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Sorry, guys. For the slight delivery. Just having some technical difficulties. Um, just gonna Okay, so you stopped. Okay. So hi. Everyone were or skis, E. So, as you may already know, this is a pre kidneys. The session will be covering case one today. And we have Becky speaking today about case one. Um, so I ask Is is just a company that we have, um, lots of different branches. We have finals. Easy. So if you want help with PT, we have that surgery C, which is about to launch newly and have premed is E. So if you have anyone that's wanting to apply to med school and they want some tips, we have some really good team working there. Um, but this is a frequently session, so we'll be covering some pre clinical science content, and they'll be SPS throughout. And if you have any questions, just pop them in the tap on. We'll be happy to answer. Um, so this is all happening because of our sponsors? Is MPs has really helped us a lot on they can provide you medical protection on Do we also have Christmas, which is a really good Christian bank if any of your interested SPS on em do as well, which is for medical protection as well On metal, which help us help you all have the slides after and help you watch the feedback form. I mean, what's the recordings after is? Well, um, so if you want a discount code Christmas who have a 20% off code, so use the word Oska's 20 to get 20% off. There's really good SPS there. So if you want to look at some pre clinical or just clinical SPS are highly recommend that you go on that, um, we also have Oscar, the community on our Facebook so you fall or socials will be posting updates. But when I was a Facebook page, we have a specific page where it would be posting SPS and you guys contract to us. Ask any questions on. We'll be happy to answer. There's usually usually reply within a day. Um so yeah, highly recommend that too. Onda. We're launching a news serious cause they're juicy, I briefly mentioned earlier, but it's the biggest or one of the biggest collaborations between any surgical come use throughout the in the UK, So we have the British in the medical association. We have the British urology research and says you call training. Um, they have insicion UK. We have the National Surgical Teaching Society a ball on. We have all to eat dandy involved. So if anyone's interested in any firearm surgical finals teaching, I just want to explore any specialties. Then you shouldn't miss this at all. So keep an eye on our socials and we'll post when the events are happening, but highly recommended. Go to this. Yes. So these are some of our ground rules before we start the session. So we have so first, just please don't, um you are 10. Your camera on a Z. This could be quite distracting on. Do you? Maybe on the recording afterwards. So please interact in the tap. You have any questions? We'll be happy to answer them. This is a learning session, so it's good to engages. Well, so I would be happy if you engage in the polls to on. Please don't. Please be respectful in the tattoo on this session will be recorded. So anything you do say will be on the recording afterwards with this message is if you have any concerns on will be sending out feedback forms at the end of the session. So if you have any questions, just ask us all messages of any of our social socialize. But we'll be happy to help. Um, I'm gonna handle it. Becky. That's okay. It's very powerful. Me 100 over. I just wanted to add one thing. I know it's the surgical Siris might not be making hand over the surgical series. You guys might not think that it is teaching for finals, but for those who are surgically inclined are interested in a Korean surgery, but we do provide certificates. And since the big collaboration, it would show your commitment to surgery. So feel free and consider attending. All the events will be out tomorrow. And it's all delivered, uh, by registrants or doctors. Cool. Hey, Becky. Are you ready to go? Yeah, I am a sham. My screen now. Thank you. Course. I'm going to assume that you can will see that. So welcome to my case. One. Right. Okay. Yes. Or I thought was not me. Thank you. Yes. Welcome to case one. Um, well, I hope you found it. Okay. Let your first case and hopefully find your January. It sounds okay, but these are some of the topics that we're gonna be going through to the day. So we're gonna be fixing on M S K on to get us started. We're gonna look at some inflammation, so I've got a picture off somebody's thumb here and it doesn't quite inflamed on. The first thing to remember about inflammation is the five cardinal signs. So you can see in this picture here some of those science you can see that the thumb is quite red. You can't see heat, but no, that is one of the signs. There's some swelling as well in that thumb, the person that is gonna be experiencing some pain and some needles function. So just remember those five cardinal signs on what might cause this