Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

a minute going. Just get back that start the presentation. Hope nobody caught the answers of the first SBA could never see my screen. Yep. Uh huh. All right. Yes. So this is another of our finals. Easy sessions. So, uh, yeah, today we're doing orthopedics, orthopedics and specialty that I'm personally very interested in on de my hope I could make it interesting for you guys. So this is our first sp to kick off the day, so please do join. All right? Okay, so he's in tub them a good set of antiscalping in. So I think the majority of gone for be just over 50% of people, so we'll end the pole over there on not share the results with you guys. Okay, So, yeah, that's actually the white answer in this question. So in this question, we have a 65 year old gentleman who comes to emergency department. He has pain in information, is left knee on. He previously had, um, an ankle fracture, which he was treated with surgical fixation. And then you notice track marks on his arms. That indicates to us that he's an IV drug user on Do also, he's slightly pyrexia well as well as yes, mildly elevated inflammatory markers. And he also has the elevated HBA one C, which would probably suggest that he might be diagnosed with diabetes. So he is a tiny bit immunocompromised to. So the reason why a pseudomonas is the answer to this question is because osteomyelitis so this guy's susceptible to osteomyelitis because he's a IV drug user on Also though they're the inflammation suggest that there's three information and pain, as well as the pyrexia suggest that there's infection off the bones. So if we look at the cost of organism osteomyelitis, then the most common Lee, the most common causes of agent is staphylococcus aureus on that is in seen in both immunocompromised people on the healthy population is well, however, in IV drugs uses, you see a high percentage off pseudomonas infections in sexually active in younger people. There might. There's more instance of my serum gonorrhea, Ondas well, as my bacterium on in chronic osteomyelitis, you see a polymicrobial picture where there's loads of different organisms that actually in fact the bone eso, then leading team moving on to the diagnosis. So as we saw in the question so you can have raised inflammatory markers on then you also need to send out the rest of the blood cultures as well as bone cultures on. That will help guide our treatment, which will discuss in just a moment on then, looking at the imaging we want to look at, we want to look at X rays, CT scans and MRI, and we'll step there, step it up from one to the other. So X rays would be our initial course of cool to see whether there's any bone license. Any osteopenia on then on the CT scan will look the sequestrian on Ben on the MRI will actually for bone marrow Dema, so you'll be able to see in the middle of the bone that there's a Dema on. Then that's an early sign of osteomyelitis. So if we can get it, as with all things in medicine that we can catch it earlier than we can treat it earlier, which is best of the patients, um, in terms of symptoms, then so we get your general in a signs of information to be on the signs of infection. To be honest with, you get fever pain, you get the systemic symptoms like malaise as well on. Also, there may be signs of previous trauma and then previous surgical scars, which could all cause it. They might also be some kind of adjacent infection, like a bursitis of and then that makes osteomyelitis, um, or, more plausible, enter to USPS and then on a more problem. Diagnosis is well on, then, in terms of treatment. So you start empirical treatment, which is normally separate Aczone on vancomycin, which is taken once daily on. Then you are. Then you wait for your, you know, so you can take the advice from micro and local guidelines on. Then you want to wait for your blood cultures and bone cultures to come back, and then you can get a more specific, um, antibiotic. So after that, then if if that doesn't actually work and it's not responding to the antibiotics or is always a particularly large bone that's affected, then you can have surgical deployed mints on then this is often happens in case so we can have, um, human tardiness spread. So, for example, if a elderly patient came with the UTI on they, they also had some previous spinal surgery. The infection might pass through the blood through back to us through the blood to that re to a different bone. However, if that's not the case, and it's more likely to be more organic causes like a bursitis the sleep, too. And it's very localized osteomyelitis. That's when you're more likely to have the surgical department on. If there's an abscess forms that also makes it more likely So then, if we move on to our next SBA, let me just re launch the fall. Yes or somebody. That's a question. Can you go straight from X ray to MRI? And if you have a high suspicion, ah, high index of suspicion, then yes, you can. But more likely than not, you might. You might think there's other infective, but there might be just a separate It's affection, or you might not know exactly where the infection is coming from. You might be doing an infection screen. So do you guys know what you're doing in infection screen? Yes, so we can see some cultures. Is one of the ancestors come through some of this point probably