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on do the hearing was going to move through my slides. So open fractures, dislocations, septic arthritis compartment syndrome, vascular injuries related to former, primarily neural compression, specifically quarter recliner and hemorrhage related to major former. Those are the common those of the orthopedic emergencies we see on dope unfractionated. Probably one of the biggest and most common things we see, so I'll spend some time on that. This's when somebody sustains a fracture on the bone ends. Communicate directly with the external world because of the wounds being created. They usually high energy injuries on the reason that extremely important and it's vital that we treat them very urgently and properly is because of the risk of infection. If you get deep infection inside the bones, that's really difficult to eradicate and can cause a result in loss of limb. This is a really important injury, and timing on the way it's managed is extremely important. So when you see these injuries, we want to assess thumb for the grade of injury, the severity of injury and how much energy has gone in and these are treated and specialist centers in the way the former system is set up in the UK is that we have these major trauma centers, like since George's in London. We've got four major trauma centers, and then you have former units, which is the peripheral hospitals. And they will refer these injuries into us it on a very urgent basis in a blue light type of manner. And we would expect the emergency department to emergency department transfer without any delay. We the reason these need to be treated, and specialist senators it because especially centers have all the infrastructure. Next, the TC offer a multi disciplinary approach, particularly orthopedics and plastic surgeons being available to a C and assess and manage these injuries. We also have expert microbiology on when you, when you get a lot, this expertise together, you get better at it. So if you have lots of different units treating these open fractures, it's hardly It's unlikely that one of those would be an expert. Whereas if you concentrate the effort and concentrate the expertise and experience, then you get better and better treating these. And I know in my own units that 10 years ago the infection rate for open fractures was extremely high. It's something like 20% and now we've got it down to about 7% which is world class because and that's because of experience and knowledge being shared. So we have something called boasts guidelines the stairs for British Orthopedic Association standards of trauma care guidelines and that they have got really very detailed, very clear, concise protocols in how you manage these injuries. And we've we've come up with this guidance. Provisional Pedic associations come up this card. It's together with the plastic surgeons Radishes Association back Press on again, they say. Treat these injuries in month, especially centers it with multi disciplinary approach. Together with orthopedic and plastic surgeons. Give IV antibiotics within an hour off the injury on brick. Order the neurovascular status that will have the damaged vessels have a damaged nerves. Have they got compartment syndrome? Record that immediately because that's critical. Realigned the boat as soon as you can and split them, get it, get images. So that's X rays and see potentially CT angiogram when they get into the oh dear, when they get into the er the emergency room at before you get to that stage. If there is obvious gross contaminated issue with large amounts of debris just physically remove those buy saline, so two cores to cover and take a photo breath. In the olden days, people used to wash these out in any with, you know, syringe in normal saline. We no longer recommend that. We don't recommend that because there is a risk off a delay be increased in contamination. And really, what we want to do is get them into theater, a prompt manner. Take a photograph. In the olden days, people never used to do that, and as a result, multiple people will come and have a look. You know, they'd lift the dressings and so forth, and that's not good. Take a photograph and then everybody else looks at the photograph rather than reassesses and removed dressings. Get the consult to orthopedic surgeon and, ideally, the consultant plastic surgeon at the initial Debride Mint as the most standard for a and that's really important. We want both experts to be available on in the operating theater doing this initial debride mint because the initial department is really important and we were aimed to fix definitively fixed and close these fractures cover these French is soft tissue coverage within 72 hours. That's the boast four Be standard on that's really important. If we're going to get eliminate the risk of infection or reduce the risk of infection on timing for surgery is really critical. There's some situations in which you want to take the patient to theater as soon as they arrive. So once they've arrived in our A knees and been stabilized, get them to the operating theater. Now those open fractures will be the ones where you've got agricultural or syringe type contamination. Or they've got a vascular injury or they've got compartment syndrome. Those are what we call the free sees in terms of the gut, still a grading. I'll come to that in a minute. If it's a high energy open fracture