Computer generated transcript

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

conversation. Thanks. So, um, one thing we forgot one thing I forgot to mention is that with this, of course, we'll put it back on on catch up. So you can always look at these presentations after the session. Indeed. So, like I said, the four cases success are basic anatomy, types of fractures, the factor deformity being able to systematically present X rays and, of course, basic management. So the basic anatomy we start off with bones, uh, in every single bone, you have a proximal emphasis epithet, Asus and a distal epiphysis ISS. You have the meta fees is which represents the neck of the bones. And of course you have. The diabetes is which can then be further split into the, uh, approximal middle and distal diet. Fees is now types of fractures. You can either get complete or incomplete complete fracture, self explanatory. It breaks all the way through the brawn, producing two or more fragments. If it produces more than two fragments, then it's known as a community fracture. And of course, when you have incomplete fracture, the break doesn't pass through the entirety of the bone. Um, and these tend to occur more commonly in Children because they tend to have more flexible bones than adults. Then we also talk about the fracture deformity. So the deformity are when you describe the deformity you have to. It's always important to describe the deformity of the distal fragment in relation to the proximal fragment. Now there are different kinds of deformities. Displacement is one is displacement is when there is a separation of the bones itself, and you have to describe the displacement of the display fragment in with respect. The proximal fragment shortening is when the fractures ends, overlaps or effectively the bone, uh, almost seems like it's become smaller angulations. The angle created between the distal fragment and approximate factor due to the fracture and rotation is if the bones have rotated along its long axis. Now, Like I said, it's important to be able to systematically present an X ray, you know, in the trauma meeting. So you would always start on by describing the film projection or the film view. Is it an entire upstairs review? Is it a lateral view? Is it in a bleak view? All right. And then you then go on to explain what the X ray specifically of is of is there an X ray of the right hand? Is it an X ray of the left femur? Right. So you'd first would kind of describe this as an Antara pissed a review of blah, blah, blah, blah, blah. You then talk about, uh, you know, if you know how old the patient is, you can say there's an an therapist a review of the right hand of a 43 year old gentleman. Alternatively, if you're not sure of how old they are, you can then say skeletally mature and adults are skeletally immature in Children and, of course, state in the gender. If you don't know the gender, then just state as a person in general. Uh, and then, um, the last thing I'll say is described the site of the track. Describe the site of the fracture, if possible, try to explain if it's proximal distal or if it's closed open and and they I mean, you can name a type of fracture whenever possible. Uh, for example, a distal radial fracture. You have college fracture and Smith patches, but the thing is being able to know which one is always a bit different. So if you if you are very confident with your knowledge, then go by the name of the fractures. If you don't, then I would just stick to the standard way of presenting an X ray. So, for example, is this is an AP film of the right forum of a skeletally mature male. A clear distal radius close fracture is identified, which is displaced laterally. That's how you would present the X ray. Um, now the the only the only thing I would say is that during your trouble meeting, do not say it appears to have a fracture. There is either a fracture or there isn't a fracture. If you can't see the fracture, don't say there. You know if you can't see a factor, just be honest in the trauma meeting, because the more you try to figure out, the more you're prolonging. You know the pain. Not just for you, the painful, all the consultants. So if you're not sure, just be honest. And at the end of the day, the orthopedic surgeons, they have specialized and done this for many years. How many x ray, how we looked at during medical schools and so on. They're not expecting you to know everything. But if you're able to present an X ray case like this, you know, it would most definitely surprised. And, of course, impressed the consultant in the registrars. And then more like take it into theaters in that way as well shows that you have got an appreciation, uh, and an interest in their specialty. So I'm going to attempt to, uh, to present this X ray to you to give you a clear understanding of how we do it. So this is an an therapist there. A film and therapist there, a view of the right leg, specifically the right tibia and the right fibula of a skeletally mature person. Um, there is clearly a displaced fracture of the, uh of the right tibia. Where you have now. It's going to sound really weird, but there is a lateral displacement of the tibia, lateral and posterior displacement of the tibia. And of course, this is indeed a close fracture because you don't see the bone protruding out through the skin. So that's a comprehensive way of being able to describe an X ray. And without further ado, I'll give it to Marta, you'll be able to explain to you more about how to present him, and we want you to give it a go as well. Don't be shy. All right. Hello, guys. Yeah, My name is smart to how, um I hope you guys are doing okay. And I'm quite excited to present today because I've got a special interest on reconstructive surgery and orthopedics. So, yes, we would like this session to be as interacted as possible. So we've got a series of X rays, and it will actually quite useful if you guys just can sort of either type or feel free to sort of a mute yourself and just present the case. Okay. Maybe if you put we got an ocean market to put hands up many people. Is there such a thing? Uh, they can put a reaction at the bottom. Uh, if you guys put just our reaction, then we can sort of let you go, and then don't worry. We're not here to judge anything. It's just to learn together. Okay. So just, um, for you guys to be aware when we display we, we describe the sort of fresher we always describe The distal portion of the fracture in relation to the proximal bit. So that's why, as dashes say, this will be a fresher That is an or isn't a fracture, as you can see here on the AP view until you pursue view. And it is the feeble that is lateral. So it's lateral displace. Okay, so this is the next case We've got any volunteers. People just wait, like, a couple of minutes. So don't worry. Don't be shy. We go here a little bor. Reminded of how to describe it. We've got someone, um, lovely with the, uh I can't see who is, uh, just one