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according on that, Greg. Okay. I'm just gonna have a quick look through all the participants, guys. Ah, especially since I'm seeing people that I have seen before. Ah, fantastic. Fantastic. Oh, on most here. Fantastic. Nice to nice to see animal. Ah, we haven't checked in a while. Ah, Okay. So, uh yeah, guys, keep it. Keep it Super interactive. Ah, it looks like we were nice little crowd here. All right, so if you're not doing so already, guys follow our instagram page at at six PM Siris. So we've got your codes here. We've got institutes on the page. It's probably our most active social media pages apart from our Facebook. Keep an eye on it on. You know, we'll be posting Events will be posting are both essential videos. We're hosting them on Metalazone. Well, uh, you can you can You can watch them in your own time and request a certificate if you'd like to do that on, but yeah, so So that's it. Let's go to the next side. So the end. He has been a fantastic organization. Guys in helping us out Put put some of these actors through. They've seen one of our sponsors in our previous Siris, and they continue to help us out there. Probably a very important organization TOB aware off, given what's been going on with the latest ruling, uh, about that poor GP that ah, uh, ended up being sued retrospectively s. Oh, yeah, it's got me thinking a lot about how I document and, ah, how things are in our day and age. But yeah, um, do you guys that urine F one or if you're a medical student, checked them out? Uh, half of your 10 lbs description will go health medics with the emotional needs or financial support. So they're great organization to keep an eye out for All right. So, guys, let's get started. Uh, you make sure everyone's care. Great. Can you see this? Oh, good. Okay. So, guys, if you weren't here previously, we did a basic introduction on managing Prohm A on what we're really, really focusing on is the 80 assessment on that was the primary and the second resurvey on these things. They're quite important on sometimes you may get to a CT scan or you may get to some kind of a scan before you get to second resurvey. But the idea here is that you do a reasonable or at least ah, good job at, ah, the primary survey. And you can exclude any or include any life threatening injuries on intervene. A squiggly as possible now, uh, mostly in orthopedics. What? We're worried about these things like nerve damage on, uh, basket or damage. So we're always looking for if a patient is near a vascular attacks on often, you'll see in the notes that scribbled as NVI. But what I'd like you guys to do is a bit more than that. It's something that I do at least 80% of the time is actually describe what it is that you examined, what they're able to do on that might seem that pedantic. And people be like, Well, what What is this like? Where you going in such details? Are you Are you Are you a medical student or are you Ah ah Okay, that's that's not the point is the point is one you're documenting everything that you're finding. So if you, you know, just NBI is not defensible if you miss some, if you document exactly what the patient's able to do are they able to extend their knee? Are they would effects their need for the Are they able to are things like compartment syndrome where you really need to be careful? Are they able to feel sensation? Do they have a pulse? Are they able to pass it, stretch their toes? Just writing NBI is probably not going to cut it. And I haven't I've had an incident where, you know, I was quite sure someone has compartment syndrome on There was They probably had none of the early signs or the late signs, but they must have developed some of the early signs after I'd examined at that time, and they ended up having compartment syndrome and we might. We managed to measure their compartment pressure, and the compartment pressure was about 50 the meters over mercury, which is quite high and best not, which should be. So you know, a anything over 40 treating very seriously, right? So that's all out of the way now. Today we're going to talk about it fractures quite a bit. The injuries, ankle fractures, pediatric hip injuries, abnormalities We weren't quite sure about the pediatric stuff, but it might do some people some good. So let's go through on go faster. I'm gonna I'm gonna watch my pace today. I do read all the feedback, and someone told me last time I'm really, really fast the way I'm talking. So give me a bit of feedback. I need to slow down. All right, so let's bring this here. So first thing guys were going to talk about neck a femur. Fractures. Uh, has anyone ever seen an echo femur fracture? Know what it is or has any idea of how to manage it? Can you type in the chat and tell me if you've seen it? If you know what it is or if you being involved or ever had some kind of a case space discussion in along the lines of management for it. So that way we can sort of base how we go further while you do that, I'll continue talking. So, guys, this can be divided into Intron extracapsular er ah, fractures. So intracapsular fractures are fractures that passed through the joint capsule, and they disrupt the blood supply on they're more prone to a V e n, which is a vascular necrosis, and they require arthroplasty your joint replacement, uh, and extracapsular fractures, air fractures that are outside the joint capsule. They're less likely disrupt the blood supply, but But they have the potential fixation, and we'll talk a bit more about the blood supply in a second. So if you look at this image is nice image I luckily found on Wikipedia and open source. It describes these different types of fractures. It's actually got some prompters. So you've got the head there that started with the pelvis and the acetabulum. You've got the greater trochanter and then you've got your less Cytra counter. And these consorted be, uh, these convenio are markings for how you want to constantly I some of these. But what you really want to remember is that everything between the greater trochanter on the less it counter so about it. Approximately two. It is something that you can classify as intracapsular on everything below that is going to be extra capsule. So that could be anything that is introduction Terry less of dropping Terry. So pre truck Terek or Septra these air technical terms you don't necessarily need to get into them. But what can help is if you have an idea what it is, if you ever get quizzed on it. And then when it comes to contract captured, he's actually have divisions as well, although they're rare to find some of them. But if you can kind of have an idea of what the divisions are, might be helpful. Someone asks you about it. So one thing that you need to look at when you're dividing this is the head in relation to the neck in relation to the rest of the femur on the reason I start with the head is because sometimes you can have a fracture that is going pretty much right across the head on what you're thinking about. There is a subcapital. Then you have a transcervically fracture and transcervically fractures can sometimes be crush. Injuries on these aren't always obvious. In fact, over my set of nights that I had, I had a lady who was probably in her seventies who had a fall on Monday on. She only came to the hospital on Thursday on. The reason she was able to get away with it was because she was able to sort of mobilize on. She was mobilized and she had a transcervically fracture. She was mobilizing, able to straight leg raise. She was sent home from E D. Because their fracture wasn't clear on X ray on actually got reported by the radiologist. She came back in on. That was that was that story. And yes, she she required an operation. So yeah, so remember where it is in relation to the head is a crush injury. Is it a cold fracture? Can you tell it out? Trying this into what the mechanism of injury is on? You know, don't always just go buy some. Some kind of ah obvious sign if you feel that the patient has pain and a lot of pain, especially when they're loading their hip. And