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Uh I'm gonna show you how to read pelvic x rays. Um I'm gonna get you a bit more confident with suggesting management for these fractures. I'm gonna touch a little bit on some surgical anatomy around the hip that I think might be useful for you. Uh And then I'm just gonna sort of kind of gloss over some less important fractures of the femur. OK? And then throughout the talk, if you see this little symbol, it's like a little pearl, right? So the, these are the slides that if you forget everything else in the talk, if you try and remember these, you, you won't go far wrong. OK. So neck of femur fractures start with um why do you care about them, by the way, when I say neck femur fractures, this is the same as hip fractures. Um One of my consultants insisted we call them proximal femoral fractures. OK. They're all the same thing. Um But they're really important that people go on about them a lot. And the reason is, is cos they're really common, there's about 70,000 of them in the UK every year. Um And it is really expensive. It's something like 2% of the NHS budget is spent on hip fractures, ok, every year. And, um, this is by far the most common orthopedic injury we see when we're on call, uh, definitely around my neck of the woods like, um, in Norwich and Great Yarmouth and Peterborough where there's an elderly population. Um, but everywhere in the country this will be the same. Um, I think Norwich and Peterborough are like the two busiest hospitals for neck of fractures in the UK. OK. Uh And it's becoming more common with an aging population. Ok. And the reason we care about it so much is these are the figures from about 10 years ago. So about 10% of these patients used to die within a month after having a hip fracture and 30% of them would die within a year, which is pretty bad. And some of this is just because they tend to be old frail patients who might be dying of other things. Um But also we kind of think of a hip fracture as a sort of pre morbid event so that the whole trauma of going through this fracture and going through the operation does shorten your life expectancy. And then another reason why we care about you so much is something called a best practice tariff. OK. So basically this is a sort of nice guidance uh thing. It's a bit like if you've done a GP um placement, those Q targets they have where they get a 50 P or whatever it is for checking someone's asthma review on time. This is like a bigger version of that. So if you do all of these other things, the trust gets 450 quid. Ok. Um, which doesn't sound like that much, but actually, the trusts care about it a lot and they put a lot of energy into doing this and actually, since this was implemented about 10 years ago, the 30 day mortality for these patients has almost halved. So money does talk. All right. Um So I'm just going to skip through this list of seven. Basically, there's two in here that we can actually influence as doctors. The first is number one. So getting these patients operated on within 36 hours. So that's seeing them quickly in A&E uh making sure they're all worked up properly for an operation. Uh, you know, making sure they've got a group and age ready and all that sort of stuff trying to minimize delays to theater. And then, uh the other thing that we can influence is doing a MT S scores. You know, there's little memory tests out of 10 on the patients. So you can imagine, you know, if you, you only get the 450 quid, if you do all seven of these things. So if you as the doctor forget to do this score, then that's 450 quid down the drain, you know, just because you didn't spend 30 seconds doing this score. Ok. So I just wanted to go through how you actually assess a patient with a neck of femur fracture. So I've put up here assessing enough now, you know, in hospitals how you get um all patients were referred to by their injury, right? So you go, oh there's a disor radius in bed four or there's a, you know, an appendix inside from two. So I don't really like that actually cos it kind of dehumanizes the patient a little bit and you got to remember that there is a patient at the end of this, but everyone in hospitals refers to these patients as kns. OK? But what they mean is a patient with an edema fracture. Ok. So let's say you're the sh you're on call, you, you're asked to see a patient with ne femur fracture. So the first thing that comes into your head is, well, it's the fracture itself. So I'm an orthopod. So I like to think about the fracture first. OK. Um So these are all the things you're starting to think about. So is it intra and extra capsular, we'll come on to that later, you know, have they had adequate pain relief, uh fascial blocks, I'll talk about a bit. Um What was their premorbid status? So what I mean by that is what was their mobility like before they fell over? Basically? So, were they using a frame? Were they using a stick? You know, were they, were they walking five miles a day? All of that stuff is really important as you'll find out. Then I'm thinking about consenting them. So, can they consent or do they have dementia? Uh You've got to speak to the family to make sure they're on board and they know the patient's gonna be in the hospital for about two weeks and they're gonna have a high risk operation. And then you're thinking about planning for theater, ok? And a lot of people just think about this side of things, ok? They just think about the fracture and they don't think about anything else, but there's a lot more to think about. So the other stuff you got to think about is other injuries with these patients, ok? So there's something called silver Traa, which which is this idea that basically all frail people when they have low energy mechanisms of injury, they often get the same kind of injuries that you or I would if we had a high energy mechanism of injury. So if, if I was in a car crash, I might get the same injuries as an old person if they fell over, ok? So you've gotta kind of treat them a bit like a high energy injury, right? So II actually only started doing this a couple of years ago, but I now all my neck of femur fracture patients when I admit them, I do