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Welcome everyone. I'm Jing Jing, 1/5 year medical student at the University of Edinburgh. And these are my colleagues, Christo and and Nan, who are also year five medical students today. On behalf of the Edinburgh Students, Surgical Society and accessibility in medicine, we're gonna be teaching the final part of this series and operative approach to anatomy focusing on trauma and orthopedics, which is by far the best specialty, just some housekeeping before we begin, I'm sure you'll be familiar with this. If you've attended our previous sessions, we're gonna answer all questions via the chat. Um So do use the chat uh to answer to ask any questions, please note that the session is recorded and slides will be made available via meadow. After the event, the slides do contain pictures from real surgeries. Uh So if you're not comfortable with this, please turn away at those points and we'll give a uh trigger warning beforehand. And we also have some uh polls that we'd like you to fill out so that we know whether or not our teaching is useful or not. Remember that attendees of six out of eight of these sessions do get free R CS student affiliate membership and do follow E SSSS social media and med all to see all our future events. Just a disclaimer that this is a pure to third session by medical students. And although we've tried our best to make sure the information we're teaching is up to date and accurate, there may be some mistakes. Please also note that all media shown is not owned by us and will be credited on the slides and when not credited, they're likely to come from complete anatomy before we begin. Um, I'm just gonna release some polls into the chat, uh, that help us see if our teaching is effective. There's six in total, please fill them all out. Note that with these poles, you can open and close them and you can find them again in the chat. So it's not a matter of, um, you've got to keep the pores up always and that's all six in the chart. So if you can fill them all out for us, that would be fantastic. Thank you very much for those of you who have just joined. We've got some polls on the chat. There are six of them. If you could please answer them for our own uh feedback, that would be great. Thank you very much fab. So I won't waste any more time for those of you who have just joined. Please do fill out these six polls in the chat which are very, very helpful for us to see whether or not this teaching is effective. There's only six and you can scroll up to vote and I'll be just starting the teaching session. Now, today we're going to be bringing you through three trauma orthopedic cases featuring a total hip replacement, an open reduction and internal fixation, also known as an orif and a fasciotomy. Uh You'll learn a bit about the relevant pathophysiology, the anatomy, clinical features, investigations, management and complications where they get you all to interact with a simulated case and follow this session up with some MCQ S to check that you were listening. No previous understanding of surgery is required as it will all be built on throughout the tutorial and all the polls on MC QS are anonymous. So please don't be shy if you're not sure a guess is always better than nothing. So to start off, uh what do trauma orthopedic surgeons do? Well, trauma orthopedic surgeons or TN O surgeons basically diagnose and treat conditions of the musculoskeletal system including bones and joints and structures that enable movements such as ligaments, tendons, muscles and nerves. Most consultants work alongside general surgeons in emergency trauma, dealing with bony and soft tissue injuries, admitted through their local A&E departments. The vast majority also have a specialist interest in a particular orthopedic condition including some of the following. To surgeons undertake operations for a wide range of conditions including the cases. We're going to be looking at today, which fall under these main categories. You can find out more about the specialty through resources like teach me surgery, the Royal College of Surgeons and your local and national T societies. For example, the British Orthopedics Association, the trainee Organs at the training organization, BOTA and their medical student group BSA. So to start off with our first case, we're going to be talking about total hip replacements. We'll touch on hip anatomy, hip fractures, uh and total hip replacements followed by the interactive patient case. So to start off with the hip joint is a ball and socket, synovial joint. It's covered in a hyaline cartilage and that helps to reduce friction and aid movement of the joint. The hip joint is formed by an articulation between the pelvic acetabulum and the head of the femur. It forms a connection from the lower limb to the pelvic girdle and trunk. And thus is designed for stability and weight bearing rather than a large range of movement. Movements include flexion and extension, abduction, and abduction, medial and lateral rotation and circumduction. Looking at the acetabulum first, the acetabulum is a cup like depression located on the inferior lateral aspect of the pelvis. The acetabulum is divided into two surfaces. The lunate that articulates to the femur and the acetabular fossa which is like the floor of the sort of crater if you will, the lunate is a horseshoe or crescent shape uh and opens um at the and open at the inferior aspect forming the acetabular notch. And this acetabular notch is spanned by the transverse acetabular ligament. The acetabular fossa is where the ligamentum terras ligament of the head of the femur is what sometimes also known as and that's where it attaches and it connects to the head of the femur of the fovea. This ligament contains a branch of the obturator artery which supplies the head of the femur. There's also an acetabular labrum which is a fibrocartilaginous wedge bound to the acetabular rim. And this deepens the acetabulum enhancing the stability of the joint. The head of the femur is hemispherical and fits completely into the concavity of the acetabulum. And both the acetabulum and the head of the femur are covered in articular cartilage which is thicker at the places of weight bearing ligaments are also important as they uh increase the stability of this joint. It can be divided into two groups, intracapsular and extracapsular. We've already met the ligamentum terrace that connects the head of the femur to the acetabular fossa, extracapsularly. We have the iliofemoral pubofemoral and ischiofemoral ligaments that spiral around the outer surface of the joint and act together to stabilize the hip. This unique spiral orientation causes them to become tighter when the joint is extended, making it more stable, but also preventing it from moving further. The iliofemoral ligament is the strongest of the three. It arises from the anterior inferior iliac spine and then bifurcates before inserting into the intertrochanteric line of the femur. And it's got this sort of y shaped appearance just here. It uh prevents hyperextension of the hip joint. The pupil femoral ligament spans between the superior pubic right eye and the intertrochanteric line of the femur reinforcing the capsule anteriorly and inferiorly. It has a sort of triangle shape and it prevents excessive abduction and extension. So there's the triangle shape, the ischiofemoral ligament spans between the body of the isi and the greater tranter of the femur reinforcing the capsule posteriorly. It has a spiral orientation and prevents hyperextension and holds the femoral head in the acetabulum. The proximal aspect of the femur articulates with the acetabulum of the pelvis to form the hip joint. The proximal femur consists of a head and neck and two bony processes. Greater tranter and the lesser tranter. The greater tranter is the most lateral palpable projection of bone that originates from the anterior aspect just lateral to the neck. The next just here. Um It is the site of attachment of many, many muscles in the gluteal region such as the gluteus, medius, gluteus, minimus and periform. The vastus lateralis also originates from this site. The lesser tranter is as expected smaller than the greater tranter. It projects from the posterior medial side of the femur just inferior of the neck shaft junction. It is the site of attachment for the ileus psoas muscle, forceful contracture or damage to the aforementioned muscles can result in fracture at both of these sites. There are also two bony ridges connecting the two trochanters. The intertrochanteric line anteriorly and the trochanteric crest posteriorly. The arterial supply to the hip joint is largely via the medial and lateral circumflex, femoral arteries. And these are branches of the profunda femoris artery, also known as the deep femoral artery. They basically anastomose at the base of the femoral neck to form a sort of ring structure. And from that, uh smaller arteries arise to supply the hip joint itself. The medial circumflex, femoral artery is responsible for the majority of the arteries supply and damage to this can result in avascular necrosis of the femoral head. This is particularly important to note um as intracapsular fractures. Uh so, fractures within the capture of the hip joint at the neck of the femur and further proximal can damage this artery, the artery to the head of the femur and the superior inferior gluteal arteries also provide some additional supply. But it is the uh medial circumflex femoral artery that does most of the blood supply. Here. The hip joint is innervated primarily by the sciatic femoral and obturator nerves. And these are the same nerves that innervate the knee, which explains why pain can be referred to the knee, uh from the hip and vice versa. The