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So I thought we'll go through um some questions. So how it'll work is I'll give you a question. I'll give you about a minute to answer. I think Aggie's created a poll so you can take your time to pick which of the options A to e you would go with and then we'll go through um and discuss. So I've done about 10 questions and they cover different topics within orthopedics. So hopefully you should get a general idea. So we'll start off with question one if that's OK. So a 50 year old woman who is normally healthy and independently mobile presents to the ed complaining of severe hip pain after sustaining a mechanical form, plain radiography of her pelvis reveals an undisplaced intracapsular fracture of the femoral neck. There are no signs of osteoarthritis visible on the radiograph. So, what is the best form of treatment for this patient's hip fracture? A cannulated fixation. B, hemiarthroplasty C total hip replacement, da non operative management and e intramedullary nail. So I'll try to give you about a minute and then Aggie, if you can tell me what people pick after that, please. Yeah, no problem. You can also tell me if everyone's answered already, then we can move quick. Uh, we've got two responses of, uh, most, uh, like both of them picked a. Ok. Um, fine. Is that everyone or should I wait a bit longer? Um, I think that, um, was it, there's a few on that a little but like I think, um, yeah, that's all. Ok. Fine. So, uh, you pick cannulated screw fixation. So, that's correct. So, we'll go through a little bit about NS um, the important things to recognize in this stem is that the patient is 50. So she's actually quite young in terms of your typical n population and she's independently mobile. So that's quite important when you're, especially when you're trying to decide between total hips and hemiarthroplasties. The next part about it is that it's an undisplaced intracapsular fracture. So that tells you quite a bit. So it's intercapsular and it's undisplaced and that can help you determine which stage of the garden classification this kno is. And then there's also no signs of osteoarthritis. So we'll go through kno and it'll make a bit more sense as to which one we picked. So this is what a cannulated hip screw fixation looks like. It's basically three screws that are cannulated, which ba means they're hollow in, in between. They have a hollow segment in between the, in between the screw. And that allows you to basically screw over a guide wire and you put three in a triangular sort of pattern to get three point fixation. So it basically prevents the femoral head from rotating in in the acetabulum. So neck of femur fractures, we always operate on them and that the reason is 10% mortality in 30 days and there's a 30% mortality within one year. So the option that said non um surgical isn't really an option at all. So the aim of any neck of femur fracture fixation is to make sure that the patient can weight bear fully without restriction in the immediate postoperative period that massively reduces any risks of complications um with the fracture and the fixation of it. So the garden classification is really important to know it comes up quite a bit. It has four stages, you have stage one and stage two where the fracture is undisplaced as stage one. It's an incomplete frac fracture and stage two, it's a complete fracture, but they're both undisplaced. When a fracture is undisplaced, you can actually try to fix it. It's only in stage three and four where there's displacement and um and a complete fracture that you need to replace it. Ok? When it comes to replacing a fracture, uh and fractured uh neck of femur, you have two options. The options, a hemi arthroplasty and a total hip, a hemi arthroplasty is half a hip replacement. So you only replace the uh the femoral neck and the femoral head which is um and the stem and you keep the acetabulum of the patient in a total hip. You also uh create an acetabular cup and then you replace the femoral head, the stem and the neck. So to pick if your patient will have a total hip or a hemi, there's three criteria on nice guidelines that need to be met. So the patient must be able to walk outdoors with no more than one use of a stick with the use of no more than one stick. They shouldn't have any comorbidities that makes the procedure unsafe for them. Total hips have quite a high risk of bleeding. They're quite in invasive procedures. It involves cementing sometimes and reaming all of these increases your risk of fat embolisms of pulmonary embolisms. Um So these are things to be aware of. So the patient can't be someone who has a lot of comorbidities and they should be able to carry out activities of daily living independently for more than two years. So they basically need to have a life prognosis of more than two years to be considered for a neck, a feur fracture. So then you have your extracapsular fractures. So within the capsule, your intracapsular fractures can be split into subcapital. So that's just underneath the femoral head, then transcervical. So in the midway of the femoral neck and then basal, which is basically right just about at the edge of where intracapsular is. So between the trantas, then you have extracapsular So you can have an intertrochanter fracture, a per trochanter or a subtrochanteric fracture. So, intertrochanter as the name says is between the two trochanters. So GT and LT, those fractures and uh are always treated with a dynamic hip screw. And then you use an IM nail, which is an intramedullary nail. So it's a large nail that goes from the top or from the knee, sometimes when most commonly