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Okay, We're live. We're live now. Um, so Hello, everyone. My name is, uh, bathroom, the presidente of, uh, the Q B orthopedic society. Uh, I'd like to welcome you all to this to our session today, which is on orthopedic emergencies and some complications that we can see in orthopedics as well. We have our two lovely speakers today, Um, Alan McDonald, fourth year medical student at Queens, and Monte Shirk, 1/5 year medical student as well. I'm just going to hand it over to them now and, um, done with the session. Okay. Happy enough to start. And so, yes, welcome everyone to the fourth lecture in the Orthopedic Society series. And so, yeah, we're starting with orthopedic emergencies and some complications of fractures. So today, I'm just going to talk about briefly first of all, neurovascular damage, and I'll move on to avascular necrosis, and then I'll talk about a bit a bit about post traumatic arthritis. Okay, our those slides moving. Okay. Sorry. I can't say them ommaya. Uh, yeah, they're moving. Okay. Yeah. Okay. Perfect. And so just for a brief overview, then about neurovascular damage. So it's an early complication of fractures, dislocations, other forms of trauma, etcetera. So there's particular vessels you should be worried about, depending on the location of the damage. So, for example, the axillary nerd in a humeral neck fracture, the radial nerve in the humeral shaft, fracture the brachial artery and really all the nerves in damage to the elbow, the sciatic nerve in the hip, the popliteal faucet in the knee and the perennial or common fibular nerve in damage to the proximal fitness. So when you say a patient with one of these injuries in particular, it is vital to perform a full neurological examination, both sensory and motor, paying particular attention to the area distal to the injury. And it's really important to fully document this in your patient's notes, you must ensure that the pulses, especially, are palpable distal to the fracture. And if there's any doubt, you should use a doctor probe to confirm. So there's a Sunderland classification for peripheral nerve damage, and this is because there's several different types of nerve injuries, so Neurapraxia means that the nerve is stretched and damaged, but it hasn't actually torn, and then when it does tear, there's two different forms. So Axonotmesis is where the nerve is only partially severed, so the axon and the myelin sheath are torn, but the surrounding connective tissues are preserved. In these cases, natural recovery is possible. Three axonal regeneration. So these injuries can be often managed conservatively with sports and physio, and you're a missus. The nerve fiber is completely severed on the only recovery option is surgery. So then a bulge in is where the nerve root is torn off the spinal cord at its origin, which can happen in break of plexus injuries and then a post traumatic neuroma is also worth mentioning as well, which is a growth of scar tissue at the site of a previous nerve injury, leading to compression of the nerve. So, as I mentioned earlier, you'd be worried about the axillary nerve in particular in a humeral neck fracture. So just as a quick reminder, the axillary nerve is a continuation of the posterior cord of the brachial plexus with the roots C five and C six, and it's gonna wind immediately around the surgical neck of the humerus and then divide into three more branches. It gives sensory innovation to the lower delta, would buy the upper lateral cutaneous nerve, and it gives motor innovation two terrors minor and the deltoid muscles so this nerve can be damaged through humeral neck fracture, shoulder dislocation and also I a Tradjenta Klay during shoulder shoulder surgery. And so working with the clinical presentation of peripheral nerve injuries can be fairly easy once you really know your anatomy and what the nerve does. And so patient with axillary nerve damage will be unable to abduct the limb beyond 15 degrees. Due to the loss of function of Terry's minor and deltoid, I'll have a loss of sensation over their inferior deltoid, which is called the Regimental Badge Area and then in chronic axillary nerve damage. Patient's will often experience permanent numbness over the lateral shoulder, muscle atrophy and neuropathic pain. Clinical tests include dealt with extension lag and external rotation lag. It's also worth mentioning M Herbs palsy at this stage, which is a similar presentation. So it results from damage to C five and C six, so the axillary nerve is affected and the patient is unable to abduct or externally rotate at the shoulder, so this commonly occurs whether it's an excessive increase in the angle between the neck and the shoulder, which will stretch the nerve roots. And then the severity of the injury can range from neuropraxia to a version, which will, of course, determine um, the recovery. So moving on to the radial nerve. So you worry about the radial nerve in particular and a fracture to the humeral shaft. So it again is a continuation of the posterior cord, the regular plexus, and it contains fibers from nerve roots. C 52 t one. So it's sensory innovation is the posterior forearm and the lateral dorsum of the hand, including the dorsal lateral 3.5 digits. As you can see in the images and then motor innovation is to triceps. Break I on the forearm extensors so you can damage the radial nerve. In many ways, I've broken it down into four