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The hi, everyone. Can you hear me? Yeah, good. I can't hear you. Hi. Uh everyone in the life. Can you hear me? We just want to be sure everyone can hear before we uh carry on. Cool. So, um, let me see how many people we've got. Ok, so we got 20 people logged in. That's fine. Uh My name is Greg. Ok. I'm the teaching coordinator for sa orthopedics. Um Today we've got Mr Khalid Yag who's taking us on the management of open fractures, uh A comprehensive guide. Uh Khaled is an ST four in the London Sports uh rotation. Uh He's taking us through in this very exciting topic. Uh So just keep notes that when he's during the presentation, if you have any questions, you could always write them down and at the end of the presentation, you put them in the chart, um, ask questions so uh K can answer them in record time. Uh So, uh coming over to you, please. Thank you. Thank you Greg and uh welcome everyone to the session and, and thank you Greg for inviting me to this. Um I'm just going to share my screen right now. So that we can take a look at the presentation. I'm hoping that people can see this. Uh Greg. Does this show the entire screen? Yeah, it shows on my screen. Um Can everyone confirms if it shows on their screen so we can proceed? Is that a yes or no? Because I can't really see except for my screen at the moment. So everyone says that it uh y has said you can show on the screen. So wonderful. OK. Uh Wonderful. Thank you, Greg. So um good afternoon, everyone. Good evening everyone. Um My name is K um and as uh Greg has mentioned, I am one of the registrars on the president. Um I'm currently in ST four at Queens Hospital in Romford. Um I thought about giving a topic which is very commonly seen in orthopedics. Um and one that's um quite challenging to manage sometimes, but if you have the basic principles can be quite straightforward. Um my talk today will be fairly interactive. I do want you guys to, to, to pitch in your answers. Um And there's no right or wrong and we're all here to learn and help each other. I'm not going to talk as much. So if no one pitches up to answer, it's going to be a very silent conversation and lecture. So, um the first question that I want to ask, um anyone that wants to s um unmute themselves and answer, what, what is the definition of open fracture. How do you know when you are presented with a fracture? How do you know that this is an open fracture or if it's not an open fracture? Anyone at all? I can't see my screen except for my slide. So um you guys might want to just speak up. Um Greg, I don't think they have the option to speak someone just messaged on the chat. They can only um uh put your responses on the chart so you can read from the charts. OK. So they can't actually speak. Uh No, but they can give responses on the chat. So you can just read. That's fine. OK. So if anyone can um write the answer in the chat box, what they think and racist, we'll give it one minute if no one answers, that's fine. I might ask a great then. OK. So Ashok has written down uh fracture or breaking of bones complete or partial. Um Diana has said it's, it is a partial or complete break in the bone. Um open laceration, underlying breaking bone from Yasser. Um All your other open fracture is when there is come, I think what you mean is communication. So I think and yeah, we have to any fracture with an associated communication with the external environment in the same fracture area. Fantastic. Yeah. Correct. So almost everyone has the right concept. So uh an open fracture is technically a fracture whereby there is um actual communication with the external um environment, there's a breach um of the soft tissue and the skin. Uh and therefore, you are uh by definition managing an old fracture. And this is what it says over here, it's an injury where the fractured bone is exposed to the um um the the is sorry, it extends um it's exposed to the external environment through a traumatic dilation in the uh of the soft tissue on the skin. And that's by definition, a open fracture. So the next question that I have is how many of you here consider this to be an open fracture? Or is this not an open fracture? Just a yes or a no? Is it an open fracture or is it not an open fracture again if we have um responses on the um message? So Yasser says, yes, it is an open fracture. Ashok says yes, Diana says, yes, wonderful. That's actually very true. And, and that's, that's an important point to consider. It doesn't matter how big the the wound is or how big the break in the skin. It is. As long as there is a a puncture in the wound in the sorry in the skin that allows communication between the inside of the uh limb and the outside environment. Then this is immediately an open fracture and you need to manage as such. So it doesn't matter how big or small it is wonderful. So um the next slide we'll talk about a case. So we have a 24 year old male who, um, was brought in as a trauma called by the ambulance. He was, the motorbike driver crashed into a stationary car at around 50 miles per hour. Um, the heart rate is 100 and 10, BP is 100/60 the respirate is 15, temperature is normal. You are on call, you're brought into this