that come off the motor bike, get these two theater within 12 hours on the lower energy injuries within 24 hours. But in an ideal world, you want to get the open fractures within in your operating theater a safely. It's possible. Obviously, sometimes there'll be other things that come into consideration, like polytrauma, other injuries, stability of the patient and so forth plan. As I've already mentioned, we want definitive stabilization of the fracture and closure or the wound or cover virtual wound within 72 hours. Here's the hostility classification. And, um, this you When I was a medical student, people used to talk about this quite a lot on it really used to focus on the size of the wound. And the emphasis has really shifted away from a simple size of the world with innocent within a centimeter over sent me to set that it is much less important compared to the energy of the injury. Is it low energy injuries? It moderate or is it are high energy that becomes really important that the energy that's going to cause the fracture and damage to the skin is the most important. How much contamination there is really important as well. On the degree of soft tissue injury and the degree of fracture combinations. That minimal moderate is it severe? Have your segmental fracture in front of you periosteal stripping again really important, and all the free class three fractures and above will have significant periods still stripping. This has an impact on how well the French is that the hell is it going to be a non union, or is it gonna heal reasonably well and then local coverage? This is where the plastic surgeons are really important on. They will see, assess and, um, you know, help us treat the patient and they'll be experts on you know what types of flaps a required, or whether direct closure is possible or not. Record the neurovascular injury on. And it's the three C's where you can get vascular on neurological compromise, and that's really important to treat Address. If they ask you a injuries suspected. A CT angiogram is key. In fact, in our unit's a lower limb, open fractures will have a CT angiogram as a matter off routine on. The reason for this is that sometimes it can be really difficult. Teo Identify clinically a vascular injuries. Sometimes the limb will be perfused. There, the pulse will be quite good, and yet the patient has got a significant into more tear on that can become obvious. Intraoperative Lee As you open when you're when you're operating on the patient and they're undergoing definitive fixation and the infection rates for these breakfast with the lower energy injuries are less than 10%. But when you get into the higher energy you're looking at. 7% 3 B's will be, but between 10 and 50% and even higher for the three C's on compartment syndrome. So this is something we do see some time to time. And the commonest scenario in which you will see a compartment syndrome will be in association with traumatic lower limb injury. Particularly, uh, you know, a tibial open tibial fracture. These are really this is when the pressure within the anatomical compartment to become so high that blood supplies compromise the blood vessels become a bit constricted on compressed and also the nerves. So the presentation will be severe pain, a lack of active movement, a pain on passive stretch and then the the other, um uh, peas, the pallor, the pulse listening parasthesia. Those are very late signs. You want to pick up these for him This situation way before you get to those you know, peas off parallel pulseless and parasthesia is far too late at that stage. So low index of suspicion will help you diagnose this in a prompt manner have with the high energy tibial. French is lower limb injuries. Think about compartment syndrome. Does the limb look extremely swollen. Does it look tense? Um, have the pain. Has the patient got a huge amount of pain on def They have, and it's not responding to energies. You must think of compartment syndrome and again compartment syndrome. We need to act very promptly when you're assessing the patient. A lack of active movement. If it's lower limb, we're looking at the toes. Can they remove them if they can't move them? That's a worrying sign on when you passively move or stretch those the toes. Does it cause excruciating pain? That's half economic off compartment syndrome. So a very low index of suspicion for those and this diagram here shows you the various compartments in the lower limbs. So there's an anterior, a natural and to posterior deep and so superficial, and when you do a fresh bottle needs to release them, you need to access all of those. So, as I said, this is a clinical diagnosis. Um, you know, we the patient's pain on the clinical signs that we just talked about lack of active movement, pain on passive stretch. Sometimes people do use compartment monitors, and they're various devices that are available commercially to do this, and I I tend not to use them, partly because they can be falsely reassuring. My concern with them is that, um they re assure you falsely, the reading could be Ms inaccurate, and then you don't act promptly, and the patient could lose their live or have significance compromise in some situation. In some situations, compartment pressure monitoring is useful, and that's if you got a conscious patient and they hooked up on I. T. U to the monitors, and we can sometimes do that. But again, even in those situations, if