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um So the three pictures in front of you are the rims dot TV platform. We're going to be just hosting orthopedic surgery in the morning. Uh, we're gonna have to set a whole dedicated day aside for anesthesia with, like, streaming of supplies. Patient, uh, anaesthetic techniques, regional blocks. Uh, so we've dropped that for this afternoon, and we got it all started from the orthopedic surgeons who is leading the orthopedic dreams today. Demonstrated in public techniques. Three shots you have in the spring in front of you. Are the website access on your mobile phone? Just rooms dot TV. If you click on catalog, you've got a whole selection of videos that you can stream for the rest of the day. We'll have the platform on from 95. So we have previously hosted properly Lola Orthopedic and shoulder as well. Uh, with this and fill. So that's your content for the afternoon. If you actually click on the text on the top, right, that'll take you into the YouTube channel, and that loads the 3 60 videos. And I'm gonna give you an instructional video of how you adapt your mobile phone into a VR headset. assume you've got the headset. So that's the content for today. We've got introduction, election lecture, um, and then some various approaches with the coffee break at 10 o'clock in the posterior approach Q and a apologies. The data that has the one that we have, uh, has had some abdominal approach is already the global medicine. Uh, fenced I'll approach for the, uh, training session, and there's a midline lactulose musician as well. So the chaps have kind of patch things back together, whatever they can see from a layer perspective, but that might slightly influence. Uh, you got a very demonstration. Um, So I've got a video here just to demonstrate to you how you can use a platform on your laptop computer. You don't have to use a VR headset if you don't want to. Uh, if you're on a desktop, only have a desktop without a headset. What you will be able to do is to be able to tap and scroll through, uh, on your desktop with the stream again on TV, But this time you need to pick up the live sections just sort of live stream. What you'll be able to do is just tap and scroll or whatever perspective you want. So if you've got this kind of a headset quite uncomfortable. But these are pretty cheap and easy accessible. Headsets. 15 lbs from Amazon moment. These headsets allow you to adjust your period distance and your focal debt give you much more comfortable experience and you just use your mobile phone as the headset. So short video. Have to convert your mobile phone to be a headset, and then we'll get you guys going. Yeah, I just had it before. Before the are you make sure you have downloaded the YouTube. We need the YouTube, your mobile phone, because some of the content is 18. Plus it already you need the YouTube and you also need to have registered. You can do that with the Google account. You click the leaks. The leaks actually direct directly to the, uh, the YouTube feed. When you click on the life section, you just want to enlarge that image, put it in landscape. You look at the dog was like on the bottom, right? Uh, your headset. As I said, if you got the cardboard headsets, let me just fix. But if you use these not sophisticated, just that. Okay, that such as a recap. So click on the link to the video. They are secure codes on some of the content as well. So you can just put the phone QR code on the desktop landscape. You. I'm not Goes right. Change it to my office with you. I'll get your headset. Yeah, it's impossible. Just like it's a light, a light. And then I just start to help to get much of the days. Okay, Final comment to make about the setup. Is that the default resolution to be quite low on auto, you can certainly see very fine needle and 10, 80 even two. Okay, so just just the quality to either put you on 60 or 10 8. Depending on the bandits desire, you get a much clearer image. So this is a flat screen version of what you're going to see. You can see the multiple camera streams to use the redundant space within that 3 60. And those extra feeds just allow us to be able to use cameras that can zoom in and give you a much better perspective. You have a camera from the light cameras coming from the side bullet camera to get right into the abdominal cavity, and we'll also be running a separate stream with the presentation slide as well. So if you imagine, this is a hen's helicopter uh, hep C being an emergency thoracotomy, if you imagine with your headset on your head to the left, you got one perspective of the camera from the left, a second perspective of the camera coming from the top and the headlight, and then the bullet cancer perspective. If you turn 100 and 80 degrees to see writing, to be in this case of thoracic cavity, so that's our camera set up. The content from previous course is is available by just scroll down to the plastic. The orthopedic section. Uh, there we are, So you've got lots of approaches. Ankle hit scapula, humorous, Um, and that's all going to be available for you to sleep for the rest of the day. I'm going to show you the website quickly, Uh, and then I'll hand over to fill. So there's the website. If we just type in going to Google and just type in the ribs on TV at the top of the URL and return on the right hand side is a menu. The live button takes you into the livestream. But if you go into the catalog section, you