messaged about urine dipstick. You also do a chest X ray looking for carditis. You can take a full blood count, take a CRP. So there's a lot. There's a variety of things you can do to check for word generalized infection. Onda also on. So basically they might see the mark first taken X ray on, then the CT, and then it might be it might look, they might put the clinical picture and then it more looks like an osteomyelitis. But this is not most common condition. So then they might do an MRI and see the bone edema. But you don't have to go to an MRI if you have a high suspicion index. Are antibodies is given intravenously. Yes, they are. So I'm going to end the pole over here. But the majority of people have gone for actually a Weber see fracture. Um, so if I just had the results of the guys so in this faction is in this in this question, actually, a, um, let me get the pronunciation correctly is amazing. New fracture, Which is most likely. Um, so here we see a 23 year old gentleman who's had a motorcycle accident on he's had a rotational injury to be to the ankle, and that's very characteristic of ankle fractures, that rotational injury eso. And now he's complaining of severe ankle pain is unable to wait there for three for more than three steps. So does anyone know why? Why that significantly unable to wait there for more than three steps in the chart? Um, and then he also has a joint, which is very swollen on the severe pain on flexing extending the leg. So the pain on flexing in the extent the leg suggested this pain in the knee joint on when this pain in the knee joint yes, the office to our uncle rules. Yes, perfect. So yeah, if it's if the if the pain, the pain has to be there for weight, bearing for four steps. So if he was able to take five steps, you're you're less likely to want to do an ankle X rays from less likely to be a non called fracture. So, in this question, Yes, sir, there's pain upon flexing and extending the need so that suggest that there's pain with the off the leg, and that's then by the knee. So you think there could be some some knee pathology going on as well as the ankle fracture on in a maze. A new fracture. You have a Webber's weather type C fracture, but also you have. You can have a factor of the proximal fibula, which could be a spiral fracture ahead of the fibula, for example, on then it often seen in high in case of high trauma. So it's very similar to weather side. See Fracture. Um, so this is my own little drawing off the ankle joints. Um, I'm very sorry about the before artistic policy. Yes, of the media. On the medial side of the ankle, we have the tibia on the lateral side. Then we have the fibula in the middle. That said, this is this is from a posterior view as well. Um, I should say with the Talacen the calcaneal on. Then we also have the deltoid, um, collateral leg of the medial collateral ligament, also known as a dealt with ligament, which then connects the tibia, the tibia till calcaneal on. Also, there's a smaller, bigger mints within this, which also will can connect tibia totalus on so one. There's also the lateral malleolus, and we also have the lateral collateral ligament on this side on. We have the syndesmosis, which connects the tibia and fibula, and the reason why this is important is that the damage where the classification off ankle fractures so whether type A fractures are normally seen in an inversion injury of the ankle on basically this, all the entire fracture will occur below the level of the symbols most it so if you look back at our, uh, diagram of the of the ankle from the posterior side, so the syndesmosis to see us a lot. The ligaments, which are connecting the tibia to be a two the fibula on so distractor on the weather type A will be below will be below the syndesmosis. Then, if we move over to a weather type B fracture. So in a weapon type B fracture and there's an inversion ankle. There's a version injury to the ankle, so it goes the other way away from your body on then, so this is abnormally at the level of the syndesmosis. So there's there's that destroying between the tibia and fibula on this doesn't have be necessarily unstable on its own, however, it is unstable if there is associative fracture at the medial malleolus on but the deltoid ligament, which will cause an instability in the joint. And then you have with this type, See fractures and weather's type. See fractures actually occur above the level of service, mostly so above the ligament, which are connecting the tibia and fibula together on then that can also be associated with an abortion fracture off the medial malleolus or rupture of the deltoid ligament once again on because it's above the level of this in this, most of these are always unstable on they require surgical succession. Eso that's our uncle fractures then. So next we'll move on to hip fractures are Thanks very much for looking the pole. Oh, no. Yes. So I'll just end the pull over here and share the results with everyone so we can actually teach. So let me just move under the next lied. So, yeah, this 81 year old woman has fallen down a set of stairs on she's had it. I am not put in. And then what? So what factors can we have managed with an I am nail? So actually, in this question, it's both in into a truck and Terek fracture on day subtrochanteric fracture. Eso I think majority of people went for a subdural