Computer generated transcript

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

right, Patrick, you're asked to see this child. Can you see that? Okay, you're asked to see this, um, 14 year old child in the pediatric orthopedic clinics. They've got a painful medial side to the foot. Um, they hadn't any specific trauma, but they're in, um, sports person. Um, and we undertake these X rays after examining them. Uh, can you look at those x rays? And, um, tell me your management, please. Uh, so we have, uh, oblique and lateral X rays of a ankle in and foot in a school. Yuki Mature individual. Um, it appears to demonstrate some atypia within the, uh, Taylor's potentially A and the calcaneus. Potentially a coalition type. I'd like to take a full focus history and clinical exam of the patient. Uh, you know that they're keen sports person that come in with the medial side of ankle pain. I'd like to assess that they had any, uh, antecedent trauma. If they've had been having any issues while playing sports, if they've had any history of the current ankle sprains, I'd like to take any pre pre and postnatal history ensure they've been hitting their milestones, assess their weight and height and then assess their their gait as their ambulating. I'd like to see if they have any significant media sided pain if they had a normal medial longitudinal arch. Uh, and if they had any gait, abnormalities? Um, so from those x rays, she said that you're concerned about her coalition. Uh, what's the reason for that? Can you describe to me they find it? There appears to be a C sign on the on the lateral X ray there. Okay. Um, so, uh, you said you wanted further imaging? Yeah, I'd like to get just a further image of the foot. The the other issue is that they appear to be quite, um, quite cavus in their nature. So that was the other thing I'd like to assess as well. Okay, So how would you assess cave? I'd like to just get a full lateral x ray of the foot and calculate Mary's angle in order to assess whether and and then it was the long axis of the talus was the long axis metatarsal. And see if we're a greater less than four degrees deviation from that, uh, and you said you're going to assess if they've got k vis when you examine them. Yes. So how would you when you're examining them? So I initially I assess their gait and then I'd assess, you can visualize visualize the medial longitudinal arch of its excessive. And then what I'll do is I'll reach my finger under the arch and see if I can reach as far as their fifth metatarsal. Uh, I'd also like to then assess them. If they are caves. I'll put them on a Coleman block in order to assess whether it's flexible or a rigid, uh, whether it's flexible or rigid. So if you imagine the foot is a three pronged stool, you can assess whether the cavus is either a 4 ft driven cavus do too hyper plant reflection of the first ray or due to a rigid hindfoot. So if you swing the first metatarsal off the Coleman block and it's rigid, it won't fall. But if it's unregistered, will collapse down, and then that will indicate a first metatarsal driven pathology. So it's it's whether they foot uh, so you you assess it or not by visualizing from behind to to assess the hindfoot to see if it swings back from Vegas into neutral or various international. What's over? Imaging, Would you like, um, So I'd like to get a full, full, further ap of the photo. I'd like to get an X ray of I'd like to get a CT scan. I'd also like to assess if I am worried about cannabis. I like, as the other associated conditions assess their hand, assess their spine. So I'd like to get an engine of the spine also and joint above and below. Okay, so, um, you want X rays of the foot? You want a CT scan? What's the CT scan of, uh, ct scan of the foot and ankle just to assess for any other? That just appears to be some atypia on that lateral x ray that I'm not particularly happy with, Uh, your peak X ray. Uh, and then I also like to get just for completeness. I'd examine the spine and get a, uh, Patrick with regards to the CT scan. Just from the radiation point of view. Are there any other modalities that you could use for the foot and ankle? Uh, there are. We can use an ultrasound of dynamic ultrasound of worrying about any of the soft tissues within the foot we can use for pediatrics. And now they use an E s scan quite frequently. So it's a low dose X ray. Um, it does give three d type imaging, but it is operator dependent, and it can be highly movement dependent of the child of the foot and ankle. Say, Well, that shows. Okay, So this is an MRI scan. Uh, I wasn't sure if you want to go that high order and everything. So we have a a criminal image, T one and T two weighted MRI scan in a in vascular