convenience of reasons. But I've listed some out here, and it can be extra in deprivation, physical agents, infectious agents or even an immune reaction. So just be aware about so inflammation itself can be acute or it can be chronic. So I'll talk you through. What kind of makes what the differences between them. So in acute inflammation, neutrophils are yourselves that really important. And you get rapid inflammation on termination off the inflammation because, like within three months or so. So it kind of occurs when you're offending. Agent is eliminated on. As a result of this, you're kind of a complete resolution. But if you don't a complete resolution, you end with chronic inflammation. So chronic inflammation macrophage is are your set of importance, and you'll have active inflammation as well as attempts to kind of prepare that inflammation at the same time. On this Congar for weeks to months on, it can be caused you to persistent infection, prolonged exposure to any agents that are toxic on auto immunity. So just be aware that so with inflammation, you have to know some of the vascular changes. So I've got a picture here in the right hand side, and I'll speak you through it now. So the top in the chair shows you're kind of normal blood vessel. So you've got some resident lymphocytes and macrophage is around, but your blood vessels are generally looking okay, But when you have inflamed during inflammation, you can see how the change between the two images your blood vessels, a little dilated and you've got a lot more. A lot more. Macrophage is in a lot more like blood cells surrounding speaking through that now. So with your vascular changes, your macrophage is your white blood cells were gonna detect. There might be a pathogen or damage to she going on, and you're gonna have some site of kinds are being released, and that's gonna cause some local be's a construction initially. But overall, cause vasodilation do to kind of local Marcel secreted histamine on, you know, on this result in increased permeability of your vessels, you have a lot more proteins leaking out from your blood vessels. You have Stasis of blood, and you'll have neutral Add neutrophil migration as well into those but vessels. So I've spoken through some of the vascular changes, and I'm gonna talk you through some of the side of the changes. But before I do, I like you'd have to go this question so worried up to you I ate or neutrophil receptors stimulate end of your your cells to express lectins what process is being described, So this question might seem quite overwhelming, but just have a look at that diagram there and I'm basically asking you. There's four different kind of sections to this image. So you got four yellow circles here. Is it this first kind of process here? Is that the second process? That process before process on what's the name of it? So a lot of you're sending in some art is that's great. So I'll give you 10 more 10 more seconds or so 54, very to once, if we could close the pool hop. Thank you. So this was quite a tricky one. So well done to those of you put tight binding. And as you can see, here is the second process in the diagram here, I'll speaking through this amateur. It's just the good structure to remember the cellular changes. So festival you will have your neutrophil kind of tethering on to your extra side. And make sure matrix in this office is I'm with in the type binding process in the SBA. The eye a late, uh, receptors on your neutrophil stimulate. And if you'll yourselves to express selectin so it kind of binds on to that endothelial south is quite tightly, and then you have diabetes is so that neutrophils gonna move across that memory on it's gonna try and follow the I'll eat Grady in by chemo taxes as well on the neutrophil. Is gonna extend pseudopodium between those cells to get into that sub and a TV or start space in order to move into, um, during inflammation. So here. So I'd mentioned skin. Um, just quite briefly because you wanna be aware of some of the layers that you might be damaging during that kind of initial inflammation process. So I've got an acronym here called Come, let's get some band. So you can remember Siefert corneum alpha lucid um, GI for granulosa, um, s for Spinoza And be for basically so just kind of when you get the slide back for another look at this. And I thought I'd mentioned some of the receptors in the skin, so we've kind of listed the epididymis layers here in this left arm image. But the weather is also Dermasil underneath on the hyper Dermus on. There's different receptors in different layers. So you got, um, your kind of person Ian under Fini and your hyper damaged and the others are mainly in your dymista layer, so continuing on too windy and now this looks like quite overwhelming slide. But I'll speak uterus. So this red box here, we kind of spoken just now about all of the kind of inflammation process is. So you should be an expert. Now on. We'll come back to that in a