Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

All right. So I think we're live. Cool. Um Can you see the slides? Not uh Yeah, I think so. One sec. There we go. Yeah, I can see them. Ok. I think it's still processing the rest of the slides, but I think at least half of it's uploaded so we can get started when you say, yeah, I think whenever you already lists, let's take it away. Cool. Um, hi guys. So my name is said, I'll be talking about tr orthopedics. Uh This is aimed at finally uh medical studentss. So clinical years essentially, uh we'll be looking at tr orthopedics and just like all the sessions we've had in this series will be using an SBA approach, same as you probably will have in your finals. Um So I prepared a series of questions and then we'll sort of just go into each of them and treat them as sort of case based discussions. Um And we'll get started with the first question then, but before that, so I have a disclaimer that I've used orthopedics as one of my main source of information and I don't know any of the photos or uh any of the content, really. Everything here is just for education purposes. So this is the first question. I hope you can see it and then, um, we'll launch the po, once you've read it we'll give you a minute for this. Mhm. Ok. You've got six responses. We'll wait until there's at least 10. I guess it's completely anonymous. I can't see what you've put. So, just worth putting down anything anyway, um, treat it as a test for yourself. We'll wait for one more and then get into it. Cool. OK. So majority of you have gone for option, a closed reduction immobilization and sling um the standard color and cuff treatment for proximal humerus fractures, which is what this is that, that's the image we're looking at that is usually correct. But in this case, there's some significant displacement um x-rays as shown. So usually the question may not include an image of the x-ray. Um and sometimes it will just be a description of the x-ray and then the management plan is based on that. So if you have a look, there's a complete sort of displacement between the head of the humerus, the bit of the um greater tuberis is off as well. And then you've got the humeral shaft as well uh off to the side. So this is a significant injury. Um movement is significantly restricted as well as described. So this patient will likely actually need an aura. So an open reduction and internal fixation. Um, so we'll go through all the options because it's important that, you know, the right answer. But you should also know when the other options would be correct because that's the best way to sort of go through a s so close reduction and immobilization. The sling is good when the fracture is non displaced. Let's say there was a line through, let's say the humeral head. Um, I don't know if you can see my mouse, but let's just say if there was a subtle line through the humeral head and the overall sort of um the overall sort of bone looks as it would other than that fracture. So you would call that relatively non displaced or if it's slightly moved and it's minimally displaced, then you can do something called closed reduction and immobilization thing, which would usually be collar and cuff treatment. Um And then it's essentially gravity uh pulling that using, using gravity to pull that sort of distal humerus um down and then over time it will heal on its own. Um, percutaneous pinning, using things like hay wires is good for minimally displaced fractures. But again, usually a non um uh a non operative approach would be used if you're, if it's non displaced, displaced. So that's what the first three options are talking about in this case or if it is appropriate. So, or it would be opening up um and approaching the bone. So you cut through the skin you get to the bone and then you put on a plate. Um But first you would actually put traction, which means to pull the bone and try and get it to restore a normal anatomical alignment, that's called reduction of a fracture. So you would do that intraoperatively and then you would apply a plate to keep that in place. Um So that's what an or would be hemiarthroplasty is. It's like you have in the hip, so you can replace the head of the humerus. There's also something called a reverse shoulder replacement as well where um whereby the, well, I think I've put an image in for that in a second. But essentially, in this case, it's an or hemiarthroplasty or replacement of the humeral head would be done in the case of a complex humeral fracture, um severe displacement. So if it's really off and then there's also comminution, uh so the bone is broken into multiple fragments and then you have intraarticular compromise, which means that the actual bit of the humeral head that's articulating with the glenoid um coming off the scapula. So the actual joint there, there's a fracture that extends into the bone that is touching the joint. So that's when you would consider hemiarthroplasty as well. Additionally, if you're worried about blood supply to the humeral head, same as if you were worried about blood supply to the head of the femur, you'd replace the humeral head. So this is an example of the sort of uh operation that this patient would undergo. So this is the same patient actually from the same website of taking it. Um and it's a, it's place and screws to fix that fracture. And the whole idea is to restore that anatomical alignment and get the patient back um to function as soon as possible. So we'll just go over proximal humerus fractures. So it's more common in elderly patients with, with osteoporosis um than in young patients. And if it were to happen in young patients, most likely to be uh going to be due to high energy trauma. So it's more common in females. Um and as uh you sort of get older, you're at more risk of osteoporosis. Um which is why it's more common in elderly patients. So the most common pattern is a two, a two part surgical neck fracture so that it just means that the bone is split into two add around the surgical neck. Remember there's two bits of the humerus, there's an anatomical neck and a surgical neck. Um but fractures more common at the surgical neck risk factors, osteoporosis. As we've mentioned, diabetes, that's also a risk factor for bone healing. Um Epilepsy, epilepsy is also a risk factor for spontaneous shoulder defecation. Um It's, it's rare but it can happen. And then again, as mentioned before being female is a risk factor for this kind of injury. Um diagnosis usually just with a plain radiograph as we've seen for x rays, you get the AP view, lateral view and something called the scapular wide view as well. I don't think that will come up in exams, but when you're actually planning things like an aura, you'd actually get a CT. So you can visualize it in a 3d space. You would rarely get an MRI, but you would, if you were worried about things like soft tissue injuries such as rotator cuff, um it's rarely indicated. And the two most common injuries associated alongside approximate humerus fracture would be damage the axillary nerve. So you would see some sort of sensory deficits in the regimental patch area, the C five area just around the shoulder, there would be decreased sensation. Um and they would be, they would find it difficult to abduct the shoulder or externally rotate it, which is what the axillary nerve is responsible