see the various catalogs section you'll be able to search for content in the top, and we've also got a duration of each of the film. But if you then finally go down into some of the sections, just started to put, for example, global medicine uh, QR code on the screen. So you just scan that into one of our phone and we'll take you into the YouTube live YouTube stream of that video. It's actual preference, so I'll hand over to fill. Now who's one of my colleagues at Brighton? Antibiotics. Who is going to give a short lecture before the demonstration? All right, well, let me get your presentation. Up you go. Mm. Thanks, Jane. Mhm. So coming on if you want to. So when it comes on so you can see me. So I'm Philip. Stop. I'm a pelvic tablet surgeon hip surgeon at Brighton, and I'm here with my register at the moment. James, not I don't know if you can see him or so to start with. We're going to do a little bit about pelvic as a tablet fractures in the radiology. People often get scared about pelvic and tablet fractures because you don't see it in most district general hospitals. But it's actually reasonably simple as long as you know the basics. So what we're going to do is give you a system for looking at, uh, well, we can ask the tablet fractures and then we're going to go through to the lab next door and look at the anatomy. And as Jack said, unfortunately, they've done some of the approach is already so We may have to redo this section on a fresh. So the aim is looking at the anatomy, uh, imaging and classification for both acetabular fractures and health fractures. And just remember, there are two different beasts and the chalk and cheese. We've got a small tablet, fractures and pelvic fractures. They're not the same thing often. Sometimes the patient has both the pelvic and NASA tablet fracture. Very often, uh, it's one or the other, so that's a tablet factors the acetabulum is the structure is a socket that supported in the pelvis between two columns of bone so it's often described as a y in inverted y, with the boots attaching it to the sacred. So normally the sacred will be here. And, uh, you got the two columns. If you get a pelvis, look from the side, you can see the socket. And, uh, the anterior column is this half, and the posterior column goes back up towards the same. Traditionally, we have two types of fracture with the elderly, traditionally low energy and the younger high energy. But now elderly people are doing high energy sports too sometimes, and sometimes you get them combined. I've had elderly parachutists, very complicated fractures, and the fracture pattern depends on the direction of force, the position of the hip and bone quality. Now the Lipitor. No classified. It's a classic reaction into five elementary and five combined, uh, fracture patterns to start with. When you look at this, you think, Oh my God, this looks complex, but it's not Not too bad at all. You've got five simple ones, which are posterior wall anterior posterior column anterior column transverse and they're all well, um, you know, very descriptive. And then the five associated we've got a tea type fracture with the transverse fracture and a fracture going through into the pubis. Combined posterior wall and posterior problem transfers with an extra bit of posterior wall anterior wall or common with posterior and transfers. This is different from the tea because the T those exits anteriorly through the acetabulum. There's this one. X it's above the table anteriorly and then the, um two column or associated. Both column. So the plane A P is the key to start with. I was taught to look at as a tablet fractures on a plain X ray and not on the CT. So there's, um, some lines that we need to know. The first one is the idea is, um, starting. The idea is, um, up coming down the medial bit towards the ischium. Um, and that line represents the post area column, and we've got the idea Pectinate line starting at the same place. You're going towards the pubis and you'll see the retinal fashion. Hopefully next the next session that represents the anterior color, the anterior wall of the acetabulum, starting at the bottom of the teardrop, going super lateral to the acetabulum in the posterior wall, and then the reef. With these lines, it's often possible to say which sort of fracture we have, and it's important to know which facts you have as to how you're going to treat it. And again, I wouldn't expect to register or s h 02 no how we're going to treat each fracture. But as a consultant, we do, and knowing what fracture you have is obviously very critical to know how to fix it and whether it needs fixing. The last structure is the teardrop. So, as I said, the idea of skill line represents the posterior column and the idea of putting your represents the anterior problem. So we've got an example here. I want you to run through your head. We've got the normal side and the left and the abnormal on the right. When you see the idea effect on the Align and is it intact or is it fractured? So we run down from the video, uh, any affect on your line? You can see there's a a break. It doesn't run smoothly. That's the idea. Is that the new line? And that's the idea. Is that the line? So it's moved. There's a fracture through it. So the anterior column is gone. Is the rescue line intact? You can see the polio. And then again, this line here it's not intact, is that that's the idea. Is Caroline starting from the bottom, starting from