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Fractures of the Femoral Neck, Mr Nigel Rossiter

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Summary

This on-demand teaching session will go over strategies to deal with common Neck of Femur traumas in medical professionals. It covers the various factors that make up the composition of the Neck of Femur, its anatomy, blood supply, and why fractures in this area of the body are so hard to treat. It also covers ways to reduce fractures in younger patients and the importance of ensuring a rapid response when treating elderly patients. Attendees will leave with greater understanding of the Neck of Femur, the risks involved in its fracture, and strategies for success in treating these types of traumas.
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Learning objectives

Learning Objectives: 1.To understand the definition of a fracture and how it relates to soft tissue injury 2.To identify the watershed of blood supply for the proximal femur 3.To be aware of the current medical guidelines and best practice tariffs for elderly patients with neck of the femur fractures 4.To gain an understanding of the implications of osteoporosis in elderly patients who suffer from a neck of the femur fractures 5.To differentiate between a young and elderly patient suffering from a neck of the femur fracture and the implications for treatment and management.
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Computer generated transcript

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

All right, I'll start again. Uh, good afternoon to you all. Um, I'm sorry that, uh, for those of you who are listening to me this morning, you've got me twice in a row in one day. So I apologize for that. I'm stepping in at short notice. So we're gonna change tack a little bit from my introduction to trauma this morning and we're going to talk about, um, uh, one of the most common, uh, things that, uh, uh, we get presented with certainly in the UK and, um, actually globally, uh, this is probably one of the biggest issues that, uh, you will ever get presented with in trauma and certainly in orthopedic trauma. Um, when I started as a consultant as a, uh AAA senior surgeon. Uh, most of the trauma cases I were doing, I was doing were still ones of the neck of the femur and it, the elderly patient. Um, but we were dealing with lots and lots of young patients coming off the road and I suspect in many of your countries that's still most of the, the things you deal with. But as we have an aging population, as medical care of medical issues gets better. Uh People get older and unfortunately, as they get older, um they tend to fall and unfortunately, uh particularly for ladies, uh if ladies fall, uh you tend to become osteoporotic after the menopause, uh the bone becomes less uh dense and this is now what we call in the UK silver trauma. This is the thing that dominates all of our trauma lists. Uh So, uh it almost all of our trauma work is around elderly patients who break bones and by far the most common is the, is the neck of the femur. So let's get into this. Um, it's uh uh really comes as a dichotomy. There are two groups of patients, um you have the young patients and as in terms of numbers of patients who break their hip, they're really relatively rare. Um, young patients who break their hip probably make up in, in the UK, make up probably less than 1% of the workload of femoral neck fractures. Um, they usually are high energy after polytrauma. People coming off motorcycles. Um uh road cycling, road racing is a, er, er, push biking is a, is a real sport in Europe and um people coming off, uh push bikes at high speed. Uh breaking a hip is a, is a not an uncommon scenario, but by far the most common scenario is the low energy fall from a standing height in the elderly and in this country it affects 15% of all women and 5% of men and osteoporosis is by far the most common cause. And it costs our health economy, billions and billions of pounds a year. And unfortunately, even though we think we've, we've got this reasonably well covered, um, the, the mortality hasn't dramatically changed in the last 10 to 20 years. So 10% of these elderly patients are dead within a month and 30% are dead within a year. And it's usually due to causes that are totally unrelated to the hip fracture. They die from related causes. And it's unfortunately usually the related cause that often causes them to have the fall that gives them a hip fracture secondarily. So the hip fracture is rarely the the the primary cause of death. It's usually due to other things and the hip fracture unfortunately is a sign of a failing body. Now, why does it happen? And what is osteoporosis? Well, hopefully, most of you are young and fit. And if you know what a Cadbury's crunchy bar is your bone um is made up of the cortical bone on the surface and then the light can sell us bone that gives the bone uh its lightweight structure and its ability to flex. Now in you, you will have largely have an image as you see on the left, the healthy bone. But as we get older, the mineral within that bone uh becomes less dense and gets resorbed and it is unfortunately much more common uh in patients who have um uh osteoporosis and are ladies as the lack of estrogen is a real drive for this. Unfortunately. So let's talk about uh the elderly in the first instance because this is by far the biggest workload in this country, we have um a national guidelines and what we call best practice tariffs that we need to achieve to be paid properly for looking after these patients. And one of those is to get