for. You can also have arterial injury as there is a rich blood supply around the area. That's relatively uncommon. So in terms of management, there's non operative. So minimally displaced, surgical and anatomical neck factor. So minimally displaced or non displaced, you can essentially treat this usually with a collar and cuff. Um And what they usually look at is how displaced the GT is. So if it's displaced less than five millimeters, you can accept that and treat it non-operating. But if there's more displace than that, what happens is there would be impingement and you wouldn't be able to abduct or externally rotate your shoulder anyway. So the patient would likely need an operation. So the options would be close reduction, percutaneous pinning. So that's things like K wires. Um or if with plate and screws as we've just seen, um which is usually the most common approach for this type of injury, then you can also intramedullary. Now that um this is biomechanically inferior, but there's good factor healing range of motion. That's also pretty rare. It's usually an or if that's indicated or in certain cases, you'd have arthroplasty which is replacement of the shoulder head. Um And there's also things such as reverse shoulder replacement. So if you look on the left, that is uh intramedullary ring again, pretty rare. It's usually in younger patients with surgical neck fractures, with those of proximal humerus and humeral shaft fractures. So if you've got essentially three part fractures, whereby it's broken proximately at the humerus, then somewhere down the middle as well and the shaft is gone and then you put the, the nail in to line up all the fragments. Then if you look at the 12, 3/4 image anatom where it says anatomic, that is a hemi of the shoulder, you replace the humeral head. Um that can happen in younger patients, 40 to 65 year olds with complex fracture, dislocations. And then it can also be done in elderly patients if you're worried about the um the actual humeral head. Uh, and if there's an intraarticular fracture as well, and if you're worried about blood supply to, to that humeral head, avascular necrosis of the humeral head is also a possibility. So you would want to replace that. And then finally, there's something, uh, it's a bit clever. It's a reverse shoulder replacement for elderly patients with poor bone and nonreconstructible tuberosities. So essentially it flips the sort of anatomy of the shoulder on its head, but that isn't likely to come up in med school finals. It's just more for your interest. So, move on to the second question. Um We'll give another minute for this and then we can get the pull up as well. Cool. We've got six responses so far, we'll wait until around 10. I know crack on, you can give it a guess if you don't know, it's completely fine. We don't know who's putting in the responses. Um just for your own practice if you want. So we'll give it another 10 seconds and then crack on. Ok, thank you for your responses. So, in this case, what, what you have is um a young patient with a fall. Um This is not an uncommon scenario actually. So it's a very common fracture in the pediatric population, usually in the age ages of 5 to 7. Um So it's a super common a fracture which is essentially a fracture of the distal aspect of the humerus. Um And what's happened here is that, that has come off and it's definitely unstable in that position. So that's why um if you have a look at it, there's limited range of motion, there's tenderness of the humerus and then there's loss of the normal carrying angle. So usually if you have your hand out wide next to you, it would be between 5 to 15 degrees and then if it goes less than that. So in this case, if it goes from out wide to narrow, you have something called Cubitus virus. Um and that's decreased in the normal carrying angle. So that would lead to poor function if, if left untreated. In addition to obviously, the fact that the bone is not joined there. Um Luckily the neurovascular examination is normal. So that's, that's really important that you assess this, especially in the pediatric population because these, these kinds of injuries can have serious sort of arterial injuries or neurological injuries. Um So it needs to be documented clearly and we'll go over exactly what needs to be documented as well. Um But ultimately, what you have here is displaced super the fracture of the humerus. And um the options are tied between C and D. But the correct answer is C. So you would try and pin so it would be K wires. Um They would fire K wires in and try and connect up that distal fragment with the rest of the humerus. I don't think you can see my mouse, but that's what I'm trying to point at. So going through the observations, um, splinting an observation, you, you may consider that a minimally displaced under fractures, nonweightbearing with a sling. It's not really a common approach used for lar fractures, nonweightbearing with a sling is usually um used more in the pediatric population with lower limb fractures. Um, open reduction, internal fixation would only be attempted if you've tried percutaneous pinning and it hasn't worked. So you want to try and keep this, keep the skin intact and try and fix this essentially with two percutaneous pins. If possible or a few percutaneous, you don't want to open that up and approach um the humerus because there's a lot of structures around there and then putting in a plate, especially when there's um essentially an eight year old that's gonna continue to grow as well. So they will likely need a second operation to get that plate out. So if you can ideally try and fix this with percutaneous spinning in the first instance, that is the ideal outcome. Um and patients tend to do quite well with that. So you would reserve or for complex fractures with intraarticular involvement. So, if it's extending into that um sort of joint between the humerus and radius and ulna, um additionally, if there's vascular compromise or you've had failed attempts with close reduction, as already mentioned, serial casting means that you're just putting on cast, taking it off and having a look again, that's not commonly used for super fractures. So this is what it would look like. Essentially you f the pins in and you're trying to connect the broken bits with the rest of the humerus. Um If that goes goes, well, essentially what you would have is a bit of the wire sticking out of the skin, you'd cut it and then there'd be a cost on as well after a few weeks, they come back and then you'd remove just the wires and see how they get on. So again, common pediatric fracture, especially in around this time of year. So in the summer when people are jumping on trampolines, jumping from trees and landing on the elbows, especially kids, this is what they usually come in with. Um So you diagnose this with clinical assessment and plain radiographs. So just x-rays are enough and then a common finding on an X ray would be the fat pad signs. So even if you don't see a very sort of definitive fracture cross on the humerus there, if you can see that fat pad sign, which is just the sort of dark shadow on the posterior aspect of that humerus towards the left, that is a fat pad sign which indicates that there is a fracture somewhere. Um and it's a sign of essential life of heros. There is a fracture somewhere and you just have to look for