second. But this top diagram here where my right pointer is that is the initial point of where you got your kind of wound injuries. Since I cut my finger, I'm at this point here on I've got scale that moved all the way along to 300 days and I'll speak you through kind of an acronym. I used to remember what happens during this process, so I remember using it all. So I've cut my finger on the first stage is hemostasis. So I'm gonna have is this black box here? I'm gonna have increased vascular Pam ability to remember in production and some clotting as well. And inflammation is gonna car with my fingers Well on. Just wanted to point out here the neutrophils are gonna come in. The early inflammatory stage on macrophage will come in the late inflammatory stage. So then you get proliferation Soapy and HIPAA on here you'll see some angiogenesis, some collagen deposition, which will be type three from fiberglass epithelial ization. Migration of correcting the sites and some wound contraction as well. And remember, with wound conduction, it is because my a fibroblast and these come from fiber glass of just differentiated intto my fiber loss. So the last face is the remodeling face. So I mentioned here you got some type through college in deposition and in your remodeling phrase, it turns from type three and two type one. So it just kind of realize there's college in strongs on your fiberglass kind of also over expressed college into former um, it matrix and the dents scar on this increases the tensile strength of the wound. But over time, any unneeded settles, I will be a pop toes. So I hope that all makes sense, but definitely reviewed this in your in thymus. Well, so I've got another SBA here for you. So which option occurs in primary wound healing? So the top row hair I've helped you out is kind of primary wound healing and the bottom right here, a second room feeling on which option is most likely to a car and probably will be in to feeling. So the PPO is launched now. So just how the guy Okay, so I'll give you five more seconds just on the guest. Three to one could stop the PPO. How are think you so it was quite close between, um a D But the answer is actually day, so I'll explain it in the slide. So this is a nice little table. So primary wound healing your wound edge is gonna be bought together and you'll see epithelialization, which I mentioned in the S K before. So that was the correct answer. On here, you'll see some minimal scarring is, well, well a tip toe secondary retailing, which will have wound contraction on heating by granulations your bottom up on. You'll have broad scar on this. Although there's a rescue infection. Obviously, in both of them, the risk of infection is significantly higher in secondary wound healing. So just be aware about so meaning on So there some factors that affect going to and then you need to be aware of, and I've listed them this table here there could be either local to the wound itself or systemic. So around your whole body, and that might be stress hormones the age of the past in, or any medications that that wrong on some definitions to be aware of when I'm talking about infection contamination is the presence off or organisms in your wind. A colonization is replicating organisms in your wound without inflammatory response. Local infection is an organism on a tissue response on a spreading, invasive infection. Is organism inflammation on spread? So now, talking about pain pain needs, it needs to be recognized that pain is a subjective experience. Experience between persons, person on this looks of factors that affect it. But you can categorize pain in the duration of the pain on the nature of the pain. So the duration I'll speak through now can either be acute or it can be chronic. You can kind of tell by the name what's going to come now, But acute will be recent onset, limited duration and generally caused by activation and noise. Deceptive sensorineural. But chronic pain is persistent. It's gonna keep feeling painful after the healing time on an absence of injury, and it generally is categorized by lasting for longer than three months or so. So another way to categorize pain. It can be the nature of the pain. So nice, deceptive or non night is active, so nice, deceptive will be with obvious tissue Injury kind of can be somatic coming from your skin. It can be vessel coming from your organs or no noises active will be in your pathic. So coming from your nerves or, um sympathetic, which would be more unexplained and generally both. These would be because of nervous system damage. So some of the nerve types to be aware off is there's lots, but I'm going to focus in on the story to explain my substance. Subsequent slides. So the top two here are both alpha, so alpha be turned, the left on side and alpha delta on the right hand side. Both of these myelinating the alphabet. A. Ones are slightly FICA in modern, a shin um, so the alpha Byetta and travel faster on the alphabet. Delta will be