a secondary survey on them. So I literally feel down from head to toe, feeling all the limbs, making sure there's no missed injuries. Ok? Um You of course, looking for the big stuff, ok? Like the head injuries, the intracranial bleeds, the c spine injuries, the rib fractures and hemothorax and pneumothorax and pelvic fractures and all that kind of exciting stuff that might kill the patient in the next hour. But you're also thinking about more innocuous stuff. So things like a distal radius fracture, right? That's really easily missed in the context of enough. But if you've got a neck femur fracture and a distal radius fracture, your mortality is double than if you just had a neck of femur fracture, ok? Because they can't mobilize as well on the frame. So they'll be bedbound for longer. So they're more likely to get chest infections, all that sort of stuff. So you really want to think about all this other stuff and then the orthopods worst nightmare. You've got to think about their medical issues. So these patients are often the sickest and most medically complex patients in the hospital. Ok. So they might have pacemakers or implanted defibrillators. So they'll need to be checked preoperatively. They might have heart failure. So they might need an echo preoperatively. They might have had heart attacks in the past where they might have stents. So they might be on clopidogrel. So you've got to kind of weigh up. Do you stop it and increase the risk of the heart attack but reduce the risk of intraoperative bleeding. Loads of them are on af and luckily, uh lots of them don't take warfarin anymore, but they are on things like Apixaban. Ok. Which needs to be stopped. Do they have COPD? And are they on home oxygen? So they might need a spinal anesthetic instead of a general anesthetic? Loads of them have uh pneumonias and UTI S and things like that, which is what's caused them to fall over. So if in any doubt, get a chest X ray start on antibiotics and quite a few of them have cancer and they have metastases which have caused them to have pathological fractures. So their leg is just keep them way underneath them because there's a met there. So there's loads of things that and you know, this list is literally endless. But basically my point is you can't just focus on the fracture. You, you genuinely have got a look at the patient as a whole. OK. This is just a quick slide on the fascia iliaca block. OK. So this is basically something that all Neema fracture patients should get in A&E it's done by A&E doctors. So if you end up with an A&E job, this is the kind of thing you'll be doing. Ok? And basically the point of it is to try and get a local anesthetic around your femoral nerve basically um to reduce the pain coming from the hip. And that means we don't have to give quite so many opioids, um analgesia to these patients, which you know, they've also often got dodgy kidneys and things like that. So you don't want to overload them on opioids. So that's the point of this, more and more this has been done with ultrasounds. Ok? But um mo most of the time it probably still is done with the landmark techniques. I thought I just walk you through how to do this. OK. So basically you're on the affected side, you draw a line from the aci to the pubic tubercle. OK? And then you divide that line to three and at the junction of the medial third and the middle third is where all your nasty stuff is. So your artery, your vein and your nerve that you want to avoid and then on the junction of your outer third and your middle third, one finger's breath below is where you inject. And basically you put your needle in, you feel two pops, you feel a pop as you go through the fascial lata and you feel another pop as you go through the fascia Iliaca and you try to get into this space and you fill it up with a long acting local anesthetic. OK. So that's the fascial IAC a block. It doesn't always work, but it works most of the time. OK? And um it's not often done, but you can repeat these as well. So it lasts about six hours. If somebody's got a delay to theater or something and they're in a load of pain, you can do these repeatedly. OK. All right. We're just gonna go on to a bit of anatomy now. Um, I just wanna make a quick point. I don't have a slide for this, but I just wanted to say that. Um, I remember when I was a medical student, I was thinking, well, hang on. These patients are really old and frail. Why are we doing operations on them? And basically, this is seen as a life saving operation. So, um, if somebody's broken a hip, they can't walk. Ok, if um, your object is to get them up and walking as quickly as possible. Um, the alternative to surgery is letting them lie in bed for about eight weeks. Ok, waiting for it to heal naturally, which is essentially guaranteeing chest infections, uh DVTs, pressure sores, all of these complications, which will probably kill the patient. So it has been proven that although there's risk in doing a surgery with general anesthetics and all of this sort of stuff, the risk of actually not doing the surgery is greater. So that's what I tell the patients. So unless somebody is literally bed bound before they have their fall, um, surgery is almost always the right thing to do for these patients. Ok. So blood flow to the femal head. I'm sure you all know this, but I'm just going to go through it again very briefly. So, um you have your profunda femoris artery, OK. That gives off lateral and medial circumflex arteries which wrap around the neck of the femur. And then you have these guys which are called retinacular arteries which branch off from that and they supply the head. Now not shown on this diagram is there is the ligamentum teres which comes off the obturator artery to the pelvis and it goes into the femoral head. OK. That gives no blood supply to the femoral head. OK. Beyond adolescence, there is absolutely no blood supply that comes from that it is obliterated. So basically, if this, if this blood supply is disrupted, uh the femoral head will die, it will undergo avascular necrosis. OK. So what that means is that where the fracture is, is very important. So along this line here where the neck meets the trantas, this