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Yeah. All right guys. Just checking, you can hear me if you just wanna put a thumbs up in the chats. Ok, great. Thank you. Um We'll just give it a couple of minutes and then we can, we can get going. Mm All right guys. Well, people can join as and when. Um so hello everyone. Uh my name is Rishi and uh welcome to the third and final orthopedics revision revision session, uh run by BSA. Um So today we'll be covering a range of topics including material on spine, hip, knee and foot and ankle, anatomy, physiology, and other clinical conditions as well. So I hope you find this session useful if you have any questions throughout, just put them in the chat and please feel free to interrupt me as well. Um So the session should last roughly 45 minutes to an hour. Um So let's get going. So we'll start off with the question. Um A 44 year old female presents the ed with reduced lower limb sensation and urinary retention. So, a full peripheral neurological examination is carried out before the patient was sent for an MRI of the whole sign. So the F one doctor suspects a diagnosis of corda quina syndrome. So, which of these features is not a clinical feature of CHD Equina Syndrome. Is it hypotonia, spastic paralysis, hyporeflexia, down go implants or lower limb weakness if you wanna put your um answers in the chat and then we can go through them great, so well done. Um So it is number two. So spastic paralysis, so called equina syndrome, it typically produces lower motor neuron signs and symptoms. And these include hypotonia, hyporeflexia, down go implants and altered lower limb function and sensation. So, corda quina syndrome. So, this is a surgical emergency and it's caused by compression of the cord equina. It's called a peak age of onset between 4050. Um and essentially the corda equina, it's, it's a bundle of nerves that's located below uh the spinal cord. So the spinal cord ends at approximately um the level of L1 with its nerve roots leaving L1 to S five passing down the spinal canal and this is known as the cor equina. Um they didn't exit at the respective from. So consequently, the cor corner is formed by lower motor neurons containing motor and sensory impulses to the lower limbs and motor innervation to the anal sphincters and parasympathetic innervation to the bladder as well. So, as I said, Cordo equina syndrome is caused by compression of this ch equina and there are multiple causes for this and the most common being a disc herniation or disc prolapse. This most commonly occurs at the level of L5 S one trauma. So, a vertebral fracture, um neoplasm. So this can either be a primary cancer or a metastatic bone cancer. Um infection such as discitis or um pots disease, which is seen in tuberculosis or any other sort of chronic spinal inflammation can result in cordia equina syndrome, such as ankylosing spondylitis. So the clinical features, so as I said, lower motor neuron signs and symptoms and these symptoms can include low altered lower limb sensation, bladder or bowel dysfunction, lower limb motor weakness, back pain, um and impotence as well. So you should always assess bladder function um and specifically assess whether the patient is in uh urinary retention or not. And you can perform a bladder scan in ed and just to check if the retention, bowel incontinence should also be investigated. And on examination. Um features will include perianal or saddle anesthesia. A loss of anal tone on pr exam, um and lower limb weakness and hyporeflexia. So essentially a full peripheral neurological examination should be performed including the upper limbs in order to compare the two. So, moving on to investigation and management. So, Mr is the Gold standard investigation and you will always need an early neurosurgical review for the urgent decompression and all Corio Corona patients will usually be recommended for this form of surgical decompression and this aims to prevent any permanent sphincter or lower limb dysfunction in terms of prognosis. Um it's pretty variable. Um So one study stated that if the patient was operated on early enough and who were in theater within 24 hours of the onset of any sort of autonomic dysfunction, then they had reduced bladder problems after a longer term follow up. So, um that's just a bit of an introduction to call equina syndrome and um we'll move on to another question. So a 72 year old female presents with significant lower back pain and upper motor neuron signs including hypotonia, clonus and a positive babinski sign. So, an MRI of the whole spine reveals a diagnosis of spinal cord compression secondary to bone mets. So which of the following primary uh malignancies does not commonly metastasize to the bone. Is it prostate breast, colorectal thyroid or lung? So, again, if you were, let's see. Yeah, really good. So it is number