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Hi guys. Uh my name is Da here. I'm one of the ST four trauma and orthopedic register stars. Hopefully you can see my screen. Uh and basically, uh I'm in the Birmingham rotation, but I'm also an NHS England uh teaching fellow. Uh And today I'll be talking about trauma and orthopedic emergencies, which is the most important part of uh orthopedics, not pediatrics or knees, no emergencies. Uh because that's the, that's the main thing. So what I'll be, uh just to let you know about what topics to be discussed, but for all of these conditions, early intervention is required and that's why it's so important uh to know all of these. Uh and you must have heard a lot of people throw these things around but like, uh even to, to be extremely honest as a, as a core trainee, I have seen so many of these injuries and the only reason why was because I was so focused, uh and I didn't have to call a registrar which you guys should, but just to let you know, I would have already started the treatment, initial treatment and then go on. So the topics to be discussed today are compartment syndrome, open fractures, Corinna trauma, and em other emergencies that I feel are extremely important that not a lot of people think that they are emergencies. But I genuinely think so. And as an sho when your register is at home sleeping, you're just being inundated with these calls of referrals. I just think those are the most important ones to worry about and that should be raising alarm bells because that's the most important thing. Now, uh compartment syndrome, I'll talk about first. Uh everyone talks about the definition and has their own spiel. As long as it makes sense, it works. So the one thing that works for me is an increase in manufacture. Compartment pressure. I'm a simple man. So I go for simple uh simple definitions. You'll see by a lot of the slides of this uh talk, but you have to understand why it happens. It can happen with like fractures, but others as well such as burns, hematomas infections, um crush injuries. That's the thing. You have to have a high level of suspicion for it. So the cascade of events is the local trauma and soft tissue destruction that leads to bleeding and edema that leads to increase inital pressure, which leads to vascular occlusion and then myoneural ischemia. So the only reason why I put the cascade of events is because of that last one. Myoneural ischemia and vascular occlusion are the last cascade of events. If it goes to that far. It's already too late. So that's why the sign and symptoms are very simple pain, pain, pain. And there are two other pains that I didn't want to go into. Now, you have to realize pain when. So this is when, uh, your detective skills come in place you talk about, uh, you ask the patient? Oh, ok. How long have you had the pain? Uh, you ask the nurses, you ask, ok, how many pain medications has this patient had? If the pain is out of control, uh, out of, uh, out of control or proportion to the injury? For example, if someone has just been, uh, just had a tire go over their, uh, over their foot and the patient is in horrible pain. Yeah, tire goes over, uh, over feet kind of seems painful. But you weren't expected to last that long. You would, you would expect, ok, if I give like the best, um, painkillers such as morphine or anything else that would help. But if it still isn't, that's when alarm bells go off. And then the one sign that I find is the most sensitive is pain or passive extension. A lot of people will talk about, oh, tight compartments, this and that, this and that. No, I think it's just these two that you have to really worry about. Now, when it comes to investigations, I, uh, you always have to take a history examination first and that I un unfortunately, I'm old school. So that's what you have to do. But then it is all clinical. If you have to resort to intercompartmental pressure monitoring, that means you are not sure, call for help, you're not the best person to think about this. But then obviously, intercompartmental pressure monitoring is very important as well. For example, if there are patients who are ventilated and they aren't able to tell you they're in pain, but you see their vitals and uh and their obs in there, it's going all over the place and there's no other sign then intercompartmental pressure monitoring is important. It's a very cool device uh that you can rarely find, I've never found it. Uh but it's basically you check each compartment, er, and it gives you a reading and there are very specific readings that you really have to worry about. The normal. One is less than about er, it is less than 10 people give a range of 5 to 10, but absolute of more than 30 ma G. That is your compartment syndrome. But there are these values that I don't want to remember because if I suspect someone having a compartment syndrome, I'm not waiting for monitoring. So that is something, there's both guidelines on how to uh what to do and what not to. So then it comes to management. So management is very simple. So I'm not expecting you as uh a junior doctor or anyone else to do what is, what is uh what, what is shown on the picture, which is a huge fasciotomy. But I want you to do these four things which is cut the cast. You know, most of these patients will have a cast on which would be horribly fitted uh by A&E uh you elevate the limb