is where the capsule joints, OK? Everything inside the capsule. So here that's an intracapsular fracture. This is that's going to be through these blood vessels, these retinacular blood vessels and most likely will disrupt the blood supply of the femoral head. So what that means is you can't just fix it and sit you because the head will die. So you need to replace the head. OK. If on the other hand, the factory is outside of this capsule. So somewhere along here, it's nowhere near the blood supply. The blood supply is not affected so you can fix it. OK. So we're gonna go through that a few more times. All right. So, OK. So this is my here. OK. That's my pearl. Right? So this is probably the most important slide in the whole thing. OK. Uh This is my attempt at kind of simplifying and protocol, quite a big part of orthopedics. OK. So just, just shout out, does anyone know who this is at the top? Any anyone death, deathly silence? OK. It's the queen mother. OK. Right. So she broke her hip in the late nineties when she was in uh Sandringham in Norfolk and she was taken to er Kingsley Hospital and uh basically, as soon as she got there, she didn't want to stay. So she got helicoptered out and taken to London to have her hip fixed. So she's our neck of femur fracture patient, right? OK. And then as soon as you get one of these, you've gotta decide, are they extracapsular or are they intracapsular? So this is what we've just spoken about. So if they're extracapsular, they're in this highlighted zone here. OK. We can fix it if it's intracapsular in this yellow zone here, we've got to replace. OK. And then you split it down further. So you decided you're gonna fix it. OK. Is it quite a nice simple fracture? It's just in two pieces and the lateral wall So this bit is intact. OK. In that case, you can do a dynamic hip screw DHS. OK? I'll show you what all these things look like. If on the other hand, it's smashed to pieces, it's in four or five bits or you've got what's called subtrochanteric extension, which is that the crack is going down here somewhere into the shaft, then you need to do animu nail, an IM nail. OK? Then if we go over to the replace size, so you decide it's intracapsular, you're going to replace it here. It's all about what the patients like. Ok. So most of our patients are like Captain Tom. Alright. So they're over the age of 80 they're pretty frail. They've got comorbidities, they use some sort of walking aids and they, they might be a bit rude about Captain Tom, but they might have dementia, ok. So any of those things, most likely they're going to get a hemiarthroplasty. So they're going to get a half hip replacement. So we're going to replace the broken bit with a metal ball and we're going to leave the acetabulum alone, ok? And that will do them absolutely fine. That will last 10 years without significant problems. People do a lot better with those than we initially thought. Ok. On the other hand, if they're more like this guy and they're under the age of 70 they're fit and well, they don't have dementia, they don't need any help to walk around those patients. Actually, they probably wear out the meth on bone um that you get with a hemi arthroplasty. So those people have a total hip replacement, ok. So you replace the socket as well. So you get metal on metal and that lasts probably about twice as long. Ok? And it gives them a little bit better function, but it's a longer operation. It's got high risks for things like dislocation, ok? So it is a trade off. Now, the Eagle eyes amongst you will notice that actually there's, there's a cohort of patients that, that is missing here, right? That fit in between these two categories. And this is where the nuance comes in. Ok. So this is the new one. So this 1.6 0.3 this is from the nice guidance on hip fractures, which was updated um only about six months ago. Ok. So what this says is that we should consider total hip replacement instead of hemiarthroplasty for the following people who can walk independently outdoors with no more than one stick and they don't have any comorbidities that make the procedure unsuitable for them. So that includes dementia. Ok. And this is the new bit they're expected to be able to carry out activities of daily living independently beyond two years. Ok. So that's really hard, isn't it? So you've gotta try and look at someone with a broken hip and work out in two years time, what they're gonna be like, so basically take a message of this is this is above your pay grade. We argue about these kind of patients every day in the trauma meeting. OK? And if you asked uh you know, a load of different consultants, you'll get a load of different arguments. OK? So all we can do and II would say that at my stage as well is just make sure our history is really good. And we've got a really good social history about how good they are beforehand to enable the consultants to make the decision. OK. Right. So we're gonna try some cases now. So if you Google slider, spell it like this. OK? And you put this code in, I'm hoping uh that you will see about eight or so questions come up and this is your first one. OK? Just let me know if you can't see it for any reason or people getting on that seem to be working. So Alex um I'm able to get onto it with slider. Yeah. Um He doesn't or at least I can't see it anyway. It doesn't show the questions. Mm OK. Mm Let me try that. What about now? I've started the quiz. That's probably what I needed to do, isn't it? Oh Yeah, I think that works out great. So this is your first case. So I'll give it a couple of minutes to, to answer that as you know, I'm sure you've all seen this before. You need two views. Right. Otherwise you can't make an accurate view of the situation. So, ASIO lateral, which isn't particularly useful. Ok. One person has answered which is probably Joe, the, the voting is closed. I haven't, or at least. So the voting's clear. Yeah, I can see that. At least I haven't voted for anything so. Hm. Interesting. Ok. Fine. Well, why don't, why don't we just forget this and we'll, we'll, uh, get someone to speak up. Does anyone want to describe this? X-ray? I'll be nice to you. I promise. I can't see you. So you just