three. So colorectal. So it's pretty rare for any sort of colorectal cancer to metastasize to the bone. Um the most common is prostate cancer and myeloma is something that you should also consider as a potential cause for acute cold compression. So, spinal cord compression, so this is essentially caused by any sort of pathology that can lead to compression of the spinal cord. And as I said, metastatic, spinal cord compression is the most common cause. So other causes um can be trauma usually uh again, as a result of a vertebral fracture, infective causes such as an abscess formation, a disc prolapse. Um This is a pretty rare cause of spinal cord compression and this is because disc herniation typically causes compression of the cord equina rather than the actual spinal cord itself. So, any other sort of um pathology that can predispose it. A narrowed cord canal can increase the risk of developing spinal cord compression. And these can include um rheumatoid arthritis or uh again, ankylosing spondylitis. So, clinical features, so, um sensation and proprioception. So these will be impaired at the dermatomal levels below the cord compression and pain is usually made worse through um straining such as when you're coughing or sneezing and there will be um bilateral or unilateral weakness in most cases and most patients are nonambulatory at presentation. So, so they're unable to walk. There will be upper motor neuron signs present as opposed to lower motor neuron signs seen in called equina syndrome. These upper motor neuron signs include hypotonia, hyperreflexia, babinski signs. So you can see the image on the right, which uh shows a positive babinski sign. Um and you may also get clonus as well. Um Clinical features can include bowel incontinence or urinary retention and there may also be evidence of an underlying cause. For example, malignant features such as weight loss. Um over time, I guess cord injuries at, at the level of T 12 or above. They tend to cause bladder spasticity and below this spinal level, it can cause facid as well. So, moving on to investigation and management. So the Gold Standard investigation as for um called equina syndrome is an MRI of the whole spine and this is particularly in cases of malignancy. Um in the sort of the interim high dose corticosteroids can also be given in an attempt to improve the patient's functional prognosis. And if the patient is fit enough surgery is the definitive treatment option for metastatic spinal cord compression. And surgery involves urgent decompression, um followed by radiotherapy and chemotherapy. One of the best sort of indicators for prognosis is the mobility states at the time of treatment. So, 90% of patients who are mobile um prior to treatment will remain mobile. Whereas only a third of those who are unable to walk at presentation will regain the ability to walk for treatment. Unfortunately, um prognosis is poor and the survival rate for those with metastatic spinal cord compression is only about six months after after onset. So, question number three, a 63 year old female who had a fall on the Jeremy's ward, she's fallen onto her left rip hip and uh xray reveals a subtrochanteric femoral fracture. So what's the most appropriate surgical intervention for this type of fracture? Is a, a total hip replacement. Um A DHS cannulated hip screw hemiarthroplasty or intramedullary Nel, the, if you wanna put your responses in the chart and then we can go through them again, any takers good. Yeah. So it is number five. So an intramedullary nail is used for subtrochanteric Neco feur fractures. Um And then we'll, we'll go into the management of different types of neo feur fractures in the coming slides. And so there are over 65,000 hip fractures recorded in the UK every year and the mortality is also pretty high. So 30% of one year um and these fractures are caused by either low energy injuries such as a fall and a frail osteoporotic older patient or high energy injuries. And this can be as a result of road traffic accident or a fall from a height. So a neck of femur fracture can occur anywhere from the subcapital region of the femoral head to all the way five centimeters distal to the lesser trochanter. And there are two essentially distinct areas for um the neck of the femur. This is the intracapsular region and this is from the subcapital region of the femoral head to just above the, the the level of the trach cancer. And then you have an extracapsular region which is divided into intertrochanteric, which is between the greater trochanter and the lesser trochanter and subtrochanteric regions, which is from the lesser trochanter to five centimeters distal to this point. So it's really important to uh first of all know the anatomy and also the blood supply to the femoral head and the blood supply is runs in a retrograde fashion predominantly um through the medial