muscles and ligaments work in a reciprocal fashion at the hip joint anteriorly where the ligaments are strongest. The medial flexors located and uh are fewer and weaker posteriorly, er where the ligaments are weakest, the medial rotators are greater in number and stronger. They effectively pull the head of the femur into the acetabulum. I'm not going to go through the muscles in depth because I only have about 20 more minutes. But the ones to be aware of when you're doing a total hip replacement are the abductors, abductors in total hip replacement. You're going to take a lateral approach. So you're coming in at the lateral hip. So the muscles that you dissect through are going to be the muscles of the abductors. And the ones that are worth remembering are the gluteus, medius, the gluteus minimus, the piriformis and the tensor fascia latte. So moving on to a bit about neck of femur fractures, they are a very, very common fracture. Uh and the causes are usually low energy trauma like falls rather than high energy car crashes or other forms of high energy trauma. Risk factors include age because of increasing fragility history and risk factors of osteoporosis, like menopause, smoking, physical inactivity and long term or high dose corticosteroids. Um Another risk is having a previous fragility fracture, having a history of falls, poor nutrition, low BMI and anything that basically might increase your risk of falling like dementia, visual impairment and medications like sedatives or antidepressants. Neck of femur fractures have really poor outcomes. One third of patients with them die within the first year one third have a decline in their independence and one third will return to their baseline function on examination. Uh When a patient has a neck of femur fracture, you'll notice that their leg is characteristically shortened. So this is the effect of leg, it's characteristically shortened and externally rotated. So rotated outwards and that's due to the pool of the short external rotators. Um And you'll also find that they also get pain on pin rolling and uh on axial loading. So they can't weight bear either on this. Some differentials for a neck of femur fracture include uh alternative fractures like uh fractures of the pelvis, uh S acetabulum, femoral head and femoral diaphysis. Um they can also be slipped cap femoral epiphysis, also known as SUFI. Uh but the history for that would more be like intermittent pain for months. Uh and pain worsening on activity. It could be a dislocated hip. It could be um sort of idiopathic femoral head avascular necrosis. It could be tendonitis of any of the muscles of the hip hip bursitis or even osteomyelitis. But with osteomyelitis, you'd expect some sort of clinical picture that includes fever chills and probably some swelling and redness in the area as well. X-rays are the first line imaging for suspected hip fractures. CT can show the fracture in better detail and MRI is the gold standard for diagnosing fractures, but these imaging modalities aren't always available and x-rays are much faster and much cheaper and you want to act fast when you think someone's got a neck of femur fracture. These patients will need basic routine blood tests including full blood, count your knees. Uh You want to also take a creatinine kinase in case they have rhabdomyolysis from uh being on the floor and having a long life for a long time. And it's also worth taking a group and save because uh the blood loss from a neck of femur fracture can be really significant and the blood transfusion may be required either um uh to stabilize the patient or uh after or during surgery. A urine dip, a chest radiograph and an ECG is also worth doing an ECG would be, for example, for looking for coronary events that might have precipitated a fall if that was the likely history. And these are really useful in assessing the older patient group. And figuring out what exactly the reason for the fall was. Initial management of a neck of femur fracture should consist of an a approach to stabilize the patient. And uh basically make sure that they're ready and uh stable for surgery. Um It's really important that these patients get adequate analgesia as hip fractures are incredibly painful. And uh the types of analgesia they can have is either opioid um or even a block or like a regional block. You'll need uh IV access as well because you're gonna need to give them fluid recess. Uh You're gonna need to maybe give them a blood transfusion and you'll probably need to administer medications at some point. Definitive management is always surgical. However, the specific procedures depend on the type of fractures sustained amongst other factors like patients, fitness for surgery and baseline mobility after surgery, early immobilization is really important and this will require MDT support. And of course, our wonderful physios to decide the surgery type. Uh you need to know what kind of fracture it is, whether it's intracapsular or extracapsular, displaced or non displaced a neck of femur fracture occurring proximal to the intertrochanteric line. So the intertrochanteric line is here between the greater tranter and the lesser trochanter. Um these ones proximal. So in this direction, um involve damage to the joint capsule. As a result, the blood supply from the femoral circumflex arteries, er and nutrient arteries inside the bone might be disrupted. Um And this er may result in avascular necrosis as a result intracapsular fractures. So, things from uh the interenteric line uh proximal uh are at high risk of avascular necrosis and really, really uh will likely need a total hip replacement as the or uh uh a hemi arthroplasty. Um as it's unlikely that the head of the femurs actually gonna survive extracapsular fractures are different. So, these are fractures that are below the uh intertrochanteric line. Um And so this to the in intertrochanteric line. And these uh typically in include intertrochanteric and subtrochanteric fractures where the joint capsule isn't damaged at all. And blood supply to the fracture site is sufficient. Meaning that um you're not, you're likely going to uh still be able to save the uh femoral head. Some patients may not be suitable for surgical intervention. It's quite complex. Um if they're too unwell or if perhaps it's a patient choice. But uh conservative management comes with a very, very poor prognosis and a really, really significant mortality rate. So it's not advised surgical options for a neck of femur fracture include cannulated screws, dynamic hip screws, intramedullary nails, total hip arthroplasty or hemi hip arthroplasty, er cannulated screws basically involve a set of screws being driven into the femoro head here er across the fracture which stabilizes the fracture. A D HSA dynamic hip screw is a dynamic plate screwed across the fracture line into the femoral head. Er and A DHS basically permits organized collapse of the fracture when the patient weight bears and this improves fracture healing and union arthroplasty. On the other hand involves the removal of the femoral head and insertion of a prosthetic replacement in a total hip replacement, the acetabulum is also replaced. But in a hemi arthroplasty, it's just the head of the femur. If it's a displaced intracapsular neck of femur fracture, the blood supply to the femoral head, uh mainly the medial circumflex artery is likely affected. So we're going to need to do that um hemi arthroplasty or total hip arthroplasty. Whereas if it's an extracapsular fracture. We can just use a dynamic hip screw or an intermedullary nail if it's a non displaced intracapsular fracture, uh It's, it's a sort of different scenario because it's likely that um the blood supply may be maintained. We're instead going to try and fix the native femoral head using either dynamic hip screws or cannulated screws in the hopes that it will survive and have better outcomes. Right. So, moving swiftly on to our first patient, Mr Arthritis who's 75 years old. Um, he unfortunately tripped over his dog and was found on the ground by a neighbor. He's doing pretty well for 75 year old. Actually, he's pretty medically fit and an avid hiker. Um and he was brought quickly in by ambulance who very kindly gave him some analgesia because obviously very painful and we put him through our X ray to see what exactly is going on here. Can anyone tell me whether or not Mr Itis has an intracapsular or an extracapsular fracture? Just on the chat? Oh, I'm noticing. Hi, Bianca. Yes, the slides will be made available and the feedback form will be posted here. Any takers intracapsular or extracapsular. It's a 5050 choice intracapsular. Thank you, Lydia. Perfect. Perfect. So, yes, indeed, he has an intracapsular fracture. What kind of surgery is he gonna have? What type of surgery? Any takers? Since he has an intracapsular fracture, it is likely the femoral head is not going to survive to hemi arthroplasty. Thank you, Valeria. Perfect. Right. Moving on now that we've got a game plan. Yes, he will indeed be getting a total hip replacement and that's replacement of the femoral head and also the acetabulum with the surgical prosthesis, not to be confused with the hemi arthroplasty, which is just the femoral head replacement, not the acetabular component. Mr Actis has really good mobility and high baseline function. So even though it's not a severely displaced fracture that he just had, we're gonna give him a total hip because we want to preserve his mobility and we expect he'll do well after surgery. If Mr Itis had any conditions that prevented him from being able to um effectively adhere to post surgical management like severe dementia or psychiatric disease, then this is likely not to be the right operation for him. In addition, if he had systemic infection