Computer generated transcript

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

Good evening. My name is Jeremy, one of the court surgical trainees that stepping out, you know, I'm going to go through some upper limb cases. Two key cases, I think that you should be able to identify and quickly managed North Peter guess Ijo. Um and the relevant anatomy behind them and also some advice on your basic neurovascular exam you should do is Neff on our F T. So outcomes of this, understand the relevant anatomy behind this Kia pollen orthopedic presentations. I want you to understand the function of the ki neurovascular structures and then be able to perform this concise hand exam to assess your vascular status that you'll be doing on a daily basis. You're on court on a ward of patient's pre and post up. And from this, I want you to be able to identify upland neuro vascular compromise, an orthopedic echo, which will be one of the key emergencies that you need to talk to your regimen about. So I'm gonna give you two cases. You're the orthopedic as it show on call, you're going a couple of years ahead or if you have to, you're doing this, your register on I'm sleeping, you want to wake them up if they need to, you're gonna be referred to cases from a knee. So these two cases, I want you to identify the problem and then the greatest concern the structure at risk and your next key Axion. So I've got some polls that you can answer for the to answer these questions. Case, one common case, you have a 25 year old right hand dominant artist. She falls an outstretched hand. She's got an isolated closed injury with the X ray there. A motor is normal. She's got reduced sensation of the thumb and index finger, three out of 10 and have Oscar status is normal there. So with the polls, can you identify the greatest concern? Is that the limited range of movement she's got, is it the reducing section or is it the fact that the dominant hand, what is the structure at risk here? Is that the median nerve, the all the nerve or the brachial artery? And what is your next reaction? Are you gonna put a slab on center back to French clinic? Are you gonna reduce this? Put a back slab on re examine, do a check X ray or are you going to call your reg? So I will submit my answers to for this one. So this is the right side, dorsally angulated intraarticularis, the radial fracture. The great concern is the fact she's got a loss of sensation, limited range of movement not is expected. And the dominant hand injury doesn't really matter structure at risk. You know, you can see the spike at the distal radius is going to be tending the median nerve causing these symptoms and your key actions. So if you're, if you know you're confident is reducing these, you should be doing this yourself, reduce them, put them in a below a backstop, for example, getting a check X ray. But I don't think you're, if you don't experience, you're, we're just going to mind if you give them a call for, of advice or even to come in and if you're very new, so you reduce this and the sensation comes back after production, your check X rays. Great. You just outpatient home with French clinic and you didn't call, register still faster sleep. So they're like in the morning. So for the median nerve, this one is a risk, a lot of injuries will cause issue of the median nerve. So media nerve starts at the brachial plexus that comes from the fork between the medial lateral cords from C 52 T one nerve roots. As you can see that it's got all with the roots from the brachial plexus. In the upper arm, it starts at the fork which go passes under the, the pack here. Um And it has a very close relationship with, with the brachial artery starts lateral passes anterior and then goes medial at the A C F. It starts between the pronated Terry's and the biceps. Then we'll pass between effects, degenerative fish, RS and the FDP. So the uh in between them is in FDP and the middle layer in the way. And then the so FDS and the intermediate layer and the FDP uh deep layer and then later on, it will pass between the two is a side by side. So the FBI will be on the lateral side and the FDP will be on the medial side as well. You will see at this point, we've got a key division here. You have the anterior anti osseous nerve coming up, which is above the on head of predicted Terry's. And this will innovate the deep muscles. We'll go through the function in a bit at the very end in the wrist. It you'll have a branch coming over the trans carpal ligament, which is the recurrent. So which is the superficial branch of the median nerve. Uh And then the rest of it will pass through the capital under the trans carpal ligament. One branch coming back as the recurrent branch and the rest going into the multiple digital arteries, uh digital nerves, you've got, this is a schematic. I find helpful for nerves as well. So as you can see, there are no branches of media know that will come off in the upper arm to it because it's all four um lower. Uh you'll have your initial branches going to the hereditary Zflex couple radio uh Parma longest and the fact that you turn superficialis, then you have your key, one of your key motor branches that you need to know how to examine your anterior interosseous. This one will innovate the prenatal quadratic this which is difficult to examine the lateral half of the flexor digitorum profundus and the flexor pollicis longest. These two you should be able to examine for. Then just before the carpal tunnel, you have a branch coming over the trans carpal ligament, which is the palmer cutaneous, which will innovate the lateral palm or the radial side of the palm. And then the rest of it you'll have to ke branches. You have your current branch coming back onto your thena uh innovate your oath muscles. So your opponents policies, Flexor pollicis Brevis and your uh doctor. Uh so your absolute policies, brothers and the rest will split into the multiple digital cutaneous branches which will innovate your 1st and 2nd lumber calls and the rest of the sensation of that palm. Okay. A lot to