committee or individual, which demonstrates some edema within Payless and the, uh okay, that's fine. Uh, right. So, um, Joe, just given those my cases, shall I run through the first lot and then, um Okay, get you. Do you want to? Uh, so this is a five year old who's been brought to the emergency department. Um, they've done a residential. They're a little bit sore around there. Um, around the elbow. Um, Mom has noticed a bit of deformity. Um, so the registrar calls you up to ask what you would like to do about at this patient. Okay, so this is a a p. Uh, and the literal photograph of the elbow showing this interior dislocation of the radial head. Uh, I will first, uh, check if the child has any trauma and and or this is, like in cities, uh, onset of the pain. And, uh, and I will then examine the child. I will check the soft tissue and around the elbow. Check the universal status. Check the range of motion if it's a acute trauma, Uh, give the energy, say to the patient and, uh, Splenda limb in the, uh, for the trumpet. So when you examine the child, actually, they're not sore at all. They've got a great range of movement. They said eight a little bit when they were when they were doing their activity weekend, but they feel absolutely fine now. So, um, there are of motion is they can hyper extend by 10 degrees. Um, and they can fully flex. They've got full super nation and pronation, and there's no history of trauma at all. There's no history of Trump. Yes. So it could be a united dislocation of the radial head. Uh, So I will examine the child risk as well and get the extra of the risk. Uh, um, is there any problem with, uh, there's a radio and the joint, um, and, uh, and and And the option is if the child are really is symptomatic is not having any any trouble, then you can give them the a sling and then follow up in the in the clinic. Uh, okay, So you've given them a sling. You've sent them home. You're bringing them back to the clinic. And what are you going to do? Yeah, it's good. Could be just a, um um mhm. It's a congenital. It's a congenital dislocation of the I will check with the mom if you notice the Is this default like any swelling from the pain? Is just she noticed now, or has it been there for a long time? So is the new thing is, uh, we're going going on for a long time. Mom had only just noticed it. She said that, um, the child had an injury 2.5 years ago. Um, but apart from that, there's been no no problems. At that time, it was a pulled elbow. She was treated in the cast for a couple of weeks. Um, and that was what? Yeah, so it's a It's a complex, uh, scenario I will discuss with my, uh, like the biotic. Uh, colleague. Really? So it needs some kind of a surgical procedure. Uh, but not as in kind of an urgent thing is it's a long term thing, so I will, uh I will. It needs maybe, uh, and kind of mdt approach and discuss with the senior colleague. Uh, it needs, uh, to reduce its It's a dislocated radial head. So, uh, but it needs to be done as an elective rather than an emergency, uh, scenario. So it may need a some kind of a reconstruction of the, uh, soft issue or maybe, uh, some fixation, but like, it needs a bit of further, uh, thought process and discussion. Okay, So is there any further imaging that you would like? So I will. We will get a m. R. S. And just to check the any ligament damage. OK, so, you, uh, look through the images from when the child was seen in the emergency department two year, 2.5 years ago. And, um and these were the pictures. Yeah, it's this picture like, it looks like it's just, uh, interiorly. So it's maybe a cold elbow, which is left, and it's not been reduced at that time. So but now it is a chronic, So it will be difficult to reduce it, like, close the so it needs to open procedure, which needs to be done by the specialist, uh, surgeon. So I won't be doing it as, uh, day one consultant. So I will be referring this to the pediatric. So this is a congenital dislocation. So if it is a second, you do an event as you're describing me that the child has one, uh, even and that caused this problem, and I would take it as a, uh, It may be just a cold elbow, or but if it is going off, it is, uh, from the book. Okay, we're gonna we're gonna stop there. Okay. Um, Patrick, you're up again. Uh, we might do this one. So, Patrick, you're asked Colton Neonatal Ward where you're asked to see this This baby. Um, can you describe to me what you can see and then the treatment that you would undertake, uh, clinical photograph of a young baby which demonstrates marked, uh, congenital Taylor pays a coin of various, uh, defeat are extreme inversion various on a Qantas. So I'd like to assess for any other signs of packaging disorders. I'd like to take a