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Just, just one, just bear with me for a second. I guess it's so meanwhile, we can introduce ourselves. Sorry, I didn't want you to join, but maybe we can use that time to introduce our network. Um Hello, everyone by the, well, just uh just want to say welcome to everyone. We're so happy that we, you, you're joining to our teaching session today. So, um we have a new network which is um UK newcomer doctor's network in meal. So a couple of months ago, we said we just set up this um set up this network to help everyone who wants to come to the UK or who has just joined to the UK. The main reason we decided to do this um do this uh network is actually when we first moved to the UK, we, we just um felt like um we just felt like we don't know the system at all. So we were having so many issues about it, like um feeling like feeling lost well, in, in our first months in the UK. So after that, we decided to, after a couple of months, we learned about the system more and we decided to have to do other doctors was just joined to do NHS. Because even if you have a great medical knowledge, I know, like most of us have that medical knowledge. It's so difficult to understand the system of the NHS because most of the time it's so different from the system that we used to have, have back in our country. So, um, so that's why we decided to um have this, we decided to have this um network. So today we're going to talk about the TNL on calls, like the emergencies that you can have uh in the emergency department while you're working in an emergency department or while you're working as an sho because it's not only the only, only while you are working in the emergency department also, like while you are working in any board, any medical boards, for example, you might have a patient who has a fall in the board. So then you need to have a bit of knowledge of trauma and orthopedics before calling it trauma. So today, um Doctor Gen and also Doctor Arri um Carlos, they're gonna talk about the uh emergencies that you might have that you might um come across in NHS and also in, in any department you working at. So, um thank you for joining us today. Thank you a general and thank you, you Carlos as well. So I'm gonna give uh stage Carlos and they say to you goodbye, sorry for keeping you, um, for, for a couple of minutes and everything must be, I think ready now. Ok, thank you. Sorry for the uh, a small confusion I had, um, I had left the wrong flight for starting from a previous presentation. Uh, so as, uh Yasim, uh, kindly introduce me. Uh, my, my name is Carlos, uh, uh a if you would like to introduce yourself or if you prefer, uh, we can go directly into the presentation. Hi, everyone. My name is, I'm one of the orthopedic registers at Saint George's Hospital. And let's hope that we all enjoy the session. Ok. So, um we have to sign this, this session as uh a few different cases. The idea is that we're going to start with uh each case as these patients will present into ed or as these cases uh could be referred to you as doctor. So we're gonna start with uh a small amount of information uh with a, with an X ray in the case that it's needed. And then we will progress. Uh We will ask you what things you would like to know about this patient, what things uh would you want to look into blood analysis, uh further tests and uh just let us know what you think uh you would want in a, with a, a referral like this and then we will progress into it uh and learn a little bit as we go. So the first referral uh we would find is, um, a 68 year old male, uh, is presenting to Ed with a four day history of knee pain that's been worsening. Uh, has a past medical history of diabetes, rheumatoid arthritis and hypertension. Uh, the thing, the only thing you know is that this patient reports Ed that he's unable to weight bear, the knee is swollen and it's painful. Uh, all seem normal. Uh, and you have an X ray um in a patient like this. Um What other things are? Um What other things would you be interested to know? What things would you be asking this patient? So if you can type in the chart, uh things you would like to know and please feel free to unmute yourselves as well. Sorry, I said they can unmute themselves as well if they want to see. Yes. If you want to do to unmute yourself and, and speak, we can do that too. Oh, no, it's uh we cannot do that. Sorry, osteoarthritis. Do they have fever, fever redness of, of the knee? Those are very important things for you to know is the first things you're going to be looking into when you go and see that patient and look into that patient's knee. But I still want to say what is the most important thing on examination? Espe, especially when you think about it. Someone said trauma, septic arthritis, range of motion. Exactly. What when you say range of motion can you make it a bit more specific for me? What type of range of motion and why Aly Bale decreased range of motion is quite expected when you look at this X ray because clearly this person already have an extreme uh osteoarthritis of the knee. So I expect this person to have decreased range of motion and pain, which would be natural. But for me, most important thing is as an on call registrar is, does this patient have an active range of motion? And uh I'll leave it to Carlos and he will explain to you why and with the rest of the findings. So, in this patient, uh we go see them, this patient is denying any trauma. He's denying any history of recent illness. But he's saying he's feeling unwell since yesterday. He has rheumatoid arthritis that affects his knees and his hands and he's on methotrexate and the nsaids for flares. But now it's more painful than usual. His knee is red, it's hard, it's swollen, it's painful to touch. It is getting extension and he does not tolerate any flexion. Uh You can see this image of the knee. Uh His blood hemoglobin is normal white cell count is slightly raised, neutrophils are raised and he has a raised CRP in a case like this. Uh What would you suggest? Uh What would you suspect as your differential diagnosis? So, we're gonna have a, a poll if you could answer that poll, we can check, uh what most of the people think can see the pole. Can, can everyone see, see the pole? Ok. We have 66 answers now and it seems most people are, uh quite uh suspicious of the possibility of septic arthritis. Um, a couple of people suspecting it could be gout, it could be rheumatoid arthritis. Um, general. What would you think, uh, if a patient like this presented to you? Well, I have to think as a, when you're on call and like as a register, I think it depends on where you are as an as a too, you have to think about what would, what would kill the patient and what would, you know, make the patient lose the limb and in this case, we don't want him to have septic arthritis. Anything else can be dealt in a later fashion, right? Or slow fashion. The reason why we don't want anyone to have septic arthritis, although this patient has severe osteoarthritis is, but when you think about even especially in younger patients, it would eat out the joint, right? So the patient's joint will be terrible afterwards. So you need to and it will make them very, very septic and ill. So the thing is there is a four days history of pain. So that makes me think about look mm, four days doesn't really sound like septic arthritis in the sense that it would usually hit you very hard and it should be shorter, but it's still with this red hot, swollen, um painful touch. You know, I think um patient toler doesn't tolerate flexion or extension depends on at the range of motion for me. Um Also we need to know about um kidney functions. Sometimes those um param those patients can have different, you know, blood results as well. But again, um as this is not, I don't want to give away further information, but when I looked at the previous x-ray, I know that this is a native joint. So um and the pictures can be faulty if the patient doesn't have an active range of motion. Uh that means this is septic arthritis are proven otherwise. Um fever wise II, the I know the news wasn't showing me that but like do we know if the, if the patient has fevers at home? Uh No, in the, in this case, this patient was denying any, any presence of fever and one did not also show a temperature. I mean, he has, he has high C RP, right? That w does increase your rate is possibly normal here, right? 