury can cause fracture. Um like if they are frail uh or if the bone is pathological, like it's, it's got cancer in it, then it can break with minimal injury. But some fractures are subjected to huge mechanisms of injury. Ok. Now, when you have a fracture, um uh and as I said, a limb fracture, in this case, lower limb can be trivial. It can be a little avulsion of a little bone. Ok. But it also could be limb or life threating. So, can you uh just think of anyone suggesting uh lower limb? Remember with lower limb today, some limb or lifethreatening fractures. Can you think of any? It's not coming anyone? Hello, ABIs, some fractures that can be a limb or life threat to the patient. Jian says pelvic fracture. Ok. We are not uh doing pelvic fracture today, Jiana, it's just lower limb, it's hip and below anyone good to see you again. OK. Fat embolism is a complication. Femoral fracture. Gabriella says femur fracture aces. Absolutely. So an example is the reason is that uh that fracture of a shaft of femur can result in so much of hemorrhage that lose about 2 L of blood and that can have an impact on both the limb from uh and, and, and from the life. OK. So this is one example where you would do your initial assessment, uh ABCD and controlled hemorrhage, et cetera. Ok. Um In terms of limb threatening that long bone fracture of the shaft of femur that you mentioned that can cause. Ok, amputation as well. That's, that's a catastrophic injury, no question. Um Now that can cause uh the limb itself can be threatened by uh vascular injury, arterial or even neurological injury. Ok. So that's now, in terms of structures involved, as I said, last time, if you look at a limb, a limb is made up of what? From, from outside in, you've got the skin, you got the subcutaneous fat, you've got the muscles, you've got the bone and alongside it, you've got the nerves and the vessels. That's all you've got. So you got to remember when you're assessing, you've got to think of all those structures and you've got to make sure that those structures are intact clinically. Yeah. Ok. Sometimes you might have to take a course of investigation. So if you're thinking arterial injury, you might have to do an angiogram, et cetera. So those are the structures that can be involved. Ok. Um The next point is um the fractures can be isolated. Now, if it's an isolated fracture, which is a minor fracture, you can take action on it. Ok? But a and, and what happens is you, you, but if it's a part of a major trauma, ok? Or the fracture itself, as you said, in the femur fracture is limo limb threat. Then your primary survey comes first and then comes the secondary survey when you assess the limb for fracture. Ok. So in a primary survey where there is limb threat or life threat, OK. What is the emphasis? What emphasis do we put on in terms of primary survey? What is the key thing that we need to be worried about? Anything Janta mentioned amputation? Absolutely. In the war field in, in you know, uh circulation Gloria says uh which is hemorrhage. OK. So it's the hemorrhage that we need to emphasize on. We'll come to that in, in ABC. If there is amputation of a limb, there's catastrophic hemorrhage and that's a complete different to a arterial injury. OK. Can you think of some risk factors that can cause fractures um in the lower limb, for instance, uh the risk factors if you think of can be uh patient centered or generic? OK. Clot. So yeah, clott is another complication. That's correct. OK. So um osteoporosis gabriella says, if there, if you, if, if one has got osteoporosis, the bones can fracture very easily with minimal trauma. OK. Uh of and then, then you know, um patients on steroids, the bones can be affected. Uh the diabetic uh Now in, in terms of other risk factors are the injury. OK. So the the injury age itself. Yes. Yes. And osteoporosis is linked to it. Tas says in terms of injury, malignancy Absolutely. I ii, if the, if there is malignancy, uh either primary in the bone or, or um uh or, or metastasis, then they become weak as well. So it's pages disease as Bossy says. Now, uh, from the trauma point of view, uh how can a fracture happen? You can either have a indirect injury like a twisting, um, or turning or a direct impact? Ok. So, uh some risk factors or, or mechanism of injuries like high speed road traffic accidents, a fall from a height or even assault, direct trauma, sports injury. All these are risk factors. Ok. Uh causing causing injury. Yeah, Davies has metastasis. Absolutely. Right. Ok. Now, classification we did it last time. So these are for people who weren't there. So, um how would you classify because when you see a fracture and you could refer to an orthopedic specialist for definitive care, you need to describe it, isn't it? So, I've, I've put the first one, a closed fracture and an open fracture and, and, and what is it, uh, an openness where the fracture is exposed to outside through the skin breach. So there's a wound overlying the fracture and, and it, it has to be a breach of skin. So a bruise is, doesn't account or even an abrasion, it has to be a, a discontinued of the skin. And now in terms of the wound, depending on the wound nature, the size, the depth. Then there are classifications which I can't go through that in a minute. But the what's the reason of knowing is this fracture an open or a closed one? Why do we need to know? Forget the referral from management point of view. Why do we need to know? Why is it important? It is crucial infection? All he says, brilliant. So because an open fracture is prone to infection and hence, if you see an open fracture, you've got to exert the principles of open fracture management. I'll come back to that at the end of the slide. This slide, OK. The other other term to know is comminuted. OK. So comminuted fracture is normally if you break a bone, you have two pieces, two pieces comminuted is when there is more than two OK, multiple fragments because that has impact in terms of prognosis, recovery and treatment, especially by the orthopedic specialist. And can you think of other ways that you can describe fractures? You