can Terek fracture. So that that is that is definitely correct. But you can also have intercontinental factors. So if we just move on to the next slide So this is there. This is a diagram which was actually made you if I could just exit the pools. Yes. So this is a diagram which is actually made by knish through most of ever in here will know on is actually a screenshot screen grab one of his tickets. Oral videos, which reviews with this permission on, actually actually helps us to look at the management of the interest interplanetary into a capsule of fractures on extra capsule of fractures. So, yes. So if we think does anyone know why we're likely to have a neck of femur fracture? What makes the neck of the femur lot more likely to fracture than, say, other bones in the body or other parts of the femur? Yes. So we've got a couple of answers come in in a spot. Yes. Oh, yeah. Absolutely. Right. So this is actually the weakest part of the femur on the reason why is that there's no periosteal layer on been at the neck of the femur on then. It also has a reduced healing potential due to that s so it's less as structurally, it's weaker, and it has a reduced healing potential, which is obviously not the best for us s. Oh, yes. So if we look at this diagram, then we can see that we can have displaced, um, intracapsular fractures and undisplaced interest. Um, undisplaced intracapsular fractures on then. So if we look at young people in undisplaced intracapsular fractures, they can. They're normally they normally have a surgical fixation with screws on. The reason why this is is because that if you do a joint replaced and you should do a hip replacement or a hemiarthroplasty, then that's likely to need revision in the future. And if you give a 20 year old a hip that needs to be pretty replaced every 10, 15, 20 years, he'll be coming back, and he needs major surgery again. However, if you can actually preserve the native for moral help, that means that you're like it's better for the patient as they require less surgery and it often promotes better outcomes. and it causes less generous of changes by the time they're older as well. However, if you look at elderly patients, they're split into 22 categories. So we have those with dementia or who have been more unwell, who are unaware of their actual fracture risk, as well as those who are bit better, who have no significant morbidity. Co morbidities on those. Excuse me. Sorry. Those can often be treated just like our younger set of people. They can be given a surgical succession by screws because because you can prefers that preserved that joint. And if they have a long life expectancy, then there's no point in getting them to come back for another for another operation. However, if they are the are quite and well, then a hemiarthroplasty is better. Now, if we look at the displaced into capsule of fractures, um, so we can once again spit that into the young on the elderly on Once again, we want to. In the younger people. We want to preserve that native for moral head on. Then, if we look at the elderly, we can look at the fit people. They actually go for a total hip replacement. This is because there's significant injury on then. A total hip replacement is best for their outcomes. As on then, we look at people who are dependent on supports walking aids, etcetera. Then they haven't hemiarthroplasty moving onto extra capsule of fractures so we can have into trochanter IQ extracapsular fractures or subject. Can't Eric Extracapsular fractures? The difference between these is that the Internet or cut Intercounty fractures there between the less active counter and the greater trochanter. Where's the subject? Can't Eric Fractures are actually just below there, below the letter to cancer on then, So they always go for surgical fixation by I am nails on. Then you're into to contact fractures. They had to go surgical fixations by a dynamic hips group. Yeah, so that is hip fracture sorted on. We're going to be moving on to a next topic. I'll just realize the pool. Say I will stop the pill over here so the majority of people have gone for a collies fracture on, but unfortunately, this one isn't a collies fracture. However. It's a very similar fracture to a police fracture. So this thing question is actually about a this Sorry. Let me just remove this pull. Um, this this actually is the classic presentation of the bottoms fracture, which is very similar to a police fracture. Eso yet. So if we look at all the diesel the day, this is a summary of all the different types of fractures in the upper limbs. One we're most common is we most commonly encounter is a colleagues fractures because they are the most common in clinical practice on dad's. We'll know the mechanism of action is a fallen out stretched, Um um and that is actually also the mechanism of action for a Radiohead fracture as well as a skateboard fracture. Um, does anyone know what fracture outside the upper limb is? Um is more likely to be broken with a foreign. I'll stressed Arm Yes, clavicle. Perfect. Yeah, so? So our colleagues Fracture is caused by a full amount stretched arm. On your classic, your classic presentation is a dinner for deformity on. Basically, what I call is fracture is it is a transverse fracture through the radius, and it's actually one inch proximal to the radio carpal joints on. There's also