the operation done within the 1st 36 hours. And there is really, really good evidence that if you do do that, the risk of mortality very significantly drops in that first month. So we aim to get those patients in theater within 36 hours and those patients get priority often over many other patients. We aim to do one operation and we aim to do some form of fixation that it is stable, that allows that patient to get out of bed immediately. And we aim to have the patient out of bed and ideally weight bearing fully and walking on day one. So we minimize, we get it right to minimize the uh potential of implant failure. We maximize the potential to get back to pre fracture mobility and we'll talk a little bit about that in a minute. Now, why is the neck of the femur such an issue and it comes down to blood supply? Um As I said to you earlier today. Uh If you need to define a fracture, if you're ever unfortunate enough to sit in front of me in an exam. And I ask you what the definition of a fracture is, a fracture is a soft tissue injury that happens to have a broken bone and it all comes down to the blood supply. So the blood supply for the proximal femur comes from the medial circumflex artery and it travels up around the neck of the femur. And uh there are branches that come off that artery and travel up uh the capsule of the femur supplying the femoral head. And it's really important to remember that and to remember the intertrochanteric line, the greater trach at the top, the lesser trach Cantu at the bottom and the line that goes between them because that's your watershed. So um that's uh uh where the blood supply comes up. So, any fracture that is distal to the trochanteric line in what we call the inter or subtrochanteric region does not interrupt the blood supply. The blood supply is preserved and we can therefore, we can fix that fracture, we can mend the bone and expect the bone to heal. However, if you break the bone proximal to the intertrochanteric line in the region of the femoral neck s of vital fractures, then the blood supply is at risk. And the problem is the head may die. You get avascular necrosis of the femoral head and it may die. And so the treatment for um uh neck fractures in, in the elderly is to replace the head. Whether that be with a half hip replacement, what's called a hemiarthroplasty or a full hip replacement that replaces the ball and the socket. And we'll talk a little bit about that in a minute, slightly different in the young and we'll talk about that in a moment as well. Ok. So let's start with those fractures that are proximal to the intertrochanteric line that interrupt the blood supply to the femoral head. So as I said to you in the young patients and, and the definition of young is extremely gray and we'll talk about that in a moment as well. Um But let's for argument's sake, say in a patient under the age of 65 who is fit well active and independent, we're going to try and reduce the fracture, put that broken bone back to where it's meant to be. So, if the fracture is uh sorry, dropped off, we're gonna try and reduce the fracture and fix it in the right position and then fix it with stable internal fixation that allows the patient to get up the more displace the fracture before it uh it is fixed, the more likely the blood supply is in is interrupted. The timing of that reduction actually doesn't matter what matters is the right person doing this, the operation with the right team in the right hospital that's been shown to give the best result. And we're trying to do this because we're gonna try and aim for that younger patient to not have some form of a full hip, uh either a hemiarthroplasty or a, a full hip replacement so that they can get back to their free pre fracture mobility. And we'll talk about that in a moment. The unfortunate thing is that in 30% of these cases, even if you get that reduction. Absolutely perfect what I call A FT and a flipping tonic. If you get it perfect, 30% fail and they fail because of that interruption of the blood supply. The fracture either does not heal what is known as nonunion or the femoral head dies because it gets no blood supply and you get avascular necrosis. A va so uh cycling on road or off road in this country is um uh is very common. Uh Those are, in fact, three of my colleagues, they are all orthopedic consultants competing in the cycle race and uh one of them has come off and broken his hip. Now in the elderly, it is different in the elderly. Um As I said to you, we want one operation uh and one operation that's going to work well and we're going to do it in the 1st 36 hours because that reduces the mortality in the 1st 10 days and the first month that patient may have very limited physiological reserve. And so you need one operation that's going to work for them, allowing them to get up fully weight bearing, restore that pre fracture mobility status. So that we avoid the complications of prolonged bed rest. Why don't we do that in the younger? Because most of the younger patients have a physiological reserve. And even though 30% of those operations may fail, most young patients if they fail, will tolerate a second operation, but the elderly will not. So we want one operation. OK. Now, in all bits of, of surgery and particularly in orthopedics, we talk about classifications and I'm gonna go through this briefly, but I'm gonna tell you to ignore it because I'll show you why in a minute. So with um there is an internationally agreed uh way of classifying broken bones and it's an alpha numeric system. So the bones are numbered, your humerus is number one, your radius and ulnar are