to the level of the heart. So to improve the systolic BP, you give IV fluids, you give pain relief. But then this is where the important bit comes in. You review in 30 minutes. I, when I've seen about uh quite a few compartment syndromes. Um and whenever I have to review in 30 minutes, that is my goal. Uh That is my time. I will consult the anesthetist. I will tell theater staff, I will tell my consultant, I will tell everyone that I have a suspected compartment syndrome and this patient, I would rather have them that they're read alert and aware of it rather than ooh not telling everything and then reviewing 30 minutes and then doing it. That's a sign of uh that's a sign that you are not taking this as seriously as it should be. I do uh ii preemptively tell everyone and if it's not compartment syndrome, I give them another call and say I apologize. This is a false alarm and everyone will understand if they don't. That's OK. They're paid to be in the hospital. Uh But then most importantly after that, you have to understand is fasciotomies. Now, the most compartment syndrome that you will see uh is or your ton off is of the of the leg. Can I be honest, I've seen of the thigh three times. Now, I've seen the leg multiple times. I've seen the hand, I've seen feet. You will be surprised where compartment syndrome can happen. But then the rule is the same management is the same. You do the E four, you do a fasciotomy unless in the foot. But that's a deeper subject that I don't wanna touch. That's a can of worms. But then how long should the f show to me? For example, if you see the uh II, if, if you see here on the right side of the picture, that's where the tibial tubercle is, that's really long. And if you see all the way on the left side of the picture, that's a big cut. And they have used this uh this, this is probably the left leg. So this is the lateral. So they probably use this to decompress the anterior and the lateral compartments. So both of them. So it has to be big. So you have to understand this is a very emergency situation that you should always have a sus uh have a high level of suspicion for because when you do these fasciotomies, the the intention is that it, you should close them within 72 hours with plastics. So go big or go home. Ok. Now, the next one is open fractures. So, you'll see there's quite a lot in a and knee, uh, or in orthopedics. Uh, they'll probably tell you that. Oh my God, there's an open fracture. Can you come in mostly ankles and tibias, uh, and stuff? But then sometimes a knee will tell, say, oh, by the way, it's a, a AAA tibial fracture or a distal, uh, ankle or, or a distal tibial fracture or an ankle fracture. And then when you open the air cast boot that they're on, uh you realize it's open, but what is the most important part of open? You shouldn't be distracted by it. You see the patient as a whole, you make sure this is an isolated injury, it's neurovascularly intact, it isn't closed. But then you go on with the measurements and then I won't, I won't bother. But in the history is the mechanism of injury, which is the most important. You have to know if it's a high energy trauma because if it's a high energy trauma, as mentioned, you don't want it, uh you don't want to miss something else because this patient can easily have a pelvic fracture, which is a lot more dangerous than this and will kill the patient. So that's uh that's what you have to look out for. You have to look out for agriculture, marine and sewage because these are the three indications and two others that I'll talk about for taking this patient patient to theater within six hours because these are high contaminants and then low energy trauma because this actually tells you these three things just with the history will tell you when you need to take this patient to theater. Now, there is a Gel and Anderson classification in orthopedics. Uh I think you guys have been through the six series. We love classification. He still Anderson classification is actually the classification which is given to the size of the wound of the fracture. So as you can see, it is 1 to 31 is less than uh or less than uh three centimeters, two is 3 to 10. Uh T three is more than 10 by A B and C A is that there is good tissue coverage. B is tissue coverage is gone and C is a vascular injury. Now, no, our classifications are perfect and this is not a perfect classification. Why I say that is because how can you be certain that a one, a tiny injury is not a vascular injury unless you open it up and debride it. And therefore, if you read the original paper of Rason classification, they will always say this classification is only should be done at the time of debridement. And that's where this is a very good or important question to be aware of and just to uh have a bit of sense in which we don't care the size of the wound we're still treating it the same way and how do we treat it? We give it IV antibiotics in the first hour. And Tetanus, you take a picture of it. You have to not on your phone. Please. Everyone does it. But please. No, you take a medical photographer if they're not put it on silo, do an encryption, put it on yourself and then, and, and it should be encrypted all the way. And then why do you have to take a picture? Because your next step is Saline gauze with a back slap and then x-rays should always be done after initial treatment. This is where