that's when you're thinking about further imaging, we'll discuss that actually come up. Probably one of the questions. Let's have a quick look of the shot. Is there anything going on? Ah, yes, sir. Greg's handle that. I'm going to leave that alone. Okay, guy. So if some of you don't know where the capsule is, So this is a very good image of the capsule that you can see so you can see it's encasing the entire head and part of the neck on as I mentioned anything proximal to you, the Greater Trochanter. You can pretty much presume that as being part of the capsule on, especially if it covers the femoral head or the femoral neck. So I found a really good you're not during a really good paper that, uh, it's probably really good if you want to learn a bit more about images and it's from it's it's done by radiologists, but they're trying to look at it from the lens of an orthopod, as it's called traumatic. It desiccation on. It covers quite a lot about blood supply on actually fractures, so it's really, really good on Scott. It's got a lot of good images, so included the actual citation there as well. But I did the title, as was the first daughter. So you can Google that if you'd like it your leisure and have a look at that paper. It's quite good, and some of the images that we have are from that on. It's an open source article. So what's what? What are we talking about when it comes to disruption of the blood supply? So, uh, we're really talking about the medium federal circumplex artery, which branches into the friend we'll head on. What happens is that if you have a fracture going to you, the head or the neck, then you have, well, the neck more so. But if you have fracture going to the neck, then you have a disruption of that on. You have sort of perforating retinacular branches that arise from the video femoral circumplex on DA. That's what we need to remember. There's also an operator artery that supplies into the, uh, head through the ligamentum Terry's. You might get this asked. I got this last one time for a scrubbing in for ti Attar. There's a trick question. Ah, I think I remember that. But yeah, it's a tricky one to remember eso. It's the operator artery, and the one you need to know about here is the medium femoral circumplex. That's the one that you always get asked about, right? So, guys, I want one of you to raise your hand in the crowd. Um, on describe this X ray. We went through X rays previously on, but I described sort of a system that you could use to talk about next. Ray I'm going to give you an age. We're going to presume this a female. I want you to tell me, uh, the what kind of x ray this is. What can you see in it? Is there an injury? Is they're not injury. So that's the great. Can you find someone who ever raises their hand? If not, I might be a bit me and just pick someone randomly. No one has raised their hand. Let me see. Ah. Okay, so maybe I have disabled the hunting. Uh, maybe that's that's what's going on. But if that's not the case, I am going to let me find someone. Okay? So I'm going to allow you Teo underneath yourself, and I'm going to allow you to start video. Ah, that. See? Isa? Do you wanna Are you happy to chat? No. Ah, that's the Ah. What about Risha? Are you happy to try it? I don't really know. Work to say. Okay, that's that's a no. No worries. Don't worry about that. But you did the first right thing, which is Ah, you know, you're just taking the step forward to to do this. Oh, if I'm sorry, my wife doesn't work are, you know, took a door. Okay, so how would you go through this? X ray? What do you see here? So it's Ah, it's That's a 70 year old. Ah, female. The most obvious thing would be the the hip replacement. Would you cool with that one? Yes. So? So that's Ah, Hemi. So it's hemiarthroplasty. We don't really see an acid tablet component there, so we'll say it's safe to say it's a Hemi. So? So what you want to do is you want to know, You know, you have some identifies, but you can have one identify a 70 year old female with an A P X ray off the Elvis on. Do you see any abnormality on it? Do you see any other fractures on it? No. No. So? So there's there's no fractures on it. It wasn't designed to be a trick, but you can't see any fractures. So you see a 70 year old lady who's got an A p x ray of the hip and she's got a left or right sided Hemi. Right sided? Yeah, right side. That can be okay. Fantastic. So just if you remember a system and there's a system in your head on this can apply the same Teo if there's a fracture. So imagine on the left side there's a fracture. That's imagine there's a lost their right. So someone's gonna ask you, Can you describe this X ray to me on Really? What they're looking to see is if you are missing any other injury, so imagine there is a, uh, there is a, uh, not on the left side, and there is a pair of prosthetic fracture on the right side on. What they want you to do is they want you to go to the extent of systematic fashion. So you've got a 70 year old female and you've got a a pea on. Sometimes you can have a lateral X ray as well. So you have an A p x ray of the hip, all right, And on this x ray, you can see that this patient's got a right sided hemiarthroplasty. I can see a neck a few more of fracture on the left side that could be demonstrated by disruption in the tuberculation or destruction and Shenton Zain. And the fracture seems to be evidently displaced or not. This based on. Then on the right side, I can see at the distal and off the femoral component. There seems to be a disruption in the cortex on I am suspicious off, you know, peri prostate fracture. So if you if you go about it in that kind of a fashion, then you know you'll never really get it wrong. If you try and jump would be like, I think there's a fracture there. I think there's something going on there, you know, that might not see much liquor. It's clean someone that's, Ah, examining you. But that's it. At a medical student stage, you don't necessarily need to know it in any more fashion. Not. I'm going to turn some of this off. Okay, let's go. Are you guys as we as we spoke about in the last sector, these air, some landmarks that you can remember. So you've got the in your pack to the line on. This is important for things like as a toddler or pelvic fractures. You got the issue line on this line goes towards the pubic Ramus, and this is important for you to distinguish if there's any kind of ah, pubic Ramus actual er on then, as we mentioned before is well and not included in this picture you have Shenton. Oh, well, you have sentences. I know on the right, which, if it's disrupted, you can think about an extra few of fracture on. You also have the tremor today, which are a patron that you can see in the approximate femur going towards the neck on if that is disrupted, you can also take about a naked femur fracture. So that's it, guys, Let's go to the next side. So this is our first question. Uh, correct. Can you try out the polls, See if they work? No, that's okay. Uh, that I see them. Does everyone see them? Should be up. Yeah. Permission. Now, did I click their backs? And that's okay. I'm guessing this quite easy, but that's Ah, that's really launched the polls. Very guys. So we've got a 56 year old patient. Let me put this down. You got 56 year old patient presents after being knocked off his bike. He has a shortened, externally rotated left leg with pain in his hip. X ray imaging is a quest didn't seen below. Uh, I'm gonna let you answer this question through the emcee Cuba in the chart. What would you do? What is the first thing you're going to do? How are you going to examine a patient that's involved in a high energy? Ah ah! Ah, High energy injury. What? What's the What's the examination pattern that you're gonna follow? Fantastic. Fantastic. Okay, good. So 80. So guys always remember that in the patients like this 56 years old and they're knocked off their bike, it's likely that they've been slung. This chances that there's a deceleration injury. That's chances. There's other injuries, you know. All of their body may not be fully covered. So the night