and sepsis, we would absolutely not be operating until that was well controlled and he was all better complications of this procedure include bleeding and hematomas nerve damage. Uh fracturing of the femoral shaft when you're putting in the prosthesis, dislocation, uh either uh post uh prosthesis, uh prosthetic joint infection, loosening of the prosthesis, periprosthetic fracture, leg length discrepancy. If your prosthesis isn't quite the right size. Uh your surgical site infections, which are a risk for all surgical procedures and also venous thromboembolism. I've highlighted prosthetic joint infection here because this is what every orthopod fears and why every orthopedic operating theater is perhaps the most aseptic of all the surgical specialties. Since you cannot treat a peri prosthetic infection with antibiotics, you need to reopen, wash out the wound and then do all your hard work and put the patient through another grueling surgery. So now that we have a game plan, let's head to the theater and meet the team. We've got our lovely friendly consultant, our very grumpy ridge because he hasn't slept in. God knows how long our lovely anesthetist plus or minus a Sudoku pad and helpful theater nurses and a fantastic scrub nurse. Before the procedure starts, the scrub nurse lets you know that you might see some things that you haven't seen before. So if you're not comfortable, feel free to pop out or in your case, tune out and if a faint is imminent, take a seat on the floor before you become another patient. As you enter the theater, you, you'll probably notice some people are wearing these odd contraptions. Uh These are lead aprons which basically protect you from radiation exposure during intraoperative x rays. It's really important that you take care to minimize your exposure to these risks. And boa have some excellent resources about this that have come out quite recently in response to some studies in America that showed increased breast cancer prevalence in female orthopedic surgeons. Now that that's out of the way you're called over to assist with transferring the patient from the bed to the operating table. Which direction do we transfer patients laterally vertically or obliquely? I'm gonna send out a po now remember these are anonymous and you can close them and go back to them and you can find them in the chats. Great. We've got eight responses and most of us are going with laterally and laterally is absolutely correct. It is the appropriate direction to shift patients from the bed to the operating table. Laterally essentially means sideways. So as you imagine, if you're sideways on a bed, you get shifted sideways onto the operating table, you can use a vertigo transfer. Uh For example, if the patient was already on the table and you wanted to reposition them either further up or lower down on the table. Uh And curious, a number of you selected obliquely uh please don't do that obliquely essentially means uh slanted or diagonally. I can't imagine any scenario in which you diagonally transfer someone. But I suppose it could be a technique that's looked into, right, moving on to how to transfer a patient assisting with transfers is something we we often get to do, but we're not really taught, you just kind of end up doing it because you get called in. Uh first uh what you do is you turn the patient towards you onto their side and then slide the slides sheet under one side of the patient, you then turn the patient onto the other side and pull the slides sheet through to the other side. So that when you lay them back onto their back, there's one slides sheet completely underneath them. Now you can slide a sliding board underneath the slide sheet and the patient and together with members of the team supporting the head and all the airway adjuncts attached the arms and torso and the legs and feet. You can then shift the patient from surface one AK a a bed to surface two aka at the operating table. Note that you're not lifting the patient. When you're transferring them, you're just sliding them. One of the team members will usually lead this doing a countdown. So everyone shifts at the right time. It's also important to be careful of any attached cables or tubing that might catch and note that when the patient is unconscious, they can't cry out if they're in an uncomfortable position. So please be mindful of potential pressure points and positioning, right. So the patient has been transferred, anesthetics have done their magic and everyone's scrubbed up and the patient is positioned in a lateral position because we're going uh to do the hip, total hip replacement from a lateral side. Uh with the affected leg flexed, the patient's all draped and everything's ready and the consultant feels for the greater counter to make sure we're in the right place. The consultant then makes a first incision. It's about 10 to 12 centimeters long depending on the patient. Uh and it's a longitudinal incision over the tip of the greater tranter, extending in line with the femur as she dissects down through the skin and the subcutaneous tissue, she asks, what muscle are we going to see next? Is it the gluteus medius, the piriformis or the tensor fascia lata? I'm gonna start a pool. The polls are anonymous. So, feel free to answer anything even if you're not sure. Right. I don't think I'm going to get any more. So I'm gonna stop the pole and most of us have gone with tensor fascial lata, which is in fact, absolutely correct. Um Great job. The tensor fascial lata is a muscle located in the proximal anterior lateral thigh situated between the superficial and deep fibers of the iliotibial band. So well done. If you had answered the gluteus medius or the piriformis, um you get the snarky, snarky red. Um And essentially these, these while correct to some extent, they, they are um abductor muscles. Uh these muscles are deep to the tensor fasciolata. And so the first muscle that you're going to see is the tensor fasciolata. The primary hip abductor muscles include the gluteus, medius, the gluteus minimus, and the tensor fasciata. And the secondary hip abductors include the piriformis, the sartorius and the superior fibers of the gluteus maximus. The consultant then moves on making a small incision into the tensor fascia lata and the leg is abducted using blunt dissection the fibers of the gluteus maximus are parted and then the leg is externally rotated, the tip of the greater trachaner identified and then the fibers of the gluteus medias split. I did try to find a good image of this. I could not, it just looked like a mass. So I apologize that I'm I'm just sort of narrating at this point. The insertion of the gluteus medius uh into the greater tranter is freed and blunt dissection is used to expose the joint capsule which is then excised. Uh The limb is then rotated externally and the hip is dislocated. An osteotomy is performed er to separate the femoral head from the neck of the femur using a saw and then a corkscrew is used to remove the femoral head. The registrar then asks you what ligament connects the, the femoral head to the acetabular fossa. Is it the iliofemoral ligament? The ligamentum terras or the ischiofemoral ligament? And I will send out a pole. Also for reference, these uh images come from a youtube video of a Thai surgeon who's doing this total hip replacement and it comes with the most relaxing studio, Glis music in the background. So I highly recommend having a watch. Uh If, if you're interested, I think that is all the votes we're gonna get, I'm gonna stop the pole and all of you have correctly identified that it is the ligamentum terrace. There is only one intracapsular ligament er which connects the femoral head to the acetabular fossa. And note that it also contains a branch of the obturator artery which supplies the head of the femur but not really the main supply. The main supply is the medial circumflex, the femoral artery, the other arteries, um sorry, not arteries. The other ligaments are actually extracapsular ligaments, not intracapsular. So they wouldn't be able to connect the femoral head to the um acetabular fossa FB. So just to chat a little bit about ligaments again, um we have one intracapsular ligament, the ligament of terus and we have three extracapsular, the iliofemoral, which is the strongest, the pupil femoral and the ischiofemoral next to the acetabulum is prepared with the clearance of soft tissue and reaming of the bone. The acetabulum metal component is then fixed into the prepared fossa. And following that, a lining is placed. So there's two components to the acetabular part, there's the metal bit and then there's whatever is the lining is made out of, it can be ceramic, it can be plastic. But the the key is that you want something smooth that's not gonna cause lots of friction. OK. The femur is then prepared by creating an entry point in the posterior lateral aspect of the femoral canal. And then the femur is then sequentially reamed and the canal, the canal grasped to fit the shape of the implant using the sweet tool here. A trial was then performed with a dummy acetabular and stem prosthesis to assess stability, a range of movement and leg length because we don't want to put in the and cement in a uh not a perfectly fitting implant. And then once we're sure that everything's fine, we put in the appropriate sized implant and we cement it in the wound is then washed. The deep layer of the external rotators and joint capsule was closed with nonabsorbable sutures and the superficial subcutaneous tissue was closed with absorbable sutures. Before you get away, the consultant asks which of the following may result if the abductor, A BD muscles aren't repaired properly before wound closure. Are you going to get scissors? Gait? Trendelenburg gait