things get a bit uh uh a bit confusing. You'll have um a need just slapping a back slab on and say, oh it's an open fracture. Have you taken a picture? No. Have you given IV antibiotics? No. Have you at least done a saline, put a saline gauze on it? No. So cut it all the way down and you start from top doesn't matter. And then they would have already done the X ray anyway. So that's fine. But then the surgery, the most important part is the timing of surgery which we've already discussed with the mechanism of injury. So that I think is the most important part of it. Surgery could be external fixation. Uh You can uh I a lot of, a lot of centers just do external fixation for these. Uh Because of the fact that you need time to, uh, for the wound to heal properly. Because if you try fixing it, the chances of infection are very high. Uh, however certain centers go like, ok, if it's a tiny, tiny exit wound or something else, just fix it primarily. So the patient doesn't have to come back and you do it in such a way that, uh, that, uh, the chances of infection are low. But then because this is a trauma surgery anyway, the chances of infection are high. So devil's a de a devil's advocate. You could do whatever you like at the end of it, but you need to fix it one way or the other. So you put an external fixation, which is a scaffold. Now, before I go on to this behemoth of, uh, of an emergency, does anyone have any issues with the two pathologies that I've spoken about? So, unfortunately, I can't see the, uh, the chart. Uh, anyone have any issues? I see. No, no one in the chart so far. Yeah. All good. All good. Perfect. Now, the next one, I apologize sincerely of this will, whenever you're an sho in orthopedics or register in orthopedics, you will be thrown this term. So many times you will be told I have a patient with backache and this patient has co and you're just like, why? Because this is where the things go wrong. You have to know what is Coquina syndrome to begin with? And once you have a deep understanding of it, you will literally be able to cut through all of the amazing referrals that you get from me. Now, let's start with basics. OK? Because that's where I think is the biggest problem. Ca Quina, as we all know, as you can see on the picture on the right is a group of nerves that have already come off from the Conus Malaris at the lower border of the L1 and the upper border of the L2 anatomical variations. No, when a nerve, for example, as you can see on the right side, the disc disc spaces of just below L2 LL two, or so, for example, L2 L3 L3 L4, all of this can protrude back and actually compress it. This is actually a surgical emergency because within 24 to 48 hours, if you don't fix it because these nerves, uh nerve roots are so important for lower limb function and uh urinary function and fecal function, you have to act on it fast. So it's what is the syndrome called. It's basically compression of this nerve roots, the bunch of nerve roots or the horse's tail that everyone keeps on talking about in the lumbar spine. And most commonly, this is caused by an acute lumbar disc herniation. Now, this is an important term, acute lumbar disc herniation if someone has back pain for two years and now has come back with the same type of back pain with no fecal incontinence, no urinary incontinence, no signs of new neural impingement. This is no syndrome regardless of what A&E says. OK. But I really urge you to look at the picture diagram on the right and make a mental note of it. I will not mind if you take a picture of it, but you have to give me credit for it because I don't, I don't care. It's not mine. Now, the sign and symptoms. Now this is the most important thing. Back pain with bilateral radiations because most of the disc herniations are eccentric, are not eccentric. They're concentric or they're central. So when they're central, they will have an equal compression unless it's eccentric. But that it wouldn't cau wouldn't cause cardiac because that'll just, uh, that'll just catch one nerve root rather than all of them. Now, before I go on and talk about s anesthesia, which is extremely important, bladder and bowel dysfunction because of nerve root damage of S 23 s four or five, loss of renal, total Pernal and perineal numbness. Just want to ask because I feel everyone would be sleeping. Does cardia guana have motor or sensory weakness? So if you don't mind writing on the chat and face again, I apologize sincerely. If you don't mind telling me, can I say both? Ok. Fair enough, but more, more sensory, I believe. Ok, anyone else? Because I can keep keep on talking for England. Uh but it's just that I need you guys to interact with me because it'll, it'll be fun. So Rena says sensory, OK. Anyone else I Ivan says post question mark. OK. Question mark. But, but, but uh Hayden, uh thank you very much. But you're literally saying what I've written on the slide. So that's cheating. Fine. Now, chronic R syndrome will rarely have sensory deficit. But if it does have sensory deficit, it will only be in the saddle region or the perineal or perianal region, it will not be down the legs. That is the most important thing, motor weakness. Definitely. Uh I saw a patient that was referred uh by the lovely A&E department as Cardona Syndrome with flaccid paralysis, immediate. Uh and you know, you would expect people to take a history from these uh such