from the top, from the GT down through the bone all the way down to the bottom. So those can be used for anything below the trochanters. So subtrochanteric nails, any mid femur fractures and for what's called a reverse oblique fracture. So if they say it's a reverse oblique internal uh so a trochanteric fracture, remember that you can't do a DHS. So that bottom picture shows you what a reverse oblique fracture is. It's how the fracture actually extends um from the lateral cortex into the um towards the femoral head. So that's a reverse oblique cause you don't have a, a good lateral cortex. And in the DHS, that's where your plate sits. So you wouldn't be able to sit that onto the femur. OK. So question two, a five year old boy is brought to the emergency department after a severe fall uh onto his right knee. The child is in a lot of pain and the right knee appears swollen. Radiography of the right knee reveals a fracture of the distal femur extending through the epiphyses, pfizers and the metaphysis, which type of epiphys injury has this child sustained according to the Salter Harris classification. So A is type one, B is type two C is type 3d, is type four and E is type five. So again, Aggie, if you can just let me know when people have answered. Uh Yeah, no problem. Um I've got one response of, I've got two responses, then we'll just give it a short while and then I'll let you know. OK. No worries. Uh Right. So most of the demands are type four. OK. So that is the correct answer. So, um we need to look a bit about the anatomy of a bone to understand this. So the regions of the bone. So your fasces basically is your growth plate. So it's a hyaline cartilage growth plate. It's where your endochondral ossification occurs. So that where that's where your chondrocytes basically replace what's cartilage or preliminary bone with real bone. Your ps is present present in females up to 15 years and in males up to 17 years. So Salta Harris fractures are only in Children. So anybody below 15 and with girls, anybody below 17 and males, you can start using Salta Harris classification. OK? So when you look at the bone itself, you have an ep epiphysis, which is the sort of most distal end, you have a pisis and then you get your metaphysis and then becomes the diaphysis, which is sort of the shaft of the bone. So, Salta Harris and this is a really easy uh way to remember the classification and the classification does come up quite often. So you have your normal bone that you can see um towards the left hand side of the screen, then you have type one that's straight across the piss. They're quite hard to see generally because they are just straight across the piss. OK? Type two is where it extends above. So it's going into the metastasis. Type three is uh lower. So it's going through the phys and below. So into the epi epiphysis, in this case, epiphysis and the T is through. So it's going through all three parts of it. And then type fi uh type five is where it's basically crushed. So the pus gets closed. Type two is the most common uh generally in Children. So that's something to remember as well. So if in doubt, you can't remember them and your exam goes with type two and then type five gets very commonly missed actually because as you can imagine, it's kind of just looks like an adult bone because the Pfizer just closed. Um And those patients can actually get picked up a lot later with um growth restriction. So that's something to consider because it's very important in Children to re recognize the importance of making sure that the Pfizer stays patent if you have uh put a instrument through it. Um If you've like drilled through it, put a screw through it, you're basically going to cause growth, arrest and limb length deformities. So, discrepancies. So that's something to keep in mind. So type one and type two Salter Harris fractures, they're generally minimally displaced. They have quite good outcomes. You can just conservatively treat them, obviously, depending on where the um fracture is. Then you, it does that dictates which type of cast you use. But you can just do like a closed reduction and maintain them in plaster. Then type three and four ha is greater displacement and it's a lot more unstable. So you need to have a lower threshold for an oro and then you have type five fractures and they are generally a retrospective diagnosis like I said, where the patients presented with growth or limb deformity, those fractures tend to only be treated in specialist center care. So it's very unlikely that they'll ask you the management of those type of fractures. OK. Question three. A 30 year old lady falls onto her outstretched left hand. She's taken to a local ed where she complains of severe pain in her left forearm, under posture and lateral radiograph of the affected forearm, reveal fracture of the proximal ulnar with the disruption of the proximal radioulnar joint, which of the following best describes this sustained injury. So A is a Barton's fracture. B as a Collie's fracture, C is a Gallii fracture, T as a Montag fracture and E is a Smith's fracture. Um So some of them answered Monte and some of them answered Gallii. OK. Fine. So we can go through that. So this is actually Monte Fracture. Um I used to find this really confusing back in the day when I was also studying for my part. A so the we but the it comes up so often that we just need to kind of go through it and try to find ways to remember it. So we'll go through each and every one of them. So you have your barton's fracture, which is the first option. So that's a distal radius fracture, as you can see in the X ray. And the specific thing that makes it