have to shout out. Go on, I'll, I'll, I'll have a bit of a go, um, go on. So it's an ap of the pelvis. Uh, right pelvis and femur. Mhm. And I think that there's a fracture of the femoral neck or a proximal femoral fracture. Oh, very good. Yes. II think, or at least that to me looks intracapsular. Yeah. And which side are we talking about? Just to be absolutely clear, right side? Ok. Fantastic. And is it displaced or undisplaced? Um, well, that looks relatively undisplaced to me. Yeah. So I'd say usually with these ones, if you can see it then it's displaced. Ok. So if you do shen's line. Ok. Which is, I'll come on, I'll come on to later. You probably know this anyway. But if you trace this night, so if you, if you go on the normal side, you can see how, there's this lovely kind of smooth arc, right? All the way around here. If you do this, you go this and then you go, oh, hang on. What's this? And then you've got this bit sticks out and then it continues. Ok. So that's your break. And the fact that you can see that has moved a bit, I'd call this displaced. It's not massively displaced, but you can also see it's a bit shorter as well. This kind of head looks like it's sunk down a bit. Ok. So they're 84 they've got dementia, they're in a care home. OK. So let's go through my copyrighted algorithm. OK. So Joe, is this extra capsula or inter capsula isodes intra? Great. OK. So that means we've gotta to replace it, right? Yeah. Ok. And do you think this person's more of a Captain Tom or are they more of whatever this guy is from the beans? I mean, they've got dementia, they're in a care home. So they, the Captain Tom side, right? So he, yeah, I agree. Yeah. So that's what we did. Ok. So you can see big metal ball here. Acetabulum is still their own. Here's the metal stem that goes down and this kind of light gray stuff you can see here. That's the cement sticking it in there. Ok. Great. So I, yeah, so this was the little bit of surgical anatomy I wanted to put in um, cos Hemiarthroplasty is probably the most common operation we do. So if you're on placement in orthopedics or if you're, you know, uh a foundation doctor and you're going, you're asked to assist or something, it's probably gonna be a hemiarthroplasty. There's a good chance. Ok. So these are almost always done through this Hardinge approach, which is a direct lateral. Ok. So we're looking at this patient from the side and we're just going straight down on top of the gated cancer. OK. In line with the femur. And basically, I just wanted your takeaway message here to be. So here we go. So here we go through the fascia, gone through skin, something fat, gone through the fascia. And this is what you presented with. So I just wanted to cos you, you look at this in the, and I remember seeing this 3rd, 3rd year medical student being asked questions about what in this bloody mess, various muscles were and er I had no hope in hell, but basically simplifying it. This is what you see when they cut down to the muscle layer and on the superior end of the wound up here, this is Gluteus Medius and minimus, OK? Gluteus Medius is on top and gluteus minimus is hidden underneath. So they're your abductors A B ducts, OK? They're at the top of the wound, OK? Connected to the greater cancer, which is under here, OK? On this tendinous portion. So gluteus Medius minimus at the top and at the bottom, you've got vastus lateralis. OK. And basically, those are the only three muscles you can see on this approach. So that just keeps it really simple. So just remember gluteus medius minimus at the top, vas lateralis at the bottom and then you cut through those and you get to your uh femoral neck. OK. So just wanted to sort of touch on that right case two. OK. Is this slow working or have I done something wrong? Do you think whoever answered the first question? You got it right. Anyway, uh what can I do? Ok, I've changed and that's uh let's try this. So you should be able to see. Question four. Yeah, I think I'm on the question pool fine. So I'm not sure if they've somehow said it's only one person answer which would be a bit annoying. So one person's answers. Can anyone else answer? Oh, there we go. Seems to be working. That great. Four answers. Brilliant. Mm. Ok. Give you a couple more seconds just in case anyone else wants to answer fine. So three out of four people have said extracapsular, one person has said intracapsular. So this is, this is extra capsular. OK. So it's quite close to the neck, isn't it actually? So it's not that obvious. So I can, I can, I can see where you've gone wrong, but the correct answer is extracapsular. OK. So the break is sort of coming down here. OK. And the capsule would be touching probably around here on the neck. OK? And this is kind of a what we call a classic intratrochanteric fracture. So it's going from the greater Trant to the lesser tranter, right? So it's intertrochanteric between the two. OK? I haven't given you a lateral on this one, I don't think, but you don't really need it. So can I get you to the next question? That's the fine. So I'll put the next question up. So are you gonna fix or replace this? OK. One person says fix, OK. All four of you said to fix. OK, perfect. That is correct. OK. OK. So what are you gonna do then how are you gonna fix it? Next question is up. OK. We've got one for DHS. We've got two for DHS. We've got one for nail. What about our fourth person? The non for DHS, three for DHS, three for Dale? Yeah. OK. So let's go through our algorithm. So we've agreed it's extra capsular. OK. Cos it's kind of around here somewhere. So we're gonna fix it. And I'm guessing all people who went DHS have basically gone uh have looked at the lateral wall is intact. So here's the lateral wall, the less tranter has snapped off, but we kind of ignore that. So this is kind of a two part fracture, right? One big part here, one big part here, lateral is intact. So that would absolutely be reasonable to do a DHS having said that there are some hospitals like Peterborough who just put an iron nail in everything. Ok. So it is a little bit dealer's choice. You can argue most of these either way. But yeah, I would, I would do a DHS for this. Ok. So there we