or antalgic gait? And I'm gonna send out another pole. Great. So most of you have gone with Trendelenburg gait. I'm gonna start pulling now and you are absolutely correct. Yep. So the Trendelenburg gait is caused by unilateral weakness in the hip abductors. And so if you don't close up the hip abductors properly, you're gonna get that weakness because it's uh not got that structural integrity. If you had chosen scissors, gait, scissors gate is a very different type of gait, it basically looks like um the legs are scissors. So they cross over each other as they walk and that indicates an underlying condition um that is related to muscle weakness or spasticity, something like cerebral palsy. Antalgic gait is basically a fancy word for saying they're walking funny because they're sore and um it's, it's sort of an important thing to pick up that is different from a pathological gait with an underlying cause. The Trendelenburg gait is caused by unilateral weakness of the hip abductors. Uh and it primarily affects the gluteal musculature. This results in the pelvis tilting downwards on the non weight bearing limb. So the weight bearing limb is this one here. The non weight bearing limb is here. But you can see the pelvis has gone down this way to compensate for this. The lateral engages, uh the individual engages in a lateral tilt of the trunk away from the affected hip. So the affected hip is here and you see how they've sort of twisted laterally or they've, they've gone a bit sideways here. And this gives them a very, very characteristic walk that I'd highly recommend watching on youtube if you can just so you know it and it's in your head POSTOP Mr Itis will be getting good analgesia and physiotherapy. So he can get up and weight bearing and eventually back to his dog walking as well as thromboprophylaxis because all surgical patients are at higher risk of thrombosis from decreased mobility. And he may also get a falls risk assessment. Uh about half of patients presenting with a first fall will have another fall within the next 12 months. Recurring falls are linked to increased risks of fractures, increased mortality and also higher rates of hospitalization. They also result in a loss of confidence, fear of falling and diminished quality of life, which can further aggravate the situation. So it's something that's very important to consider doing with patients who come in with falls. Uh It might also be worth doing an axial bone density densitometry. Er, and that's indicated um if he would likely had uh a fracture because of osteoporosis. Um but in, in Mr Itis case, he fell over his dog. So it's somewhat unlikely, healthy young and physiologically fit individuals with uncomplicated fractures tend to have really good prognosis. Whereas frail, more elderly patients are unlikely to fully recover from a neck of femur fracture, even though with the best care provided, around one third of patients will die in the first uh in the 12 months. Uh neck of feur fractures have a significant impact on quality of life and functional status of patients. Um But a total hip replacement can do wonders only around half of the patients will return to their baseline function, but we'll do our best to take care of Mr Itis. We've now reached the end of our case. Hurra. Uh It's now that Mr Itis has been successfully transferred to the ICU for recovery. You've bid on farewell and safe travels. When you check the theater list, you see that an aura is happening next. And with that, I will pass you on to an N whenever you're ready. Sure. Hello. I'm going to take over from drinking. I'll just please share my slides. Is that was good. Yup. All working. Yeah, that's good. Well, welcome again. Once again, my name is Anna and I'm gonna take you from Jingjing and cover our second scenario and it's going to be on open reduction and internal fixation otherwise abbreviated to or if it is a type of surgery. But before we go into that, we'll just go over the learning objectives. So you have a better idea of what you'll ideally take away from this case. The main things I want you to look at are getting to terms with the the types of distal radius fractures. Uh Also the key clinical features, investigations, management and complications of distal radius fractures, and just some of the more general principles of fracture management. Well, I only need you to walk with a little bit of an idea of what's what's generally happening or if you don't, you're not going to be an expert by the end of this. But it's good to see these things just so that you're familiar with it if you do ever get the opportunity to see in person. And lastly, but potentially, most importantly for you is to get an idea of the anatomy that you'll potentially see during these procedures. So for this scenario, we'll be looking at specifically an or of the distal radius and we want to cover this as an upper limb case because distal radius fractures are incredibly common. So they usually are seen in either very young, so 5 to 15 year olds or in the elderly because it is associated with fragility, which is something we often seen in elderly. But either of these age groups can have it because the mechanism of injury remains the same. It is often a foot injury. And if you've never heard of that before, FFO OS H stands for fracture. Um sorry, fall on outstretched hands. So if you can just imagine yourself falling forward and putting your hands out straight, you can imagine that your wrists and the palm of your hands is going to impact the ground first. And the pathophysiology of this without going into the nitty gritty is that your scaphoid bone will most likely impact first. However, about 4/5 of the axial load will go to the radius and because of the way that your wrist will suen and pronate during the fall, it usually can result in a fracture of the distal radius. There are different types of distal radius fractures. Though the most common one that you'll most likely have heard of is col these fractures. Col fractures are what happens when you do have a foot injury. The main differences in these is where you have the fracture as well as the direction that the bone fragment moves in. So both Collies and Smiths are transverse extraarticular fractures, which is to say it doesn't, uh the fracture itself doesn't cross the joint space. Uh but in collies, you have a dorsal displacement of the bone fragment, which is to say that it's going backwards. If you can look at your wrist, think of the bone fragment pushing further into the back of your wrist. Whereas in Smith's, you have a volar displacement. So that fragment will go forward. The reason why you have a collies when you have a foot injury is because when you impact that bone fragment is going to go blow backwards. Whereas in a Smith, you're going to likely have a Smith fracture if you fall onto your wrists while they're flexed. So if you flex your wrist as far as they can go inward, and if you imagine yourself falling onto that, it's easy to visualize how the tip of your radius can then fall forward. So those are the two main ones. Collies and Smiths. Smiths can even be known as reverse collies just because they're so similar to each other. It's just two different directions and two different uh mechanisms of injury. Whereas you have Barton's fractures, Barton's fractures are comparatively rare. However, this is an intraarticular fracture as opposed to the extraarticular, it crosses the joint, the joint space and it can either dis it can displace in either direction. However, because it is an intraarticular fracture, it's much more complicated to treat and it won't heal as well and multiple bones can be involved. However, we won't go into too much details about that for now, so looking further into distal radius fractures, the risk factors are mainly to do with osteoporosis. And from there, you can kind of make a mental network of the risk factors just from that one sentence. What can cause osteoporosis? You already most likely know that increasing age will decrease bone density and you'll have osteoporosis. Similar is found in female in the female gender as well as those who suffer from early menopause smoking and chronic steroids are also a common cause of osteoporosis. And all of these together is what usually results in these fractures from happening more so in the elderly. Uh And that's why these are often similar to what Jim was talking about earlier. These are low energy falls in the cases of osteoporosis. If a younger person were to have it, it might it may be a higher energy situation. The clinical features do remain the same regardless. It's always a incident of trauma, a fall followed by immediate su sudden onset pain. You may or may not see a deformity in uh a growth deformity in the hand and uh a swelling that comes on straight away. And one important takeaway is that you always have to remember to check for neurovascular compromise of the hand and also to examine the joints above because this will tell you whether there's any neurological involvement, what's the state of the vasculature? And if there's any bleeding and moving on, the last thing to say, is, the investigations are quite simple. You're wanting a plain x-ray in 99% of the time. The only times that you would need act or an MRI is if, if either a particularly complex case or if you're, if the orthopedic surgeon is wanting it preoperative, we need to look at things in more detail. And lastly, we'll just talk about the complications as well before we move on to the surgery. It's the, these complications are mainly if the distal radius fracture is untreated. However, do keep in mind that even post treatment and post surgery or even post when these uh complications can occur. Just they're the, they're less likely. The main one to touch