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In Glasgow Doyle just now on orthopedics. Um So I'm going to go through some common orthopedic presentations. So firstly, this is a very broad topic which unfortunately cannot be covered in one session. Um Tonight, I will try to focus on some of the topics with a view of further sessions in the near future. Um All the images are not my own and belong to the original authors which I have referenced at the end. Um So pleased if you're taking any images or reproducing any of these slides, please just bear that in mind. So tonight, I aim to discuss some of the common upper limb fractures, some of the common lower limb fractures and be aware of more serious orthopedic issues. So firstly, we'll talk about distilled radio fractures when discussing the upper limb. So, distill video fractures are common fractures and um common reasons why people present to in the orthopedic department and particularly they seem to be an increased incidence of them, particularly over the festive Christmas period when there's icy conditions. Um and commonly people are slipping and falling um naturally, when you slip and fall, you pop your hands out to protect yourself. Um And often this can result in a district radio fracture, the most common of which the mechanism of injury is a fall on an outstretched hand. Um When you're taking a history from a patient, you want to know the mechanism of injury, um particularly that will tell you a lot of information before you've even examined the patient or got any radiology imaging on them. Because often by them telling you how they fell, you can work out by which direction the bone is likely to have moved based on in the kind of loading that was put on the bone when they fell. Um You want to know whether or not it's high energy or low energy. And this is particularly important because elderly females who tend to have more osteoporotic bone intend to have fragility fractures with very kind of low energy mechanisms. Um You also want to ask your patient's because that's important in terms of kind of surgical management because for example, if they're involved in a job, which requires a lot of dexterity, for example, a mechanic, dentist of surgeon, anything like that, then they will require kind of as close to baseline um previous hand function that they had hand and wrist function. Um So often these patient's would um kind of be put forward if surgical management was indicated. And it was the dominant hand when you're examining the patient, you want to particularly look at whether it's an open or closed fracture. Um particularly open fractures are important because not only is there an increased risk of infection with these and you would have to cover with antibiotics, you would also want to know the tetanus status of your patient and whether or not they required any subsequent boosters. Um And often there's a higher risk of kind of vascular or nerve injury with open fractures. Um Typically you want to look and see whether or not there's any obvious deformity. Um and often any kind of fractures that I have seen, it is pretty obvious you might not know what has been done until you get the radiological imaging, but often there's kind of swelling or there's bruising or there's um kind of clinical signs to be seen. Often patient's will complain of pain and sometimes they can describe it as diffuse pain all over. But often when you kind of inspect, look and then start a new palpate, normally, they kind of localized pain will be over the distal radius. Um You want to do a change of movement that a patient has in their rest. Typically, this is often limited by pain. Um And if they're not able to do so, obviously, don't force them. Often, sometimes a bit of analgesia helps before examining them. Um But it's particularly important which we'll discuss in in the next slide to determine the range of movement because this determines whether or not they have any underlying nerve injury because you've got to make sure that um the function of the rest in hand is still as it was before the fracture. A common phrase that's used by orthopedics. I'm and they obsess over is um you know, vascular and tap. So whether or not they can feel in terms of sensation, whether or not you can palpate the pulses, both the radio and the ulnar pulses and the cap refill time of um the limb itself, particularly you're concerned when you've got kind of pale pulseless limb because this is often an indication that there's been a vascular injury. So as you can see from the image at the top right hand of the slide, which I've taken from Kiki Medics. Um This focuses on the dermatomes of the hand, which are particularly important when you are assessing and kind of, you know, vascular injury. Uh just can everyone turn off the mic, squeeze it's sounding a bit crackly or if gabby, if you stand with further away from them from your mic. But if, if everyone make sure they're Mike's off, please, can you all hear me better? Now? It's still a little crackly. It might just be my laptop, but just we get some in the comment. Is it all right to here just now? No. Uh No. What is it? Sound quality is bad? Okay. Um Kraft was still quite crackly. Okay. Fine, fine. Um Gary closer. Could you move a bit closer to your Wifi area. Let me try and thanks a lot. Is that better? I know it's still quite crackly. Um, I could try pop some