circumflex, femoral artery. So, as a result of this retrograde blood supply, um any sort of displaced intracapsular fracture can lead to disruption of this blood supply. And so, um patients with neck of feur fracture are at risk of avascular necrosis. And patients with a displaced intracapsular fracture will therefore require a um a joint replacement rather than any sort of fixation. So this is just um a classification for neck of femur fractures. And um it's known as the Gardens classification. So types one and two are non displaced fractures. Um And the difference between one and two is that number two is a complete fracture, but it is non displaced. Um Types three and four. So G classification types three and four are both displaced fractures. Um whereas type three is a complete fracture with partial displacement, but type four is a complete fracture that has been fully displaced as you can see in the image. So in terms of features, so as with every fracture pain is always going to be a predominant feature and they'll typically have an inability to weight bear. Um On examination, you'll have this typical uh finding of a shortened and externally rotated leg. Um And this is a feature that um will be highlighted in your exam. So a shortened, externally rotated leg in a patient who's unable to weight bear points towards the neck of femur fracture in terms of investigations pretty obvious, but an X ray should include both the AP as well as a lateral view of the, of the hip as well as the pelvis. And you should try and obtain a full length femoral x-ray too, just to see if there's any sort of pathological fracture as well. Um A CK level can be, can be requested to assess for any signs of um rhabdomyolysis, say. So management, it is a bit of a heavy slide. But if you try and um um to memorize this table, it it it can make it a bit easier. Um So as with every sort of trauma related injury, an A to E approach needs to be adopted, particularly in AY that just mentioned that I would like to assess this patient using an A to E approach. Um make sure that the patient has been given adequate analgesia and then surgery is always gonna be the definitive form of treatment for any sort of me a feur fracture. So, for displaced subcapital fracture, the surgical option is a hip hemiarthroplasty. Um So, um you can also consider a total hip replacement in those patients who are systemically well and those who are able to live independent prior to suffering from this injury to those who are able to walk freely without the aid of a Zimmer frame. For example, the management of intertrochanteric fractures would typically be a dynamic hip screw, um non displaced intracapsular fractures. You can consider a cannulated hip screw or again, a total hip replacement or hemiarthroplasty depending on again, the functional status of the patient prior to the injury. Finally, subtrochanteric fractures, um they are typically always managed using um an intramedullary nail. Um I wouldn't worry too much about the summary of how you put them in, but just remember the surgical option. So these are just a few images of various different types of hip operations. So cannulated screws are typically used in non displaced intracapsular fractures, dynamic hip screw in intertrochanteric fractures, an intramedullary nail in subtrochanteric fractures and either a total hip replacement or hemiarthroplasty in um displaced subcapital fractures. So this brings us to an end um on neck of femur fractures, uh we'll move on to another question. So a 24 year old footballer presents with significant knee pain and joint swelling. He describes twisting of the knee when attempting to tackle a player. The F one suspects an ACL tear. So which of the following tests is specific to an ACL injury? Is it mcmurray's Apley's Lachman's noble compression test or Trendelenburg test? Ok. So we've got a couple of twos and it's three. So the answer is actually three. So it's Lachman's test. Mcmurray's and Apley's tests are used to assess meniscal damage. Um Noval compression test typically used by physiotherapists, but it's used to um assess for it band syndrome. So iliotibial band syndrome seen in runners and finally, Trendelenberg test um is essentially a physical examination finding and, and it indicates weak hip abductors, uh particularly the the glutes. So ACL, so ACL is a really important stabilizer of the knee and it primarily limits any sort of anterior displacement of the tibia relative to the femur. And typically the history of an ACL tear will be in an athlete. Um And um there'll be a history of twisting the knee whilst weight bearing on examination, they'll most probably be unable to wait there, there'll be rapid swelling of the joints. Um And this is because the ACL is highly vascular and sort of any damage to the ACL can result in a hemarthrosis or blood within the joint