number two, your femur is number three. So we're talking about a fracture of the uh number three bone and then the bones are divided into segments. The proximal segment that you can see here is number one, the shaft of the bone. The diaphysis is number two and the distal segment is number three. So we're talking about the proximal segment 31. Now, if it's below the intertrochanteric line, it's an A type fracture. If it's above the troch enteric line, it's a B type fracture. If it involves the neck of the femur or a cty fracture. If it involves the head, don't get hung up on this. So I'm gonna talk to you largely about the B type fractures which are by far the most common and the age and the status of the patient, their physiological status dictate what we're gonna do for them. Now, you can get some of these where the, the ball breaks and it impacts backwards slightly. So the ball breaks and instead of er dropping off, it impacts backwards slightly, it's what we call a valgus impacted fracture. And these are very stable and there's massive controversy about what we do with these fractures. Do we leave them alone? Do we fix them in that position? And I hope they're gonna heal or do we uh actually uh um uh operate on them and replace them and there is controversy and I'll talk to you a little bit about that in a moment. Um If it goes across the neck of the femur and there is some displacement, a bee type fracture then by and large, we're in the young, we're going to do a, a reduction and fix it in situ either with something called a dynamic hip screw or sliding hip screw or possibly something. Uh things called can screws, which I'll show you in a moment. But in the elderly, we will most of the time do an arthroplasty, replace that broken ball. We get gradually more unstable and as we get more and more unstable, we're more likely to do a, a fixation uh uh a replacement. Sorry. Now, one of the most common classifications that's around is gardens classification, a garden, 123 or four. And I wanna tell you that actually all of those classifications are not helpful at all. All we want to know is if the fracture displaced or undisplaced because if it's displaced, we're gonna do something about it. If you can see the ball has moved, we're gonna do something about it in the young and the fit. Most of the time, we're going to fix it, reduce the fracture, fix it and either fix it with an open reduction, a percutaneous reduction or a closed reduction. If it's grossly displaced, uh in the young, we may still try and do that rather than doing a hip replacement. But in all of the displaced fractures in the elderly, we're almost certainly going to do um uh an arthroplasty. We're going to replace it with some sort of hip replacement. The really controversial ones are the undisplaced ones now, 12 years ago. Um I was the president of the Trauma Society. I chaired an enormous international meeting and we had 1000 surgeons in the room and I showed them a picture of an undisplaced femoral neck fracture in a fit 68 year old and asked them what they were going to do and 80% of the audience said they were going to fix it. I then brought along a friend of mine, a chap called Jan Erich Jar and Janne is, runs the Norwegian Hip Fracture registry. Now, we run a hip fracture registry in the UK and we do er, um assess the outcomes of the patients in terms of whether they get back to their original place of er, that they came from. But in Norway they also assess the functional outcome of the patient. And the Norwegians have shown that if you replace the broken ball, you get better function at every time point at, in all age groups. So I presented that I got to present that evidence to the surgeons and then asked the surgeons to revote and guess what happened? Orthopedic surgeons are thick people and they didn't change their minds, which is just crazy. So we're doing now doing a randomized controlled trial of these undisplaced fractures. It's got a lovely name. It's called Fruity and I hope in the next year or two, we'll have an answer for you. Um So if we're gonna replace the hip, you will see lots of different things being done. A total hip replacement, what's called a constrained hip replacement where the ball cannot dislocate from the socket. A slightly newer one that's known as a dual mobility. A slightly old fashioned one called a bipolar where both segments move a modular hemiarthroplasty where uh you put a, a stem into the femur and you can change the size of the ball or a mono block where the stem and the ball are all one piece. Now, there is no evidence that constrained dual mobility bipolar uh or modular have any use at all. Uh uh The sorry, the constrained dual mobility or bipolar have any extra function. The only advantage or disadvantage they have is they cost between four and 10 times more. But the outcome is the same. So the real debate is whether we should do a total hip replacement, replace the ball and the socket or just do a hemiarthroplasty. It was a big trial done in four countries, uh, published in the, um, the New England Journal of Medicine a few years ago called the Faith trial, which showed that the function of hemiarthroplasty and hip replacements at two years was exactly the same in all ages. What we don't know is out to 10 years. So you're talking about putting a hemiarthroplasty into me because I'm over the age of 55 which was the cut off in that trial. And I'm not sure I would want another operation some years down the line. I probably want a total hip. So we'll wait and see. And I could do a whole course on that. And there it is the subject of lots of other courses. So, in