headphones in. Yeah, you want to try that? Yeah. As long as everyone doesn't mind waiting. Yeah, I'm sure we all right. Thanks a lot. Is that better? Try speak again if you mind. Is that better? No, it's still quite crackly. I am. I'm not sure how to fix this. It was fine. A few moments at the start in the first, maybe five or so minutes. Did you move at all or any of that? Is that better? Uh speak again for me? Hello. Uh There's still a bit of crackles but I think we might just have to go on with it. I wouldn't stress too much about it. Gabby, if you um sorry about the sound quality, I'm just gonna kind of go on in the interest of time, but obviously, if there's anything that I've missed and you're welcome to email me and I can give you the slide after. Um So I'll just go back. Um So typically you want to um kind of assess the nerve function of the hand. Um So for example, if you're testing the median nerve, often asking a quick kind of screening tool as adding the patient to make an okay sign. And that very quickly tests the muscles that are supplied by the median nerve. And if they're unable to make an okay sign, then you'd be concerned about this. Um looking at the tones as shown in the picture on the top right hand screen, I'm kind of touching the tip of the second digit and as well, touching the thinner eminence and asking the patient can feel that and comparing it to them hand that's not injured and, and does it feel the same or is there any difference in such and sometimes they can feel it, but it might be very different to the unaffected um limp. Um You would want to test the radio nerve. I am basically getting them to put their hands out straight in front of you um and popping your fingers on top of their fingers and asking them to put, push up against you. If they're not able to do that, then you have concern over the radio nerve being injured and you get them again to close their eyes and compared to the opposite side by testing for sensation in the door. So first Webspace for the radio nerve for the on the nerve, you get them to slay their fingers out in front of you. Um The very fact that they can splay the fingers out in front of you is kind of testing finger abduction. Um If they can do that, it's very unlikely that they're on the nervous damage, but trying to pop their fingers back in by pushing against resistance. Kind of tests tell the nerve again, often, sometimes sometimes it's very painful and it will stop. But if they can hold their fingers splayed for a reasonable amount of time, then it's unlikely. And that you've done well on the nerve and again, testing the sensation, the tip of the little finger, your three kids that scream out at you that you would want to get early senior involved movement. They're not, they're complaining of numbness thing. I mean, is this disproportionate to the actual injury? You've got a feel pulseless and injury so can to speak to someone senior because it could be that you've got vascular compromise and don't forget to always examine the joint above and below. This is particularly important because Kohli's fractures, genuinely 50% of them have an associated on a styloid fracture. So you might miss that if you weren't palpating the ana side, um as well. So, immediate management. So what do we do to immediately Spanish? Um These patient's so with any patient you do I can or is I guess, uh destroyed back and often gabby, you're breaking up just now. Are you, are you close to your wifi feel the most painful Trump procedure? Eat gabby. Can you hear me things up? Um So it's really important to establish that you would ask for some A P and natural X rays um to health and do your kind of baseline work up, um which includes blood's CCGS. Um And anything else that you think end based on your history examination. Um You want to give these patient's analgesia, they often come in very, very sore and they're reluctant to let you even examine um the rest if you've not given them any pain relief. So kind of first thing, if you're suspecting, give them some pain relief, continue with your clerk in of medical assessment and then go to the examination of the rest. Last, once the analgesia has had some time, um reductions of fractures are often done in the a new department. Um It's important to note that not all fractures need to be reduced. Always discussed with a senior and always referred to your fracture guidelines in present in all hospitals. Um Once the sugar has been reduced, often a patient's pain will improve and the tension is taken off of the neurovascular structures. And if there's a delay to surgery, for example, if you're not able to get them in for theater until the following day, um Book emergencies on the list such as a neck of femur fracture coming in, then a reduction is really important because better alignment aids and kind of primary and secondary bone healing. Um open fractures should undergo surgical intervention within 72 hours. As per the both guidelines, often reductions will be done under blocks. Um So local anesthetic blocks or hematoma blocks and they need department and it's often the orthopedic clinical fellow or one of the junior veges that will be doing it. So colleagues fracture um is a common distal radial fracture. Um It's a extra rib fracture. So, what we mean by that is it's not involving the joint of the distal radius with dorsal angulations and dorsal displacement. So