a Barton fracture is that you can see that it uh it extends into the articular surface. Any fracture that extends into the articular surface is quite um you should uh you should like try to treat it as much as you can. The reason is there's a higher risk of developing postoperative arthritis in any fracture that involves a joint. So that's something to also keep in mind. The next is a Colles fracture. So a colli fracture is basically when you have a distal radius fracture and it angulate dorsally. So you have your dorsal aspect, which is sort of the outer aspect of your hand and your palmar aspect, which is the palmar aspect of your hand, which is also called the volar surface. So when the radius gets broken, it can go either way, you have a lot of tendons on the dorsal side. So you can actually pull it down dorsally. And that's called a coli fracture. OK. It's a bit more common than your Smith's fracture. So you smit's fracture is again a distal radius fracture. So everything we've seen so far is radius. OK? So Barton's is intraarticular collis is dorsal angulated. So, and then you have Smiths, I used to think of it like c is closer to da as co uh collis. Dorsal and Smith's s is close to be. So it's var angulated. OK. So this comes out towards the palm. So again, collis is more common than Smith's. Next is your Montia fractures and your Gallii fractures. So the two things that make it uh two things that differ with both of them is which bone is broken and which joint is affected? Is it the proximal or the distal radioulnar joint? So, with a Montet fracture is actually an ulnar fracture. OK. And it's a dislocation of the proximal radial ulnar joint. So in this x-ray, you can clearly see that you have a um sort of a proximal and um ulnar fracture and you can see that the radial head has come out out of the joint. So you have a proximal radial ulnar joint, uh dislocation and you have a um ulnar fracture, the radius isn't actually fractured. OK. In a Gallii fracture, it's a bit different. So your radius is fractured and it's your distal uh radioulnar joint that's uh dislocated. So that, that's how you need to somehow put it together. So your Gallii fractures is radius and it's your distal distal radioulnar joint. Your monia fractures is your ulnar and your proximal radial ulnar joint. OK. So question four, a 28 year old footballer is injured during a football match, sustaining a closed fracture of the left tibia and fibula. The nurse is an ed apply and above knee back slab. He requires a lot of analgesia. What is the next most appropriate step in managing this patient? So A is admitted for observation on the ward B is advised to weight bear as tolerated and discharged with fracture clinic. Follow up c is advised not to weight, bear and discharge with fracture clinic. Follow up request act scan of the affected area. And then the last option is arrange operative intervention at the next available opportunity. So, Aggie again, just let me know when people have answered. Um So we've got a few mixed answers. So there's um ad and e fine. Ok. So this question's QA bit tricky because it is um it's a bit vaguely worded. So the first couple of things is it's a patient. It that's young who has a fracture of the tibia and the fibula. So we kind of already know what the fracture pattern is and tibia fibula, you can know that that's quite an unstable fracture. Already, the Ed team I applied an above knee back slab. We don't know whether it's too tight if it's compressing onto the uh onto the calf. So that's something to take into account. He requires a lot of analgesia. So as soon as you read that sentence, the first thing that should go off in your mind is oh, could it be a compartment syndrome? And then what is the next most appropriate step? Those the key words in this entire thing that will help you decide which is the right answer is next most appropriate. And the reason is um ok, so let's go through our options. Admit for observation on the ward, very reasonable. So we'll keep that on there advised to weight bear is tolerated, discharge with fracture clinic, follow up discharging this patient and weight bearing is very um it's just not appropriate at all at all. Firstly, tibia and fibula are gone. So that means that the ankles are completely unstable joint. So the patient weight bears, there's no hope that this is gonna heal two is that uh discharging the patient home when they're having a l ongoing severe analgesia. Uh sorry, severe pain isn't really appropriate either. So I would cancel be out, see, advise not to wait, bear and discharge with fracture clinic followup. Yes, they shouldn't wait bear. But again, this is a patient with a very unstable injury that needs a um that needs af an or if most likely and also is again in a lot of pain. So when a patient's acutely going through something, let's not send them home. So we'll cancel CD request a CT scan of the affected area. Normally a decent idea. Now, the reasons for organ organizing a CT scan in orthopedics are almost always one operative planning, but they're not really going to ask you about that in MRC S two is if you don't really know the injury or it's a big trauma and then three would be like your CT angiograms in something like a um knee dislocation and you need, and you're worried about the popliteal artery. In this case, we actually know his tibia and fibula are fractured. It's a closed fracture. So because we know the fracture pattern, the CT won't really add anything in terms of the most appropriate next step. So I would actually say that that's probably third on our list of what we could do and e is arrange operative intervention. That is a good