240 is not that high. So that would take me away from um gout or rheumatoid flare up. Yes, it could be something else like, I don't know, septic bursitis, blah, blah, blah, like infected bursitis. Sorry. But again, the only way for me to take uh rule out is this is a septic arthritis. If the patient doesn't have an active range of motion until proven otherwise. So the question is, how do we rule out? So I think in a, in a patient like this, uh there's um another thing too that, that we could do uh if anyone, OK, someone has answered, we, we could do uh seno fluid culture. So I think that that would be the, that, that would be the thing that could confirm what, what does it mean? Yes, throw aspiration. That's what I was trying to get to. So call us, you're, you're doing orthopedics, tell us how you do um a joint aspiration. So, joint aspiration, um of course, you need to change techniques depending on the joint, you're, you're going for uh the most common you might, you may do is the is the knee and in the case of the knee, um you might want to do it. Uh You might want to flex the knee a little bit, but in this case, this patient is having a lot of pain so we can do it with the knee straight. We can do either from uh above the patella suprapatellar or infra infrapatellar and we go from a little bit on the side. So um the technique I use is uh two fingers from the patella on one side and down, you can insert your needle and then aspirate as you go. Mm It's not the best technique, but so far I understand what you mean. But like if anyone is sitting for, I don't know, co surgical training or any sort of, the more exam answers would be like, oh, I would get the verbal consent from the patient from patient's name side. I'm just saying, just saying this is a teaching session and you, you, you have a septic technique and your m landmark is for me, the easiest is superior pole of the patella. You don't want to go underneath the patella, it's very painful. So that should be more than enough. So you palpate the patella after like you initially palpate, then you know, get the septic technique, clean, clean, clean. Um and then you feel the patellar pole and then just uh you in, you introduce your needle. Obviously, you need to consent the patient that it could be triab, you know, pain, bleeding, infection, all, all sorts of stuff. Then the what is the next step? Once you obtain your sample, the most important stuff medic legally, especially. So I out of hours when you think about it, anyone with an ultrasound is not really needed. As you see, this is very swollen anyways. Um if it's like if it's an ankle joint, which I had to aspirate a few times, then like sometimes it's not as easy and you might need ultrasound, guided aspirations in those ones like shoulder ankle, but knee is quite straightforward after the aspiration. What's the most critical thing to do medical legally as well? Out of hours especially anyone you took the sample. What are you going to do with it? Of course, send the label for uh for analysis and culture to look into the cells, into the, into the uh look into the cells, look into the crystals and see if there's anything on gram stain. So, microculture sensitivity uh and crystals. Yes. But medical legally, you have to make sure that the micro technician is aware. So there, there are technicians on call in the NHS. So you need to make sure that you or your sho someone is contacting from your team that you have sent this sample. And what they need to give you as soon as possible is the ground stain. Because if there is no gram saying, you know, positivity or anything, um then you can relax that not a septic arthritis, but if it's gram positive or something, then that means this patient will need washout as early as possible. How, what's your approach to? Um let's get this patient is still in A&E Carlos, let's say. And people um we took the Yes, we took the culture and sent the and this patient is using zero still in A&E. We are waiting for the culture results. What to do next in A&E. So um it's, let's say 4 a.m. Um I would admit this patient. Um I would, I would look into the rest of his blood work. Um Optimize this patient for surgery. If anything needs to be done. Um I would discuss with the patient that they might go for surgery uh, in the morning, start the, uh, keep the patient near by mouth, uh, maybe start some, um IV hydration if needed. And definitely I would uh the area and mark the limb that's affected, mark the erythematous area very specifically to see. Um, what would be more concerning? Obviously, this is like the redness is staying stable, but let's say someone who's very, very unwell, you know, but rapid progression of the redness in front of you. What would be the nightmare station like? Uh what, what would be the worst case, let's say I'll be drug abuser. It's not the knee but it's by, by redness swelling. I'm a bit out of topic right now. But would you be, would you be concerned that this is uh um and necro fasciitis overly overlying the? Yeah. So I mean, I don't want to confuse you guys, don't get me wrong. So this is this is a septic arthritis knee, right? We are talking about, but I always want you to think broadly. So not all red swollen joint is septic arthritis, but also it could be something terrible as like, you know, neck rash or it could be as as benign like cellulitis. It's a broad spectrum. So you need to be thinking of all of it like and see the whole big picture basically, that's what I try to get because it could. Most of them are actually just overlying cellulitis as well. Not all of them are septic joints, but it is threshold is quite low anyway. So anyone with swollen knee painful knee, they, they refer it, oh, is it septic arthritis without not checking the range of motion or taking the full history in that sense? It, as a few general concepts on, on septic arthritis, uh, especially on the knee. Just keep in mind, it presents like a hot, swollen and acutely painful joint with restricted active and passive movement. The patients tend to keep that extremity in the position of most volume for the joint. So it tends to be extended with a slight amount of flexion and in the case of the hip is the faber position. So um e each septic joint tends to adopt a specific uh position of least pain. The symptoms of infection can range quite a bit. You can have patients that present uh without any fever or that present a slightly unwell or they might present septic. Um The most common joint is the knee but other large joints uh can have septic arthritis and any joint can have it. Indeed. Um IV drug use predisposes quite a bit, especially on the sternoclavicular and psycho IAC joints. Um It is much more common in people who have already problems in joint like rheumatoid arthritis or gout or that they are immunocompromised or elderly. This can also be even more increased if these people are getting things like steroid injections into the knee that this can bring those germs inside. There's a high risk if any patient has had a, any history of bacteremia in the past, in the recent past, or if there has been trauma or invasive procedures to, to the joint and the risk in prosthetic joints is much higher. The investigations you would want in a, in a patient like this. Uh, you will be looking into the white cell count into their C RP into the synovial fluid. You would be looking for a cloudy or pouring fluid with a low viscosity. There's a thing called the string sign, which is that when you pour uh the synovial fluid from a syringe, it doesn't form a string. It, it's much less viscous that what the normal um synovial fluid is. You're going to analyze this for white cell count for glucose B cell analysis and the gram stain and always suspect if you're in a, in a patient with a prosthetic joint that's presenting with uh an a an acute uh painful joint. Um In the, in regards of the management, if you have a patient that is stable, if you don't have active concerns. Uh for this, the wellbeing of this patient, you can postpone the administration of antibiotics until after you have obtained uh synovial fluid samples. This will help a lot in determining which uh agent is causing this infection. And that may be uh quite a key piece of information to manage this joint effectively. Um In ed do not aspirate prosthetic joints. That is, that is a, that is a big no, do not do that. This will be done in theaters. Um The IV antibiotics are going to be empiric in initially following your micro guides, but you need to be aware of the risk of these being M sra and if you're concerned about the patient, uh having septic arthritis admit them optimized for surgery, they may have a wash out in the morning and the debridement and they may have long term antibiotics. So, um generally, I would want to ask you. Um, so we have talked that uh acetic joint changes quite a bit if there's a, if there's a prosthetic joint inside, um could you tell us a little bit about how you approach uh when you have a case that involves a prosthetic joint and that joint is painful? Yeah, of course. So I was talking about the, so basically, there are a few things. Um I would think about a patient who has just say this one is TKR, right? Um I need to know when did this patient have this for? How long in the history? I