it. So how would you assess the child in. We, we spoke a bit about neurovascular assessment. If you guys want to put on the chat, if anyone has any ideas, what, what would you be looking for in particular to assess the child in Ed or in any setting? Really? What are the main things you're worried about? We've gone, we've gone over what, what you're worried about. But how would you, how would you assess it? Any ideas? Ok. We can go on to the next slide which, which sort of goes over there. It's a really simple test and especially with kids, you don't want to be sort of moving their hands too much when they've already injured the elbow. So you just play a simple game of rock paper, scissors and then ask them if they're OK, essentially. So each thing is assessing um different nerves. So you've got the radial nerve, median nerve, the anterior interosseous nerve, which is a branch of the median nerve. And then you also have the ulnar nerve, the most commonly injured uh nerve is this anterior interosseous nerve and close behind that is the radial nerve. So, with the radial nerve, you're assessing for extension of the wrist and the metacarpal pharyngeal joints with the anterior interosseous nerve, you're assessing for flexion of the thumb, um and flection of the distal interphalangeal joint of the index finger. And with the ulnar nerve, you're looking at the intrinsic small muscles of the hand, which is why you're trying to see if they can spread the fingers. The deep ulnar nerve is responsible for abduction of the fingers. Um And then with the median nerve, you're just trying to see if they can flex all their fingers into a fist. So really simple exam and then the, the main thing that orthopedics always want you to do is document this at the point of injury before and after you pass, uh put a cast on them if you plan to do that before and after operations as well, just because having that neurovascular status documented is very um very important. So there is a classification system that's used for this. You don't really need to know this for finals. But um officially, there's only three types and type four can only be assessed in uh intraoperatively and essentially type one is non displaced. You can treat that with just cough, even type two can be treated with cough. But sometimes if there's essentially angulation and the surgeon is worried they'll put in pins as we saw before. So those are those, the pins are technically K wires, wires is what they're called. Um And it would just approximate the distal aspect to the proximal aspect and then um allow it to heal. Then type three, you have complete displacement and you would try with the pinning first. And if that fails or same with type four difference between type two and type four is type in type four it is instable in flexion and extension. But you wouldn't, you wouldn't even try and assess this in with, with the patient awake because it would be so painful for them. That's something that they would assess on um in theater under anesthetic. So, associated injuries. So this is why it's important to document. So you wanna understand if there's any anterior intraosseous nerve injury. Secondly, there's radial nerve palsy injury that, that sorry. Second, that's the most, the second most common. Um then you have ulnar nerve palsy as well as per or bullet, which is the resource I use for this. It has nearly all resolved spontaneously. Um What you're also worried about is vascular compromise, which can occur in 5 to 17% of patients. So anteriorly, you have the brachial artery which then splits off into the radio and ulnar arteries. So that's damage. You can really have compromise towards the um the the fingers of the hand. So collaterals may still maintain circulation, but that, that bra artery is really important for your forearm and hand. So it's important to assess that. Um and then assess the radial pulse and then you can also have an associated bone injury distal to that. So you need to have a look at the wrist. So anytime in orthopedics when you have an injury, so let's say it's the elbow. In theory, you're meant to examine and image the joint above and below. So in the case of the elbow, that would be the shoulder and wrist joint. So that's a bit on super condylar fractures. We'll move on to question three. We'll give this a full minute um for people to have an attempt at answering it and then we'll launch the pool. So it's been a minute. Um The responses, we'll wait, we'll wait for a few more responses. Cool. So we've got nine responses and yeah, this is one that may be a bit controversial. Um But the official answer for this is that it would be treated with or so you can usually, and this is something that may change in the future based on there, there are some trials being done. One of them is called draft two. looking at whether operative versus cost management alone, um whether there's any sort of difference in outcomes down the line. So at this point, however, the official advice for a fracture of the distal radius that is displaced with significant dorsal angulation would be an or um we'll go over all the options. So you can do closed reduction cost immobilization for a fracture that are stable with minimal displacement or it would be done for significant displacement, intraarticular which this is not um or instability in general external fixation uh is not commonly done unless the comminution or soft tissue compromise and that should be in the context of major trauma as well. So non operative management with splinting can be done as well for minimally displaced um slash stable fractures. And then physical therapy and occupational therapy would not be a primary treatment that would always be an adjunct on top of some sort of um reduction and cost mobilization or splinting. Um So let's go into this, just this radius fractures in general, it's quite a common fracture even in the adult population. So, as with a lot of these orthopedic fractures, um it has a typical bimodal distribution which means that in young patients, um it's common with high energy trauma and with elderly patients, it's common with a low energy mechanism, often associated with things like osteoporosis. Um If this happens in women over the age of 50 they do recommend a Dexa scan. And as mentioned before, this is, well, I mentioned it in the context of dis radius, but it's more common in females ranging between 2 to 1 to 3 to 1. Um And there are associated injuries with this as well. So you can have the R UJ stands for distal radio radio ulnar joint. Um You can have an injury there. You can have a radios fracture as well, which typically indicates a high energy mechanism. And then you can also have soft tissue injury such as ligaments of the hand. Um There's also technically, you could also injure any of the hands of the, any of the bones of the hands. So skateboard as well as one to worry about. But these are the most common associations. Yeah. So management as we know can be non operative or surgical. So this is where the strict indications for this dictate whether or not you go for uh operative or non operative at this point in time. So, closed reduction splint or to immobilization is therefore, is indicated for extra articular fractures. Um those with less than five millimeters of radial shortening. So you would need to compare that with the other uh with the, with the other