on is malunion. Malunion is where you have poor realignment of the bones and this leads to a shortened radius compared to the ulnar. And you can imagine how this can then lead to reduced wrist, wrist motion. You can have wrist pain and also reduced forearm rotation. Uh If this does occur, you'll most likely have to treat this, uh with corrective osteotomy. Uh Otherwise, the patient will have long term consequences of this. Uh The only other things to mention is that you can have a medium nerve compression depending on the way that the bone fragments move and osteoarthritis from things rubbing each other wrong and the irritation over time moving on. We'll just touch on the basic principles of fracture management as well. Uh A general framework to have in your head for managing any fracture is reduce, hold rehabilitate. It's as easy as reduced cycle, but just apply to orthopedics. Reducing is a fancy way of saying you want to put things back where they are restore anatomical alignment. You do this by correcting the forces that were applied to it. You usually do the same thing that happened to it and this uh alignment will help with the uh tampon the bleeding. And you can also help to reduce traction on the surrounding soft tissue and nerves as well as the blood vessels around the frac the fracture site. Holding is another fancy way of saying, immobilizing the fracture. You just want to make sure things aren't moving and getting worse. The main thing to think about here is whether there is a need for traction. So um this will most be most important in fractures such as neck or femur fractures. Like what was just mentioned, femoral shaft fractures, displaced acetabular fractures and most things in the hips and the pelvis. And this is because there's a lot of very strong muscles that apply quite a strong muscular pull across the fracture site. And this makes the fracture site quite uh unstable. Hence the need for mm traction and hold, rehabilitate is quite simple. It's just that after you've mm uh done your management, you want to always consider physiotherapy afterwards because it is a patient and you want to try and bring them back to as close to their baseline as possible. Ok. And now we're going to get into the details of this. The first thing we're going to look at is the for forearm anatomy and the best place to start is as deep as possible with the bones. Um Most of you will recognize the picture on the left. It is a picture of mm the hands bone, the forearms, bones with the radius on the la lateral side and the on the media, sitting media. The picture on the right shows you a bit more detail and more uh labeling. But the main thing I want you to take away from the picture on the right is this the membrane that sits between the two bones. So that's the interosseous membrane of the forearm. This is going to be key for understanding the muscular compartments of the forearm and also just getting an idea of what the two bones look like. So you can tell them apart easier on uh scans and such. So one tip is that the radius usually has a wider di uh distally. However, it can be deceiving uh in size because the ulnar is actually a much larger bone and mainly it's from the epon that that is in contact with the humerus. This is looking at the bones of the wrist, there is eight carpal bones and I won't make you learn all of them. However, it's important to look at this and try to pick out what's most important and relevant here. And I would say that the most relevant thing is what's highlighted in green. That's the scaphoid bone. So the scold bone is one of the things that you would be worried about fracturing during first falls. However, and it is the main bone that is transferring the energy to the radius apart from the scale for you'd also be considering the lunate as well as potentially the trapezium bone. Mm But it is worthwhile getting to grips with the uh pun intended. Uh getting to grips with the wrist bones. There's eight of them just get an idea of where they are. And if nothing else remember the peloid and we keeping that in mind, we can now look at the the real meat of the anatomy once again pun intended. Uh and that's the muscles of the forearm. The forearm has a whopping 20 muscles and it's split into two compartments. The anterior compartment, otherwise known as the Bolar compartment and the posterior compartment sometimes addressed as the dorsal compartment. Um You can see from this white line here that this is the interosseous membrane that lies between the radius and the ulnar. And this is this whole thing that's separating these two com compartments. And you have the anterior here and the posterior split here. The anterior compartment has eight muscles split into another three subsections. So you have four in the superficial layer, only one in the intermediate and three in the deep, the posterior compartment only has 22 subsections. You have seven superficial and five deep muscles. We'll look at each of these in turn and break it down. Looking at the anterior compartment as a whole. First, you can see a highlighted diagram on the right that just shows you all of the muscles in a cross section. Um The general function of the anterior compartment is all to do with flexion. It is the flexor compartment. It's flexion of both the fingers and the wrist. Everything. Mhm All the muscles are anterior to this intraosseous membrane that we looked at before. And in terms of nerves and blood, blood supply, the nerve supplies mainly from either the median or the ulnar nerve and the blood supply. What looking proximately is from the brachial or ulnar arteries. But when you get further distal, it becomes a larger portion from the radial and ulnar arteries. Looking first at potentially the most important or often questioned um compartment, sub compartment of the forearm. It's the superficial anterior compartment. There are four muscles here there, there's the prona teres, the flexor carpi, radialis, the palmaris, longus and the flexor carpi ulnaris. You can, there's a helpful picture on the bottom left showing a movement you could do with your own own hands if you put your fingers across your other arm with just four of them and lay it with your pinky sitting on the medial side and if you can remember that it starts with prosal teres and then it goes straight into a flexor and mhm Looking at the naming is going to what's is going to be, what helps you remember them? It goes into flexor carpi radialis and it skips one before another flexor, the palmaris longest. Oh, sorry, I'll break it down. Uh Let's look at each turn. The pronator teres, the pronator teres is um it's a muscle that forms the middle border of the cubital fossa of the anterior elbow. It's uh functionally very important because it helps with uh wrist flexion. However, it's the one that doesn't go very far as you can see is highlighted in yellow. It's the other three where you'll encounter in wrist surgery as we'll see later. An important one is the F cr the F cr is a medial muscle. It's in the superficial layer and it's relatively um broad and it connects right into the middle of the wrist. And you will be able to see this and its neighbor is the palmaris longus, the palmaris longus. Unlike the FCR is less functionally important, it's less functionally important to the extent that it's often used for grafts and it's even not present in a lot of people. It's only, it can be not present in about 15% of people. And the last thing to look at is the flexor carpi ulnaris and it is a mimic of the radialis just on the ulnar side, one thing to say now is if I just go back here, there is a naming system that's used for all of these muscles and it can be quite daunting to look at them just as a list. So my suggestion is to break down the words as much as you can ask yourself. Is it a flexor or extensor that will tell you which compartment it it's in and it's also in the names. Does what, what does the muscle move? If it says digitorum, that is um talking about the digits in the fingers. That means it's either flexing or extending the fingers. If it's something carpi, it's talking about the carpal bones. If that means wrist, it means it's either flexing or ascending the wrist. And the last thing to remember is Pollicis Pollicis is talking about the thumb. Is it abducting, abducting or just controlling the thumb in some way? And the only other thing, oh, actually, there's two other things. There is radialis and ulnar and it kind of tells you whether it's on the radial side. So the lateral side of the arm or if it's on the ulnar side of the arm, medial, occasionally you'll find either the words Longus and Brevis. This just means that there is a pair of similarly named muscles and one of them is longer and the other one is shorter. The longer one is longest, the shorter one is Brevis. Keep this structure in mind as we look at all of these muscles, because it can help you understand, looking at this diagram, you can now see the nerves will always be on the medial side. And it can help you remember that moving on the intermediate compartment of the uh anterior side has only one muscle and it's a flexor deorum superficialis. There's, although it's an important muscle, there's nothing too special to say here. Apart from it does have two heads and the, the ulnar um sorry, the median nerve and the ulnar artery pass between these two heads and they travel posteriorly. The, in terms of naming it's just useful to remember that it's a flexor digitorum superficialis and there's one below it in the deep compartment called the Fletcher digitorum profundus. This one is functionally much more important. I like to think of it as it's a flexor, it's digitorum. So it's working on the fingers. Profundus, it's a profound flexor of the fingers. It's