if the presentation is delayed, um the, the leg itself may be um unstable and the patient will describe the leg as sort of giving way specific test to assess a cr damage or Lachman's test and anterior jaw test. And Lachman's test essentially involves placing the knee at about a 30 degree flexion. Um put one hand on the femur to stabilize it and then try and pull the tibia forwards in order to assess the amount of um forward movement of the tibia relative to the femur. Um, an anti jaw test involves again flexing the knee to 90 degrees and you pace and you put both of your thumbs on the joint line of the knee and essentially push forwards just to see if there's any um increased tibial laxity. I would say the Lachman's test is is more sensitive compared to the anterior jaw test in um in uh diagnosing an ACL test. So, investigations and management. So an X ray should be carried out. Um This is just to include any bone e exclude rather any um bony injuries uh or any joint effusions. Um Sometimes there may be um a fracture um that uh can be evident. Uh but that's pretty rare. Um An MRI is always going to be the gold standard. Um And it's also good at picking up any associated meniscal tears. Um So all, so about 50% of um ACL tears will also have an associated meniscal tear and the medial meniscus is um is more commonly affected in terms of management. Um I remember the pneumonic rice, so rest ice compression and elevation. Um So that's just immediate management. But specific treatment of an ac rupture can either be conservative or surgical. So, conservative treatment involves um strength training physiotherapy. Um Whereas surgical reconstruction um of the ACL typically uses um a tendon or an artificial graft um to replace um the ACL in terms of prognosis, it's typically pretty good. But um osteoarthritis can occur later on in life as a result of the ACL injury and also as a result of the surgery. So, moving on to another uh another question. So, um bone fractures are always worth considering um as a differential diagnosis in patients presenting with um acute knee injuries and the awa knee rules can be used to determine whether a patient requires an X ray of the knee after an acute injury to look for fracture. So which of the following requisites is not part of the Ottawa Neles? Um a bit of a complex question. Um Let's see how he gets along. So, is it age 55 or above? Uh patella tenderness, fibular head, tenderness, tibial tuberosity, tenderness, an inability to flex the knee to 90 degrees or an inability to wake back. So, which of the following requisite is not part of the Itala needles which suggests organizing an X ray following acute knee injury. Ok. So um got a, a few twos, um a one. So uh the answer is actually four. So tibial tuberosity tenderness. Um So as I said, the OTA knee rules are used to determine whether a patient requires an X ray of the knee after an injury to the knee to check for any fractures and tibial tuberosity tenderness isn't a requisite. So it's not part of the OTA knee rules. So, um there are five requisites that make up the Italian neural. So if they're age 55 or above, they have patella tenderness, they have fibular tenderness, they have an inability to flex the knee to 90 degrees and they have an inability to wait there. If they're meeting this criteria, then it's worth ordering an X ray of the knee. So there's a similar set of rules for ankle fractures, but we'll go into that um in a few more slides. So, meal ta so um the menisci, so they rest on the tibial plateau and they have two main functions. So first of all, they act as shock absorbers of the knee joint. And second of all, they increase the articulating surface area of the knee joint. So the medial meniscus is less circular uh than the lateral. Um and it's attached to the medial collateral ligament. The lateral meniscus is not attached to the lateral collateral ligament. Um and the most common cause for any sort of meniscal tear um are trauma and any sort of degenerative disease. So, in traumatic tears, um as I alluded to during um ACL ruptures, the typical mechanism involves a patient who is twisted that knee whilst it is flexed and weight bearing. And there are a number of different types of meniscal tears. But the most common is a longitudinal tear and this is known as a bucket handle tear. And this is where the central tear becomes separated from the lateral fragments. So, millions of clinical features. Um so patients will typically report any sort of tearing sensation in their knee. Um and this will be associated with sudden onset intense pain in the knee. In comparison to an ACL tear, the knee will swell slowly. Um And in cases where the meniscal tear results um in a in a free body within the knee, um typically seen in that bucket, bucket handle, um, type, the knee may be locked in flexion and they'll be unable to extend