second that run through the people. Uh oh, no, they put down the hand. Uh, the lower the hand. Sorry. Uh, lovely. It's, uh all right. Uh, can you hear me? Yeah. We okay, Uh, not attention in, uh, TNO. So don't judge. Okay, this is a mantra. Posterior view of the right, uh, virus. Uh, that shows a, um, media dislocated OBL equal fracture. Uh, I don't know. Okay, is that correct? OK, so as we say, that's perfect. We got the first thing and AP view of the you know, as you say the right humerus. That's perfect. Is that an escalated material or escalator? Immature patient. Uh oh. You know, they were a model or is a Children or is a kid. So it's an adult. It's called full looks. An adult. So, yes. So it's an escalator. Mature patient. Lovely. Yeah. And then what? We can see. Yes. You say there is a fracture of the humerus. Is this close? We we just can sort of close or open. Would you say closed? Yeah. Perfect. And, uh, in terms of the description, we want to, you know, be a little bit more specific. What type of fracture is this? You said oblique, but we actually see. It's more like a spiral fracture. Can we see that? Yeah. Yeah, definitely. Yeah. Another person know there was another person with the rise and the Sorry. Okay, that's fine. Guys like we got quite a lot of them. Oh, maybe they might be able to join the one to join the discussion. Or should we wait for the next one? We will wait for the next one. Okay. Perfect. And as we say, we describe itself always okay that the PSA portions or this portion intends to the proximal portion. So we will describe this one. Okay. And as you say, yes, there is a media displacement, so that's perfect. Okay, so you read you. You did really well there. Okay? And that's the only thing that we need to know. And yes, as you can see here, there is extended, and this is a flexible, but Indiana are really Well, we don't need to know anything else, so that is really well presented. All right, we will move into the next one. So next one, any volunteers at all and actually really happy about this X ray? This was one of my first patient when I did my TNO job as An S h o. I'll give you a couple of minutes to think we have got Adama Abou Tiia. So I must publish. Activate your Aubagio. Adam. There you go. Hello? Can you hear me? Yeah. Perfect. Yeah. Uh, this film, uh, it's, uh maybe, uh, the studio, uh, to the leg. It's mature. Adult. Uh, there was no empathy. Zhel Bleidt about the details. There is, uh, approximal, uh, end of TB and fibula. Fraction. Uh, there is angulations in mhm. Uh, no, just look, because just or spiral. Yeah, All right. Yeah, that is really well, just remember, as I always say, the sun, the heart is our center. Okay, so this will be instead of proximal, as you say will be a distal fresher. Okay, so that is the only thing. And would you say it is displaced immediately or laterally? Literally. And the reason why, uh, the fibula? Uh, perfect. That's lovely majority of the patient that has today. They actually told me it was, uh, displaced immediately. Because as the impression here resistant, but yeah, as we explain before we always shake for the, you know, distal in relation to the proximal. So that's lovely. Really Well done. Okay. And then this was my first attend. I'd rather doing reduction on this type of pressures. We will go into more detail afterwards, but when we have such a fresher, uh, that is quite angulated. And, um, this place, as you can see, there is no a lot of gap between the bone and the skin. And this is a high risk for a close pressure to be converting to an open pressure. So we need to reduce manipulating and reducing as, uh uh, as good as we can. And this was my first attend. I did. And I'm actually pretty, you know, happy about that. I got really good coming from the consultant, so I take that. All right, we'll follow up on the on to the next one. It's quite tricky. No reason to have a look at this. Second to fourth film. Just stick to the first one. Any volunteer? Yeah. Hi, there. I don't mind having a goal. Lovely. Can everyone hear me? Yes, we can hear you. Hi. Nice to meet you. My name is Zak. All right, So this is an ap of the of the right hip. So the most obvious abnormality is say, um, Midshaft commuted fracture. And there's lateral displacement of the distal fragment. Lovely. Yeah, that's perfect. Really? Well, the only thing that will say clearly is a skeletal Matthew patient. That's also if you want to be picky, but that is really well done. And you just can see this is something called a peri prosthetic. Fresher, we call it, and there are actually quite complex, the fresher that they involve, like a long entity. discussion with different consultants. Uh, and as you can see, they they they just reduce the fresher that did. An internal is called open reduction and internal fixation with a long plate, as you can see here and quite a lot of scripts so you can see on the picture. But the patient actually recovered really well after that. OK, trigger one. Let's see if we go. Any brave people in the route? Uh, Martha, there is a question. A post recovery. Is the plate left or taken out? Yes. Majority of the pay a majority of the patient's. With this presentation, we'll leave the plate. As you can see, this patient already had what you can see. We we can see here like a hemiarthroplasty, which means that this patient is quite all Well, I I know the history of the patient's that the patient was actually another patient, so we just put the plate on over there. But it's normal. We tend to keep plates. All right, next one, it's quite tricky. Is there a fresher or the recent? We have sikota shash wa to with raise hand that so I don't see a fracture. Fast dancer. I wanted to hear. Uh, that's perfect. There is a fracture, actually. Really mild. I will explain you later on. But don't worry. I have smart earlier on and have stash earlier on, and they couldn't find the fresher neither. So don't worry, guys. Okay, so I'll point the fresh for you guys. So can you see this here? This is a little bit bulging. Can you guys see that? Yeah. So this should be a straight line. Yeah, by a point. It's really certain. And it's really difficult. I try to find a really good X ray. And probably this was the best X ray I found about this type of Russia. Marta, there is a Georgia's Which Canton Mutant cell phone. Oh, yeah. I think that is a child Radio is, um hmm. Yeah. Someone go there. Some will go there. It's a buck. A fracture? That's correct. Lovely. Yes. So in Sabah co thrashes. So these this representing like going through the systematic approach that we explain. So there's an AP view of, uh, escalate a little immature patient of the form arm right for hand. Okay. And we can see we don't see it. We say we can clearly don't see. We can't see the Flasher, But on this case, it's got a really subtle, you know, back or fresher. So it's literally a compressed, fresher. They are quite often, um, kids suffer this type of pressure quite often. We just sort of put it on