drama call as part of the Trump team. And the first thing that you come across is something of the sort. Um No, I'd like to know from people in the audience. How would you manage something like this? You are the uh orthopedics um uh sho or registrar on call. Um What principles will you want to use to manage such a fracture? Ok. So says ABCD E um Tulo says ATL S principles. Absolutely correct. Um Is there any other um guidelines principles that you guys are aware um when you manage something like this other than the ATLS? Ahmed says ABCD E correct. So we all agreed that we need to manage this as per the ATLS protocols because it is a trauma. Um um There's, there's another set of guidelines that we must follow when we manage open fractures. So, Francis, yeah. Um Both guidelines. Absolutely correct. Um Yes, sir, you are correct. We will do the LFI move or examination in general, a strong protocol, but Francis is Francis. You are correct. Both guidelines for open fractures. So we need to manage it. As for two principles, we come across open fractures in the setting of the trauma court, we need to follow the the ATLS protocol. And again, we want to manage the uh open factor as per the guidelines for open fractures, which is a document available on the internet. You just Google both guidelines for open fractures. It is a full um explanation as to how you should be managing open fractures. Now, the most important thing is to, to, to appreciate with open fractures is that they are highly traumatic and therefore in the setting of trauma, you don't want to wait for time to pass by because it's worth leaving cause of death globally. Um 50% of trauma patients, they will die in the first four hours and the remaining 50% will die in the 1st 24 hours if they are not managed appropriately according to the ATLS protocol and also according to the guidelines for open fractures. Um and if you actually look at the literature and you look at these studies that have been published every minute in trauma will count. Um The the the deaths are broken down into various segments. You have an early phase where you have immediate death. This can be manage, this can be caused by um uh vascular injuries, um cardiac um conditions and also uh traumatic injury to the brain. You have also second phase whereby patients can die within minutes to hours. And this can be again due to intracranial bleed or it could be due to abdominal bt injuries or um lower limb or upper limb um, injuries leading to massive hemorrhage. Then the, the third phase, which is the late um period of death in trauma patients is normally due to multisystem organ failure or sepsis, secondary to um for example, infections. Um Has anyone heard of the, the golden hour in trauma? Anyone ever heard of it at all? Ok. So op says, yes, he has heard of it. Um It's the first one hour. So what, what, what is the golden hour for anyone that knows if you want to describe it? Um What is the golden hour in the setting of trauma? So the critical period? Um OK, what a critical period for what exactly why is this golden hour so important in the setting of trauma? First hour? So Dion says first hour after the accident? OK. But why is it important? Why do we put so much emphasis in the golden hour? It's called golden hour for a specific reason. Um says determining the mortality. He also says identification of life-threatening injuries. OK. Um Diana says the chance of survival, tho says the first hour after injury where treatment that influences outcome positively should occur. So you guys are all roaming around the the the right answer. Ahmed Abu says increases the likelihood of survival, correct. So the golden A as well. Uh AAA patient managed properly in this hour, he will have better survival chance. So, so it is correct. That's, that's primarily the concept of what the golden hour is. Um Basically, it is the time following a traumatic injury when, when um prompt medical treatment has been highest likelihood to prevent death. And this links very well with our early phase, second phase and the third phase whereby every minute in the traumatic setting is important. That's why the golden hour is very important. If you as a trauma team intervene and identify life threatening injuries in the first golden hour, then you are very likely to save the patient's life and prevent death. Um So here we have a traumatic uh sorry, a, a graphic distribution of um when uh trauma deaths occur. And in the um golden box over here, this is the first hour you can see that 50% of the people die. And over then the, the, within that hour, the second highest distribution is 30% percent of death. And that's why if we can as a trauma team intervene within that first hour, then we are going to have a significant improvement in the, in the, in the survival rate. So that's what it says over here. The golden hour, 80% of trauma deaths are in the first hour after injury. Um And that's why it's important for us to appreciate that when we get an open fracture, don't focus so much on the bone. Don't focus so much on the, on the, on the, on the uh blood and whatnot. Focus on, as you guys said, the ATL principles so that we can identify life-threatening injuries within that first golden