their knee on examination. They'll have joint line tenderness, they'll have a joint effusion and they'll also have limited flexion of the knee. And specific tests to identify meniscal tear are the mcmurray's test and the Apley's test as well. So in terms of investigations, an MRI is the gold standard, um, and an X ray should be um performed according to the tower rules as we, as we went through earlier. Um in terms of acute management, as with an ACL tear, I remember the pneumonic rice. Um So rest ice compression and elevation. Um Most meniscal tears if they're less than one centimeter, um they will initially swell, but uh the pain will typically improve over the next few days as the tear heals. But for larger tears or uh those patients who remain symptomatic arthroscopic or keyhole surgery will be required. Um If the tear is in sort of the outer third of the meniscus, then the tear can just be repaired using sutures, but if the tear is within the inner third, um then the tear is usually trimmed to reduce any sort of locking symptoms. And in terms of um prognosis, um a significant complication um of both the meniscal tear and any sort of surgery is osteoarthritis later on in life. So, moving on to question six. So a 42 year old male presents to Ed with a varus deformity. He was hit by a cricket bat across his right knee and the X ray shows a split depression of the tibial plateau on the lateral side according to the Schatzker classification for tibial plateau fractures. What type of fracture has this man suffered from? Again, a bit of a complex question. Um But SZA classification is used to classify tibial plateau fractures, any guesses. OK. So, um let's see. We've got one. OK. Four. OK. Thank you for guessing there. I appreciate it. Um So the answer is actually two. So it's a type two classification. Um And the charts fur classification is used to classify any sort of tibial plateau fracture and it's dependent on whether the fracture is fracture site is medial lateral bicondylar. So involving both condyles and if a depression is seen within the um tibial plateau as well. So type one is a lateral split fracture. Um Type two is a lateral split with essential depression. Type three is a lateral sort of pure depression uh which is quite rare. Type four are medial plateau fractures and type five are bicondylar fractures. And finally type six is where there's complete disassociation between the metastasis and the diaphysis. So I go pick coming up in the next few few slidess which will better illustrate the various subtypes. So, tibial plateau fractures. So they're the most commonly um like a fracture in any sort of high energy trauma such as a fall from a height or any road traffic accident and they occurred due to compression or impaction of the femoral condyle onto the tibial plateau. And it's typically a, a barrister forming force. And this means that the the lateral tibial plateau is more frequently fractured uh than the medial side. In terms of symptoms, there'll be sudden onset pain in the affected knee, there'll be unable to weight bear and there'll be swelling of the knee. Um secondary to um lipohemarthrosis. On examination, there will be significant tenderness over the medial or lateral aspects of the proximal tibia. Um and there will also be potential uh ligament instability as well. So, investigations and classifications. So the first line investigation for any fracture is an X ray, both AP and lateral and a CT scan will be needed in almost all cases apart from undisplaced fractures. Um and the CT scan. Um and you can see in the top right hand corner, um you can see that the red arrow indicates a lipohemarthrosis. So, tibial plateau fractures can be classified using the Shakia classification as you can see on the image image on the bottom right hand corner. Um So lateral epicondyle fractures are most prevalent. Um This is followed by bicondylar fractures and finally, um medial epicondyle fractures. Mhm Same management. So, um in terms of non operative management, um this can typically be used in uncomplicated tibial plateau fractures. So, fractures where there's no evidence of any ligament damage. Um There's no tibial subluxation um and where there's an articular step of less than two millimeters. Um and these are typically managed with a knee brace alongside physiotherapy and uh painkillers. Operative management is warranted in more complicated tibial plateau fractures and any medial tibial plateau fracture will require surgical intervention. So an RF so open reduction, internal fixation is the mainstay treatment for most of your plateau fractures and postoperatively, a knee brace will be fitted. Um external fixation um with any sort of delayed surgery is indicated in cases of any significant soft tissue injury. Um and a highly combinative fracture where immediate or if um or ap induction, internal