need to know um how long this history goes back to like? Is this pain? Is it something that started new? Does the patient also feeling unwell as well or is it something like? Oh, I had it years ago and I've been suffering with this for the past two years. So joint replacement cases uh with unsatisfied needs can have mu multiple things. Um When I see them, um let's say this case has an infective background, but like even without the infection or any painful knee, you need to rule out a sep. So basically, you need to rule out septic loosening. This is a bit advanced. I uh I don't want to confuse like, I don't know the our audience's background. But basically, um I don't know if you can see my um uh if you can show the tibias um com tibial component um size like more proximally, especially that's the ce cement but that, but yeah, so you look at you, you look around your um components to see if there is any loosening because that will cause pain. Um So, and then you look, so you ask yourself is the co is this joint replacement? The components are they loose or not? And then the thing you need to rule out is infection, infection, infection. Let's say someone came with this, that knee but not the native joint, but with this TKR uh underneath, there is something that we won't do. Does anyone know what that is like in terms of um management? I still want to examine him. Like does the patient have active range of motion, passive range of motion, tenderness? All those like ops wise, blood wise and so on. Um But what am I not going to do in A&E that we did with the native joint? Anyone feel free to, you know, there's no rights or wrongs. It's a safe space. If not, I'll sacrifice Carlos. Don't worry. So, II think what, um general is pointing at and I think if I did, I would get shouted, uh, quite a bit or maybe even worse is, uh, get a sample of synovial fluid from a prosthetic joint. That is, that is a, that is a big, no, you do not do that outside of theaters. Yeah, exactly. So you won't do an aspiration in A&E in the, in, in the not joint basically. So, and then the second thing we are going to do differently is um let's say this patient is not septic C RP of 96 white cell is 17. What patient is clinically well? Um And it's like four ami don't know 2 a.m. What are you not going to do? So, I, if the patient is clinically well, and I am not actively concerned because they're not, they're not septic. Uh I would not start antibiotics and I will also not wake up uh my consultant for this. I don't know if that's what you were asking, but II wouldn't do any of those things. I, the reason for awaiting for starting the antibiotics is if you start antibiotics, you're gonna sterilize the samples you're gonna be taking in the future and not knowing what bacteria is there or not having a, a clear confirmation that there was a bacteria uh can, can hinder quite a bit on, on the treatment. So two, like, like we said, so the first thing is never aspirate uh a prosthetic joint in A&E that's orthopedics drop in theater under sterile conditions and to get sterile samples because what you don't want is to infect, not infected. You know what I mean, prosthesis. So never ever do that. That's why you always have to get an X ray before you stick a needle be you know, to into any joint. That's one thing, the other thing is Carlos is right. Um There is a bit controversial but again, the I think overall agreement is if the patient is clinically well, let's say C RP of 96 white cell is 50 17, whatever and the patient is using zero but in pain. So you give pain relief, you definitely take blood culture and send it to from A&E like when they arrive in both patients. Uh but you don't start antibiotics right away because um arthroplasty consultants will not like you if you do that. If someone is septic, however, like clinically septic patient or you know, tachycardic, hypotensive fever, blah, blah, blah, then you can give um a dose of antibiotics and see how they're if they're responding or not. If they're still not set. Settling. This is for I think any patient by the way, but, uh, you need to, obviously, this is a bit more senior level decision. Um Is there any, I don't think that there is, there, there are no registrars in this group. So all sho levels. So that's not a decision, you know, to, for you to make. Um, but native joint or not native joint, anyone can do a simple washout or even if it's overnight. So if patient is getting more and well and well and well and well, you might need to take them overnight. But that's again your job. If you're on call and alone on site, making sure that there are no by mouth for the next morning, um assess their situation, you know, do your crisp protocols, assess patient and do follow your sepsis six, but don't give antibiotics if they are not septic. Um And, and if someone is obviously on mild tachycardic and so on, even though arthroplasty consultants don't like it because they, they are worried that this will affect their aspiration results. You have to make sure that patient is not dying. Life is above limits in that sense. So you need to give that. And obviously, if you have, you know, if you have your seniors that again, you can ask them as well. Um That's how I would approach that. And in cases where uh a patient might present where they already have a history of gout in the joint or you have a already have a history of rheumatoid arthritis. Uh So you think that that joint being swollen and or being red can, can be just uh the normal preexisting condition for, for this patient. Uh What are things that help you decide between suspecting septic arthritis or uh being a bit more confident that it may not be well, if it's more repetitive uh pattern. So some patients come to come and tell you like, oh this, this, you know, happened like last month as well and my knee is swollen again. It's not just rheumatoid arthritis by the way, or gout, it could be just simple, uh osteoarthritis, swelling up, uh uh causing pain and swelling to the joint as well. And the problem is sometimes in elderly patients who are on anticoagulation because they don't only swell up, they also bleed as well. And then what you're going to do becomes a huge issue. Usually it depends on the. So again, you go back to zero and then you assess each patient differently. You take proper history, you examine them. The most important thing for me is um, skin might not be red in septic joints, don't forget that. So, not all septic joints will be red, not all red red, knees will be septic arthritis as well. So, no, no panicking, but like active range of motion is very important for me. If someone is not active in the moment, then I'll be more, much more concerned. But my So you, you usually won't have the rate you won't have E sr or blood cultures, any of those in real life because the ed, like when they come, they just send the generic bloods. Um So until you get to them, oh, you know, you can't wait for that, you can check lactate to see what's, you know, you try to find that you, you, you basically assess them as a whole and each patient is different in any, any, any concern. Obviously, my threshold to aspirate the joint is low because like I said, the worst case scenario, um I'll aspirate it after consenting the patient telling them that look, I might give you an infection. Are you happy to take this risk? Risk? Um and so on and so on. Sometimes if it's a daytime, you can do ultrasound plus minus aspiration if you are lucky enough. Uh because that's a bit more so like, you know, they, they can tell if it's like more blood or just sign of fluid and depends on their, their suspicion, they can aspirate as well. The radiologist, mostly these cases that that won't happen. So it's always overnight be cases. Um I think um what would be the worst case scenario, what, what's worse, missing aseptic arthritis or doing an a aspiration and it's being negative, obviously missing as septic arthritis. So, um m most of the time, like I said, they are not septic arthritis, um especially if they have the range of motion. But again, um, you just assess each and every patient, you know, separately from the beginning. You also, most of the time patients don't even give painkillers. You'd be so surprised. My II give non steroids. Well, if they can take nonsteroids, I don't kill it with morphine. I give paracetamol and Ibuprofen or naproxen to see how they are going to respond. And you, we see them in, in an hour and they are like f in and standing like, you know, like they're ready to run. So all these tiny things matter, I think. So we're gonna move on to, on to the next uh case. So uh the next, this next case would be same situation as before you're getting a referral. Uh This uh nine year old girl, uh patients report, uh parents report she's feeling well. She has been complaining for a few days of pain on the lateral aspect of the