hand, and then whether there is dorsal angulation of less than five degrees or within 20 degrees of the contralateral this radius. I don't think you need to memorize this for med school finals. I think the main thing to understand is if there's significant displacement, most likely they're gonna need an operation if it's minimally displaced. And I think usually in the context of um med school finals, it's going to be pretty um pretty clear which, which way they're headed with the question um whether it's gonna be non operative or surgical management and then the options within surgical management you have pinning or if with um plates and screws. And this is used especially in the case of intraarticular fractures um with more than two millimeters of um extension of a fracture into the intraarticular region. Um As mentioned before X six would be used for open, highly common and um medically unstable patients. So that would be in the context, usually of major trauma, they come in and you don't have much time in theater with them. So you just put in an X fix to stabilize because the bone will continue to heal. So you don't want it to heal in a bad position. So this way, this fractures, I think uh it is a bit tricky but simple, simple sort of rules if, if it's really sort of angulated and it's really shortened. Um And significantly displaced, don't need an operation if not most likely non operative um treatment with closed reduction and spent so some autonomous um upper limb fractures finals, this is not an exhaustive list. Um but you have fracture which is uh fall onto an outstretched hand and then you have dorsal displacement and then the opposite of that also known as reverse called is Smith fracture. You're usually falling onto a flex wrist or direct blow to the back of the wrist and then you have ventral displacement. So that's just one worth memorizing. Um I don't know if there's an easy way to remember this. If, if you're a cricket fan, I usually think of Steve Smith um falling, trying to catch a cricket ball in a flex position and that's why it would be a Smith fracture um with er or anterior displacement, but however, you want to memorize it, then there's also um these fractures to be aware of. So you have Monte and Gliz. So and you um which is to do with the ulnar fracture. And then you have a dislocation of the radial head. So the way they recommend that you remember that it's a proximal dislocation of the radial head. Uh Well, the first, the radial head is proximal that. But if you can't remember that, you just have to remember there's a proximal dislocation of the radius. And the way to remember that is that there's an a in this, I don't know, I think it's easy to just to try and understand the um associated injuries rather than these uh pneumonics and get confused in the exam, but their own if that works for you, that's great. Um And then you have galii as well, which is a radius fracture with dislocation of the distal radio, the joint. Um So that's affecting it distally. Um Another thing I think it's on pass me, it's usually like Manchester United versus Glasgow Rangers. You remember that as Manchester United first and then Glasgow Rangers second. So then, you know, it's proximal distal, whatever works for you really. So we'll move on to lower limb injuries now. Um But just going back to this, there are other eponymous fractures as well. Um But I think for the context of medical school, those for the ones that I remember um seeing the most, if you know of any other ones, then it's worth um sort of going over those as well. And then if any of the, the other ones sort of come up and pass me just worth, um, making a note of them. I know another one is Barton's as well, but I don't remember seeing that in med school. So, uh, these four definitely worth knowing. I think though, we'll move on to this question now. Um, and then we'll launch the pool in a minute. We'll wait for a couple more responses. Ok. Fine. We'll just start going through the question. So, essentially what you have here is an elderly lady. She's got, um, she's had a fall, um, and she's not able to wait there. That that's sort of a sign of a pretty serious injury. Um, she has a past medical history of osteoporosis. You, you know, her bones are potentially weak. Um, and she's already taking calcium and Vitamin D supplements, whether that's sort of helped her bone strength or not, is to be seen. Her A NTS is 10 out of 10. That's relevant and we'll, we'll talk about that next step. But, um, there's no sort of mention of dementia or anything like that. So she's cognitively essentially with it and she usually walks with a walking aid and usually only around her house. So on physical examination. So even if on the x-ray, you can't really see the fracture, um, although the ii feel like it is somewhat sort of clear to see an left-sided intracapsular fracture, but let's say you haven't revised how to look at fractures. Um, just based on the history. If you have something like a shortened, excellently rotated, left, lower limb, that's indicative of some type of, some type of neck of feur fracture. And then if you have a look, you can't see anything outside of the capsule, you can see that the actual neck of the, of the femur is shortened. You can see the head quite clearly and then you can the, um, and lesser, um, as well, uh sorry, great and lesser trantas and they look fine and there's no fracture across them. So this is most likely a left-sided Intracath fema fracture. So, it's about how you treat that. So we'll go into all the options. So, close reduction, internal fixation is generally not appropriate for an elderly patient with a neck of femur fracture. Hemiarthroplasty is appropriate. In this case, total hip replacement would also have been appropriate in this, in this case, but it's appropriate in different circumstances. So we'll, we'll go into sort of when it's a hip, a total hip replacement versus a hemiarthroplasty. So, in the context of a hemiarthroplasty, you're just replacing the femoral head in a total hip replacement, you're also replacing the acetabular. So both ball and socket are placed in a total hip replacement where in a hemi just the ball of that hip joint is replaced non surgical management with bed rest and analgesics is not appropriate. Essentially, you would have sentenced them to just bed rest thereafter. Um And they wouldn't really be able to mobilize with a fracture like this. Um And then referral for consideration of palliative care would not be appropriate in the absence of any sort of um malignancy or any sort of poor prognosis. Essentially. What, what, what this point was is if you were to give the patient a hemi, you can significantly um increase their quality of life from as opposed to leaving them alone with this fracture where they're not gonna be able to mobilize that. That's essentially the point of this. So we'll talk about neck of femur fractures. What, what it comes down to really is age and fracture pattern. Um You have young versus old. So that's one way to divide up your patients. And in younger patients, the aim is to preserve the native femoral head. So you don't want to be replacing that femoral head unless you absolutely have to. Whereas in older patients with a bit of osteoarthritis, and then they've got a fracture as well. It's fine to replace that femoral head because it's