a package lab of cast, and we just monitor vent on fresher clinic. They don't need any sort of fixation anything like that. And they tend to heal quite nicely. All right, moving into the next one. To be honest, these fresh is are quite nice. The majority of them we don't tend to see this sort of fresh is on a daily basis. To be honest, I think they're quite interested in tensile knowing how to describe extras. You can also type in the chat box. Uh, any volunteer? Let's see, uh, I get a couple of second more. If not, we've got an answer. Uh, fracture. Yeah, Okay. By historically to the diagnosis. Yeah, it's an another answer. Which there are other two answers or radial, a humorous joint displacement ulnar fracture, or a fracture of the proximal whole. Numb. Yeah, give me some guys because I got quite a lot of message on our instagram page. I just want to do the quiz, because this is one. I'm just gonna take a picture of this and put it on a instapage. We were going to do a case of this our last Saturday, today. Now Perfect second. All right, so, yeah, it's a monty. A fresher, as they say, and I've got a really nice sort of pneumonic for you guys. All right? So as, um, they already say they're the tricky part. And please, let's not make this, Braun, because consultant will sort of laugh at you. Unfortunately, we need to remember that we go out radius and an ulnar. I know we all know that. But the important thing is that the owner is always sort of thicker, um, in this part than this part, as you can see. So you go thicker to thinner, and then the radius goes saying it goes to Thena to thicker. Okay, so that is a way to remember. There is a dislocation of the radios head, as you can see. And then there is an asset sort of fresh to here on the owner. Okay, um, move into my so good memory. So yeah. So Montoya fresh is okay. They are on the threshold with dislocation of the radial head. Uh, and there are not to be mistaken by gelastic. Fresh is that there are the opposes. So there is a fresh oh, of, uh, the radius of the distal radius with this location of the this radio. Oh, not join. Okay, so just always remember, Monty. Yeah, that's how I learned. A always a fed bonds proximal. Yep. And, uh, galaxy they always affect the set. Always affect the bond. Distally Cool. Any questions after this? I hope you guys feel like you're confident on how to sort of present X rays. No. Okay. Cool. Oh, someone just misses me privately, OK, that's fine. No worries. Yeah, as, uh, we When that you said earlier on. We are recording this session, so we will put it on the middle of counsel. You guys can go through the images again. Okay, Lovely. Okay. We will continue forward then. So one Oh, the mechanism of injury for this for this one's he He always, uh, depends on the mechanism. Uh, injury. And, um, actually, now that you say that I forgot to tell you guys something really important. So let me just give me a moment to go back. So this type of pressure that is part of pressure is, uh, Isabel. That is the one that you're the one who described the the X ray. They are quite important. If you get referred sort of patient like that, it's really important to go through the history of the mechanism of injury. Simply. Why? Because you will be surprised at the amount of patient's that will come to A and E with this sort of type of fracture. And they will tell you about Dr. I haven't fallen of doctor. I just fall from, you know, a decent high, or I was just sort of clinic and I was cleaning on the kitchen and sort of slipped and then fall into my shoulder and this happened. And as you can guess, these type of pressure. They are highly suspicious for malignancy, so they are sort of called pathological. Fresher. Okay, so this these fresh is it's really important to say in a thorough like, uh um, investigations for cancer on the majority of this patient tend to go for a pet city. OK, intense of this mechanism of fresh for the Monte. Uh, threshold. There are a lot there. There are a lot of courses, and there are a lot of mechanism of ash in most of them. Seen on patient's that can after skin, I mean or sort of high impact sports. Uh, they're quite common as well on sort of motorbike accidents. And, uh, they are actually, um, they're actually quite common as well on teenagers. Okay. And I'm afraid that these sort of rashes, they have to be fixated. And the way we've accepted is with plates and screwed. Or in the case, we can we do something called a K wire. Okay, but we'll go through that in a bit. Good. So just just remember the four kids that she was saying. So, after doing all of these, they will, um They will, um, have you for basic treatment. And this basic treatment will be either conservative management or surgical management on conservative management guys. It's really important. All trauma patient's okay. There's trauma cases, okay, that they have got the pain under control. So don't be afraid of optimize the pain or give good painkillers because it's needed. All this place rashes have explained earlier on, they have to be reduced. And for a proper manipulation and reduction, they have to be pain free as much as they can. Okay? And then we secure the fracture. And I wrote down here back Slab versus CASS. Can someone tell me the difference between these two does anyone knows at all what a back slab is And what actually a cast is? Because when I was a med ask you at school, I didn't know the difference, to be honest. And I only learned when I started the Tino job. Oh, perfect. George's. Um Yeah, perfect. So cars covered, the walls suffer. So there are circumferential cast while a back slab. All the Kobe's the back of the pressure, and then we sort of would leave a gap on the top that we covered with bandages. Okay, Um, always when we do a reduction of freshers, we need to do X ray, pre and post. And always we need to shake the neurovascular status pre and post manipulation. Okay. And we will go into Olivia more detail. War with me with neurovascular. Um okay. Okay. Bianca, All right. I was gonna explain earlier on. So Bianca just asked why will we need to leave a surfeit open? Okay, which is actually a really good question. And the reason why is because there is a high risk of a condition. To be honest, I shouldn't I shouldn't just give me Bianca. Just bear with me two minutes, otherwise you will realize now why? Okay, I will explain you in two minutes. My father is Adam with the hand on. I guess that you would like to ask something. Uh, yeah, maybe not. Yeah. I talk about why the black slip is open one style, So I'll explain. Uh, answer the I go to the answer. Uh, you will answer. Uh, I'll answer the question in just two minutes because actually, we got a case. Um, next sli. Um, so that's why you guys will find out the unsaved. That's all right. Yeah. Okay, that's fine. OK, that's fine, but it's a good question, and it's something that is needed. Um, meaning it's good for you guys to know. Um, yeah. So all these guys, we need to shake