ankle. Uh pain is fluctuating between quite subtle and very severe. Mom says she got hit in that side with people playing some sports. What other things would you want to know about this child? Uh What other things would you want to look into or ask the parents? This is in the chat guys. So please try to be as active as possible. Uh This is a patient I've seen in clinic to be honest and um na I Yes, good, good, good defense. You, what else? For anyone not aware. Na I is non accidental injury. We would be talking about any uh either self inflicted injury or anything that could come from um lack of care from the parents or from active harm from them. So that would be all fall under non accidental injuries. N A. You don't have to give me differentials right away. You might wanna ask questions as well. Good. So I don't know if I'm saying your name correct? But so fever at the range of motion, inflammation markers. Very good. So no bloods were done. Um And when I saw this child, I asked about those things like how has she been any fever recently? And mom was saying that she actually has been spiking temperature for the past 23 days. But this is because she was soaked under, under the rain. The blood came later on. Um And uh and she was like, oh no, the uh she was spiking temperature because she was soaked under the rain. It's just like common cold. That's so normal. I'm giving her paracetamol and so on. So that's what she said. Um what else? Like what do you, what else do you want to ask mother or what, what are your differentials? Like when you look at the X ray especially, we're gonna, we're gonna send a, a pole. You can, you can click what you think could be the, what you're most suspected on sus suspecting on. So we have 60% of people suspecting of fracture. 40% of people suspecting of a stimulis and uh 11 benign lesion and a few people also suspecting of non accidental injury. So overall 50% spreading of fracture. Ok. Um I want to say whoever like, you know, 50% of the people can, they come and tell us why they think it's fracture oritis people lesion, people, non extent of people, 11 people each like, can you tell us why did you think that? So we can have a discussion around the topic? So if you want initially, when I, when I saw this X ray, I was concerned about uh and II was concerned about the fracture because it says it to my opinion, it was slightly abnormal around this area. So that made me think about the possibility of a fracture a a slightly um like an almost an undisplaced fracture. Mhm. And osteomyelitis people, non dental injury, people, lesion people, I want to hear vision people if possible, don't feel so by the way, um this patient initially, um so this was a very active girl. Um This girl is very active like gymnast, all sorts of activities and she was um up in North somewhere presented to A&E for with the ankle pain and they did the X ray, they said no fracture or anything. So they discharged her home. Mum was told to give uh Paracetamol Ibuprofen and then she came to red and mom was saying that, oh, she also plays hockey, someone hit her, you know, ankle from the side, like from lateral side. Um maybe that's it. And um then a consultant, radiologist reported as a fracture in the fibula. Um And then she was referred to us as via um B FCV Virtual Fracture Clinic and then came to our fracture clinic and then I saw her and then she was spiking temperature. Um and uh there was no blood as well. So I think a leash, a leash, right? So don't confuse the fractures with the growth plates, that's completely normal. If you're not familiar with the pediatric fracture, uh pediatric x-rays. And uh I can see why you guys are thinking um there might be a fracture in the, in the growth plate near glo growth plate in the, in the distal like tibia. Um But I'm, I was, when I first looked at the xi was like, oh, there is a lucency at the distal fibula near the growth plate. If you can show it to them, Carlos, do you see the this area here? Yeah, this is before seeing the patient, right? So I'm going through what the A&E people wrote and so on and then I look at the X ray and then I look at the report, but the don't forget that radiologists are also just informed as much as what A&E people tell them which is oh hit by hooky stick and so on and so on. So they, that's, that was reported as, as a fracture as well, but there was a lucency. So I was like when I, whenever so, so whenever you see a child related to orthopedics, you always need to think about four things, tumor trauma infection. Na I if you rule out these four things and you know, in a broad spectrum, let's say again, tumor trauma infection, na I an infection has two important things. One is septic arthritis, the other one is Osteomyelitis because these needs admissions and then they might have uh transit sinusitis, which is fine, like you can send home with reassurance and follow up in the clinic later on. Um but again, that's an, these are other topics. But again, in your head, always, always, always tumor trauma, infection, N A tumor trauma infection, na I and you're seeing a lucency. So I'm more con now concerned about possible malignancy because any like kind of LNC are a bit like you need to make sure that this is not a malignancy. And the other thing is, is could it be Osteomyelitis because lucencies and like basically malignancies in Osteomyelitis mimics itself, like mimics each other quite similarly on x rays. So then you see the patient and I saw the patient basically started asking these questions. Patient had active range of motion in the ankle, but had this pain, blah, blah, blah, mom was mom was trying to be more on the side of like, she was more focused on the trauma and was focused on the fever aspect that it is because of cold. But like then you also take family history, right? And it turned out this child's brother had a um what did he some form of lymphoma uh when he was a baby, the this girl's brother, older brother. So they had a like terrible three years because he had um bone marrow transplant. They had to live in literally live in the hospital. Then that got that. It, his body rejected that. And other things was so traumatic for the whole family and everything started someone saying that there is a lucency. So mom was so scared of this is going to be another malignancy in her second child and she had only two kids. She was in her head trying to be like, oh no, no, this is fracture and this is going to heal, which is understandable. Not an easy thing to deal as a mother as well, but you've got to deal with them. Um So what I did is because they were in clinic, I sent them back. So I need to do the blood because that's how we do it like uh the pathway. Uh And then uh basically blood markers came up high. So more suspicion on osteomyelitis. Um But so you need to do what, what scan, tell me if it's um more tumor or osteomyelitis, which scan will tell me anyone anyone. So I said um yes, very good, very good. So you do an MRI scan and then obviously this is a multidisciplinary team approach with pediatrics, um pediatric, infectious, same orthopedics, pediatric orthopedics, and radiologist, and so on and so on. And you liaise with uh if it's tumor, then obviously we liaise with the sarcoma unit and so on. So way beyond your level. But again, um things can be, um you all probably just looked at the tibial side. Uh mum was hinting towards like kind of manipulating everyone to, you know, ho stick injury. And that's why Ed did that. Luckily by the time they saw me, she had the fever because, you know, but again, lucency was there. So we wouldn't. Um So we, we admitted her and as an inpatient, we got, we got it in a couple of days, I suppose the MRI scan, someone asked how long it took. Uh it took to get an MRI but if she wasn't feverish, um then it would be like a two week pathway in this way because she was also spiking temperature and osteomyelitis needs urgent IV antibiotics. You know, you need to follow the guidelines. Um You need to admit and that was another hassle as well. But then eventually we came to a compromise and, and related the kids for antibiotics and brought her in and out for, for those stuff. So we're gonna talk a little bit about a stimulis. So, os stimulis, the mean age is around six years old in kids. Uh it's also much more frequent in elderly. So you have a bimodal distribution. Um It is typically located in the metaphysis. Um it is going to be like all infections more common in in kids with diabetes, milliliters or immunocompromised kids. These are going to be Children who present uh limping with uh with pain with um frequently a history of infection or, or or trauma and fever may or may not be present. It's not something you can rely on to guide yourself on the diagnosis of osteomyelitis. Um You can also have x rays that may be normal uh in early on stimulis. The X ray might not