know, um one is open, closed, comminuted. Um and it it it what I mean is the way the fractures look on an X ray? OK. So you have uh I I'll just wait for a minute, see if anyone has any comment. Spiral fracture where it's a spiral. OK. The bone breaks in a spiral manner transverse OK. Across the bone displacement. Yes. So what kind of displacement, transverse displacement? Yes. The bone moves um against each other uh horizontally. Um You can be angulated. OK. Uh et cetera. And the last thing I want to say is Salt Hers classification. Now, Salta, her classification is the way to describe uh injuries or fractures or bone injuries in Children where the epiphyses has not fused. OK. So we are all adults. Our epiphyses, if you look at your X ray, they'll all be fused but in a child it won't. OK? And I'll give you an example. Uh I'll show you the classification here. Uh This is, this is a diagram and, and you can see there are four classifications. OK? Salta. Her is one to sorry. Five salt. Her is 1 to 5. Yeah. In Children, ba says uh Melvin says P absolutely. So if you look at there is epiphyses um in the lower part, then below the epiphyses, you've got the epiphyseal bone and then above that is your metaphyses. OK? And above the metaphyses, you've got diaphyses. So the salta her is one is where there is no fracture. All you have is the slipping of the epiphyses. So the epiphysis slips from the metaphysis. OK? As soon as you have a fracture, then you, you are into type 234. OK? And two is as you can see fracture through the um uh metaphyses. Um then three is fractured to the epiphyses where both epiphyses and metaphyses involved. You have type four and five is where the epiphyses crushed. That's the worst prognosis. OK? Um So let's say the fracture that in the lower limb, let's say shaft of femur. Um And there is uh you know, a lot of blood loss. So you can't, you can't concentrate on the fracture. Uh But if it's a team approach, then somebody can look after the fracture while the other teams can go through the initial assessment because you've got to make sure that ABCD S are stable. Ok. Now, I'm not going to dwell too much on the A. You need to have oxygen high flow. Uh B you've got to make sure there's no life threatening chest injuries. You've got to check your respiratory rate and oxygen saturation. It's the C somebody said it's a bleeding that we need to make sure that we do something about it. And what are the considerations in c that we need to make in initial assessment in a lifethreatening or a limb threatening lower limb fracture? Can you think of? Ok. Tourniquet. So, GTA said if, if there's an amputation, yeah, then there's exsanguinity hemorrhage. So in, in fact, I should have said C ABCD C is a control of exsanguinating blood in the hemorrhage. So if you got an limb uh hemorrhage, then there are several ways you can control it. One is as a tonicaine or you can put um a bandage. Now, the bandage that you, before you put a bandage, you've got to stuff the wound with gauze um and then wrap it up and lift it up. So elevation and, and, and uh you know, bandaging, that's another way. Uh you can put the limb in a splint. Splint is more for uh uh pain control rather than hemorrhage control. Now, if there is no, not exsanguinating hemorrhage, but the patient is in shock. So the tachycardia and hypotensive cause, remember, a tibia can lose a fracture shaft of tibia can lose about a liter. A shaft of femur can lose about um uh a liter and a half to 2 L. So you've got to start shock therapy. Yeah. Uh says P RBC and F FP. So if the patient is in shock, you activate the major hemorrhage protocol and what it does, you give pranic acid bolus, you give pranic acid uh infusion and then the lab sends you the red cells and the FF PS OK. You start blood because you start the fluid resuscitation, small amounts of crystalloids warm until blood comes. When blood comes, you replace that fluid with blood because what you need is the red cells that to carry oxygen to the main vital organs. Yeah. So that's your shock therapy. You got access, you take bloods for routine plus uh you know, the cross match, you start the fluid replace with blood. And in terms of principles of um open fracture management, there are two more things to do. Can you think of at the same time might as well because you've got the access, you've got the fluids running what would you like? What, what can we do for open fractures? Any thoughts wash out? Ok. So says wash out IV antibiotic. Ok. Um So we, we said infection is a risk. So you give intravenous broad spectrum antibiotic based on the policy of the hospital and what the orthopedic surgeons um feel. Uh no, they, they, they have decided and, and the, the bug that causes is, is, is uh staph aureus or even depending on the contamination, it could be even uh pseudomonas as well. Now, and the, the In Ed in emergency department, you get the first chance of actually cleaning the wound. So you don't, you don't scrub it. The final toilet happens in theaters by the orthopedic surgeon. But what we can do is just run a bottle of warm saline through the fracture and then cover it up, you know, cover the wound. So that's the first washout. And then these fractures should be dealt with within eight hours depending on the situation. Ok. Yes, you cover the side and antibody is ba and all he said? Excellent. Then make sure the GCS is assessed. And in ee there are other considerations from a fracture perspective. Can you think of what? So you've done your shock management? Now you come to ee you've seen the fracture. What other considerations might you have to make from the fracture perspective? What does a fracture do? What's the main symptom of the patients? Any thoughts reduction alignment. GTA. OK. So analgesia, OK. GTA give others a chance as well. You're doing well. Um So look for, so, so you give pain relief. Yeah. And the way you give pain relief is intravenous opiates or depending where the fracture is. So if you call a neck of femur fracture, then we give what's called a fascial a block. OK. Uh So either a nerve block or a intravenous