go through. But I think your key things you'll need to know as that one. The sensory distributions you should know is from medical school. It is the radio or lateral, basically, 1st 3.5 fingers on the palmer aspect. And then it also includes the tips of the fingers. So you can see the highlighted bits and blue there, your key autonomous area that will always be always, always be the median nerve is your index fat pad, but uh the index digital pad. So if you need to examine immediate no sensation, it will be that part always. Um there's a lot of crossover, two different nose and an topical variations. But this one is you can rely on to test distal motor function of the median nerve. There are two branches here that you will need to test for. You need to test for anterior interosseous and then your recurrent branch of the median as well. So your I would say your autonomous motor for median is between index I PJ flexion with from I P J flexion. You can test this by this okay sign. Get it really tight and ask them not to let me break it. You can only do this Axion if you have full anterior interosseous function. The other movement is resistant abduction. So this is really key. Some people say that you do a thumbs up for this movement that's wrong. Your part needs to be flat out and your families to be coming up towards the ceiling. So hand on the table thought towards the ceiling. So it's resistant abduction. That test is your abductor policies. Breakfast. So autonomous sensory zone, the digital part of the index finger, the autonomous motor, you have your anterior interosseous to test which is your okay sign. Don't let me break it and your thumb up sign. So I caught a thumb left, so hand flat back on the table, push up. So that's the the nerve covered in detail. Um Here's your second case. So you will have a call from the ps AMP. They have a seven year old who's fallen off the trampoline and their elbow hurts a lot. It's an isolated closed injury. She is screaming in pain. She is non compliant with your exam. So you observe her, you can see the spontaneous finger movement here. She's not wanting to be the elbow is held in this predated position. She is saying however, that she's got a tingling hat and you can't distract her to do proper sensory testing. Here. Your test her from a vascular perspective. A capillary refill time on the left hand side is three seconds on the right hand side is too drive your radio posts and you can't feel it. The hand looks pink. It's not white again. What is your greatest clinical concern? Here is the fact that she's not complying is the fact she's got a tingly hand or she got no radio pulse. What structures could be at risk here is that the median nerve you wanna know, break your artery again? And what are you going to do again? Same three actions. Are you going to put her in an above elbow backstop this time and send her the fracture clinic? Are you going to reduce, put her in a back slab? We examined your chest X ray or are you going to call your registrar for this one? So again, the only signs you can really see here where the fact you've got a tingly hand, the fact that you've got refill on the left hand side, um compared to the right and Chicago, it does not a radio pulse. So for the answer here, I think there are multiple concerns in each of them. So, so you've got a pool, you can only answer one. But I think the greatest concern is the fact that you've got no radio pulse. Obviously, you'd be concerned about the single your hand here for your vascular issues, but often sensory deficits. After you reduce these type of fractures can persist for months, we'll often will recover. So it's not your greatest concern. The greatest concerns have actually got no pulse, stretch it out. You've got to stretch the risk. I would say your break your artery is more of a concern than you need. But both of these are concerned. So as mentioned with the median nerve anatomy, your um your media know will run along the anterior border there next to the break your artery. And if you can see by mouth will be tempting over here as well as you break your artery will be your next reaction. Here is absolutely not to reduce, put a back some at this moment, you need to stabilize it, but you don't reduce these at the moment. You need to call your registered patient needs to go to theater as an F one F two. You're not seeing enough to do this. So right thing, you call up your edge there, bit tired, but they've thank you for calling them. Uh this page. It goes for an urgent closed care reduction and K wiring with the consultant in theater. After reduction, the motor is fine, they will come back. She's, they've still got reduced sensation over the index finger, thumb on their radio pulses present or community to the subclavian. Uh this part, when it passes the lateral margin of the first rib, it become the auxiliary in three parts. And then when it passes the inferior edge of the Terry's mine, it will become your break your artery. It's um a blood supply to the open. Then uh it turns out it's a relevant anatomy or, or relative anatomy to of structures around the face. It lies medial to the biceps here and runs, as mentioned with the median nerve. If we take away all the muscles in this scenario, you've got a few branches that will go to branch off and then come back here. So you got your refund to break your eyes, the first branch and then your superior or no collateral. These will both join later on, not the break your butt in different places. You also have your Humira Humira or nutrient artery here as well and then lower down your inferior or no collateral. Now you prefer the break I will join later and we'll join the radio radio artery and your or Newcastle's join the or no later run. Bit more of is relevant anatomy at the A C F. Again, you can see the relation with the median nerve. Here, it will bifurcate just, just next devices, braking tendon uh under the pronator teres and we'll split into the radio artery and the owner artery. Now, the key thing here is with this injury, you're super condo