look like much, it might be a completely normal x-ray. Uh an MRI is going to be uh quite useful tool if you're trying to detect it early. But early detection is going to be to be depending most on your uh clinical examination. Uh CRP is going to be high. Uh but white cell count may be normal and one of the very important uh reasons why you need to be aware of this and you need to be looking for it is that it causes bone destruction. It can become a chronic infection and it can create a thing called the prolix abscess, which is basically an abscess shielded by bone, which can be very complicated and very destructive to treat treatment is going to be IV antibiotics. Um It's, it's possible that IV antibiotics alone might be uh a treatment but very frequently it requires surgical drainage debridement. And this might have important implications for the, for the bone of the, of the Children and um end up resulting in situations where you are affecting growth plates or other important areas. Um There's in this case, some special considerations, um the possibility of malignancy consider that there there might be a malignancy in cases that present with bone pain or with lumps, get urgent imaging x rays or ultrasound. In the case of lumps. Um the most common malignant um malignant tumors in Children and are the osteosarcoma and the awing sarcoma. You will see the most eaten patterns or eccentric destructive lesions. And in the case of non accidental injury, look for things like frequent attendance to emergency service, abnormal fracture patterns, uh evidence of neglect, abnormal behavior to the child or to the parents or an abnormal state and importantly, also refusal of care or examination by the parents. So um another case, uh this would be our our last case. Uh we have a 30 year old male. Uh This person fell while climbing a tree in a public park. He fell from higher than 3 m. He was brought to emergency services shortly after it was a witness fall. There was no head injury, there was no loss of consciousness, no red flags. Uh Primary survey has already been done by the registrar. There's, it's showing no electro injuries and the c spine is cleared. Crom is clear and it is an isolated injury. It's an open fracture of the tibia and fetal s are stable and bleeding is controlled. This is how it looked like how it looks like. Um We're going to ask a couple of questions in pulse. Um If you would like to answer uh these polls regarding what we would be doing in a, in a case that presents like this. I like this question, Carlos curious to see the answer. So there is three important things to consider here is, should I do a washout? And if I do a washout, do I do it with Saline or with iodine? Do I give these patient antibiotics afterwards? Do I give them IV oral? Do I give them earlier? And uh do I reduce the fracture? Get the bone inside? Uh Do I do it? Do I not do it? Do I only do it if the bone is clean? So, um most of the people are answering that we would do uh a washout with Saline. Um What is your opinion of, of that? I kind of want to go through all poll questions first and then go through all. Go through this. OK. We're sending the third pole now. So we have uh three questions. Do we do washouts? Do we give antibiotics? And do we reduce the fracture? OK, so we have a few answers for each question already. Uh question number one. What, what is your opinion about this? So my, my opinion about this is we have something called Bo Guys. Um British Orthopedic Association has um guidelines for these type of emergencies and both also has a guidance on Open factor management as well. And it is quite clear um for um not to wash out these in A&E Um What we do is uh we do s Saline. So ghost obviously, if there is any gross debris, I'm not talking about that, you kind of pick it up, but it's not like washing out, washing out, washing out like the the sense that you're thinking. So you if there is any like gross debris, then you, you pick those pieces out. Yes, but not like, you know, with the washing in the sense that pushing all the debris inside. So try to pick up like if there's any major debris that you can see. And then Saline, we take a photo of the fracture with the patient's consent because everyone needs to see what type of fracture is there and then Saline. So it goes touch it on the, on the open area and then kind of you do and or whatever you like in that sense, does that make sense? Everything the purple was shot and the bride will be happening in the, in, in, in the, in the theaters. 11 of the things they also mentioned is uh a lot of people when they learned, they don't, that you don't do a wash out. They started doing what is, what would be called like mini washouts, which is like, I'm not doing a thorough wash out. I'm just irrigating it with saline, things like that. That's also not a, a recommended uh thing to do if, if there is a bur contamination, just remove it. But don't start doing small things that don't provide, let's say a motorbike accident. You know, if you see a crossroad contamination like massive, you know, stone, you know, inside the wound, just take that out. Obviously, like something that makes like a common sense, like massive growth debris, a massive, I don't know um anything big you can pick it out, take it out in a controlled manner. So you don't need irrigation. He, the patient will get p washout and debridement in theaters anyways with us. And to be fair, um lower lymph open factors are managed in major trauma centers anyway. So mostly DHS shouldn't be dealing with that. So it's mostly A&E um care what you need to be doing, which is this. So, and let's say somehow the the major trauma network failed and they, they brought these patients to your center instead of if you are in ad DH not in a major trauma center, um then obviously, you will do your ATL S because why life is above limb, right? Don't get distracted by the open factor and make sure that airway is F and C spine is ok. Breathing ventilation, circulation, pelvic binder if needed. Um No, no worries. Um, so basically you do at E and what I tend to find is, um, we get transfer patients from, let's say, from other deviators. The resuscitation is a bit always un like, not always but sometimes underdone. So if they need blood, give blood to take, say don't, don't be shy about it, don't try to resuscitate them with like fluids or so on. If they need bloods, give them the blood, you know what I mean? Like cancer is also something risky. So make sure that patient is very stable alive and then focus on your or factor. Um That's, that's very important. Once you come, let's say this is an isolated injury, patient is stable, you obviously will call orthopedics. And if you are orthopedics, then you will examine what, what do you do? Carlos? So for a patient like this, um of course, primary survey, make sure there is no life threatening injuries. Uh Once I'm focused on this injury, I want to know if there has been any damage to any vascularization or nerves. Um I want to assess how much is this patient bleeding. And if maybe this bleeding has been controlled with a tourniquet, then uh I need to ensure there is no damage to any of the arteries, um damage to nerves and then once that has been cleared that this is uh through um neurovascular s uh quite thoroughly, don't repeat it multiple times. Uh I would um manage this uh manage this uh fracture um with uh I'm not gonna say how because that's uh the next two questions. OK. So, uh let's come to the other things. I, by the way, put the Boss guidance on the chat just in case if you wanna have a look and if you need any evidence because mini washouts are not recommended by Boss. Uh Anyways. So if, if your center does washouts, thorough washouts, they shouldn't be doing actually. So, um, you can read about it um with the false evidence. Um So you examined the limph. What, what do you give to the patient? What medications call? So, um, II would expect this patient to receive antibiotics as soon as possible. Uh Depending on where you are, these antibiotics might be given by ambulance service or they may give, may be given when the patient arrives. This is something you should double check, make sure the patient has received uh proper uh broad spectra antibiotic. Uh ideally within one hours, within one hour of the fracture. That is both guidance. But uh as soon as possible is the, is the objective and it's IV antibiotics. Yes. Yes. And what else, what else do you need to give the patient? Tell me? And II would of course, uh give someone LGS. This is a very painful situation and we're going to have to do some things with this and those things are going to be quite painful. Uh But it's going to be important also to not um overly sedate this patient with opioids, of course. But what else, what else guys come on? There is one more key thing you need to be. Yes. So uh I