arthroplasty, we're talking about a hemiarthroplasty or total hip and here's some, uh, x-rays of it. This is a hemiarthroplasty. This is a stem inside the femur that has been cemented in place. And there is good evidence that cementing the femoral component is better than not cementing. Um Very good evidence. We have the National Institute of Clinical Exence in this country and you, we are advising all surgeons they should cement the ball. You can see is a great big door knocker that goes in the acetabulum and that is uh does not replace the socket in a total hip replacement. We replace the socket as well. So you've got a smaller ball articulating on a full socket made out of, in this case, poly uh ultra high molecular weight polyethylene. OK. In this country, n the National Institute of Clinical Excellence says that we should do total hip replacements in patients who've got preexisting acetabular disease. So they already had hip arthritis patients who are are able to walk outdoors without a stick with no more than one stick. So they're functional, they're not cognitively impaired and they're fit. And so about uh between 10 and 15% of all in caps and neck and femur fractures in the elderly in this country get total hips, 85% get hemiarthroplasty. No, we can insert some sort of fixation device and we'll go through this in a little more detail, bit further on, but there's a stepwise uh way of doing this. But by far and away, the most important thing is the reduction of the fracture. That bone must be perfect. It must be. And a flipping tome, get it right. And the key to doing it is on a traction table using some traction, which looks like some sort of medieval torture device um to reduce the fracture. And we try and do it closed without opening the, the uh uh the hip up. But if we can't get it reduced closed, we will open it. It has to be perfect. And then we might insert some cannulated screws like this uh to hold it in place or a sliding hip screw. A dynamic hip screw, which I'll show you in a little bit. But as I said to you in the intracapsular fractures, 30% of them will go on to nonunion or avascular necrosis. All right. So let's have a quick question after thinking about the intracapsular fractures. Um Here's a question for you. A complication of uh internal fixation with cannulated screws is either hip dislocation, heterotopic ossification or nonunion. I have a think. Alright. And you should have got nonunion, right? As I said to you, 30% of them will fail. All right. What about the indications for a total hip replacement? Bye bye. Who gets a total hip replacement in the elderly, a displaced fracture? Someone who's got intact cognitive function and, or someone who can walk outdoors with no more than one stick. Have a think. Well, the answer is all of them, right? They're all correct. So you have to have all of those to get a total hip replacement for a displaced intracapsular neck and femur fracture in this country. OK. What factor is strongly r related to nonunion in these fractures, the age, the gender or the amount of displacement initially? Well, it's the displacement. If you remember, I said to you, the more it's displaced, the more likely the blood supply is uh has failed. I said I we'll come to some questions at the end. So don't worry, I will come to you. All right. So for those intracapsular fractures, um the blood supply is the thing that makes it at risk and particularly in the elderly. If we're going to fix it, we got to get that reduction. Absolutely perfect. We need to know what we're doing and if we plan it properly, we will reduce the intraoperative complication rate. All right. So let's move down. Let's move south slightly on the femoral neck. And let's look at those fractures that are distal to the intertrochanteric line, the in intertrochanteric fractures where the blood supply is intact, right? And if you remember, I said to you, the blood supply is intact. Therefore, we do not need to replace the ball of the hip joint here. We're going to fix it and allow nature to heal the bone and we'll use something like a dynamic hip screw, right? I've already talked to you about the other fractures. Now, there are different types of this fracture. And essentially, it comes down to the stability of the fracture and the stability dictates what we're going to manage these fractures with. So the one of the most common is the A one or the simple fracture where there are just two parts to the b uh the break, there's the proximal segment and the distal segment. And for almost all of those, they're best managed with a dynamic or sliding hip screw, which I'll show you in a second which allows the fracture to compress and almost, almost always, the fracture will heal if the fixation is done correctly. The next one is where they become slightly more unstable. And there are three parts to the fracture and the key is the lesser trochanter and this is what we call the medial calcar. And when the medial calcar is broken, the fracture is less stable. Now, there is controversy about this because actually with the A two fractures, when the medial calcar is is off if it is done properly, a sliding hip screw is still the best treatment. But there are some surgeons around the world that will use a cephalomedullary nail, a nail that goes down the inside of the femur, which I'll show you in a moment um uh to treat them. And there's nothing wrong with that. The only difference is the expense. A nail is eight times more expensive than the sliding hip screw. And then finally, you have fractures that are below the level of the trochanter. And these are much more