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Gonna be doing the orthopedic session today. Um So we're gonna try and cover as many topics as I as we possibly can as time permits. Um, there would be some more additional topics that you might have to just read. Uh, but we're gonna try to cover as much as possible. So, these are the topics I'm trying to cover in the session. Um, we're just gonna go through the main points and a few questions and see what can be actu what actually comes for the exams and what type of questions come for the exam. So I've used the resource, I've used past medicine for the questions that I've made. Um, just because I think it's closer to the exam, right? So let's go ahead and try and with answering a few questions and then I'll explain uh based on the answer and so I'm just gonna read it out. So 41 year old man presents uh to his GP with a painful right shoulder. He is normally fit and well and plays regular tennis but has been limited recently due to the pain on examination, his shoulders appear symmetrical with no changes to the skin but he has mild tenderness over the right acromion. He can fully abduct his arm but struggles with pain approximately halfway through the motion with the start and end of abduction being pain free. He has no symptoms and a normal examination in the rest of his limb. So I'm just gonna give you a chance to answer like everyone just try and make your best guess out of it. It's, it's all right. It's, or it's Ortho I know like it's a difficult question as well, but just try and guess the answers and we'll talk about it and discuss it further, right? So I'm going to move on to the next slide. Um So the answer here is subacromial impingement. So, subacromial impingement is a part of rotator cuff and um let's go the next slide. So rotator cuff injury is something that actually prevents um the motion of abduction. So, in a question, when it comes that abduction is limited and especially the um 60 to 1, 20 degrees of abduction is limited. It's usually to do with a rotator cuff pathology. So we'll talk more about it in the next slide. Sorry. Right. So this is rotator cuff injury. So it en comprises four major pathology. So one is subacromial impingement. That's when the ligament is uh basically rubs against the acromium process. And because of that, you have pain on abduction. So if you look here, these are the four rotator cuff muscles. It's supraspinatus, the infraspinatus. Um Both of these are behind the scapula, just one is above the spinus PSIS and one is below the spinal sclerosis. There's the subscapularis in front and then there's the TD spinor as well. That's r right at the bottom. Um So these are technically the abductors of the upper limb and these four pathologies are seen in uh rotator cuff injury. So, like I said, subacromial impingement is when the uh tendon gets impinged and uh gets irritated because it's rubbing against the chromia process. Calcific tendonitis is basically there'll be calcific deposits. So the reason for this is not, um there's no specific reason for this is idiopathic. It could be because of inflammation. So, because there are calcific deposits in the shoulder joint. Again, the abduction is uh limited. Then there's rotator cuff tears and rotator cuff arthropathies. Um rotator cuff tears is basically the entire muscle gets ruptured. Um and tendinopathy and arthropathy is again, this inflammation and pain uh on abduction of the. So, um this is the test that we do. So you try and abduct the, you tell the patient to abduct the upper limb and usually the initiation is abduction is fine, but then from a 60 to 120 degree, the major portion of the abduction is controlled by the rotator cuff muscle. So that will be severely limited. Um And after 120 it's again, it, it's not really, the rest of the abduction is carried out by the, uh, deltoid. So it doesn't really affect it. So, the next topic, uh, right. So, let's try and answer this question as well. Sorry. I think the slides went a little bit a while. Um, a 50 year old diabetic. Right-handed lady presents with left shoulder pain. She describes a stiff shoulder, often more painful at night and has difficulty dressing or doing up her bra on examination. There is no point tenderness and you notice weakness in external rotation. What do you think uh is the most likely cause of her shoulder pain? Mhm. Right. So it's a that of capsulitis. I think most people have gotten it. Right. Um Right. So uh that's a capsulitis. It's also called frozen shoulder. So when the exam, it would either come up as a, there's a capsulitis or frozen shoulder. So this is inflammation and thickening of the. So the shoulder joint is uh basically a ball and socket joint and the tendons around the capsule around that the fibrous capsule gets inflamed and this causes uh pain and the external rotation is usually inhibited. So, in this situation, both the active and the passive moment is affected. Um and patients usually have three faces in a desert capsulitis. So the first is the freezing face, um which is quite painful and it's, you could still have limited uh external irritation, but it is a very painful face. And the second one is uh there's a face when um, it's all frozen together and the pain would have subsided a little bit, but you won't be able to abduct the arm because of the extensive thickening around the capsule. And the third one is a recovery phase. So it's self-limiting con condition. Usually you just control the symptoms and manage the symptoms eventually. Um, in around six months to two years, the patients would recover completely. Um, in a, in about 20% of the patients, this is bilaterally seen. Um One thing we should remember, at least for the purpose of this exam is that it's associated with diabetes. It is also associated with things like trauma or um immobility um or even ischemic heart diseases. But for the purpose of this exam, what I've seen in the questions is that they ask what is the most common um association and that's usually diabetes. Um So remember the diagnosis is usually clinical. Um it's based on the fact that external rotation is affected the most uh for management again, like I said, there's no single treatment that would cure it. It's usually self-limiting. We can give nsaids or physiotherapy to help with the pain. And if the pain is severe, we can even try intra intraarticular corticosteroids, right? Um So moving on, let's talk a little bit about lateral epicondylitis and medial epicondylitis, which is actually quite an important question for the purpose of this exam. So one thing we have to remember is lateral epicondylitis is also called tennis elbow because sometimes it just comes as stenos and it's a little more confusing when it comes like that. And medial epicondylitis is golfer's elbow. So lateral epicondylitis affects the common extensor tendon. Uh whereas medial epicondylus affects the flexor tendon which is at the medial epicondyle. Um So what do we see as clinical features? Um, pain and tenderness on the respective epicondylitis on the respective epicondyle. And you can also see numbness and tingling in medial epicondylitis of the 4th and 5th finger because the uh because the ulnar nerve is compressed at this level, um pain is uh also aggravated by wrist flexion and pronation in medial epicondylitis. Uh because that when you flex the wrist and you pronate it, you're compressing that area more, you're compressing the flexor tendon more. So the pain becomes worse. On the other hand, in lateral epicondylitis, pain is worse on resistant unresisted wrist extension because when you extend again, that tendon gets more uh stretched out and this causes more pain. So you should try and remember this as well that this is the situation in which the pain gets aggravated. So you can answer