essentially, it means that the displaced part of the fracture is moving posteriorly. Um if it's severe enough, the classic term that's used to describe these fractures as a dinner fork deformity um which is often a lot of dorsal angulations which would lead to this. But commonly the x rays that you will see will be the ones that can be seen on the right hand side where if you look closely, you're able to see that there's a fracture and it's dorsally displaced but kind of onset of looking at it. It's not an obvious dinner for deformity. Um As we spoke, about 50% of them can have an associated honest styloid fracturing important to make sure that you examine and palpate the mechanism of injury is typically falling on an outstretched hand. So as they said, these fractures tend to go up an incident sort of around the Christmas festive period. People slipping and falling on the ice, they tend to be a fragility fracture. So that means that they tend to be low mechanism in injury and people who have osteoporotic bone. Um but they can occur in kind of sporty young fit, it goes and as well in trauma and the management of these is typically closed reduction. So by that, we essentially mean, trying to reduce the fracture back into its anatomical position under the cover of some local anesthetic and some pain relief and then immobilizing them in a cast. So often they'll have a cast from below their elbow to the metacarpals and, and they'll have somewhat flexed and an ulnar geez. So this is in the kind of opposite direction to what the initial fracture is and usually that's in 4 to 6 weeks and you want to follow them up and fracture clinic. If they are unstable or there's any kind of unsatisfactorily closed reduction, then you want to list them for theater because it's likely that they'll need open reduction and internal fixation. Um How we find that out is any fracture that's been reduced, requires postop check, check x rays, um sorry, postreduction, X rays. And so you would then compare it to the initial injury and make sure that the bony alignments and everything look. Um the patient feels much better. If it's an unsatisfactory position, then they'll likely be listed for theater and require kind of plates and things to fix that in place. A Smith factor is essentially the opposite of a Kohli's fracture. So it describes the angulations of the distal fragment of an extra articular fracture of the distal radius with or without valvular displacement. So essentially the fracture is moving anteriorly. Um So as you can see in the top right image, the head of the distal radius is a displaced kind of anteriorly or valvular displacement. Typically, um the mechanism of injury tells you what it's going to be before you've even imaged it. So patient's will say that they have fallen and they've placed their hand backwards, planting it on an outstretched behind the body, or they'll fall forward, for example, in off of a scattered are coming off of about a week and they've landed a full. Um Unfortunately, these years that are always and stable. I am before our surgical vacation, I am still still in comparison, assistant fractures which you can stop. He talks always reduction. Uh complete extraction, it won't land okay be, can I? Yeah, but B I kind of promotion that decision pain. Um sometimes it can be new pain because it's a refer pain but often it is coming from the hip and they'll be unable to wait there and they'll often have limited range of movement. Again, these typically tend to be a fragility fracture. So low energy elderly females with osteoporotic bone. However, there are other causes so high energy trauma um including if somebody was involved in a traffic accident, if people had underlying malignancy, then they can have a pathological fracture because they've got disease bone essentially which is more prone to break and cracks or reduce bone mineral density. So patient's that might have underlying conditions for which they need to take long term steroids. Alcoholic patient's who will have a low bone density due to um large amounts of alcohol intake. So the key point to our orthopedic history when dealing with a hip fracture is firstly, why just why did the patient fall? Um, often this can be overlooked. And um, it's something that certainly we need to focus on. Um, particularly because people will come in, they might have their fracture fixed and they might have, you know, a hip replacement or a dynamic hip screw. But, you know, no one's actually listened to their test to hear that they've got an injection systolic murmur and they've got aortic stenosis and the reason they're actually falling is because of their aortic stenosis. So these things often get picked up kind of later and it's important to make sure that you're doing a full 80 e in orthopedic Clarkin to make sure we're not missing anything. Typically, I am, the reason for a neck of femur fracture is a mechanical fall. So often patient's of trip or they'll slip or they'll be coming out the shower or they've slipped on ice. But, oh, and on July, I Corey isn't though. You neat. You're thing. It, that's it. You know, be your wife is breaking up again. Can then defect Jobby. Gobby. Can you hear me and Gobby? He's in if you think apnea trapped Gabby, gob, you cut out for a minute or so there. Gabby. Hi. We can hear, you know, but you just cut off for about a minute or so there. Can you hear