go, blah, blah, blah, blah, blah. And that's what we did. So that's what DHS looks like. Ok. So you basically have this big lag screw, OK. That's just threaded on the ends that goes up the femoral neck. Um And that's attached to a plate which has four big screws to it. OK? And the kind of interesting thing about the DHS is the thing that makes it a dynamic hip screw is that this screw can slide through this barrel. So when the patient stands on this, which they can do immediately postoperatively, it's strong enough to do that. That's the whole point. OK? This will actually slide a bit through here. The two belts, the fracture will compress together under gravity and that will help it heal. OK. So that's dynamic hips screw. OK. We have another case. Have I given you a lateral on this one? Yes, you get a lateral on this one. Uh Let me work out how to get to the next. Oops. What have I done here? Right? I hope, hoping you can see case three now. So I think case three. So I've, I've skipped everything. So I'm, I'm getting you to go straight to how you're gonna manage this. Ok. So I'm sure you can all see the fracture, but I'm gonna point it out anywhere. So it's just here, right? So it's quite, so, quite low down. Ok. Yeah. Oh, wow. We got the full spread here. Ok. Where, where's our casting vote gonna go? So at the moment we've got one for Hemiarthroplasty, we've got one for DHS. We've got one for nail is our fourth person gonna answer. Not sure. OK. Fine. So this is good. All right. So I would definitely put a nail in this. OK? So this is one of those examples. If we go back to here, this is a subtrochanteric extension. OK. So can you see how low this fracture is? OK. So just imagine if you tried to put this on this, so you'd have your big screw going up here through the head and then you'd have a plate here. And most of that whole construct will be in this bit of the fracture, right? And the only thing you'll have in this fracture is maybe one or two screws. So that's not gonna be, that's not gonna work. That's not gonna be strong enough. OK? Um Hemiarthroplasty. So remember this is an extra capsular fracture. OK. So the capsule somewhere up here. So this is well away from the capsule. OK? There's extra capsular so we can fix it. OK? We don't need to replace it. OK? So this is one for a nail. Uh Definitely. OK. So extra capsular, I'm gonna fix it because it's got a sub subtrochanteric extension. We're gonna put a nail in it. OK? And that's what a nail looks like. OK. So basically you, it's all done through like three tiny cuts. You, you make one cut just above the, the great caner here and you thread this nail down and all a nail is, it's about a one centimeter thick metal rod. OK? It's usually titanium and that you post down the int Medullary canal and then through that you sort of thread a screw which is very similar to the screw on the DHS. OK? So it goes kind of in the same place and then just out of shot down here somewhere, there's a distal locking screw. So there's another little screw that goes through the bone and through the nail just to stop the whole nail falling down in like down towards the knee. OK? So this, I would say is pretty non negotiable. It kind of has to be a nail. OK? I'm just um sorry, Alex, I was just wondering um I've got to be honest and that I've never seen this done, but more theoretically, would you do an R for those an or if? Yeah. So, so do you mean putting a big plate on there? Yeah. Yeah. Yeah. So you could um so, so you could put a big plate down here and some screws coming across. What, what do you think is the, can you think of a disadvantage of that? So if, um, if you put a big plate on someone with some screws, would you let them fully wait there on it straight after the operation? II, guess you wouldn't, would do it, it would be a bit of a risk. Ok? Because it wouldn't, it wouldn't quite be strong enough. And if you think if you do a plate kind of everything's on one side. So it would have, it would be, it would be at risk of everything tipping this way, this tipping this way and it's sort of bending at the fracture sites, whereas a nail cos it kind of goes down the center of the bone, all the weight is kind of central. So it doesn't. So basically if you do a nail like this, uh they can fully wait there on it and that is the number one priority for these frail patients. You've got to get them up. Ok. So yeah, the answer is, yeah, you could, but um this would be better. It's also much smaller, cut, less blood loss, shorter operation, uh lower risk of infection. Mhm. Ok. Um I'll come onto some plating later. OK. Right. Case four, I think this is possibly the last question. Uh Oops. OK. So. Right. So this is quite an interesting one actually. So these are all real cases, but this is a case er we discussed a couple of weeks ago. Ok. So that's the x-ray, that's the report. Ok. And I want you to answer this question. Can everyone see the question or are you just busy looking? I can see the question but I'm not able to vote. Are you not able to, uh, box? Hang on a sec. Uh, anyone vote. Now, stop. Let me restart it. Hang on. Right to quiz. It's back on but we're back to case uh we on case one. Yeah. Ok. Ok. Try now. I hope you can. Can you answer that now? Ok, great. We've got an answer. Ok. OK. We're getting the full spread here. This is good. All someone's changed their answer. OK. So you've got a 5050 split. So two of you think is not broken and two of you think the left side is broken? Ok. So this is a really interesting story actually. So, um this guy, he had a fall from standing, unable to wait there afterwards came to A&E they did this X ray and this is the report from the reporting radiographer and they sent the guy home and then 10 days later he came back in um still having pain and they did act which showed that the left side is broken. OK. So this is a really good one for applying shen's lines. OK. So if you draw out shen's lines, so here's the normal size. OK, you got a nice smooth arc. OK? If you do it on the other side, you go, it's nicer speed and then you're like, oh hang on. What's that? Ok. And that just can you see how that highlights that bit of fracture there? Ok. So yeah, it's