of injured their arm or their shoulder or their c spine critically. So you you need to you need to think about these injuries. Don't get distracted by just the one orthopedic injury. But we do tend to gravitate of that. Uh, but yet, uh, remember So someone said here, see 80. That's fantastic, James. So it looks like you were watching the last time. Yes, the C A T guys, if you weren't watching, is where you're thinking about catastrophic hemorrhage and you're thinking about vascular injury. So let me close this. That we look at the pose. Okay, so, yeah, that's in the polls here. Yeah, so see is correct. So that is a displaced intracapsular fracture. So Greg's on this side to the street, gets a fracture. Occurs inside the capsule. Is we discussed? And above the introduction Terek line. So it's an interesting story. Enough eso nondisplaced fractures may not be obvious on an X ray and require CT MRI. So this was talking about a nondisplaced and two cups a fracture. You maybe we'll see on X ray, you may not, but uh, you really want to do is look out for what your examination is like Is the patient would wait. There are the Olympic Are they able to straight leg raise? Uh, these things are very important. And then if you're still suspicious and there's pain when they're loading or when they're standing, then you need to think about things. Further images subtrochanteric The fracture would be below the truck and terrifying. So that's discussed into a truck and tearing the fracture be present between the greater and less trocanter on television, we can't see any obvious injuries to the pelvis itself. But you need to be careful about this because you can get an open fracture of the pelvis. And that's kind of strategy, because television is potentially able to fill up about 23 liters of blood s Oh, more than that, actually, depending on the type of injury. But you know, when you're thinking about patient with that kind of mechanism of injury, especially on a motorbike, or they're more prone to an open book fracture, Uh, then you need to think about public finders. All right, Next. Not next question. So we've ended this. Stop sharing the score. Good question. Here she here on. How do you assess displacement? Is it just by or is there a system? Yes. So that's Ah, that's a really good ah question. So I think the best thing you can use there is Shenton design. So if you look at Trenton's, I know that's going to traverse to the bottom of the femoral neck and the head and it's going to go all the way across the pubic Ramus. That's a good way to do it. You can do it by I as well. There are different systems in place. Um, I'm not sure if your gas that in your exam, but, ah, the best way that you can kind of check any time that you're examining the hip. Uh, so if you're examining one hip, are you trying to compare the height or position of a hip compared to the other hip is look at a familiar point in the femur. So look at the lesser trochanter, for example, and you can draw a straight line across one. That's a trick counter to the other. So I don't know if I could do this hair on our side, But can you see my mouse? Yeah. Yeah. Okay. So if this was a normal hip or these were to normal hips, then we could pretty much draw a line across. The less the trick counter, and it would it would align. But what if we drew a line against the normal less intercounty here, Um, on we do across, we've noticed that the restaurant on the, uh, the injured side is actually a bit more proximal. You know, there's an obvious disruption that we can discern from our eye, but that's a subtle way of being able to tell a swell on. Sometimes that's useful because people do it after arthroplasty to find out what the position off the hip is. S o. They're worried about their family component specially if they're cementing that, you know, either, um the the femoral component sitting too high or too low on this we will. Obviously present is a problem. They're gait. These things like offset on diversion and all of this that are involved. We can talk about that in another that year. But it's got more to do with the actual operation that south if you're interested. And I love to talk about and can bring someone on, it's about to talk about it, but you can let me know in the chat. Ah, fantastic. Got it. Good stuff. Okay. So, guys, what's the most appropriate management for this type of north that start the polls really long? No. Yeah. All right. So I appreciate that some of you may not know, but since there's only turkey nine of you and it's probably like you that you're all interest in orthopedics, I'm pretty sure most to you probably know, um, so we only give about 30 to 40 seconds for this. So that's interesting. Um, treat ended there. Yeah, Yeah, we should end up there. I think Greg did this site, so I actually don't know what the answer is, but we can have a little debate about that. Um, because there could be there could be different answers for this. Um, so if you share those results, yeah. So, um, if we go to the previous side, um, I think there was a mention off this person being 56 years old. They're on a motorbike. Ah, they must have good mobility. Uh, if they're, they're on a motorbike. And they were at such a speed that they were involved in an accident, So they're probably someone that's normally quite fit. Well, on their probably someone that, you know is doesn't require any kind of a globalized. So this is quite interesting, because from that point of view, we actually have ah, the way, This way, this patient could get a total hip so they could They would be a good candidate, in fact, for a total hip, because their degree off ability and their activity is actually quite high on a heavy may not be the best thing for them because, you know, we we want the shots, like, back procedure to be a lot higher s. So we know that this patient requires more ability. We're gonna think about total total allows. You have more freedom of movement. There are some, um, there are some disadvantages to it, but yeah, that's something we think about, uh, let's go to the next slide. Fantastic. So Greg did choose that. So that's Ah, that's a fantastic answer. The next thing is, uh, Cannulated Struth. Does anyone know why we wouldn't do cannulated screws on this guy's just drop it in the chart? Any ideas? Has anyone ever seen a contradicted screen or seen an instance where contradicted screw would be? Uh, you know, indicated? Yeah. So do you to displacement. Thank you, Ryan. That's a fantastic answer. Anyone else? Okay, so whoever ask em is they got it right on the dot Ah, blood supply disruptions. Absolutely. So, yes. If we're worried about disruption to the blood supply, especially in such a young person, uh, of course you can. Of course, you can always always do stratify risk and do all these other things. If it's not disrupted, that's a very subtle fracture. Um, then you can think about cannulated screens because you want to avoid this patient having arthroplasty because they may need more arthroplasty depending on how long do they live? But yes, So cannulated screws will not happen because the blood supply is disrupted. Uh, does anyone know why we wouldn't do, ah, DHS or a dynamic? Keep screwing this person, guys, just to give this question of context? This is a question that we actually had in our exams couple of weeks ago, just so that you're not thinking we're trying to capture out. There's a real one that we had in our card if exams. And so just to talk a little about about it, a couple of you put conservative management. And so for neck of the femur fractures, you've never do conservative management as you're here listed above, like because of that risk of a vascular necrosis and the complications that come in with that disrupted blood supply. Yeah, so I think I think the reason I asked the HS again a swell and Greg Solu to use that does supply is the most important thing that you need to, uh, take away. When you're thinking about like a few more fractures on, you know, it's an easy thing for you to over think so. Just always remember that any time someone asks you