me? Yeah, I can hear, you know, you know, don't worry, don't worry, it's all good. We can hear you. Are you ready to restart? Okay? Um Just up until the neck of femur fracture, you're just there. You cut out a couple of times. Are you, are you near your wifi box? Most of the wifi so I can be okay. That's great. Thanks very much. Um You hear me okay. Yeah, we can hear you. Well, thanks. Uh Are you asking them if anything else? Harps? It's an apart from the hip to make sure that you're not missing anything else. As with any history and examination, you want to know the past medical history. This is particular, really important because if you have somebody who needs kind of theater which pretty much all of the neck of femur fractures do um the in the anesthetic dot Come up, we'll want to know there s a score and they're not going to know that if a bit kind of full Clarkin hasn't been done drug trees particularly important. Um When clarifying the timing if they've had any Apixaban and Warfarin um to work out when they last had the dose, if you're not able to find out from the pay fused or they're under any wi and they're from a nursing home. And then it's important to sure you make every best effort to contact the carers contact the nursing home and passed given um also address nearly on their admission, but you can ex during the intubation within the orthopedic department, any potential risk factors for why they might have fractured their hip and a smoking management and getting the fracture. It's involved to get them a Dexa scan and consider whether or not vitamin D or calcium replacement is indicated and advise them on. So how do you make a femur fracture? So typically before you've even laid a hand on the patient, um you're able to factor because leg will be written and it will be externally irritated. It's not always but a large proportion of the patient present like this. A very quickly of your neurological and vascular status. Can you wiggle your toes and can you pop your eyes closed? Never continue there. I am foot provision. Something for the pulse is uh horses pedal this pulse and typically, if that's difficult to would move kind of more proximal and see which pulses you can palpate um just kind of skin overline. I'm down five seconds and lifting off and making sure the foot view is under two seconds for cap refill. Um often just rolling the like uses fect. Um uh a perfumer flat is very, very painful and just a gen screaming out and you can get her at the time and drawn on the leg. So that then when the orthotics consultant comes in, they able died in by which like uh greater trochanter tenderness, big, I'm in front of your foot to touch my hand and the majority of them to do that, so they won't be able to straight leg raise off the bit. Um often to hospital as well as very telling as to what kind of fractures things. So most of these patient's will be weep. Um uh So in management in the neck of femur fracture, as with any patient, always be doing an A B C D E, which we've already discussed the importance of with the digital video fractures. You want to get an A P, so an anti office X ray, um including a lateral X ray. And you also want to do a full work up. So you want to do a chest X ray E C G bloods and particularly you want to have a group and save and these patient's because pretty much all of these patient's will be going to theater. Um and A C K because often a lot of these patient's have a long lie and their CKs up in 1000 odds. And if you don't check it, then um you know, can have significant impacts on their renal function. And it's important to make sure that you get IV fluids up and running for these patient's. Um they may require an MRI or CT of the X rays are inconclusive and often that is the case. Sometimes X rays may be reported as kind of no obvious acute fracture, but the patient on the ward is unable to wait further, unable to mobilise a complaining of severe pain. Um and the orthopedic consultant. So then they get a CT hip and often low and behold, there is a fracture there. Um Specific investigations are often guided by the 80 assessment. So for example, if they have complained of cardiac chest pain prior to falling, then you want to consider whether or not a troponin would be indicated if they lost consciousness well as falling, whether or not a CD heads indicated or if you can see an obvious head injury and they're on some form of blood thinner, then you would want to do a safety head analgesia. I cannot stress enough how important it is to make sure that your patient's pain is well controlled. There's no point going to examine them and not being able to do any of it because their pain isn't adequately controlled so often and down the need department, the doctors are fantastic down there doing a nerve block which provides local anesthetic to the site and the nurse involved. Um and often kind of gives immediate pain relief, um, regular paracetamol and also regular auto morph, particularly a 2.5 mg dose four times daily. Um It's indicated often small doses dosages are given because there's lots of trials and lots of audits and everything that went on in the hospital and that have shown that kind of, there's large and instances of delirium um and patient's who have neck of femur fractures and kind of lowering and monitoring the opioids. Um usage can reduce the risk of this. Um So there is prn there if