categories, so you can damage the radial nerve in the axillary area due to a shoulder dislocation or approximal humeral fracture. Or sometimes do the excessive pressure, which is interesting. So like a badly fitting crutch. And so this is patient, unable to extend the forearm rest and fingers, and I'll have a restaurant which is unopposed flexion of the rest, and you can see it in the the image of the top. And so they'll have loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal lateral 3.5 digits. So again, just remembering back to everything that this nerve does, you can damage the radial nerve in the radio groove due to human sharp fracture. So that seems common way to damage the radial nerve. And it's really easy to damage it there because it's one so tightly within the radial groove. Um, so again, the tristesse break, I might be weakened, and the patient will again be unable to extend that the rest and fingers and they will experience a restaurant, and they'll also experience sensory loss to the dorsolateral 3.5 digits. Um, and then you can also have a stabbing or lacerations of the forearm, causing that sensory loss. Although it won't cause any motor effects and in a fracture of the radial head or a posterior dislocation of the radius, they'll instead have the opposite. So no sensory loss, no restaurant because extends are extensive. Carbi radius will be unaffected, and they'll still be unable to extend their fingers. Okay, so moving on just a a brief overview of the management of acceleration radial nerve damage. So particularly in the humeral neck and hero shelf fracture, you should have a low threshold of suspicion for damage to these nerves. Um, around 90% of nerve injuries will improve within around three months without any intervention, though for those who need treatment, management will include nonsteroidals physio and possibly nerve grafts, depending on the type of nerve injury. So before talking about the elbow then and the elbow joint, just as revision is supplied by the cubital anastomosis, which includes recurrent and collateral branches from the brachial and deep brachial arteries. And the nerve supply is the median musculocutaneous and radial nerves. Anteriorly at the other nerves posteriorly so an elbow dislocation that usually occurs when a young child falls on hand with the elbow flexed. Most elbow dislocations are posterior, and just as a reminder and supporting of the elbow, dislocations are named by the position of the radius and the ulna, as opposed to the humerus. So in this case, the distal end of the humerus is driven through the weakest part of the joint capsule, which is the anterior side, and the ulnar collateral ligament is usually torn, and there can be also some ulnar nerve involvement. 95% of super condo or fractures will occur them in the opposite scenario, so fall into an outstretched hand with an extended elbow. It can also rarely occur via a direct impact on to a flexed elbow. It is typically, um, a transverse fracture spanning between the two big condyles and in this case, direct elbow damage can interfere with the blood supply of the forearm there by compromising the brachial artery. So the resulting ischemia then can cause a Vulcan's ischemic contraction, which I will show you briefly in the next slide. And that can also be damaged to the medial ulnar, or radial nerves. So, as a result of the neurovascular examination and documentation of all patient's, presenting these injuries is vital, and it's worth noting. Some young Children with a super contour fracture may present with a peel pulses slim and may need emergency surgery. So this is a Volkmann ischemic contraction, so again it can follow Super Contour fracture fracture in the elbow, so it's due to interference in the brachial artery and the flexor muscles of the forearm will therefore undergo ischemia. And sometimes in the process, they can then fibrosis and form a permanent contracture, as you can see here and in terms of management of many complications of elbow damage. So the elbow has a very rich blood supply, so it's really important to thoroughly perform an arterial examination. So that's your temperature. Pallor, pulses, cap refill. UM, however, because the elbow joint is so highly, vascular patient's can still maintain our cap refill, even if the regular artery is compromised. So it's really important to have a low threshold for using a doctor check and getting some vascular surgeons involved. And then just as a reminder before talking about the hip. So it's innovated by the psoriatic femoral and obturator nerves and arterial supply is the medial and lateral circumplex femoral arteries, and damage to the medial circumplex femoral artery, in particular, can result in avascular necrosis of the femoral head, which I'll talk about a little bit later. Um, yes. So as I mentioned at the start, we're most worried about the sciatic nerve in hip damage, specifically in posterior hip dislocations and acetabular fractures that it can be caused. IATROGENIC Lee. The damage to the sciatic d'oeuvres in these cases is often you're a practical, and the symptoms are similar to sciatica. So it includes paresthesia as loss of muscle power, pain week reflexes and you can't get contractures as well. And just some breakthrough Manders about the knee Then, so the knees supplied by the femoral tibial and common fibular nerves and the arterial supply is the genicular Alistair Moses. So the genicular branches of the femoral