dorsal displacement and angulations, so it basically sticks out to the side your bottles fracture then, is what we described in the previous question on. But, um, it's a radio is a district radial fracture. However, it also has a radio carpal dislocation. Um, however, uh, yeah. So it basically it has, um, a radio carpal dislocation as a post of displacement, then Yeah, so then we move up. Sorry, I don't know. I was waiting for then Apologies. Yes. So then we have a skateboard fracture, which is the commonest carpal fracture on That's from the form outside charm on DA. This is commonly we Commonly, the doctors like to instill fear of medical students by telling us that if you forget to, um I forget to feel the anatomical slept box in the hand examination, you could get sued on the reason why that is a fracture in the skateboard reads to swelling and tenderness in the anatomical snuffbox. So it's very important to just press here and check it during our hand examination. Then we can also have a radial head fracture on. That's very common in young people. You can also have tenderness over the with these. Then you can also have tenderness over the radius on then pay. You can have pain in the lateral aspect of the elbow when at the peak of pronation and super nation of the arm, so look throughout the entire pronation. But just the very end that last 10 degrees there's there's Ah, there's also the Bennett's fracture on the lens. I fracture, but I'll let let you guys read that in the slides because they're they're not very common in clinical practice. So if we move on to our next SBA, then now just relax the pool. So I'll just end the pull over here on share the results with you guys. So I think in this question, the majority of people went for a They went into the, um they went for the Cubital Tunnel syndrome, and that would be correct. So the reason why it's cubital tunnel syndrome and this question is because we have the weakness in the 4th and 5th finger on then that is then followed by the intermittent tingling in the 4th and 5th finger. So does does anyone know which nerve is affected? Yeah, it's the alternative perfect, and we'll move on to one SBA before we go into the explanation. One more SPF before we go into the explanation of these questions. Just closed the window over here as well. Okay, All right. So real. And the pole over there. And I'll share the results with you guys. So yes. So this question the majority of people have to have to see got it right. Victim 5% with you went with osteo Malaysia. So you have 37 year old women a woman presents to present with new onset pins and needles. Yeah. So 37 year old women presents with new onset pins and needles in the thumb and index finger. She recently falls onto an outstretched arm. Onda The pain is worse at night and she has a stake. A hand for the pain to subside. She's also been recently diagnosed with rheumatoid arthritis is now pregnant. So many of these things mentioned here are characteristic off couple tunnel syndrome, so that the reason why her thumb index index finger affected is to dictate to compression off the medial nerve. You can also have the middle finger being affected as well. The pain is often worse at night, as often happens with carpal tunnel syndrome on shaking the harm thie hand help to reduce alleviate the pain in most people. She's also been diagnosed with rheumatoid arthritis. It's not pregnant, so both of these things are both that can both cause, um called paternal Citrus. Um, I normally it's idiopathic How if they can also be caused by a diva, edema could be seen in many conditions, like heart failure, cetera, which will cause swelling which will cause compression of the nerve. How have osteo Malaysia? Malaysia is not associated with carpal tunnel syndrome, so cause of pain a TL both. So this is a This is a table of the main cause of pain. Below the elbow. We have your cubital tunnel syndrome, which is actually the apologies for the spelling mistake here, which is the compression off the almond move on. Then what we see is we see tingling in the 4th and 5th digit. It's a compression on later numbness, although this should be the other way around. Well, I do really apologize. Then we have lateral epicondyle itis, which is also known as tennis elbow. This is normally present with initially with acute pain for like 6 to 12 weeks on. Then, as we start treating it. It can last up to two years, unfortunately, but more commonly resolves around the six months timeframe on Do normally there's pain and tell them this at the lateral epicondyle on. Then it's the classic movements they use in tennis, which are affected, like wrist extension on do, um Elber a wrist extension while the elbow is already extended. Then we have the medial epicondylitis. So as you can imagine, this is just the opposite to the lateral epicondyle. The medial epicondyle, um, is pain. 10 is pain and tender, painful and tend even on then this is known as Golfer's elbow on. There's a numbness in the 4th and 5th digit moving on, then we have a radial tunnel syndrome. So this is a compression off the branch of the radio lives on. That just leads to similar symptoms like the luck a lateral epicondylitis. However, this is actually worse when extending and pronating the forum, So couple tunnel syndrome, then a Z, said before it's ah, compression of the medial news