opiate. Once you do that, then you look at the fracture. If the fracture, it needs alignment, they're angulated or displaced, then you need to align them and put the fracture in a splint. Ok. Yeah. Excellent. So, uh, all considered pain, you have to deal with the pain and, and otherwise it is unkind. Ok? Uh Pethidine, we don't use vim anymore. Uh, because of its hypotensive effect. Uh, we use morphine in titration. So you don't give 10 mg straight away, you give one mil a minute as much as you need. Ok? Um, and so what you, the, the reason you need to align them because an angulated fracture causes injury to the soft tissues, causes bleeding causes pain, et cetera and loses fluid. So, by aligning it and putting the limb in a splint and, and what you need in low limb is a traction splint, I'll, I'll come to that discussion in a minute. Uh, so you put them in traction splint and what you do is you reduce the pain and you, uh, reduce the blood blood loss, the fluid loss and the soft tissue injury. Now, this is only temporary. Ok. Now, some patients like with the tibial fracture, the prehospital paramedics sometimes put them on a traction splint. Now, if they are on a traction traction spleen, neurovascular, the limb is intact, then you don't touch it. The limb, the spleen can be taken off in theaters. If they don't have a spleen, we need to put them in a spleen. I'll come to the discussion in a minute. OK. Right. So this is uh a quick x-ray, a quick uh slide to tell you uh those who are on my last talk, we know about it. So the way we assess an X ray in a limb is uh this is a system, I think it's a safe system. First of all, you make sure that you've got the right patient because you may be seeing the wrong patient a wrong date. All those are important. So, uh the hospital number, the date and the, and the patient make sure you see the right x-ray. OK. The right side important. I have done mistakes. So I've learned lessons and I'm telling you this can happen every time you've got to make sure these checks are done. Once you've done that, then you got in a limb x-ray. Normally you have two views, an ap view that you can see. Uh it's an ap view of the knee. Remember if it's a long bone. Remember you need to do what special, what do you need to ask the radiologist or radiographers to do if it's a long bone X ray? Otherwise it's incomplete. Janus says nerve blocks. Yes, Jer, anyone, you've got to do the x-ray above the joint below the, so above and below the shaft. Otherwise it's incomplete. Ok. Same with immobilization when you can include the joints above and below. Excellent. Same with immobilization. You've got to include the joint above and below. OK. Yeah, both joints mel was ap and lateral view. So ap view, lateral view and sometimes you have oblique view, especially on the foot, X ray when you come to see it. OK. So what do you do? Let's take this AP view. The system is ABCD S the A is, this is not airway breathing, this is um alignment. So is the bone, bone and joint aligned or are they displaced or dislocated? And then A is adequacy. Can you see what you want to see? OK. If not make use of what you can see and tell the radiographer, I need another view. Then B's bones, you look at the bones all surrounding, starting for the cortex and going all the way around um using a marker maybe uh and, and the metal as well. OK. So Davies says full length texture of the bone and two joints a and lateral. Excellent. Uh then see, so don't forget the joint line as well, if they participated in a joint, see is cartilage which is in between the two bones. If there is a joint, make sure the joint space are symmetrical and these disc spaces because this system is also used for a second spine, x rays. Ok. So these disc spaces not for limbs and is soft tissue injuries. Now, there are some x-rays, uh especially elbows, which I showed last time some soft tissue shadow as an indica indicates indirect evidence of fracture. Uh So that's something to think about. Ok. So it's up to you whether you use it, but it's a safe system. Now, before you start managing, you've done the initial assessment, you've managed shock, uh you've given analgesia but you still need a bit more information. So that's what we call secondary assessment. Ok. Now, in history, key things are the event what happened so you can deduce the mechanism. So in ankle, for instance, it's key to know, is it inversion? Is it uh um uh you know, um inversion or reversion or in a sporting injury of a knee? Was it like a rugby tackle or was it a direct impact? So event is important mechanism helps you understand the injuries. So you can go looking for it. There are other history that you need to ask, I'm not going to go into that. Then you come to examine when you examine the limb, you expose it, you um you dealt with the open wound, you examine uh look, feel, move that the these are the three principles inspection palpation. So you feel for bony tenderness, you feel the soft tissues, you look a distal neurovascular deficit for sensation and motor and capillary, refill and pulses. OK. Very important. Um And you, you, you, you, you do both sides to compare. You also uh you know, do the other limb as well, then comes the treatment. OK? So treatment, what we're gonna discuss is what we do in ed at the point where we refer to orthopedics uh for definitive care. OK. Uh And, and that's, that's beyond the remit of this talk, right? So here we come, we start off with hip. OK? And, and I'm going to go around if you look uh if I go clockwise. So these patients present having had a fall and now you can get AAA dislocation of the hip in a virgin joint where it's not displaced in patients own bones. And you can see the bottom, right? Um On the bottom, right, you can see uh inferior dislocation of the head. You can see superior dislocation, the bottom, the top, right. Uh You can see this is looking at the slide the top, right? You can see superior dislocation of the hip. Now, if the patients had a hip replacement, uh beat a total hip replacement, um then you can see dislocation as well. So can you see the prosthesis