the question appropriately. Um The next one look at is cubital tunnel syndrome and radial tunnel syndrome. Um So again, I've just put it as comparison just for ease of understanding. So then maybe you can remember it easier. Um So, cubital tunnel syndrome is the ulnar nerve gets compressed at the cubital tunnel. So, um as we all know, the ulnar nerve supplies sensations to the uh medial 4th and 5th fingers. Um So you would see tingling and numb, numbness of this area. You would also see weakness of the muscles supplied by the ulnar nerve and the pain is worse on leaning on the affected elbow. Um So a radial tunnel syndrome, so that radial tunnel syndrome, like the name says, compresses the radial nerve and the posterior intra branch of the radial nerve. Um So over here, pain is seen 4 to 5 centimeters, distal to the lateral epicondyle. So another way to diagnose this is if they say pain 4 to 5 centimeters, distal to the lateral epicondyle, it's usually radial tunnel syndrome. On the other hand, um and lateral epicondylitis, lateral epicondyle. Um again, pain is again worse on extending the elbow and fating the forearm because at that point, uh the radial nerve gets further compressed. Um So this is a picture of the radial tunnel. So radial tunnel lies under the spinal muscle and uh the radial nerve runs under it. So when it gets compressed, that's where the pain happens. Um So let's try and answer this question. A 24 year old Gardener presents to a GP with a three week history of elbow swelling. She described it as having a gradual onset with no apparent precipitating factors. It is painful and warm to touch. She has no swelling elsewhere and is otherwise systemic, systemically. Well, she has a past medical history of well-controlled rheumatic rheumatoid arthritis for which she is on methotrexate. But no other medical conditions on examination, you feel a soft fluctuant mass on the posterior aspects of her elbow, which is very tender given the above findings. What is the most likely diagnosis? Right. So I'm sorry, I don't know if you guys are getting it right. But I've, I've asked one of the moderators to just let me know once you answered. Um So you're right. The answer is no bursitis. Um So let me ask you something. So, in this situation, what would be a very important differential diagnosis to rule out, please put your answers on the chat box, right? You're right. So, septic arthritis is something that's very important to rule out. Um So we'll talk about septic arthritis uh towards the end because I've clubbed it along with emergency conditions. Uh Let's talk about electron no bursitis first. So what is electron bursitis? It's also called student's elbow. So this is inflammation of the electron bursa which lies posterior to your elbow. Um So it's seen most commonly in men and it's seen in 30 to 60 year olds. Um So usually when a patient presents with electron bursitis, um if it's not very obvious, you do aspirate to see, to rule out septic arthritis. So what do you see? You see a subacute onset of a fluctuant swelling over the electron process So, if it's very obvious and it's limited to the posterior aspect and there's tenderness, erythema only over the bursa and the inflammatory markers are not too bad. And the patient still has some amount of uh mobility in his joint. You might not have to go ahead and aspirate, but septic arthritis, like I said, is an emergency. So if you have any suspicion of it, it needs to be ruled out. Um Right. So this is just what I said. So we would need to aspirate most of the times because no one can be 100% sure. And in case, um it is septic arthritis, we can't miss it out. The only way it doesn't happen is because it, if the clinical features are very, very diagnostic about it, non bursitis. Um So let's move on to try to divide the topics into just limbs. So we finished the shoulder joint initially. Now we've done the elbow joint, let's move on to the wrist joint or just a bother this joint. Um And then we'll go to hip and knee. Um So first let's talk about buckle fracture or torus fracture and we'll compare it with greenstick fracture as well. So these two are fractures that are actually seen in Children quite commonly and they're seen because uh for fall on and outstretched, how much happens quite often in kids. Um The difference between this is a buccal or tous fracture is by bulging of the cortex, it's an incomplete fracture of the long bone. And you basically see uh on an X ray an image like this. So when you look at it, you can see that it looks like a stable fracture like even if you do not um go ahead with a close reduction or cost immobilization, it'll still heal. Um On the other hand, greenstick fracture um is a partial thickness fracture. So one part of the cortex is completely broken. So this is a very good picture to understand. So a buckle fracture, there's basically an axial force like on a fallen nostril sh and the cortex doesn't break, but it gets smashed up. And in a greenstick fracture, one area of the cortex breaks. So there's a high chance that the other one breaks as well and then there's a deformity. So because of that reason, we do uh immediately go for a close reduction in cost immobilization. Whereas in bal Torres, you just need to give a removable splint so that the patient doesn't immobilize too much and make the fracture worse. Um So pre fracture again, uh refracture is quite common, you can break the other side of the cortex as well. So you would need to uh arrange an orthopedic follow up from the ed if the patient presents to the ed. Um So these are just, I haven't gone into too much detail about the fractures because um at the emissary level, this is all you need to know. Um You just need to know what it is and how would it be seen? So you can answer the question. So Boxer fracture, it's again seen when you punch a wall or uh when you put force in that way and it's just fracture of the fifth metacarpal, you can see it here and that's the fracture. Um Scaphoid fracture is actually a slightly more important topic to discuss. Um So something you need to remember about scaphoid fractures, it's usually tenderness in the anatomical snuffbox and ne it's not necessary that the X ray would show you a fracture. Uh What are the symptoms that are seen? Sometimes patients present with just pain and tenderness at the anatomical snuffbox. Sometimes there's a loss of pinch strength or grip strength because the bone is fractured. It can be joint effusion. Uh Pain is elicited by telescoping of the thumb and pain is there on not deviation of the wrist. Um So even in this, like I said, so all the features from 2 to 5 will usually be seen if it's an obvious fracture, but sometimes patients don't have any much swelling or, or anything else and it's just pain and tenderness at the stuff box. So we immediately do an X ray. Um And if the X ray shows a fracture, we would need to treat it. Uh but x-rays sometimes don't show the fracture and we will need to go ahead with an MRI to confirm the fracture. Um So in a situation where the x-ray doesn't show a fracture, you can assume that if there's a fracture, it's an undisplaced fracture of the scaphoid waist. So, what we would do is we would give a cast for 6 to 8 weeks and see if it improves. Um One thing is if there's a, if there's uh if there's a suspected uh scaphoid fracture, uh something that we should remember is that uh you can't just leave it if, if the pain patient has pain and tenderness at the anatomical snuffbox, um you should technically splint it before you discharge the patient. Even if you can't see uh obvious fracture. If it's a displaced cho base fracture, this requires surgical fixation. Um and the proximal scaphoid pole fracture as well requires surgical fixation. This is because there's a high chance that, that uh bone