fixation may not be suitable. S let's move on to ankle conditions. Um So a 32 year old female presents with an achilles tendon rupture 48 hours after starting antibiotic therapy. So, what class of antibiotics are commonly associated with achilles tendinopathy and rupture? Is it penicillins, cephalosporins, tetracyclines, quinolones, or aminoglycosides? Great. So, you've got quite a few number fours. So the answer is right. So it's quinolone, uh antibiotics and ruptures. They can occur spontaneously within 48 hours of starting treatment. Um and typical quinolone antibiotics include Cipro ciprofloxacin and levofloxacin. So, achilles tendonitis. So this is inflammation of the achilles tendon and it can lead to full tendon rupture resulting in sort of complete loss of function of the calf muscle. Um and most of these injuries occur during um sports. So any sort of sporting injury. So it's important to remember a bit of anatomy. So the achilles tendon, it unites um the gastro soleus and the plantaris muscles in the posterior compartment of the leg, it inserts onto the calcaneus. So the heel bone and it produces plantar flexion of the ankle. So of moving downwards and repetitive action of the tendon, it can result in micro tests and this can lead to localized inflammation. And over time the tendon can become thickened fibrotic and also lose its elasticity. So achilles tendon eruption typically occurs when the sudden force is applied across the tendon. Um and these forces could be secondary to a sudden jump a rapid change in direction whilst running. Um and risk factors are any sort of sport that stresses the achilles tendon. So, um tennis, track athletics, basketball, all these, all these sort of sports, uh precipitate achilles tendon injuries, other inflammatory conditions such as rheumatoid arthritis, diabetes have raised cholesterol and as we alluded to in the previous question, quinolone antibiotics as well. So, clinical features. So typically, patients will present with gradual onset pain and stiffness in the posterior ankle and this is worse on movement. On examination. There'll be tenderness over the tendon on, on palpation and in severe cases and 10 cases of tendon rupture. Uh the patients will describe sudden onset severe pain in the posterior calf and they may even hear an audible sort of popping sound and a feeling that something went on examination, there'll be a loss of power of an ankle, plantar flexion and simmons test. As you can see on the on the right hand image can be performed to determine tendon rupture and it involves just squeezing the calf. And if there's no plantar flexion, then a rupture is highly likely on examination, there may also be a palpable step step in the achilles tendon. So, investigations and management. So both achilles tendonitis and rupture, they're typically clinical diagnosis. But if there's any doubt that an ultrasound can be performed and in terms of management, um always start off with supportive measures first, including physiotherapy, um good painkillers, um and as with everything, rice. So rest ice compression and elevation. Um initial management um for acute achilles tendon rupture. So if it's been less than two weeks and since the injury, they require good analgesia and immobilization and the ankle should be splinted in a plaster and um the plaster should be kept in place for at least two weeks. In total. The patient will remain in a plastic cast for about eight weeks in total until full function can, is is, is buck in terms of delayed presentations. So, more than two weeks after the initial injury, these patients will probably require surgical fixation with an end to end uh tendon repair. So another question. So a 25 year old male presents to Edie having fractured his ankle and the X ray reveals a Weber type B fracture. And the Weber classification classifies lateral malleolar fractures. By what is it the number of bones involved? Is it the level of injury in relation to the syndesmosis? Is it the degree of displacement? Is it the ankle position at the time of presentation or the degree of subluxation of the ankle joint? Any takers good? So it is number two. So weber classification classifies any sort of lateral malleolar fracture by the level of injury in relation to the syndesmosis ankle fractures. So, these are more common in males between the age of 2040. Um and females over the age of 65. Um So we offer a bit of anatomy and the ankle is comprised of a talus bone. Um and this articulates with the mortis. So the mortis is um comprised of a sort of tibial pla medial malleolus and the lateral malleolus. As you can see in the, in the image the tibia and fibula, they're joined by a syndesmosis. So this is a really strong fiber structure um and it's comprised of various ligaments. So the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament and also the intraosseous