pre pre and postnatal history from the mother if they had any issues throughout their pregnancy. Any issues of oligarch polyhydramnios nose? Any intrauterine issues, any birth, birth delivery issues, any family history of same uh, and then I would like to assess the child for any other issues. Any signs of arthrosclerosis any signs of other dislocation of the knee dislocations that I'd like to assess the hips, upper limbs, torticollis or any other potential abnormalities of the child and like to take a quick history as well Providing this is a simple, congenital taylor basic kind of virus. I would like to proceed along the route of Ponsetto casting really Fine. So can you just talk to me about how you would score? So how you would assess the severity So you assess the severity based on the piranha score. So you assess both the mid foot and the hindfoot in the mid foot. You're looking for a curved medial border. Medial skin crease posterior you're looking for, uh, rigid varies. Absent. He'll sign, uh, and a posterior crease. Okay, Um and so you do this and you score all six. Uh, and can you talk to me about the the assessment of the rest of the child? You said you're going to check them over? Yes, absolutely. So these have other associated conditions, so I want to make sure they have no congenital dislocations of the knee. They're not hyper mobile. They have no signs of arthrogryposis. I want to do a Barlow smart elonis test on the hip. Um, I want to ensure that the child is symmetrical. Uh, they are the correct weight. Again, This is a is a neonatal child. I want to make sure that they have normal respiratory and cardiac function. Uh, they have no torticollis. They're not holding in any particular affect. Uh, and that, like I said, the entire birth courses was reasonable. Okay, Um and so, um uh, you do that, and mom says, Well, apart from the surgery they had to have when they were first born, okay. And then I'd like to Absolutely So these can be associated. What? While it can be considered a packaging disorder, there are other associated issues that kind of can occur with these, including bacterial invader, hold or, um, Fanconi anemia. Uh, these all occurred you to the, uh, fact that during birth that they can during limbo development at the 6 to 8 weeks that the other intraabdominal organs form at the same time. So I'd like to assess what other? Uh, what surgery the child did have when they were born. It was spinal surgery. And the scar on the back also says for any signs of spinal dysraphism. Okay, I'd say you've, uh this child has spina bifida. You can't see that fact of motor function. The child is kicking the legs out, but the feet don't appear to be moving. What's your treatment course? Um, if the feet don't appear to be moving, I I still probably would proceed down the line of, um of Ponsetto casting. Uh, the idea here is to create a plantigrade foot. Uh, that is in a position underneath the tibia that allows for even if the child has no function in the limb that allows for wearing shoes in the future that allows for adequate footwear Not going to develop potential stress holders. So, yes, While they may have an insensate nonfunctional foot, it would be ideal if the foot was in a reasonable position to allow them to, uh, where she were in the future. Okay, um and so, um, you do your pentetic casting. Um, and and actually, you get quite a good foot correction. Um, you what's your next step in the process? Uh, if they do get a good casting level, if they depending on whether they needed t l releases, but I'm going to then put them in boots and bars, which they'll wear full time for three months, uh, and then into it and then at night for for three years. Uh, there is some research to say with with a child like this, it's obviously if they are completely insensate. I'd be very wary about pressure sores. I've been monitoring that closely. There is talk of using the French method, but also someone with this point of if a child wouldn't be unreasonable to use something like an AFO, as opposed to put some bars also. Okay, um and what might be the problem with an AFO versus bit. Okay. You're saved by the bell. Uh oh. We've lost your head. Um Right. OK, so, um, Patrick, how did you find that? That one. I should have gone for the spinal ist raising. It was quite a marked one, but I wasn't thinking global picture, I suppose. Yeah. So, um, so, you know, a conference been comin if you're looking at BILATERAL you absolute. Right? So 50% of idiopathic a bilateral. Um, uh, it's not a packaging, just with hyper mobility. Um, so use those, but you do get joint dislocation. So, for example, if you got, uh, you definitely wanna be checking the hips, Although there's that that's slightly