can get avascular necrosis. And uh because of that, you would surgically fix it, right. Let's try and answer this question. So a 35 year old woman presents to her general practitioner with a two week history of wrist pain. She reports that pain began gradually with no ancient trauma and is now affecting her ability to work as a medical therapist. The patient reports no significant past medical history on examination, the wrist appears symmetrical and there is no obvious scars or deformities, thinners, test is negative bilaterally pulling the patient's thumb with ulnar deviation and longitudinal traction over the left radial styloid produces the patient's pain. Uh What do you think is the most likely diagnosis? I think most of you have gotten the answer. Uh Yes, it's de de steno sinusitis, right? Um So what is this? So this is inflammation of the sheath containing the extensor pollicis, brevis and the abductor pollicis longus, um which comes in the extensor muscles. Um It's the first compartment. Um So what, where is it seen? It's most commonly seen in females aged 30 to 50 years old. Um What are the clinical features? So you see pain on the radial side of the wrist because of this because those two tendons. So these are the two tendons, those two are inflamed and because of this, you'll see pain on this side. Do you see tenderness over the radial, radial styloid process? Because that's the area that can get most compressed. Um, abduction of the thumb against resistance is painful and we can do the finger ST test as well. So this is this picture here is the finger sign test. So you're essentially holding your thumb and crossing it. So you're, you're in, you're stretching this area more and that's why it causes more pain there. Um How do you manage it? Um You can give analgesia steroid injections just to manage the pain. Um You can immobilize that area with a thumb splint. Um Sometimes surgery is required if, if the symptoms don't improve over like 6 to 8 weeks, we would consider surgery. Um So these are again, two topics that actually seem very similar and uh can be confusing in an exam. Um So they present quite similarly. So you would need to really read the question to get the answer. So let's go with trigger finger. So what is trigger finger? So trigger finger is an abnormal flexion of the digits due to difficulty of tendon passing through its sheath due to thickening of the fibrous tissue. So this means like you can see it in this picture, I think. So, the tendon here gets inflamed because the sheath has thickened and the area proximal to it gets inflamed and it presents like a nodule or a fibrous tissue like it, it looks like uh swelling in that area. Um And associations. It's more commonly seen in women. In the question, you could have a rheumatoid arthritis or a diabetes mellitis association and it's most commonly seen in thumb, middle or ring finger. Um So another way to identify is that there's a snapping sound that's heard when extending the digit and the nodule can be felt at the base of the finger. Um On the other hand, s contracture is due to thickening of the palmar facia under the palm causing a nodule. So if you can see here that facia around the tendon gets, uh that gets thickened and it causes a thick nodule there. So the risk factors are different. So that's one way you can identify it. Uh I think there are a few questions about the phenetole being a cause of s contracture. Um, trauma, manual labor, all this causes thickening of that area. Um Clinical features are seen. Uh So this usually occurs in the ring finger and the little finger and the patient presents with both those finger being slightly bent. Um So management in trigger finger is usually just sort of injection and give a finger, splint finger splint and usually the swelling improves. Um, and contracture. You would have to consider surgical uh treatment because it's a longstanding issue. Um, you can try conservator for a while, but, um, usually it would go on to surgical management. Let's try and answer this question as well. So, um, a 54 year old man comes to see his GP with numbness and tingling in his thumb, middle and index finger. This has gone on roughly for six months now and it is starting to interrupt his work as an accountant. He has an unremarkable medical history except for hypothyroidism, which he has had for 20 years and takes thyroxine for it, which of the following nerves are affected in this condition. I'm just gonna give one minute and right. So I think a lot of you got it right. So it's median nerve. Um So median nerve affects the thumb, middle and the index finger that's nerve supply nerve, um affects the middle and the uh ring finger. So, symptoms specific to those fingers would ideally point you towards that nerve injury. So, um this is essentially Down syndrome. So they can also ask uh what the condition is and the answer would be carpal tunnel syndrome. Um So what is carpal tunnel syndrome? So, carpal tunnel syndrome, the median nerve gets entrapped at that region um under the transverse carpal ligament. So there are a few associations. Um it's usually idiopathic but um walking more or like typing more is something that uh is commonly associated with carpal tunnel pregnancy also causes is an association lunate fracture. That region can also cause carpal tunnel and rheumatoid arthritis is not the cause but most of the time it is idiopathic. Um the clinical features that are seen like I said, so the median nerve is compressed under the sheath. So because the median nerve is compressed, you would get symptoms over the thumb, index and middle finger. Um So it would present as pins and needles in that region or pain as well. And sometimes there's weakness of those fingers as well. Um Usually patients shakes the hand but it doesn't really provide much relief. Um You can see weakness in thumb abduction as well because um the abductor p brevis is supplied by the median nerve and you can see wasting of the thenar eminence because the thenar muscles are supplied by the median nerve. Whereas the hypothenar muscles are supplied by the ulnar nerve Um So it's usually a clinical diagnosis. What we can do is you can do a motor and sensory. Uh so you can do an electro physiology where you can see, um I think that's the wrong word. Sorry, you can do an eeg where you can see prolongation of the action potential. What's the treatment? Uh you can try it for six weeks, conservative management. You can give analgesia cortico steroid injections and wrist splints and most of the time this does help. But um, and if the symptoms improve, you can just continue the conservative management. But if patients still has severe management, despite um trial of conservative treatments, you would have to proceed with surgical decompression where you basically just release that uh transverse carpal ligament. So the median nerve has more space, right? So let's transfer this. So this is a different type of questions. I think this is also a type of question that comes in the I'm sorry. So A to J are the options and below that, I've put out two questions. Um So let's call this question number one and this is number two, let's read the first one, first six year old boy with a limp, uh, parents report that this has been getting steadily worse over the past few weeks. He complains of pain in the right groin and hip region. X ray shows widening of the right hip joint and flattening of the femoral head. Right. Yes, you're right. The answer is b coming to the second part of the question, we'll talk about it more on the next slide. Um Seven year old boy is brought in by his mother for the past day. He has felt generally unwell with the headache and nausea this morning, he complained of pain in his right hip and now just able to walk with a limp on examination, flexion