the limb is very tense on do you can't assess for pain, then it's safer to perform fasciotomy. He's on demand. Management is prompt. Surgical decompression. You need to do this in the operating theater for lower limits. Double incision fasciotomy is the dark friend shows you the, uh, positioning or fasciotomy. Then you need to take into consideration the vessels on the perforators when we do this, but most of us will do a two incision medial natural non B TUNEL fashion incision fascia for sure. To me, in order to get to every single compartments on, be talked about the consequences off, not suspecting promptly on their list. Of course. Permanent soft tissue damage permanent vessel. A nerve damage on also can result in potentially amputating the lowland. Moving on from open fractures and compartment syndrome. Septic arthritis We again see this from time to time, particularly in infants and a day other end of age spectrums in very, very elderly patients in immunocompromised diabetics, these other patients who are risk of septic arthritis. Septic arthritis is a deep infection involving a joint affecting the synovial fluid, the soft tissues around the joint and the articular cartilage. And if you get if you get bacterial viral or fungal infection within joints, I can destroy the articular cartilage within a matter of hours. So this and then you get perceptive arthritis on degenerative changes so the joint is destroyed on their four. Prompt treatment is essential again. A low index of suspicion is required to make sure you don't miss it. You know if you have a Sometimes infants are extremely difficult to assess on gum, and you need to think about for warm joints that they're reluctant to move on. Do sometimes ultrasound scanning could be really helpful to visualize the joint, but again, do not delay. If you can't get the tests, you should, you know, usual clinical acumen. Proceed, watch these joints sounds, stuff or eus is the commonest organism that effective you have to. These people get infection in the first place, but it's usually hematogenous spread through the blood stream. It can be a urinary septus that causes it on that. In some situations, it's a penetrating injury. Such a bite. So around the hand, which is my area of expertise, people who punch is called a fight fight way. The the person punches on the knuckle hit somebody's tooth. And, as you know, the dentition is covered in bacteria on that star it inoculation of the joint. And that's why those fight mites are treated really very promptly. And here's a good example. Here's a picture of one you could see where this sort of skin has been damaged. We got those black and areas over knuckle on, then you've got surrounding erythema readiness. War of swelling on. That's a classic appearance off a fight bite and such subsequent septic arthritis that paint the joint is really painful to move. And if if you if you as the Examiner try and move it. It causes excruciating pain, and the treatment here is prompt. Surgical dobriant and antibiotics. Nerve compromise. So this is another thing that would make us get out of bed and take the patient to the operating theater. If patients sustain a fracture or dislocation, such a a hip fracture dislocation than the femoral head will put pressure on the sciatic nerve, and the patient will present with numbness or tingling in the foot or a foot drop. We're still on. But because of compromise decided nerve. And in this situation it would be strongly recommended that you take the patient to the operating theater and reduce the joint as quickly as you can in order to prevent permanent neurological injury. That's a reasonably, um, frequent situation, we say we see with French dislocations around the hip and also the risk fractures and acute carpal tunnel syndrome. See that quite a lot, obviously wrist fractures, a really common on, but from time to time you will see evidence of numbness and tingling in the hand because of pressure in the carpal tunnel haven't increased as a result of the trauma in that situation, you want to reduce the wrist fracture as quickly as possible and elevate and stabilized them and, if necessary, release the compartment syndrome as well. When you take into the operating theater quarter, recliner syndrome is a really important condition. This is where you get your okamba Um um, spinal cord, where the Conus medullaris ends and you get these 10 pairs of nerve roots, which supply sensory and motor innovation to the pelvis, the black brown bladder on the lower limbs, and these will present with severe lower back pain. Bowel bladder symptoms such as numbness, tingling, inability to feel that they want to go for a we on, but they can get fecal or urinary incontinence. Any change in the bowel bladder habits should make you very suspicious of quarter a quarter in the context of back pain on. They will get these deficits very quickly on Byetta and can indeed be permanent. You can also present with perianal sensory loss, loss of anal tone, sensory loss around the genitalia. So this is this is a real emergency, and you want to treat them very promptly. Litigation is really common because this is a diagnosis that's quite commonly missed causes off quarter require syndrome is frequently a disc herniation. As you can see in this image here, fracture would put in pressure on the quarter a quarter or a tumor. Causing pressure on the cord require an urgent referral. Urgent