patients because the differential diagnosis of Cor Corner syndrome is something known as metastatic spinal cord compression, which is caused by metastatic uh lesions in the spine that cause the same type of principle, but it cause flatter paralysis. Uh and the patient had motor weakness and didn't have any sensory weakness. Uh but then had bladder dysfunction and couldn't feel the blood, uh couldn't feel the catheter. So you have to be very careful. But yes, if someone comes in to A&E saying, oh my God, I have nuance and numbness uh in my right leg, which is in the distribution of L4 L5. Or if someone comes in with saying I have weakness and this is new onset, happened in the last two weeks and it's getting worse. I'll be more worried about the mortar than the sensory. Ok. But down the legs, I'm not worried about it because those are long track signs, those are long tracks. But if it is in the saddle region, Perianal and Perianal, that is where it is the most issue. Now, anal tone has lost its fashion now. So you'll see a lot of pe people not uh not warranting for apr, I apologize. I if you come in with aod and compression, I'll put a finger. Uh I'm, I'm expecting a finger inside your b and I apologize for how uh how rude uh that was uh because I'm not taking any chances. This is something that needs to be done as soon as possible. So you will see a lot of new guidelines saying pr is not important, blah, blah, blah. I agree loss of anal tone is subjective, but Pernal anesthesia, perineal anesthesia is the most important symptom and it has the highest sensitivity to have cardiac RNA syndrome. So if someone says, oh, I've done APR exam, er, which is, should be your reflex or should be a knee's reflex to do, uh I wouldn't worry and they say, oh, lots of a lot, uh there's reduced anal tone and I'll just be like, how do you know it's reduced. You have no idea. You ha you have not done APR on this patient a week ago. So you don't know, you know what I mean? So that's most important. But you do apr exam to check the perianal and perineal numbness that is more sensitive. Now, another thing which is the most important, which is the best bedside to see pre void and post void bladder scan. Now, a lot of papers on uh out there a lot of things in the literature. But what do you think would be a post void bladder volume? That would literally make me one to call the neurosurgeons and send this patient across a person surgery. Now, if you don't mind writing on the chat, I apologize. I'm picking on everyone but it's just because I'm getting bored talking anyone a guess a post void bladder scan, uh maybe above 200 mL. OK. That's very good. That's cheating. You probably did your research. But yeah, 200. OK, good. Anyone else? So I'm talking about the post void. So that means you've literally just uh passed water and you've just done a bladder scan. So 200. OK. Anyone else? No one, no guys guess a number, any number. So if I say 1 to uh 1 L, so one ml to 1 L, what number will cause me to see this patient urgently? And if I can do an MRI scan, if not send this patient, not, I won't wait for an MRI scan. I'm I'll be bluntly honest, I'll send this patient to neurosurgeons. So we've got 250 mL from, oh, someone googled it and Rena thinks above 100 concerning, but 300 to 400 is, is very, very, so Rena, that's actually very good. But can I be extremely honest? Uh When you start working as an F one F two, you, you, you probably have post void uh of, of the same amount. Uh I did, I still do. You, you barely have time to pee even if you have time to pee you pee a little and then you run off. So 100 probably not that much, but 250 is a magic number, but a lot of people say 200 as well. So it's anyone's guess, but to be extremely honest, anything over 200 I would be a bit worried about. I would take it seriously. Uh And there has been how many ones I think I've seen, oh my God, I've seen a lot of suspected cardic one. They have been, I think a handful that I've just been like, oh my God, this is actually a card one and I've sent them across as soon as possible for neurosurgeons or if we have spinal services, whatever. Now, those are your best side tests like apr exam. You do a pre post with a bladder scan, the most sensitive test to identify Cor cor uh Cor Cor syndrome is an MRI scan, but you have to see the limitations of the hospital that you're in. Sometimes your hospitals will not have overnight MRI scans. So that's why if you have a high level of suspicion, you send it across to the spinal services. Every hospital has to have a spinal services attached to it. We will then give you the advice, ok? You can wait till the morning or just send the patient across. But I cannot enforces enough MRI scans should always be secondary to clinical examination and bedside tests. There is you can get so much out of just having a good neurological examination, checking everything, reflexes, both tone, a motor sensory, appropriate exception, everything and then do the best side test. The special test is your pr exam but as mentioned, say it with me, we're not doing it for the tone, we're doing it for the perineal numbness. But then is the is the bladder scan I II apologize. I assume everyone was saying it with me. Now, this is an MRI scan. So I'm pretty sure uh where everyone can see where the issue is. But still I will I just want to show you because when I was a medical