they need it but often starting something smaller is good. They're warfarin. So if they're on morphine, you want to hold it, you want to reverse it and you want to recheck the eye on are because nobody's going to operate on a patient that's got a sky high. And I am important to preempt all the things that are required for the orthopedic surgeon to then get the patient to theater and particularly the things to sort out are always in relation to the medication. So words, we had a lady who had a neck of you be more fracture um home and she unfortunately, at Parkinson, um lots of her Parkinson's disease may burb or oh, and she was now by mouth. So, and the importance of kind of converting the equivalent dosages to patch form so that our Parkinson's and her agitation levels can be well controlled but also not delaying the surgery for her diabetic medication. So, and whether or not they're on insulin, whether or not you need to end their auto diabetic tablets based on what time they're surgery might be. Often they tend to do diabetic patients' first on the list. And, and if their insulin dependent diabetes, then you may consider the need for a sliding scale. So when we talk about neck, the femur fractures, it's essentially intracapsular or extracapsular. And this is essentially the location in relation to the intra chalk enteric line. So the kind of definition of each can be seen in black which you can read for yourselves. But I often find that quite complicated to remember. And so an easy way to remember it is a intracapsular fracture is everything promote to the intertrochanteric fine. So as you can see, the intra trick line is here, so essentially yellow and above is intracapsular. Whereas extracapsular can either be the intra chalk intake picc line which is between the Jader to cancer and the lesser to cancer or it can take where it's from the lesser to five centimeters. Discover this point which can be seen in this image taken from teach me anatomy. So why do we care so much? Just if you want to defer it about an eight capsular. Um And the reason is do blood five in the joint. That's you, the blood's company, the particular artery, essentially it's a mean brand flex, femoral artery. Uh Gobby, Gobby Gabby, for sure. Gabby. Caption. Sorry about this guys were just hopefully you will join us in a couple of seconds. Hello, you just cut off again. Sorry. Is that better? Yeah, I'm quality is good now. Sorry about this guy's worry about it. Um You want to take off from where you left? Yeah. Do people just want to post on the trap where they didn't heat up to and I'll just start from the good. Yeah, the that slide is probably the best one to start from the blood supply. Okay. Um Okay. So I'll start from here. So why do we obsess over the blood supply and where the fracture is and basically any fracture that's intracapsular has the risk of compromising the main blood supply. If the fracture is intracapsular and it's displaced, it moves kind of towards the back. Um and it can compromise the medial circumflex, femoral artery, which is the main blood supply to the ephemeral head and and it can lead to avascular necrosis. And this dictates why we do a specific surgical management depending on whether it's intracapsular or extracapsular. So how do we classify inter capsular fractures? So I often find it confusing um and it can be simplified by the gardeners simplified um criteria. So the way to remember it is gardens class one or two is non displaced and gardens class three or four is displaced and then you can take each one of them in turn. So if you have a gardeners class one, you have a non displaced fracture with, with a incomplete fracture. Whereas if you take Gardens class two, you have complete fracture of the neck of femur, but it's still not displaced. So you're still not worried about that compromise to the blood flow when you have a displaced um gardens fracture three or four. Um It's dictated whether or not it's partially displaced or fully displaced. So I'll speak about each one in turn so that you can understand the difference between them. So type one is typically an incomplete fracture which you can see here, which is not displaced. So as you can see in the image, there's a fracture which doesn't go across the full kind of neck of femur and there's no displacement. So it can be difficult to see sometimes on X ray, but I've tried to label it with a blue arrow. So you can see a crack along the neck of femur, but there's no displacement of the joint. Type two is a complete break across the neck of the femur. And again, there's no displacement. So the only thing differentiating type one and type two is whether or not it's incomplete or complete. And as you can see here where I've tried to label with the Blue arrow, there's a crack all the way across the neck of femur, but there is no displacement. Type three is when you have a crack across um the neck of femur. So a complete fracture um but on this occasion, you do not have you have partial displacement. So I've tried to show you with the Blue Arrow, but you can see a complete break, a complete crack and then you can see by the position of the kind of greater church, Hanta er and as well, if you were to draw a line from the middle aspect all the way up to the head of the femur, if it's not your typical ice cream on cone appearance. And so there's a degree of displacement type four is when