MRI scanning and refer to the spinal surgeons is critical here. Vascular injuries s so these can happen, particularly a level of a popliteal. Fossa has shown in these diagrams to the Triflex away run off and cause ischemia and loss of limb die. Prompt diagnosis is really important. Clinical assessment and documentation off the vascularity This perfusion off the level in is critical if it's suspected, and you should suspect it with any hope in tibial fracture, for example, then you clinical assessment is ky. A CT angio room, Mr Gold Standard Investigation. I would recommend Sometimes people do use hand held doctors, which can be helpful, but they're not as sensitive or a specific and early. Recommend that a CT angiogram is performed again. These are treated in specialist center specialist trauma centers where you have the expertise off Orthopedic surgeons trained looking after these injuries plastic surgeons and particularly vascular surgeons who can repair blood vessels on draft in these patients were often also require fasciotomy. He's Typically these patients would undergo, um and ah, a stabilization by the way of external fixation followed by vascular repair the same time on then later, definitive stabilization off the orthopedic injury hemorrhage hemorrhage Is that a big killer? Five million deaths worldwide every year because of former related hemorrhage. Major hemorrhage. Merger hemorrhage is defined as loss of the blood volume within 24 hours or loss of half the blood volume within three hours. Um, and um, typically polytrauma pelvic fractures. Those abdominal injuries cardiac, chest former will be, um, will be what causes hemorrhage 40% off. Drover, mortality in the UK is because of major hemorrhage on off These about half will die before they get to a hospital. And this is potentially preventable death. A third of these patients coagulant the perfect on deacon exciting going on within hours. So prompt treatment prompt recognition is essential care bundle approach. This has worked from a role London Hospital here in love, um, here in London with Obama other major former centers. You want to make a rapid early diagnosis and rapid early control off the bleeding points, damage control resuscitation. So court and the use off. So you want to my direct compression and elevate the limb on then the use of Foley catheters on day hemostatic dressings like these are from been loaded dressings like see, locks are applied. Talk use of 20 K is really good. That's a positive thing. Would learn that from our experience in military warfare and, um, the potential need for pre hospital thoracotomy in extreme situations. You know, if you think you're gonna have to do it, get on and do it promptly on, then rub over. Theoretically can help us. Well, this is resuscitated in endovascular balloon occlusion off the aorta on this is where we are under ultrasound guidance vial. A femoral artery passed on endovascular balloon up on include the aorta on. Do that can stop major hemorrhage. And you know, obviously people need to be reasonably experienced that doing that A said earlier, third of these patients will become curricular perfect. The clotting cascade goes array on, but, um, you know, this needs to be addressed just simply pouring in red blood cells is not going to help so tranexamic acid 1 g IV I just give it immediately. Give it a soon as you get there, um, at the scene on give red blood cells packed red blood cells and also fresh fruits and puzzler on in certain situations. Other cryo agents are also given. Maintain that perfusion off the lower limits. Best you can on minimize the inflammatory response when they're specific code red or major hemorrhage protocols for a while, Hospitals and in our hospital, a typical code red protocol would be Give pack a A medially. So that's six units of blood on before units of fresh frozen plasma. At the same time, give them immediate blood. You can't wait for cross matching here. You give them groups zero blood, which is the universal donor. Warm the fluid, if you can, because the patient will rapidly become hypothalamic and that close of Children have given tranexamic. Acid is before, I already said, and when they you can do something called a tag, which is a non invasive test to see if the blood is capable of clotting. That's a form but last Agassi than a pack be, which is given after Pack A, and this involves giving six packs of red blood cells, four packs of fresh frozen plasma, one pack of platelets and to cryo. If the bridge in is not working properly warm the blood aimed for a 1 to 1 red plaques else, too. For FFP fresh frozen plasma. Repeat the tech. See if the blood is beginning to clot. Correct the calcium and warm the patient up. That's our approach to major hemorrhage, and this is what our code red transfusion protocol looks like us and George's. And it is a zoo just talked about, um, use off FFP as well as red blood cells and cry cry proteins were necessary. Tranexamic acid involved the hemotologist Call them. They're your friend. They'll help you get on top of this. You always get you get the right people in the room. So here's a summary. These are key message is for all of these orthopedic emergencies. Early recognition on diagnosis is absolutely key. If you think about it, you're diagnosed that you'll recognize it on. But that's the key thing. Here. Have a low index of suspicion, a low threshold for thinking that this could you