in the middle, lower middle is a prosthetic dislocation superior and also in the, the middle uh left, you can see the, the, the ball and socket. Uh it's come out of the, the acetabular prosthesis. OK. So they present with a fall or a kind of twisting movement, they complain of pain. Uh Any thoughts of uh So in the, in the top middle, uh what is that picture? What is that showing? This is what the leg looks like. So when you look at the limb, what it will, what will it look like? There's a rotation, I'll give you a clue. Which way is the rotation, you can shortening and internal rotation joint. That is absolutely the shortening because the leg, the leg length is reduced because of the dislocation and internal rotation. Um not lateral alley. It's internal, as you can see, the leg is internally rotated, the right leg. Um And, and, and so what you do is you give analgesia uh either a opiate. Now, these are elderly patients. If they're elderly, we try to avoid opiates. So we give IV paracetamol if they're not allergic or uh we give them uh a fascial like a block. I can't describe fascial like a block. Uh but you can have a look at it in your, in your own department. And then we refer now very few emergency department. They do this dislocation reduction in their own department. Most of them um refer to the orthopedic surgeons, ok. We come to this condition. S UF E. So have you heard the term S UF E? This is uh what is it slipped? Upper femoral epiphyses. Johnta says yes. And you can see uh on this picture. Uh So ali this is uh in a patient in a child where there is epiphyses still present. As you can see in this picture that due to a trauma, the epiphyses uh slips and you can see if you look at the, the, the right hip, it's intact. Yeah, they are aligned. If you look at the left, the epiphyses are slipped above, OK? And that's slipped. Upper femoral epiphyses. This is important referral to orthopedics needed. They need internal fixation because it can affect the growth of the limb itself. They complain of pain. Uh You need to give analgesia well, move on. Ok. We come to the next, the commonest fracture in the, it's a fragility fracture of the older people called fracture. Neck of femur. OK. So in the neck of femur, the femur has a head, the femur has a neck and it's joined to the uh the shaft with and with two trochanters. Ok. Now, they have a classification um and you can see the fracture can be ha you can have the fracture at different parts of the femoral head to neck. Ok. Uh So the, the, the classification because when you refer and when you diagnose on X ray, this is what you've got to look at because it has implication in the treatment. OK. So there are extracapsular and intracapsular. So remember the capsule I it starts from the from the joint and finishes somewhere around the middle of the neck. Now, anything proximal to the capsule, uh reflection is intracapsular, anything distal is extracapsular. So there are four types of fracture necho feur, there is uh transcervical just below the head. There is transoral through the neck, transverse. Those two are intracapsular. And the what is the importance of knowing is it intracapsular or capsular fracture neck of femur? Why are we? So why is it so important? Any thoughts? No J to this time, please. I'm only joking. Carry on blood supply. Excellent ali so the blood supply comes uh this way. Yeah, and result in a vas. So if there's a fracture, the arterial supply gets knocked off and you can get a vascular necrosis of the head. So that's why it's important and the, the way they are treated in terms of operation is different. OK? Because intracapsular needs the head replacing, needs a, needs a hemiarthroplasty or even a total hip replacement. Whereas the extracapsular where there is no jeopardy of of the, of the head, you can manage it because it's distal um you can manage it in another way. So the two types of extracapsular are uh intertrochanteric between the two trochanters and subtrochanteric. OK. Uh And, and they can be fixed with uh you know, screws and plate. Now, within the intracapsular, I haven't got a picture the these patients, how they present, they have a fall, they have a minimal fall and, and the the weather in UK is coming such that uh in snow, they slip, they complain of pain so they need analgesia. So what we do in Ed is as soon as they come in, we look at the leg. Can you see the leg in the top uh left? This is the attitude of the leg. This is different to the leg position you saw. So what's the rotation here? Janus says, prostheses into fixation. Absolutely. What's the, what's the rotation here in this leg? Any thoughts? It's shortened? Can you see the shortening because the leg length is is is is shortened. This is this not lateral all not laterally. It's external rotation was says, absolutely right. Can you see the leg is externally rotated? So as soon as we see the leg, we saw them see the injury, we give them analgesia. Now, either we give them opiates small amount because a lot of big analgesia, big opiates in the elderly. Can zom them off uh make them drowsy or IV paracetamol or um but, but we give the fascial e block. Once we diagnose a fracture on X ray, you can see the pictures on top, right? And, and uh the middle one. Yeah. Yes. Jon says fascial ECA. Now that's done either anatomically but more and more these days is being done under ultrasound guidance. So we give them analgesia, they go to X ray, they come back and we give them facia like a block and we refer to orthopedics. Yeah. When is it? When, when do you think in a fracture, neo femur, we might do the CT scan, not fracture, neo feur in a hip injury. If you do an X ray, you can't find a fracture and the patient is still having pain on weight bearing, ok? You need to do a CT scan to make sure that you're not missing anything. So the patients get referred to orthopedics. Um and we do a CT scan, sometimes CT scan can pick up, ok. Join the fragility and elderly fragility fracture. This is an example of fragility fracture like the colli fracture in in upper limb. Ok? Now, the other thing to say to you is there