hour and prevent that 80% of trauma events. Now, speaking of the principles of ATL S, what is ATL S made from, what are the, the aspects of it, if we can break it down into two segments? Um What would you say ATL S principles consist of if anyone could say anyone at all? So primary survey, basically and secondary survey, right? Um and if we um um break down the primary survey that basically um entails, what, what are we, what are we considered in primary? Um What are we achieving in the primary survey? What are you hoping to get? Why is it when we get this? Why we, if we get this injury in the trauma setting, why can't I manage this immediately? What is the problem tools says, recognizing life threatening injuries and addressing them uh should says treat immediately life threating injuries, bag says immediate approach to a trauma patient. ABCD. Correct. Very correct. So this is this is basically um why we approach the trauma patient uh in, in a, in a primary survey and then we do a secondary survey says, ensure the first three components of the A two E fine. So the pri principles of ATS are like we said, it breaks it down into a primary survey and a secondary survey and the primary survey, the most important thing is that we don't want to be distracted by what we can physically see in the patient. For example, in this setting, the open fracture, we don't want to be distracted and focus on managing it while we actually forget the most important things, which is the airway, the breathing circulation. That's where the primary survey comes in. We want to have a structured assessment to the in patient. We want to up any lifethreatening injuries, identify them and manage them appropriately. So we can resuscitate the patient and then focus on the secondary injury, which in this instance is the open pressure. And then the secondary survey is basically a systematic approach of the patient examining them from head to toe so that we don't miss any secondary injuries that can later on cause either morbidity or mortality to the patient. Ok. So, um coming back to the primary survey, um just very briefly, I'm not gonna go into uh a depth discussion about what each segment entails, but it's primarily the airway and then the cervical spine. So you want to immobilize the spine to ensure that there is no cervical injury. You move on to breathing circulation disability and we move on to the exposure. So going back to this primary injury, which we have over here, we have done our primary survey, everything is fine. And now we want to go ahead to manage this uh open fracture. I think someone already mentioned that we're going to follow divorce guidelines. Um Where should this injury be managed? Do you want it to be managed in any hospital setting or do you want it to be in a special hospital setting with particular services present inhouse so that you can manage this, any idea whatsoever? Um Anyone can answer this in the chart. So would you be happy managing it in ad GH, would you be happy managing it? Um in a large D GH in a trauma center? So Yasa says, um trauma center tho says special hospital setting with orthoplastic input available. Um Han says vascular surgeons. So you, you guys are all absolutely correct. So whenever you have and open fracture, you're not happy to manage it in a DH, you want to be in a trauma center, uh you want to have an orthoplastic card and this is actually what the most guidelines mentioned. So where would you manage an open fracture? You need to be in a specialist center that can provide orthopedic care and and also um plastic surgeons available to provide the appropriate care. Now, the second thing that we want to take from the BO guidelines is what would you very clearly document in your examination, any idea whatsoever? So when you're examining this patient, you've done your primary survey, you've done your second survey, you're happy that this is the only injury that we have. And in our case, this is the only fracture or open fracture that we have focusing on this. How would you examine, er, says nerve injury compromise, correct. That's one aspect of our examination. Anything else that we want to examine uh to says neovascular assessment on the affected limb, correct? So this is very important when you're managing open fractures, you want to document very clearly and examine what is the um um um vascular and the neurological status of the uh i injured limb. And you want to also um document it clearly before and after any sort of maneuver that you may do in the instance of uh limb injuries. If you're going to put them in a cast and a splint or anything of that sort, you should very clearly redocument and examine the patient's neurovascular status. So everyone's writing down soft issue law status, neurological examination, vascular irrigation assessment, bleeding disc. But as you're all on the same page so far, we have spoken about where you want to uh manage this patient, an orthoplastic center. How do you examine this patient? Now, the next two things that are important and as an on call, you will come across this a lot. Now you have this patient in your uh A&E you've examined, you are in the appropriate center. What would you want to give or administer