fracture line is about their um with this displacement and pushing forward, it will disrupt the main was supply distal to this. So as it bifurcates into the radio and all the arteries, this will have reduced blood supply because of this collateral circulation though you will still get perfusion. This is why a lot of these cases you will have a capillary refill, but you won't necessarily have a strong radio pulse. This is a common misconception you will see on the ward as an F one R N F to where you'll say capillary refill is fine. It doesn't necessarily mean your vascular status. Is there it to quantify the capillary refill, you to try and measure on dopa if possible as well. So here in this case, your capillary refill time can be maintained without pulses. So in order to proper Norvasc exam, where possible to measure radio pulse and your capillary refill, often when these patients are in a below elbow, backside and above elbow, they not necessarily be able to reach the radio artery. Either in some cases, people can essentially make a window in the uh in the dressing or in the bandage or you can even test for digital pulses if possible. So by putting your hand there and directly over the MCP there, you can sometimes feel a pulse there. If you can feel that, then you know that more proximal pulse is present. So these are my two case. And I think in order not to drag this on and go to focus on the two of them, there are two other nerves that you need to know about. So you have your radial nerve which will wrap around your humerus, that these are the key branches that you have. It comes from the posterior cord, um go to the C five T one nerve roots. Um two key branches of the radio, the radial nerve will have unlike the media that will have innovation in the upper arm. So innovator triceps, break your hours. Yeah. And the extensive carpet radios long as um it will inspect into your deep radio and superficial radio. Now, the superficial radios, pure sensory, um it will go into a medium natural uh and innovate radio aspects of the thumb. And then the dorsum of the hand, the dorsal 1st 3.5 fingers, excluding the tips. So the distal to the D I P D I P j the other branches, deep radio which will become the posterior into osseous. Now, in some textbooks, they say it's the same thing, but some people disagree with this. So you have two branches coming off the supinator and the extensive couple radio is British and then it becomes the posterior interosseous and innovates almost all the extenders. Uh and the doctor pulses longest now to test sensation for the radial nerve. It's the dorsum of the 1st 3.5 fingers or the lateral 3.5 thing um hand with part uh also aspect of the hand as well. The autonomous. So is the dorsal thena Evans. It's not the anatomical snuffbox at some think it's the dorsal thena eminence there, the motor, you got two areas to test here as well. So although extension is also um essentially the risk is also partially with the all the nerve of the, you see you tension at the radio aspect. So resisting by pressing onto the second carpal. If they can resist that, then you know that they're extended carpal radios numbers and brevis will be intact. So stop sign. Uh The other one, if you want to be really particular about extension of the things is if you have a rock on sign, so straight fingers. So extension at M C P I P J and D I P J of the index and little fingers, which accounts for your extended, showing minimal accenture indicis as well, so rock on sign and stop the to, to do that last last key. No, I would say in your distal Norvasc exam with all the nerve, um it comes from O E C eight and T one nerve. It, since the medial cord, um not much happens with your nerve above the other or the rest of the muscular branches and then the palmer branch which innovates the palmer hyposthenia evidence. So just here, it will pass your genes canal and it will innovate mostly intrinsic muscles of the hand instead. So your superficial branch is both sensory and motor or the Pomalyst brevis doesn't really do much. So it will innovate the medial 1st 1.5 fingers over that. Then you're deep branch will go into all your intrinsic muscles of the hand. Apart from 1st, 2nd number calls and the O A F of the remnants, which is, which is medium instead, in terms of sensory testing for this. Again, the autonomous area is the digital part of a little finger here. Um And it's the media 1.5 fingers of the both sides, both palmer and uh dorsal as well. You're to motor actions, you're two ways of testimony. See into RCI, which will be responsible for abduction of the fingers, whatever's easier getting to spread their fingers or do a peace sign and they can't push them back or cross your fingers as well. Depends what seizures at the time you, sometimes it's just due to pain, it's a bit difficult to examine. So I've never gone through a lot there. But in summary, I think any F one on the ward round or any sort of F two as an S H O, this should be your standard neurovascular exam for your hand. You should be able to test three separate areas. So three autonomous areas of the hand for sensation, which is your radio dorsal fin, your eminence, your owner, which is your little thing, a digital path and your index finger as well. Compare them with the other side or compare them with a neutral part of the body. So your forehead, chest, etcetera with your median nerve. So you need to do proper and your anterior interosseous which is a thumb lift and the okay sign. So wait to do this smoothly is thumb flat, the table up okay. Cross stop rock on. So, Tom left which is testing the abductor uh was just texting back spots, brevis, uh the thumb, which is your current branch of medium nev okay, which is anterior into osseous fingers crossed, which is ulnar radio proper. I would say resisted extension, pressing on the second metacarpal to make sure that you're testing for your extensor carpi radialis and then rock on which is testing for your extensive DCIS and your extensive extensive DCIS, extended ditch humana. Me your vascular test too many