not the most obvious one, but I was a bit surprised that that was reported incorrectly. So it was just a lesson to be uh careful with the reports and look at scans yourself basically if it's an X ray. OK. Um Fine. So that's his CT. So um sometimes you do get these non obvious x-rays, OK. Um You need more imaging to work out whether it's broken or not, you can go for a CT or an MRI. OK. MRI is a little bit better. It's the gold standard, but if you're out of hours, um CT is easier to get and it's quicker to get in hours. OK. So CT is a reasonable thing to go for in the first instance. OK. OK. And now we're going to go on to just a few kind of weirder things. OK. So these are the type of things that I don't think will come up in your finals. OK. But this case in particular is something that is becoming a lot more common. OK. So this is what we call a periprosthetic fracture. So you can see on the left side, they've got a total hip replacement in, OK. You know, it's a total hip replacement because you can see, there's a metal cup and there's a metal uh femoral component here which has quite a small ball. If you, if we go back to the hemi arthroplasty, we, we saw, um which is there, can you see how it's got all this great big ball cos it needs to fill the whole acetabulum. Uh Whereas a total hip replacement has a comparatively small ball. OK. Can you see that? Ok. So that's the way to tell and you can see they're falling over and there's this whole chunk of bone that's just cracked off the side. Ok. So, per prostatic fractures are important because they're becoming really uh more and more common, something like that. We do 100 and 20,000 total hip replacements in the year in um, every year in the UK. And we're doing them in older and older and more and more frail people. So you're gonna see a lot more of these, OK. Periprosthetic fractures. So, um and it might not just be the hip, it could be at the knee, it could be at the shoulder anywhere where someone's had a joint replacement. Ok. And um, all I want you to do is basically be aware that they exist. OK? Because there's loads of different types, cos they can break like this or they can break at the bottom of the stem here because you can kind of think it's, there's gonna be a bit of a stresser there or they can even break all the way through the bone and, and the actual stem itself can break as well. OK? Um A always in these get act scan, OK? Basically what you want the CT to show is two things. Firstly, er you wanna see the whole fracture pattern, OK? Because there's this big bit of metal in the way you can't see where this fractures going behind it. So you get CT S, you get 3D image and you also want to know is this metalwork still nicely fixed by the cement and the CT will be able to show you that because if it's still nicely fixed by the cement, what you can do is you can kind of cobble these back together, which I'll show you in a minute if it's all, if the cement is all loose and this implant is basically kind of falling out of the leg, then you need to revise it. So you need to do a um total hip replacement revision, which means basically take everything out and redo it. So this is what we did. So we basically cobbled it together with these which are sur large wires. OK? And we just literally stuck it back together and that will heal. OK. So just be aware of them, this won't come up in exam 22 things. Um Yeah. The first thing is just because you're on this slide. Can those patients wait that straight away or? So you have to wait. So, no. So, so this kind of patient that you would keep the non weight bearing for six weeks? Ok. So these wires don't really add any strength at all. All they do is put the two bones back into contact and then the body needs to heal them before they weight, bear on it. Yeah. Makes sense. Um The second thing, there's just a question in the chart. So sorry that I missed this. But um do you mind reading out? Yeah. So Newland said uh so even if it's a simple fracture in someone with poor premorbid mobility, would you choose? I am nail over DHS. Um So sorry, sorry, say read that out again. Uh So even if it's a simple fracture in someone with poor premorbid mobility, would you choose? I am nail of a DHS. OK. I don't, I don't know what the context of that is, but are you talking about weight bearing? So you can, you can fully weight bear with both A DHS and an IM nail? Ok. They're both, they're both as strong as each other. No, I'm not sure. I don't know if you are able to. Hello? I can hear you. Yeah. Hi. Um No, I think it was when we were doing case two. And for some reason that question popped up in my head. I don't know if it was because in one of my med school lectures, um they were saying how it's very dependent on like mobility and age. And so I guess I was wondering even if they, um, they have such like a simple fracture. Um, would you choose the I AM nail over the DHS just because they can't move very much? Yeah. So I think um the whole mobility and premorbid status thing is only really relevant for when you're trying to choose between a total hip replacement and a hemiarthroplasty. When you, when you've decided to fix a fracture, um we wouldn't, you know, pick a DHS over a nail because someone was more mobile or something. It's, it's that one is purely based on the fracture pattern. OK? You can both, they, they can both wait bare fully afterwards. They both get pretty much exactly the same outcomes. Ok? And that's why some hospitals just do nails. Uh some places just do dhs's and most places do a mixture of the two. Does that answer your question? Oh, ok. So it's more like down to preferences and like trusts and things. Uh Yeah, but, but, but the, the, the biggest thing is, is the pattern of the pattern of the fracture. Ok. So there will always be a big area in the middle where you can argue either way. Um But uh something like that where you've got, you can kind of think if you, if you, you know, if you imagine your DHS is gonna sit, it's gonna compress that really nicely. OK. Whereas something like the soft trip enteric extension on this one, you can see how that has to be a nail. So those are quite cut and dry ones, I would say, wouldn't