about a displaced like a fever fracture or a neck if you're fracture in general, where you worrying about, Ah, blood supply being disrupted. So intracapsular fractures, blood supplies. The main thing, and that is going to decide how you treat it. So that's it. That's put that to bed for for good. Let's go to the next one. Okay, So, guys, this is from one of our cheat sheets that we have for neck. If you're fractures that we set up for our Ortho Essentials Videos s So you got our neck If you're a fracture. Surgical management kind of simplified and described it in a simple enough manner. Hear if someone ever has confusion, it's a good thing for you to have. Let's say you've never done orthopedics before and you just rotating through orthopedics. Uh, can you explain? Are candidates cruise different? Two Dynamic hip screw. Yes. So dynamic kids screw. There's a very technical explanation from that for that, but I'll explain it very briefly in. Ah, uh, this way. So a cannulated screw is simply justice through That's providing compression on, but, uh, on what is providing compression two is the femoral head on. It's allowing the bone to hear by primary intention, because the compression is such that the bone is that the two fragments are very, very close together, and they can. Then he'll, because the blood supplies and disrupted a dynamic hip screws slightly different. Now the blood supply at the head isn't disrupted. But what a dynamic hip screws trying to do is it's looking at the femur as a whole in in an undisplaced fracture. You know, actually worried about the femur. The fracture is not displaced on. You don't need some kind of a stabilization towards the the lateral wall of the humor, a dynamic hip screws providing, ah, compression at the level off the femoral fracture or, well, the femur. It's providing that compression, and it's a sliding mechanism, so it allows the feet. It allows the femoral head on the neck to slide, but at the same time, it's providing stabilization at the femoral wall on. That means that fractures are on extra capsule, a fracture where it's commonly done isn't going to, uh, you know, be unstable as compared to a candidate. Screw you can do a candidate. It screw in younger people that have, um, haven't undisplaced fracture, but you would do it in younger people. You do it only if it's undisplaced only if you're completely sure that there's no ah, disruption to the blood supply on. If you're sure that it's going to be in a stable position. If you're not sure of that, DHS would be the best option to do. There is a ton that we can talk about the HS on. I'm not sure that would be relevant for this talk, but what I will say is that if any of you are at F y or at C t level, or get you are interested in this, then, uh, you know you'll get asked extensively. I will get asked extensively at ST Level interviews, the actual principles of a DHS, the approach of a D. A chest, my steps involvement DHS and why is, uh, you know why is that? DHS indicated in a particular kind of injury, so we can actually have an entire lecture talking about approaches thie orthopedic principles on what a DHS is actually trying to do. If you're interested in that, then guys get in touch with me and we'll try and organize that. Is that okay? I hope that briefly answered. Ah. What? Ah, what you were trying ask? Okay, so explanation time. So hemiarthroplasty guys is half a preplaced mint. It's got a femoral component only with an articulating head on. This can be by or unipolar said bipolar is probably It means that the oak so it can be mono block a swell, which is an extra type stand, and that's slightly different. So how that works is that Ah, the head, uh, head on different component are all one block of metal on that is often used in super old medications that sustained trauma on. We want to get them just back on their feet on. They may not have a good baseline on, and, you know, they're very comorbidity. We want the operation to be done very quickly. Uh, so unique polar and bipolar again, another technical term. But you might get asked about what your sense you need to take away from this is that bipolars got so the the the femoral head is basically attached to another head, and they can move on on bipolars air, something that are commonly used in total hips. But you can sometimes get asked what a bipolar unipolar is on. A unique color is just going to be one head attached on to the femoral component on that is going to articulate with the acid. Help them. Uh, so this is usually the management in the Intracapsular femur fracture, because most of your neck, if you're fractures there going to be in patients that are elderly that are co morbid or multi morbid. Our have multiple coverage he's on. Remember that the deception of the blood supply is the most important thing for you. Teo. Think about here. It's Ah, preferred as I mentioned in patients with decreased mobility is the baseline. You want to get the back on their feet. We don't want them to be running around again. That's not really the go. A total can be offered for candidates with a better baseline, as we discussed, and it will discuss this again the next light. So what you can see in this X ray here is that you can see a femoral component can see an established component on there quite clear to make out. This is a total hip or ah, total hip arthroplasty on it involves, Ah, both of those components I mentioned. So this is often done in an elective setting for osteoarthritis than it's an elective procedure. But it's offered in the trauma setting as well, especially if someone is very, very fit active on. You know, we want to offer them good mobility after their, uh, injury, so this is more prone to dislocation. So total hips just the way that they are, uh, depending on who's done it and how it's done, UH, can be plus or minus on but shape of the pelvis. Ah, plus or minus more prone to dislocation, usually a posterior dislocation. There's a way to fix that, and it basically involves inserting a lip around the labrum at the back on. Uh, that's known as a whole lot Onda. You don't really need to know about that, but you need to know that if it keeps dislocating that it requires intervention on total hips as opposed to Henrys arm or prone to desiccation, the biggest reason why people don't like these and the risk associated with them, especially elderly patients or comorbidity patients, is that they have a longer surgical time on. People are really worried about that because it increases the time that patient is under anesthesia. It's also something that's got cementing involved, although this I don't think has a cemented femoral component. Onda, uh, you know, all of those things increase your risk on you have a higher chance of dying at the table. You don't really want that. Your idea is to fix the patient, not, uh, not to make things worse. So people often just go for a Hemi if they're worried about ah patient having ah lot of core morbidities and they're elderly, right? That was a lot of talking on. Hips were going a bit onto the pediatric side here. We decided to use one topic that we thought would be useful to know about and get examined. So, Greg, if you keep the polls ready, so we have a 14 year old boy who comes to and you with a short externally rotated right leg. Ah, this was following a fall. Uh, well, it says up the stairs, but he's obviously going down the stairs. In addition to this, he's walking with severe a limp and has pain in his right here. What is the most likely cause of this patient's presentation? So, guys, is anyone remember from the last time what I told you? What? What are the main things you want to do when you have a pediatric patient or you have a young patient? Uh, how do you want to make sure that those efficiently? You don't, uh, sort of terrify the child? And, uh, what would your step speed? Someone wants to answer that in sort of a 1 to 3 fashion in the chat. Uh, we'll find the best answer will give you a bit of time to answer both. So don't worry about that. There's no restriction on the time. So nothing yet on the chart. I'll give