already at risk of avascular necrosis from an intracapsular fracture. And there's probably a bit of osteo osteoarthritis there as well. So another way to divide up fractures would then be intra and extra caps and we'll go into what that really means. The significance of this, as I've just said is that in an intra femur fracture, you are unlikely to have good supply to the head of the femur, it's unlikely to heal. And essentially, you will have risk of avascular necrosis of the femoral head. The bone will die and ultimately, that femoral head will need to be replaced. So if we look at the blood supply, sorry to go back to preclinical sort of knowledge, but the main supply to the femoral head is from the medial femoral circumflex artery. Um In adults, you get a bit from the lateral circumflex, femoral artery and a bit from the artery of ligamentum tears. But the main one is medial femoral circumflex artery coming off the uh the the deep femoral artery essentially. And in kids, the artery ligament and tears is more common. Um That's just if, if as a spot diagnosis, if that question comes up. But looking at intracapsular, extracapsular, you can see that this image sort of points towards when it's extra capsular in a broad sense and intracapsular. But if you look on the top, so trochanteric that you have the greater counter basically on that top, left bit of that bone and then you have less count on the bottom, right bit of that bone where it's sticking out. So across those would be intratrochanteric. And I II think as a general rule, anything proximal to that um essentially in that intracapsular region is an intracapsular fracture. Anything distal of that is an extracapsular fracture. So, intracapsular fractures occur proximal to the point at which the hip joint capsule at attaches to the femur, which is roughly along the intro line, um extracapsular fractures occur distal to the hip joint capsule. So along the line of the um transtrochanteric or in intertrochanteric line, and then can also be subtrochanteric. So in terms of managing intracapsular fractures, as we've said before, you divide them up into young and elderly and then another way of dividing it up on top of that is undisplaced or displaced. So, in young patients, you would aim to internally fix that, which means to try and preserve the femoral head. You may just put in a screw or you may just put in some pins and align the fracture and reduce the fracture essentially to restore anatomical alignment. In elderly patients, it can become a bit more complicated. Um And it's based on whether or not uh they were able to mobilize independently with no more than one stick, whether they, they're not cognitively impaired. So essentially, you need a high A MT score because in the context of essentially, if you're looking at this for an elderly patient, you're trying to decide, are you gonna give them a total hip replacement or a hemiarthroplasty? One of the things you know about a total hip replacement is that the operation is longer because you have to also replace the socket, um which is the acetabular component. So the operation can be between an hour and a half to 2, 2.5 hours in complicated cases, as well, uh whereas a hemiarthroplasty can be around an hour. So in an elderly patient with multiple comorbidities, you're more and with poor mobilization and with poor cognitive impairment and unlikely to be fit for anesthetic for a long period of time. That's when you go for hemi. Now, let's say you have an elderly patient with a displaced intracapsular fracture. Previously, they were walking, you know, a few kilometers with one stick, the A MT S is 10 out of 10 and they're medically fit for anesthetic, then you go for a total hip replacement. So in, in the case of the question, we just went over, the patient is using a walking aid. So that's more than one stick. Um Although they have good cognitive impairment and they may be medically fit for anesthetic. They, they also have type two diabetes and high BP, um which doesn't really make them unfit for anesthetic, but it's just other risk factors to think about as well. So one thing that I didn't know as a medical student that is worth knowing is that the reason why it's important whether they're cognitively impaired or not is because hip replacements, total hip replacements, it's really easy to dislocate. So you need a patient that has good cognitive impairment to remember not to go into certain positions that can dislocate that total hip replacement. So if you were to give somebody with severe dementia a total hip replacement and they would suddenly sit crosslegged on the bed that hip would pop out and that would necessitate a visit to Ed and then they may need further anesthetic to pop that hip back in. So you need to be careful about when you're giving out total hip replacements for and you need to think about these three factors mainly. So that's a lot about intracapsular fractures and hopefully that sort of drives on that point. Um If you have any questions, put it in the chart, but this is the main thing to understand. So, what was the preinjury level of mobility like, was it essentially good? Were they fine with one stick or better? Were they um not cognitively impaired? And are they medically fit for a long sort of anesthetic procedure? So this one on the left, you have an image of a displaced femoral neck fracture in the middle, that is a hemi arthro where just the femoral head is replaced and then on the right femoral head replaced and you also have the a component, the A cup there replaced. So that is a total hip replacement. Both aspects of the ball and socket are replaced. So now going back to intracapsular versus extracapsular, and we'll focus now on extracapsular, that's everything distal to that where the joint capsule inserts, which is roughly along that transtrochanteric or in intertrochanteric line. So if you have an extracapsular fracture, you're not as worried about avascular necrosis of the femoral head because there's likely to still be good blood supply to the femoral head because you haven't injured it intracapsulary and the middle femoral circumflex, the medial femoral circumflex artery is likely to be intact. So, looking at extra capsa, there's essentially two ways you can fix it. And it's based on whether it's an intratrochanteric fracture or a subtrochanteric fracture. So, if it's an intertrochanteric fracture and it's essentially diagonal along that line between the greater tro and lesser, you can give them a dynamic hi screw. There's obviously an exception to this as well, but you don't really need to know that for the context of medical school, but a reverse oblique um in intertrochanteric fracture would necessitate an intramedullary nail. But usually the questions would be pretty clear as to whether it's DHS or an intramedullary nail. So subtrochanteric is technically defined as a few millimeter less um lower than the lesser trochanter and that would require an intimate nail. So on the left, you have a dynamic hip screw, you can still see a bit of that fracture across that transtrochanteric line. And then on the right, you have a sliding hip screw and in this case, they've done it for a um if you can see subtly that there seems to be a fracture that goes across there. Um And they've done an intra now for this, but both are extra capsular and neck of feur fractures. This