are fractures of neck or femur where patients will don't come straight away. They come few days later and they have been walking about because normally with this kind of fracture that you see, they will not be able to weight bear, but such patients weight bear and they come because the pain is getting worse and reaching a point where they need sorting what kind of neck of femur fracture will such patients have? When you do an X ray, you'll know that any thoughts impacted fracture. He says beautiful, wonderful. So what happens is the head uh and the gets impacted into the sort of shaft and that maintains the align such that patient can still mobilize, that's absolutely crucial to know. So that might need an not only xray ct scan, one more thing to ask you to in an intracapsular fracture, there are still, there's a further subclassification cold. The classification rule is called what? And II, II can't go through the classification. It's called gardens classification. And gardens classification is important to know by the orthopedic surgeons when they treat it. Ok. Move on. OK. We come to femur. Now we talked about femur. So this is shaft of femur. Usually the leg is deformed and the fracture as you can see is either angulated or displaced and they need alignment. Uh OK. Powell Melvin says now when they come from ho uh outside hospital and the, and the usual mechanism is either a fall or a high speed road traffic accident or even a bike, you know, uh fell off a motorbike or a push bike. And, and remember x-ray, you got to see the joint above and joint below. So these are incomplete x-rays, both of them, the, the top right and the top middle. OK. How do they present extreme pain, unable to move the limb they need uh in opiate analgesia, we can also give them femoral nerve block. So I have used femoral nerve block but before you give femoral nerve block or any block, 01 thing you need to assess and document what is that in a limb? Yeah, Melvin says hypotension they can bleed internally and cause cause hypotension shock. What do you need to assess and document before you give any kind of nerve block? Any thought sensory? So, neurological deficit, neurovascular as well, but more important neuro. Ok. So motor and sensory, you have to document that before you give the block. Now when they, so they, they give, you give the analgesia, then you send, then you splint the leg. When they come from hospital sometimes, can you see the, the, the, the bottom left one that's called a Kendrick Splint used by the paramedics. We leave the limb as it is check the neurovascular deficit, send them for x-ray. Refer to orthopedics. You don't take it off in if they don't come with a splint, the middle bottom middle is the splint that we use to. It's a traction splint as well. Any idea what it's called? Anyone who's seen it, anyone? Thomas spleen genus is brilliant. Yeah, that's a Thomas spleen. You've got to, uh, you need few people to put it up. Uh, the leg goes through the ring, the ring sits underneath the buttocks and there is a, a bandage and a and a cord that provides the traction. Um Usually we put the traction. We, we, the orthopedic surgeon says if there's no neurovascular deficit, let's do an X ray before we put the splint on. But if there is neurovascular deficit, you need to release that pressure from the fracture fragment. So you need to align the limb before x-ray. OK. So you put the limb and then we refer to orthopedic surgeon, they need fixation. OK. Internal. So the the the usual word that we use orthopedic surgeons use is called orif O ri f open reduction, internal fixation if you remember, OK, knee fracture. So we come to knee now. Um So you can see some pictures the top right. Anyone will tell what top right is very obvious, uh very commonly caused by direct trauma or even indirect trauma by the twist. It's a patella fracture. Now, if you see the patella broken into two halves, they need fixation. Ok? That will need orthopedic referral. That might need a wiring. Ok? Now, remember uh what muscle, what tendon attaches to the tip of the uh of the, of the patella because that tendon might be ruptured, causing problem with the limb, high extension uh patella ligament. Yes, quads. The quads becomes the patellar ligament and gets attached well done only. So, uh so that's that they present with again, uh pain you got to give analgesia. Now this is where you can put the leg in a splint that that kind of splint we use in such situations is called an A box splint. It's orange in color if you've seen it. Now, the bottom middle Cordy says femoris eye says, yes, the bottom, the top middle. Any idea what that is? You can see the, sorry, I'll bring that. You can see the femoral condyle, you can see the tibia uh and in the articular surface there is a shadow. Uh and you can see a little, can you see the A and the B so A is uh avulsion of the tibia of the, of the lateral tibia plateau, tibial spine is B so these are associated with meniscal and cruciate ligament injury. If you see this, you've got to, it's very difficult. If the joint is swollen and painful, you can't assess there's clinical tests for meniscus and cruciate ligament. You, if you can't do this, you need to refer to orthopedics because they need MRI scan to make a definitive diagnosis only well done. OK. Now, uh then we come to the, the, the left extreme left x-ray. Uh What can you see there again? That's usually caused by direct trauma, assault. They have pain. Um You need to splint the leg x-ray. I mean, these are only one view need to have ap and lateral. Can you see anything? You can see the, OK. Melvin says Schatzker. But this is what I'm saying is if you look at the tibial plateau, uh on the uh the tibial plateau, it's a tibial plateau fracture. You can see the articular surface, it's uh it's depressed. Um OK, tibial plateau fracture. They need fixation, they need a screw maybe, but they need referral to orthopedic. But this tibial plateau can be associated with soft tissue injuries. Like the collateral ligament may be ruptured or the meniscus can be torn as well. Ok. Coming to the middle, uh