things to test. You can test the radio post and capillary refill. Ideally don't just test one, but this can be limited by casting. So in summary, three main areas of sensation, five movements and two for vascular, you can't feel a pulse, get a doctor. Uh huh. And that is my whistlestop tour of upper limb, kind of cool anatomy. Um Please ask any questions if possible. Thank you. Thanks very much Jeremy. That was great. Um I could have used that talk before I started my orthopedics F one. So thanks very much for that. Um I forgot to say at the start, but if anyone has any questions, please feel free to just type them in the chat and we can try around to it either at the end or during the talks. Um So, uh thanks again, Jeremy. I'll hand over to Sarah if you want to share your slides and uh start your talk on the lower limb smashing. Thank you. Great. Hello, everyone. Yeah. Thanks so much for that. Talk to Jeremy. That's great. Uh Let me share my screen. Perfect. Okay. So I'm hoping everyone can see my slides now. Um So let's get started. So this is probably one of the most common patient's you'll have on the ward is an F one, uh the elderly four and it makes up a huge amount of your workload as an F one mostly in the post operative period. But we'll talk about the pre operative period here. And how would you go about assessing a patient with an elderly fall, um, examination the investigations, the important anatomy to keep in mind and a little bit about the operations we can do uh for these. So let's start with our case. So you have an 85 year old lady brought in following a fall at home just confused, unable to give a history. You take collateral from the sun who says that there was an unwitnessed fall earlier in the morning uh unable to get up. Uh He came back around lunchtime and found her on the floor. So she might have been there for around four hours or so, it's difficult to tell. Um He tried to get her back up into her chair but it's too painful for her to move. So they called an ambulance and she was brought in okay. So then as with all trauma, you, you start with the A T L s. Um So airways patent in her breathing, her respiratory rating, saturations are good. Chest is clear, moving onto circulation. She's a little bit tachycardic. Her blood pressures are borderline low but her heart sounds are normal. She got dry mucous membranes uh with trauma especially we're worried about hemorrhage. So I think in this case, it's likely just dehydration from the long lie. So it's important to have a lot of differentials in the back of your mind. Uh moving on to disability. So G C S 14 out of 15, she's just scoring one less for verbal because she's a bit confused. Her pupils are equal and reactive. Her blood sugars are okay. Uh And then uh exposure temperature is normal, abdomen, soft, nontender, bowel sounds are present. There's no skin breaks or obvious blue uh bleeding. So that rules out a open fracture. There's a noted limb deformity that looks like this. Okay. So her leg is shortened than externally rotated, okay. Uh After your primary survey and 80 s, you do a second resurvey. So make sure he doesn't have any injuries that you know, noticing which can happen, especially if they have one major injury, the pain from that can mask other minor injuries. Uh So feel along the head, the neck, the spine, the upper limbs, the lower limbs. Uh and here you feel you feel that she's got a very tender left hip, unable to move the hip and a very sensitive test is a straight leg raise. So with them lying down the bed, can they uh lift their leg up in a straight manner which she's not able to do? And you've already noted this deformity. Um and similar to Jeremy's talk, we always have to check neurovascular status, okay, which we don't go into in this talk. But in the foot, similarly, you want to go, um you're not thinking about, you only think about dermatomal distributions when it's a spinal problem when you've got peripheral fractures and you think about peripheral nerves And so, um, for the lower limits your, uh your superficial and deep perennial, um, nerves and your tibial nerves. Uh, and then your dorsalis pedis pulse and your posterity bill pulses. Um, so then you, you're the F one or the F two and you've seen this patient and now it's time to think about some investigations. This is the part where, especially when you're starting out. You're like, okay, well, where do I go from here? So I always try to break it up. So at the best side, what can I do? Ok. So observation, we kind of already done that without A T L S E C G. Uh, this is important because, well, first of all, why did she fall? Okay, we can't get a clear history, you know, has she had a cerebrovascular accident? Is it something neurological or is it something cardiac actually have palpitations? Uh The other reason really important to have this is, and I, I'm probably, um, this case is leading towards a fracture and an operation, but any patient you didn't, you think might need an operation will need an E C G in the perioperative period. Any elderly patient's okay. Uh, because the anesthetist will want to see that. Uh, and then blood's what can we do. So, full blood count using these, um, uh LFTs to get a baseline for all of these full blood count, especially, it's quite important. One thing people underestimate is how much you can bleed from long bones. Um So for, you know, from one female, you can lose two liters of blood. Um from humerus is and tibias, you can lose 1.5 liters, pelvises, you can lose up to two liters. So, um in the acute setting, the hemoglobin won't be low, but it's important to monitor that as the day goes on, the days goes on. Um you want to check bone profile because if there is a fracture here is what counts as a pathological fracture. Because if someone falls from standing a normal person, you wouldn't expect to have a fracture. And so by definition, that would be a pathological fracture. So you want to check their bone profile. What's the vitamin D like? What's their calcium like? Are they deficient in anything courting in group