the top, and there's a gap in it. So the idea skill lines disrupted, so that must be a that's right posterior kind of injury. Then we look at the roof and that appears intact, so the fracture is below the roof. The anterior wall is difficult to see. Um, but that's the anterior wall coming from the supernatural bit towards the teardrop. Um, and it's I can't really see the front of it in the game with the posterior wall, you can see there's a disruption down the bottom. Looking around the rest of the pelvis. You can see a fracture through the pubis, so this is a tea type fracture when you got a fracture through a transverse fracture through the acetabulum, and it's exciting here. So that's the two type and just thinking about this going all the way through. With each fracture, you can often get the classification. So again, here's another example is the IUD suture line intact on the left. So, yes, it is as the idea is that the line you can see that's intact. The idea Peritoneal line coming through here. No, that's not intact. The roof know the anterior posterior was very difficult to see. I'm afraid of this image. I can tell you, the posterior was definitely intact. I can't see the anterior wall, the teardrop that we're missing part of it, aren't we? So if you have any effect on the lines in taxes, so are you still on Zantac? See, any effect on your life is gone. You know, that's going to be an anterior column that you. So we have that there is a method of looking at these fractures that tells you exactly what sort of fracture is. And again, I'm not expecting you to know how to do that at the moment. But this is just to show you if you're interested, if you see an acetabular bone fracture, Green line recommend is a yes. And the red line, you know, So the only affecting your line intact? Yes. Um, you have to go down this, um, branch of the tree. And I'll tell you as opposed to your wall. Supposed to call? Um, posterior wall posts your problem. And again we can look at a X ray and see what fracture we have just purely by following this algorithm. So again as a tablet, fractures isn't that complex. People worry about them, but it's not. It's very logical. Nowadays, however, we see more of them on CT and looking at CT, I had to learn it as a consultant because we won't talk about it. So basically, the wall fracture is vertical and a column fractures horizontal. The wrong and transverse fracture is vertical on the actual CT. When you look at a CT image on the actual slice, it's all about these. Two points for fracture starts in the acetabulum and exits anterior. To that point, it must be a war fracture with the exits. Um, in this side, it's a common fracture. So that's why the column fracture is horizontal and the war fractures vertical. The transverse fracture goes all the way across. Obviously again. It's called transverse fracture because it's going across the image. But it's, um, transverse fracture appears vertical on the CT, and again, that's the same for posterior side in the posterior problem. Um, horizontal. It exits above that point. It's a common fracture. It's vertical or exiting on this side of the Let's see acetabulum. It's a war fracture. Well, so here's an image. Have to think about what this shows. So is the fracture. Main fracture line is it's vertical horizontal and does it, except above or below. This point, it's in the post here. Half of the time I'm supposed to have a fracture. It was supposed to be a fracture, and it must be a column fracture because it's exciting. They're This little chip is a wall fracture, so it's supposed to be a problem and the posterior wall, because it's exciting on this side of that point, it's an X ray just showing what's called the gold sign. This is the posterior wall, and it's fractured and gone up. Uh, often happens with the dislocation of hit, and that's most of view of the fracture in an associated both column fracture that most of the all of the Astelin has to be fractured off the skeleton of the skeleton. This is the only bit of the the pelvis that's attached to the sacroiliac joint and all of this other bit is fractured off and you see sometimes a little spare bone poking out laterally. That's the spare sign. That's the POSTOP. Okay, so we're going to go through in a little while and look at the some of the approach is we've got the I oh, England, all the modified Stop that and the cocker Langenbeck, the workforces of modern acetabular fractures. Sometimes we combine the ilioinguinal and the carpet and back together. There's also the idea of Femara and the tri radiate, which we're not going to talk about today. The Ilioinguinal used to be my main bridge for looking at the anterior column, Um, fracture, but it's much less common. I haven't done one for some time, and we produce three windows. This is how we're going to do it. It's basically approaching through the Inguinal Canal and the blood vessels, but the main work spaces between the vessels and the nerve, and so that's the middle window. This is quite a time consuming, large approach, which can give you hernias, lateral femoral, cutaneous nerve damage is very common because we're working between the nerve and the vessels, your vascular injuries Unfortunately, reasonably common modified stop approach is a much more common approach nowadays, and you'll see hopefully how I watch that the view we get. So now we're moving on to pelvic fractures, and remember, this is a different beast. The