you have a complete fracture with complete displacement. Um So you can see in the middle image, this is when you've got the kind of transfers, complete fracture and then you've got displacement of the bone. Um So if you can see on the left hand side, again, you've not got that typical ice cream head sat on the cone anymore appearance and this indicates that you've got displacement and you can see again in this image here. So why do we obsess over centonze lines? Um So centonze lines are just a ready radiology kind of tip in order to quickly identify whether you think somebody has a neck of femur fracture. So two things to note when Lymes is it needs to be continuous and it needs to be smooth. So as you can see on the right hand side, you have Shenton Slime where it's continuous and smooth and you can make a curve all the way down from the pelvis, all the way down the shaft of the femur, whereas when you move over to the r left hand side of the patient, right, and you see when you start to make the curve of the line, it doesn't follow the same path as the hip which is not injured. Um So if you look at image a, can anyone identify which side the fracture is based on what I've just told you and you can post in the chat and can uh you can put the mic on and let me know. So uh everyone's saying, right. Yeah, exactly. Um So using Centonze Line, there's no kind of clear obvious curvature and, and the fracture is uh intracapsular fracture um of the right hand side. So how do we manage these? So uh inter capture their fracture. The definitive management often is a hemi arthroplasty. So the reason this is as we spoke about is because often the blood supply is um compromised. So the head of the femur is essentially going to die because you have um compromise the blood supply to it and it will get a vascular in a process. So this is why patient's will go for a hemi. Um The only kind of situations that you would maybe consider not doing that is the gardens um one or two class because these structures tend to be undisplaced. So there's no movement of the bone which kind of goes retrograde towards where the main blood supply is. So often if they are a young fit individual patient who doesn't have a displaced fracture. Sometimes the orthopedic surgeons who just made the decision to do either cannulated screws or do a dynamic hip screw and kind of warn the patient that there may be a risk that this might feel. And if that's the case, there's a risk for further operations and you might require a hemi or a total hip replacement. But we can start with this in the first instance, but they are the only two exceptions and when it's not displaced, now why some patient's get a total hip replacement versus hemiarthroplasty um is basically based on the kind of functional baseline before they came into hospital. So a total hip replacement, ideally nice cafeteria asset that they need to be previously independent and mobile. So either using one stick or less, they need to be cognitively intact. So there's a very high mortality after kind of operative neck of femur fractures and a total hip replacement is one of the biggest operations you can do. Um So it's important to make sure that their cognitive, cognitively intact and also that they're medically fit and often you're anesthetic S a score can guide you in this often. Um the surgeons will up for a total hip replacement if they get an image of the hip, and there's a large degree of osteoarthritis in the pre existing hip because if they fix that fracture of any way with a hemi, um it might mean that they would need kind of further operations in the future. And so they do tend to opt for a total hip replacement, extracapsular. So there's no concern over the blood supply being compromised. So often fixation can be done and that can be done either with dynamic hip screws. So they're using lots of different drills and guidewires, drilling in kind of screws to aid with primary and secondary bone healing by creating um compression on the bone and intramedullary nailing. Um And often the surgeon will decide which one they want to do um in relation to this. And this particularly dynamic hip screw allows the fracture ends to slide. So as they're sliding on each other, they're able to promote bone healing because you've got constant kind of osteo class and osteoblasts activity, postop management. So as I said before, delirium in neck, a fema, um fracture patient's is often common in the elderly, but also it's a big operation often requires um quite a not a long time, but sometimes depending on the patient, it can be a couple of days, even up to a few weeks, um kind of POSTOP rehabilitation process. And so you need to be monitored in uh for things of delirium. Often they're getting a lot of opioids because they're very, very sore, which will knock them off. And so kind of early time bundles, early involvement with the nursing staff to look out for signs of delirium and explaining to patients' families. You know, this is expected, this is delirium and um this is what we planted to reassurances often enough and you need to stratify them in terms of risk, whether or not they're moderate high risk, particularly for their V T E. And is that will dictate how long they will have, for example, enoxaparin for. But typically it's 5 to 6 weeks of an oxy pattern and that's often starts six hours post operatively, you want to have early