extension and rotation of the hip is painful and limited. Um examination of the rest of the systems is normal temperature is 38.2. Try to your answers, right? So let's go on to the next slide. So we're gonna just stop touch upon hip pain in Children. Uh just very briefly because it's an important topic and it comes a lot for the I'm sorry exam. Um So the answer for the previous question, you were right. It was uh Perthes disease. So, pe Perthes disease is just avascular necrosis of the hip it's seen. So it means the the femur bone, the head of the femur, uh the blood supply gets uh inhibited. And because of this, you see avascular necrosis in that region, this causes that bone to basically flatten out. And uh in an X ray you would sort of see it like, right? So it's seen 4 to 8 years old and patients usually present with hip pain. Uh what are the X ray changes seen? Um Early changes just include widening of the joint space. Um, later you would see a flattening of the femoral head and that's how we identify it. Um How do you treat this? You keep the femoral head in the aab and that's the treatment. So, um, you can use cast or braces in kids that are young and um, you can't surgically fix. Once they get older, you would have to proceed with surgical management. Um The next one we're going is to SUFI. So in the exam, an easy way to identify this is by the age. So usually uh Perthes prescri Perthes presents in a child that's 4 to 8 years old with hip pain. Uh They might include the X ray findings, but that's not necessary. Um And usually the question is to identify the disease in Sophie. On the other hand, it's seen in more obese Children and the age of presentation is different. It's 10 to 15. Obviously, in clinical practice, this can vary here and there. But for the sake of this exam, it would usually come based on the age. So in again, me and distal thigh pain can be seen and there's limitation to internal rotation. So, um Sufi, uh it's a condition where the bone slips out of place and the femoral head is basically displaced and falling infer actually. So it's, it's called an melting ice cream cone kind of picture. Um So usually if it's just slightly slipped, you can give bed rest and non weight bearing give some analgesias and uh just see if it improves, but if it's a severe slippage, you need to pin it back into place because it's, it basically looks like a fracture at that point. Um Right. So that is what that looks like. It slipped out of place. Um I think you can, I think you can see it here, the head is slipped out of place and it's not lying appropriately. Um This is for like you can see that the area is avascular and you can see that there's widening in that region. Um So moving on, let's move on to developmental dysplasia of the hip DDH. Um So this is more commonly seen in younger babies and it presents mostly in breech babies. Um So you can um in an obvious situation, you would see a leg length inequality, but that's not always seen, it's diagnosed in infancy. So this kind of a question comes, usually the child would be very, very young. Um Something we do is if the patient's been, if the child has been born via a breach, you would immediately do an ultrasound for all kids to make sure there is no DDH. So there are two tests that you can do. It's called bars and Orlan test. So bars is basically you dislocate the hip and it comes off easily and orlan you can relocate it. Uh You can relocate it as quite easily as well. You can also see unequal skin fold or leg length. Um, so it is leg length inequality, but that's not always obvious in a baby. Um, what we do is initially we manage with splints and harnesses and if in later years it still presents and it doesn't get better. We would have to go with osteotomy or hip alignment procedures. Um, so this is the harness that we use for D DH. It's a public harness and, uh, this is how it's seen. It can ba basically, it can be just dislocated and relocated really quickly. OK. Let's try and answer this question. So an 80 year old presents to the emergency department after a fall from a standing height on examination, her right leg is shortened and externally rotated. X-ray imaging reveals a stable intertrochanteric proximal femoral fracture. Uh What is the most appropriate management? I think we have a few people saying DHS and a few people saying I am nail. Um So the answer here is DHS. Um So I'm just gonna show you a picture that would make this a little bit more simpler. Um So these are the kind of fractures that are seen in uh neck of femur. Um So it can be divided as an intracapsular part or an extracapsular. So that's the first division. Um So extracapsular would be outside of the capsule. So anything that comes below this line would be extracapsular, um intracapsular is basically any fracture that involves the capsule. So there are three types, the subcapital transcervical and both ba cervical. So, subcapital is right at the end of the neck, at the edge of the neck. And that's this first one. Transvaal is through the neck of the femur and ba cervical is at the upper end of the trochanter. So all these 312 and three are classified as intracapsular fractures. Anything below this is classified as extracapsular fractures. Now, extracapsular can be of two types. One is intertrochanter, one is trochanter. Um So this one that goes from trochanter to trochanter, from the great trochanter to the left trochanter is called intertrochanter. That's here. That's four. And this one, anything below that is called subtraction fracture. Uh That's number five. So what do we do in these situations? How do we manage this? So, if a patient comes with an extracapsular fracture, um you can either put a dynamic hip screw or an iron nail. So the problem with intracapsular fractures is that they can easily undergo avascular necrosis because the femur bone is something that easily undergoes um avascular necrosis. So just fixing it might not actually give the best uh management to the patient because it might undergo a avascular necrosis over the next couple of years and it will be completely pointless. So, in a situation where there's an intracapsular fracture, we try and do either hemiarthroplasty or a total hip arthroplasty, sometimes you can try open reduction and fixation as well. If it's quite below. Um, and number one and number two, we don't usually do a fixation. Um, on the other hand, um, so this, whether you do a hemiarthroplasty or a total hip arthroplasty would be decided based on comorbidities. Um, there's no specific age as such. It's not like if they're over 70 they can't have a thr but, um, it's more based on how many comorbidities and how well the patient would heal after the surgery. So, one of the main things important in any neck femur fixation is mobility. So as soon as you fix the fracture, we would like the patients to walk immediately because it improves the outcomes. So, a patient who has severe comorbidities and we do a TSR under anesthesia, which is a longer procedure, it has more risk. Um They might not actually survive the whole thing. On the other hand, a patient who is well and healthy and um not having too many comorbidities, we would go with the total hip replacement because it has more mobility and the patient would use the hip for a longer period of time and she would probably be able to handle the anesthesia patient with a lot of comorbidities. We would go for a hemiarthroplasty. Basically, if she's unfit, we would go for a hemiarthroplasty, sometimes we do fix it. If the fracture comes around that region, we can try fixing as well, but that's less commonly done uh in an extracapsular fracture. If it's an in intertrochanter fracture, you would go with a dynamic hip screw, it's Trant Trahan. So this is a dynamic hip screw. It's a screw that mobilizes it. It pushes