pelvis is a strong bone, the ring with highly vascular cancellous bone, and it's close proximity to major blood vessels, nerves and pelvic organs. There's a lot of blood vessels around the pelvis. Um, there's a pelvic venous pelvic plexus, and we've got two arteries that are easy to eat to be, um, injured. And you've also got bleeding from extra pelvic sources to so my system to look at a pelvic X ray. Look at three circles, eyebrows and the L5 transfer process. I can see your eyebrows are raising when I said eyebrows with pelvic symmetry and agenda. So you look at a pelvic X ray. There are three circles first circles, easy. It's the it's the pelvis. What we're looking is we we want to trace the pelvis and see if there's anything disrupting that circle to look at any joints, Uh, the other two circles of the obturator frame looking at the synthesis pubis and the two sacroiliac joints to see if they're open. And if they look normal next, we're going to look at the sacrum again. When you with the classification, you look around the bone, you can see the back of the sacrum and the front of the sacrum. This is more difficult to see, especially with bowel gas. You got bits of bowel gas. You've got these lines easier eyebrows, and they show the same for phenomena. You can look between the two to see if they're disruptive, and very often you can see a little kink or a dent in the eyebrow. Showing a simple fracture. You got the L5 transverse process in the open book fracture. This is often torn because the there's a ligament between the back of the eye, um, and the transverse process that tears the transverse process off so sometimes you'll see a crack in it, or it will be right off. And sometimes with the vertical sheer fracture, you see the transverse process by that last thing is symmetry. The two sides of the Valium, uh, show the rotation, and I want to see the distance. The width of the island is the same on both sides. You can see the same risk, your spine, both sides and the teardrop looks the same in the pelvic fracture. Often your rotation, the one side of the pelvis and the teardrop is wider. So when you're looking at them, have a look at this yourself. So here's an X ray of the pelvic fracture. When you see the three circles, can you see any disruption in those three circles? There's only one circle. It's not disruptive, isn't it? That one. This one's got disruption. The main one. It's got disruption here. No. Five. Transverse process. Poorly visible. But there is a fracture through it. And I know there is because this is my patient. The eyebrows look at sacred, difficult you got the belt is in the way of symmetry. What do you think of the two sides of the blades? Are they the same? Both levels of the previous, the previous level is the same. That one's higher. The back of the belt is the same. Here's another example. Three circles. You look for the eyebrows now on this one. See the eyebrow here and the eyebrow there. Are they the same that zoom in on that so you can see the eyebrow here is disrupted, so there's a fracture is really good out of this of this Satan. I want a CT scan. That's the same image. So that's the POSTOP view of pulling the pelvis down, putting screws in and the columns creeping up the anterior problem. So with these fractures, you need a men's external forces to fracture a pelvis. Remember that pelvic trauma is rarely isolated with a pelvic fracture. There's to classifications. Um, we've got the anterior younger burgesses, the one that we use the anterior posterior compression lateral compression vertical share in combination. So anterior postal compression. This one is an obvious injury. Nowadays, you don't see this so often because patients come back the package. But this is a plain X ray that was taken my trust, showing quite a large disruption at the front. So this is usually a crush injury. Front to back, often with motor cyclists you don't know, and the trouble with an anterior approach to compression fracture, uh, opens the true volume of pelvis if you bleed in your pelvis. Tantamount often, but when you've opened it, open fracture. Um, you can bleed a lot, and nowadays we treat this in a and E and in pre hospital care with a binder. Lateral compressions are blowing from the side, and what happens is that the impact comes from the side. You get sharp spikes, the bone that comes across the kink, the either the sacrum or you can open the back of the sacroiliac joint. Or sometimes the fracture goes through the island and into the sacroiliac joint. Trouble is, this sharp, like a bone, gets pushed across the pelvis, often damaging the bladder and sometimes the vessels around here and sometimes contralateral vessels. And it's going to be the way across. So in this, the pelvic funding decreased usually always get limited blood volume loss from the pelvis. More commonly, you get blood loss from other organs. So I remember the time when I came to Resource to see a patient who was bleeding with the lateral compression fracture, and I looked at the X ray and it showed the left side a little compression fracture and the patient was unstable, and the GI Consultant was saying, You've got to take this patient to theater to fix their pelvis is like the blood is coming from the spleen, you know, to to orthopedics I patient. I haven't even examined the patient or looked at the patient, but because it's the left side did lateral compression injury. The spleen is most vulnerable