very functionally important. Flexor pollicis. Longus is a powerful thumb, flexor, pollicis and prona quadratus is, it's just another m muscle. You can think of it as a pair to the pronator teres, which is a superficial muscle and it just helps to stabili, stabilize the format uh pronation of the wrist. And you can think of it as a helper muscle to the superficial pronator teres moving on to the posterior compartment. Uh We have yes. Uh uh it highlighted in yellow, you can see that it's mainly to do with wrist and finger extension and it involves the thumbs as well. It's posterior to the o intraosseous membrane. And it's supplied by the intraosseous branch of the radial nerve blood supply is very um uh not quite the same, sorry, it's the radial recurrent and this um in interosseous arteries that branch off from that. In terms of muscle, there is seven in the superficial compartment, there is seven of these, but I'm going to try and break it down. So it's a bit easier. You can remember that. Uh there's only four things that the posterior compartment really does. It's either a forearm fixator, it either works in elbow extension and supination. It either works on the wrist and finger extension or it's for thumb adduction, brachy radialis. The first one is a forearm fixator, the extensor carpi radialis twins, they're both for wrist extension, extensor digitorum and its little brother, extensive digi digiti minimi works on finger flexion and minimi works on pinky flexion, pinky extension, sorry. And the EC U is also for wrist extension. The anconeus is the odd one out. It's just a small muscle and it supports other groups and there's not much more you need to know apart from that last but not least, it's the deep uh 45 muscles of the posterior compartment. You have the super nasi, the abductive pollicis, longus, extensive pollicis, longus extensive po brevis and extensor indices. You can tell its functions all from the name. Once again, the super, it's super risk. The, the next three are all working on the thumb to do different things. Uh And you can tell from this portion that the, the tendons called the nice anatomical snuffbox. You can see just to the side of your thumb and the extensor indices is the odd one out where it's uh looking at the extension of your index finger indices, index. That's the only memory pneumo I can give for you. That's all for the muscles. We'll just quickly touch on the vasculature before we move on. It's mainly always going to be the radial artery or the ulnar artery. The radial is the posterior vasal aspect of the forearm where it's mostly concerned with and the ulnar is the opposite anterior. This is just a cross section of everything we've been talking about. It is quite overwhelming and my advice is to just take some time to look through it and it'll get better as you understand each word that builds up the muscle name. Lastly, we look at or before getting into the case or if it stands for open reduction, internal fixation. So looking at reduction first, you have, you can have a close re reduction, which is relocating the bone into place without exposing them. This is what you'll see most of the time where people are putting bones back to place after they've been broken. How, how however occasionally you'll have to do an open reduction. This is where you're repositioning bones intraoperatively. So you are able to visualize the fracture as you reduce them. The second part of the procedures, the internal fixation, this is just a method of reconnecting the bones using all sorts of hardware screws, wires, nails, plates, and this is to achieve proper alignment and to aim for normal healing. The times that you do, uh the oral procedure is after conservative treatment is no longer an option. You'd always want to do conservative, which is using analgesia and splints. But if it's particularly complex, if you have a risk of abnormal healing, because the fra is misaligned. If it's open or otherwise, then you have to consider an o risk and it is quite an intense procedure because you can tell uh that it takes 3 to 12 months to heal. And this is just uh a visualization of what it can look like. And uh some of the instrumentation that's used. So you can see the plate in green and brown as well as the screws and the aiming guides are just to help with the screws in. And that's uh what you might encounter is K wire. So K wire is uh abbreviation of K wire commonly used in orthopedics just to hold uh these plates in place while you screw things in or you check other things using the radiology. Now, I'm gonna give you the quick content warning before we get into the case. This is where the procedure starts. If you do at any point, feel woozy or nauseous, feel free to sit up and come back in whenever you'd like. Cause there might be some graphic images. This is our patient's vignette. We are looking at a patient who is 16 year old, a female and her name is Brooklyn Reese. She went rollerblading with her friends and was too cool to wear any safety equipment. And unfortunately, was going quite fast when she fell onto the pavement with her arms outstretched in front of her. She has no past medical history. And the only drug mm uh medicine she's taking is DC OCP. This is the x-ray that the consultant shows you uh before the surgery begins, you can have a good look. Uh and this is from two different angles. But whilst you look at that, we can look at the first question. So based on the patient's x-ray, what classic sign or deformity? Is this wrist activity? Is it a the garden spade deformity? B the dinner fork or three, the waveform? So we've got six repo responses so far and 83 5% are going for dinner fork. Uh Great uh thinner fork. That is correct. The consultant smiles and not to her head, you've done a great job. You see this once and it's hard to ever forget. This is a classic thinner fork that you see. It's where you have the dorsal displacement of the fracture site, uh the distal radial head. And that's what results in that bend in the wrist just before you see the hands. This, I'll show you the other al alternative answers as well. So this would be the garden spade. You can see how it's different from the dinner sport because this mix fracture results in a molar displacement. So you have a wrist that comes further inwards and looking more like a garden spade. And lastly, there was no such thing as a waveform deformity and we'll move on there to the next part. You see that the patient is now being put under general anesthetic and the right arm is pretend the limb is exsanguinated and the tourniquet is inflated to 2 50 mg mm millimeters of Mer Mer Mercury. The surgeon grabs their scalpel and starts to make a first incision. What tendon is this over? Ok. So what you're seeing on the top, right is the tendon sheath of the tendon that um in that I'm asking about. But if you can recall back to the slides of the superficial muscle that might give you a hint. So we've got six responses from my side and we're going for a flexor digitorum superficialis with 75% right. I'll click that and oh, you've met with the specialty by your start, looks at you questioningly and says that you've got your superficial muscles topsy turvy, there's only 20 muscles in the form. How hard could this be? And that is me admission, how difficult this is. I'll show you the correct answer. And it was the flexor carpi radialis. It's quite difficult to differentiate. But if you can remember that in the middle of your wrist, the two tendons you're most likely to encounter are either the flexor carpi radialis or the palmaris longus because you, you can tell that the flexor carpi ulnaris will run quite medial and the pronator teres is quite short and doesn't go that as far. Um So superficially. So you have the choice between the two and the flexor carpi radialis is the more consistent uh tendon that you find and is the better anatomical uh landmark to even finding say the radial pulse. So that's that was the answer here. You can see the tendon was exposed. Once the F cr sees is in incised from the top, the F the F cr is mobilized in the picture. It's just slightly in white here and it's moved this way. It's um to expose the floor of the F cr tendon sheath. So the, the sheath below that tendon, it's this is also excised and the F pl tendon is re retracted, ulnarly to expose the pronator quadra. The pronator quadratus is cut to expose the fracture site. Next, this is the fracture site as you can see it after it's been irrigated and cleaned of any other bone fragments that you might see around it. Uh You are now going to perform the open reduction. What's the first step in the reduction for this case? Is it a traction and flex the wrist, a traction and extend the wrist or just traction? You can maintain the extraction, maintain the traction. So, on my screen, I've got six responses but it's 5050 currently. Does anyone want to break the, the tiebreaker? What is the 5050 for 5050 between traction and flex the wrist and traction and extend the wrist? Oh, we're going with traction and extend the wrist sev, 57% kudos to whoever broke the tie because that is correct. Uh It's, you may think that you'd want to flex the wrist because that seems to be all corrected. But in reality, it's the opposite of what you would think helps. Um It was not traction and flection because I'll, I'll show you a diagram after this and it's not extended traction because that's something we only do in closed reductions to tire out the soft tissue if it's too stiff to reduce by itself because maintaining traction can just tire things out. So this is a diagram of what you, you'd want to do with traction. You'd want to the top left shows traction and then the extension will pull the fragment out further and this will allow for you