unstable. And particularly if the fracture line, if you look at the one above the fracture line goes in that plane, whereas the one below goes in the opposite plane, and those are known as reverse oblique fractures. And those are fractures where a sliding hip screw will fail. So those should not have a sliding hip screw, they should have an intramedullary nail. Oh, like putting in the cannulated screws, putting in a sliding hip screw, the progression is exactly the same and the key is exactly the same. The key is the reduction. So here you are, here's an A two fracture one where the medial calcar has been broken off and it's been treated with a dynamic hip screw or sliding hip screw. And this has been done really well. There's a, a screw up the center of the femoral head, a aiming to the center of the, the femoral head itself. And we'll talk about that in a moment and the plate on the side with four screws holding it in place and the fracture has been beautifully reduced. This will do well. Again, the, the absolute prerequisite is getting a perfect reduction. If you get a perfect reduction, it will heal. Now, when we're putting in the sliding hip screw or AAA Cephalin Medullary. Now, which I'll show you in a second, the most important bit is where the tip of that screw ends on the femoral head. And there's a chap called Mike Baum Gardner. And Mike's a very good friend of mine. He's the professor of orthopedics at Yale University in Connecticut in America. And Mike looked at failures of sliding hip screws and he worked out that if you get that sliding hip screw within 25 millimeters of the center of the femoral head, when you measure the distance on a good A P view and a good lateral view and add them together. If it's less than 25 millimeters, the screw is unlikely to fail. And I tell my trainees that they need to get that as close to 10 millimeters as possible. And that's known as the tip apex distance. Baum Gardener's tip apex distance and it is critical to get that right. The same is true with the nail. It's exactly the same the reduction insertion of the nail getting it in and then uh putting in locking in the nail. So here's a nail that goes in. You can see uh we've got a nicely reduced fracture, a nail that has a screw or a blade that goes up into the femoral head, aiming for that perfect ti apex distance and then goes down the intramedullary canal. And the nails can be what we call short, long, short and this is a long, short one or long, so short ones usually are 100 and 80 millimeters long and usually end where that screw is or just below it. This is a sh long, short nail. It's 230 millimeters long and goes just beyond the isthmus of the diaphysis. The narrowest bit of the, of the shaft of the femur and the long nails go all the way down to the distal fice or scar. Just like with putting in a dynamic hip screw. The absolute prerequisite is the reduction. The only difference is we win sweep the, the top of the patient, we slightly push the top of the patient over because we're gonna be putting something that goes down the femur and we need just that little bit of extra access to get down the shaft of the femur. Now, there is real controversy er with whether you put in a long or a short nail and you will never go wrong with putting in a long nail, but they are much more expensive and, and the distal locking of a long nail has to be done freehand most of the time and some people miss and it certainly prolongs the length of the operation. So most short nails are for fractures above the subtrochanteric level, long short nails, you can use for almost any fracture as long as it is uh above um uh the diaphysis of the femur and it's not pathological, it's not a fracture that has been caused by metastasis uh from a, a bone tumor, uh a tumor from somewhere else. Uh If you have a pathological fracture. One of the absolute axioms in orthopedics is, you must instrument the whole bone, you protect the whole bone. So they must have a, a long nail. If you have a fracture that goes below the subtrochanteric level, then you should do a long nail. Oh, now what can go wrong? Well, the most common is just like with the DH S is getting that position in the femoral head wrong that the screw or the blade cuts out of the femoral head. So just like with the DH S, you get the tip apex distance, right? Um or the wrong implant is being used. So here you are, here's an example of this, here's a fracture. And uh if you look, this is a cty fracture because the obliquity of the fracture goes the wrong way. It's a reverse oblique and it also extends well below the subtrochanteric level. Now, someone has tried to fix this with a long dynamic hip screw and the reduction actually isn't bad. But the problem is that this implant is, is not designed for looking after that obliquity of force. And so what happens? It fails. And if we go back and you look at the, the where that screw is in the femoral head, if we had a lateral of that, the distance from there to there on the A P and added to the lateral is going to be more than 25 millimeters. And the screw has ended high in the femoral head. And so what happens? The screw cuts out the best bone in the femoral head and neck is posteroinferior. So the higher the screw, the more likely it is to cut out. And because this was a reverb fracture, the fracture has failed because this implant won't resist. That force should have had a nail. All right. And then uh uh as we say, and I excuse my expression, shit happens. Um uh Things can go wrong. Uh And an infection can always bite you. So we're really, really careful and we have AAA reputation in orthopedics for