neurovascular status pre and post manipulation. And what I mean, with near vascular status. I don't want you to sort of go and do a full neurological exam because no needed. Okay, we will go into detail, as I say as well. What? I mean with neuro vascular status before Okay, in the next slide, uh, all fractures benefit from elevation. So if you've got an ankle fracture, important to elevate, okay? And when I say elevators not to put your leg on top of a pillow and sort of live flat on your on your head. But we need a decent high, okay? And always, always prepare this patient for surgery in the case of the surgery, So majority of the upper upper limb flushes. Uh, if we put them on a Pakis lab or a cast and we check neurovascular stated afterwards, and we are happy with it. Majority majority of these, um, pressures can go home on the same day and then can be can be follow up on clinic. So we will follow them up on fracture clinic, where we will just sort of assess the patient again, do a repeated or X ray. Then we will take from whether this patient will actually need surgical physician or no for patient's that have got any sort of neurovascular, um, symptoms. Then we should admit the patient's for observations. And, uh, for this one that have got a fresher on the lower leg and they are limiting them to walk. Always admit the patient for observation as well. Okay, especially if you are on the middle of the night. And then the surgeon called, uh, management. There is quite simple. We have got open reduction and internal fixation. We got an open reduction with external fixation. There is no really use is more useful, open sort of accumulated ankle flashes. And then we got replacement. Okay, so I'll move into the next one, and then I go quite too simple. Fresh is this one is by mail. Eola fresher of the ankle. So this is one of the male Eola. This is the medial malleolus, and this is the lateral, and there is a fresher here, and then it's a fresher here. Okay, Probably here as well. That's what they put it that way. Okay, so we just fixated with plates and Scrooge and this plate, if patient's have fit and well, this place tend to come out afterwards. This is one of the place that sometimes we don't keep it there for long. Okay, Uh, and this one here, which we can see it, is, um, a fracture of the owner on the radius. Uh, well, we have got here is something called K wires. And then there are wise that we tend to use them in kids quite often. Uh, we aren't afraid that the x ray just cut here, but we tend to sort of make a small cut or leave a little bit of the wide out and sort of covid with bandages, and then we bring it into clinic and we tend to when we are happy of the bone healing nicely, we take the we plan for the wires to come out, and they are called K wires. Okay. All right. So moving on to everything that this is the case. Okay, so we have got you are the orthopedic E f one. Okay. Or junior doctor covering nights. And you get a belief from one of the neces to see a patient. There is 34 year old, uh, that's complaining of excruciating pain. And, uh, she just told you that his day to pause Open reduction and internal fertilization for, uh, right. Try Malala fracture. Okay, what are your worries in this sort of patient compartment syndrome? That's perfect. Yeah. So we worry about compartment syndrome. Okay. And now Bianca will go to explain the difference between cars and so on. So I'm going to quickly go quick definition of what a syndrome is. As you can see in this picture, this is a picture of our leg, and, uh, compartments injury is simply a condition in which there is increased pressure, either cause, per swelling of bleeding within a compartment. And as you can see, for example, on the leg, we got an interior compartment lateral compartment, and then we got a deep and superficial component. And then we've got bonds and then every compartment I've got, um, capillaries, nerves and muscles around there. So what happen is when there is increase, um, pressure within this compartment, this can compressed, um, the capillary, the Neff, and the muscle within that compartment, causing ischemia and muscle enough damage. So as mentioned here, the fascia does not stretch. And when you have got a patient example with a fracture, Then there is this increased swelling within that compartment. Okay, if we put someone on a cast cylinder cast around it, Yeah, that is not living. And And And that leg will be quite swollen, isn't it? So there's no living enough room for the swelling to go away. Okay, so that increases the pressure within the component that increases depression. We didn't say leg. Okay, Um, without I studied supply of the, uh, Austrian nutrient Neffa muscle cells can be damaged, and this is actually an emergency. In orthopedics, there are only quite there are only a couple of emergency, and this is one of them. Okay. Causes can be external, as I say, as sick, uh, corporation full cast surrounding that area. So it's not letting ruin for the swelling to go away. Um, we can be in turner, sometimes fracture a hematoma, soft tissue injuries. Okay. What do you think the sentence will be? Your compartment syndrome. Any ideas? Six piece. Lovely. Dominique. Yeah. Dumb. Lovely. It's very good. So you know, this intense looks perfect. So in this case, the six speaks of the five piece. The most important is that excruciating pain unbearable. Okay, Uh, there is no pulls. Pulls sometime is difficult for patient's are puzzle like in this case scenario, because I got a cast. So there is no room to actually, you know, fill the polls. Yeah, there is paler. So you you look at the the toes and there is a little bit of paler. The leg is no looking the same color, isn't it? As the the opposite leg there is parasthesia. So there are no feeling okay. And they will complain on this sort of pins and needles Sensation now hanging down the leg or shooting sort of pain. Okay. And then there is paralysis, unable to wiggle the toes. Okay, so this is important. And this is what I mean about neurovascular uh, neurovascular examination. So it's just five piece. I always approach my patient's when I reduced the fracture putting on a back slab because I'm not that brave of putting them on a cast just simply because, as we explain, we put it on a cast. The risk for then developing component syndrome is a low higher because there is no room for the swelling to go away. It's a clear guys. Yeah, perfect. Bianca. So Yeah, there is no room. So what we just put is a back slab that sort of secure the fracture in place? Yeah. And then we just put some bandages on top, but it looks like a cast, but you actually need to pop a. So if you're one of the junior doctors on the world and you see someone with a cast be sort of specific on your documentation, whether this is cast or this is a back slab and it's so simple to just sort of pupate and you will feel that it's really hard on the back and it's sort of soften the, uh, top because bandages that we put. Okay, so