membrane. An ankle fracture is sort of any fracture of any malleus with or without disruption to the syndesmosis. So this is a classification and ankle fractures. So they can be described as either an isolated lateral malleolar fracture, an isolated medial malleolar fracture, bimalleolar fractures or trimalleolar fractures. And this occurs where there is a medial lateral and posterior malleolar fracture. And the most common classification used is the Weber classification. Um and it is used to classify lateral malleolus fractures. So type A is um a lateral malleolar fracture below the level of the syndesmosis. Type B is at the level of the syndesmosis and type C is above the level of the syndesmosis. So this picture highlights that nicely. Um I guess it's important to remember that the more proximal the injury, the higher the likelihood of ankle instability. And so type C fractures, they'll typically require surgical fixation. Um just something small, the the Hansen classification. So it's another classification system and but this is based on ankle position at the time of injury and the deforming force involved. So clinical features um as with any fracture, ankle pain and deformity and where there is any sort of um diagnostic uncertainty. Um the A tower rules can be used and like in the knee, these state that in the presence of any sort of of the following an X ray should be undertaken. So if there's bony tenderness of the lateral malleolus or bony tenderness of the medial malleolus, or if there's any sort of in inability to weight, bear both immediately and in the emergency department. For at least four steps on X ray, you should always check the joint space for um uniformity and also check for any evidence of a talar shift. So you can see that on um the image on the right hand side as well. In terms of complex ankle fractures, um this is where there is a displaced posterior malleolus fracture. And these will require a CT scan for surgical planning and in terms of management. Um so they require immediate fracture reduction and once reduced, the ankle can be placed in a belone back slab And you should always perform a full neurovascular examination, both pre and post reduction and also request a repeat X ray following reduction, conservative management. So this can often be used in, in patients with a non displaced medial malleolus fracture or in Weber type A fractures or in Weber type B fractures provided that there's no talar shift. An open reduction. Internal fixation can be used um in any sort of unstable ankle fracture. And these include any displaced bimalleolar or trimalleolar fractures, type C fractures or type B fractures with a talar shift. And finally, any open fracture will require um fixation. So, question number nine. So 42 year old female presents to Edie having inverted her right ankle on plantar flexion. So there's swelling and pain of the ankle and she's unable to wake bear a right ankle sprain is suspected as to which ligament is most likely to have been damaged. Is the anterior talar fibular ligament. The calcaneofibular ligament, the deltoid, the posterior talar fibular or the medial talar fibular ligament. Um So these questions just require a bit of anatomy but uh see how you get on. Ok. So it's a bit of a complex question, but the answer is number two. So it's the calcaneofibular ligament is um most commonly injured ligament in any sort of ankle sprain. Um So, in terms of ankle sprains, these are any sort of ligamentous injury and can be classified into high ankle sprains, which are injuries to the syndesmosis, only lower ankle sprains, which are injuries to the anterior talar fibular ligaments and the calcaneofibular ligament. And as I said, the calcaneofibular ligament is the far more commonly injured ligament. One final question. Um So a 60 year old female presents with sharp pain across the plantar aspect of her foot. It is most severe in the heel and on examination, she over pros and a high arch is noted. So, diagnosis of plantar fasciitis is suspected. So weak plantar flexors are a risk factor for plantar fasciitis and which muscle is characteristically tight in this condition. Is it the gaseous aus the semitendinosis, semimembranosus, bicep, femoris or the gracilis? Yeah. So we've got a a question glove and stocking, peripheral neuropathy in diabetes, patients with peripheral vascular disease. Could that pain sensation be compromised? Delay? Um So yeah, I guess with any patient presenting with any sort of peripheral neuropathy, whether this be as a result of diabetes, um then it can um delay that presentation to um delayed presentation risk among. Yeah, of course, it, it can be. And that's a significant risk as with every sort of diabetic patient. And it's most commonly seen in diabetic ulcers where these diabetic patients present it at um at a later date and sometimes it