student, no one taughtt me this well, technically no one taught me even as a core trainee where I had to learn this myself. And I want to inculcate the importance of trying to understand an abnormality. Ok? Now So this is an MRI scan of the back. So an MRI scan, the most simplest way to understand is it's completely opposite. The colors are completely opposite to a CT or an X ray. So you start off with an X ray. White is bone, uh black is the ear viscera or gray. And if it's blood or fluid or fluid effusion or anything else, it'll be very, very white. So water basically is white. CT scan is just 200 X rays spinning in a rotation like 3d MRI scans are slightly different. They, they depend on densities, they depend on fluid sensitivities and stuff. So this is at two weighted image, please. Disregard of what I just said. T two weighted because it doesn't make sense. All I want to figure, want you to know is on the right side of, can I can everyone see my cursor, please? Yes. Yeah. So wait a minute, wait a minute. I knew this. I knew this. Yes. Can you see the laser pointer? Excellent. Now, this is the posterior part of the patient. So that's the skin that you can feel to see. Now, this is the anterior. Now, anyone know what this is? It's retroperitoneal. Anyone. What are these amazing shadows without which we will have no life. Nothing to do with orthopedics because it's too squishy. Biggest hint I could give you anyone. OK. That's the aorta. Uh Now most importantly, this is the vertebral body that's uh that's the uh spine process. But unfortunately, this cut isn't very central. So between each vertebral bodies, you can see a disc. Now, a disc has two sections. One is analys fibrosis and the other one is mucous pulposus. And you don't remember all of that jazz when you were in first year and second year. Now, you can see the different densities of both. One is they are different type of collagens. But now you can see that this one seems healthy. So does this one. So does this one. So does this one? It starts becoming a bit more gray here that you don't like and then you see this. So this is completely different than this. I hope everyone agrees. Now, what's happened here is this is protruded Priti. Now, I should have mentioned this is the spinal cord right in the middle and it's white. So we know there is fluid uh and a different consistency and that's why it's being picked up in that MRI scan. Now, as you can see, this is a disc that's gone, right? That's gone right in the canal and there's barely any fluid passing through, right? And all of these nerves, this black bit or gray bit is being compressed. So this is an MRI of a patient who actually had called syndrome. All right, eczema. Now, as mentioned before, multiple times, the only management is urgent decompression surgery and this should ideally happen within 24 to 48 hours where the issue starts is 24 and 48 hours of what patient coming to A&E patient having their first symptoms, patient having their 1st 1st symptoms or patient when you saw them, they should be at the time of the patient's first symptoms started. Unfortunately, you will always miss that window unless you are very lucky and the patient is very, very good because some people, some people will be like, er, it'll get better, it'll get better. Sometimes they come after 24 hours. So you just have like 24 hours to act. And that's when you give a call to the spinal services and go like boss man, I'm worried about this patient. Magic words. It always works. I don't know why if I say it that way as well. Perfect. Now, hope everyone's following me till now. Now before I begin to trauma, I won't talk too much about this. Everyone. Ok. With coquina syndrome. If you're ok with it, please be silent. That's, that's sarcasm, please. Please, please say yes. Or if you want me to go even further because card go syndrome is something that not a lot of people understand. Uh, and not a lot of people understand why it's so important to differentiate between normal back pain and something else. I had a question. Uh maybe, um, maybe it's a bit too specific but in terms of compression, is there, is there a difference that you've seen in symptoms uh when you have more central compression and more lateral compression, very good. That's actually a uh uh uh that's genuinely a very good question. A central uh prolapse will always cause bilateral symptoms always because that's the nature of it because you're uh if you see how uh if you see a transection of the spinal cord that everyone keeps on uh reminding you and like neuranatomy and stuff, you will see that most bulk of the Neer neurons go in the central. But then if it's gone laterally or eccentrically, it will only affect one or two nerve roots, but not more than that. That's why you see a lot of patients having, oh, my foot is numb and I can't uh dorsiflex or plantar flex my foot that you know, is an L4 L5 or L5 S one DS compression. But if it's central, you know, for a fact because the way the nerves uh go is so, oh, how can I draw this? Hm. If you picture a circle, but then picture multiple circles within that circle. If there is a compression right in the center of that circle centrally going outwards, it will affect all of them. However, if it goes laterally, because that nerve root has already come out, it will only affect one or two. But if it's central, it will affect all of them that actually are still in the spinal cord and have not come out yet. Do you get what I mean? Yeah, that makes sense. Thank you. Thanks. Excellent. Uh good question though. Very good question. Hope II did a justice. I hate spines. Should have, should have warned you guys that anyone have any other questions about Cony Quina open fracture compartment syndrome before I move on to trauma. Thumbs up. Yes. No. Yeah. Stunned. I think everyone's happy. Yeah. Stunned silence there. Leg. Just like uh what time is it there? Uh six is it 536? 