you need to be like quite mobile in order for the DHS to actually work its magic if you know what I mean? Cause it's do you mean do you mean the dynamic part? Yeah. So all you really need to do is stand on it once, to be honest. So if you think you can get the patient standing just once, not even walking, just putting some weight through it, then it will dynamise. OK. And equally, even if it doesn't dynamise the fracture will still heal. OK. You can see on you can, you can you see on that one how it's fairly well squashed together and this is before the patient has stood on it. Yeah, because you, you, you're still giving that good immobilization so it should heal. Mm OK. OK. Yeah. Yeah. Thank you. That's all right. Um Are there any more questions in the chat? Cos I II can only see my presentation. You see, I can't see any more. Um That's it for now. Sorry, sorry. We, we No, no. Yeah. Yeah, that's OK. We're, we're, we're, we're almost at the end actually. So um OK, fine. So this one I'll just run through. So d does anyone want to describe this X ray? OK. Just in very, very basic terms, it looks like a, any takers. Um So I think this is the right, this is the right side. Yeah, that's, that's, that's pretty hard actually. So, are you basing that on the fibula? Uh Yeah, I think that's the fibula just on the um on the left side of the image. That would be the right side of the patient. I think it's a challenge. Yeah, I think it's the right side. It, it looks like a, it's like a multifragmentary spiral fracture of the distal femur. Yeah, exactly. Really good. OK. And um displaced or undisplaced uh displaced. Yeah. And how would you describe where it is in the femur? So I know you said distal femur um but can you be any more specific? So bye. So I think that I'm not sure whether to describe it as uh it extends kind of from the shaft towards the metaphysis and probably into the medial condyle or, or maybe not going into the medial condyle. But or whether to describe it as um kind of, I guess what I'm trying to say is I'm not sure whether to this, I'm not sure whether that it extends from the shaft distally or distally approximately if that makes sense. Yeah. OK. So I think a a good way of describing it usually is, is divide the bone into thirds. OK. So is it proximal third, middle, third or distal third? And this is distal third? OK. And then you've also got to think about, oh, you know, is that intraarticular? So are these fractures here going down into the joints? Um, pro probably not. Ok. Um If you're unsure, you can get a CT scan, we'll go through one of them in a minute. Ok. Um, now this is a femoral shaft fracture almost invariably. Um, a femoral shaft fracture that doesn't involve the joint will be treated with an intimidator nail like that. Ok. So because it's not going through the joint, it doesn't matter that these fracture lines aren't perfectly healed up. Um Because it will heal with callus. Um And the metal rod going down the middle will mean they can wait there on it straight away. Ok? Um So that's almost always the treatment for femoral sha fractures as an intrau nail. Um Now, the things you remember about femoral shaft fractures is you have this bimodal distribution of uh people happens to, right. So you've got the old people and these, you basically treat like a neck of femur fracture. Ok. So, uh they usually fall from standing, they might have the associated frailty injuries, blah, blah, blah, blah, blah, all of the same stuff that you get with neck of femur fractures. But yeah, you also get the subset of young patients and these are usually high energy. So car crashes, motorbike crashes, jumping off buildings, that kind of thing. And then you've gotta go into your A TLS advanced trauma life support type algorithm where you know, you're checking the airway, breathing c spine, all of that sort of stuff, um, to make sure nothing is going to kill them because a big fracture like this is a distracting injury, which can distract from things that are actually going to kill them quicker. Then you've got to decide is it an open fracture? Um Have they got compartment syndrome of the thigh? Um And you've also got to think about blood loss, cos fe femur fractures, mid sha femur fractures and distal femur fractures like this, they bleed quite a lot. So you can easily lose a liter of blood just into your sort of soft tissues around your thigh. Ok. So do they need tranexamic acid and that kind of thing? So take away from this is basically, it's a bimodal distribution and you've got to treat the two patient populations very differently. And then this is a little quirk of sort of distal femur fractures is it's one of the few places in orthopedics where we still use traction. So, back in the day, you know, like 50 years ago, lots of fractures were treated with traction and you just put weights on to pull out people's fractures length and you just leave them sitting on the wall for six weeks while it healed. Ok. We don't really do that anymore. Um But we do use it for uh femoral sha fractures. Uh basically until they get their operation because it's uh for pain relief and it also reduces the muscle spasm and things. So, um, you might have to set this up as af one F two. So you just calculate about 10% of their body weight, put on the skin traction and then that will just make them a bit more comfortable while they wait for their operation. And then I think this is the last slide. Ok. So this is a, er, one I had a couple of weeks ago. So this, I'll just go through. So this is a distal femur fracture. Ok. So it's actually quite hard to see what's going on. So this is the AP and you can see there's a, there's a crack here somewhere and maybe there's a crack here and maybe there's a, can you see that maybe there's a crack there, it's kind of difficult to tell, tell what's going on. And then if you look at the lateral, you can sort of see this crack going along here, can't you? But you can't really see what's going on. And then the other thing I wanted to point out on this X ray is, can you see what's going on here? So this is in your sort of suprapatellar pouch here where there should be synovial fluids. And what you've got here is a