and pocket tail arteries, so following knee damage, the most common. Your vascular complications will include popular tail dissection or common figure nerve damage, particularly in tibial plateau fractures and tibial shaft fractures, and just remind her about the common fibula nerve Then. So it innervates the short head of biceps memories, as well as some muscles in the lateral and anterior compartments of the leg. And it does provide sensory innovation to the skin of the lateral leg and the dorsum of the foot. So the common fibular nerve is most commonly damaged by a fracture of the fibula or the use of a tight plaster cast, which is interesting. Uh, the nerve is particularly vulnerable to damage because again, it's really tightly wound around the neck of the fibula, as we saw on the last slide. So patient with common fibular nerve damage will lose the ability to dorsiflex the foot of the ankle joint. So it'll be permanently plantarflexed, which is victor up. So there will also be a loss of sensation over the dorsum of the effect on the lateral side of the leg. So I'm not sure if anybody can even read this next slide because it's very small. But it's a nice little summary of everything I've gone over so far, So moving on to a vascular necrosis then avascular necrosis is defined as a degenerative bone condition, and it's characterized by the death of the cellular components of the bone secondary to an interruption of the subchondral blood supply. And it can be a symptomatic with some slight joint pain early on, but it will progress to more and more pain until there's eventually a limited range of motion in the joint. So on examination, you will clearly say this limited range of motion as well as stiffness, tenderness and if it's in the legs and abnormal gait, so There are particular injuries which are most susceptible to avascular necrosis, so these include a skateboard fracture, an inter capsular hip fracture, a tailor neck fracture and a culminated humeral neck fracture. So this shows a skateboard fracture, so it's most commonly associated with a fall onto outstretched hand and will present with anatomical snuffbox tenderness. And the skateboard bone is at a particular risk of avascular necrosis because it has a retrograde blood supply, so it enters at its distal end. So a fracture to the middle of the scale void may interrupt the blood supply to the proximal portion rendering at a vascular. And interestingly, patients with the mist skateboard fracture um, are more likely to develop osteoarthritis in later life. So, as I said earlier, intracapsular hip fractures would also be susceptible to avascular necrosis, and you can see these on the slide here. And the blood supply, then to the neck of the femur is also retrograde. So it passes from distilled approximal along the femoral neck to the femoral head, and this is mainly through the medial circumplex femoral artery, which lies directly on the inter capsular femoral neck. Consequently, displaced intracapsular fractures will disrupt the blood supply with the femoral head and therefore the femoral head will undergo avascular necrosis even if the hip is fixed. So patient's for the displaced. Inter capsular fracture will therefore require a joint replacement rather than fixation, and then Taylor neck fractures So they're classified by the Hawkins classification, which I've included in the We table here. So it AIDS management and it can also determine the risk of avascular necrosis. Uh, most cases of avascular necrosis are seen with type 2 to 4 factors, and then Hawkins sign, which you can see over here, is also a part on X ray, which is a sub contra lucency of the tailor dome that is visible 68 weeks following injury. So that's indicative of you know they're being sufficient vascularity. So there's a low risk then of avascular necrosis. And there is a risk of avascular necrosis in these situations because the talus is reliant predominantly on extra osseous arterial supply. So which is highly susceptible in the context of fractures? Um, so that's why it makes it high risk and the next slide we've got common ated humeral neck fractures, which is our last one. I think and there's a risk of avascular necrosis here following humeral neck fractures as they may disrupt the blood supply from the anterior and posterior humeral circumflex arteries. So in such cases, hemiarthroplasty or reverse shoulder arthroplasty may be required. So I've nearly talked about post traumatic avascular the process. There's also non traumatic avascular necrosis, and I've included some of the treatment A for that on this side as well, just as a bit of context. So that would be your cholesterol lowering drugs, your osteoporosis drugs. Your end said anything like that, physio, the conservative management um, and that will mainly be whilst the patient's are waiting for surgery anyway. And and the surgical options include core decompression graphs, osteotomy and or throw plastics. So my last resection is on post traumatic arthritis, so post traumatic arthritis is inflammation of any joint after a traumatic insult. So, like a fracture or dislocation, it's usually temporary, but it can be chronic, and it's more common in younger people, and then relevant investigations will include the usual imaging, so post traumatic arthritis will mimic also arthritis on X ray on in clinical presentation, and so most of you should remember that the signs of osteoarthritis on X ray are loss of joint space