idea because this patient likely has compartment syndrome and will need fasciotomies. However, that's the most definite, that is a definite management. The ideal next appropriate step would actually be admitted for observation. OK. So let's go through a compartment syndrome. It's when there's critical pressure increased within a confined compartment space. So you have your fascia around your muscles. So you have four compartments in your lower leg. That's the place that they normally tend to uh give you compartment syndrome in any M CQ. Um And your fascia basically is like a tight stocking around the muscles and it doesn't expand. So when you have any fluid build up within that compartment. So from reperfusion, from DVTs that have caused venous congestion, um from fractures, causing bleeding. All of this basically causes swelling of those muscles, but you have that tight fascia that's holding it in place and then that can compress on any arterial inflow. It can compress on nerves. And so what happens is you have a patient who's in insanely severe pain. The main symptom of com of compartment syndrome is pain. It'll be pain out of proportion with the injury, pain on passive stretch, you'll get later signs of your six ps that they love to say. So you're evolving neurology like your pale, pulseless perishing cold limb, the pulses don't have to be gone and they don't need to have paresthesia to consider compartment syndrome. So the picture there shows a forearm compartment and they're using modified Henry's approach to do a fasciotomy and release the fascia. So how I would treat this patient is you should ideally keep the limb at a neutral level. So they're lying in bed, make sure you have pillows underneath the leg and keep the leg at the level of the heart. Ok? Put the patient on high flow oxygen. If they're hypotensive, we need to increase that BP to make sure they're getting uh blood down to the, down to the foot. Then you need to remove any dressing splints and casts. So this patient who's had this above knee back slab, very likely that might be the cause or even in the lower leg tib fib fractures, there is a very high risk of compartment syndrome. So we need to consider that as well. So remove the dressing, the splint and the cast and then look at the legs see if that helps give them lots of analgesia and then prep them for theaters and take them over for for emergency emergency fasciotomies because that's a limb. Say a limb threatening condition and needs to be operated on very quickly. Ok. Question five A biker is brought to Ed after being involved in a road traffic accident, primary and secondary survey reveals injuries only to his left leg. Examination of his left leg reveals a five centimeter laceration over the medial aspect of the leg with as an associated commun fracture of the tibia, the wound is moderately contaminated but without any obvious soft tissue loss, neurovascular status of the leg is intact. How might this injury be classified on the basis of the Guilla Anderson classification of open fractures? So A is type one, B is type two C, is type three A T, is type type three B and E is type three C. Um So there's a mixture between B and C OK. Fine. So the correct answer is C So type three A. So let's go through this classification. So this is your classification for all open fractures. It's important to know again, it did does come up. So type one is if it's a wound is less than one centimeter. So type one to type three, the way to differentiate is generally if it's based upon sizes. OK. So type one, less than one centimeter. Type two is 1 to 10 centimeters of and the wound is generally clean. Type three A is if it's greater than 10 centimeters or if there's some soft tissue damage or there's some contamination to it. Ok? Type three B is a greater than 10 centimeter wound is a soft tissue damage, contamination and periosteal stripping and type three C is anything that has a vascular injury involved. So the size doesn't matter for type three C. Ok? And actually for all type threes. So in this patient, I know that the wound was only five centimeters. So you'd be quite keen to go for type two. But the important aspect to rec recognize is that the wound, it it is moderately contaminated. So contamination is only really involved in type three, type one and type two wounds are clean. Ok. Contamination does change the game a lot with open fractures because you need to be a lot more aggressive with your antibiotic treatments. So we'll go forward with open fractures, sorry for the kind of scary picture. So IV prophylactic antibiotics within one hour is, is key. So give them as broad spectrum an antibiotic as you can and make sure it's intravenous. No, no role for oral antibiotics in these cases. Then you can tailor it uh, later on. Ok, then you need to give them a tetanus vaccination or booster depending on their vaccination status. All or contractors need to get that open fractures again. can bleed a lot with the open wound. You don't do anything to it. You, there's no role for manual pressure to it. There's no role for um sticking your hands in it a lot and like exploring the wound. There's no rules for any of that. The only things you do is if there's obvious gross exam, uh contaminations, let's say they have fallen in mud or there's a glass in the wound. Things like that, you can remove that. You have to get photos of the open wound and you can wash it out in A&E with about a liter of fluid. Ok? And you just put a saline covered, like soaked gauze to just cover the wound. And that's all you do. You need to realign the affected limb and that's really important. And the reason we tend to realign