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Oxford, earning accolades such as best training of the year and best tutor of the year. Her phd at Imperial College focuses on optimizing outcomes in patellofemoral joint replacements for which she has secured multiple prestigious research grants. Martinique has also contributed internationally to knee surgery research and developed bone sheet, a performance app for orthopedic trainees. Um Without further ado that's how to give us some teaching. Yeah. Thank you very much. Thank you for that introduction. Um Yes. So I understand that this uh talk today is uh for people who are either sitting the MRC S part. And I understand Kyleen tells me that apparently there are some keen medical students interested in orthopedics. Um So what I did was I went on the MRC S syllabus and hopefully this presentation will cover um the orthopedic uh section. Um It's just essential stuff that you need to know it's going to be interactive. So what I have done so lucky you, if you've joined first, I've taken a picture of the people who are currently online and I'll go to each one and then I'll ask you a couple of questions, right? Cause otherwise I'll just be talking to the blank screen on my own, right? Ok. So let's start. Um, so we have a 60 year old admitted with a severe uh back pain. You are the sho on call? Ok. So we're going to go through a couple of questions. So Ashok Kumar, can you please tell me what you are going to ask the patient? Er Kumar? Yeah, let's see. Has he looked out? Yeah, I've got Asher Kumar here. No. Ok. So how about Auta Caria? Ok. Can people talk here or not? Uh, I'm not too sure. Maybe in the chart. Uh, ok. I've got a tutor code note only on the chat. Ok. So I guess it's not going to be interactive then. Um. Ok. All right then. Ok. And then we'll have to do it this way. Uh, so, so no one can talk then I suppose. Is that right? No, no, but you can type in a chart. Ok. So basically we'll do it with a chat. So basically, um, a tta then a 60 year old male admitted with severe, uh, back pain. What are you going to ask you the sho on call? You've gone to the patient. The registrar is at home. What are you gonna ask? Sight? Yes, onset, good character. Mhm. Anything else specific? So you have a 60 year old with severe back pain, back pain, radiation, correct, loss of function. What do you mean by loss of function? Anna ana carriero, what do you mean by loss of function? Um Yes, exactly. So, that's what I'm looking for here. Uh, uh All Tobi. Um, that's exactly what I'm looking for here. Ok. Um, basically when a 60 year old admitted with, uh, severe back pain, yes, those are the key points. Uh, how long, uh, site and on onset, however specific, if you are the sho here on call, your registrar is at home, what you need to determine is, does this patient need an acute intervention? Uh, now? Ok. And what you are looking for is one, is this pain going down one leg? Is it going down both legs? When did it start? Did it start 24 hours ago or has this patient been having this pain over the past, uh, three months? Ok. So if it's over the past three months and it's something chronic, if it's something that's got worse over the past 24 48 hours, this is when you start worrying. The other thing is, yes, I would, that was what I was looking for is, uh, loss of function in terms of, has the patient had any urinary, urinary incontinence or fecal incontinence? Um, so what we're looking for here is, has there been any, um, um, change in bowel habits, um, or the patient wetting themselves? And normally what I also ask patients is, have you had like a different feeling down below? Some people sometimes have a different feeling down below and they're not able to explain it. But it's important to ask. Now, in terms of um we've covered history now, in terms of examination, can anyone tell me uh what they would examine specific to this patient? I want one clinical examination and one other investigation. Yeah. So anyone that's fine power, lower limbs, yes. Correct. Lower limbs, sensory and motor exam. Anything else in particular I'm looking for? So, yes, you are correct in terms of lower, lower limb sensory and motor exam. But I'm also looking. Yes, exactly. Anna Yes pr exam for anal tone. Correct. And there is something else in terms of the um uh the urinary system, what are we going to do? It's a one investigation. Ok. So um correct. Yes pr exam for anal tone. The other investigation is a bladder scan. Um You would need to organize a bladder scan. A bladder scanner is very easy to operate. So what you do is you organize a prevoid and a post void bladder scan. What does it mean? So a prevoid, you basically scan the bladder and document how many mils of urine there is in that bladder. You ask the patient to go and pee and then you scan the bladder after. Now, can anyone tell me a threshold of a post voided bladder scan that you would likely be worried about anyone? No. Ok. So basically the threshold, um the thresh the threshold that you normally uh become worried is anything that is greater than 200 after a post voided bladder scan. Uh, the reason being is that you are highly suspicious that this, um, bladder system, urinary system is not working. Why is it not working? Um, so think something about orthopedics, someone with back pain. So the uh nerve messages are not being sent out to the bladder. The bladder is not emptying properly properly. So it's retaining uh, urine. Um, uh, and we'll go with that. So what is um so what, so what, what is your management plan? What are, what would you like to do? So? Yes, correct. 100 mils. But what would you as the sho on call? You find everything positive, right? So you have poor uh poor anal tone, you have a post void of 200 mils. You're the sho on call. Your registrar is currently um in hospital. What are you going to do as the sho? Yes, analgesia. What is? Yes, correct, Anna. Yes, you need an urgent MRI query called equina. Perfect. Yes. Um You will be, some people will be working in DGH S. Some people will be working in MTC S. Uh Basically uh the T thinking is the same. Uh you will need to discuss this with the acute spine on call. It could be either orthopedics or it could be a mixture of neurosurgery and orthopedics depending on where you work. Basically, there needs to be a decision maker who needs to decide. Um Yes, this patient needs an MRI scan thresholds. In terms of does this patient need an urgent MRI scan anyone with severe radicular leg pain, unilateral or bilateral um poor poor pr uh tone or a post void bla bladder scan, uh greater than 200 mils, highly suspicious that this patient uh may be complaining of Cordona. If uh someone has a postvoid bladder scan of more than 200 mils, it's basically 20 times more likely for that patient to have a Cordona. Ok. So, um and also as you may know if you miss Cordona, um uh it is severe clinical negligence. Um Also the uh renumeration. Um if this, this goes to court is significantly quite high. So the trust would rather um get a quick MRI scan. Um There are times where I've had the patient, for example, who we couldn't do a better scan because the patient was retaining urine. And in that case, what you do is you insert a catheter and you do what we call a catheter tuck test. Basically, it's you put on the catheter and you ask the patient if they can feel uh down below. Basically, you're checking for a sensation. Uh The next thing uh So you get this, you get the MRI, you get the MRI scan and uh