is just to show you what they look like so summary of neck of femur fractures. Uh What we haven't spoken about is parallel implants, but this is what it would look like. That, that first image on the left is what it would look like if you're trying to preserve the head in a young adult patient. So someone who's, let's say 50 with a native femoral head and they've got that fracture, you just try and keep that femoral head intact and you're trying to restore anatomical alignment with screws and you're not trying to replace the femoral head, then you have a sliding or dynamic hip screw, they can be called either. And then you have an instrument already. Now, these two are used for extra capps and a feur fractures. Then you have hemi arthroplasty and total hip arthroplasty. So I feel like I've spoken for a while about that. So why don't we go over um this? So just if somebody wants to put in the chat, what, what, what would you diagnose this as? What, what do you think is going on in this pelvic X ray? So let's say you have AAA great situation for this. So it's a 75 year old lady. They've had a fall, they're not weight bearing and they're complaining of severe right-sided hip pain, the lying in bed. Um The leg doesn't appear to be significantly shortened or externally rotated, but they're not able to stand on it no matter what. So is there anything you can see on the X ray and what, what would you do next for this patient in this hypothetical scenario? Anything there are no wrong answers. You can, you can just type anything, we can have a sort of discussion about it. OK. So ultimately, this is a normal X ray, which is probably why um no one said anything, you're probably looking for a fracture when there isn't one, it's a bit of an arthritic hip. Um And essentially what happens if you've got a patient that's not weight bearing and you've got a normal x-ray like this and they're in pain, you need to still be thinking of neck of femur fractures because even if you can't see it in an AP view, which is what this is or a lateral view, and you suspect strongly clinically suspecting an IC fracture, you would then get act for them. So even if you can't see it on an X ray, which is just a two D image and you're suspecting that you would go to act. So that's not the type of question that can come up. Um This is a more clear cut case anyone want to put in the chart, how they would treat this sort of having gone over the algorithm for intra and extra caps and fema fractures. How in like literally two or three were on? What, what, what would this patient need in terms of an operation? OK. So if we just follow sort of the algorithm we we spoke about. So I've already said this, let's say there's an Elly or is there the chat that I can't see messages? I can't see anything for this. Good. Right. Uh We've got three answers for this one. So we've got one intra nail, one, either a DHS or an IM nail and one saying DHS. Yeah. Yeah. You sent me a photo of it. Thank you. So, yeah, essentially this would actually be a an so you can see the great is fine. It's the in the capsule is fine. So it's obviously not in this extra capsular. And that looks pretty subtrochanteric just because you can't see the lesser on this image. Um doesn't mean it's not there. You can, you can see from the distal fragment that it's pretty um sort of like a transection of the, the femoral shaft. So this patient would probably need an intramental right now. So the point of this question is just to make sure that we've sort of driven home the point of how you'd manage inverse extra capture of this, of which you know that this extra capsula and then it's DHS versus I MN. So in a typical exam question, as long as there's no line between the greatest count and the less count, it's gonna be an interim. Now, um if it is between the greater and lesser and that sort of diagonal line, that's when it's gonna be a DHS. So that's all about the neck of femur fractures. If you have any questions, feel free to put them on. Um But we'll move on to this question now. Sorry. It, it was meant to be a gift of the patient walking but can't really see it. Um Because it's PDF that I've uploaded. Sorry about that. Mm So in the absence of a video or any sort of imaging, it's, it's really important to just make sure that you can pick it up from the inspection and examination. Um So give it a few more seconds. Ok. Ok. So everyone's got the correct answer here. It is indeed the superior gluteal nerve. What's happened here is that this patient has a Trendelenburg gait, um which you can, you couldn't really see based on that, but you can see in the URL down there, which is a bit of a giveaway. Um And what's happening is that because the superior gluteal nerve has been injured from when the patient got stabbed, they haven't been able to abduct their thigh and because they haven't been abducting their thigh, they've essentially had um essentially muscle atrophy of the buttock muscles. So that would be the gluteus, medius and minimus muscles which are responsible responsible for abducting the thigh and that's why they have a waddling or trendelenberg gait. Um So nerve injury is also pretty fair orthopedic questions to ask at med school finals. Um So in the gluteal region just a bit of prey, gluteus, maximus, medius and Minimus, as well as 10 fasciata innovation of Medius and Minimus is L5 S one, which is the superior gluteal nerve. Um It also innovates 10 fasciata and then you have the inferior gluteal nerve, which is L5 S one and S two nerve roots. That's, that's the, sorry, that's an innovating gluteus maximus. Um So, Medius and Minimus are the ones really responsible for abducting your legs, which is important um aspect of being able to walk. So the waddling gate or Trendelenburg Gate, um essentially is that the unaffected pelvis will sag um or tilt to compensate for the affected side in uh when walking essentially. So it's counterintuitive in that the side that's dropping down is the normal side. It's the other side that is affected and has a weak luteus Medius, whether that's secondary to nerve injury, which, which was in this case, um or general sort of muscle atrophy. Um and that's called Trendelenburg sign. So when the pelvis sort of tilts to one side, um to compensate for a weak gluteus medius, so move on to the next question. This is about the knee. Um We'll give it a minute and then um if everyone wants to put the answers on the poll, OK. So with these questions and just all sort of medical final questions, it's really important to read the actual thing that they're asking. So this is specifically about first line management. So it's not about definitive management. It's about what would you recommend to this patient first line they in the GP clinic. This is their first presentation with this kind of thing. Um Somehow they've got an X ray as well. Oh, yeah, sorry. It is 730 running probably 10 minutes, 1015 min minutes behind schedule. We should be done by um quarter to eight. But if you're leaving, it'd be great if you could fill out the feedback form. Thanks for dropping that for me. Got three responses so far. What do people think? Ok, fine. So, yeah, pretty tricky question, I'd say. Um just because of the wording and the way the guidelines have been chopped and changed, but the majority of you have got it right. So it is indeed e we'll, we'll go through all the