and the carpal tunnel. Um, their 1st, 2nd and 3rd digit are most commonly affected on, then the symptoms can send approximately through the media nerve distribution on there's weakness Normally seen upon the hand examination in some adduction on, do we diagnose it? Normally, it's a clinical diagnosis. However, I do apologize. There's no surgical treatment for this. This is an error on my part. When you do electrophysiology, you can have a prolonged action potential when, when looking at the action potentials at the 1st, 2nd and 3rd digit, the treatment, then for carpal tunnel syndrome could be causing your steroid injections at the sites of the patients can wear wrist splints at night that this is often when the pain is worse on. Then if none of these men in the's work that patients off to go go for surgical decompression. So I will, uh, shared the next poll with you guys. Hey, Alan. Well, the people are doing the question. Do you mind explaining again what was supposed to be the other way around just for clarification? Do you mind explaining what you said was supposed to be the other way around just for clarification? What did I say? Was there the way around bourbon. I do really apologize. Sorry I had I had to go for a bit and I I missed it as well. But someone was asking in the previous explanation. You were just telling you, Do you want, uh if anyone can put in the chapped, you want to be safe. Which part? Section I was talking about if you're a message in part. Sorry. Sorry. When with medial epicondylitis, all I meant was that it is the opposite, too. Lateral epicondylitis I I do apologize if there was any. Um, if if there was any confusion about that Oh, yeah, and I think I also I think in the slide as well. If I just go back to it now for just a moment I mentioned that there is that days intermittent tingling, which is then later followed by numbness. But it would be the other way around that be numbness followed by intimate and tingling. But I'll correct these in the sides before I played that. I do apologize that, um so I'll and the pull over here and share the results of everyone. So yet this was actually eso this woman comes the emergency department with a swollen right. Me, She's unable to weight bear on. She's had new replacement. Four months ago so her past medical history is of poorly controlled diabetes on which and followed. Do you think is responsible for this? So in the general population, most likely that you'll have a stuff or es infection causing the septic arthritis? However, when you have people with prosthetic joint infections with with prosthetic joints, this the infective organism actually changes of bits. Eso If we look at our septic arthritis in their prospective prosthetic joints, we can actually see that different organisms are more likely, depending upon we're doing what time frame after the operation that they're presenting, um, it really Iran. It's more likely to be staph aureus straight after the infection as well as grand negative rods. However, if there's an insidious onset on, there's no, there's no real cause for the septic arthritis to occur. There's no infection. Any other side to the body on septic arthritis does develop. Then it's more likely to be a different course, a different causes of organism. So in this one we went for ever So in the question here, the most likely organism if I just moved back, was thistle organism right here, the appropriate bacteria. Magnus on You also have a coagulation negative staphylococcal I, which can also present with an insidious onset So normally they do have a new inflamed joint. However, they are less painful on DA on day, and they may even be just commonly seen after I mean not commonly seen. Sorry, they might be seen on a routine blood. For something else, however, they are painful. Guess not as painful as the early onset, just straight after the district after the joint replacement infections. Then, after 12 months, it's unlikely to be anything linked to this. And you're more likely, once again to go to Staphylococcus aureus in sexually active people. Do you guys know what is the most common cause? What, which is the most common organisms found? Yeah, nice area and gonorrhea, Perfect said. Just We're just looking acceptable fighters, sometimes more detailed then. So the reason why this actually a kids is because there's no there's no basement membrane in the sign ovulating, which makes it more susceptible to infection. We also, um, we also see that there's existing doing damage. So where in Terre lead? To increased risk? However, as we mentioned, the prospect prosthetic joint is what causes the highest risk. And once it sepsis. You guys all know that protocol. The sepsis six we've managed is emergency on dates. Important. Treat them as soon as possible to stop any long lasting damage. The clinical features. Then, as we mentioned with the hot, swollen, tender avert missus joint, they often have a reduced range of moment movement on examination on they also have your systemic symptoms of systemic features of illness, like fever, malaise, etcetera. Then on your, um, on your non specific active phase reactant your CRP and your yes or maybe raised, um, And at this point, you want to send off blood cultures to identify the infective organism and also do your joint aspiration treatment, then, is with IV antibiotics on. This is