from the same image from the same force pattern, so you know it's most likely to be from the spleen rather than Elvis. It was the CT Hispanic rupture rather than bleeding. Now a binder isn't often helpful, and in the picture you saw before as well the binders in the wrong place the binders at the level of the greater the counter. And when you're binding and compressing these, you're pushing it further across. But you're not going to put it as far across as when the original trauma and that motorcycle accident happened. The pelvis to be pushed a lot more force, and you can push with a binder, so it's not doing any significant arm, but it's not helping. So vertical compression. These are usually a jumper, a full, and you can see there's the bottom of the I am, and it's between level of S. One s two was on this one on this side. It's the level of S three, and the key to this is broken. So the impact is going through the female and taken the elbow itself. And this tears the pelvis from the same tears, the veins, arteries and nerves. And again you get an increased pelvic volume. The binder again is not doing any harm, but it's not doing you much good. Sometimes it does good attractions, often helpful here to reduce the fracture. But remember, it's not going to help with bleeding in the pelvis of the torn iliac veins and the torn and pelvic plexus. So it's a good quote from somebody up north. It's a skirt, and not about the binder. The pelvic binders should be at the level of the greatest counter and out of these three images that all came into my recess. If you're putting the binder on to reduce the pelvis is often easier to do it. If if the if the pelvis is really open to tie the knees together, a pillow under the knees and that makes it easier to put the binder on, there's another example of the fact that she had a fracture. People ray my fracture UM, these have an intact back of the sacrum, and sometimes their fracture exits into the acetabulum. But it's still, it's a, um it's relatively stable. Injury doesn't often need treatment. Don't get confused between that, even if it exits into the sacred into the tablet. The tile or the classification is also commonly used. Classification you don't use it in Brighton is divided into types A, B and C that is classified as a stable fracture is partially stable, and C is completely unstable. Be partially stable is also known as rotational unstable, and C is often known as vertically unstable. So unstable ring injuries. Uh, these are fractures of the island with the Ramus or the transfer Second through the coccidia fracture. They they often don't need surgery, but sometimes they do need surgery. If you have asked your skin, for instance, it's stable, um, a convertible force, but it often still need to fix it. Be either partially stable or rotation and unstable. Be one is the open book fracture. Um, be two. Is the lateral compression be three? Is the bilateral rotational unstable either open book or lateral compression, and these are the more traumatic ones that completely unstable. See one unilateral. Remember these are not only vertically unstable, but irritation unstable. Um, see to is bilateral with one vertical share, one rotation really unstable and C is bilateral rotation vertical. So when you see a pelvic fracture, they often have a leg length discrepancy. Not always or rotation deformity. So one leg is commonly externally or internally rotated. There'd be blood in the urethral meatus or around the labia, and you see swelling, bruising, laceration to the perineum, vaginal, rectal and buttocks and look out for shots. Why stabilize it again? That support that stuff? The manufacturer website. But it should be looked at the level of the greatest counter. If you don't have a pelvic binder sheet tied around, the counters will help. Um, external fixation still got a place that's much less than it used to. We tried to get surgery ideally within three days. Um, if the physical physiologically impossible. Sorry, let's see is excuse me can be used to reduce fracture at the back. Um, if you put a pelvic binder or an ex fix when you're, um, when you get an image of, uh, an injury in the back, you can often displace the the deformity at the back of the pelvis. The trouble with the C clamp is that sometimes these points can slip down, and there's lots of sciatic nerve damage caused by C clamp. So it's only really put on in especially centers and by, uh, somebody has done it before. It's not have ago, uh, type of procedure I just got. This is an image of somebody with a pelvic fracture. It's obvious to see there's a fracture through here, and this is a patient coming to any, Um, it looks fairly symmetrical, doesn't it? But in theater, when we took the binder off just to show you this is the same patient that they've got. A very big diastasis difference between the symphysis pubis has opened up. So don't be fooled. If they've got a binder on, you still needed to check with the with the binder off, but they but it's still stable. This patient actually had an open fracture of the pelvis, and, um, that's how we have to treat. So thank you for that. I I hope you're stuck with it. That's my system for looking at X rays. We're going to just have a quick break, and then we're going to join us with headsets and we're going to go on the Caduet. And I hope this works as again. I apologize because somebody else has already been in there. So stop showing the screen. Thank you.