being really rather over the top in trying to ensure sterility. And it is one of the most common complications um o of this. So, um I don't know who's just put that on the screen. Whoever it was. Could you see if you can remove it, please? Um uh The, one of the most common things we do is we put up AAA screen and we tend to operate with our back to the uh um Thank you uh to the theater staff. So it's really important that you, you, er, maintain your sterility and careful of where you stand. The drape goes up and everyone has to be really careful when that drape goes up, that they don't sterilize themselves. And then we use the image intensifier when we're putting these implants in and it swings from an A P view, an anteroposterior view to a lateral view and when it comes through, it is easy to deer, uh, the surgeon and the patient. So it's very important to keep an eye on that for this to go. Well, you need to know the kits, know the instruments, they're all slightly different and you need to be really, uh, sure, you know how the instruments go in. Uh, because if you know what you're doing, um, uh, things will go well and you sh if you don't know, you need people to help you out. So in summary, the intertrochanteric fractures are the ones below that intertrochanteric line, the blood supply is intact so we can fix them because they will heal. As long as you reduce the fracture, you must recognize what the fracture is and choose the right implant for the majority, a sliding hip screw will work very well. But there are some where a nail is more appropriate and for those people who like putting in nails, that's fine, but you are spending eight times more money, make sure you know your instrument and plan, plan plan. There is a saying that if you fail to plan, plan to fail, OK. So little bit shorter than this morning, I'm sure you've had a lot of lectures today. Um I'm gonna stop sharing at that point. Uh Anyone um got any questions anyone like to er uh either put a question in the chat or stick your hand up turn your camera on and ask a question. No, I've baffled you. Ok, Hazard again. Welcome Hazard again. What would you like to ask? Uh Yes, it was. Uh I mean, I would like to put the slides again back. I would request to put the slides back open in because it was regarding the, the technique of the washers and the screws. Ok. These uh it was before the quiz, the, the quiz, the set of quiz you asked. So it was a sled before it. Can you please show me again? I, I, as I'm not gonna actually do that, uh, because we're getting into technicalities and there is a lot of controversy about it. Uh, whether you do three up, one down, uh, uh, uh, two, up, one down, two down, one up, whether you put four screws in, whether you put two screws in, there's an awful lot of controversy if you really want to learn that in detail. Come on an A O course. Uh I chair lots of A O courses and, um, uh, and we will answer all of that for you. That's really once you start doing the surgery and that let's not get too bogged down in this at the moment. But the short answer is, um, if there's a controversy about something, then you should probably take home the message that it probably doesn't matter. Ok. Asthma, I hope I pronounced that correctly. Um, doctor, I repeat the classification again. OK. So um essentially the, the classification that's used globally is called the A OOT A classification. And it's an alpha numeric classification where the bones are numbered and every single bone in the body is numbered. So we're talking about bone number three, the femur, the top of the femur, there's first segment 31 A fractures involve the head of the femur B involve the neck and c involve um uh the intertrochanteric region and below. But for the insular fractures don't get bogged down in classification because it does not help. What you want to know is whether the fracture is displaced or undisplaced. That's all you need to know for the uh for the intracapsular fractures because if it's undisplaced, the femoral uh head blood supply might be intact, but 30% will fail. If it's grossly displaced, the blood supply is interrupted and it almost certainly will fail. So for the elderly patients, we will replace the ball of the femur. For the very young fit and active we might fix but accept that 30% of those will fail. For the ones below all we need to look at is for the lesser Traa, is that or is that not intact? If it is intact, it's stable and it can have a sliding hip screw. If it's not intact, we look at the obliquity of the fracture. If it's what we call a reverse oblique, it needs an intramedullary nail. If it's not, it can have a sliding hip screw if it goes below the level of the sub. Ok. Thank you doctor. You're very welcome. Anyone else? Got any uh, questions? Good. Well, I've bamboozled you with science. Bored you to death. Er, I hope you and now get a little bit of time off for a cup of tea before the, the next talk. And um, I'm giving another talk at the end of the month on the 29th, er on trauma again. Uh we're gonna go into trauma in a bit more detail and look at the physiology of trauma in a bit more detail. And as I said, hopefully later this year, we will run a primary trauma care course for you. So you can understand the ABC DES and learn some of the hands on techniques to uh save people's lives. So have a wonderful day. Good afternoon to you all and uh look forward to seeing you again soon. Thank you, Mister Rosita. I've just put in the chart, the usual feedback form. So four students could please be reminded to fill that in and then yeah, you're free to leave. But um thank you very much.