to this patient other than analgesia? Are there any specific sort of, um, medications that you might want to give these patients in a, ok. So anything at all that you might want to give, you've given analges you've examined the patient? Yes, it is. Antibiotics. Absolutely correct. So, you want to give IV antibiotics, um, and every hospital would have their own protocol, um, as to what they want to give in terms of antibiotics for open fractures, specifically. Uh, total mentions Tetanus shot. Absolutely correct. I Tetanus shot antibiotics, Tetanus by um everyone over here. That's correct. So the most important thing now that you've examined now that you've resuscitated, um and you documented your examination, you want to give um IV antibiotics and you want to give it as soon as possible, ideally, and according to the boss guidelines, you want to give this within one hour of injury and every hospital will have their own protocol as to what antibiotics you need to give um for the management of open fractures. And obviously, Tetanus is very important um regarding um the, the open fractures. Now we've examined, we've administered, you're in the correct place you've done x-rays. Is there anything else that you want to do in terms of imaging that you want to get for open fractures, imaging wise? Now, um what would you want to get other than x-rays? We do have x-rays. We're happy we've seen the, the, the fracture pattern. We know it's an open fractures. We've given antibiotics. Tetanus we are in a trauma center. We've documented our examination. We're happy about it. What sort of investigations? Yes. It, a CT angio. You're absolutely correct to a trauma ct head to toe. You will definitely get a CT head to toe. Absolutely. But the one that you are as an orthopedic surgeon, the one that you are mostly concerned about and you want to, to get immediately is a CT angiogram. And, and that's because almost um um majority of the open fractures, they may have a concurrent uh vascular injury and you need to know about it because not only will it affect healing, but it can lead to ischia and it can also impair uh the soft tissue coverage in terms of healing. Um um Once plastic surgeons do their own uh management of the injury, wonderful. So we know now what do in terms of the imaging, we said we want to get a CT angio and we understand why the CT angio is important. The next thing that we want to do is the management now of the open fracture itself. Now that you have given everything you've received, uh you, your patient has received antibiotics, tetanus, you've done a CT angio, there is no vascular uh uh supply compromise. What is the first thing that you'd like to do to the open fraction? Now, we're focused only on the open fraction. And I think someone has mentioned already the correct answer. But I think they've deleted it. Um What would you like to do now? Urine A&E this is the only injury is isolated. You've done everything until this point as per divorce guidelines, what would you like to do? Someone has written the answer, I've seen it but someone has deleted them. Um So tho says, reduces, make leg look like a leg and immobilize in a slab, then reassessing your vascular status. That will definitely be part of our management. Um Someone has also mentioned wound irrigation debridement. Ahmed says irrigate the wound. You're all correct. But before doing all of that, there is one thing that we need to do clinical photos. Absolutely correct. And I think you've mentioned it earlier and you've, you've deleted, but you're absolutely correct. You want to take a clinical um photograph of the, the, the uh open fracture. It's very important that you do this. So those guidelines mentions you need to take a photograph of the open uh fracture wound and you need to take it as soon as the patient presents to uh your A&E you need to take another photograph before debridement and you also need to take another photograph after debridement. And at any point of further intervention, um whether it is by the orthopedic team or the uh uh surgical team or by the plastics team. Fantastic. Now that we've taken our photographs, we are happy about that. Uh the next step would be um in terms of the management is, is the the the uh contamination and the irrigation and the washout, which all of you have mentioned. So the first thing that you want to do is you want to remove any gross contamination that you can physically see. The important distinction over here. You're not going to be poking around the wound looking deep, trying to find out if there's any deep contamination, that's not your role in A&E your, your basic principles in A&E is that if there's any visible gross superficial contamination that you can wash out with some saline, then go ahead and do it. But the guidelines specifically mentions washouts or mini washouts outside the operating theater. And in this instance, in A&E, they're not recommended and they're not indicated. So do not do that. You can get AAA bag of Saline uh wash the superficial wound things that you can only see, remove it, but otherwise don't go in deep poking around because it can cause more damage and actually benefiting the patient. So now that you have um removed any gross