we put like a cotton wrap around just to preserve the skin. And then we put the bandage, okay. And then I just go to my patient. Can you wiggle your toes for me? You have any pins and needle? Do you go? Any numbness? Have you go any, like, shooting pain? No. Doctor or yeah, doctors, you know, Or when did the pain started or sorry. Nose and severity from 1 to 1000. Then you know, it's compartment syndrome. Okay. Um, in patient's I've got back. His life is quite easily to sort of pop a day, do salads. Perry's because there is room for your things to go inside. So do feel free. Okay. And, uh, will anyone What will your first thing that you would do if you're suspecting someone having compartment syndrome? In this case of a patient, I stay to put up? Yeah, emergency fasciotomy. But can you do? Can you do something? Meanwhile, before you wait for the surgeon to come to do our emergency fasciotomy, is there any way you can improve the pain? Exactly. Yeah. Yeah, it got right. So you just remove the cast, okay, But to be more specific, you don't remove the cast, okay? Just cut the cars, Okay? So just take a sisters. It's sometimes impossible to find it on the wood. I'm afraid so. It could be C c. Even if it's a back slab, cut it cut throughout the bandage. Okay. And sometimes fresher cleaner. So and these will have little cactus, so just find one of the cutest, have a lot of careful and try to try to remove a special kind of cast. Okay? It can be quite challenging to remove a full cast in the middle of the night if you don't have anything, uh, any of these equipment? Okay, but yeah, I'm perfect. And after that, we would just do an emergency fasciotomy. So it's just literally a cut just to release the pressure that has been building out of these components. Um, and that is basically it. Then we leave it open. Once the symptoms sort of settled, we sort of close the layer. And unfortunately, they got a really nasty sort of scar. Sometimes we have to do a skin graph in this patient as well, because there is a big opening, and there is no way we can sort of put back the layers together. All right, Perfect. So now we'll move it onto Well, let me just go back Any all the any question from Dominic, your BP is high. Do you try and lower it or you just need to, uh, so it's quite tricky. Done. Because normally, as I say, if there is compartment syndrome, there is too thin. Either there is an increase in swelling or there is bleeding. Okay. And especially on patient's I post up, you will expect to be bleeding and to be the cause of the compartment to be bleeding, isn't it? So they do need life full examination, a TUI assessment. They need, um, Bloods and, uh, BG. That is all important. They will. They normally have a group and safe group and say, because they just have operations recently. But just make sure that you send all those blood tests out okay, in terms of BP, Uh, if their BP is low, definitely should be resuscitated because, as I say, in case of possible patient, they are the main cause of why uh, they develop compartment syndrome is mailing because of bleeding. Okay, there's a Okay, so this is just because swelling, but the priority number one is been in this case as well. Okay, so definitely always is maintaining. And that's why I will always suggest to do your blood face and a BVD just to monitor the the hemoglobin and make sure that there is no a massive drop. There is, um if there is a massive drop in hemoglobin and the patient is him, him a dynamically unstable that will give you a reason for what the compartment seem to happen. Is that clear? Done? Yeah. Lovely. All right. So we will move into the next two cases. Okay, Next case. Um, it's not an emergency. The last one it is. But the next case the matter is going to present is one of the cases that you're gonna encounter the most when you're on call. So I just leave it to you matter. So so do you want me to stop sharing the screen or do you want me to go through the slides? No, no. Stop share ing. I will use mine. Can you see my screen? One second. I just stopped showing right now. Yeah. Lovely Poke idoki. Um, so this was actually the first patient that that ever Clark has an F one because I was doing a t e n o n or surgery last year as an interim if wanna so in April Because we've started before. So 82 years old female who presented to the E. D department following a full unable to with bare due to pain upon presentation, you examine you always examine from eight we so I don't have to repeat it. Uh, as as yesterday but always approach the patient from a to e. And during the examination, or you found you find, uh, these legs Uh, what can you see from this picture? Marta, can you see anyone on the shot? Because I can't see the shot at the moment. Oh, there you go. I can see the chapter neck of femur fracture. Femur fracture. Extradition? Yes, exactly. So this patient has most probably got a neck of the femur fracture femur fracture because it's presented with a shortened, uh, and an external rotated leg. So these are the two most common characteristics. And when you perform a physical examination of a patient with the neck of the femur fracture or what we say in the UK as an abbreviation enough, um, an external rotation and assures for the LaGon. So what would you like to know, apart from the history, So usually when you're pro gun approach, uh, patient that just had a full, uh, especially elderly patient, you're gonna ask a lot of questions. Uh, and indeed, in the UK, we have also a team that is present all in the UK, known in other countries, which is polio to geriatric team and this Ortho geriatric team is actually gonna take care of the frailty patient. So that a go under orthopedics? Um, so usually these patient's will also be looked after both by your stupid ick team and by your surgery, a trick team. So you're gonna ask a lot of questions. But most importantly, you're also gonna ask about the past medical history, Um, and about the social history And in a few minutes, and we're also gonna see why we're you're gonna ask for giz, um, estrogen supplement? Uh, well, yes. Some people they already have. I mean, we usually don't put them already on estrogen, a supplement station, so we usually put them on on the vitamin D if it's low, because most of them and they've got low vitamin D. And we give, uh, podiatry. That's what we usually give in order to prevent future fractures. Because indeed, that old early, so moving next to the next slide, this is your x ray. So we have begun through several X ray with Martha. So I would like you to describe me this X ray. Now, anyone see, it's actually one of the most common X ray that you can find, uh, an orthopedic, Any north a geriatric, Because again, Ortho geriatricians will look after older elevations that are under orthopedics. Garden. A photo? Yeah. You already went to the to the proper classification. No. Yes, it is, actually, indeed, the Garden four. Okay, ap pelvic extra. Showing a neck of the femur fracture. Okay, so