slower on the C fibers, a lot slower, so that helps to explain the gate very pathway. So we'll get theory. Just know that when the gate is open, it's because your Alpha delta and the C fibers are activated but when you get is closed, it's because of your alpha beater are coming in. Activating this inhibiting your own, which stops kind of any pain on projection. Urine's carrying onto the brain. So because, as we said in the last like the alphabet are traveling a lot quicker than these other two, it can come in and stop. The inhibitory nerve can inhibit this path by before any kind of pathways coming on this other side on this is used, um, during the tens, like the tens machine, which can be used during labor for pregnant women. On this helps to stimulate those alpha beta fibers and kind of reduce the sensation of pain during childbirth. So this is a table explaining the pain pathway, and there's four steps to remember this transaction transmission perception on modulation. So I've got an image on the right hand side as well to help explain S but we'll start off with transactions. So over here you can see, uh, picture of a fire that that's gonna cause some tissue damage on you. Have a release of chemical stimulation of your pain receptors on the signals will travel by the outfit and Delta and C fibers. The next stage is transmission so your nose is active in per enters your CNS at the door. So born on the substance of gelatin. Oh so received them. Put the nerve sign ups on the second of travels up the opposite side of the spinal cord towards the brain. So perception the Thomas is the second real. A station on it has many connections. Toe loads. A different parts of the brain on the's part's kind of influence. Your experience, your emotional and subjective kind of perception of pain on the main area. Pain perception because is in your cool tax, um, modulation. So your perception pathways going up toward your brain. New model modulation part was going down away from your brain. So it's the descending pathway from your brain to door so on, and it causes like facilitation off inhibition of noise, deceptive output. So I'll explain some more about pain modulation in the next lives. But if you could try, answer this question so I'll read it to you. Sure, during the descending pain modulator, Resis tum into neurons in the substantia nigra release opioid neuro transmitters that bind to which type of receptor. So if we could launch the pole. Thank you. So this question is very niche. A lot of you are putting in your answers, which is great, but just have a good This tends to come on up on exams. It's just like a fine point. So your best just have got give you five more seconds. Okay. 32, one. So if we stop the colder hop, Thank you. So well done, guys. Really good. After that, the majority of you put the option A, which is the new opioid receptors on. That's kind of stated here and 0.5 on this pathway. I would just get these slides and learn about these kind of steps up on the right hand side. But overall, um, you want to inhibit substance? P, which kind of acts is a neuropeptide that acts as a neuro transmitter to facilitate kind of pain pathway. So, overall, those me your period receptors are gonna help inhibit substance p from binding and kind of transmit this pain sensations. So now meaning moving onto analgesia six. So this I'll speak you through this kind of mechanism here. Let's start on the left hand side. So We've got two boxes here. Iraq of Danek acid, which you can also know is a on this is derived from your cell membrane. It's actually cleaned from something called Phospholipase a two, which creates a rocket on the acid, which is an amiga six fatty acid on on the bottom. Here you have oxygen. So both of these two kind of ingredients go into this massive kind of. It's called your prostate gland and hate sent days on. That's made up of two other domains called a cox and your proxy days. Both of these feed into this kind of main system, Onda. What you'll get produced is Cox will produce on the wood P g two on this will go into your proxy days and then over we'll get overall. You will get PG hate to produced, and I'll speak about the signature significance off this pathway because other enzymes can act on PD. Hate to on produce. Other molecules have kind of effects and loads of different tissues, so P G E to seven days will calm that PG hate to into P G two from Bach same or combat PG, which tune to t X 82. Um PG 12 some days will combat PG hitch to into pt 12 and have a look at, um, the effects that have listed here off those molecules. But the main one I want to point out is on the top here. COPD to has a significant role in your kind of gastrointestinal and renal protection. So when you inhibiting some of these pathways using your insides, which I'll speak during a little bit, you're not gonna have asthma protection off your GI I renal systems, which is why it can, um, cut cause it, like an 80 are within those kind of