think you're pointing um II think it would be tetanus prophylaxis. So depending on how this has happened and a couple of characteristics of the patient, uh we, we're gonna have to give tetanus prophylaxis. Yeah. And you depends on the patient age like if they are brought up in the UK Tetanus, um let's say 18 years old probably is up to date but if, if they can't remember if they are not sure blah, blah, blah, like then just, just give it and depending on a, on a couple of characteristics of the wound. So if there's anything like uh sea witch or um any, any type of dirt from the, from the floor or any plant material, um those are definitely some things that increase the risk of um contract uh contracting tetanus. So you might need to consider if uh if a torate is needed. Uh there is very clear guidelines about it. So following that you will make sure that you do a bride call. Yeah. So I think there was another question within the Yes, it was a, a third question which is uh if you would manipulate and reduce this fracture, this is quite controversial as well in a way. But what do you think Carlos? So, uh II can understand people thinking uh that you don't want to put the bone in because you think like, oh the bone has come out and it's dirty. But if you don't reduce this fracture, then you're gonna start having problems, you're gonna start having more bleeding. It's gonna be very painful. The right goal is to manipulate and split. Uh put it into uh reduce the fracture and splint it. So my answer is what I have been told. No, my answer. I think you're right. Um But I've seen this, that's why II changed my answer a bit. So ideally any fracture, obviously, you try to reduce it in a, in a position, you know, um in a good anatomical position, you try to get it in a better position. But the, the problem is, um, sometimes not all of them gets reduced. So it doesn't easily go back in. So I had one patient where um patient has an open to fifth, something like that whilst playing rugby. Uh And when the alerts arrived, someone came up and said like off and off, I'm an orthopedic surgeon. So what the person did on the field was the nick, the edges of the wound, cutting the edges. So he tried to manipulate in, on the grass and uh basically poke around the wound site and you know what I mean? Like he tried, the person tried so hard and it didn't run, it didn't go back in as well. So obviously you try to manipulate this, you know, as much as you can. And ideally, it should go back in and the skin should not be threatened as well because even this picture is actually quite good an example that the skin is a bit threatened here in the sense of necrosis. And then when you close this wound, then it will close the break, risk of breakdown and then infection blah, blah, blah. So you want to take the pressure off from the skin, you want to reduce it. The orthopedic surgeon will wash out the bride it like so much. So don't worry about the clean bone, dirty bone, bit, but equally don't be a hero by trying to open up your own bone. So the bone would get in, you know what I mean? So there is, there is like a common sense. Um In fact, if the I think the best thing to do, especially if you're on an N TC, um let's say you tried it and the skin is not like, you know, this is not going and it's quite stuck in the skin, but patient somehow is almost kind of reduced. So you can let the on call consultant and the patient can have the surgery on the same day if there is any capacity, so the skin wouldn't be threatened as well. So always let your seniors know, make sure the patient is ready for theater any time. So as the moment you see these people star them, give them fluids if they are stable anyway, so don't be shy to keep them starve if they, if there's a chance of, you know, having the operation for earlier, let's say let them take it there. There's also in a, in a patient like this. Um There's a also a very good reason to keep this patient near by mouth and ready for surgery since they uh present to the to the emergency room. And there is the possibility that they might develop compartment syndrome. So if this patient is presenting something like 6 p.m. surgeons are no longer operating, it would be co uh but it has reduced. Everything seems to be fine and can wait until the next day. I would still not um not be happy for this patient to have dinner. Um Because of the possibility that things might, might go wrong during the night. And this patient may need urgent intervention. Even when you think about in sedation, in A&E, they need to not like, you know, they need to start for a while anyway. So if you are in AD DH and transfer, start starving them in D DH whilst transfer, the time will go and by the time they come to DC, they will be ready for sedation and reduction of whatever they need. So just to clarify a little bit uh on the management of open fractures, the objective is antibiotic prophylaxis in all of them. Aim as soon as possible if you can do it within the hour. That's ideal. Uh A lot of trusts uh have protocols where these antibiotics are already given uh by ambulance crew, but make sure double check that that has been done, consider the need for tetanus prophylaxis and choose antibiotics. Uh according to the classification of the of, of these fractures. So, open fractures are classified with the gasification. Um Type one would be a small fractures less than one centimeter, type 21 to 10 centimeters without extensive soft tissue damage. And type three is larger uh injuries with extensive soft tissue damage. And we can classify depending on whether we have soft tissue cover of the fracture, whether there's exposed bone or whether there is associated vascular injuries. It is really important to stabilize re the limb and very importantly, obtain medical photography before you start manipulating things before you start doing things to that to that wound. That is going to be a very good reference point later on to understand what needs to be done for this patient only handle the wound to remove G contaminations. Do not do washouts, do not do mini washouts, just cover it with a saline. So gauze keep that wound from drying, this is going to be handled in theaters, uh as soon as it can be done, split the limb. And if you are manipulating anything and you're splinting, repeat the x rays just to make sure that is uh an acceptable position to keep this patient. Um A CT might be, might be uh necessary, uh depending exactly on what's going on with this patient and very importantly, document and check neurovascular status repeatedly uh during the whole assessment of this patient. Do it before uh you manipulate, do it after you manipulate and repeat overnight. If this patient is um not going to theaters uh directly be aware of the signs of compartment syndrome. I think um just a quick um for completion, let's say this is a question to you, Carlos, let's say you palpated, you tried to get the pulses and you didn't get, what can you ask from A&E. So a A&E should have uh Doppler to check the Yeah. Um Also another thing if I don't uh fill up ho before I have manipulated the joint uh before I have manipulated the, the fracture. Um II would manipulate the fracture and then check again. It is possible that that artery is just compressed. Exactly. You took the pressure off and then that now the is beating, let's say, and you still couldn't find the, the, the pulse with the Doppler then which imaging you are going to get. This is just for completion. For people, I don't know the level, it will be a, a city angio exactly about them. The compartment syndrome, this is something that can happen in a, in a case like this. Uh It's a condition where the compartment pressure rises leading to ischemia and it's gonna cause uh neuromuscular damage that might be irreversible depending on how long we take to act upon it. Uh The most characteristic uh the, the most defining uh aspect of it, it's, that's really, really painful. It presents with pain out of proportion, uh especially on passive stretch and, and it can have altered sensation when we're talking about pain. Order of proportion, it may be a little bit difficult to think. Um how much pain is indicative of uh compartment syndrome when someone already has uh a major injury, a major broken bone, it's already going to be very painful. So it's, it's that this can be a bit of a, a complicated clinical judgment. Um How do you approach um judging how, how much, whether a patient is having out of proportion pain compared to uh uh the fracture and suspecting of uh compartment syndrome. So, like you said, and I'm glad that you actually highlighted that every patient is different in terms of pain threshold. Some patients are like so agitated and so much in pain that can be a bit faulty but equally, you can see like some, you know, moan men saying like, like their legs are so tight. But