controversial, isn't it? As to whether there is association or not. Um, so I think it would go to the first case. I think you sort of found the answer and then talk yourself back out of it, and yeah, I thought it was. And then I thought, uh, yeah, so you can. So you're right. It was subtalar, uh, coalition coalition. Um, it doesn't have to be flat for, so that can confuse. And that's quite like that one, because it's not. It's not all the case. Then I then panicked, so Oh, you'd say if you know, if you are going sort of the kava roots, they say, Look, I'm suspicious of Tarsal Coalition. You wouldn't generally do a CT scan. In Children, you tend to go straight for an MRI scan. Uh, assess, um, you want to weight bearing film if you're going to be talking about Caven. So that's weight bearing film, isn't it? Yes. Um, so you'd want to, uh, don't talk. So look, I'm suspicious. I would examine them if they didn't appear to have much in the way of hind foot movement. Then I would, um, investigate them for tarsal coalition. If, however, and that there was neurological issues, then I would be more concerned. Etcetera. Um, just yeah, with your description of cavus, you're absolutely so you look at what the hindfoot does not what the 4 ft is doing. So it will tip over as in the the first rate. Even if you compensate for it, it's just the heel will stay still in a position. Yeah, that sort of valgus position. Sorry. Whichever position is currently, it will stay stiff as opposed to going tipping ground into valgus. Um, yeah, Joe, is there anything you would add to that? No, I don't think so. I think in terms of more general Point about your presentation, I think it was very, uh, very You came across quite confident with the material. I Helen said you kind of you did sway between the two diagnoses, but I still think you sounded confident throughout, and, um so that was really good. Um, what was also nice, because these you don't have a lot of time is that you did get to the main diagnosis pretty quickly and didn't spend too long before saying that you knew what it was. Um, so I think in terms of an exam technique, point of view, that's very good. Get fairly quickly, um, so that you can then move on to the higher scoring opportunities. Um, and then she said, How did you find that? It was, I think, didn't burn very, uh, swiftly in that one. I think that that was, uh, yes, So a little bit because, but actually I mean, you recognize that it wasn't an acute dislocation, but it's just is this congenital or is this A, uh, What do you think? Is this congenital, or is this a mist or chronic Mantega? I can't see any plastic deformation of the never know. But if it happened 2.5 years ago and they're five, they would could be a model that it's more than they have. A It looks like it could have gone into the into the joint. So it's sorry that looks reasonable for the joint, which is unlikely to be a congenital Radiohead. Therefore, Joe, did you want to add anything to that? No, I think. I mean, the thing is, obviously when you're, uh, getting to the diagnosis, obviously going back to the first principles of describing what you see, um, and then talking through what you'd expect to see with perhaps a congenital dislocation of the radio ahead you might have, you might have sort of cottoned on in doing that that this doesn't typically appear like one. Um, but yeah. And so if you see something that just completely freaks you out, then going back to those first principles cause otherwise you won't progress. So I was wanting to talk about Okay. Can I see an X ray of the other Elba. So I could have showed you that showed that it was nice and normal. Looked like once they're in an X ray from that original injury 2.5 years ago. You look at the one from 2.5 years ago. You can see that it's not quite normal, is it? So this is when. So they've had a Montevideo. That station, it was, has sort of slowly slid out over the last couple of years. Um, and then you're absolutely right. I had to do a open reduction and on your osteotomy in order to get this back in. Um, but it's it's, you know, and it's taken that process. And then you could have talked about you know, the fact that you need to do an owner lengthening, um, uh, reduction procedure. And, um and, uh, Plus, for this I had I did avoid approach and actually didn't a belt. Also took a bit of the triceps to reconstruct a little ligament so you can take place is so if it is a congenital radial head, Um, this occasion the Radiohead looks pointy, so it looks like it's never been in if it looks like it's got a socket to it. And that's true of any joint. If if the joint So your same of your d d h. If you've got this weird sort of pointy head, then it probably has