systems, so and sets two points to remember. Oh, and said's inhibit the cox two main here. As a result, you won't get any conversion off p g two. So you get no production of PDD too, and no production of PT too. So because NOPD hate to is binding at your tissues, you'll get a reduced extent and duration of inflammation less beta dilation, left mascular permeability as well. So I have another SBA here for you. So what is the mechanism of action of ibuprofen? So if you haven't seen any way, just know that's mechanism of action in case you see it again. So just have a guy looks about is coming in. Even if you don't know just gas. It's a really good way of learning. So I'll give you five more seconds. Five for very To what? Tops of replace the pole. Okay. Thank you. So, while done to those of you who hurt my slides don't want to meet tonight. Went under the age of you Have option D on unexplained this now. So yes, that story I want to speak truth. I'm a proof in Compete with a rapid on acid for your cox two Main on this is reversible the aspirin acyl It's your Syrian residue in the cox domains. It's kind of different on it's irreversible. Paracetamol may be chosen before and NSAID so maybe before these two. But the mechanism of party tall isn't actually known. So here, unlisted some 80 ours and contraindications with NSAID. So I've kind of highlighted this before because you don't have as much protection off your GI on your renal systems. You could end up with gastric ulceration, um, renal impairment. So that is an adverse reaction. You might see and you don't want to give somebody, um, and and said, if the pregnant, if they're sensitized Sallis Sallis Leights and said allergy or if they're already on an NSAID on if they're under 16 year, uh, years old because there's an increased risk of various syndrome on, this is another thing to be aware of. Examiners kind of love this, and it's good to know for clinical practice is well, so this is your World Health Organization pain bladder, And it's just saying, if your patient has mild pain, you would want to be looking at paracetamol, an NSAID use on. Depending on the severity of the pain, you can increase this pain bladder or the way up to dimer feen or sedation if they're in severe organizing pain as well. You can use this as a good kind of tool to figure out what is the appropriate pain relief to get my patient So now onto, um, things. So bone fractures. I've got some diagrams here, and I'll speak you through them. So if your bone fractures open, you can see here that the bone has broken through the skin. But if it's a closed fracture, there's gonna be no skin penetration, so it's just gonna stay within arm here. But if it's a simple fracture, you will have the bone fracture. But there will be no external damage to the kind of external tissue around that bone or the skin on what my cause, some bone fractures is maybe a single traumatic event, repetitive stress or a pathological fracture on. There's loads of other subtypes to be aware of. Hisayuki see that the fracture could go horizontal so it could be transvestite. Could be linear, oblique, oblique displaced. It could be spiral greenstick where there's kind of a fracture on one side that hasn't continued all the way through to the, uh, to the other side of the bone, it could be commuted where there's kind of shards of a bonus miles. It kind of shotted. So bone information on bone remodeling the information here in the left hand side is just saying that osteoblasts deposit osteo I'm not osteo read kind of material is mineralized, um and it takes 10 days for it to become mineralized between being deposited a mineralization. But when you're remodeling, you have, um, osteo class that comment and resolved the damage bone on the osteoblasts, then come along and deposits more steroid. So it's kind of a loop on dust. Remember the osteoblasts up last time into Australia? Sites differentiate into them, and there's something I wanted to focus on here. This was just results shin of bone that the osteoclasts do on this diagram. That's very scientific. It's not. I'll speak during now. There's four steps term in the said. The fast one is poor. Decisions extend out from the osteo class, which you can see him. He's kind of ends, so they kind of stick out their owns to attach onto the bone. And the second step is that osteo points pontin type attachments occur so alpha and be two integrin. It's kind of concentrate down onto those arms where they attach onto the bow on. That kind of creates, like creates a seal around that bone, so under hit, you can see like a white gap. And that's still you can also call your house ships. The kuna on that becomes the perfect environment for breaking down collagen on breaking down counseling for state because of lots of reactions going on inside your osteoclasts. I'm one of those directions come be including your Coumadin on hard race. And so it just becomes very acidic is well when it's a perfect 4.5 ph in there. So