osteophytes subchondral sclerosis on subchondral cysts. So again, just decide to remind you that it's osteoarthritis you would be looking to compare this to. And it just involves doing a really thorough joint examination as you always would, and then for treatment of post traumatic arthritis again conservative would be physiotherapy, weight management, if applicable. Ice and hate. Uh, pharmacologically. So you're analgesia your non steroidals and for acute flares can use intra articular cortical steroid injections and surgery options would be a joint fusion to bride mint joint replacement. It is, um, notably a lot harder to treat than osteoarthritis. Um, and I think the main safe treatment is just about patient education. And trying to use the more conservative management with surgery is the very last option. That's my section. Thank you. Thanks, Helen. That was really helpful. Uh, so now I'm gonna My name's Nancy, and I'm gonna be talking through a few more, uh, orthopedic emergencies and complications as well. I'm going to start with compartment syndrome, and if you want to take something main thing from my talk would be the compartments room is the most important thing you would. You would want to know for your exams as well as your working life as a junior doctor. So as you know your leg and even your different parts of your voice such an arm, a divide into different compartments. If I were to talk about the leg, there's your anterior compartment posterior compartment, lateral and deep posterior as well. So when there's a fracture, a complication that can occur is that the pressure within these compartments can become raised, and there's no way for this pressure to escape. And that's exactly why, uh, the patient's present the way they do. So normally, this will be a young patient who is presenting with an extreme amount of pain, even though they have a good background cover of, uh, analgesia. So this will mean that they've got a good amount of morphine running. They have prn morphine running as well, but they have, but they still have a significant amount of pain, and this pain also gets worse and passive flexion. What this means is that when you go to move their photo when you go to examine, therefore the pain will be worse. than when they try to do it themselves. So this is really the main presenting complaint of patient with compartment syndrome. Something else that you mean, which is is that pins and needles? And this is, uh, pins and needles may be observed, and this is more common in compartment syndrome of the arm. So the tips of the fingers of the 3rd and 4th digit 3rd and 4th digit would be, um, uh, whether we parasthesia observed in these fingers. It's not so common with the leg, but it's more common with the hands and then maybe pallor present, which is paleness, arterial pulsations as well and paralysis of the muscle group. But these are less common. The main thing, really is paying out of proportion, uh, passive flexion and parasthesia. Now this is a clinical diagnosis, so there's no real, uh, diagnostic test or investigation. That's gold standard for compartment syndrome. It's something that, as a junior, doctors should be able to recognize um and escalate as soon as possible. Although you can measure the inter compartment pressure and uh, into compartment pressure of more than 40 of mercury is diagnostic for compartment syndrome. But this rarely happens in a clinical practice because of the acute nature of and and the treatment for compartment syndrome is fasciotomy as junior doctors, we won't not be doing fasciotomy. Um, once we recognize this, we have to escalate this condition to our seniors. This can be by bleeping your registrar on call or and the orthopedics department as well. And this patient has to be taken to the theater as soon as possible. Um, the cast has to be split open, and, um uh, fasciotomy has to be done so you can see a picture of a fasciotomy. Um, just on the slide here, Uh, and it's something. It's a specialist intervention. So essentially, yeah, And if this is not done in time, um uh, multiple complications can occur, And the main complication, really, is that the muscle death occurs within 4 to 6 hours. So this is really a time sensitive, and this can be followed by renal failure and read an injury. And the most sinister complication that can occur is amputation, Which is why it's so important to recognize this. Uh, I'm gonna move onto fat embolism, so this is not, uh, as common. It's a rare complication of fractures, but it's also very serious and has a mortality of, um uh as high as 5 to 15% as well. So fat embolism is essentially what it means. It's introduction of the fatty tissue into your systemic circulation, so risk factors for this will be young age long bone fractures and fractures that have created conservatively, that is, fractures that are not operated upon are at increased risk of, uh, fat embolism. So the presenting symptoms can be divided into respiratory dermatological and CNS as well. The most common presenting symptom that you're going to see is early, persistent tachycardia, which is really nonspecific. So it makes really makes it really hard to diagnose this condition, but the patient will have persistent tachycardia. Uh, they may also have tachypnea, which is, um tachypnea, shortness of breath dyspnea hypoxia. And this use This usually occurs for 72 hours after, uh, the injury. They may also have pyrexia, but this is not as common dermatoligically. The