let's take it to stop the bus stop. So this is an AP view. Pelvic ax ray showing an, uh, neck of the femur fracture. Left or right? Um, left. Exactly. Remember, always that this one is your left complete or incomplete them complete. Complete. Exactly. Displays are not displaced. It is a garden for a so so it's a displaced. Exactly. So it's a displace. It is a displaced complete them left the neck of the femur fracture in an old early patient's following. A folate is the most common presentation in the A. D. It is not an emergency, but in our hospital, I don't know why the blip goes off. Like if it is a trauma cola, but it's not a trauma cola. It's a neck of the femur fracture. So after that, we have the described this Aksaray so keep it simple. Um, so these patient's that they need to be operated that even if they are old early, Uh, most of the time. So for a very important reason. Because around the neck of the femur over here, you've got all of the, uh, vascular supplies that come from the femoral artery. And if this blood supply is actually gonna be cut off, you will have increased risk for a vascular necrosis. Um, so obviously they need to be operated another feature of the X ray with a knack of a few more fracture that I forgot to mention in the previous light. And it is to say, if it is an intra or an extra capsule or a neck of the femur fracture, because it's really important to know the management. So if it is an intracapsular, you're gonna have this extracapsular. Not really. Um, so here you've got your last trochanter. You're greater to countries over here. Obviously, this one is as a displaced fracture. So it's a the femur, a bit routinely, so you can't really see the greater the greater trochanter over here. Neither here, but anyway, it's on this side. So it's actually intracapsular intracapsular It means that it is inside above the intertrochanteric fracture so that it is an imaginary line that goes from the last test the counter to the greater war. Okay, so here it is, inside the capsule, and below it it is the extra capsule. Or so Another important thing is, I forgot to mention, uh, so that this actor is actually, uh, really straightforward. Recognize that of a few more fracture. But there are some X rays where you can't really see if there is a knock of a few more fracture. Especially when you don't have a lot of experience as well at the beginning. So what I learned to do goes one. Uh, no. Okay, um, what I actually do it is to check what we call the Shannon line. The Shannon line. It is this imaginary line that you can see here. It's without any interruption. It is a cure line that goes from your pube. Is, um it goes towards the neck of the femur and it I send them here instead. Uh, it is interrupt that the channel line when this again. It's really easy to recognize that there is the neck of femur fracture. Uh, mother, actually, where it's a bit, uh, it's a bit debut. Some recognize it, Uh, so it always use your mouse on the computer and try to check for this channel line if there is any fracture. Anyway, Inter extracapsular this one. It is an intracapsular neck of the femur fracture for these days on the left side in an older patient that we can see also some signs of, uh, sort of priorities over here. Uh, that's not really important at the moment. And it is an intracapsular. So it is a garden four again really important to curate on these stations because you have increased risk of a vascular necrosis to meaning that the, um, vascular supply around the neck of the femur will be cut off and this one will lead it to a vascular necrosis. Um, and here it's about the management. So it's really important to know about again if it is an intro, an extra capsule or a fracture. Because you need to know about which surgical approach you will use. Uh, in this case is, uh, so let's start from an, uh, from an intracapsular one. You've got over here in the last 22 replacement, the first one it is and what we call an hemiarthroplasty year. So a partial keep replacement. And the second one, it is a total hip replacement. So this one now, you will usually use it for an intracapsular one. But there is a difference. Um, totally hip replacement. That is very good, because it lasts for a lot of years. So it has got actually along the patents here, but it does also increased risk, uh, to, um, to be displaced, and and, uh whereas the hemiarthroplasty, it does decrease the patency compared to the total hip replacement, but it usually stays stuck into the bone, and it does not displaced so easily. And this means that you need to take a little history about your patient. They're gonna clerk them because you need to know about the past medical history if they've got any dementia, if they are really frail and not about the age, because some people, they are actually 90 years older, but they're really fit and well, uh, and then there are some people that they are 70 years old with a lot of morbidity is, um this means the data. You will use an Emmy arthroplasty in case of patience with a lot of comorbidities, um, and that they have got order that end or that they've got also cognitive impairment. Um, and you will use a total hip replacement in all the other cases after the death. Uh, you will have them. Um, you will have that. These are extra medullary implants over here. So you've got a cannulated screw over here That there to screw that they're gonna enter through the, uh, in the collateral approach, then a sliding hip screw have got a plate and screw and an intramedullary nail. Um, so you will use, uh, in preference, a sliding a hip screw in preference to an intramedullary nail for patient's that come with the truck and tarik fractures above them and including the last er to counter. Whereas you will use an intramedullary nail to treat patient so with the subtrochanteric fracture so that they are usually over here. So this is the last er to counter subtrochanteric. It is from this point below. So again you will use a sliding hip screw for patient's with a fracture about them or inside the last search a counter and, uh, an intramedullary nella for a patient's coming away in a fracture below the last search. Countering, um, that she has a Yeah, it's me. Sorry. I just got a couple of, uh, private messages, and they're all about the same. So it's a matter. You answer. I'm happy to answer quickly. So there are being a couple of people who just messaged me about impatient that are present with an impacted Neco. Female pressure meaning non displace, where there is any possibility to treat them conservatively. Okay. And there is a there. There is a big debate on orthopedics. Yeah, some of them will say yes, Some of them will say no. But there is something called a trial or mobilization. So you realize that there is a lot of patient that can do any with new confusion, something like this. They are complaining a little bit of hip pain. Uh, they just, um they just, uh, do a pelvis X ray. And they found out that this patient is