the fracture back in because the screw is mobile. And um that would basically be the best option for an intratrochanteric fracture for subtrochanteric fracture. On the other hand, it, the fracture would be somewhere there. So there's no point in pushing the neck and the head back in. So you would go ahead with an IM nail. So this is an IM nail where you basically just fixed it in place. And because these bone, these kind of fractures do not really undergo avascular necrosis. This is the best option for it. This on the other hand, is a hemiarthroplasty. So moving on to knee injuries, so we're just gonna go through this quite quickly. Um There are questions that can come on it, but on a very basic knowledge level for all of these to actually um identify it, you would have to go ahead with an MRI at some point. Um So ACL injuries are usually high twisting injuries that are seen to bend knees. So usually when a patient presents after a sports injury, they've um twisted their knee or they've uh say fallen and twisted their knee. So it's usually a twisting injury and it's usually a sport injury. So if you see a patient presenting like that, um and they say that there was a rapid joint swelling and it was painful and they couldn't immobilize and there was a loud crack of pop sound that's usually points towards an ACL injury. Um How we confirm this is we do an anterior drawer test. So we hold the patient's leg like in the second picture here and then you pull it forward. So you would feel some laxity in the anterior drawer test and you, you know, it's an ACL injury. So if the patient has a posterior cruciate ligament injury, um that's usually a hyperextension injury or a knee hitting a dashboard sort of injury. So when the knee hits the dashboard against a lot of force, maybe because of a sudden car accident or a break that uh ligament, that's basically, I think I should show you the ligaments. So this is the ACL which is on the anterior side and behind this line across it is the PCL, this is the medial collateral ligament and this is the lateral collateral ligament. Those are on the other two sides. And this over here is the menisci lying under it. So for the ligament on the posterior end to be actually injured, you would have to hit your knee with a high four, so you have to extend it. Um you should hyperextend it so that um that area actually gets injured. Um In this situation, you would again see immediate knee pain and swelling, but it would be seen in the posterior side of the knee. On the other hand, this would be seen on the anterior side. So both of them can have hemarthrosis because um there would be blood pooling in that region again, in any situation where there's an. Uh so if it's a non accidental injury, um you should always suspect septic arthritis in these situations, it would be um there would be a trauma based injury present. Um So for PCL injury, we do something called the posterior row test, which is we hold the leg again like this, but then you push it the other way and you push it backwards, you would see again, some laxity uh towards that region, which means that ligament is injured, the third type injury that's commonly seen, it's a meniscal injury. So again, this is also seen in a sporting injury, but the difference between a meniscal and an ACL, the main difference is that the knee swelling is delayed. Uh You wouldn't see a swelling immediately, you would have pain but not immediate swelling. And um eventually the patient would progress to have joint locking because this area is basically injured or told and uh joint locking is not the symptom that patients can present with. Um So what we do here is Lachman's test. Um it's basically done in this way, you hold the leg um in that position and you try and push it and when you push it again, it would cause severe pain. And um laxity. Um so we can just quickly touch upon this. So, um Right. OK. Um So these are actually a few syndromes that have a few names that come again in the questions. Um And they have just a slight difference in their presentations. Um So, ILIT band syndrome is a common cause of lateral knee pain in keen runners and the tenderness is above the lateral joint line. So, in a case scenario, um there would be a patient who is a keen runner and the tendon is, they would say that the tendon is above the lateral joint line and that would point towards an irritable pain syndrome. Mhm So Osler disease, that's also known as tibial aci. So this causes pain and swelling over the tibial tubercle. So it'll be below the knee a slight bit below the knee. So it would be somewhere here. So I think that's a picture of um Osler. So the pain and the tenderness would be here not at the knee. So that's one way to identify that disease. Um Osteochondritis dessicans would again cause locking and swelling of the joint as well as tenderness. So, if there's a patient that presents with locking of the knee and swelling of the joint, and they don't really mention that the swelling is at the tibial tubercle, they say it's at the joint, it points more towards the osteochondritis dessicans. Um Patella pain syndrome is also known as chondrosia patella. So this again, would classically present with anterior knee pain that's worse on going up or down the stairs. Um And uh this is a sign that would point towards this diagnosis that the pain is worse on going up and down the stairs. You can also see quadriceps wasting and this is commonly seen in teenage girls. Um, two other conditions are intrapatellar and prepatellar bursitis. Um So I think this image shows it. So this is a pill region. This is a prepatellar region. This is intrapatellar region. So it would, they would say that the pain is in this region, whether it's prepatellar or the intrapatellar. And um they would usually the question would be what the condition is and these would be the option. They would be the named conditions and you would have to choose. So, um in pear is called clergyman's because it's associated with kneeling prep is known as housemates because it's with upright up kneeling, not really continuing. Let's try and answer this question. So a 23 year old presents with a painful ankle following an inversion injury while playing tennis, which one of the following findings is least relevant when deciding whether an x-ray is needed. So we're asking for least likely, what is the element? Oh, I'm sorry. This first option is swelling immediately after injury. Uh The surgery is the word is wrong. So sorry about that, right. I think we've gotten a mix of answers. So the answer here is swelling immediately after injury, it's not surgery, sorry. Um It's after the injury. So, swelling immediately after the injury does not necessarily mean that there's a fracture. So why are we doing an X ray to see if there's a fracture or not? Um, swelling can also be seen in ligament injuries or in muscle injuries. So, swelling after an injury is not necessarily a rule for an x-ray. So how do we identify if we need an x-ray for an ankle injury or not? So, the they formed an a rule called the OTA rule. Um Right. So this picture here is the Ottawa rule. If you can see it, can you read the slide? Can you see the image? I'm assuming you can. So um uh the four, the four things that comprises the OTA rule, it's called ot ta W A OTA rule. I don't think I mentioned it on the slide, sorry. Um So one thing is there's bony tenderness at the medial malleolus. So if there's bony tenderness at the medial malleolus, you would immediately request for an X ray, uh bony tendons at lateral malleolus. Again, you would immediately request an X ray um if there's an inability to bear weight both immediately. So that's the rule that I was saying here. So this is what they say in the rule that they cannot walk more than four steps, which is essentially