never been in the in the joint. Um, so whereas like, your c p dislocations, they're nice and round because they used to be in the joint, but they're now they're not. Does that sort of makes sense? Yeah, uh, and it's just been a little bit more enthusiastic. Yeah, I think I know. Yeah, you know, it's not funny, but you just want to You just want to be sort of, you know, uh, because, um apart from any think it's just, you know, you just wanna keep, you know, give the impression that you're not hating every second of it even though you are, and and they're aware of it. But yeah, it will just it's just helping help, you know, it's just progressing. So just exactly. She did say what you say and then work from there. Um uh, montage areas are really you know, So you're absolute, right? So if this was an acute montage where you'd want to reduce it, wouldn't you? But you'd look at it. You know, this could be an acute Monte JIA, and you say Okay, well, fine. I would want to reduce it, but with completely asymptomatic and no history of trauma, that doesn't fit so well done for picking that bit up of it. And and it's Yeah, it's just been quite step, boys. Was it? Is there anything you guys would like to ask? Um, with the with those see TVs, would you? I probably committed too early. Would would you kind of do the broad strokes, make sure there's nothing else. And would you Would you probe a little bit more? Or would you kind of say I would ask the mother if they had any issues and then see what the Examiner comes back with for the club foot? Yeah. Yeah. So you could just say I would ask about I would ask about birth history. Was there any prenatal? Uh, antenatal diagnoses were old man's all nice and normal. The baby is born. I'm going to do a full examination looking at Lim range of movement because you're looking for arthrogryposis. Yeah, I would check the spine for signs of spine. This phrase is, um I'll examine the hips to see if there's any sign of dislocation. And I would examine the needs to see if there's a normal range of movement for a newborn. So don't let newborns have little knee contractions. Can't fully straighten a newborn generally, um, and then, uh, And then I would proceed to examine the feet. And I'm looking at for the Peroni score. And these are the the six points that I'm looking for. Perfect. Um, uh, boots and bars. Five years. Five years. Okay, that's sadly forgotten. Um, what else? I think that's all I write down. Was anything else from your side? No, I don't think so. I think, uh, in the you need to be in case. I thought you sort of manage the complex decision making. Well, because again, in the real thing, they will push you for, uh, slightly more higher little higher order or higher level complex decision making. So not your typical case. And I thought you managed that quite well. Patrick. Yes. Uh, on older kids, make a naive one. You use it on recurrence. There's used or recast to use it on. Uh, just keep doing Ponzi tick. It's only it's only if it fails. And if it does, you need to be sending it to a tertiary center of high volume to make the decision about doing a poster media release. Okay. And you you tried twice. No, it's not regular. Uh, in the exam, I got both comfort, and, um, and also we got onto What structures do you release? Impostor. Media release. But I can safely say that that was because Pete was my only good station. I think my periods brought up the rest of the exam for me. Okay. Um, so, yeah, just just recognizing that, uh, thank you. OK, Joe, do we need to go on or what's the I don't know if we're supposed to be waiting for a notification. A little pink, A little pink. Fine. Okay. Is there anything else? Uh oh, there we go. Thank you very much. Ok, Bye, guys. Best of luck. Thank you. Uh, we're three. Yeah. Breakout room three. Think we moved to Breakout room three. Yeah, I'll see that. Yeah. All right. That's true. He can you hear me? Yeah. Great. Who's what we're doing? Three or three or someone doing something. One, I think we're doing two in one. She heats up first this time without the heat. Last time. Should we do the two together? So So you're going to do two in a row, and then Patrick, you're going to do a third. Can I ask you guys to be very specific and do the five minutes? So, Patrick, do you mind typing for the first five? I know Ricky is doing it, but we'll try and get started early, so we've got a bit more time to have a chat. Perfect. Is that right? Yeah, absolutely. Okay, right. Do you want a 30 seconds at the end of just let you know when you're finished? Just let me know when I'm finished. We'll be fine. We'll just stop talking now. Why wouldn't let me share my screen now? Suddenly? Uh, mate, what's going on? Uh, it's