now to talk about bone healing a lot of diagrams kind of split up bone healing into four steps. But this is how I just remembered it. So hopefully it helps use while and I spit up into five to just make it a bit more clearer in my head. But it's up to you. So the first age I've done is hemotomas. Steve, you've had a traumatic event to your bone on blood vessel Tearing is gonna occur on the fracture is gonna be filled up with a blood clot, which you can see here. The next step is inflammation. We've spoken a lot about information tonight, but the injury results and acute inflammation macrophage is will invade that clot on. Don't destroy some of the pathogens that might be present in some of the bone fragments is well on our vascular, and growth starts to occur as well. Third step is granulations granulations tissue forms releases growth factors to get vascular in growth. Chondroblast also a present here and they form a small kind of groups of cartilage within the cord itself. On my day five that granulations tissue has replaced the pot itself said the fourth step is the color, so you can see here in this diagram, there's lots of islands of cartilage that appear on. This is quite like a immature. It's it's an immature waving bone on calcium starts to get deposited within this cartilage on osteoblasts is, well correct. The seem of Australia around the fracture itself, on type to college in turns into type one religion at this point, to just be aware of that on remodeling is your final stage on this can take years, and it's often incomplete. So you're immature away from bone is replaced by lamella bone on access bonus slowly resolved over the years on, interestingly, your fibers within your bone, your bone structure gets aligned in the way that it's most stressed. So kind of maximum weight bearing position, how you're kind of using your bones over the year well, kind of influence, how they're going to heal on what they kind of looked like a swell. So osteoporosis. This is a high yield kind of condition to be aware off, you would diagnose it using something called a dexa scan on that compares kind of samples taken when looking at your spine and your hips so we get a T score generated on. If that T score is greater than minus 2.5, then it indicates osteoporosis. If the T scores between minus one at minus 2.5, that it's osteo Pena, which is kind of known for a soft bone, it's it's similar to osteoporosis, but not quite as extreme. Some of the signs your patient might be shorter than they were. They might have Scalito tenderness on that might be a bit unsteady. A swell some of the risk factors if well, female. If you're over 50 if you don't have Children, if you're slim on increased alcohol and smoking as well, you would treat it. Obviously, stop the smoking. Increased calcium and vitamin D uptake reduce alcohol intake, and there's lots of formula tickle interventions, a swell that can help. So arthritis is another one to be aware off when talking about those you can split them into degenerative on inflammatory so degenerative would be osteoarthritis, and you can remember this for the acronym loss, you would see Ah, loss of joint space osteophytes, which is kind of bone projections, which you might see on this X ray here. Subchondral sclerosis. Subchondral sis is well, but inflammatory Arthritis would be rheumatoid arthritis, so you would see a loss of joint space. Erosion of the bone, soft tissue swelling and soft bone is lowers. We said osteo pena. So now going on two level in, I just want to say, um, within these lights, I tried to include high yield content because I know going through case one, I was quite overwhelmed myself. Know how much I needed to know. So hopefully this clears things up to you so we can get started by spitting up our lower limb intto different regions. So the first region is your blue tea or region here, then your thigh region. So that would be anterior and posterior. You had your knee joints, your legs and then your feet on your ankle joints here is well, so the first thing to kind of main thing to focus on is your femur. I've put in a label diagram here, but all you can really do for that is just kind of have a look at it, and you were in time and try to memorize that kind of key landmarks of your femur. If you are on, I kept some information about if you were to have a female injury on on the bottom. Here is kind of your hip joint I focused on. So if you have an extra capsule, a fracture so much and this is your hip joint and this is your femur, if your fracture is a bit lower down, it's not really in that men hit joint. It's known as extracapsular on. We would rather fix the fix the hip rather than replace it so you might do a dynamic hip screw in that instance. Obviously, it would depend on, like your pre more morbid state and the age as you get further. But for now, just know that, whereas if it was an introduction, uh, so it was more inside of that joint, so you can see you're on this