41? 630? My God, everyone's, everyone's going close, it's close to midnight here. So anyway, now trauma is very, very important. It is an emergency because you have to identify life and limb threatening injuries. So you need to know how to do it properly. Now, I'm biased here and everyone must have heard about ATL S. Yes. Can I assume you guys know or heard about a TLS? Yeah. Yeah. Excellent garbage. Completely. Get rid, get rid of it. The only reason I'm saying is cause I made a trauma course uh which is being uh which will uh which is being started by a royal college now. So all you need to do is just keep a picture in your head. Life threatening injuries, first limb threatening injuries, second life threatening injuries comes in primary survey and secondary survey. I'll talk to you about it. Now. What do you mean by primary servant now over here? Because I I've made this presentation before and I should be shocked. It doesn't matter what you do. So, the course I, uh, I have built, we start off with C first which is catastrophic hemorrhage and then we go on to ABCD E but because you're medical student, I just want you to get your concepts clear first and then do the right thing. Which is my way. Obviously, I'm biased. Airway is always number one. What is the most easiest way to identify if someone's airway is patent or not? Because we're just, uh, we're very close to the end of this, uh, talk. So I'm just gonna try making it as interactive as possible. So anyone, if they could tell me what's the easiest way to identify someone, someone's airway patent when you're seeing them? Rena says if the patient can speak. Excellent. Very good, Rena, you're my favorite person here. Thankfully. Very good. Very good. Now, very simple, trauma calls are very busy. So my voice is very, er, er, it, it's a bit weird. So I like screaming as well and I like talking so I make it sure that everyone knows what I'm doing. If I'm doing the primary survey as a trauma and orthopedic register airway is the most important thing because the anesthetist is there and they need to know what's going on. So the second you ask them, hi, my name is Tahir. Would you mind telling me your name? And the second if they say my name is John, my name is, uh, Henry. My name is, uh, th anything, you know, for a fact they're airway spa because you listen very closely because if they're gargling when they're saying something, you know, there's something in their throat and you need it to be out if they cannot finish their sentence, you know, there's something going on in their breathing and you need to act fast. If they're a bit drowsy, they don't know what, what's going on. You know, there's something going on in disability. So it's a very good, easy way of identifying. Ok. Something is wrong and where so not a lot of people do this and it grinds my gears but it can also be because it's so busy, it becomes so busy. But you're doing the primary survey, you are in charge of that patient whilst doing primary survey. So primary survey is airway. You check for any foreign bodies, you check for any like gargling sounds or anything else that can obstruct the airway. For example, if someone's in burns, y everyone must have seen Grey's Anatomy by now. Er, 15 or 20 seasons. I can't believe it. I stopped watching after the third season. Er, everyone must have seen that someone whenever carbon monoxide poisoning, poisoning, or burning house and they've come out so around the throat, all of this you can identify in your airway very easily. Ok. Now let's come to breathing, breathing starts off with the monitors. You check in all two saturations. You check uh uh you, you check the respiratory rate by asking someone else to do it. You don't have time to do that and then you start off with breathing. Now, a lot of people jump and see the chest breathing starts with the, with your hands and just like in your respiratory examination, check the hands. This patient have peripheral cyanosis. No, perfect. Go for central, check them out central sinuses. No, excellent. Now, while, while you're doing that in my head, this makes sense because if you go from the hand, you see the mouth and then you go directly to the neck before you go on to the chest in the neck. All you're doing is that cliche examination you're inspecting, you're palpating uh you're percussing an auscultation. Ok. So inspecting to see, oh, are there any bruises in the neck? Is the JVP high? Yes. As an orthopod, I know what the JVP is uh or is there any signs of respiratory distress? Are they heaving? Are they, are uh can you see uh they're, they're using their respiratory muscles right? Then it comes to palpation. You check for the trachea, you check if it's deviated to one side or, or, or the other because you could uh you could, you could uh you could clearly identify if it's deviated. Oh my God. There's something going on