these open fractures is one, it reduces a fracture, but it takes the pressure of the surrounding skin, which it can cause ulceration of the skin. You can damage the skin and then it's gonna be really hard to ever get some skin coverage over, over that. It'll reduces the, uh, pressure that it exerts on any surrounding structures of vessels, nerves cause you can get sort of uh neuropraxia and things like that. It also will help with pain once you realign it. So splinting a lower limb fracture, um, that's something that you can also learn about. So basically, you just need to have traction and then you put straps around the leg and you connect it to a a it's kind of like a bar that you tighten and therefore it continues to give that traction. Then all organ fractures need operative management. And the operative management is debridement and fracture management. If there's any vascular injury, which would automatically make it a type three CG Anderson classification. Uh You need vascular input as well and the aim is to get definitive soft tissue coverage within 72 hours. So this is all in your bo guidelines and that's quite important e important guidelines, quite easy to read. There's only about 10 documents or so, but they're all like one page single, a four pages. Uh and they tell you how to manage uh common things in orthopedics and trauma. Ok. So question six, a five year old boy is brought to Ed by his parents after falling off, a carousel examination reveals an angulate, sorry, that's meant to say angulated, angulated right elbow and cold distal right hand with no palpable brachial radial or ulnar pulses and poster posterior and lateral radiographs of the elbow, rar displaced supracondylar fracture of the right humerus. Which of the following options describes the most appropriate initial management. A apply a plastic cast and arrange an outpatient review. B initiate thromboprophylaxis to prevent further ischemia of the upper limb c manipulation of the fracture under general anesthetic d open reduction and internal fixation of the fracture, e surgical exploration of the right antecubital fossa. Um So it's a mixture between C and E C ne OK. Fine. So let's go through it a bit. So five year old boy, so Children are tend to be treated a bit differently to adults in certain things. So for them, we try not to traumatize them because uh they can get very scared and needy when you start manipulating things like you can do in an adult. So that's something to keep on. Uh keep in your head. OK. Um The patient is neurovascularly compromised. So very clearly has no palpable pulses. OK? And there's a displaced supracondylar fracture of the right humerus. Kids tend to get supracondylar fractures very often and they often look like the scariest x-rays you'll see. Um So that's also something that does occur quite commonly in Children. So ever they start, I if they ever talk about upper arm fractures in five year old in children's start thinking about supracondylar. OK. So first apply a plaster cast and arrange an outpatient review not really appropriate because the patient's neurovascularly compromised, it's not gonna get any better if we don't do anything. So let's take that away. B initial thromboprophylaxis to prevent further ischemia that's not really appropriate in a child that's not gonna fix the situation. And generally kids are not vascular paths who are developing clots everywhere. So it's not something that we generally consider. You don't really even give uh prophylactic V TVT E prophylaxis in um Children with fractures. We tend not to do that because they will uh they're not very uh quite, they're not at high risk of developing clots. OK. See manipulation of the fracture under G A very reasonable on the G A because again, we said we don't wanna traumatize Children in adults, you can give them um Entonox and do it in ed. So that's a thing to be aware of d open reduction and internal fixation of the fracture. That is what this patient will inevitably need. However, that's is that the most appropriate initial management perhaps not cause how quickly can we get them to theater? And this arm at this point is dying. So we need to intervene a bit better e surgical exploration of the right antecubital fossa. So that's quite an extreme measure. It's not something that's very commonly done. Yes, they very clearly have this brachial radial ulnar pulse um that's occluded. However, in this case, it's most likely to be because of the fracture. So, exploring that area, you know what the cause is, it's your fracture. So you need to fix that fracture. It's dislocated, it's massively displaced. So the most reasonable thing to do would be manipulation of the fracture under general anesthetic. That's generally what we do with most kids. Ok. So supracondylar fractures, it's a very common pediatric elbow injury as we talked about, the peak incidence is 5 to 7 years. So this child who's a five year old really fits in, they tend to fall onto an outstretched hand with the elbow and complete extension. So all the sort of like pressure goes from their hand into their elbow and the elbow breaks. Ok. They'll have an obvious deformity, there'll be swelling, there'll be reduced range of motion and supracondylar fractures because it's in the elbow which where your all your nerves pass, all your vessels pass. There's a high risk of it being associated with neurovascular compromise. I've seen quite a few myself within one year in orthopedics. So that's something to uh keep in mind. So always assess for your median anterior endosteal nerve, radial and ulnar nerve function. And for any vascular compromise in these kids, uh orthopedics, we