again, they're like, no, no, I'm fine. I'm man, I'm, I can take it but like it's pain out of proportion. But pain, pain, pain, there should be some form of pain. If the patient is not in pain, then that's good. Um, but then again, you should always ask yourself, um, and think about it, um, who wouldn't be able to feed back any pain to you? Right. Does that make sense? I can repeat it? Who is not able to um um able to feed back that pain? Who might not be able to tell you that if they, that they have pain or not any, any thoughts from the audience? So A BPI is a bit historical um um to all schools. So currently, um the guidelines are um suggesting CTA um and let's say you did like a massive above knee cast or below knee cast, how are you going to get that ankle brachial pressure index? So that's why um and someone asked, uh what about ankle brachial pressure index? Which is a good question. A BPI used to be um like instead of CTA, people would check a BPI but it's a bit person dependent, not really there. So if you have access to CTA, you just do CTA, that's why um that, that's a very good question, by the way. Um So patient group wise, if you go back to um who wouldn't be able to feed any, you know, feed back any pain to you. Any faults, anyone, no rights or wrongs. So you go ahead has, has commented elderly, um elderly people with reduced sensation. There's also a, a particular group that's going to have even more reduced sensation. Uh which I think uh diabe diabetic could be. Yeah, I'm talking a bit more specific stuff. Unconscious is a good one. Yes. So that means someone who's intubated, ventilated, you know, in ICU won't be able to tell you that um neuropathy. Yes, but still um not quite the question is a bit more aggressive than neuropathy would be a severed nerve. That has happened that a person who has severed their nerve when they had that injury. So who wouldn't be able to tell us their pain like pain out of proportion um In, you know, in like compartment syndrome would be the question. So which patient group you can't really rely on compartment syndrome? One is IC patients who are intubated, ventilated won't be able to say that Children cry though, you know, to patients, mental patients, mental demented, demented, demented, they still, they can still feedback something like something is not right. They would drag, they might not say pain but the nurses will tell you that this patient is acting old or something. I want you to think about something more like, you know, outside the patient. Think about like yeah, sedation is like pretty much same with the no, but stroke is in a way similar, let's say someone had a car crash and has a unstable cervical spine fracture. Mm. Or like, I don't know, lumbar spine causing lower limb paralysis. Hm. Right. It in spinal cord patients like cord syndrome patients or someone with that kind of. So, yeah. So spinal cord patients uh intubated patients or when you think about it, um what do the in like Carlos and orthopedics? So I say don't do to my patient. They like a general anesthetic plus. Uh you repeat uh the question is uh the the anesthetist when they put the, put the patients like in G A, we ask for G A and they also do something additional, let's say lower limb operation. Uh they, they might be doing a block. Exactly. So if someone is blocked in any recess without you realizing, will they be able to feed that pain back to you? That's an important consideration to have. I mean, it is a, it shouldn't happen. It's, it is quite rare but something to think about, right? Um There was another group of patients I would say, but not coming to me at the, at the moment, maybe it would come to me later. But overall, try to keep your minds broad and think about again, each patient is separate without their background. So I would ask myself if I see a five in front. So the again, both as a guidance and I will send you the link if you interested in a bit more reading into this topic. So, the first thing you do is you go through the patient's drug chart, right? To see what they had. Because if they don't have any proper painkillers, like, you know, regular basis, some simpler pain relief and P RN stronger stuff. And if they are not appropriately analges, then obviously they are having a big fracture is going to be painful. So you make sure that their analgesia is properly topped up in the sense that not like, you know, making them junky kind of level, but like, you know, sensible level of appropriate level of painkillers. Um and you need to remove all the bandages, all the cast, you need to examine the patient basically. And what I do is I tell basically, you do a full neurovascular examination of that limb to see and you, it will be intact if it was intact before you see them. You know, because you the in in Compartment Syndrome, this pulselessness, the the the, you know, tingling sensation. Why did that happen? Anyone? What is Compartment syndrome is? It's like um it's like a vicious cycle. The fracture disrupts the circulation in a way and then the the compartment, the everything starts swelling up and the the the venous, the venous congestion starts as it gets more swollen and more filled up. The the the system will more tend to, I don't know, in like in a sense that it will tend to get collapsed as well. Um So the less venous return, the more swelling is getting accumulated inside that compartment, everything is getting more swelled up. Eventually, it will press on the nerves and the uh vessels. So until you get to the vessel and the nerve, it will be a bit later stages. So when you examine these patients, they most likely will have the neurovascularity intact, let's say if you are not too late already. So, but you still check it, obviously, you know, you to assess them fully, but that doesn't sh so it shouldn't be like, oh, the patient has a P oh the neurovascular intact. So it's not, there's no such a thing. That's what I'm trying to say. You know, what if that makes sense, what you do is elevate the lymph top of the analgesia. Check the, if there's any tenseness in that limb, um You see them when you see them without the photo, it's difficult to explain. Uh you palpate it and it's, you know, p at your own calves, you see, you feel a bit softness and those ones like, you know, swollen up so much, it's like so tense. You, you, you, you see the difference and that would be more and the most important thing. Obviously, you always have to check passive stretch test. Do you have any picture of that Carlos on your slide by any chance? No, I don't, I don't have a a picture of it. That's OK. So, passive stretch test is uh let's type it here. The people can. Um, basically it is like you do a flex and plan to flex the toe and um you ask the patient. Um So when you do it's all about anatomy actually. Um do you remember what uh maybe the first one on the left top, this one, this one? Yeah. So, I mean, the hand is closing but basically you all you do is this is let's say a toe, you do this passive stretch and then you do this and this thirsty and plantar flexion. Why Dorty and plantar flexion? What am I doing? Actually when I do stretching any thoughts, you know, colors. So you're stretching different uh muscle groups. Exactly. And the so basically when I do dorsiflexion, which muscles getting stretched one second, that's the homework. It's OK. There's different uh muscle groups in the calf. Um The compartment might be uh only affecting 11 of the uh so di different compartments have different muscle groups. You, you need to test for the di the different type to, to localize it well. Mhm But basically, if passive stretch is um is positive, then you'll be alerted a lot regardless of the pain relief. Because when you do active some so some certain movements that uh anatomical uh compartment will be stretched and you will see like, oh is this compartment under pressure? So that will you know, trigger you. But what you do is if the pain relief is not, you know, appropriate, um then you do the, uh you do the top up, you make sure that you talk to your nurse colleagues, like very deeply and very important that you will ring me. If this patient, you know, gets worse, you won't like, you know, unless they are like massively ballooned up, like, because most of the time, hopefully it's not going to get to there. But an anyone can, you know, hopefully recognize the massively ballooned up end state compartment syndrome, which wouldn't, which shouldn't get there. Um I'm talking about blurry lines, like is it compartment or is it not compartment cases? So you monitor the patient elevation, you give pain relief, you yourself should examine the patient like serial examinations. If the patient is relief, relieving, you know, let's say you gave them the painkillers, their pains are same or reduced. Obviously, it can take a bit. But despite giving more