to push it back into place. So you, you don't want to skip the extension before you do the flexion essentially. And this is a blurry picture of them, quote unquote, opening the book and extending the surgical site. And last question, it's the plate has been applied to the volar surface of the radius and the K wires hold the plate in place while the screws are put in and the proximal shaft mm uh into the proximal shaft through an over hole. What is the next step after the screw is put into the proximal shaft? Is it to repeat an X ray? Is it to repair the pro teres or to align the screws for distal plate implantation? We've got seven responses and we're going with repeat X ray. That is correct. Good job. Uh the consultant nos your head. That's right. We want radiographs to assess the provisional plate application before we do anything to the distal site. So, as you can see from the top left, this is after they have done the x-rays and they're comfortable with the position because if you don't uh x-ray first and your proximal plate has been screwed into the wrong place, you're essentially stuck and you don't want that. Hence why you always check first with the x-ray. This is a clear picture on the bottom left of what that would look like. And what's done is they use a torque limiting screwdriver to just finish all of the mm everything up at the end and to ensure screw capture, I'll whiz through considering the time uh Miss Reese is now transferred over to the recovery room after they've closed her up and you get managed a chance to catch your breath, but you don't want to wait around too long because there is an emergency fasciotomy coming. I will pass you over two crystal with case three. Sounds good. Um Can everyone see my side? Yes, we can. Yeah. Ok, perfect. So hi guys, I'm Crystal from my part of the teaching. I'll be covering fasciotomy for the management of acute compartment syndrome. Compartment syndrome can occur anywhere in the body. But for the session, I'll only be focusing on the lower legs. So that's anything below the knee but above the ankle. Um I am also aware of the time, so I'll try to make things quick. So here are learning objectives. So by the end of the teaching session, you'll hopefully be able to identify the anatomy of the lower limb relevant to fasciotomy. Understand the pathophysiology, clinical features and investigations of compartment syndrome, explain fasciotomy in the management of compartment syndrome, including its possible complications and apply this knowledge of the above two relevant um MC Qs. So as with any type of learning, we need to have a good foundation of knowledge before we get into the nitty gritty, clinical aspects of things. And so it's quite important for us to understand a bit about the anatomy first to really make sense of the condition and its management. So in our lower leg, we have two bones, the tibia and the fibula, the tibia, which is also known as the shin bone is located at the front of the leg, as you can see here. Um and its main function is to weight, bear in the lateral aspect of the leg. Right here, we have the fibula and that, that's main, its main function is to act as an attachment to the muscles. So the muscles in the body together with some blood vessels and nerves that supply them are organized into compartments. Um Each of which are encased in a thin but tough membrane called fascia. The main function of the fascia is to keep the muscles in place and therefore, its ability to expand is quite limited. Um In the lower leg, we have four muscle compartments. So we have the anterior, anterior, lateral, superficial posterior and deep posterior. In the anterior compartment. There are three main muscles, the tibialis anterior, the extensor helicis longus and the extensor digi tori longus. The tibialis anterior muscle is located alongside um the lateral surface of the tibia. Um Then we have the extensor, he he uh sorry, the extensor digitorum longus, which is right here. And that lies lateral and deep to the tibialis anterior. And lastly, we have the extensor hallucis longus, which is positioned deep to the tibialis, anterior and extensor digital longus. And all of the muscle in the anterior compartment are innervated by the deep peri perineal nerve, which is also known as deep fibular nerve and their blood supply comes from the anterior tibial artery. The key functions of the muscles in the anterior compartment is to enable dorsiflexion. So when you draw your foot back towards your shin and extension of the toes, the tibialis anterior and flexor hallucis longus also plays a role in the inversion of the foot. So just before I go on to the next compartment, I'd just like to note that there is another muscle in this compartment called the fibularis tertius muscle, which is not on the slide. Um It is thought to arise from the most distal part of the extensor digitorum longus and it is not present in all individuals, but it's just good to be aware of it. So, in the lateral compartment of the leg, we have two muscles, the perineal longus and the perineal brevis. The perineal longus is the larger and more superficial of the two um which you can see here. And the second muscle is the perineal brevis right here, which is deeper and shorter um than the perineal longus. They are both innervated by the superficial perineal nerve and their function is for plantar flexion. So, moving the foot in a downward motion away from the bo the body and eversion. So turning the sole of the foot outward. Yeah. So the posterior compartments are divided into superficial and deep. The superficial compartments has three muscles. The gastrocnemius is the most superficial of the muscles in the posterior leg. It forms the characteristic calf shape of the leg. Um The soleus is a flat muscle located underneath the ga gastrocnemius and deep to both of the soleus and the gastrocnemius muscles lie the plantaris muscle right here. Um They are innervated by the sural nerve which is formed by the union of um the lateral and median cutaneous nerve. Ok. So the deep posterior compartment has four muscles. The Popliteus is located behind the knee joint and acts only on that um joint. So here and the flexor digitorum longus is a thin muscle and it's located media medially within the posterior leg. Um The flexor hallucis longus muscle is located laterally which is funnily counterintuitive because its function is to flex the big toe, but it's on the opposite side of the big toe. Um And lastly, the tibialis posterior, which is the deepest um of out of the four muscles and lies between the flexor digitorum longus and the flexor hallucis longus. So, yeah. So the muscles in the deep posterior compartments are innervated by the tibial nerve with its blood supply, mainly coming from posterior tibial vessels. The main function of these muscles in the posterior compartments are to plan to flex and invert the foot. So we've gone over the different compartments of the lower leg quite quickly. Now, let's talk about the compartment syndrome. So compartment syndrome is when the pressure inside a compartment or multiple compartments increase beyond the capability of fascia stretch. Um Here on the bottom right is a diagram representing of representing all of the muscle compartments in the lower leg, swelling up and compartment syndrome. This increase in pressure that we see leads to compression of neurovascular bundles. Um due to the increase in compartmental pressure, there is a reduction in venous outflow um and this causes pooling of blood in the compartment further aggravating the whole process. And if the pressure within the compartment gets even higher than arterial inflow to the compartment is compromised. And if you have have both venous and arterial supply being compromised, this can result in decreased oxygenation of tissues causing ischemia. And if the deficit of oxygenation becomes high enough, then you can cause irreversible cell death. Um So compartment syndrome can be categorized as either acute or chronic in acute compartment syndrome. It al often follows uh trauma or cast or large bandage bandages that are too tight. Um Also the use of anabolic steroid can cause acute compartment syndrome as this can increase muscle mass too quickly. Um and also the sudden return of blood flow after it was blocked for a long time can cause acute compartment syndromes. So for example, during a surgery or loss of consciousness, chronic compartment syndrome develops with muscle overuse and commonly occurs in athletes or military personnel. For the purpose of the talk, I will focus on acute compartment syndrome. So acute compartment syndrome typically occurs within a few hours of incising the trauma. However, it can present up to 48 hours after the earliest physical finding is the tense or some people describe it as a wood like feeling of that compartment. Um Pain is usually severe and out of proportion to the uh injury and early on the pain may also present with passive stretching. Um may only present uh with passive stretching, but it may also be characterized as a burning sensation. So, but if the disease progresses, then you can have features of the acute limb ischemia with and this is often um referred to as the five ps. So you have pain, pallor, perish, perish ling, uh perishing cold paralysis and pulselessness. So, compartment syndrome is a clinical diagnosis. So it's based on the history and examination. Um but the most reliable diagnose, then diagnostic test is through the use of an intracompartmental pressure monitor if there is some clinical uncertainties to it. So, this is a device that detects the pressure inside a compartment by measuring the resistance that is present when saline solution is injected into the compartment. So, if the intracompartmental pressure