and save again, you're thinking about this patient going to theater. So these are really important for your preoperative work up and then creating kidneys. So we've got from the history that she's had a long lie. So you want to creating kidneys, make sure that's not raised. Um And as and for most people, you were creating kidneys is um test for rhabdomyolysis. Uh So if you've got a long lie, muscles can get crushed, you get muscle breakdown and myoglobin in the blood, you get rubbed on my license, which can damage your kidneys. And then after bedsides and bloods, I think about imaging. Well, um what we need, we need a chest X ray. Again, this is more because we know this is going to towards theater, but especially elderly's going to theater, they'll need baseline chest X ray. Uh This, this will want to see that and then we want to take some imaging. So she's got a very tender hip. So you want to a pelvic X ray which is an ap anterior, posterior view and you also want to do a lateral view of the left hip as well. Okay. So you do the public radio graphs and this is the A P pelvis and it looks like this. Okay. So um I'll give you a minute or I'll give you a few seconds for, I want to take a look, see what they think. Okay. Now, one thing uh that's really helpful here is Centonze Line. So, Centonze Line is a um uh rada graphical tool that uh it's a landmark that if you follow the inside of the femoral shaft, the inside of the neck and then the superior pubic ramus, it should form a nice, perfect art, art like this. Okay. That's called Trenton's Line. On this side. It's nice and preserved. Whereas on this side it's kind of gone. Okay because on this side, you've got your uh neck of femur fracture. Okay. So this lady has got a neck, a fema fracture, pathological mcafee um a fracture. Now, if we can launch our first poll, what do you think the mortality rate is at one year for these patient's. So mortality in one year is actually a third, a third of patients. Unfortunately, um di um you know, probably correlated or causally because of this uh fracture. Um at one month is a 10% mortality, uh is roughly 9000 of these that present in the UK. And it costs us the NHS around two billion because these tend to be very old, very frail patient with multiple comorbidities. They came in uh with the neck of femur fractures. The operation are relatively straightforward, but they tend to have a very stormy postoperative period where they can get very unwell on the, on the wards. And even if they get to a point of being medically fit, uh you find that because of their reduced function and reduced movement, they can't return to their daily living as they previously had. And so then you're thinking about social care packages of care and that's what really keeps patient's in hospitals for quite a long time. So let's talk about some anatomy. Uh This is a female. Uh specifically, this is the right sided female um concentrating here at the top, just some landmarks to remind yourself. So this is the head of the female, this is the neck. You've got your greater trochanter and your lesser trochanter with your intertrochanteric line between them than your femoral shaft below. Okay. And then you go down and then you've got your um your distal femur down here. Uh nine in most adults, this angle of their head towards the shaft is 100 and 35 degrees. Um plus or minus around seven degrees. Uh not very interesting for the average of fun, but if any of you are interested in orthopedics, um this becomes very interesting when you start operating anything about hip replacements and dynamic hip screws and fixations and where you're aiming your drill and what kind of angle uh equipment you use is really start scared. Very interesting. Um And then there's also this 10 degrees of anti version, which means the the head is tilted forwards around 10 degrees, okay, which again becomes it's something to consider when you're operating. Okay. Um The femoral head attaches to the acetabular which is part of the pelvis. Uh it's attached here by a ligament called the ligament and Terry's. Um And then around it, you have this labrum which is a cartilage. That kind of in case is the the head of the femur within the acetabulum. Okay. And then surrounding that you've got a capsule, the capsule runs around where the rim of this white thing is on the neck of the femur. Okay. So it's around half to two thirds of the way down the neck. Uh and then surrounding this, you've got reinforcements with these extracapsular ligaments. There's three of them really nicely named the risk, you know, from fema to whichever bone of the pelvis. So you've got your, um, iliofemoral, uh iliofemoral ligament, your pubic femoral ligament in the front and in the back, you've got your issue of femoral ligament, okay. He's kind of uh produce stability to the joint. Um, and he here are just some landmarks on the radiograph. So you got your lesser trochanter down here. You're greater trochanter, your neck, your head, uh your normal centonze line. Okay. And then you've got some uh polyps, nothing up here. Um Okay. So what muscle is responsible for this limb deformity? This is the thing that your consultant will turn around and ask you or quiz you. So if we launch our next poll, okay. Okay. Uh I must, must be, you've got that. It's your iliopsoas. Okay. So you're Iliopsoas muscle is an uh external uh uh kind of like an adductor and external rotator. Okay. Um So it's two muscles. You've got your psoas major which runs from um your lumber spine and your Iliacus muscle which runs from the uh like fossa. Uh They merged to become the iliopsoas pass under the inguinal ligament and then attached to the lesser trochanter. Okay. It causes a bit of flexion, bit of abduction, but mostly external rotation. Okay. Um Now, the reason that's happened is when you've got your fracture of the neck, the, the head is separated from the rest of the shaft. And so the iliopsoas is free to pull up the, the lesser trochanter and that's why you get this external rotation okay. And you can see that really nicely and pelvic