contamination, the next thing that you're going to do according to the most guidelines is you're going to get yourself some gauze, you're going to soak it with saline and then you're going to apply it on the open fracture, you're covering it also with an occlusive occlusive film. Now keep in mind that these steps happen after you have put the bone back into the uh leg and reduced it inhaled it in place. So for example, in this setting over here, you will attempt with appropriate sedation with your, um, A&E colleagues and resource to push the bone back into the leg itself. Only then will you, um, remove the gross contamination? You're going to put the saline soap gauze and you're going to put as well, occlusive dressing over it. Remember, don't do any mini washouts only removing gross contamination. And also once you put the bone back in, you're going to realign it, you're going to splint it, whether it's in the cast or not, you then get another x-ray before that. The most important thing that we should not forget is examination of the limb should be repeated after any manipulation or application for spent because we can very easily damage the neurovascular structures whilst moving it. Ok. So the next thing that we're going to do is what, what do we think now that we've managed the patient in a, what is our next step? You've done everything right now as per the world guidelines, you stabilized the patient, antibiotics, tetanus, clinical photographs. Ct Angio. We realign the limb. Um We give it a small wash, we put this yellow in salt gauze and we've splinted it. What is the next step? Now, in terms of management of this patient, it is 2 a.m. Um you're on call. What do you do? Do you take this patient to theaters? Um OK. So bak he says secondary survey and admits obviously absolutely correct. Secondary survey w we're done with it. We're happy we have an isolated injury. Diana is called the specialist. You're the specialist in this situation. You're the orthopedic surgeon, you're the one making the, the, the incisions. So what would you like to do? A&E are asking you? We've managed everything so far. Um What is your plan? What would you like to do? You're going to admit the patient tan. Um We've already given all the antibiotics. What is the next step in managing this patient? You have admitted the patient, you're presenting the patient in the morning, arrange for orthopedics, you're orthopedics, you are the orthopedic surgeon. So the question that I want to know here, um what is the next step in the management of this patient? Are you going to? Ok. So tho says, admit the bride and wash up in theater? Absolutely correct. So this is the correct answer now that you've done your basic management. The next step that the bo guidelines talks about is debridement. This is the most important part and debridement is very important in the setting of open fractures because you want to reduce the risk of infection. Um Yeah, debridement and wash are absolutely correct. So this is the correct answer. Now, after we've done everything, the both guideline says, the next step that you need to do is the right the fracture. Um And obviously we mentioned that and as per the most guidelines, we want to manage this patient in a trauma center where there's orthopedics and plastics. And that's because once we want to plan for the fixation and coverage, um we want the this management decision to be done by consultants in both orthopedics and plastics. So, um we've all agreed now that we want to write this patient, we want to take them to theaters. The question that I have for you all is when do you want to debri this patient? This you have this clinical picture, you have this open fracture. Like I said, it's 2 a.m. in the morning. Um You need to make a decision. When should you debride and take this patient to theaters? Are you going to take this patient to theaters at 2 a.m. Are you going to admit them and keep them the next day? If you are going to keep them the next day, when would you like to take this patient to theaters? Are you going to wait until the end of the list? Are you going to take them? Um First on the list, is there a specific duration from the time of the injury? Um And are there any specific factors in the mechanism of injury that you want to consider when taking patients to uh uh theaters? So, um Ahmed Ead says during the golden hour, um so the golden hour is only for resuscitating the patient from life threating threatening injuries. It's not necessarily pertaining to the open fracture. So Diana says it is an emergency. So I says, let's do it right away. Uh Sultan says first on the list in the morning. Ok. Um Han says when there's no blood flow or severe nerve damage, fine, um less than six hours from the time of the injury. Ok. Fine. Yu says next available emergency theater and whether there is neurovascular compromise or not, Patrick uh depends on wound contaminant. So it's absolutely correct. So that's that is very important, Patrick. You're absolutely correct. And, and the these are the factors that I'm saying that are very important when you're taking history from the patient or from the ambulance. You want to know, where did this open fracture happen? Is there any