not letting me share my screen. Sorry, guys. I think if there's an issue, they said hit hit. Just refresh the page. That was the issue. Okay? Still not working. It will not make me sound free. Okay, uh, we can start the first one doesn't need a picture. I'll just email while we're waiting. Okay. Okay, so So he tell me, uh, lots of hits. The knees. Uh, tell me, is there a difference between the poly and the hip and the knee? Yes. So Nepali. We use a highly crosslink polyethylene because it is, uh, parents are working in the, uh, high, uh, conformity and the low contacts persist. Uh, and it reversed below the endurance limits. So we we want, uh, politi which last, uh, for longer time. So we use a highly crossing polly a tree when the in the, uh, totally replacement, we used, uh, high molecular weight polyethylene because it's working in the, uh, low conformity and high contacts process, uh, environment. So we want the poly, which is the, uh, more fatigue resistant. Okay, so So just quickly go through. What are the different types of where where you get in the hip and the knee? What's the difference? So the and help you normally get the get the aggressive type of there and adhesive type of year, But in the totally replacement, you get the A catastrophic, uh, sub suppressive delamination. Okay, Because of the context versus just for your point of view, tell me what you think is the difference in the manufacturing process to both colleagues. So then, uh, manufacturing highly crossing polyethylene. We get the, uh, cross-linking by gamma radiation. And we do this gamma radiation in an inert environment to avoid the, uh, you know, mixing the, uh, with the oxygen and getting the free radical, which can cause a catastrophic failure. And we now, uh, recently started using the vitamin E me as well, which will produce a production of the, uh, these three Radica violence and highly cross-linking politician. We want, uh, less cross-linking. So, uh, because the cross-linking, uh, it is is aware rate, but it makes the polyethylene brittle as well on the other side. But for the, uh, totally different, we want more of a crystalline structure of the polyethylene rather than the amorphous structure the politician can found into types. Um, or office form and the crystalline form amorphous form give us more of a cross linking, whereas a crystalline form gives a less cross cross linking. But it's a more, uh, fatigue resistant. And so we need a kind of a balance in these two forms. So in, uh, highly crossing need on more, more press than the crystalline form and totally replacement. I need more discipline for me, which is more particular assistance. Okay, So how do you How do you create the crystal initi the amorphous doctor? I don't think so. It's it's it's a balance. So I'll, uh, so I'm not sure how to get it, really, But, uh, that's okay. So So let's start with the manufacturing process. So talking through started polyp manufacturer. So start with the colonization. It can be turned by, uh, addition, polarization or administration. Politization, uh, referred to have a conversation problem in, uh in which this, uh, this eater line, which is a monomer. Uh, the molecules come close to each other and they release, uh, water molecule, and it's called administration polymerize Asian. Then it goes into the process of, uh, uh shaping, which can be done by, uh, the rand bar exclusion of compression molding. And what's the difference between those two Rambert one or the other? So this this ramble decision is, uh, done by the machining, and it's not very, uh, preferred method of, uh, shaping the polity. Uh, we, uh, like compression molding is without the machine is, uh and it's a preferred method to, uh, get the shaping. Uh, then, uh, do the, uh It goes through the, uh, uh, process of industrialization, and it's preferred method is to do through the different matter. Uh, added to the line of fried or gamma radiation. Gamma radiation is preferred matter, especially in the inert environment, which give us a more of a cross linking. And then it's a sterilization packaging of, uh, again, it needs to be, uh, type. Okay. All right, let's stop there. We'll come back to that. Okay? I'm just trying to see if I'm going to share my screen, which, uh, fill Rishi, can you? Hi, Xue. I'm right here. I wonder whether it's just the icons on your desktop. Might be obscuring the chair. The first one. So I'm not sure why I can't share with this one. Do you want to refresh Z and come back? Yeah, you know? Yeah. Mhm. No. Doesn't work. I still haven't got Do you see the mic and cam buttons at the box? Yeah, uh, and then present. Now, uh, and then share slides. Uh, you probably just minute. I think you just minimize your screen. If