the bottom middle. Uh Any any thoughts, um you can see some shadow at the posterior part uh of the knee. Um Your Davies sib bladder fracture, that is a avulsion from the tibia posterior part and this is a reflection of a posterior cruciate ligament injury. Can you see that little avulsion? Ok. And then we have this uh uh bottom right uh x-ray um any thoughts about this could be not a, not a very clear picture. I have to say uh if you can't read, um I won't go into that. Probably we'll leave it. Uh But that's, that's you around fractures around the knee. And now we come to tibia. Now tibia is the main bone of weight bearing bone. Um and uh discoid meniscus. Yeah. Ok. Well done Melvin. Now the the thing to talk about is tibial shaft fracture that's common is one of the common fractures. Uh But remember you can get spiral fractures. This is the left picture and spiral fracture in a child uh can be associated with non accidental injury. So you need to exercise child protection. But these fractures are caused either by sporting injuries, direct trauma or assault or a fall. They complain of pain, they can be compound. You need to manage the shock, they can lose about a liter of fluid. Uh, you need manage shock, manage the wound, uh, the compound fracture management principle. But in terms of fracture, they need splinting x-ray and then referral to orthopedics. Ok. Now, if they're not angulated, as you can see, this is oblique on the right hand side, this is spiral. Uh, if there's neurovascular deficit, you might need to, uh, uh, uh, you know, uh, manipulate uh usually done under under sedation. Uh Remember x-ray needs to involve both joint above and joint below. And if you're mobilize immobilizing til theaters, um then we put a plaster back slap, pop, plaster of Paris back slap involving the joint above and there is what we call a full leg poop. Yeah, neurovascular. Now another complication that is can happen in this kind of fracture. Can anyone tell you need to go looking for it? There is something here but all around the leg. Actually, it's uh osteofascial compartment. So what might you see compartment syndrome? Ok. So compartment syndrome is something you go looking for it. They complain of pain beyond the injury, they can have neurovascular deficit. The muscles could be very tense and you sometimes have to do. Yeah, compa uh sometimes you have to do, yeah, no guias compartment you have to do uh compartment uh you know, expose the compartment by uh what we call is is is um um opening the compartments through incisions, fasciectomy, Melvin says that's great. Yeah. Ok. Now we come to ankle, ankle injury is one of the commonest in the lower limb. And the commonest mechanism that causes ankle injury is inversion injury. And the way you assess ankle injury, there is a, there is a rule, a clinical decision rule uh originated in um in, in, in um ca Canada called auto ankle rule II won't go into that in the moment, but you need to look at auto ankle rule that generates the need for x-ray. Uh an ankle can be really badly broken, not only fractured but also dislocated. Clinically. You can tell if you look, look at the middle bottom, middle picture. That is that the picture of an ankle. If that's the patient, what has happened is that the, the tibial, the the proximal tibia is sticking out of the skin. Can you see that? And if you've got a tinted skin that needs immediate manipulation for alignment and there is a technique to do that, we do it under either PRX which is a kind of deep analgesia or sedation. OK? And then x-ray. So you put them in a plaster back slab, but let's go through the x-ray findings. Uh If you look at the top right, you can see this is trimalleolar fracture and you can see the fixation done as well. Um You can see the uh this is uh lateral malleolar fracture. Now that is classified by Webers, um This is would be what Weber? Probably three sorry, Weber C. Um There are three classifications A B and C uh CS below the syndesmosis BS uh around the syndesmosis and proximal to the desmosis. So basically A is stable. You don't need intervention, but B and C are unstable, they need intervention surgically. Also, you've got avulsion of the tibial malleolus. But the important bit is if you look at the articular surface, they are OK. You can see equal space all around symmetrical. So there apart from the bones, you need to look at the joint space. Are they displaced? Now, if you come to the middle, top, middle, can you see the the joint space moved? The tibia has moved anteriorly and that's what the is sticking to the skin and you can see the avulsion and posteriorly. Uh there is a little, there is avulsion of the tibia. So that's trimalleolar 23 malleolar as, as so to speak. So this is dislocated ankle fracture, dislocation. OK. Again, the the the top left again is fracture, dislocation quite badly displaced. You check for neurovascular deficit, you give them analgesia and then treatment. Uh now the bottom left f uh x-ray, there is something in that x-ray that can, can anyone pick it up? It's got a name to the fracture. I, if you can't, I'll tell you in a minute. I know we are running out of time. 15 minutes. Uh Can anyone spot the fracture in the top uh bottom left. Where is the fracture? Mason Melvin Superb. So all of you look at this fibula. Can you see there's a fracture of the fibula? Usually the f it's a bit lower. Usually you see near the neck of fibula. So if you have a fracture of the neck of fibula, OK. What nerve can be injured? And you go to go looking for it, frill and neck and tibial displacement join that says, ok, so what nerve can be injured can be, can be injured and you got to look for it. Look for uh Peroneal nerve and you look for foot drop. Ok? Now, the thing to say is if when you're assessing an ankle joint, foot drop, Melvin says when you're assessing an ankle joint or ankle injury, you've got to the structures, you've got to clinically assess is not just the malleoli and the tibia, proximal distal tibia, but also the Calcaneum because the Calcaneum can be broken. You got to assess the talus and also you got to assess the navicular and the fifth metatarsal because following an inversion injury, you can break all those bones but not forgetting the two other structures. 