it another couple seconds. Observe the patient when they're walking yet. Fantastic. Yet that's absolutely correct. And something that's mentioned here, the patients got What do you want to do with the parents? Who else do you want to get involved in this? Uh, what kind of things are you thinking? If the injury pattern doesn't make sense to you. Uh, what do you want to do? So say, say, in this situation, uh, the child found down the stairs. Uh, but, you know, if the story doesn't make sense or the injury practicing safe, guarding fantastic, excellent to safeguarding is a big thing to think about. Observe the patient when they're walking, rule out abuse. Fantastic. On the next thing is built a good report with the parents and get your other colleagues involved that it might be useful to get someone from pediatrics involved. It might be useful to get someone supported from median vote coming together. Don't seem like one person attacking. If you're worried about safeguarding, make a team effort, have a conversation. That's what you're trying to do. So this is the main thing tombo this. Okay, so let's go answer this question. I'm going to end the polls. Well, share the results. Okay, so So 77% of you answered D on DA. That's ah, that's that's fantastic, because that's the correct answer. 14% of you answered. See, on 9% of the cancers, be so I think. What? This should have to be fair included. Ah, and it didn't include in this is Ah, high B m. I. So Whoops. We'll skip this for a second. Okay? So yeah, it's sutra. So, uh, does anyone know what Sufi is? Write it down, and I'm sure you do, if you answer that, but the thing with acronyms is we forget what they're meaning is Write it down if you know. So this is because it's seen in a teenage I'll following a minor trauma in the hip. It's also commonly seen in teenage Children with high bm I've a result of displacement through the growth. They So, um, this high B m, I think, is actually something that was tract in measured in Scotland because they measure, uh, Children's birth at our Children's weight at birth. And then they tracked their weight as well on their able to determine that in almost all cases, patients that had ah, high B m I, uh, regardless of trauma, were more prone to having Sufi. Then you know, patients with the lower BMD eyes or average body weights. Let's see the chat said a performance purposes. Yes, fantastic. That's absolutely correct. So, uh, transient synovitis so patient would probably normal on examination. It's very subtle. Uh, DVH no one really answer that, which is absolutely fantastic. I don't want you to make that steak. So that's the thing that you see in babies. Uh, Perthes disease. So, yeah, some of you did on to that. And it's something that scene at a younger age. Um, it's not seen in teenage years and teenage years. You can almost exclusively think about, see if you because that is an age that they're growing. But that's probably the only agent you're going to get this injury, and then intracapsular enough know that's probably not it. Uh, they fell down a couple of stairs. Children do that all the time. They're probably not going to get enough. Uh, so the absolute let's go to the next night. I think we have a bit more. So this is an explanation of Perthes here. Super. These typically presents Children. Age 47. You're thinking about a vascular necrosis of the femoral head there. It's a big problem that you need to, you know, be always. Have your let's see what's in the chair. Not always have your eyes open about why soupy associated with and the crime disorders. That's a good question. I feel like I've heard that before. A swell. I'll get back to you. Um, so do you have any particular end of crying order in mind? Ah, well, we'll discuss this in a second because I feel like I've heard this question before. I can't remember the answer and top my head, so I have to look into that. Ah, what this predisposes a patient with a party So exactly everything here. So it's basically pain in the hip or knee with a limp on its reduction in the movement of the hip. It all planes, especially internal rotation on abduction. See, you can see the X ray here. It showed joint space widening in early ridging and decrease in signs of femoral head on. Management usually is non weight bearing with nonsteroidal anti inflammatories, and you want to you want to measure them with the X ray, so let's go to the next slide. So sip upper femoral uh, emphasis or Sufi that's present in teenage years. It's the Children age 10 to 16. It's almost always obesity with traumas. A cause as we mentioned, uh, on this, the the injury itself involves displacement through the growth plate on that presents following a minor injury within Ping pain in Thai and the growing that's most common of these Children. Limited selection, abduction, medial rotation management is usually with that's Go back on his usual with early internal fixation so you can see some wires being placed here and you can see on the left side you can see the slip. And if you can see the femoral head on, the growth plate is not aligned with each other, and they have slipped. I have been fixed in place with these wires put in place, holding them two together. Okay, let's go to the next side. You know it's into the whys Sufi associate with endocrine disorders. So there's a paper here, and it talks about how metabolic and endocrine factors come. Result in a week. Vices. However, the exact method of why this happens is unclear Is thought to be to do with the evening should have been like growth factors on D um, growth hormone kind of access. But if you imagine a week of prices will result in like increased chance that this slip through that vices, it's to do that. Yes, that's interesting. I'll do curiosity. Did someone get asked? This is an exam question because that's not that's not, ah, clear the sort of, ah, known mechanism itself. But I'm curious if you if you got asked this in the example it's not an exam. But in my presentation on Sufi. Okay, fantastic. So So it has got to do with growth factors? Not much. I knew, but I wasn't quite sure on. Um, I wasn't quite sure of the exact specific mechanism, so I didn't want to answer. Say something wrong. Uh, if you could probably pace that paper in the chat, Greg, it might be useful to ah, me and other people. We could read up a bit more about it. But I'm sure in that paper it talks about that. The metabolic, the metabolic pathway doesn't necessarily coincide. It's problem with the growth factors. Did you get a reader that summary know is getting unclear in terms. Okay. Yeah, yeah, that's it. That's a mean question for your electric to be asking you is a medical student if that's the stage that you're at, But maybe maybe we'll talk about that another time right. So let's go to the next question. So this one is a very classic question. S o u 22 year old male presents the anti department after injuring his need A rugby match. Hey was tackled from the side on. He had his knee planted. Uh, so he had his foot planted while he did that. And he got tackled right on his knee, his knee swollen tender, and describe that feeling very unsteady, whatever that beats. So that's rock open the pose there. Fantastic. This is Ah, some of you are just going to know that straight away. This is quite tricky question as a couple of them all ballet dancers. But yeah, it's all of SBA. It's what's the most appropriate. So think about the mechanism of injury There, guys, probably more than anything. We'll give you a bit of time for this. So just imagine it. Visualize it in your head. You're running, you're running. Uh, you put your foot down As you put your foot down, you get tackled and it's your right at me. On your knee is sort of going like this on the side to think about what could be involved there. Okay, so, uh, we can end it here. I think everyone that want to dancers answered. Okay. And the pole share the results. All right. Does everyone see that? Okay. So fantastic. So 41% of you answered with the unhappy Triad, which I think is the right answer. 