perfectly horizontal line and whenever you get a perfectly horizontal line on any x-ray, if it's a chest X ray in the lung or if it's an abdominal X ray in the bowel, it always means a fluid level, right? If it's perfectly horizontal. So what this is is it's called a lipo hemarthrosis. So, lipo fat, heme blood arthrosis in the joint. So fat and blood in the joint. And basically what this is is it's a layer of blood, which is the light gray stuff. And on top of that is floating a layer of fat like bone marrow fat. And you get this lipohemarthrosis. And basically what that means is that there is a fracture somewhere, communicating with this joint. So it could be a tibial plateau fracture that we can't see. It could be a distal femur fracture. But it means that the fracture is going into the joint because that's where the blood and the bone marrows come from. OK. So sometimes you can look at these bones and they look fine, but you see this sign, you know there's a fracture somewhere, OK. So this is kind of a bit of a mini pearl, right? So I put here in all intra articular fractures. So fractures that go into a joint, consider getting a CT. OK. So that you can actually see what's going on. And this is a slice of the CT. And you can see now that basically this whole um is that the lat, yeah, it's the lateral femoral condyle that's kind of snapped off. And then the reason why you need to see this so closely with the CT is because whenever you have an intraarticular fracture, you need to achieve anatomical reduction with your fixation. Ok. So you need to try and get the joint surfaces back to as close as what they should be as possible because if you don't and you leave a little step that's gonna lead to arthritis and things like that. So in contrast to the femoral shaft, you can't just leave it looking a bit dodgy. You've got to try and get it perfect. OK. So this is where the plates come in. Sorry, there's my pearl spinning around. So this is where the plates come in. So what it did here was it did a plate. Ok? And the nice thing about a plate is it's really good at getting the anatomical reduction because you can put things exactly where you want to put them. But the catch is they can't fully weight, bear on this. Ok? So she will have to be non weight bearing for six weeks. All right. So that is the end. Um Any questions I'm gonna come out of my presentation so I can see just in case anyone puts anything in the chat. Uh fine. Um And so yeah, so I guess so there are two aspects to this, right? There's the part of me that's like, you know, the future orthopedic surgeon thinking about that stuff. But then there's also the part of me that's will eventually be like, you know, the F one and the F two, what do you think are like, what do you think are like the most important steps to get? Right? As an F one as an F two in terms of like prepping a patient, um, that maybe people overlook or people forget fine. Ok. So I'd say two things. One when you're on a call and when one, when you're sort of looking after the walls. So when you're on call, your job is to take a thorough enough history and a relevant enough history that the consultants in the trauma meeting have all the information they need to decide how to manage somebody. So, with the neck of femur fractures, it's finding out, you know, do they, you know the, the difference between them using one stick or two sticks or the difference between them having an AMC S memory score of 10 out of 10 versus six out of 10 might change the operation they have. So, it's really important you get, uh, a really thorough history. Ok. That's what I would say. And then from the ward aspect is that, um, orthopods have this reputation of not being very good at medicine. Ok. Which is mostly true. All right. Um, so when you're the F one and F two looking after orthopedic wards, you kind of are the medical, you know, you're the ones who know all the medicine. So when these sick patients who have lots of comorbidities get a medical problem, which they often do. You've got to spot it. Ok? You don't have to deal with it because almost all hospitals now have an Ortho geriatric team. So basically a group of medical, you know, geriatrician consultants who go round and see the, the frail patients, but you as the F one F two is gonna be able to spot it and escalate it appropriately. So that's what I would say. Mhm Yeah, that makes sense. Thank you. Um Any more questions hoping you can, can you see the slide? I've got up there now which says what we've got next? Yeah, II can see that I'm gonna everyone else can as well. So, so these were just some, I sort of wanted to do maybe four or five of these over the next few months. Um And these are just some ideas of talks that I thought might be useful. So I wanted to do one on sort of emergencies like apartment syndrome, open fractures Qui syndrome, things like that. Um I've got a friend called Matt who's act two, who's got a polytrauma and ATS torque he can give and then I wanted to do one on upper limb trauma, going through clavicle fractures, humerus fractures, distal radius fractures and scaphoids. And then um I want to do one on peds or because um it's kind of one of those areas that's a bit specialist, but they are slow about it in exams from what I remember in medical school exams. So, you know, your pediatric hip conditions, um, Osteomyelitis, uh septic arthritis, Clubfoot, that type of thing. So, what's you want on that? Um If you've got any other things you want to be mentioned, speak up now, put it in the chat or put it in the feedback form that you're going to fill in. Yeah, I would, uh, I totally echo what Alex is that. Um, I think we've got a lot of scope to be flexible um with what we do and also people can message, message the um to society Facebook group um or the Instagram and yeah, we'll be able to put it on. Um Does anyone else have any other burning questions? If not, I think I think we can leave it there. Thank you so much, Alex. It was honestly, yeah. Uh really informed to talk about so much people down. Um Yeah, it was really, really helpful. Yeah, pleasure. I see you next time. Yeah. OK. Catch you later. Thank you for coming in. See you. Bye, see you.