radiographs, you can see the degree of external rotation um by looking at the lesser trochanter. So if you look at this normal side here, on the right, you can see that that's a normal size, lesser trochanter in terms of degree of rotation on the radio film. Whereas on the fractured side, you can see it's a lot bigger and the reason for that is it's externally rotated, it's come closer to the radiograph. And so it appears a lot larger. Okay. And that's your iliopsoas working unopposed to pull that lesser trochanter. Okay. Now, you've got a lot more muscles working across the hip and it's a lot more than I can talk about in half an hour. There's an f one that's pretty much the main thing you need to know about working. Anything you can be quizzed about again for those of be interested in orthopedics. Um, then it gets really interesting and then you talk about all the other muscles like to cross the hip and then when you start operating, you thinking about, okay. So how am I approaching this hip? You know what muscles do I go through? What nervous planes or intervascular planes do I go through? Okay. So, with all this in mind, you've got a huge burden of disease, a huge mortality. Um, uh, the Department of Health in 2020 2010 introduces best practice tariff. So, uh following evidence based medicine of what works best or what we've found to, uh, to work press historically, uh the Department of Health Rewards Trust for doing such things to help outcomes. Okay. So, um, and the center a lot on a lot of things, but these are the main ones. Okay. So when these patients come in, you expected to operate within 36 hours, uh, they're meant to have an Ortho geriatric assessment within 72 hours when you're in a one an orthopedics and after an orthopedics author Jerry has become your lifeline really because the the seniors on the orthopedic team are always in theater a clinic and very rarely on the wards. So is the author geriatric medical team that are there to save you. Um They need a bone health assessment, they need a pre pre operative cognitive assessment and the uniforms assessment. Okay. So, um the idea is that the evidence has shown patient's receiving these improves mortality. And so trusts hospitals get paid whenever there's a neck, a fema for doing these things. And it's kind of a checklist for them. So you is the F one, the F two when this patient comes in, uh it needs to be thinking about what you know, how can we get in these targets, which for an F one or two might be quite abstract thing because you don't really think about hospital funding at your stage. And I still don't think about it mind stage, but your consultants would really care. Um And I've definitely been blocked for missing one or two of these things off on admission on a very busy trauma meeting in front of all the other consultants. So, um surgery within 36 hours, what can you do for that to make sure this happens? You need to make sure they've got your preoperative stuff. Okay. So get the C G, get a chest X ray, get your preoperative blood's call the any PSA test. Uh If they need to review okay, the author geriatrics assessment, it works differently in every hospital. Um But let them know, okay. It's usually a registrar uncle called them and let them know that an echo fema patient has come into a okay bone health assessment. So in the blood test, make sure that they've got bone profile, a vitamin D uh and then post operatively when they're on the ward, if they deficient any of those things, you can give them supplements and prescribe that and the preoperative cognitive assessment. So when you're seeing them at a any for the first time, do an A M T S abbreviated mental test score, it's a bit annoying. It's like 10 questions. Um I kind of have it just like a checklist. I just read it off. Um Yeah, and then falls assessments. That's kind of like a post operative thing. So after they've had the operation on the wards, they can have a false assessment. How, how likely are they to fall? And then that kind of triggers like, okay. What physiotherapy can we give them? What occasional therapy can we do to help them? So, in terms of home modifications that they need to stair lift, etcetera. Um so uh the interesting things around this case are the nerve supply and the blood supply. So we'll talk about fashion a, like a block. So when these patient's are in any, you'll find that they're in a lot of pain. Okay. Um And so your usual things of um paracetamol and then codeine morphine is well and good. It might touch the pain but the especially the elderly you want to, you not overdosed them on opioid uh because they quite sensitive to opioid toxicity. I mean, essentially they will need opioids like morphine and oxyCODONE. But you don't, you know, anything we can do to reduce that level, then they're needing, we can do. And one thing we can do is a fashion a like a block. And the original doctor, I really encourage you to do it because it's really satisfying to do. Um And basically it's a regional anesthetic, okay. And usually the any doctors do it or sometimes it needs to do it. But if you're particularly keen on the orthopedic team, there's no reason why you can go down and be taught and then you can do it yourself. Um And it works by numbing the nerves that supply the region. Okay. There's a thing called Hilton's law, which states that there's sensory supply to a joint, any joint is by the nerves that cross that joint, the nerves that supply the muscles that cross that joint. And specifically in the thought in the in the neck, a fema region and the proximal thigh, there are three main nerves that responsible for pain in this area. Okay. So you've got your lateral cutaneous nerve, the thigh, your femoral nerve and your obturator nerve. Okay. And very conveniently, all of them lie in the same fascial plane. Okay. So, fascial planes are, when we're talking about in the limbs, all the muscles, nerves and blood vessels are in different compartments and surrounded by fascia uh within those compartments. They're also fascial planes. Um and these nerves all