gone impacted neck of femur fracture, but the patient's mobilizing well, and the patient is not complaining of any pain. OK, so it's quite tricking this sort of patient if the fresher is not clear and we don't know if this is a new fracture or is no fresher. That's why it's smart to say it's really important to get proper next or keen information or past medical history. Um, whether they have got recent, uh, Falls a horn, whether they have going to sort of unwitnessed fall recently, how many falls have they had over the last year and things like this? Um, if there is no sort of, um, past medical history or recent fall or trauma, what we tend to do is do a city to make sure whether this is a new or by all fresher. Okay. And when we say we tend to, it really depends on the consultant. Okay, Some patient's, they do a trial of mobilization, but the the majority of them the end, the end, they're having to have the neck of femur fixated. Okay, why common on jum patient as someone else asks. Okay. Uh, sorry, man. Just go. I know the private message. Sorry. Uh, someone who just asked that the patient's are jammed. There are a couple of patient's below 40 years old with neck of femur fracture. Those ones are high. Um, there are the only ones that are considered for conservative management just because they want to present the neck of femur. Okay. But all depends on the consultant, but there. Yeah, there have been cases that they can be treated conservatively, but there is a high incident that they will have to be treated, um, surgical with surgical treatment. All right, Cool. So just to recap, that is really important. Total hip replacement for intracapsular fracture that they are for a patient. So who do not have dementia. So no cognitive impairment. And not a lot on the background regarding the medical background, him arthroplasty for the rest. And we also explain why. And then, um, sliding a hip screw and intramedullary nail. We also said that you will prefer a sliding a hip screw for patient's that are coming within a fracture about or within the last search. The counter there. There it is that the last counter and then intramedullary one for patient's with the subtrochanteric fracture. So below the trochanter. Okey dokey. Um, now we move on. You are your two pd Kasich on call? Um, You just received a phone call from the G p. Who is concerned about his A 42 years old female patient who has been complaining of back pain, bilateral paresthesia and two episodes of a fecal incontinence. Uh, no previous past medical history. No smoker. Social drinking. Yes. So, unfortunately, GP was unable to do a neurological examination, and this happened quite possible. And has a diesel was a telephone concert. Concert station. What is your approach? So we already came to the Daniel. Is is, um uh you already came to the diagnosis. Uh, Cuda equine. Uh, and I'm also gonna say later on what it is exactly and also how to remember it. Um, So what would you do? What is your approach? So what is your approach in all the patient's that you're clerking? Uh, that we say also before And we said also yesterday, what is the most common approach that we would use? So, eight, we examination. Okay, so in this case that you were also gonna You're also gonna focus much more on some parts of the body. Um, you're gonna perform a neurological examination. Really good. Uh, and you're also gonna perform a PR exam, okay. And the neurological examination in this kind of patients' needs to be detailed. Meaning that needs to be al four or five as one. I mean, all of the myotomes and all the dermatomes and all the reflexes. They actually need to be documented. The power, the sensitivities and the tone, and also the PR examine is to be documented. It is really important to take a detailed clinical history, including the duration of the symptoms, Uh, similar episodes in the past. Um, and any history of the recent trauma or surgery? What would you look for in this case? Is, uh, So what would you look for in the in the history especially, which are the most common symptoms of a of a covid equina so paresthesia paying a new urinary or fecal incontinence? Exactly. So you will ask, uh, do you have the urinary incontinence? Do you pee in yourself and you don't realize it the same with the number two. Do you actually open your bowels without realizing it? Uh, and also, have you got an ominous, um, in your legs? Um, so these are the most common things that you're actually going to look for clinical presentations of Kodak Wanna So Kodak wanna It actually comes from the Latin, Uh, and it means that the tailor, uh, of the horse. In fact, if you actually remember anatomy at the at the terminal, uh, end of the nerves of the pelvic nerves and, uh, and of your genitalia, you've got these, uh, these group of, uh, of threads. We can call them that. Are the terminal nerves ending some that they resemble them? The tail of the horses. So this is actually why it's called the code equina. That will give you these exact symptoms because the nerves that are gonna be, uh, the wants to be, uh, to be affected are gonna be the one of the lower limbs. Um, are gonna be the one of your pelvic organs. So this is why you're gonna have a fecal and urinary incontinent. And this is why obviously you're also gonna have a na Minnis, so you will have a back back pain with the sciatica. Weakness of the legs, uh, parasthesia, or numbness of the legs, Uh, federal anesthesia, fecal incontinence and the urinary retention or incontinence. In fact, in this patient's, you're also going to ask for a possible other bladder scan when you're gonna clerk them. Okay, Didn't neurological examination assessing power sensation, reflexes, muscle tone of the lower limbs? Uh, so remember each dermatome and each myotome You need to check, uh, performing at a digital rectal examination to look for the presence of the saddle anesthesia. So what? Obviously after that, you got to the consent and that you can also get a shopper on with you. I will actually advise it. Uh uh. You're going to perform. It is a PR examination. And actually, you're gonna ask the patient's if they've got if they can actually feel your finger around the in the periadrenal area. So around the DEA nose, uh, and then you're also gonna stick your finger inside and see what it is. I mean, and, uh, document all your findings and and bladders can again check for urine retention. Okay. When and obviously to check for your attention. As we said yesterday, you're also gonna palpate the abdomen if you're gonna feel something in the standard which in this case will be the urinary bladder. When a huguely suspicious of code equina syndrome an urgent MRI lumbar sacral is needed and an urgent discussion with the neurosurgeon. Uh, so in our hospital, we don't have a neurosurgery we usually call a Sandra hospital When some patient's become like that, uh, there isn't. It doesn't exist that you miss a code equina syndrome because it is an emergency. It's really rare, but it