PT and OT input. So typically you want the patient's kind of up as soon as they are able to, to mobilize. This is particularly important and dynamic hips cruise because it's actually the mobilization that kind of promotes fracture healing and promotes, you know, further bone and healing and things. So it's really important to get the patient's up. And as I said before, a lot of these patient's are elderly patient with lots of co morbidities who are likely to become delirious POSTOP and so early Ortho Jerry input for specific patient's emergency orthopedic issues. There's septic arthritis and there's also compartment syndrome, but I will discuss compartment syndrome in a future session in the interest of time. So, septic arthritis, you want to think about septic arthritis and any patient who presents with a traumatic joint pain um is really, really important to identify these patient's early because there can be complete destruction of the articular cartilage in under 24 hours. So it's really important. Um Septic arthritis can be infection one or one or more joints and it's most commonly caused by staph aureus entering into the Synovium. There's lots of other causes a, particularly if they're sexually active, then everybody about gonorrhea and if they're an IV D, you, then everybody about pseudomonas, but typically it's staph aureus. So how did they get into the bloodstream? Um, similarly to kind of lots of infective process is if you think endocarditis, infective endocarditis, often there's a bacteremia and it seeds in through the bloodstream and the tears to kind of damage um into cardio valves. Um, similarly with septic arthritis, you've essentially got the blood stream which allows the bacteria to hit her right to get to the joint and then they just seed into the joint and, and you get a septic picture. Um Also when people are having operations, there's a risk of introducing infection. Despite all the precautions that are taken to try and minimize this, it still is possible and, and as well as patient's have kind of what can be skin wounds initially and it allows entry of bacteria into the bloodstream. Um So it's important to know um they can be either native or prosthetic joint infections. So when you're taking a septic arthritis history, and typically they will present with pain and swelling of the affected joint, um some of them can become septic as a result of this. So you need to keep a close eye on systemic upset. Do they have a temperature? Are the tachycardic? Is the BP dropping any concerns of this? You need to be activating the sepsis. Six whilst your source control, is that joint there systemically unwell? So you need to get fluid into them and you need to get IV antibiotics up. It's just as possible. And what typical questions do you want to know on a septic arthritis history? So which joints and they might come with um one knee but failed to mention that they've also got, you know, red hot, swollen elbow and that you might not see if the patient's lying flat in bed. So you need to ask them which joints is it one joint? Is it multiple joints, any previous trauma, local symptoms? So, when did they start noticing that they draw, it was swollen? When did they notice that it was red hot to touch? When did they start to lose the ability to be able to bend the knee? Because that's really important because if it's a kind of a sudden onset, then typically consistent basis septic arthritis, whereas if it's been a more chronic thing and they had a recent knee injury and then they're complaining of aches and pains and a bit of swelling and you'd be thinking less lightly sepsis, but it's still important to always have in the back of your mind and systemic upset as we've already spoken about. Um, it's really, really important to know whether or not they've had previous surgery to that joint because that will ultimately dictate what you can do. Um, if it's a prosthetic joint, you by no means want to go near that joint at all to aspirate any of the fluid out on a, on a ward in an A D setting. It has to be done sterile in an operative theater. And so it's important to know all previous surgeries and when the surgery was them, um whether or not they have risk factors. So, are they diabetic, are they on immunosuppressant drugs for another underlying condition? Because this so effectively impact their ability to fight this infection? Um And are there current IV D you because this will dictate kind of what organisms you're expecting to grow and might guide your micro management in terms of the patient's. So when you examine them, they're, they've got a lot of pain, they're very, very swollen and they're unable to weight bear. And typically a lot of them will have fevers classically, if you're worried about aseptic need, they very, very rarely are able to straighten their leg for you. And so it's held and slight flexion if you're worried about aseptic hip and it might be slightly flexed, abducted and externally rotated. So often before you even asked a patient, the question just examining them, remind the bed you're able to work out which joint is sore. Um There'll be reduced range of movement and that is on both passive and active and the joint will feel warm when you're comparing it to the other one and they'll be erythema of the joint. So immediate management as with every um admission, always A B C D E. Um if you suspect sepsis. So