main thing you need to know is that they will have. They may have a potential rash again. This is not as common. It is 50 to 2025 or 50% of the population gets this. But those who have add amble is, um and, uh, and and, uh, and they may also be confused and agitated again. This is not as, um, common as the persistent tachycardia. Again, these patient's, uh, there's no real treatment for fat embolism. They need to be managed conservatively and supportive. Care needs to be provided. So when a fat embolism is recognized, these patient's need to be transferred immediately to the H D you, which is the high dependency dependency unit or the ICU. And they need to be started on high flow oxygen and a fluid resuscitation. Uh, there's some evidence for razor presses and corticosteroids, but this is beyond the level of our, uh, beyond our level, uh, as well. So next, coming to shocks you may, you may have heard of different types of shock, including your septic shock and hemorrhagic shock. Um, in major trauma, the main thing you need to know as most trauma deaths occur due to hemorrhage. And as you know, your bone is highly vascular, and Shaq is basically tissue hyperperfusion due to blood loss. Uh, so these patient's will present with tachycardia, hypertension high tachypnea and reduced urine output. Now there's a former grading system to classify the severity of shock and blood loss. But this is again a postgraduate, a topic now coming to management of shock. Uh, so you will follow the ABCDE approach. However, you will learn this in your emergency medicine placement as well. If a patient is bleeding out, you will address that first. So it starts with C A B C D E, which is a catastrophe hemorrhage. But you should know that, uh, blood may not always be visible. So as we have different compartments in our body itself that maybe third spacing such as the pelvic cavity, the pleural oh thoracic cavity may be affected because of fractures of the, uh, the FEMA as well as the pelvis. So internal bleeding can be catastrophic as well. And the main treatment really is a multidisciplinary approach. So you have multiple members of the team involved with multiple seniors as well. Too large work cannulas. Activate the major major hemorrhage protocol and get fluids or O negative blood running as soon as possible. And take this patient to surgery. If they're stable enough. Coming too osteomyelitis, osteomyelitis is an infection of the bone and bone marrow. The most common organism causing this staphylococcus aureus and the risk factors for osteomyelitis are open fractures, diabetes, peripheral arterial disease and IV drug use. So if you see a theme between these risk factors, it really is, uh, that the bone is exposed because it breaks the breaks in the skin. In diabetes and peripheral arterial disease, these patient's are more prone to ulcers and poor wound healing as well, which can again, um, exposed the bone and make it more prone to infection with open factors. The fracture environment maybe contaminated because of a major trauma incident or injuries in farms and roads as well, which make these patient's more prone to infections of the bone. The typical presentation will be, uh, like that of any other infection, which is fever, pain and tenderness, erythema and swelling. Um, when osteomyelitis is suspected, the main diagnosis, uh, imaging to use for diagnosis is the MRI scan, which is gold standard. Uh, an X ray may be taken as well, but X rays are in early stages of osteomyelitis. X rays will not be helpful, and they won't show many changes uh, in terms of treatment, surgical department, uh, of the infected bone is a mainstay of treatment. What this means is that the patient will be taken to the theater, joint washout will be carried out and samples of the bone will be taken to culture. The organism, uh, following this prolonged course of antibiotics will be given, which is usually six weeks of Lou Cox is still in. Uh, so finally, I'm going to talk about fracture healing. So generally, as a rule of thumb your apiolum fractures to take six weeks to heal and your local in fractures to take 12 weeks should take 12 weeks to heal. Uh, there may be multiple reasons why these fractures may not heal in time, and few of these are delayed union, non union and malunion. So delayed union is basically when the fracture doesn't heal within six to tell 12 weeks, and this may be caused because of the number of factors such as smoking, NSAID use, um, diabetes, steroids and poor nutrition. So the main thing, really is that if a patient presents with a fracture, uh, NSAID such as ibuprofen should not be given for analgesia. Uh, and this is important to note. And as majority and many of the orthopedic conditions are managed with, uh, with topical and oral ibuprofen. But they should not be given in, um, in cases of fractures, a non union is failure of the factory to unite at six months, and then malunion is when the fracture unites. But this is in an unsatisfactory position, which leads to reduce range of motion and loss of function as well. So this is all I was going to talk about. So I'm just going to move on to questions, if that's okay, um, you guys can put in your answers in the chat box, um, and then we'll talk through the answers as well. So question one. So this is a 21 year old man on the orthopedic board who's complaining of severe pain in his right leg. He sustained a proximal femur, uh, fracture of the tibia and fibula this