know one of these emergencies could be happening if you investigate promptly they're thinking about. And you've got access to the appropriate investigation. Then investigate promptly. Do not delay prompt treatment. Use the protocols that the hospital has. You know, you to phone a friend, take expert advice transferred into the right units. If necessary. Many of these conditions will require multi disciplinary approach like, for example, of the open fractures treated them with a plastic surgeon. Experienced orthopedic surgeon is absolutely key on. And if we and this way, if we recognize these emergencies early and investigate and treat promptly, we can save lives on. We can save limbs. Thank you very much. Thank you so much, Doctor. Um, we have a couple of questions that was sent to this chap throughout the actual um So the first one was, How do you evaluate whether the injuries high or low energy? That's a good question. So it depends on the mechanism of injury. If somebody has sustained an injury there walking down the road and they trip on, fall over and the bone breaks, it comes out the skin. That's a no energy injury. Usually, if they come off a motorbike at high speed on sustain a fracture on the bone comes out of the skin. That's a high energy entry. So is the mechanism of injury? Asked the patient. How did it happen? What was the scene? What was the scene off trauma? Or did that look like, you know, Was the patient flunk out of the car? That's obviously high energy. Usually anything involving a vehicle be a high energy injury. So it's the mechanism. Asked. The patient asked the the witnesses off the trauma. How did it happen? Is the mechanism That's key? Okay, that's fine. On dot How do you say, How do you do any short of breath? Mint? Sorry. How do you do In a short of river meant Oh, yeah. And so they you take them into the operating theater. You you give them an anesthetic, stabilize the patient, and then the first thing you do when you see the wound is you extend the edges, you extend the wound. Um, you you must do that because if you don't, you won't see enough. And then the thing the edges of the world will often be quite confused. Removal dead necrotic tissue excised the edges off the wound on Do explore wound. Once you've done that, explore the wound and make sure you got healthy bleeding. Edge is at the end of the procedure. The commonest mistake people make is they do not do an adequate debride mint because they're worried about losing tissue, but that if the tissue is, um d vitalized or unhealthy, or if you think it is, you've got to exercise that you've got to debride it. The plastic surgeon's concern cover soft tissue really well, the expert at doing it. That's why it's critical that these patients have managed in a combined man. The initial Diprivan is incredibly important. So that's a really good question. And most of time people do not do that adequately. Okay, um, another question, as in fresh or to me, when you're releasing the pressure for the bottle syndrome, Are you releasing pressure from all the layers? Yeah, well, you you must release pressure from a little compartments and rather than layers. But I know what you mean. You mustn't leave any interstitial interstitial spaces. Where there You've got closed in an enclosed space surrounded by Fashir. All of those areas got to be, um, released fully. Otherwise you'll get ongoing from high pressure. And again, that's an area where sometimes if you do to the lack of experience, people will do in adequately. Sometimes we have seen patients whose compartments have not been fully released on. They can end up losing a lot of muscle. When muscle dies, it is irreversible on they can end up with an amputation. Okay, um on was the difference between quarter Akron on long, But this candy a shin, um so quarter a quinine A are the specific pairs of nerve roots which you see at the end of the spinal cord, but a number disc will be more proximal to that. So that will be before l. It could be a disc that prolapse is and specifically affects the nerve roots is they come out of l 45. The court require a nerve roots supply. The bowel and bladder on do the presentation is quite different because they'll have changed in your in your bowel or bladder sensation or even loss of perianal tone. Okay, on how do you do? 30 CAFTA and Humira started dressing for DC all so in damage control, we can you say, for example, if you have a, um a robo is quite a day example. We can pass a catheter through the femoral artery on gun the ultrasound gonna get it up to the aorta and then inflate the balloon. And that will include a vessel on did. It's a similar with similar principle of Foley catheter, where you pass it into a vessel that you can see on inflated on that will stop the bleeding there. And then it's a pre hospital type of approach and the dressings that we talked about, They've got some clotting agents impregnated into the dressings and you simply apply them, um, with compression. Okay, um, I would go a question saying, Why do you need food? Woman? One of our questions answered, saying Colbert would lead to hypothermia. Um, is that correct? Yeah. So if you don't warm the fluids if they because they get blood on the FFP, etcetera is stored in the fridge. If you assume it's cold and if you're replacing the blood volume, the patient will become cold very quickly and high person, and they'll become hypothermic and obviously hyper