options. So, topical nsaids or capsaicin cream is not first line. These are usually adjuncts, um or analgesics, paracetamol would be fine as sort of first line painkiller. Uh But oral nsaids are not recommended for long term use, especially in the elderly population because of risks, um such as um ulcers. And then next is intraarticular corticosteroid injections. Again, that would not be first line when this is the first presentation of um patient with knee pain. So you'd want to try some pharmacological treatments. So you can't just jump ahead to corticosteroid injections without trying things like paracetamol and um topical nsaids. So, topical ibuprofen on the knee referral for consideration of joint replacement surgery. Again, this would, it's, it's likely that the patient would be headed in that direction. Um But that's again, not first line. So the first thing that nice recommends and the guidelines recommend now is that you try nonpharmacological management. So you recommend exercise, weight loss and use of walking aids and if necessary. So that's the first line management at this point. So we'll go over the guidelines here briefly. So this is from the nice website. So you essentially need to and this is the management of any osteoarthritis. So it says it needs to be diagnosed clinically. It does not need imaging to confirm diagnosis, although it was available in this question. Um And its management is guided by symptoms and physical function. So this is an interesting thing. So you have a lot of patients with a lot of sort of osteoarthritic symptoms on x rays and then they have no complaints and you have some patients with minimal osteoarthritic symptoms on osteoarthritic signs and x-rays, things like loss of joint space narrowing, subchondral cysts, all those things. Um And then they're not complaining or you can have somebody with very mild osteoarthritis on the x rays and then they've got a lot of pain. So you, you have to manage them based on their physical function and symptoms such as pain. So, exercise and weight management are key. Obviously, it's really difficult to tell a patient that's got knee pain, that they need to walk more when obviously they are able to walk because of the pain. So it, it's sort of a vicious cycle. And what nice want is you to only provide analgesia if needed. So, what they recommend initially is paracetamol is fine. Um, but you shouldn't be giving oral nsaids an issue. So topical nsaids are preferred and then oral nsaids are, um, uh, suggested, sorry, it says do not offer paracetamol unless used infrequently or for short term pain lief. So that's changed as well. Um So first line would be exercise weight management, non pharmacological therapy if you absolutely need it, things like topical NSAID s then consider all nsaids and then you can also consider paracetamol. So that that would be an adjunct. Um And then ultimately, if all of this fails, you would refer for joint replacement. So this is a nice infographic from the B MJ. I don't think it's very clear. Um Sorry about that. But on the left, you can see exercise, weight management, manual therapy devices such as walking aids. Um They say don't offer acupuncture uh which is fine and then pharmacological management. So, topical nsaids, oral nsaids and then don't just routinely off paracetamol or weak opioids or strong and, and in general, don't offer strong opioids. So we know that ultimately, they may be headed towards um joint replacement, but the way that it's managed in the community. So in the GP setting is that they have to try it sort of step by step before just referring the patient on. Um, sometimes patients do well with just things like weight loss, topical nsaids. Sometimes they do well with just, um, the steroid injections and they, they may not need that, um, operation as soon as they think. Um, and these are good things to do in the interim because the wait list is so long. Now, for a hip and knee replacement can be up to 18 months to a couple of years depending on where you are. And then just so you're aware of compartments of the knee, there's technically three compartments and it's based on two separate joints. Technique. You have the patella, femoral joint, which is between the posterior aspect of the patella and the femur and you also have the tibia there. So here you have, in this case, the patient has medial osteoarthritis called that uni compartmental osteoarthritis. And if that were to proceed, in theory, patients can receive something called unicompartmental knee replacement. Um If they have arthritis in two or three components, that's when they usually get a total knee replacement, that's just more if you're sort of interested in orthopedics. Uh But the main thing to understand is that for these patients, it's non pharmacological therapy first and then analgesia as an adjunct and then steroids and then referral. So this is the second last question. Ok. So six people responded in the interest of time uh because I've run over, sorry about that. Um We will move on and on this. So the majority of the majority of you have gotten this right. So the main thing that you'd want to be able to differentiate is between a meniscal tear and an ACL tear. So you've got a footballer that's come in, she's just landed on and twisted on her knee and there's minimal effusions, there isn't much swelling. So, and we'll go over how you differentiate between ligamentous and meniscal injuries. And then anterior and posterior jaw tests are unremarkable, which means that the ACL and PCL are likely to be intact and then on internal rotation of the foot, the patient complains of pain and you notice a clicking feeling. So that is an examination known as mcmurray's test and a clicking feeling and a clicking sound indicates that the mcmurray's test was positive, which is indicative of a, a meniscal injury. So we'll go on to this in these questions. The main thing to do is to be able to differentiate is this ACL or is this a meniscal injury? And obviously both can happen together as well, which is the final bullet point there. But in a patient that's just come in with that sort of knee pain and that presentation of falling and twisting. Let's, let's see what it's put down. I put down um landed and twisted her knee. So that could easily be an ACL injury or meniscal injury. But the way to differentiate is, is there a positive anterior positive drug test which would indicate an anterior cruciate ligament and posterior cruciate ligament injury respectively. Or is there a positive mcmurray test? Which it was in this case, then is there acute swelling or is there delayed swelling? So, if there was acute swelling that, that points more towards the ligamentous injury. Um whereas in the case of the meniscus, which is um a fibrocartilaginous c shaped structure, swelling will take some time to develop. So you wouldn't have swelling straight away, which is again, in keeping with the overall picture that this is a meniscal injury. Um and then you can have things such as it, it, it it depends um if you want to really get into detail on this, but there's you have anterior horns and posterior horns and roots of the meniscus as well. So, different aspects of it can be injured. Um I think the latest research coming out in terms of managing meniscal injuries is that it should be repaired um especially in the younger population under