diagram. Here you are at risk off had of female necrosis, so you want to act quite quickly and it would require a hip replacement, which is also in his hemiarthroplasty so living on to your knee. Now there's a few ligaments that you need to be aware off. Onda. You might have seen it before, so this would be your ACLU anterior cruciate ligament, Your PCL. So your posterior cruciate ligament collectibles and he was either side on your meniscus. Medial. A natural here is well on when you're talking about injury, if you injured up for, um, the ACL, you might hear a pop sound, and your joint will rapidly swell up. So that's what you might see. Um, if you damage your posterior cruciate ligament, that would've car with hyper extension, uh, injuries as well. And you're unhappy. Try a they always love to bring up is just know that it involves three things that involves your ACL, your medial collateral on your medial meniscus. So just revise that. That's what the unhappy try it is on. That unhappy tried generally occurs if your fits kind of stuck in the ground and you get a blow from the lateral side of your knee. Um, because that can result in the unhappy try out on if you have a minute ski injury. So these two structures kind of under here, the swelling off me might be a bit more delayed. That's how we could potentially differentiate between an ACL was very rapid during swelling or a minute skiing jury, where the knee swelling is a bit more delayed on. There's a lot of our birthday toe be aware off when talking about the knee, so it puts him down here. There's a pre patellar one, which is your main one. And if that is inflamed, which is the most common one to be inflamed in beside us, it's known as housemaid bursitis. So just be, uh, where the So if we look on the back of the knee now, that area is known as your popliteal fossa, and I've listed some of the structures that make up the floor on the roof of your popliteal fossa. But there's an acronym I want to speak through now. It's called serve and volley next full, and this helps to remember the structures. Moving means your total actual within your popliteal fossa. So most medial on the Latin side here was have your semitendinosus and you're semi member know sis. Then it would be your popliteal artery, which is your deepest rupture here. Your thing, which is your popliteal vein on your typical nerve on because this is most superficial is the most likely structure to be damaged within your popliteal fossa. And then your biceps Morris is on the most lateral side. So you can see here. That kind of relates to the acronym serve and volley next ball. So hopefully that helps your little bit remembering structures that so another SP a fee here. What type of fracture is shown in this x ray? So hopefully the pole has been launched. And just have a look at that X ray. That's great. Lots of you're sending an answer is to keep them coming. I'll give you 10 seconds just so you can have a look and read the options. Five more seconds. No, lots of answers. So if we stop the pole there, please. Thank you. So most of you put the correct option which was see so well done. So explain that in the next slide. But first I want to mention your tibia and your fibula, so your tibia has your medial malleolus on the side, and that articulates with your tarsal bone, and that creates your ankle joint on your fibula on this side has your lateral malleolus, and that's what we saw in the X ray on. If you have excessive external rotation off your fibula, it's gonna be a spiral fracture. Generally on. If you have excessive version of fibula, it's gonna be a transplant structure generally. So explaining the SP I know it was a Weber classifications. A. Because the bone fracture was inferior to the cinders. My sister is quite a stable fracture on the Web. Classifications breaks, breaks it down into kind of a A B or C. So as in the X ray, if it's a, it's gonna be below the ankle joint. If it's B, it's gonna be kind of at the same level on you have very variable stability. If it see it's gonna be above the uncle joint on, it's gonna be a lot more unstable because you got damage to your cinders. Nicest ligament is well, so now you'll fit this diagram, or you can do is just try your best. Er memorize all the different names of your tassel bone. But from a bigger picture, you do have tassels metatarsals on for longies on this always comes up Nothing. What are the different joints within your fit on? This took me a long time to kind of remember, there's so many, but your torso tarsometatarsal joints here are plain joints your metatarsal. If land your joints, the chondroid your subtalar joint is convoluted. You're inter phalangeal joints. Hinged joints on your ankle joint is also a hinged or so just review those and you were in time that they often do you come up on if you have for injuries. This three of listed here. But the main want to focus on is the bottom one, which is a stress fracture on the most common stress fracture