01 tendon you need to assess because you can injure the tendon through an inversion injury. What tendon, any idea, achilles, tendon, achilles, tendon ali says yes. So II won't go into that. But there is a there is a way to assess achilles tendon. Uh uh called uh simmons test and also to look for this fracture. So the fracture is called me fracture. So you got to assess the uh the tenderness of uh the, the fibular head and neck. And if there is a tenderness, then you need to x-ray, that's important. Otherwise, if you miss it, then it could cause the patient uh immense problem. OK. We move on, these are foot fractures. We come to that. Now, uh again, um you know, foot fractures, again, caused by direct trauma or twisting or direct impact injury. Ok. Now, uh if we go through in order, let's go through from the extreme left. Um What can you see? You can see fractures to the base of the 2nd, 3rd, 4th metatarsal. Can you see and the tarsal? So in the foot, what you've got, you've got your navicular medially cuboid laterally, you've got the cuneiform bones, medial, intermediate lateral, you've got the five metatarsal and the phalange and the tarsal metatarsal joints have an articulation. If you got fractures and articulation is disturbed, that's quite a serious injury called what that needs definitive treatment. It's got a name and you need to identify this injury. Uh and, and then refer to orthopedic, it's called less Frank's injury giant that says it's brilliant. Ok. Come to the middle picture. Now, it, the arrow, the the arrow clearly shows uh the fracture, there is a fracture in the third metatarsal shaft. Can you see that? And there is a little swelling around it, maybe callous. So it's not a new fracture. It's an old fracture. What are these fractures called? And how is it caused? Any idea? Melvin says, still Listran brilliant. Any, any idea how you can get these fractures? You will see patients coming after a few days, maybe a week, week and a half. Um I can't walk, I've been walking and there's a key in the history, You know, they are long walkers, long distance walkers, stress fracture joint that says jogging can cause it. Ali says, absolutely. So these are stress fractures or march fractures, you know, those who used to do long distance marches in the army. They, they, that can cause it. Ok. They, they need symptomatic treatment like a walking boot and hopefully it should heal in time. The top, the top, right? You got a fracture there. Uh Can you see it's, it's a the next common. Yeah. Soldiers Salah says military Melvin says the, the, the fifth metatarsal base is quite common fracture. There is an avulsion fracture. Can you see the top? Right? Uh It's called um the the malleola fracture. Now, these fractures uh can be treated conservatively with a walking boot and there is a zone around the fracture called the green zone. Yeah, around the fracture. But if you have, if you, if you look at the bottom right fracture, uh it's a horizontal picture uh oblique of, of the picture of the xray of the foot. Can you see a, a transverse fracture uh across the base of the, that's not the same as the top, right. This fracture is caused by direct impact and causes, you know, they present with pain and unable to weight, bear. They need analgesia. But this fracture needs th th th this can result in non healing. Ok. So they need referral to orthopedics might need definitive surgical treatment. This is called Jones fracture. So if you see Jones fracture, it's very important. You seek specialist help as opposed to um they need they, they, so the top right needs um you know AAA walking boot and fracture clinic, referral to be seen by the orthopedic in the clinic. All the the rest needs referral to orthopedics straight away. Ok. Coming to Talus, you can see and Calcaneal fracture uh as I said, you can see, you know, the uh the top left, you can see little avulsion from the, the talus in the posteriorly caused by inversion or reversion injury. The middle top is a Calcaneal fracture. They, they, they, they can break like that. Usually a common common injury, common mechanism of injury of talus fracture is what and I'll tell you why. It's important to know the history. Can you see history is important? Absolutely key. You want to know the event what happened, fall from height and landing on the foot if they fall. So from a say scaffolding or a cliff. If you fall from a height and land on the foot, remember, the weight is going through your calcaneum through the weight bearing bones, tibia, knee hip into spine. So you, you are duty bound in that story to examine all those bones from the spine to the pelvis, to the hips, to the knees, to the femur, to the tibia to the calcaneum. Now you may not find injury fine but you got to assess it. Now, one of the things to assess a Calcaneum injury in details, before surgical repair, this knee surgical repair is ct scan. Absolutely key. The orthopedic surgeons do it. Now, one of the, the the bottom, the the the bottom middle x-ray, it tells you what it is and it shows a picture that is a key assessment done on an X ray, checking the bolus angle. Can you see that the bolus angle is made up of a line drawn along the superior border of the Calcaneum and a line joining the tubercle, anti tubercle of the calcaneum and the, and the and the superior tubercle, that degree is about 40 degrees, you know, and if it's less than 20 that needs uh repair. So bolus angle is quite important in deciding treatment, then we come to another fracture in the, in the in the bottom left. I don't know whether you can see the talus has got AAA mound there. It's got a neck, it's got a posterior tubercle and anterior, the neck is another common side for fracture. That's what you can see the neck of talus fracture. They, they can cause uh a vascular necrosis as well. And the top right, you can see it's, it's, you can see fracture shaft of displaced fracture shaft of metatarsals. They need fixing. Yeah. And