36% of you answered with an ACL injury, which can potentially be the right answer as well, but on its own, Probably not, uh, 5% of the answer, PCR, which is fine. That makes sense on then, 18% of you answer the medicines. Meniscal tear. Uh, I think that's a fair answer to on the No. One answer to your plateau fracture, which probably is ah, is a good thing. Okay, uh, let's go. Let's stop sharing this. Let's go to the next light. So the So the answer is the unhappy triad. Uh, or I don't know who's triad on, uh, this pain this pretty much involves all the things that I felt. Where the right answer. Probably PCR to be a plateau. So this is a typical presentation. You're basically getting a high energy force coming in from the side or lateral side on. Basically, this involves an injury to the ACL. Uh, m c out on the meniscus. So why while of these So the ACL is going to be injured because you're going to add Ah, strain towards that ligament as you're going in to the knee. The MCL is going to be injured because if you're putting a force in from the lateral side, then the medial side is going to be strained. It's going to give way on the the meniscus eyes going to be injured due to the force of that entry is Well, so any time that you're thinking about triad or if you're thinking about ah, this kind of an injury patron, always remember that it involves some one that's running and they're being tackled from side. Uh, this is a smudges. You need to know about it. We actually have a good video on the Ortho essential videos that we have on the It's crampage. You can have a look at that. We talk about some other knee injuries and soft tissues of the knee. There, a swell, uh, and that's a good one to have. I think we might have something on the Ortho essential stuff at the end. Uh, Greg, we have a drink or something. Uh, yeah, we've got a couple of things, and then you can access thumb through the six. PM Lloyd four matter or metal metal. Yeah, exactly. Yeah, metal probably be the best for stuff like the cheek on being able to do a feedback also. So we didn't mention on meniscal tears just from my experience. It s p A s and stuff. It will quite often say in the presentation that they have a feeling of knee locking. Yeah. So? So meniscal tears were almost always present. Yes, something like a knee locking mechanism or a, uh, decreased range of movement within a certain range. So the patients not able to move their knee within a certain range that those kind of things are where you're worried about a meniscal tear on. Ah, the thing about all injuries in the knee guys, is imaging imaging is probably the gold standard for all these soft tissue injuries. So you want to think about MRI, which would be the most sensitive imaging modality for any injuries on the X ray is always useful. So, you know, if you've got someone in your semen for the first time X ray, then see if you see and signs of injury or fracture. So if you see a team like arthros ist, which is basically ah darkening in the X ray, that might signify to you that there is bleeding or other, uh, biological bits coming out. So he starts for blood like a stands for fact arthrosis an injury to the bone, uh, or so soft tissue. And if you're worried about any of those, uh, you could see on X ray, try get a further image. So M c out. So MCL protects the medial side of the knee, too. Lateral forces, as we mentioned. And obviously, if there's a lot of force that's coming in, that side is going to get injured. Elsie Oh, the lateral collateral ligament protects the lateral side of the knee from medial forces. Very hard to get Ah ah ah! Some kind of force that's coming in from the medial side could literally between your legs. But that can sometimes happen. I don't think I've seen an LCL injury. That's a true LCL injury. Um, but they can get injured. ACL prevents the tibia for moving, too, until we are moving forwards in relation to the femur. So interior translation on the way you can spot on ACL injury is that, you know, if you got patients sitting down about, uh, almost 90 degrees and you're trying to, you know, push their tibia forwards normal, normally that shouldn't happen on if you could do that on the tibia goes forward, then you know you're worried about in a CEO injury, then you go down the road of scans and all that other stuff as well, if you want to do that. But this will get asked in an exam. So upon, um, it's name that you can probably get asked about Blackman test or ah ah, interior shift test on. We talked about this in our videos. Well, on these actually common injuries. Um, and then you have a PC l injury, which prevents posterior displacement of the TB. I wrote the femur and this gets examined as well as a dashboard injury. So you're sitting in a car involved the accident go forwards on, you've got your knees flex. Then you know your tibia is pushed pushed posteriorly with a high degree of force on. This is where you're worried about PCL injury. Interesting. The interesting breed. During my nights, I had a patient who I thought had a tibial plateau fracture, Uh, because they had a disruption in the cortex, But it was mainly around the posterior part of their tibia. And I thought I was validating my idea that there is a step in the tibial plateau, and then that's continuing down to the posterior side. Ah, on after discussing it and thinking about the mechanism. So the mechanism of the patient waas that it was similar to the mechanism off a tibial plateau fracture where the patient had twisted on done actually loaded there? Yeah, they're tibia. But, um, what happened with them is that they actually, uh, once they done that, they fell down for words on that probably pushed there to be a bit more on they should, on all their weight, was falling on that as the force of the injury. So it was quite unclear. So I wasn't around after my nights to see what happened to that patient. I'm still interested, But sometimes of the PCR injury, you can get a of ocean injury which comes as Austin's fragment. See if the cost eeriest type on you know you that, but that that comes hand in hand with the PCL toe. Look for a posterior fragment on devotion, injury and then test for it. So you want to the posterior transition and of translates posterity. Then you know you're thinking about PCL injuries. That's a long winded story to do, a proper telling you to do a proper examination, which at that stage, I didn't really do. And that's how I may have missed that. Uh, so the next thing is meniscus. We talked about the meniscus, the meniscus and bold protecting the ends of the bone. So they're basically like shock absorbers, and they provide stabilization so you can get tears in the meniscus. I on those tears are you know, you can sometimes treat them arthroscopically. Sometimes you do nothing at all. Uh, and it very much depends on the person's age And where those tears are you to do an MRI for that? Uh, you could do a couple of tests for that. I think one of them is called the after the test, um, which involves the patient sort of lying down prone on, uh, you are going, Teo, keep their femur in a neutral position, then you're going to flex. And me at 90 degrees. They're sort of going to You're going to stress. They're They're They're, uh they're they're remember the TBS I decide on, but it will produce a pain. But also, these patients will present as a locking injury or as a patient with a locking me we have. I think we mentioned some of this in the video as well, Greg, but we're going to try and do a video on a short video on. Yeah, we're gonna get you back there. Blackmon's anterior draw. Those kind of want? Yeah. Coming towards the end now, guys. Uh, right. So this is case three. This quite an easy one for ankle injuries, But most of these over than, uh, cases of being quite easy. Uh, I wonder if we should make them harder, but it's very hard to know what the crowd is like. Um, on, uh, I'd like to know in the feedback. Maybe we could do another lecture another time with slightly harder questions. Uh um, you know, either level off what you have to kind of discern or do Ah, when you're when you're on shor you're working on