is in your second metatarsal here, and it presents with pain, bony tenderness and swelling and antalgic gates on the reason why it's the most common stress rupture. It's because it's the longest on then it's so it's the most vulnerable metatarsal joint that bone. Sorry. So another thing to remember with lower limb is the Ottawa ankle cruise on this kind of determines after an injury. If X ray is needed or if it isn't on If an X ray isn't is determined that it's not needed, follow price, which stands for protection. Paracetamol rest, ice compression, elevation. But if a X ray is deemed that is needed, I'll talk you through What kind of determines if one is so on the left hand side here. These are the rules if ankle X ray is needed, so it would be if there is tenderness, a and tenderness at be on on or if there's an inability to kind of wait there at the time of injury and in the emergency department. So a is your posterior edge with, like the posterior six centimeters of your lateral malleolus, Um, or B is your medial malleolus on the right hand side, you can determine if you need a foot X ray if you have bony tenderness at C, which is the base of the fifth metatarsal or bonus at your navicular bones, or the inability to wait there again at the time of injury or in the imagine seeing on presentation. So musculature. Now I've tried Teo, put this in a nice little table. Um, the ones in pink are the different compartments and sign on the ones and yellow are the different compartments within your leg. Um, if you want to kind of do a cross section on these kind of the general rules for them. So do review that in your your own time and just trying to memorize that. So the on arterial supply off your level and this is a really nice diagram here on the left hand side, and I want to focus in on the femoral triangle within the arterial supply. So, um, posterior to the femoral triangle is the pectineus muscle on the continents off this Converium embers using the acronym Navy. But the boundaries I made up from your inclined a ligament, your meat, your border of your sartorius medial border of your a duct abductor longest. And if you're looking at, they're singing. Where is this? On the leg. I'll put this in contact so you can see in this image here. Your inguinal ligament is up here, so that's the top they're on. It would fit him right here. So you kind of get like, a triangle shape here, and it's really important for lots of kind of structures running through it. So just have a listen now to the acronym on a Navy so it stands and would start the femoral nerve. A formal authoring the femoral vein on Why do your deep in Guanajuato Lymph nodes? So just remember that n a b y. So that's kind of how they positioned roughly within your femoral triangle. Now the Venus supply a similar diagram hand. But something to be aware of is within the fit your Flexer retinaculum kind of area. And you have lots of structures running. I'm just kind of behind it. And you can remember the structures by Tom Dick and very nervous Harry. So t up here would be to be honest posterior d your flex it a digital and longest aortic you artery read tibial vein to be on love and then your flex a hal assist longest. So definitely remember those because that often comes up like which warder and they all so moving onto your nerve supply. Now a similar diagram on the left hand side on. Be aware that that drop is well, would be because your deep peroneal nerve injury and I've got some diagrams here is on the right hand side. And it's important to point is, well, that you're deep peroneal nerve kind of, um provides cutaneous innovation between your big toe and your second kind of digit here with your toe. That's often the common on a point that comes up a swell. The trial bastard can memorize this on. I've put the table here, um, off kind of main nerves in the lower limb at the motor and sensory innovation that they supply on the typical mechanisms of injury that might occur to them and what you might see if they were injured. So that would be a lot to speak through on. Probably won't going, um, to your head to downing review, but with the slides. So, yes, that completes my our presentation. Well, put in the feedback form into the chart now, but please do em give some feedback to see how I can improve on on completion. Who got the recording and the slides? Yeah. Thank you very much. Still sharing now? Thank you so much. That was actually so useful. I really like the diagrams. Well, I'm just about to, uh, post the feedback form. And now, um, I also had some questions. We'll also do that. I was just answering a few, but I haven't answered some of them yet that was. Yeah, sure. Wait. Let me just basis in to them. Um, sorry. This is really There we go. I think somebody has asked me to go through the inflammation slide, so I'm happy to do it up, you know, have liver on. Can have that. Sorry for the delay in the feedback. Yeah, I'm going to stop the recording. This well, okay.