love classifications. So, supracondylar fractures, it's gland classification. So type one is where it's undisplaced. So you can see that in the bottom picture from the uh left type two is where it's a displaced, but only in one plane. Type three is where it's displaced in 2 to 3 planes, but both type two and type three tend to have. So type two has an intact posterior cortex, as you can see. OK. And type four, there's just complete periosteal disruption. So in this X ray would just be the complete periosteal disruption. It's a type four. OK. How are they managed? Uh if neurovascular compromise, we need to immediately close reduction. And once we've done the close reduction, we need to do something to maintain that reduction. So we put K wires in and then we have to remove the K wires at a later date, generally about six weeks down the line. OK. When it's one of the earlier types of gland. So type one or type two, you can consider just conservative management. So you can put it in an above knee, above sorry ab above elbow cast and you end to put them in 90 degrees of flexion because that's a position of safety when it comes to your elbow. Ok. Question seven, a 50 year old female slips on wet floor, injuring her ankle, on examination. She has tenderness over the lateral and medial malleolus x-rays which are stress views. That's also like a weight bearing view. Basically demonstrates an undisplaced fracture of the distal fibula at the level of the syndesmosis and a congruent ankle mortis. What is the most appropriate management? So a application of a full leg cast b surgical fixation, uh ac application of a below knee, plaster cast d application of an external fixator and E bed rest splinting and traction. Devon's at sea. Ok. Excellent. That's correct. So, ankle fractures, you have your Weber classification, which is the most common and I think everybody should know it. So type A is below the level of the syndesmosis. So your syndesmosis connects your tibia and your fibula together. Um just above the talus, it's made of your anterior, inferior tibiofibular ligament and your posterior inferior tibiofibular ligament. So it's made up of two ligaments and that's a very, very strong joint. Uh It's what's most important in terms of maintaining your ankle stability. OK. So type A because it's below that level, it doesn't really get interrupted. So type A tends to be quite a stable type of fracture. So type B is when it happens at the level of the syndesmosis. So that can be stable or unstable depending upon in a stress view if there's any talar shift and type C is above the level of the syndesmosis. So as you can imagine if you put a fracture above the level of where your congruity is maintained, it basically takes that uh it takes out its role, it completely the, the dymo basically becomes negligible uh ne um and therefore your type C fractures are inherently unstable. OK. So conservative management is for non displaced medial malleolar fractures. So that's of your tibia Weber A or Weber B fractures without talar shift So as we said, type B without talar shift is stable or those who are unfit for surgical intervention. So as you can see, you have type A, so it's uh a fibular fracture below the level of the syndesmosis type B, which is at the levels because you can see where the fracture um joins. So extent from there all the way into where the uh syndesmosis is, but there's no evidence of talar shift. So that's an, an uh that's quite a stable ankle type C is where the f it, the fractures above because it's above the joint, uh the syndesmosis no longer functions in the way it should. And this is an in unstable ankle. So how do we, this is to show you what a Weber B fracture with talar shift would look like this is an extremely unstable ang uh unstable fracture. So you can, you can see that widening of the t between the talus and the medial malleolus. Um and that will, that is your talar shift there. You can also see opening up of the syndesmosis. So instead of the two bones touching each other, there's a clear space around it. So you need operative management and then uh with an open reduction, internal fixation for any displaced by malleola trimalleolar fractures. So, trimalleolar, the third malleolus is your posterior mal and that's basically the posterior uh expansion of your tibia. OK. The Weber C fractures Weber B fractures with talar shift and for any open fracture, you need to do an aus. Ok. All right. Question eight, a 60 year old female presents to the emergency room. After tripping on a step, she complains of shoulder pain. On examination. There is pain on initiating shoulder abduction. What is the most likely diagnosis? Glenohumeral dislocation fracture of the anatomical neck of the humerus, sterno clavicular dislocation, supraspinatus tear or an infraspinatus tear. They want it d OK. Excellent, very good. So you guys should be pros at this. So you have your rotator cuff muscles as four. So your supraspinate infraspinous subscap and your teres um lining. And so these are your four rotator cuff muscles. It's important to know what their actions are. So your subscap basically internally rotates your supraspinate starts abduction, uh infraspinatus and teres minor together externally rotate the arm with shoulder joint abduction. It's a common thing that they like to ask, especially because they'll throw in little things like, oh, it's initiating it or it's continuing it. So it's important to recognize those particular words. So 0 to 15 degrees is supraspinatus, 15 to 90 degrees is your deltoid. It's mainly the middle fibers of your deltoid and over 90 degrees, you aren't actually just abducting anymore. What