morning when he was involved in a motorcycle accident. He underwent surgical fixation for the fracture, and his right leg is set in a long leg cast. On examination, he is crying out in pain and says that his right leg feels extremely tight. He describes feeling pins and needles in his right toes as well. What would be the next best step in managing this patient? So option a is administer IV Paracetamol option B is administer IV mannitol. Option C is arranged. Uh, an urgent amputation of the limb. Option D is an urgent fasciotomy an option. E is prescribed morphine. Ellen, do you mind letting me know if anyone's answered on the chat? Yeah, of course. We'll keep a wee eye here. Okay, You've got one answer so far. Okay, So you've got two people saying day, okay, So yep, that's correct. So as, uh, I spoke about this is compartment syndrome, and it's good that you guys have recognized it. So the main key things you need to notice as MCQ is this is a young patient with severe pain and a fracture of a major bone, which is both fit fibula and the tibia. This patient is, uh, is having pain as well as pins and needles, and the leg feels extremely tight. So the next thing you know couldn't do is the best treatment for this is a fasciotomy, uh, moving on to the second question. So a 68 year old lady has been admitted to the ward for a neck of femur fracture to do, which is due to be surgically fixed. Her past medical history is significant for gout, hypertension and migraines. She consumes 10 units of alcohol weekly and as a 20 pack your smoking history. Which of the following conditions increase the risk of poor bone healing in this patient? Yeah, So I think everybody is going for Option A for this question. Okay, that's perfect. That's very good. Uh, so, as I said, delayed union, There's a number of factors that can increase the risk of delayed union, which is an NSAID smoking, diabetes, etcetera, even poor nutrition. Uh, out of all these past medical conditions, uh, smoking is most likely to increase her risk of poor bone healing. Uh, moving on to question three. So 21 year old falls onto it on onto his out stressed hand with while playing rugby on examination. There's bruising around his wrist and paid an anatomical snuffbox. Imaging shows no obvious fracture, and he sent home with pain relief on a follow up appointment. Three weeks later in the orthopedic clinic, he complains of ongoing pain and stiffness in the wrist. What is the diagnosis to A Is carpal tunnel syndrome Be is malunion See is a vascular necrosis d is complex regional pain syndrome and e is early onset osteoarthritis. So we've got one answer for this one, and let's see. Okay. Yep. So that's correct. Um, as Allan was talking about a vascular necrosis, Uh, the scaphoid bone is very important in terms of, uh, this complication, as these fractures can be missed quite a few times. And, uh, there's a new there's numerous consequences and complications of Ms Keith void fractures. The main thing you need to note is that this patient has paid in the anatomical snuffbox and post 3 to 4 weeks. They still have ongoing pain and stiffness. So it's most likely avascular necrosis in this patient. And finally, the last question a 29 year old man is brought to the emergency department after being involved in a motorcycle accident. He has significant pain in his right shoulder, and his right arm is held in an externally rotated and slightly abducted position. An X rays performed, and it shows anterior dislocation of the right shoulder there's concern that that may be there may be damage to the auxiliary enough due to the mechanism of injury. So how would this be tested? Clinically, I'm not going to read out the options because there's way too many, and I've realized I haven't put eight e, so hopefully you guys will will be able to figure that out. Yeah, so everybody's gone for option A or the first one? Yeah, that's perfect. So as Alan talked about the different nerves that can be damaged, especially in your upper limb injuries, the axillary nerve is the most important. And the the lower half of the right deltoid muscle is also known as something you may know as the regimental batch area. And this is very important to be tested in injuries such as the anterior, uh, dislocation of the shoulder as well. Uh, overall in orthopedics exams, at least at our level, which is medical student level, uh, these these these are type of questions that will come up, and it's only core knowledge that you need to know. Uh, and mostly the emergencies are the ones that are most important in terms of exams and even our life. as a junior doctor. So at this point, if anyone has any questions, please feel free to fire on. I'll just keep you in the chat box. So someone just said, Frankie, this is really helpful. You're very welcome. Hope it was okay. And just keep it up a few minutes more and see if there's any questions. Is there anyone else or no? Nothing else. That should be fine. Um, I can stop sharing my screen now and control the end. The meeting? Yeah. Grand. This is Thank you very much. Everyone for listening. Thank you. Everyone does that worked. Okay, that's perfect. Is that us? Yep. Happy days. We flew through that. Yeah, I spoke to, uh, no driven. He said the other sessions were around half an hour. 45 minutes. Anyway, so we're fine. Yeah, I know. I just talk so fast because you're nervous, as I'm just like, get through it. Oh, goodness. Yeah. I'm not sure how to stop broadcasting