pointing towards an inability to weight bear. So, in this situation, as well, you would immediately go for an X ray. Um So I think, right, so this entire region is basically if there's region six centimeter to the posterior tip of the lateral mallus, that would also include bony tenderness at a. So it can be said like that, that's bony tendon is in the tip of the lateral mallus. So that essentially means that you would still go ahead with an X ray and the same with the medial maus. So why we do this, why we follow the OTA rule is basically to see if there's any sort of ankle fracture. Um So these are the types of ankle fractures. So it's classified by the Webers classification. Um So, um right, so coming to type A, so type A is when the distal fibula is fractured. Um but this is a stable fracture. So it's fractured below the syndesmosis, which means um and this, even if it's ti tibia is fractured as well, it's not displaced. Uh So this can be treated conservatively. You don't really necessarily need to admit the patient, you can apply a cost of baloney cost and discharge them essentially. Um Type B can go either way. So type B is at the level of syndesmosis. So um if the fracture is at the level of syndesmosis, you can treat it either conservatively or uh you have to need, you might need surgery. So, um that'll depend on how displaced it is. And if we can get into a right position on fasting. So we would ideally uh reduce the fracture and put a cast and uh re X ray it and see if it's in a good position or not. So if it is in a good position, then you can, again, you can discharge the patient and uh manage it with a cost. But if it looks like it's not in a good position and it can become unstable at a later date, you would ideally have to go ahead with the surgery. Um type C is above the level of the syndesmosis. So if it's above the level of syndesmosis, you would have to go ahead and immediately go for surgery and you would have to admit the patient as well cause it's a very unstable fracture. So let's go on to the, I think. All right, we have like for a few more minutes. So let's go on to the next question. Um, a 23 year old presents to the emergency department with sudden onset cough pain during a game of squash. The patient describes hearing an audible pop and has been unable to wait where on the left leg since then, the patient reports no significant past medical history though he has recently completed a course of ciprofloxacin for anogenital gonorrhea. On examination. The patient's left calf appears red and swollen. The patient is unable to plan a flex left ankle and the Thompson test is positive on the left side. What is the most appropriate first line image to confirm the diagnosis? Right. It is cough, ultrasound. I think most of you got that right. Yeah. Right. So we are moving on to achilles tendon disorders. So this was basically uh the diagnosis was achilles tendon uh rupture, which was the audible pop that they heard. Um So what do we do in achilles tendon disorders? So, achilles tendon in the UK is considered the most common cause of posterior heel pain. So this uh the important thing to remember here is that Ciprofloxacin is a very important risk factor for development of tendon disorders of the achilles tendon disorder. Uh Another um risk factor is hypercholesterol hypercholesterolemia. Um discon predisposed to tendon and SOMA. So there's two classifications of achilles tendon disorders. One is achilles tendinopathy and achilles tendon rupture. Both of them can present in a similar way. The difference here is um achilles tendon is a sudden rupture and it would present with sudden pain and swelling. Um achilles tendinopathy is more gradual onset and the pain is worse following activity pain or stiffness. Um There's a difference in management as well. So, achilles tendinopathy is a prolonged chronic position and the management would be supportive with analgesia and physiotherapy. And if the achilles tendon gets ruptured, it's usually because of a traumatic event. And um it would require an emergency referral to orthopedics um for planning of conservative management of surgery because the patient would be unable to use the limb uh because it's completely ruptured. So, a way to identify this is by the Simone Thompson's test. Um So this is the Simone Thompson's test. You make the patient lie on his back with the calf facing upwards. Um then you squeeze this calf. So when you squeeze the calf, ideally, the um lower limb would get plantar flexed. Um The feet of the patient would go plantarflex if this does not happen and there's no movement. It means the tendon is not connected and there's a cut there and that's why the plantar flexion is not happening. Um So that's the Thomson's test. Um Again, remember that you have to refer to orthopedics for this. They would have to go ahead with an ultrasound, which is the investigation of choice for a kidney stent, right? Um I think I have just a few more slides left. So we're just gonna go across a few of the surgical emergencies that present in orthopedics. And then we're just gonna learn a little bit about spinal disorders and we're gonna finish it off there. Um So neck fash is technically a surgical emergency. It's I've written a medical emergency, but it is a surgical emergency because it's an infection that uh spreads very, very quickly and it can get septic and it's life threatening. Um So there are two types. One is type one. Second, one is type two. Type one is usually um in seen in diabetics, post surgery. And you will see a mixed variety of anaerobes and aer aerobic bacteria. Type two is usually caused by streptococcus Biogen. So, the risk factors for the conditions are so recent surgery in diabetics would be a common risk factor. Um diabetes mellitis is a risk factor and especially if the patient is using SGLT two inhibitors. Um trauma, burn soft tissue infections, all can lead to uh neck fash. Um in an IVD you, um and patients that are immunosuppressed, essentially uh would also be at a higher risk of developing neck fash. So it is seen in lower limb, but the most common site of neck pash is the peri and when it, when it occurs in the perineum, it's called the er grand. Um So what are the features that are seen? So you would see an acute onset pain, swelling, erythema of the infected site. Um So you call it as rapidly worsening cellulitis. Um but the treatment is not like cellulitis, it's not medical management, it's surgical management. So, uh the difference, how do you differentiate between citti and neck fash is that the area is extremely tender, like even if you touch with a feather, um they would still have very severe pain. So that's hyperesthesia. Um They can also, you can also see skin necrosis and gangrene. And um you would see areas of gangrene and blackened out skin, um skin necrosis, gangrene are late sign, but at this point, the lymph is pretty much gone. So, um, the important thing here is to identify it quickly and take the patient to surgery to surgery as soon as possible. Um, so in clinical practice, what we do is, uh, we mark out the area and we see the area of the redness, we mark it out with a permanent marker and see if it, uh increases over the next 15 to 20 minutes. And if the redness in increases that fast, it means that it's uh it could be a neck fashion, we would immediately uh make a referee surgical debridement. We also give IV antibiotics along with the surgical debridement. So the next uh surgical emergency that we encounter in orthopedics is compartment syndrome. So compartment syndrome again is a medical emergencies. It's uh basically seen following fractures or following surgeries. Um It means that in a compartment, there is increased pressure. Um And this causes uh the vessels and the nerves to not um basically the blood supply