Ah, orthopedic, you know. But what I want you to see here is that these are the main principles that you need to understand on. Hopefully you understand how to approach some of these injuries from the sector. So this one is a couple that are about to go out for dinner. The wife is wearing heels. She notices some toys behind the cars, goes out there to have a look at them without notifying her husband. Uh, the husband reverses care of this thing without seeing if anyone's behind on. She ends up injuring her ankle in the process. So there's more than the NyQuil injury that's going to go wrong here. But based on whatever knowledge you have the weather translocation, what can you see here? Okay, so yeah, both there that then. So even the post today, guys, I wasn't getting 80% people on street. Try. Try your best. I've got those. No one can see what your answering. No one's gonna know. You're only gonna benefit by engaging on da you know, whether you got a right or wrong is really rather than, uh because in these kind of situations, you're just you're just having to go see what it is and seeing how you thought about that question or answer, right? So that sure these results Okay, so 55% of you said that it is a Weber See on then. Ah, 41%. You said that it's a Weber A. So that's interesting. If ah does anyone does, Why do Why do you think it's a Weber? Ah, be versus the see you guys. I mean, there's an injury, so ah, syndesmosis. Well, so So why do you think it is on? What do you think Webber classification is ultimately trying to look at to answer that in the chapped. I don't want to go into the next side until someone answer. Is that so? To challenge on somebody to try and answer this? No. No one yet. Oh, somebody okay. Based on to be their fractures. Shot side. Sure. Anyone else? Any other answers? Yeah, fantastic. So the road I said Ah, fantastic were describing. I'm not sure if this clear it. Everyone but Webber see, because the ankle joint Ah, yes. So the ankle joint. So I hope you're talking about the syndesmosis there. Uh, and there might be additional thing soft tissue injuries or ligamentous injury is that we're thinking about that. That works for me. Let's go to the next side that stops cheering this. Okay, so So yes, guys, it is a, uh you ever see? So why, it's whoever C is because what so ever classifications Were you usually using this in terms of stable stability or an ankle fracture? There is another classification that it's known as the launch Hanson on. That is slightly different because what it's looking at is the mechanism of injury. But for your stage, you may not get past that, but you're almost definitely get asked about the weather exacerbation, and you almost definitely be expected to sort of understand management based on this. So if you have a fracture that's below this in this, most is that is presumed as being stable or having some degree of stability. So if we only have that small little fragment tibia that was fractured, it was below this And this posttest on the medial clear space Waas. You know, uh, normal. We'll talk about what that is next site. Then, you know, we wouldn't be terribly worried about the stability. We may still fix it. Well, we may not be worried about the stability as much if it is at the level of this in this most since then. You know you are worried about this, Um, this most is you are worried about stability on. It's almost always accompanied by another injury on the tibial side on. Then if you're talking about a Weber C, which is almost always considered until able, uh, then you know that is going to be usually ah, high figure injury, and it's going to be something that's going to involve an injury to this. And this most is on you're worried about. You're worried you're You're completely worried about stability there that's always going to be fixed on. It's probably always it's probably going to have an injury of material science. Well, so what's the big thing with ankle fractures? I never really understood ankle fractures myself early on in the sense of management, because everyone seemed to have a different idea about put him in the boot, put him in a cast or oh, no, this person gets fixed, I think what you raise you need to put it down to stability. Stability is the biggest thing when it comes to, Ah, ankle fractures. Ankle fractures, unlike a lot of places in the body, are places that require absolute stability. So when we talk of it more about management in orthopedics or we talk about it but more about principals, orthopedics and some of the basic scientist, then we'll probably talk about things like relative and absolute stability on. There's going to be things where you know the modalities going to involve, ah, degree of stability. So it's going to be relatively stable on the idea there is that, you know, you're you're trying to allow the bone to heal by secondary intention or callous formation and all that kind of stuff. Uh, and then there's going to be times when you need absolute stability. You need that injury to be fixed in a stable. That's possible. Um, and you may not need to know that as, ah, a medical student, but we'll explain it a bit further in the next life. So again, as mentioned, stability is very important in the ankle, So a weber be and the C can be seen as unstable on why? Because you see the part here. So if you can see where I'm ounces, so the tibiofibular syndesmosis. So this is a set of soft tissues ligaments that are going along between the fibia on the tibia on. Basically, they provides the stability between two of them on when that is disrupted. What you will then see is a clear space between eso. If you see this area here, you'll see a space here on. You can measure that, and if that's above 4 to 5 millimeters on a stressed weight bearing X ray, you know that can be classified as a next able on. It can have a media ligament disruption. That's what you're really worried about, and you're worried about the distal tibiofibular syndesmosis being disrupted. So these are things that will allow the tibia to not sit are stable as it should be on. That's where you're worried that if you left that ankle where it waas, that ankle is one probably not going to heal as much as you'd like it to, and two it's not going to be stable. Afterwards, you're going to be prone to Maurine trees. Uh, then you also have media ligaments that you're worried about. So does anyone know a big ligament that gets examined about a lot that we feel on the medial side? Has anyone heard of it before? I'll be impressed. Gas. Fantastic. Send in a new it's so the deltoid. The deltoid ligament is quite important. And if you have compromise to the deltoid ligament, that's almost always going to involve fixation. Because again, you're worried about, uh, you're worried about, um, stability. So any time you're examining an ankle injury, this is the way to do it. Guys, I didn't mention hair, but let me explain to you, So what? Your first thing you're going to do is if it's a high energy injury, just examine it as an 80 problem. Right? So it's an 80 examination. If it's high energy, if it's not high energy, get a clear idea what the mechanism is right. Did you twist your foot? Did you fall down? Ah, you know, Was it Ah, simple mechanism. Was it sort of a complicated mechanism? Can you describe it really quickly or not And right, everything. That that they tell you that That's really good way of someone senior being able to then understand what kind of injuries and then have a good look at the leg. Is it open? Is it closed? This is very important. Ankle fractures are more pro to open. Ah, injuries on. They can either be an open injury from the get go or translate into an open injury. You don't want that, UH, keep an eye out for any areas in the skin where you're worried about, Ah, fragment of the bone touching. If you see that it's pale or it's, uh, if it's patchy or blotting and you're thinking that there's a contact with the bone, then I probably what you're going to need to do is you might need to reposition it into a better anatomical position, even if even if you're going