painkillers, everything, if it's getting more swollen, you can take pictures to compare for yourself as well. Obviously, when you first see the patient, you'll keep them near by mouth if they are to see if they are compartment syndrome. But again, um my suggestion would be like stay calm, do what you need to do in the sense that relieve all the pressure from the leg like any bandages cause anything, make sure that they are topped off and that let give it some time to kick in as well. Most of the time, that's the case, elevate the leg, elevate the leg help quite a bit. And then one of the tools we have available in the, in the hospital that it might be a little bit hard to find, but there should be some around uh its tools to measure intracompartmental pressure. Uh If you, if you're not sure if, if you're not sure whether it is or isn't, uh that's also a tool that can help in the hospital. Um I made sure we had them because we, we had uh a couple of cases and nobody could find them. So one day I had to go dig through the stash in the, in theaters and bring a little box with a couple of them. Luckily we have, we haven't used them yet, but we, we do have some. Now. Um it's a, it's a tool you're rarely gonna use because it's not something that frequently happens. And even in the cases, it happens, you, you may not actually need it because the diagnosis might be uh clear. But if you don't have a clear diagnosis, you're doubting uh you can measure the the compartment pressure. This is done uh with a, with a small device that uh you attach a needle, you attach a ss syringe with saline and then you need to put the needle into the compartment. That is, that is important you need to follow some landmarks and you need to make sure you're in the right place. Otherwise you're not measuring uh the pressure of the part that's affected. And once you measure the pressure, uh if it's above 40 millimeters of mercury, then that's quite an important sign that you have compartment syndrome. Um If it is uh you can also do a calculation, you can do the diastolic BP minus the compartment pressure. And that should be uh below 30 that should be above 30. Sorry if I didn't get mistaken. Um Let's say the question. You, we are, we are not as posh as Carlos's hospital. Well, it and you want to measure um measure the pressure. What what can you do? I think they can't see a slide, by the way, Carlos, it's just uh no II had removed it. Let me just put it back. Let me find the post uh compartment syndrome as well. So it's uh above 40 millimeters of pressure in the compartment that is uh considered a positive finding or you can do the diastolic pressure and then diastolic minus compartment pressure should be above 30. Yeah. So this is particularly important if you have a a patient that might be a little bit hypotensive. So someone said, if you, if you are not as posh as Carlos hospital, what you do and someone said, pray um but what you can do is you ask your lovely anesthetist colleague to and you ask them if they could set up an art line, arterial line. And what you do is what does, what does compartment measurement means is it's not like how will you know? Right. So you basically stick your needle in different areas in the leg back, you know, posterior each compartment in different areas and you try to, you know, pick up the highest pressure ever. Um So you can ask your initiatives, colleague to do an outline for you set up an outline and you should be able to see it on the screen. I never, I've had three compartment syndromes, one in ICU in the thigh, one in the leg, one in the forearm. Um They were all clinical stuff um never needed to set up uh an outline or, or anything as such. Um because the, the ones I've seen were quite uh tense as well. Um But again, if you need to do it, if you're like, if you're still like in borderline, it's always safe to, you know, safe, always be safe rather than being sorry and ask someone to do set an outline for yourself. And what you can also do is measure the circumference of the affected limb basically um compared with the other leg. But you need to uh make a reference to bony structure. You can't say like, oh just med five. You know, you, you, you, let's say you feel the tibial tuberosity four centimeters down the line you're measuring the around the that area and comparing with the other leg that gives you clue about the swelling as well. Also, we, we're talking mostly uh about limbs because it, this is uh a pathology that appears mostly on the limbs. But there is also a, a couple of less known um compartments like you can have this happen on your shoulder. This can also happen on the paraspinal muscles of your back. It is a much less common thing to happen. But uh because of its right, it's also something that can be missed, but most commonly it is forearm, thigh and uh uh the lower limb. Yeah, I think we are towards the end, right? Carlos. So if anyone has um any other questions, they would, they would like to ask abdominal compartment is a, is a, is something that deals with but true. It can happen in abdomen as well and in any suspicion you don't delay, you just fom OK. So if anyone has any other questions, uh we have uh prolonged the the length of the session a a little bit. Uh But I hope this has uh this has been a good learning experience for everyone and very thankful for uh Mr J to help uh and come here to answer all our questions and give us her experience. My pleasure. Thank you Carlos. And I think there is a question saying that we initiate major hemorrhage protocol in your hospital. Basically anyone can activate it because not all major hemorrhages happens on recess or A&E even if it happens on the walls, you just tell the nurse in charge and someone, you know, you call double two, double two, for instance, in my hospital or you can go like if you don't know, just call it a cardiac crash or like give us uh uh or switchboard and say like I need major uh major hemorrhage protocol to be activated and you call people. And ideally you need someone else because someone needs to deal with the patient. Someone needs to, you know, facilitate the, you know, ask for help, bring the equipments because you need group and save also. So a nurse will need to get like other stuff like you, you need to start resuscitation, basically start TX A PPR whatever. It depends on what, what, what, what it, where is bleeding, how long does it take to have pulselessness? Um I would say, I think ideally you shouldn't, I would say 4 to 6 hours, I suppose. Um the golden hours are like, it's a very time critical emergency. That's why this is a very good excuse to wake your boss up in the night time. As soon as you suspect the compartment syndrome, call, call your anesthetist, call your um um call the boss, everyone be coordinator. But it, I would say ideally, you should, you should be open, you should open that up within six hours but II would say 4 to 6. But I'm like, I think everyone's a bit different as well. Right. The, the thing is that by the time you find uh a clinical sign like that, uh there might be already damage that cannot be reverted. And uh the, the damage you can get from uh a compartment syndrome that has not been treated early enough can, can be quite uh quite um like quite a bit of disability that the other problem is how do you know when it started? Right? Like that's the thing. So it's not like maybe initially it didn't go to right away like compartment, but like eventually it started swelling up. There was this little bleeder didn't cause a compartment but eventually reached a point that triggered compartments. You, you you it's so II wouldn't rely on the time, but I would rely on. Ok. When did I get the call? When I saw the patient? When did I take into like, you know, when did I start intervening in the sense that make sure the patient is well, so, you know, um faster, you know, grip and safe and um uh top top part from the a a analgesic side and elevated and so on examined because if it's too swollen, I'm not going to wait for serial examinations, am I? But when you think about like, you know, blurred like lines, it's like early, early um early time of the of the compartment then you, you have time to do early examinations and so on. Um, really depends. So, don't, don't say in your head like, oh, they called me at this hour. So I have six hours. That's not the thing or like four hours or you don't know what time it starts anyways. It's all about what's in front of you. Like a lot of people say we, we treat patients, we don't treat numbers. So, yeah, so if anyone else, uh if nobody else does have um any more questions, uh then we will wrap it up. Um Thanks everyone for coming and I hope this has been useful. Uh Please remember to do the feedback forms that will give you the certificate for the session and we'll see you on the next one. Thank you very much. Take care. Bye.