lie in one plane, they all lie within or on top of the uh Iliopsoas muscle. Okay. So if you can stick your needle through the skin through the fascia lata, which is the first fascial plane you go through and then your fascia uh Lyrica, which is the fascia that surrounds the iliopsoas, your needle will be in the same plane as these nerds. Okay. So, if you inject blindly into that plane, eventually, that local anesthetic will spread out along that fascial plane and will cover these nodes. Now, in reality, it's mainly the first, do they get covered really well with this? So, the lateral cutaneous, never the thigh and the femoral nerve get blocked really well. With this, the obturator nerve doesn't cause a bit more medial. Um, but it works really well and a lot of patient's within 15 minutes, which is what, how long it takes for lidocaine to the lidocaine to kick in. Um, starts feeling it. So, how do you do this? So you need your anatomical landmarks? Okay. So, um your um mid inguinal point. So, I mean, sorry, your inguinal ligament will run here from the oasis to the pubic typical halfway through. This is your mid inguinal point. This is where your um femoral artery, femoral vein run. Okay. You want to avoid those at all costs and you don't want to be injecting that. So the way you do it is this line between the aces and the pubic tubercle, you split into thirds. Um And then this between the 1st 3rd and the between the lateral, third and the medial two thirds go roughly one or two centimeters. It says one centimeter here, but I usually go two or three centimeters below. Okay. Um And then you can inject your needle left, okay. Other tips would be I always put my fingers medial to this on top of the femoral artery and make sure I can feel the pulse of the femoral artery really well under my fingers. So that I know I'm definitely lateral to it. I'm not gonna be injecting it okay, you put your needle in and it's really satisfying because you go through skin, you'll feel one pop and that's the fashion latter and then you feel the second part and that's your fashion balaka and you know your needles in the right place and then you can start injecting your local anesthetic, which tends to be a mix of lidocaine, which is short acting and bupivacaine or leave it. But if, if a cane, which is curry cane, which is more long acting. So um in terms of how long it lasts, it varies. Big last roughly around like 6 to 12 hours. Uh So it's really good anesthetic you can give to your patient's uh you get rid of, you get satisfaction from doing it, the patient gets satisfaction. That's great. Um No, why do these patient's need operations in the first place? Why do we operate on Mecca fema fractures? So let's launch our last poll. Oh, sorry, sorry, let's cancel that pole. I had my polls mixed up. Uh Sorry, the blood supply. Okay. So the reason we operate is the blood supply. Okay. So the blood supply to the head of the femur is retrograde, which means the blood goes downwards and then upwards to supply. So you've got your external iliac artery passes underneath the inguinal ligament and rename it the femoral artery. It then splits into the profunda, femoral, the deep femoral or and the superficial femoral okay, deep femoral artery, then um gives off these circumflex arteries or to wrap around a proximal femur and then these branches go upwards up the neck and supply the head. Okay. Um And so the reason we operate on these are because if you've got a neck of femur fracture and you've got this bone that's completely sheared off, there's a risk of shearing all these blood vessels on the neck and then you get no blood supply to the head, which is called avascular necrosis and the head slowly dies. Okay. So this is the reason we operate on them. Really, you don't want the shearing or if the shearing has already happened, there's a really high risk of, again, there's the vascular necrosis. Um and which operation would you do? Um So it depends on where the fracture is okay and there's loads that you can, you know, you can classify it down loads. But at your stage, f one have to just think about it. Is it intracapsular or extra capsule that I is the fracture within the capsule that we talked about or is it outside the capsule? Okay. Now, intracapsular factors then again, if we can launch that poll would be great. If not, don't worry. But um what's how do we classify intracapsular? What's the classification system called? Again, this your consult will love quizzing you on these kind of things. So it's the Garden classification. Okay. Um Vancouver, it's also for these proximal thermal fractures, but these are for paraprosthetic fractures. So, if we give someone a hip replacement and then they fall and then they have their fracture around that hip replacement, you've given them, then you'd use the Vancouver uh classification and Schatzki's classifications for proximal tibial fractures, article plateau fractures. Uh So the Garden classification, uh four types, uh type one, you've got a fracture partially along the neck, but it doesn't go all the way across and there's Vargas strain, which means um you kind of push the distal part of the femur laterally. Okay. Um Type two is when you've gone all the way across, but there's um there's no displacement, okay. So you, there's a crack all the way along but the neck is still in place. It hasn't shared or moved. Type three is partially displaced. So there's a bit of movement. Bit of sharing. Type four is um uh full displacement just completely shut off. Okay. Um And then again, the whole reason we classify these fractures are uh not for consultants to quiz you and make you feel terrible, but it's for um because it affects what operation we do, it affects the um yeah, the choice of operation. So for type one and type two, um you want to fix it. So the because you, it's either not all the way through and it hasn't shared, you haven't had the shearing motion of the neck, shearing apart and hence damaging all those blood vessels that supply the head, the risk of avascular necrosis is quite small in