contaminant um that you may want to take patient to theaters immediately or can you wait? So, going back to this uh slide, um this is this is the question that I'm trying to pose. Um Do you take the patient immediately? Is it within 12 hours from the onset of presentation or the injury or do you want to wait um uh within the day from the time of the injury? And these are the different options that we have over here. Is it you want to ask yourself, has there been a heavy contamination of the wound agricultural? Is there sewage involvement? Is there a vascular compromise? Like most of you said, is there compartment syndrome, arterial disruption? Is this a low injury open fracture? Is it an isolated high injury open fracture? So these are the questions that you need to ask yourself when you are in A&E and as the orthopedic surgeon will call, so that once you actually make a decision, you're making it based on actual evidence and guidelines. So based on this slide, um where would you put the immediate with? Is it the first box on top? The second box, low energy or the third box, high contaminated ones? So immediately, is it number one, number two or number three, if I can just have answers to see what people think? Actually, let me see if I can uh I don't think I can create a pool. So dialysis first uh T says third box. Abu says third as well uh for highly contaminated wounds. Uh Bak says third. OK. So um yours are correct. It is it is uh the third box. So immediately as soon as the patient presents, if they have a mechanism of injury that involves any sort of contaminated wound, like we said, agricultural, aquatic sewage, or if there's any compromise to the vascular uh such as compartment syndrome or disruption to the um um uh blood flow that leads to ischemia, then you want to take the patient immediately at 2 a.m. You're not going to wait until the next morning, you're going to call your your boss immediately. Um inform theaters and prepare the patient to theaters to first immediately. Um Now within 12 hours, when do you think you can wait to manage this patient in the, within 12 hours? Is it going to be number one or is it going to be number two? So my mother says number one for the 12 hours, Abanto says 12 hours. First Tulo says first wax is first, is six, is first, correct. So within 12 hours, if you have an isolated high energy open fracture, you're gonna go ahead with performing the surgery within 12 hours from the onset of the injury. You're not going to wait any longer than that because the risk of infection is much higher. If you wait and this leaves us with the uh 24 hours, you can wait to manage the patient within 24 hours from the onset of the injury if it is a low injury, open fracture. So the mechanism is not a significant one. It's a low energy. So you can wait within 12 within 2024 hours in order to manage these patients. And this is what we have over here and this is what you guys have already um correctly answered. So, immediately showing the red arrow is the highly contaminated wounds or if there is a vascular compromise leading to compartment syndrome or ischemia. Um within 12 hours, I think this is um uh all over around. So it's incorrect. This, so the purple one should be pointing towards the solidary high energy one like you guys have mentioned. So this is incorrect and the 24 hours should be pointing towards the low energy open fractures. I don't know if I can change it now, but let me see. So over here and 24 hours should go over here and I hope that this is this this showing correct for you guys now. Uh Yes or no. Is it showing that it has been fixed? Wonderful. Yeah. So that is the correct um, way of managing and deciding when to take patients to theaters as for those guidelines immediately post contamination with 12 hours if it's high energy 24 hours, if it's low energy open fractures. So you have taken the patient to theaters. Um, the, the most guidelines that says once the debridement is complete and you've done the wash out and the cleaning of this fracture, then anything else that you're going to do after it? Even if it's in the same setting, this is considered now as a clean surgery, you need fresh instruments, you need to reprep and drape as a surgeon, you need to discard your gown, wearing new gowns, rescrub all over again. So that it's considered a complete clean surgery because you don't want any contamination that was present during the and the washout to be transferred. Now to the next step of your surgery, whether it's like plastics for coverage or by orthopedics for fixation. So both guidelines then says if you're going to do definite soft tissue closure or coverage, they should be within 72 hours of the injury. Um if it cannot be performed at the time of the debridement, and there are so many instances where um you cannot do uh a soft tis coverage by the Classics teams at the time of the debridement. In this case, it's OK for you to go back after or within three days from the time of the injury. And this is according to the conference. Um We also say that the definitive internal stabilization or fixation of the fracture should only be carried out when it can be immediately followed with definite soft tissue coverage. And that's