can be too late and the patient may require a form of amputation. But yeah, diabetes patients, they're always more complex than peripheral neuropathy. Yeah, it's a risk factor as well. Um Going back to this question. So yeah, we do have quite a few number ones and that's the correct correct answer. So the gastro sinus um um so so weak sort of plantar flexes are risk factors for plantar fasciitis. Um and the plantar flexor within the calf. So these include the gaseous aus and the soleus muscles, the semitendinosis, semimembranosus in the bicep femoris. So these make up the hamstring muscles and the gracilis is found in the medial thigh compartment. So, yeah, it is the gastros. So plantar fasciitis. So this refers to inflammation of the plantar fascia of the foot. So it's a really common condition. Um it can be bilateral or unilateral and the most common cause. So it's the most common cause of um infra calcaneal pain. So, heel pain and it accounts for 80% of all heel pain complaints. So the plantar fascia. So it's a thick fibrous band of connective tissue and it originates from the medial process of the calcaneum tuberosity extends towards the forefoot and inserts onto each of the proximal phalanges. Um and in terms of pathophysiology, micro to this plant of fascia and associated with inflammation can result in chronic breakdown of the structure and main risk factors. So, include any sort of anatomical uh factor such as excessive pronation or um a high arch, weak plantar flexor or tight gastros or soleus for long standing or excessive running. Um any sort of leg length discrepancy in obesity is also um a significant risk factor for plantar fasciitis. So, moving on to clinical features and investigation, um patients still report a really sharp pain across the plantar aspect of the foot. Um It's most commonly found in the heel. Um The pain will be felt in the heel and it can radiate down the arch distally as well. On examination, we should assess for any evidence of overpronation, any high arch or any leg length discrepancy and the infra Calcaneal region. So under the heel is really tender on palpation. Um and palpation of the medial calcaneal tubercle can also reproduce the symptoms in terms of diagnosis. It's usually just a clinical diagnosis, but x rays can be done just to exclude any bony injury and also to assess for plantar heel spur, which you can see in the image. And this is um uh it can sort of indicate any abnormal loading of the plantar fascia. Um And yeah, so you can see this um as indicated by the red arrow. So, moving on to management. Um So activity moderation and regular analgesics, typically nonsteroidal. So they're the mainstay of any sort of management. Um, physiotherapy is often used especially when the underlying cause is any sort of tight muscle. Um In severe cases, corticosteroid injections can be trialed. Um But if there is no improvement following this, a plantar fasciotomy can be considered. Um And this is where it's sort of an endoscopic procedure where part or all of the fascia is released and it has about a 75% success rate um in terms of um pain improvement. So, um this brings us to the end of the, the, the lower limb and spinal torque. Um I hope you guys find it useful. Um If you have any questions, just put them in the chat and we can go over them. Um What is excessive pronation in the foot? So, no, so see if you can. So when a foot lands properly, it should land straight. But overpronation is when you sort of go inwards, when you, when you're out, when you're walking. So that's overpronation. All right guys, thanks for attending. Um Again, if you have any questions, uh please feel free to put them in the chat, but before you leave, if you could please um provide some feedback for me, that would be great. Um I'll just put the feedback form in the chat. Um So as I said, so, um this is the the, the final talk in the orthopedic series. But, um, I'm running a plastics talk next week. Um, so I'm currently act one doing plastic surgery. Um, so I thought I'd just give it a bit of an introduction to plastic surgery as well as it's not really well taught during, um, med school. No problem. So, guys, I'm glad you found it useful. Um, all the sessions are recorded as well. Um, so you can go over the slides if you'd like to. Um, can we already sign up for the plastic seminars on metal? Um, I'm not too sure, but if you follow BSA on Instagram, they should be releasing the, the sign up form in due course. So I'll be, I'll be doing it on next week on Thursday. Um, and again, six o'clock, but before then they should be sending out the, the linked to the talk as well. So I'll just put the link to the, to the plastics to next week as well in the chat. All right, guys. Well, I'll in the tutorial that, um, thanks for attending everyone and I hope to see you again next week. Enjoy your Friday evenings.