if there's any systemic upset, you need to start the sepsis six, you want to get blood cultures and you want to get the usual bloods off of them and you want to do a urine dip in an MSU. And if I'm sexually active individuals, you might consider doing an S T I screen, although this often isn't indicated in the very acute setting, but might be something you consider during that admission. And the Gold Standard investigation needs to be joint aspiration because this is ultimately going to guide your antimicrobial management. And without joint aspiration, you essentially don't know what you're treating and it leads to increased antibiotic resistance and can sometimes you can get on top of the infection if you're not treating with the right um antibiotics. So typically, um joint aspiration will be sent for white blood cells. Um gram staining cultures and crystal microscopy. That's important because obviously within your differential diagnosis is go out and so do go out. Um So if you're sending off an aspirate anyway, you may as well um investigate for other possible causes. Um with any source will enjoin, typically, they will get x rays. Are we actually missing a fracture. Um So get an extra in your patient. And also it might tell you whether or not there's an alternative diagnosis. If you notice, you know, chondrocalcinosis on the knee X ray and an elderly female and might be kind of more pointing towards gout. But the important thing to know is if you're suspecting septic arthritis, even if you have, uh, kind of other differential, don't delay giving the antibiotics, they'll come to more harm by choosing an alternative diagnosis then starting antibiotics. Um, yeah, ideally want to start them, but like after you get the joint aspirate but do not delay giving the antibiotics if somebody's not around and they're not able to do a joint aspirate until a couple hours because they're tied up in theater and nobody's able to do it, start the antibiotics, but make sure you tell your senior that this is what's happening. Um So that they know um but ideally, you don't want to get a sample off. So the main principles of management are obtained a sample, treat the systemic sepsis and treat the local infection. So how do we treat the local infection? I the septic arthritis. So native joints typically go to theater for either um arthroscopy or open irrigation and wash out of the joint. Now, the reason they do this is to reduce the septic load because of you have, you know, a source which is clearly coming from the joint and it's constantly feeding into the bloodstream. Um your tip, your patient's always going to be septic. So you need to kind of source control and remove that source of infection. And also as we said, at the start, there can be extreme damage to the cartilage and then under 24 hour period. So um wash these joints out and continue to treat them systemically. Often they will take um kind of samples, culture samples in theater and these can take a couple of days to come back and they will then tell you what they've grown. And so you're getting kind of direct source control and you get early microbiologist involvement who will then tell you to target your antibiotic therapy based on what it's grown. But typically, um they tend to get started on a regime, for example, Vanc and GEN and then once you get the cultures back, they then might advise you to start something else or change in to specific antibiotics, prosthetic joint infections. So these are, this is a serious, serious complication of surgery. It's very difficult to treat as the bacteria adhere to a bio film which is formed on a prosthetic joint and, and often the antibiotics cannot penetrate it. And so unfortunately, these uh situations often result in kind of further surgical intervention because you need to remove that metal work. So never aspirate on award or needy. This is one of the most important propose in the orthopedic department. It must be aspirated in theater under sterile conditions. There's two higher risk of introducing peri prosthetic infection if you aspirate a non operative setting, if they are systemically unwell with a possible prosthetic joint infection, they need to go back to theater ASAP. So either acutely for a wash out and kind of do bribe mint or it can be a more staged approach. So often it can be a single staged approach where they wash out the joint with kind of saline irrigation, they remove the infected prosthetic material and they pop in a new prosthesis at the time. Um if there's clinical concern, so say, for example, there are immunocompromised patient, they're an IV D you or they, they have kind of higher risk factors that mean that they might not be able to fight off that septic load as well as somebody who's normally fit young individual. Then they might consider doing a two stage revision um where they run, move the infected metal work, they wash it out, then they leave it with no prosthesis or they might pop a spacer in which is basically uh cement, which is loaded with antibiotics and leave that in place. Then once the infection's cleared, they'll then take them back to theater for the second stage and pop in a new prosthesis and reimplant it. Um Thank you for listening. Very sorry about all the technical issues. And please let me know if you have any questions or anything that you can hear and you want me to go back to, I'm happy to do so.