in the chest. It's a hemothorax. Hemothorax tension, most likely tension. Now, then you go onto the chest and then what I do is you've exposed the chest. Just the chest, please. But what, what they like doing to patients when they come to A&E is they strip them all down os man chill. It's cold. Just do it systematically but be slick. But once you do more, you have a spiel in your head. Once you do more, it just comes easy. You look at the chest, you look for any flail segments. So flail segments are, if these ribs are broken in two or more places in two or more ribs and what kind of a breathing would I give you? I'll wait for someone to tell me. Is it, is it paroxysmal para paradoxal? No paradoxal paradox. One of them er as mentioned, simple guy. Um don't do, don't do chest, it's too squishy for me. It's basically what you have to identify is because it's broken from here. Here, here, here, this segment will go opposite to the respiratory er respiratory cage. So if the respiratory cage is expanding, this will be going inside. So that is a paradoxal movement. Finally, paradoxal movement that you'll see. So you have to look out for that. You have to look out for bruises. You have to look out for any previous surgeries and you have to look out for any fractures that you could see, bleeding, blah, blah blah, that's your uh that's your inspection, palpation, you go all the way from the clavicle, you palpate all the way down and then you check also for chest expansion and I believe everyone should know this by now how to do it. Then you move on to percussion. You percuss in three different zones or I do it in three different zones. Uh Because of the fact that they are mostly three lobes as far as I remember on one side and two lobes on the other. Uh I knew that much. I've done my M CS guys. I'm not that dumb. Uh So you percuss on what I do is I just, I don't remember which side has three, which side has two. So I percuss three times. One here. One here, one here, one here, one here, one here. That's it. And then you auscultate, same upper middle, lower lobes or lower zones. That's it. Now, that's your breathing done. You will only move on to circulation if your breathing is fine, that's it. Now, in circulation, if your trauma lead is really good, they would have already put two wider cannulas in each of the antecubital fossils and taken bloods FBC s using these. Uh No one likes to do ACR P anymore group and save and cross match. Excuse me already. So that would have already been done. Now, after that, what do you wanna do? Do you wanna give her IV fluid bolus for fun? And then most important thing that, I always forget because it's always done for me. Oxygen. Everyone in airway gets a 15 L of oxygen. No, something happened right now. Which is the most important thing. I forgot a step. But I went back in real life. You can do the same thing. You will be fine. But as long as you are working in a team, someone who would have already done it. But that, that's the most important thing now. And see you give fluids, you make sure they're uh they're uh systolic and diastolic BP are fine. You then you check for the three areas where the bleeding can be hidden, abdomen, pelvis, and long bones because again, I apologize. How much blood can we lose in the pelvis to a lot. I'm not sure they're big. Give me a figure, Mary. Come on a lot. So if I was to see a 7 L in a person uh normal, which is non anemic or, or like, you know how much blood loss can happen with a pelvic fracture? D nulla says 1.5 L in the pelvis. OK? Anyone else have any numbers? I maybe say 1 L. OK. Anyone else? No takers. Uh it's 3 L guys. So this pelvis can take up to three the, the uh the uh the uh the person who's at 1.5 that's in the femur, that's in the thigh. That's why you always check the thigh. OK? So, but Now, can you imagine losing 50% of your blood volume in your pelvis? That's, that's crazy. So that's why it's the most important thing to check. So you do this really cool spring test and if it works and the patient is not in pain, perfect. Uh If the patients in pain, low threshold, you put a perfect binder on. All right. Now, moving on to um uh then after that, there's a very famous term, four places, four on the floor or something like that, but always check the floor as well. The patient could be bleeding and no one has any idea. But usually when the patients uh being transferred, you can do what you like. But uh you can, you can check but it's always good just to see the floor as well. Now, moving on the disability check, pupils make sure they're act er equal and reactive. Same size most important. Now the other thing is everyone says an AU score. E everyone heard of it. Uh So it's like uh it's alert, verbal, it's pain and nothing unresponsive. I like doing G CS. So I just do a G CS really quickly and you've already done most of it in your airway anyway. You know what I mean? Er the second you talk to the patient, the patient call talks back, opens their eyes, blah, blah, blah there and there it's easier for me to do but no one will criticize whichever one you do as long as it's just these two. If you, if you're coming up with new ones that no one's heard of, please make a course uh and uh make it national or international. But that's the thing. Now, after you've done that then comes the exposure part, you don't wanna miss anything, you don't wanna miss any life threating