you're doing is your scapula is rotating upward and that helps you move your arm up in that uh over 90 degrees. So that actually is your trapezius and your ceraceous anterior. So that's something to consider uh a lot of orthopedic questions in MRC S part A can come across as just anatomy questions. So your anatomy is really important for that exam. So, question nine, an obese, 12 year old boy is referred with pain in his left knee and hip on examination. He has an antalgic gait and limitations of in internal rotation. His knee has a normal range of passive and active movement. What is the diagnosis? So, a septic arthritis, b, developmental dysplasia of the hip C Perthes disease. D osteoarthritis of the hip and e slipped upper femoral epiphysis. De wants ae. Ok, perfect. This is quite a simple question when you can recognize what the key words are. So obese 12 year olds, it's important to know the age categories of all the child orthopedic conditions, pain and antalgic gait, limitations in internal rotation. All quite clearly indicated of a slipped uh upper femoral epiphys. So we'll go through all those conditions cause they do come up a lot. And it's quite useful to just get a good idea of what it's like. So, displacement of the metaphysis relative to the epi epi epiphysis, I can't say that word. So as you can tell you have your femoral head here and you have your femoral neck, right? And that's your phyci, your femoral neck looks like it's moved superiorly when you compare it to a head. So that's what they mean by the displacement of the metastasis. It tends to happen in 10 to 16 years of age. So it's one of the older age groups, um, within kids. It's very common in overweight and in males. Ok. So how does it present? It doesn't need any trauma. It's not a traumatic thing. It's atraumatic and it progressively tends to get worse with hip and knee pain as well cause you, a lot of Children can present with knee pain and it's actually in the hip and ankle pain, it can be in the knee so that you need to keep that in mind with kids. Ok? There'll be a reduction in range of motion and internal rotations. What's always affected the most, there's something called on an x- A 3000 sign. So what it is is these, if you look at the lateral edge of your metastasis, so of the femoral neck, that line should normally come and inter um intersect the er epiphys. So if you see it on this side, it does. So you're OK. But on your, on the right side, you can tell that it doesn't. And that is a classical sign of a SUFI and management is with percutaneous pin fixation. So it looks a lot like your cannulated hip screws that we do in adults. Ok. So, nexus Perthes disease. So what it is is avascular necrosis of the uh femoral head. So you can see here when you compare it to this side, it's basically just disin disintegrated. It happens in younger age group compared to SU uh SUFI. So it's 4 to 8 year old and it also is more common in men. It's atraumatic. Again, you have hip and knee pain and it's just reduced pain uh globally and they'll have a uh antalgic gait. So you can tell that there's joint space widening because there's complete disintegration of this. There's collapse, there's deformity and this is quite a severe one because it's basically epiphysis is just completely, almost vanished. The management is largely conservative actually with sort of rest analgesia. Next. So D DH what happens is you get a very shallow acetabulum and that can't hold the femoral head within the hip anymore. And so you keep getting the subluxation of the uh of the femur out of the hip. It's more common in your females. It's more common as being the first born if you're in a breech position, oligo hydrase, which is reduced amniotic fluid in pregnancy. And if you're a very large baby, so macrosomia, you can examine them, they're screened in their baby screen with balo and Ortolani test. So bala is when you dislocate it. So that's where you bring the knees together and you basically just push down. So you're eye acting and depressing and that will dislocate the hip and Ortolani. And if it dislocates that shows that your uh hip is generally unstable and the reason it would be unstable in Children. D DH is really high up there Artan is when you just basically bring the knees that work together and depressed up and down. And what that does is it basically puts the femur ba uh back into the hip and that will relocate it. So, depending upon the severity you manage it with pel pelvic harnesses, closed reduction, like a casting or you'd have to do surgical if it really is not curing itself. So with open reduction is surgical osteotomy. Surgical osteotomy is basically when you make um a your own sort of cut into the femur to help realign it. It's a, it's a reconstructive procedure. Next, transient sinusitis, very common. It's all it is is your x rays will be fine. You'll have an inflammation of the synovium. Um It's very common in people who have recently had a upper respiratory tract infection. So if you're seeing any kids with this, you need to ask them or ask the family, have they had any like coryza coughing and any family that have been unwell recently. It's the most common cause of hip pain and it just tends to self resorb. You just give them sort of like CALPOL and um just manage them conservatively. The important thing is to differentiate it from septic arthritis. Septic arthritis is very severe. It needs to be managed in a hospital. We can't send those patients home and that's with cautious criteria. So a fever greater than 38.5 degrees, you're not gonna get a high grade fever and transient sinusitis. That's very low grade two is that they