is greater than 30 millimeter per mercury or delta pressure, less than 30 millimeter per mercury, then that indicates compartment syndrome and the delta pressure is also known as perfusion pressure. And that's just the difference between patient's the patient's diastolic BP and the compartment pressure. Um lastly CRE creatine kinase level uh from a blood test may aid diagnosis. If it's elevated when muscle cells are broken down, then creatine kinase are released into the systemic circulation in the grade box. I've listed a few differentials but just to highlight it is incredibly important to recognize compartment syndrome early and immediately to prevent devastating consequences. So now let's talk about the management of compartment sy syndrome, um specifically faso. So fasciotomy is an emergency procedure used to treat acute compartment syndrome. It involves cutting fascia to relieve pressure in the muscle compartment. There are two types that can be um uh used on the lower leg. So you can have a single incision, Fasciola, incision, fasciotomy. The double incision fasciotomy uses um medial and lateral um incisions that are longitudinal and they are 12 to 20 seve, 2012 to 20 centimeter in length. As you can see in this diagram here. Um The lateral incision is centered between the shaft of the fibula and the spine of the tibia. And the medial incision is placed 1 to 2 centimeters medial to the tibial margin. A single incision, fasciotomy uses only the lateral of these incisions. Ok. So there are a couple of things that should be performed prior to the surgery. Anesthesia should be administered usually general, but you can also give it locally, preoperative antibiotics should be given to patients as well. Um The surgical team should complete the wh o surgical safety checklist. Patients should be positioned in a supine position with the patient lying on their back. Um, and legs should be prepped and draped to above the knees. So here are just a list of the equipments that are needed during surgery. So as with all procedures, fas ostomy carries its own risk as well. These include long hospital stays, one infection, osteomyelitis, delayed bone healing, and a couple of more are listed on the slide. So, yep. All right. Now, let's get to the fun part here. We have to be Alex, a 28 year old man. He sustained an injury to his lower leg during a rugby match and he experienced immediate severe pain. He tried to walk it off but eventually struggled, pain worsened 30 minutes after injury and was admitted to emerg to the emergency department soon after he doesn't have any past medical history or any drug history of note. So just before we start off with questions, I'll just um give a quick trigger warning, I'll be showing some images from a real surgery and that might be uncomfortable for some people to watch. So feel free to take a break and come back whenever. Ok. So the consultant on the ward ushers you to come with them to observe a fasciotomy on the way to the theater, they give you a brief run through of the patient's case. The consultant stops you before you enter the room and jokingly half jokingly tells you that you can only come in if you answer the question correctly. After hearing the patient's history, which compartment is most likely affected a anterior compartment or B superficial posterior compartment. OK. There's six responses so far and most are going for anterior compartment. OK. Go for anterior compartment. So great. Um The anterior compartment is correct. Um But I'll just go back to the slide and I'll explain why B is incorrect. So, trauma is the commonest cause of compartment syndrome, particularly tibial fracture. Um And since the anterior compartment is directly adjacent to the tibia, then it's the most vulnerable to compartment syndrome. 00, oh, no, sorry. So, after scrubbing in the surgeon starts the procedure, they make a single incision through a lateral approach, dissecting through a fatty tissue and fascia. When they reach the layer of muscle, they point out the anti and lateral compartment to you are kind. And before they continue on with the surgery, they ask you a question, what is this structure right here? OK. So we've got seven responses. Oh or eight responses and it's a 5050. Oh, nice. OK. Uh What should I go for? I'll, I'll go for B. So B is incorrect. It is not the great saphenous vein. Um The superficial perineal nerve is the most commonly injured nerve during faso of the leg. And this nerve descends in its normal chus in the lateral compartment adjacent to the intermuscular septum of the anterior and lateral compartments. The great saphenous veins how uh vein however, runs up the medial side of the leg. So, superficial, peroneal nerve is lateral and um the great saphenous vein is medial. And since we're looking at a single incision that's on the lateral side, then it's more likely to be the um peroneal nerve. Yeah. So upon seeing your enthusiasm for the procedure, the surgeon fires another question at you. What device can we use to test out muscle viability? I've got six responses on my side and it's 5050 again. Mm. Yeah, because both of the answers are correct. Um So following fasciotomy, the viability of the muscles is, is insured with diathermy or forceps in just muscle contractions and then the non viable muscle mass is divided and hemostasis is insured. So the surgeon is finishing up with the fasciotomy. They look up at you and see you staring keenly at what they are doing. They grin mischievously. I've got one last question for you. Should the fasciotomy skin incisions be left open? A yes or no. Yeah. Yeah, most are going with. Yes. Ok. So yeah, that is correct. And I'll just quickly explain why no is wrong. So after a fasciotomy, the wound is usually managed open and dressed thoroughly with moist dressings to protect the tissue from drying and traction. Early primary wound closure is not recommended as it may lead to increased muscle pressure and recurrent compartment syndrome, which is not good. That's not what we want it also makes it easier to assess for any dead tissue that needs to be debrided and if the remaining tissues are healthy, then the wounds can be closed. Yeah. So, ok, so I guess that is me done with my part. We've covered the anatomy of the lower limb, went over compartment syndrome and fasciotomy for its management. And we also went through MC QS to test our new knowledge. So that's absolutely amazing guys. Um Thanks for listening to, to my teaching and I'll just pass it over to Jing Jing again then, right. So we're gonna have a couple of MC QS just to check that you were listening. Thank you very much to Chris and N for teaching. Um Starting with question one on the next slide. Uh damage to what artery results in avascular necrosis of the femoral head. So that's death of the femoral head because you don't have blood supply. I. Ok. Ok. Yes. Right. We've got nine responses and 44% of you are going with medial femoral circumflex artery and you would be correct. Absolutely. So the medial femoral circumflex artery is the main supplier of the femoral head. Although the lateral femoral circumflex artery uh does supply a bit. It's the medial femoral circumflex artery that supplies the majority of the femoral head. And if it is uh cut off, for example, in an intracapsular neck femur fracture, then you're likely to get AVN and will need a total hip replacement or hemiarthroplasty. I'll pass on to Nan for the next. Yep. So the second question is about the muscles of the deep anterior compartment of the forearm. One of these muscles is a deep uh muscle. And the question is, which one of them is it? Mhm. Since we've had seven responses so far with the majority being uh for flex surgery to and Profundus. Uh Unfortunately, that's not the right answer. The real answer is pro quadratus because if you remember uh day three deep anterior compartment muscles are, oh, that is completely my mistake. I've included two of them. So you are actually correct flexor this term, Profundus. Uh quads are both the muscles and the additional one flex lungs. That is my mistake, a good job for getting the two of them right? Uh Pro pro teres is one of the superficial ones and it's the more important counterpart of the two pronatal muscles. Perna quadra is a more of a helper muscle for the pronatal teres. Sorry about that. I'll pass you one. OK. So the third question is, what are the ranges for compartment pressure and perfusion pressure to prompt an emergency fasciotomy. I've just added this question in to, to know whether you guys were listening. Yeah. Mhm Yeah. OK. OK. Yes. OK. OK. Yeah. OK. I've only got three responses from my side but um all of them have gone for under 30 millim oh, like mercury and over 30 respectively. Ok. So is that c Yes, yes, that was incorrect. Unfortunately. Um So the normal tissue pressure ranges between zero and 10 millimeter per me per mercury. Um and capillary blood flow within the compartment may be compromised at pressures greater than 20 millimeters per mercury, but at pressure, greater than um 30 millimeter per mercury per mercury or delta pressure, which is perfusion pressure less than 30 millimeter per mercury. Um That's when the muscle and nerve fibers are at risk of ischemic necrosis and so urgent fas ostomy is indicated in this case. Great. Thank you very much, both Krista and Anan. Uh fantastic work. Everyone. I hope you've learned a lot today and are now able to recognize the following surgical cases seen in trauma orthopedics. If we go to the next slide, uh There are are references in case you're interested, the slides will be provided after the event. And the next slide, please. Crystal. Uh Thank you for listening. Uh That was the final session of the series. 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