to the lymph is cut off because of the race pressure. Um So if we look at this one unit as a muscular unit, um so you can see that this area is one unit. This is another one, you can see its own blood vessels and its nerves. So if there's increased tenderness and swelling in this region, these vessels and nerves get cut off and because it gets cut off, it can immediately progress to a situation where you might have to do where it goes, ISMAs and you might have to go ahead with an amputation. So this is also a medical emergency. Um If you're on call, you would have to immediately call your uh consultant or your registrar without like thinking about it twice. So what do we see in this situation? We see pain, parallel paraesthesia, paralysis, pulselessness and increased pressure. So, pulselessness is a very late feature. So by the time you see pain paraesthesia, you would have to get uh the patient ready for immediate surgery. Um So what uh easy way to identify this is the this pain with passive stretch. So suppose it's co more commonly seen in the leg, but for the purpose of this uh session, I'm just gonna do it on my hand. So if you passively stretch the thumb, usually it's the toe, the first toe, if you passively stretch it and it causes severe pain in that region, that is a sign that the patient might have compartment syndrome. And if you, if it's after the procedure that causes increased edema of that region or after a fracture, which again causes increased swelling of that region, you would uh it would raise the suspicion of compartment syndrome. It's most commonly seen in tibial shaft fractures and supracondylar fractures. So again, it's a medical emergency. So you need to proceed with an immediate fasciotomy before um it gets ischemic. Um You also give IV fluids because uh the because of the increased pressure, you do see myoglobinuria where the muscles are dying down and it's getting excreted through the urine. So we need to make sure that the patient is adequately hydrated as well. Um Let me just check how much time I have left, right. Um The next surgical man su surgical emergency is septic arthritis. So again, septic arthritis, uh we need to diagnose immediately and start treatment immediately. So, the most common organism that causes septic arthritis is staph aureus. In younger patients who are sexually active, you need to consider neur go gonorrhea as well as an organism. But if the question, um if the question is, what's the most common organism in a patient who is sexually active, they would usually have other like an STD along with it to basically point you towards the direction of choosing the gonorrhea. So how does the patient present? The patient presents with a red, hot tender joint with swelling and joint effusion. And the main important thing here is that there's decreased joint mobility. Um So the patient would not be able to do passive or active moments because of increased pain and swelling. So, if the patient cannot mobilize at all, um Septic arthritis is commonly seen in the knee. That's why we're talking about mobility. So, if the patient cannot mobilize at all, um and the area is hot tender, swollen and there's um it's tender on touch and it's very red, we would need to proceed with the joint aspiration. Um So we do initially do an X ray to just see if there's any fracture of that region. Um maybe a pathological fracture could have happened. And that's why it's uh swollen and red and hot. So we do do an x-ray and to see the level of the um fluid collection in the x-ray. And after the x-ray, we immediately go ahead with an aspiration and we send this for microscopy and culture and um we immediately send it for microscopy. So that'll come back in around two hours and sometimes it can be a gouty attack. So if the joint fluid is clear of any organism, you can discharge the patient with. Uh and, and if there's some crystals in the joint fluid, you can discharge the patient with uh colchicine or uh ibuprofen if it's a gouty attack. Uh but more often than not even if there's no organism grown immediately into us, but there's a high clinical suspicion. You would still need to admit the patient to make sure it's not septic arthritis. So how do we manage um for more soft tissue um infections? As we all know, we give uh flucloxin as an IV antibiotics. We also need to do a full surgical washout to clear the joint of any bacteria. Um Clindamycin is used if there's any kind of allergy. Um Also another thing to remember is the antibiotic treatment is quite long in this. We give it for around 6 to 12 weeks. Um Right. Let's try and answer this question. A 45 year old man presents to his GP with back pain radiating to his right leg. He has no past medical history and does not take any regular medication on examination. There is a sensory loss of posterior aspect of the right leg and lateral aspect of the foot. There is weakness of plantar, flex, plantar flexion and reduced ankle reflex. What? No nerve root is most likely to be affected. Yeah. So the onset is S one. Um I think a lot of you answered L5. The answer here is S one. So the patient has presented with a sensory, OK. I'm just gonna show you image cause it might be better explained, right? So what I think about how I do this is um or how I remember this is, I just remember it's L1 L2 L3 L4 and L4 comes across the knee and goes all the way down to the medial side. And then there's L5 and S one goes to the back. So L5 also extends to the back little region, but the lateral aspect is mostly by the S one region. Um So because ankle reflex is done there, that part is also covered by the S one dermatome. So the answer to the previous question is S one. So what they've said is that there's sensory loss on the posterior lateral aspect of the right leg and lateral aspect of the foot. And there's weakness in plantar flexion and reduced ankle reflex. Um So the answer here is one, another thing that you can learn is you can look through the Asia chart which helps with. Um So this part basically helps understand which nerve root is affected in what region. Um So if the hip flexors are affected, it's usually the L2 nerve that's affected. If knee extensors are affected, it's L3. If ankle dorsiflexor are affected, it's L4 long to extensor, L5 and planar flexor is S one. So in the previous question, the answer was s one. Um So this actually quite helps me like remember this because it's just um in a tablet form available. Let's go to the next emergency, which is called quino. Um I think we're running out of time. So I'm just gonna quickly go through this. So Quina is basically compression of the spinal cord. So if you look at this picture, this black region in between the two whites is the cord is the cord of the spinal, is the spinal cord. So what happens is for whatever reason, it could be trauma, it could be a fracture. This entire region cord gets compressed and when the entire. So this is at two weighted image. So in the T two weighted image, if the entire cord gets compressed. The white region which is the CSF running across gets completely obliterated like the CSF cannot be seen anymore because the disc or the fracture is completely compressing on the spinal cord. So this again is a surgical emergency cause um delaying the surgery for this can worsen your symptoms and cause permanent symptoms. So, uh what are the causes for this? Like I said, it could be central disc prolapse, could be, tumors can be trauma can even be seen in an infection like discitis or abscess. Um Features include low back pain, bilateral sciatica, perianal anesthesia, decreased anal tone and urinary dysfunction. So, when a patient presents so low back pain can even be um attributed to either just disc prolapse or stenosis or there are multiple other conditions that cause low back pain, but low back