the age of 55 where previously they would um just remove the meniscus in all cases. And now they're trying to subtly distinguish between which cases need meniscal removal for pain relief and um uh symptomatic sort of improvement uh and repair of the meniscus as well. One of the risks essentially is that if you remove that meniscus, you've essentially increase this patient's risk of developing osteoarthritis. And it's possible that they'll get it at a younger age as well. So that's why there's a push to sort of preserve the meniscus. When possible. Question eight, this is the final question. If you guys have any questions as well, please feel free to put in the chat and then, um, I think can let me know as well. Ok, six responses, which is roughly the same as the previous one. So we will answer this and yep, the majority of you have gotten this right. It is indeed the common perineal nerve. So what's happened here since she's patients fall onto her side, which side of we said we haven't set aside fine. So the fall on to the side and there's pain of the lateral aspect of the car, which is roughly where the common peroneal nerve comes. So it wraps around the head of the fibula, um offer it splits in the pop. So you have the sciatic nerve going down, you have the pop posteriorly and the the super lateral aspect of it is where you have the um nerve split into the tibial nerve which runs straight down. And then the common peroneal nerve which comes around wraps around the fibular head and comes anteriorly. So that's what that looks like. So the second image shows that sort of sciatic nerve splitting there that would be in the p of fossa. You have the common peroneal nerve there, wrapping around the head of the fibula, which is why it's an increased risk of injury in a fibular head fracture. Or if there's bruising in that area, such as a small hematoma, for whatever reason that can compress on the common perineal nerve as well. The tibial nerve meanwhile goes posteriorly um through the pop fossa straight down. So as you can see with the image on the left broken fibula can cause damage to the perineal nerve. Um And as you can see on the right, the common peroneal nerve is responsible for a lot of the um muscles that are responsible for dorsal flexion of the ankle and foot. Whereas plantar flexion is supplied by the tibial nerve down the posterior aspect, which is why in this case, the patient is unable to dorsiflex her foot. So that's sort of putting it all together. So what they have, if they're not able to do ac flex, their foot is drop foot and this is a result of weakness of the foot. Dorsiflexor. The most common cause of this is common perineal nerve palsy. You can also have L5 radiculopathies. You can have sciatic nerve lesion. But if you had that you would also have tibial nerve signs, so they wouldn't be able to plan flex either you can have superficial or deep perineal nerve lesions. And then this can also come on with stroke um along with other signs and symptoms all of this I'm talking about is a dropped foot, by the way. So overall worth knowing the course of the nerves and where possible injuries can occur, but also important to know of differentials that are not just trauma. So things like stroke um can explain a full sort of drop foot in addition to other lower lymph signs as well. Um And yeah, that is final, this is the final side actually. So there is some nerve palsies that I have taken um from past med if you want to screenshot it, um this is mainly for the lower limb and I think they have one like this for the upper limb as well. So this is where you can get nerves caught um and injured. So, as we mentioned here, common perineal nerve, we've talked about what it supplies in terms of motor and then sensory dosing of the foot and the lower lateral aspect of the leg. And then injury often occurs in the neck of the fibula, tightly applied lower limb plastic calves can also cause compression of the nerve or a hematoma in that area can cause compression of the nerve and then that would cause foot drop. So if you're interested worth going over the other ones as well, um because sometimes they can show it as a neurological deficit and that's uh all they give you in the question. And then you've got to sort of figure out which it is based on what that would supply. So essentially marrying up your preclinical knowledge with clinical signs. But I think that's it. So just to sort of go over what we've spoken about today includes proximal humerus fractures, supracondylar fractures, disor fractures, not superior gluteal nerve injury, knee osteoarthritis, and management of osteoarthritis in general, which has changed um, meniscal injury and then common perineal nerve injury as well. There's a lot of things that can come up in med school finals. So, clavicle fractures worth going over when media versus the middle third versus distal clavicle rotator cuff injuries are common. So, so are things like tendonitis or supraspinate tendonitis? Um Also bursitis, sapid fractures are common as well. Um medial and lateral epis. So, golfers and tennis elbow can also be signs and symptoms that come up. Um, carpal metacarpal, which is the base of the thumb, osteoarthritis and hip osteoarthritis are the other common types of oa, other than the knee pelvic fractures, usually don't come up because it's very trauma related. But um worth just generally knowing that you can have pelvic fractures in the context of major trauma and then that can lead to a lot of blood loss and the management of that is usually a pelvic binder. You can have distal femoral fractures which we didn't talk about. We, we mainly spoke about the proximal bit, which is the knots. Um You can also have tibial plateau fractures. Um You can have ankle fractures as Well, we didn't talk much about we A B or C so worth reading over that ligamentous injuries as well as the ankle where the anterior talar fibular ligament is the most commonly injured. Um, when you're, uh, when you have a sort of inversion injury and then fractures of the feet or toes, things like this and um, stress fractures, we haven't gone over. So these are just some of the other things to guide your reading in the build up towards finals. But on the whole, I think it's, um, orthopedics, there's not many things that they can ask you for med school finals. So it's a pretty narrow topic that you can cover quite quickly in the build up towards finals. Hopefully this session has helped. Um, and if you're able to, I'll just drop the feedback form again or if you're happy to. But, um, yeah, thank you for attending and let us know if you have any questions or anything like that. Yeah, sid thank you so much. I've just sent the feedback form again. Um So if you guys haven't filled it out, please do fill it out. But s thank you so much for that session and for making the time to do this, that was really, really helpful. Um That does conclude our finals revision series. Um Thank you, everyone who attended. Uh And I really hope you enjoyed it. Found it useful and do keep an eye on our socials. Give us a follow on Instagram and if you use Twitter or on Twitter as well for future series announcements, uh that will be on there. So thank you guys so much for attending this talk and attending the series. And again, thanks to SID for this fantastic session. Cool. Yeah. Thank you. Thanks. Thanks for me.