you just pull your screen out a little bit, you should see all the icons I've got all those. But I've only got four icons at the bottom instead of the I think you just need to stretch your screen out a little bit. I think you've maybe condensed it a little bit, you know? Definitely, uh, about, uh, good. Uh, no. Uh, no, it's still not coming up. Just literally got four. I got at the bottom. Uh, should I do a question? The meantime, uh, yeah. OK, guys. So, uh, I would give, uh Are you guys going to go through this? So who's an accident? Paddy? I think she was going to do too. Okay, great. Okay. So what? This patient who's been treated in a cast and comes back to see you in clinic complaining of pain in the left hand. Tell me what you see. So screening a photograph of, uh, both hand left hand is a swelling on the dorsum of the foot. There's some, uh, redness and the surrounding everything. Uh uh, around the skin. Uh, check When the What's the symptoms? of, uh, the patient. Uh, what? What? You're going through your mind You said about redness and swelling. What do you think might be going on? So it could be, uh, cellulitis. It could be crps. Um, So how would how would you How would you differentiate between the two? I will check your lactation if it's, uh, hypersensitive. Uh, if he's having, uh, pain or if I will check, uh, as well. If it is, uh, hypersensitive. And, uh, is there any, uh, um, um, or cellulitis will be like the skin. It will be warm to touch. Really. And, uh, it's painful to move, although the crps will be quite painful to move as well. Uh, well, how can you differentiate between the two? Was that in the, uh, breakfast in the er case? I believe if I elevate the, uh resolve because it could, mostly because of the hypomania in this letter will stay. I will do some blood to make sure there's no, uh, unlikely to be a cellulitis after the removal of the cause. I'm suspecting more of our crps in this vision. So I would, uh are there any other things that you know about how you can make the diagnosis apart from Yeah, for crps. How do you make the diagnosis? You can use, uh, criteria, uh, criteria. So you can check the, uh, the pain. And also the you look for the, uh, sign and the symptoms to look for for the if there's any, uh, clean, uh, patient's complaining of the pain. And it's a sign. It's a hyper sensitive skin. It is there any, like, uh, motor sign? There's a rightness. Everything around the skin there's no sweating or dryness of the skin and and Okay, fine. So why does crps occur? Why do we get it? So it's just a reaction. Implemented reaction to the of the of the tissue secondary to trauma and, uh, to the autonomic system and sympathetic our Curiel sympathetic system. Okay, fine. And I'm just going to show you another image here. This is the same patient. Tell me what you've seen. Uh, and the leopard photograph of the hand showing this, uh, refusal subpoena of the, uh, around the, uh, the joints and, uh, MPPJ joints. So it could be, uh, that's time for him. Okay. Uh, zoo. Have you got your questions? yet Or is it? Uh, he's still waiting. Is it OK? That's fine. So I can give you another question. Is it, uh, things up? All right, Patty, tell me what you see here. Uh, this is a clinical photograph of a screw. Uh, so screw is a solid core with a inclined plane wrapped around it. It's use is a simple machine to convert rotational force or motion to into linear force or motion. So this is a typical screw that we use in orthopedics. It appears you may have stay in a steel. It's composed of a drive shank or run in shank court and threads. There's this fluted tip that appears to be cutting on this. The flute has a number of, uh, benefits. One. It can be cutting and two and aids to remove Swart. As this group progresses, we use screws in orthopedics, and they're they're they're a machine, and they're used to apply compression. This one seems to be composed of stainless steel. They can be typically made of stainless steel or titanium. Okay, fine. So can you talk to me about the different modes in which we can use screws? Yes. So it depends on the type of screw were using. But Cruz can be used in compression mode. They can be used in locking mode. They can be used as a lag fixation. Uh, this is a an example of each one. So in a compression mode is in this we will say, for example, using an L C D, C, p, and we want to directly apply force uh, with from the plane crew in a non locking screw in a lag. Screw would be the example. Safer exactly. A fibular fracture within a blink type where we would use either a partially threaded screw or a fully threaded screw with an over drill of the neocortex to apply compression in a lag and unlocking screw will be in the case of a