pain um radiating to both your lower limbs would be a red flag. Again, when you examine the patient, if there's any weakness or sensory deficits on both sides of the lower limb, uh it means two sides of the cord is compressed. So that again is a red flag. Perianal paresthesia, decreased anal stone and urinary dysfunction are again signs that are seen in um corinum. Um So urinary dysfunction is one of the late signs that's seen and it uh points towards irreversible damage for any patients that presents with these symptoms. You need to go ahead with an urgent MRI. And if the MRI shows a picture like this, you need to go with surgical decompression. Um So for example, I work, I work in a DGH. So what we do is we order the urgent MRI because we don't have a spinal unit there and we immediately, if there's any sort of cardiac, which I've seen, you would immediately refer to Q MC, which is the hospital that's trauma based for surgical decompression and they would do it within the day. Um I don't. Right. This is the last slide. So we're just gonna go through a few causes of low back pain, which you can come for the exam. Um So, um let's first do the red flags for lower back pain. So these um so these symptoms, bilateral sciatica, perineal threshes, decreased, anal and urinary dysfunction are red flag symptoms. In addition to this, if the age is less than 20 years or more than 50 years, it's again a red flag symptoms more than 50 years because we would be suspecting a malignancy. Um If there's a history of previous malignancy, again, we would be expecting occurrence. So again, it becomes a red flag night pain. Um So that's essentially pain at rest, which would again cause concern. Um sorry, um history of trauma. So it's, it's not. So history of trauma would make us suspect a fracture and we would have to rule out that the fracture is not cause causing a Corio minus sort of uh picture with an MRI um or a CT if it's a stable fracture, and if the patient is systemically unwell, again, we would suspect that there is an abscess or uh uh cubicle type picture. So again, it would be uh a red flag sign for lower back pain. So, one of the most common uh causes of lower back pain is a prolapsed disc. So, when there's a prolapsed disc, um leg pain usually is worse than the back pain. Pain is worse when the patient is sitting down. Um, and uh, what we usually do for management scenarios is we, uh give analgesia and physiotherapy. Uh, the first line. Uh I think that's a question I'm just gonna on. Um, so one or all need to be met. Do you mean for the prolapsed disc or for the cardiac quino? Oh, no. So any of them, even if one of them is all of them would need to be met. Any of these are red flags. So, if any of them are there, um, it is a red flag. So you do need to investigate further, basically, like you can't just, so what I mean by red flags is in case we're suspecting a prolapse list and none of these red flags are present. We would just give analgesia physiotherapy and we would dress for an outpatient MRI we don't have to do anything immediately. We can discharge the patient with first line. But, uh with, uh, with the first line analgesics with the, which is nsaids. But if there's a red flag symptom, we cannot just discharge the patient without actually ruling out a malignancy or uh abscess or a fracture. So we need to further do investigations like CT or MRI or X ray or whatever just to find out what the diagnosis is if any of this is present, so it could be nothing. It doesn't mean that it is a surgical emergency if one of these are there, but we need to find out what it is before we discharge the patient. Um So another thing that's um requires an urgent spinal, spinal stenosis, spinal stenosis, again, the cord equina, um the cord gets compressed. Um again, uh it's different from uh cord equina in a way that you won't really see features of urinary incontinence um or uh or uh paresthesia or anal tone decrease because it can happen along any part of the spine. It doesn't have to necessarily be in the lower spine. Um what we do see is unilateral or bilateral leg pain with numbness or weakness. So, there are some neuro uh neurological signs that we do see um which is not usually seen in prolapsed disc. And uh one of the signs that makes its uh obvious that it's spinal stenosis is that when the patient sits down, leans forward and crouches, the pain is relieved. So, in this situation, again, we need to do an urgent spinal referral. It's not as urgent as ca equina. But we need to do an MRI and give an urgent spinal referral because if the um if the treatment is delayed, which the treatment is spinal surgery, so if it's delayed beyond a few weeks again, um it can lead to long term uh, neurological uh deficits. Sorry. Right. So, Anky lying spotlights, I'm just gonna see a line on it because I'm pretty sure we've run out of time. So, um, it's just if a young man presents with lower back pain and stiffness and the stiffness usually worse in the morning and improves with activity, that would point towards ankylosing spondylitis. So that will be covered further in the rheumatology part of it. Thank you. Thanks very much, Marett. I'm sorry. I think I took a little bit more time. That's fine. So I think our next week of the gastroenterology is due with us at 345. Um just checking the chart. So there was a question in the chart. Uh but don't lots of elderly patients have lower back pain. I think that was due uh related to the red flags where it was saying that elderly back pain more than 50 years is a red flag. But I don't think it, that's, that's not a question, is it, it, it is important to investigate in elderly patients if they have red flags. This is in relation to called Quina. Um This is not related to Cor Cor Cor is a completely different thing that could be either way. So any of the urinary incontinence or the uh perianal paraestesia or anal to decrease that would immediately need to be investigated. Um Anyways, these are red flag symptoms like thoracic back pain is a red flag. All right. Ok. So I was just sorry a little bit in the Oh, ok. Are there any more questions? Thank fine. I don't think there are any questions now. So there's one more. Yeah, we'll send a feedback form. We're just sending it. There's up, someone's asking what is upright kneeling compared to kneeling. Um So I think uh so the kneeling is basically what the what you do when you pray that would be just kneeling. I think upright kneeling is um they've just, they further added clergyman's versus housemaid's knee. So I think I just find a picture. So it might be easier to just for bursitis. Yeah, I think it a picture would be a better to understand that. Yeah, I'm just right. Uh I've got a picture just one second. How do I share my screen again? Just on the bottom. Uh third button would be there. All right. Uh That you can see me, right? Yeah, I see. I've just taken a picture from Google. Um So that would be upright kneeling. I don't know if you can see it clearly. I'm sorry, it's a little blurred. Are you able to see it? Yes, we can see Yeah. So that would be upright and that would be just kneeling, like kneeling for praying would be just kneeling and this would cause the pain at a little more super ration. Um I didn't get you with for bursitis. I know I'm sorry. So they were saying for clergy and bursitis or for housemaids uh knee bursitis. So. Right. Ok. Ok. Yeah, it was extension of that question and, and whatever I can ask. Right. So we're just gonna take a 10 minute break and I'm just gonna send the feedback, feedback forms. I right. Please do fill the feedback forms. Um, shall we take a ten-minute break and come back? Yeah. Uh, if there's no more questions, I think we can, uh, we'll go off then I'm just gonna take us off the broadcast. We'll be back, uh, at 350. Yeah.