same. Certainly it kills two, so you've got a warm the blood and warm the fluids as they go into the patient and we were in a hospital setting. We do have fluid warmers. Okay, Um, on how long is the Ari beer A left in the patient before it states causing some organ damage. Say that again. Please. S. So how long is the R E B o a left in the patient before it starts to cause organ damage? Uh, yeah, it's a good question. You know what? It's a temporizing measure is to stop immediate, but hemorrhage on is a surgeon. Get them into the operating theater. So you this is sort of patient. You want to get into the operating theater, escapee, Your rights, You know, including the aorta is not benign thing to do. And you may well get end organ damage that if you can save their life off the patient than you know, that's all just of the main benefits. Okay, on how would you mitigate the risks of lipid amble is, um, especially in open fractures. Yeah, good question again. So fat embolism is obviously a significant problem with open fractures or fractures, actually, not just open. And that's why it's important these patients are anticoagulated on. Do you've got to think about anticoagulated. The patients, you know, thin the blood to minimize that risk, get the patient up and about and mobile as soon as you can. Prompt stabilization off the fracture is key. That is probably the single most effective thing you could do is get. That's why we don't like people with femoral fractures or tibial fractures sitting around in bed for days before they're taking two theatre on Some stabilized. So that's the single most important thing you could do is get them into the operating theater essay pre on defendable French is we would tend to fix the very next day that we can safely okay on how frequent feeds you need to do the dressing and bread mint off the initial department. So once Tooth and the initial Dobriant Mints, which is offer in the operating theater, you cover the wound with usually, um, a vacuum type dressing on. Do you leave that on? You do not touch that again until until definitive treatment, and usually we we aim for that within 72 hours. Now, I guess in some situations a patient might not be stable enough to get to theater for the definitive surgical stabilization and soft tissue coverage on. If that's the case, then every you know it would be a case by case review is to have frequently. Those vacuum dressings are changed, but typically be every 48 hours in the operating theater. But, you know, the key is get the wound covered within 72 hours, wherever you possibly can, okay, on which whatever cases can be done in the ER so initial divide lint. On which case, which case, it should be done in the operating room. They should all be done in the operating room. The initial debride mint is not something we do in the operating theater. It should be done in in in it. So it should be done in a in each We done in the operating theater. Okay, that's fine. So that was all the questions on the chat. Anyone else have any questions you can on me and ask if you too. I just want a question just regarding debrider mint on removing like say, uh, removing parts of bone and things like that. Can we Can we repair or do we can we put, commit put stuff in place off lost bone. No, you know something that's not there And then So if you've got some devitalization bone with no soft tissue attachment on, it looks, you know, dead you, then that's removed. You should do your best not to remove bone. So if it's vitalized, and if it's clean and healthy, leave alone. Obviously, despite it being common, you tid and fragments is, um, that if you do have to remove bone and you should if it's devitalized that we don't recommend bone grafting necessarily at the same time, that wouldn't be recommended. But it's likely that you're gonna have to go back and do that later. Okay? And then just one more questions regarding this in the topic CM. Do you know, like little profession to use like like beads or like different kinds off treatments for, like, infected bone or steal my litis? That's usually not the acute setting that's a bit later, isn't it? When they get Boston, myelitis is the results off a deep infection. But in that situation, we really a zoo with our microbiology team. Sometimes we will use the things like gentamicin beads you've discussed impregnate antibiotic impregnated um allograft products like Serevent, which which have gentle medicine in it. Um, and it kind of depends on the exact situation. But the key with deep infection is removing infected bone. Or in the first instance, you've got to treat it with antibiotics. And if that doesn't work, then, um, you know, surgical debride mint off infected bone on bone allograph addition. Where necessary. Bank it up there. Thank you. Um, any other questions? Well, looks like that's that I think you so much. Thank you very much. It's been an absolute pleasure. The same here. It was a very interesting action. I think they're all learned a lot from you. Um, so, uh, you can also find the feedback link in the chat box below on. Thank you again So much, doctor, for your time off for helping us out with this. You really appreciate it. Thank you very much. Has been an absolute pleasure. All the very best to your Thank you. I I, um everyone else you can you can find on extraction at three PM and it's going to be on endocrinology. So I'll see you guys then. I think he thank you.