normally a little for 4 to 6 weeks. Um, if it is a staphylococcus aureus infection, then you want to give flu cloxacillin on. If they are, have a penicillin allergy you want to give them can clean the moisture. And if it's MRSA, want to give them bank moisten. Um, and then in these patients, you want to do a joint aspiration to dryness. So you continually aspirate the joint until there's no fluid left then if you have to refer them to surgery for further joint drainage. So if they've just come off of prosthesis, then you would like me to refer them back to the orthopedic surgeons on they might do an arthroscopic washouts, Which means just like they did the surgery through the keyhole. Still go in and they'll completely wash out the joints. So that pretty much wraps of septic arthritis. So next we have a 47 year old lady who presents with severe lower back pain on right leg pain and numbness in the past two days. This is the X ray. Which one of the following is the most likely diagnosis? Just relax the bowl. Um, so I'll stop the pulled there. Um, I don't even see that. So yeah, the most common. The most common answer here was metastatic cord compression. So can anyone suggest why it would be metastatic cord compression in this? In this case, some people have suggested lung cancer. Yes. Oh, yeah. I think Lizzie's nailed, uh, melt on the the nail on the head. That's the one. Yeah. With the left mastectomy. Yes. So if we look at this, if we look at this chest X ray, not something that we commonly look for in chest X rays. However, we can see that there's a breast missing on the left side. So that indicates, is put patient as previously hard A mastectomy. Um, and therefore they've probably previously had that they've probably previously had breast cancer. Onda, um, with new onset of your back pain after a previous history of breast cancer. Unfortunately, you're worried about the worst case scenario, which is metastatic cord compression on then this. Actually, today we have a bit of a short session. So this is actually our next SBA andare fun. Less be in the evening, and we have a couple couple of slides on will be wrapping up eso. Yeah, Everyone seems to be getting this question. Right. Um let me just share the pool with you guys. That's fantastic. So yet the middle option here is is the right one to the bank of mice in the metronidazole of the cave tax mean on. So if we so before before we actually look at that in a bit more detail, One of the most common things that we see in hospital obviously lower back pain, and I think about one in 10 people that comes into the emergency department, or maybe even more than that now actually has lower back pain until lower back pain, we can actually cracked a prize it into three different causes we have. It's systemic causes of lower back pain, mechanical causes on referred causes, so mechanical causes would be things like the tibial fracture. Some kind of stress is applied on the body, which cause the fracture. It could be spinal stenosis, which may be due to, um, previous surgery and then repetitive on, then wear and tear generally, which has caused that we can also have disc radiation as well as just your regular muscular musculoskeletal sprain, which actually just causes which one of the muscles of sprained on that course quite tenderness on. You can see patients an absolute agony coming into and me with just tenderness in there paraspinal muscles, and then you have systemic causes of lower back pain to these infections. Malignancies. You can also have been your rheumatologic causes off back pain, things like your closing spondylitis and sorry after a bath. Writers and then you also have referred because it's of lower back pain. Um, so your initial question that we looked at, um, if we Sorry, the second question that we looked at here s so this actually prints picture off the of the acute infection on. In this case, it's most likely to be an epidural abscess. So an abscess is the collective is a plus collection which isn't scapula ated. I wasn't cancel ated by a hygienic membrane on then. It's normally form soup is superficial to the dura matter on Ben, the bacteria cause this they can either come from different sites. So if the patient has a UTI best But more commonly it's court because by a local bacteria on this, maybe after surgery, with our trauma, etcetera, then the features that we normally see eso the risk factors first is normal. You're immunocompromised patients, but but more commonly than other infections. Here you're looking for people with HIV hepatitis as well as your standard diabetes, etcetera. Because these patients, often very immune, comprised when they did developed an epidural abscess on Then the pain is normal. Spinal pain, pain of the bill back tenderness on. You normally have seven urological diff deficits, so this conclude normal reflexes and also a sensory disturbances. So the way you want to diagnosis then is so you can do or your bedside testing your examinations. And once you've done that, we go to the Bloods. I'm so we're testing for their HIV the hep B. That helps her to be a hep C. We're also looking for the lap in from two markers to confirm that there is some systemic infection going on on Be want blood cultures to fear the guide our antibiotic treatment as well as, um, MRI of the whole spine to localize where it is because there