because you don't want your fixation to dis disrupt the soft tissue coverage. The last thing you want to do is that um you perform a fixation but you cannot cover it or even sometimes you don't want to perform coverage of the soft tissue um without arranging with the orthopedic team where they're going to perform their fixation. There have been instances that I've actually seen plastic team performed coverage of the open wound. Um But then later on, they find out that this area of coverage is actually the area that the orthopedic surgeons want to operate on to perform their fixation and this changes everything. And that's why we say the management and final definite management, whether it is the soft tissue um coverage or whether it's the internal fixation, it should be done in coordination between the plastic team and the orthopedic team so that they avoid any confusion. And ultimately, we provide the best care for the patient. And I think that's pretty much it from my talk to be honest. Um We, we have touched upon what is the definition of open fracture. Like we said, it doesn't matter how big or small the wound is, a breach in the skin is a breach that's immediately defined as an open fracture. Um We've also then um touched a little bit about um how you approach it a principles and multiple guidelines. Uh We've spoken about the importance of the golden hour uh the early phase and also the, the, the um delayed phase, secondary phase in terms of the uh management and depth of these patients. Um We've also mentioned very briefly the principles of a TLS, the primary survey, secondary survey and I have tried to break down the guidelines as much as I could and we very briefly just um go over the headings. Once again, we've spoken about where you should manage these patients in a special center, how you would examine them and when you need to reexamine uh what you need to administer in this instance, antibiotics and tetanus, any further imaging, such as CT angiography, so that you can assess the vas structures. And then we talk about the the importance of getting a clinical photograph of the uh open fracture. How would you manage the patient in A&E in terms of removing the ross contamination? Saline salt gauze adhesive, occlusive film and splinting the uh the, the uh open fracture then comes the um um role of debridement. You need both plastics and orthopedic consultants to discuss this together to avoid any problems. We spoke about what do you do in A&E and how you make a decision about when you take the patient to theater. And this all comes down to the mechanism of the injury and where it happened, like we said, um and, and, and finally, we've mentioned that the, the um surgery should be regarded clean after the debridement. If you can't do soft tissue coverage at the time of debridement, you can come back within three days of the injury. And we should also um discuss with the plastics once we want to do internal stabilization so that um it can be done concurrently with the soft tissue coverage and that's pretty much it. Um from my side. Are there any questions that great? So, thank you, Khaled. Thank you so much for this uh explan and very interactive session. Uh If you have any questions, can you please put them in the chart so we can uh get currently to answer them. Uh You know, any questions on any part of the presentation? I have a question but I need, I need uh everyone else to ask their questions. First. So tho has a question. Uh He said, she says, does the management change when the fracture is an open Pericos fracture? Not at all. No, an open fracture. Irrespective of the, the location of the fracture. Whether it's upper limb, lower limb, if there is metal work or not, will all be the same. You follow the same guidelines and the same principles and you cannot go along with it. Uh Right now, there's a feedback form after the presentation immediately after the presentation, uh you get feedback forms uh in your email. Uh And then you get a certificate afterward. Uh Do we have more questions, please? We still have some time. So says, how's the uh cost Anderson staging for open fracture factored into the management? Um So this, so, first of all, the Costella Anderson classification is intraoperative classification. We need to assess the soft tissue and it's not something that you can um decide on when you're in A&E and you see the fracture or you see the wound, the, the size of the wound doesn't matter. It's mainly the soft tissue that you can only assess on your intraoperatively. Um And, and the way that, that it's factored in the management is mainly um related to plastics because they, they can decide the best way uh with respect to soft tissue coverage and if they need to get any labs um and whatnot. So it doesn't, it's not a major um um issue for us as, as orthopedic surgeons in terms of fixation. Um We need to consider it obviously because it will impact how the plastic surgeons will manage it. Um But it's mainly important for, for, for the plastic surgeons. And for us, it tells us the magnitude of the um magnitude of the injury really more than anything. Um Han, I think she mentioned the question about bleeding um in, in, in what sense do you mean um a um intraoperatively? Um If, if there is active bleeding in a and then obviously we need to um provide pressure to it to stop the bleeding as much as possible. And you need to actually uh um find out where this bleeding is coming from. Is it an arterial bleed that that requires vascular surgeons to be involved? Does the patient need um um uh transfusion? Um So it's, it's very dependent on the bleeding itself. 