to fix it, you can't just leave it if it's ah ah fracture and it's highly common you did on your gonna put into a backstop. So you need to do that. The next thing you need to be very, very careful about is near a vascular status, so go through the blood supply, so see if you can feel a distal pulse to the injury. That's usually going to be the dorsalis pedis on the look for the cop refill. Check for the sensation and the foot. See sensation is normal. Get them to do some kind of a motor. Function the foot. Are they able to move their toes? Okay, that's fine. That's normal. And then it's pretty safe to to move on and see. Ah, what you need to do next. So there's certain types of fractures that are almost always going to be fixed. Try mouth. The older fractures are. Are one of them on any time to see a try? Molecular fracture, which is going to have a, uh, lateral mile medium out and posterior mouth the other components. There's posterior part tibia. Usually, uh, that is almost always going to be fixed, because that is essentially someone just sitting. So it's toothpick sitting on top of another toothpick or a matchstick sitting on top of another matchstick, and there's no support around them. So I would be you're just like that. And if if you see that injury, it's almost always going to be fixed. So what you need to do in that situation see if that If that Something that needs reducing. Ah, put them in. Ah ah, Back sub Elevate their They give them adequate analgesia. Check for their blood supply on you know this thumb for for whenever they can get fixed. And then the next thing that you're worried about in these injuries a soft tissue and swelling. So this is why elevations very important elevations. Important things like compartment syndrome elevations. Very poor because the soft tissues around your ankle are sort of difficult to close. So if it's really really swollen, you may be able to get in, but you may not get out on if you can't get out, and that's a big problem. The other thing is that whenever you're doing some kind of an orifice or putting a plate or anything at all, you ready to think about the ankle is essentially right next to the skin. And if you are worried that this is not going to close or the skin is going to be sort of very close to that metal work, then the chances of it being infected are very high on. That's a that's a disaster. You want to avoid that so you'll often see people waiting a couple of days for the swelling to go down before they go in and operate on. This is, uh, this is something that people worry about quite a lot. And then compartment syndrome, guys. So any time you have a crush, injury and injury to the door, they ah or an injury, that choir that ah involves a significant degree of swelling. You're thinking about compartment syndrome. You want to monitor them for compartment syndrome. You want to elevate their that on, then open fractures, open fractures, guys. The best thing I would say to read about open ankle fractures or open fractures in general is the post guidelines. So the British Orthopedic Trauma Association has these guidelines that, uh, there's all kinds of guidelines, but especially for open fractures. Read those guidelines and they'll talk to you about specific things so they will talk to you one about how Teo make sure that you examine the patient. They'll tell you about looking at the injury and understanding whether it's an open or closed injury, and then soon as you've done so, think about things like I the antibiotics tetanus statin status on you need to not try to do many washouts and stuff in. Edie, you can do sort of Ah, gross. Uh ah. Decontamination of the area. But what you want to do is you want to get saline goals you want to cover, impact that area. If you're another center that deals with management over fractures, you want to transfer them somewhere for definitive treatment. But you ideally, you want to make sure they're getting their IV antibiotics. They've got something covering the injury, and you don't try to intervene in a place that's not suited. And then what's gonna happen next is it's probably going to be a two stage procedure where you may have wash out the bride mint on ah, later stage for a definitive treatment on depending on where you have the open fracture will really determine you know how that will be done. So definitive treatment may not be the first thing that they do in open fracture. They may try, decontaminate and then come back in. Uh, this is especially the case in common you to tibial plateau fractures or in tibial tip tip fractures that are open that are slightly higher up or mid shaft on those air, the things that you need to think about and then the next thing and open fracture. Guys, you need to really make sure you rule out the vascular injury basket or injuries and all orthopedic injuries. You know, you need to be very, very on the ball for that. Make sure that group that out, right? So, guys, we have a cheat sheet here. My voice is almost gone. I brought in the water to be today, but I'll pay for that later. Uh, we've got cheat sheets for nausea. We've got Cici's for a spinal pathways. We've done a whole load of work. Massive Hanks to Greg. He's a big, big proponent of all of this on without him, some of these or through a central projects wouldn't be happening. I really want to know. Guys, what other orthopedic stuff you're interested in or what you'd like to have covered? Um, I hope this was informative. I have a tendency to talk a bit too much. Ah, tell me from the do, uh, but generally, I tried to keep these talks very casual. I don't want them to see him. Just like a lecture. I I wanted to feel more like a conversation that you're having with a friend or a colleague friend more than a colleague we have enough colleagues on. But, um, you know, feel free to get in touch with me if you're interested in any projects or you want to do anything or you want to do a talk in your own local setting or society or whatever, Uh, we're very open to that now. And we we want to support this many people is possible, in fact, of being a talk with the ah ah students, the Physiology Society, Imperial College, Uh, in London on Tuesday. I'm doing one on course surgical training on orthopedics. So course surgical training has gotten very, really tough on competitive guys. Uh, Onda, um, I'm hoping, but through that we can discuss some of the ways you can prep for it, uh, from being a student, so you don't have to stress about it as much when you're in F y, Doctor. God only knows how stressful. Uh, sometimes that can be on. Uh, yeah. So any other talks that interested in anything else? If you want some really, really detailed, like orthopedics stuff postgraduate stuff. I know people say Post graduate, you know, orthopedic principles. We're not talk to me. I never had anyone teach the story on. In fact, I've done some of the modules, but I haven't been in to the next slide so people can fill in the queue. Okay, if it got band. Oh, yeah, Has anyone? So this is the QR code. Is this for the feedback, Greg? Yeah, this is for today's lecture, but so the chief sheets on the previous one, they're what companies are miniseries videos. So, as you said, we've got about five that we release so far, but the plan is to kind of release 12 plus. And so if you go on to meddle and then watch those many videos, you then should be able to fill in the feedback, and it should send you the she if you have any. Any issues of that? Just message six. Pm on instagram, and it should have sent the sentencing cares. Well, guys, So you can fill in the feedback here. You could be back here, eat these cheat sheets for your vision because the whole, like there's a room one page and you can revise with them. Kind of, you know, topics. Yeah, I'm just gonna put in my ah handle here is well, so bones and trauma. So you guys feel free to get in touch either on the six. PM Serious page or bone comes in trauma. We've got a lot more electricity going up in the surgical. Siris. If you're interested in any kind of a collaborative project, definitely get in touch. We have a