is an emergency. So each patient's that it is a question mark for a possible hood equina. We always have the discussion with the Send your hospital with neurosurgery. You can't miss it. If you're in doubt, call them. Tell them all your examination of all your neurological examination of PR examination of possible, their bladder scan, uh, the clinical, his the clinical details of the patient. And they're gonna tell you what to do if they think it is a code A queen, um, they will transfer the patient straight away to the hospital. If you have the neurosurgeons that they will actually come and look by themselves. You don't need orthopedics. But under our hospital code, equina comes understa pedic sand, and then it gets referred to Saint Georgia. If they don't think it is, uh, they will actually tell you to ask for an urgent MRI and MRI is about actually an investigation. Not that it's a It's quite difficult to get it on the on the day, but within a possible diagnosis of Kodak Wanna, you will always get it because again, it is an emergence because you have got the stenosis, Uh, which means a narrowing inside the spinal canal. Um, so obviously it needs to be ready. Is, um, just once I'm gonna to go to the next one, so and this is that just the last slide? I will fix the fracture first. After that, you can continue with your c p. R. This is not to usually decades of orthopedics. I don't We don't want to make, like, generalize a comment. But this is also why there is an Ortho geriatric team that looks, after all, the early patient's, uh, under orthopedics. And, uh and, uh, yeah, Let's have you got any questions on these last two cases? Uh, especially on the neck of the femur fracture, because it is the most common thing that you might actually have. What is a PR? It is a digital. So it is, uh, correct. Um, examination. Uh, so how to perform? A very good, uh, parac to make some. It means that you stick your finger inside the rectum. Um um inside Iran nose, actually. And, uh, what you're gonna do it is. First of all, you will ask for consent. You're gonna explain to the procedures, as you will do for all of the procedures. Uh, after that you're gonna ask them to stay on their flank. And after that, you're gonna first of all, check if there is any anesthesia. So if there is a if they can feel your finger around the anus after that, you will get some lube riffing Antam, and you will stick it in. And what do you usually ask for before removing your finger? Obviously, you're going to check for any mass and so on. But in this case, you are not party worried about any mass. Uh, you're actually gonna ask them to squeeze there? Ah, nose. And they're a nose, uh, around your finger in order to check for their in Altona. So it's really important to check if they've got in Altona or if they've got no in Altona because no anal tone, it has actually uh, one of the alarm signs for code Equina syndrome. So it's really important to ask them while you're inside and then you remove it and you always check your finger and you're gonna see what you're gonna have on your glove. This is important for all the digital rectal examination. Any other question? So regarding the neck of the femur fracture, uh, what I used to do when I was studying the photo Stupid IX, it is actually to go onto the nice guidelines. Some here in the UK we use the nice guidelines for everything gum they have got. Also, they're orthopedic, actually has also got to the bus the bus guidelines. But, uh, the nice guidelines that they are actually pretty straightforward, and they're quite easy to understand. Uh, And if you just type in Google, uh, neck of the femur fracture for a nice guidelines, you will actually have them from the history until the end until the surgical approach and also the post operative approach. So with this patient's and what you need to do, and, uh, I guess I found them a release instead of going into thousands of books of thousands pages of books. So just going to them if you're in in to them and just go over a lot of X rays. And if you're interested in the, uh, orthopedics, um, and try to describe them within one of your mates and and this is actually the best wave the best way to to learn how to describe a fracture because, uh, orthopedics say yes. Uh, they will not know how to do a CPR, but trust me that they really know about the exercise. Obviously, they know how to do a sippy. I'm joking. But they they are really little about the x ray. Or at least they would just want their basic doctor level to just try to describe an X ray. Very good. I don't know what I did. The guys never mind, uh, something that I will suggest as well for all of you that I've got an orthopedic placement. I don't even know to remove that. To be honest, I'm sort of painted their his the net. Never mind, uh, is an app called Ortho flow. I don't know if you guys can see that one there. Yeah, you see that motor because I can see Yeah, Yeah, it's actually quite good. And if you go inside, you will have this here and then you just press on the sort of female, and then it will tell you proximal female Misha femur. So I wanna proximal femur fracture, and then we'll explain you a little bit of intracapsular extracapsular intracapsular. And then it will tell you it's a displace, and this place it is displace. And then it will give you a little bit of what to do. So it's quite handy for those that are doing nice. And don't feel, um uh, author floor. Yeah. CRA ties the name author floor. And it looks like that the up actually looks like that slight black we'd upon. I really highly recommend this one. And in the UK, we also use, uh, quite a lot. Uh, Ortho bullets. Uh, I'm just going to type it down to the charter, and it's actually no, Sorry, I've mess. I've direct message Someone. Sorry about that. Uh, mhm. There you go. It's actually really good as well. Um, it's free for everybody. So you just type it in, and you just google it and you're gonna talk for all the fractures. Uh, and, uh, what? What I would like actually to to emphasize, um is that if you would like to to to pursue this a career in surgery, it's actually important that you know, your anatomy. I will say another website that we actually use, um, teach me anatomy. It's a very it's a free website that, uh it's actually really easy. It just highlights the most important points. The most important things of anatomy that you need to know. It's not the 5 kg a book that I was studying for during medical school. Uh, yeah, the big one of the 5 kg that I was carrying always with me. And that's actually really this website is actually really good. Thank you guys. Yeah, for those ones are still asking. You can either scan the QR code. Okay? And I'll resend the link once again for this one. They still haven't. Thank you. Sophia. Uh, Martha, can we please, uh, share the link from yesterday? Because someone at the link from this Saturday? Yes. So I'll just give me say I would just stop. I just send the link here. Guys, I'll just, uh