10 thesaurus. Ok. Uh Are there any more questions or are there any things you need some clarity on? Um Yeah. Does the guideline advise block to the uh to be done uh first like block uh prior to fracture reduction in open fractures? No, no, you don't give blocks in open fractures. And actually, for the matter, you don't give blocks for long bone fractures. The reason being is if you give a block to a limb that has either a long bone fracture or an open fracture, then you're not going to be able to appropriately assess for pain, which is the biggest um sign for compartment syndrome. So, there have been situations where people get blocks um for the lower limbs, whether it's a long bone fracture or an open fracture. Um And because the block has helped with the pain significantly, they actually go into Compartment syndrome without us knowing and the patients either lose their limb or have lifelong um injury because of the compartment syndrome. Um in terms of wound dressings, following vi debridement, um negative pressure wound therapy have been in outcome compared to other common absorbing dressings. Uh That's actually a very good question and I think it depends on the, the uh size of the wound. It depends if there's an ongoing infection. If there's an ongoing risk. Generally speaking, we don't use negative pressure dressing um initially after a en or soft tissue coverage, um we only use it if there are concerns that there is a significant amount of fluid or infection that requires the neck pressure to allow for the wound healing. Um But these, these are sometimes used by the plastic surgeons just for um to allow the, the, the soft tissue coverage or the plaque to recover, but it's not routinely used any other questions. Uh Diana asking a question, what literature do you recommend to a physician to follow the er trauma? Um uh in terms of literature, I'm I'm not sure of actual published studies. I'm sure there are lots. But the most important ones that are very helpful and ones that I use in my day to day practice is, is the both sidelines, especially in the second Phoenix. And they have those guidelines for almost um majority of the fractures or fractures, supracondylar, the radius. Um, and whatnot, but specifically for um, uh management of emergency trauma other than orthopedics, I am not sure. But for orthopedics, those guidelines are running fast. Um I'll just write down so for orthopedist check. So this is it for, for orthopedics use the post guidelines. They have um the guidelines for the fractures. Yeah. Are there any more questions? Uh Anything you need clarity about uh regarding the presentations uh while we're waiting Khali. Uh My question is uh when would you do a delayed primary uh as opposed to a primary imaging amputation uh for open fractures? Why uh in what situations would you rather do it in three days or 72 hours as, as compared to, you know, get it done? Um ASAP. So you never, you, you would never do um an amputation legal unless the limb is literally holding off by a few threads. That's probably the only situation that I can think of of there or if there's severe ischemia in orthopedics, we don't, you know, um um I've never seen um patients with trauma where they come and do uh where we do amputations for them. But if I can think from the top of my head. Um You would do it if there is, if, if the limb is literally holding by a few fibers or soft tissues and there's literally no more uh tangible um soft tissue to hold it. Or if there's severe limb ischemia for very prolonged hours that you cannot reconstruct the vessels and that's where you would do it. Um Otherwise it's highly unlikely that you would do an amputation. Um Unless the leg is almost amputated coming in. OK. Cool. Any other questions? Any other questions, guys, we still have a couple of minutes to go. Mhm So as soon as the the teaching session is over, you get um everyone gets a um feedback, email um just fill out the survey uh feedback on the presentation and then you get a certificate of attendance uh in your email and also in your middle account, you get a certificate uh there uh just one final call any more, any other questions? Uh So we want to thank uh Khali Diagno for this fantastic uh very, very uh instructive uh presentation on open fractures. We are very grateful for this um exciting session you've put out. Um there will be feedback uh from everyone. Uh I'm sure you can access the feedback colleague. Uh And then there's a certificate for each uh at each participant. Uh Thank you all for joining in uh for those who didn't join. Uh Le Khali is an ST four in the P four rotation in London. Uh Thank you all once again and we will close the session very, very soon. Thank you, con Thank you, everyone. Thank you, Greg. Thank you, everyone. I hope you guys uh found this informative.