can be skip lesions. So that could be more than one epidural abscess on If surgical treatment is required, then they want to know exactly where it is. So yes, So our medical therapy, as with all our other conditions we saw for the empirical antibiotics, Um, as we've mentioned the question the IV kept for just go. But the question of quickly So the vancomycin, the metronidazole, or on the left axis mean on there were given by the IV bruits. Then we can also have we normally give. These patients are high risk of the season, we get a 50 proof Lexus, so that will include your ted stockings. Azelas attention. You know, low molecular weight heparin on. We can also give them, um we can also treat their hypertension, as in this case on day, but being meted to repair for at decompressive surgery on this more most commonly, if they don't respond to the antibiotic therapy very well at all. And then the other question, but we saw was about metastatic cord compression. So, um, I do apologize. Um, this is this is definitely not the past of busy ology off meth addict cord compression. Somesthetic cord compression normally happens after a primary tumor. In men in women, it's most commonly breast cancer. Can anyone suggest wet? Most Where? Where which primary to miss are more likely to cause spinal cord metastases called necessities. Yeah, we have a prostate cancer. Come in and we have breast come in for women yet? Perfect. Yes. You could have ovarian cancer too, but breast is most common in women. Of course, that is most common in men. Um and then so for these patients, you want to check there? We wouldn't do. Ah, full set of investigations to check for their primary sites, as well as any of the symptoms they may have on these patients need an urgent referral normally to the painting because they're in a lot of pain. Unfortunately, I saw a patient like this just last week on depending on So most commonly the's Mets happened in the thoracic region of the spine. Aziz patients in their pain. They can also be heavily confused by the time that they come here, because if it's a relapse in the cancer, they may also brain mets on. Then in the treatment, we want to give it e prophylaxis with similar to what we mentioned previously. We also want to give these patients dexamethasone, normally a high dose of death methadone to reduce that swelling on, hopefully reduce the pain on def. They are fit the surgery, so normally the younger patients will have better outcomes. Then they could be referred to the spinal surgeons, which either consists off orthopedic surgeons and new resurgence on. Then we can also refer them to radiotherapy, unpiloted radiotherapy. If they can't have surgery, then they might have just one stat dose off radiotherapy to their back. However, It can also be given a judgment after surgery. So thank you very much. Everyone that wraps up orthopedic session stepping up the shot. Uh, yes, sir. Thank you. Everyone is joining a stories of a short session that we normally have. Thank you, Allen. That was a great presentation. Great. Thought provoking and SPS. Sure, guys, please fill in the feet before you get access to the slides and recording, as always. And if you have any questions, please. Pretty in the chat. But good job on it. Me? Thank you. Oh, yeah, Absolutely. Um, I just want to share my slides again. Yeah. Antibiotics for C? Yes. So, basically in this question So the empirical regime, before guided by cultures before you abided by blood cultures is generally vancomycin metronidazole and kept taxes mean I have, um um, yes. So? So, generally it's vancomycin metronidazole on the calf, doctor mean initially, and it's given by an IV roots. This is because the vancomycin is because normally the a PSA substantial proportion of these patients which bring them with epidural obsessed, can have MRSA um metronidazole on get tax means also given I am full weather type C and question, too, just to give me a moment. Yes, So the this question then So Option B is a fracture of the upper limb, so it's not associate with the needs. So then we have the weather's A. The weather be in the weather, see? So these are all fractures of the uncle. How the Mason New fracture is a fracture of the uncle as well as a part of fracture of the proximal fibula. So basically, in this on, normally there's an M. So if in the if you have an ankle on X ray of the ankle on, they have a proximal, they have pain in the proximal fibula or in the knee or tenderness in the examination you want to get. And, UM, you want to get X rays off the knee joint and of their whole fibula, just check. There is no fracture along the fibula because in high impact injuries and aversion injuries, they can. They can have a fracture of the fibula as well as the ankle fracture, and that's called the Mason New Fracture. So it's just a very high weather type C fracture. What's your favorite fracture? Well, I'm not sure. Think maybe maybe a cigarette board fracture, but I couldn't tell you why. Well, it's probably because the diagnosis is why the anatomical slept blocks. The honestly little is any other questions we have. Please feel free to put any question that job, but other otherwise, just go on and, uh, enjoy your use The afternoon. Good luck for anyone who has any exams coming up soon we have, ah, progress test coming up soon in Cardiff. We got a question, Alan. Yeah.