one of the ways to assess the X ray for fracture is when you look at these bones, if you go from bottom up on the x rays, they are. If you look at both the ax, both the borders, they are straight. Yeah. If they fracture, then they are all malaligned. And that's, that's something to think of. And you can see the sesamoid bones on the head of metatarsal as well. Yeah. OK. Now we come to uh you know, the, the tarsal bones, uh bottom uh bottom uh top, right. Uh uh We, we talked about what the bones are. This is where you test your anatomy knowledge, apply anatomy knowledge. You've got to know what bones you are examining. Otherwise it's no use. Uh You seek help if you've forgotten, but immediately just below just distal to the talus and Calcaneum. We've got the navicula, which is the boat boat shaped bone similar to the scaphoid in the upper limb and just like scaphoid. This bone is also prone to a complication, which is what any thoughts you got six minutes to go. A vascular necrosis. Yeah. So it's important uh that we repair this bone and identify the fracture and you can see the fracture to the to the waist of the scaphoid uh of of the navicular vascular necrosis. Yeah. Ali says, Sala says also on this x-ray, you can see a little bony spicule uh adjacent to the cuboid. That's an avulsion to the cuboid bone that doesn't need much treatment. But if you look at the middle top, that's got a fracture through the uh that's not cuboid cuboid uh that's navicular. Yeah, so that frac that bone is medial uniform bone which has got a fracture. Ok. And that needs uh you know, a referral to orthopedics. Again, the generic management, I'm not talking because I've told already you need clinical assessment, neurovascular assessment, analgesia. Once you diagnose on X ray, then referral. Ok. The top left you can see the the the little toe. Can you see that deformed dislocated? And this, this one is a child because you can see the epiphyses. So this is I in terms of Salta Harris. Yeah. What would you classify this as Salta Harris? What this is? Salter Harris. Any thoughts? The commonest Harris, the commonest Harris uh you know type is two. Yeah, join the two spot on. So this is to type two but the toe is dislocated as well. So that needs that needs a reduction and after reduction. So we're reducing the way you do it is you give analgesia, you check neurovascular status but this is such a satisfying procedure. We do it under digital block. So we give um plain lignocaine uh blocking the digital nerves on either side, dorsal and ventral. And you have somebody to traction the foot and you just uh manipulate and then the nurse is ready with a adjacent strapping. Then you send for chest X ray. Remember remember for any dislocated limb, you need a pre and a post X ray. OK. Coming to the bottom left, you can see another. Yeah, type two. Melvin says uh bottom left, you can see a fracture through the second um toe, uh proximal phalanx. That's an undisplaced fracture. Obviously, you've got to do another view and if it's still undisplaced, um no uh angulation, no deformity, neurovascular intact. All you need is adjacent strapping. They need to go to fracture clinic. Um Now the big toe is quite important the big toe because it's a weight bearing. The, the the the weight is distributed to the big toe as well. Uh You can see a fracture to the proximal f it's quite displaced. That means referral to orthopedics and they might be needing to fix it. OK. The bottom right? Uh bottom right is an avulsion of the cuboid. Can you see a little shadow just adjacent to the cuboid? That's doesn't need any treatment. OK? Ok. So that was a run through of lower limb fracture. We, we, we talked about classification. Remember you need to when you refer, you need to, you, you it, you make it, you, you make you feel happy if you can um refer with the right classification and right description of the displacements. We talked about initial assessment in terms of uh primary survey uh where there is bleeding exsanguinating and otherwise shock management. And then what we did was we went through a series of x rays describing the fractures, how they present, what would you do in terms of analgesia and how would you manage from the ed perspective? Um And then onward referral to for specialist care. Happy today. Questions. Uh Thank you so much for your time for listening. Uh Can I tell you uh another talk is going to be prepared for pelvis and spine as before? Thanks. Thanks Ali. Thank you. Happy today. Questions Sala. Thank you. I've been told by um um med all that I've got 50 followers and I think some of you are followers. It's, it's a great pleasure. Uh I'm happy that I'm able to make a difference to your learning. Thank you, Jonathan. Thank you. Thank you, Jonathan. Much appreciated uh nine guitar, right? Thank you. Thank you. It was good class. Thank you, Arjan. Any questions? Um Ria don't know whether you're around Donna. Thank you. Thank you. Who do you find it interesting? Any questions for anyone? I can't see any questions currently in the chart. Let's see if anyone has any. They're all stung to silence. I think I might post the feedback in. Ok. OK, Michael. Thank you. Come on. Thank you. Please do provide feedback. Uh It helps us me all. It helps me personally to uh you know, act on those feedback to, to help me improve and make it better. It's so nice to reach all, all over the world. It's absolute great Ben. Thank you. Thank you for that. Thank you, Nathan. Good. You found it useful. We'll just stick around for maybe a minute or two for questions. That's ok. I can't see any right. Ok. Can they send questions later? No, it has to be through this. Yeah, it does. Sure. Sure anyone has any questions for those who are still around. Ok. I'm going to assume that there aren't any more. Ok. Um, and I'll take us off live. Um, but just a reminder to everyone who's still here, don't forget to follow medical education, um, follow doctor as well, um, to get notified for more talks. Um, and we'll see you in one of the subsequent ones. Hopefully. Thank you so much everyone. Thank you. Thank you.