just should not be weight bearing on the affected limb at all. So it won't even be pain. It'll just be, they can't even it, the second their foot touches the ground, it's a lot of pain. Their white blood cells are 12 or more so, very high inflammatory markers and four is your E sr of above 40. So E sr is quite important in kids. So make sure you order that when you see a child. Ok. So cos criteria is important to try to differentiate transient sinusitis from septic arthritis. OK. Last question. So which of the following statements relating to meniscal tears is false. So, a the medial meniscus is most often affected b true locking of the knee joint may occur. C most established tears will heal with conservative management d in the chronic setting, there's typically little to find an examination if the knee is not locked. E an arthroscopic approach may be used to treat most lesions DeVos at sea. OK. Good. That is correct. So, uh trauma related injuries, they're always trauma related. You don't really get atraumatic meniscal tears, it's twisting while the knee is flexed and that's the very common um mechanism of the injury. The most common tear is a bucket handle tear. So that's basically a horizontal tear through the um through the meniscus. So sorry, vertical tear, uh signs and symptoms. It's a very tearing sensation to the knee. It's very intense sudden pain to the knee and there's a very slow onset of swelling. If there's a quick, rapid onset of swelling, your head should immediately go to maybe an ca uh associated ACL injury. Ok. On examination, there'll be joint line tenderness, joint infusion, limited knee flexion and their knee could be locked. MRI scan will assess it with an x-ray. All you really see is perhaps some hemarthrosis, some swelling, you're not gonna see too much. Uh MRI scan is how you diagnose it. You treat with rest, eyes, um, compression, elevation and then they all need arthroscopic surgery. The reason is the menisci have basically blood supply from your genicular arteries on the outer aspect. So the out the genicular arteries come from the outside of the knee and they come into the menisci. So it's only the outer surface of the menisci, both lateral and medial that have any blood supply. The internal part of it is actually very avascular. So when you've torn the internal aspect of it, so all your tests tend to happen in that area. Um like if your tear happens in that area with your your bucket handle tears, things like that they won't heal cos there's no blood supply there. Um So it depends on where the tear is. So if it's on the outer area, you can repair it with sutures because for anything to heal, you need blood supply and you need adequate repair basically. So the blood supply is there. So you can heal with sutures. If it's in the inner aspect, then you basically trim it away. So when you see it in autoscopy, they're pretty much just shaving away that as that part of the meniscus. Ok. That's me done. But uh, top tips is for when it comes to orthopedics at least. So both guidelines are really useful. They're very simple. They give you exact criteria um, to learn. So that's good. The second thing is classifications do come up. The most common ones I've covered here today. So your uh gland, your uh Gulo Anderson, um Salter Harris, those do come up and it's quite, they're quite easy marks to get when you um land those um la land them. So it's quite good thing to do. Um, MRC as part A is harder than part bi would definitely think that it's largely pattern recognition because you need to know so much content and in such depth, but they tend to ask the same things again and again. So doing E MRC S doing it twice, you will get really good at recognizing the key words and that's kind of the best way to do it. A lot of people will suggest books and things, but it kind of ends up being like you can do that if you've done E er CS at least twice. But I'd say focus on that. Uh that is majority of the papers, anatomy. So before you even get into the specialties, I'd say, like, really focus on your anatomy because even the specialty questions, you can kind of figure out with anatomy and the paper ends up being just a generalized trauma paper. A lot more than specific specialties. I remember the time I wrote it, it felt like I was in like a war zone. It was like, oh, this patient's got shot. This patient's got knocked over. This patient's been hit by a car and they like really were very graphic about it. So it was mainly trauma. So anatomy is huge. Teach me anatomy, very accurate, really good Ackland anatomy videos. Um 100% recommend as well. And then four is read the question carefully. A tip I got was read the last part of your sentence, stamp your question stamp first. So your most appropriate definitive because those are really easy ways to uh confuse this, confuse someone sitting that paper. Um So just make sure you read it really carefully and good, good luck. I will stop sharing my screen and then if you guys have any questions, we can go through it. Thanks so much brand. I think that was really great um tips as well. Um Right. So guys, the link for the feedback form is on the chat. So just to fill it up and then you'll get the certificate as well and the recording will be available later. On, uh, in our page as well and if you have any questions just unmute yourselves and ask or you can type it on the chat as well. It seems like we're good. It seems like we're good so far. Yeah. Um Right. Um Yeah, so there are no questions so far. But, um, yeah, so thanks everyone for joining in and thanks so much as well. No worries. All right, so have a good evening. Everyone take care. Bye bye bye.