type one and type two garden classifications. So you don't actually need to replace it. You don't need a hip replacement. You just need some screws or uh some kind of screw to keep that bone in place. So that it doesn't, when they're moving, it doesn't share and it doesn't move. Okay. So, and most commonly in all the patient's, we do this, we do a dynamic hip screw, okay. Um So yeah, you put a lag screw over across, you put some plates and put some screws to anchor it down. Uh If they're, if they were younger, uh you can consider cannulated screws. Okay. The reason we tend to not use it so much in the elderly is because postoperatively um on day one, POSTOP patient's can walk on a dynamic hip screw as a candidate screw that I don't think they can walk straight away. So, as part of the recovery process of neck, the femur fractures in the elderly, you want to get them up and walking and mobilizing as soon as possible because if you're lying in bed, they're developing bedsores, they're developing blood clots and DVTs. Uh So we tend to go for dynamic hips cruise for type one and type two fractures, okay. Type three and type four, you've got, you've had the shearing. So likelihood is that you've shared those blood vessels. So the neck, the head of a fema is gonna become a closed. So at that point, you need to replace it, okay. Um And you could do a hemiarthroplasty or total hip replacement. Now, um, the choice of which you do depends on the mobility of the patient. So the whole idea is a total hip replacement is you, you replace the head and you also replace the socket. Whereas uh in a hemiarthroplasty, half a hip replacement, you leave the socket intact and you're only replacing the head. Um, the total hip replacement is a more aggressive operation. Okay. There's a bigger toll on the body. So you tend to avoid an older adults. You only consider it when they're pre morbid state or pre fracture state was really good. Okay. So, you know, if they're exercising regularly, if they do their own gardening, it doesn't matter if they're, um, 70 or 80 if they're really fit and active, have a really good range of movement and they're like pre operatively and they, you know, they can walk for miles every day. You want to give them this. Um, because the hemiarthroplasty, it's an easier operation is safer operation, but their range of movement won't be as good in their function. The leg won't be as good. Okay. But for most of these failed older patient's, you tend to go for a hemiarthroplasty, okay. Um, fine. And then for extracapsular fractures again, depends where abouts it is and how low damages and how that, you know, the type of fracture. But you go for one of these two, it's either a dynamic hip screw, which you talked about before or interim modality nail, sometimes called a gamma nail. Um These, you definitely do these if they're a lot lower down um to the fracture here in this case is here. So this goes all the way down the female, okay. And this goes across. So actually, from again, if you want to be the really good f one that um covers everything you can help your seniors making these decisions by your history taking. So when you're seeing the patient for the first time in any talk to them about their pre mortgage, uh state, okay, how do they get around the house? Do the, how do they get outside? They go outside at all. These a stick to these two sticks to these are framed of these a wheelchair who does the shopping, you know, who lives at home with them? So these kind of things help you. Okay. What's their pre morbid state like? And it gives you, um, the surgeon's idea what kind of operations they do. Um, um Yep. Fine. So a lot of things and it can seem like a lot to remember. So I always, I'm a big kind of checklist and this is my admission checklist when I get a referral for an echo femur fracture. Okay. So I go down and see the patient. I do my history examination. I do the A M T S I had them to the list. Um, every, you know, department has their own list, whether it's on Microsoft Word or the systems that they use. But, um, surgical teams like their list. So Adam's or less in from the trauma coordinator again, most, um, most run off peak teams have a trauma coordinator which is a senior nurse that, um, basically coordinates all the patient's waiting for operations. Uh informed the author Jerry's team again, probably uh to advance for F ones, but let your senior know like a registrar, make sure they're marking consented uh and talk to him about the respect for. So respect forms are um we tempted them on mission now a lot more than we used to, which is a good thing, but especially for older frail patient's, we talk about their resuscitation status and their escalation. So, if they were to become and well, do you want, do they want us to restart the heart and do aggressive CPR? Um And what's the escalation status is appropriate to be sending this 93 year old with loads of calm abilities to I T U two H D you or keep them on the ward. So those kind of conversations we get had early when they're relatively well in any versus once they have their operations, they get, they stay in hospital for longer, they get more delirious, they get more complications, they become more and Well, it becomes a lot harder to have those conversations when those have happened. Um So those are my, you know, um patient facing and people facing checklists and then my investigation checklist, make sure they've got an E C G chest X ray bloods. Um and then my prescribing checklist. So prescribed the regular medication, do a VTE assessment. Uh Most of these patient would start them on low molecular weight heparin because the risk of DVTs are quite high. Um, and then prescribe them, they're algesia. So paracetamol, um morphine, codeine uh anti emetics. Um So cyclizine, prn laxatives, PRN, I tend to do these because it's um, as an F one working on nights on the ward, the most annoying thing is constantly being bleeped by all his patient feels a bit unwell. Can you prescribe on some anti emetic or patient hasn't opened his bowels in three days.