injuries. So don't expose all the patient at once. You expose them in parts trunk first or leg first or blah, blah, blah, blah, blah. And you check all of that and then the adjuncts come in place. The adjuncts are very simple. You put a catheter in. If someone needs uh a or a uh airway, you put that in. Uh if someone needs bloods, that's an important one, you do an EKG and you make sure everything. And after uh uh most of the hospitals have CT scans available 24 hours, you would get a trauma CT scan, which is basically a head to toe ct scan and that usually tells you everything you need to know and they focus mostly on the abdomen, on the pelvis and and in the thorax as well and that's it. But then if you're suspecting a head injury, you have to tell them it's a CT scan. If you're suspecting an arm injury, even a finger, that's a separate x-ray not in the scan because as mentioned earlier, a CT scan is 200 times an X ray. Why would you expose someone to that? Just be sensible? Ok. Now let's go for a secondary survey, as mentioned, primary survey, life threatening injuries. You can still pick up limb threatening injuries. All right. But that's when you, you uh you come in and when you're checking for long bones and you expose parts of the patient, that's when you do it. Now, before you do your secondary survey, this should not be done or cannot be done. This doesn't need to be done in A&E a secondary survey can be done in the ward. A tertiary survey can be done in the ward, but the primary survey should always be done in A&E and recess. That's it. Now, how do you check the back before a secondary survey? You log roll the patient, you check, you take a finger, you go all the way from the ossip all the way to the coccyx and you're checking for three things on inspection. All you're doing is you're seeing. Hm. Or is there any bruising? Is there anything else that I could visibly see? Number two, you're checking to see if there's any steps. And number three, which is the most important thing you're seeing if the patients in pain. Now, the normal thing for anyone to do if I ask you, are you in pain is for you to nod. Now in the airway, this patient will be triple immobilized because anyone who comes in is a suspected c spine injury unless proven otherwise, they will still be moving their head. Yes and no. So I am very blunt. I will tell them, please don't move your head. Just scream out. Yes, if it hurts and that's it. And plain communication is your key in horribly scary situations. If you're being in a trauma call, not the person, not the people doing it, but having a trauma call on you. It is extremely scary. You don't know what's going on and no one's talking to you. Everyone's screaming around you. You have no idea. There's beeps, there's sirens, there's God knows what. It's very scary. So you have to make sure you have good clear communication with the patient from from the start secondary survey. As mentioned, you're just trying to look out for any limb threatening or any other type of injuries. And that is literally as mentioned, a head to toe examination, you go from the scalp ears all the way down to the feet. You don't miss uh you don't miss part OK. Now, as mentioned earlier, other emergencies are very important and I, that's the thing I just wanna highlight. I will not talk in detail about them because I think my time is almost up anyway. But then I will leave you with pearls of wisdom of each because as a sho or a register, you will be uh you will have, you will have to see these. You'll be lucky not to, I'll be I'll be surprised that you don't see any of these, but it is something that you should be aware of. Now, although you talked about pelvic fractures. So I told you that you could lose 50 to 70% of your blood volume in it and that causes hypertension. So you need to know what to do. Very clear guidelines online. Uh And uh and there are standards of what, what needs to be done. You need to make sure this patient is giving trem acid in the first hour. You need to make sure a pelvic binder is on. You need to make sure that this patient is adequately resuscitated and have a low threshold to start the major hemorrhage protocol. OK. And then to treatment the surgery, if this patient has any intraabdominal injuries, you go in with the general surgeons and you pack the pelvis. If the patient has no interabdominal injuries, you ask your radiology colleagues to I uh uh uh to uh ii uh immobilize uh the artery or the vessels causing the damage. So, again, initial resuscitation is the most important in pelvic fracture because we all know it can lead. Just you will be surprised how quickly people drop their age B with pelvic fractures. Then another emergency I like to consider and I hope in the previous talks, you must have been told about this is a fracture with a neurovascular compromise. So this is very important because if it's vascular, you have six hours to fix the vascular injury. If it's torn, if it's just kinked. Uh, for example, if it's a fracture, if it's, if it's just, uh, uh, if it's just tending in and not torn it through, then that's fine, you reduce the fracture, it'll be fine. But then if it's cut, you have six hours near, uh, nerves, you can, you can chill with it, that's fine. But vascular, you just have six hours to fix it or because that can lead to critical ischemia when, when it comes to nerves guidelines, very clear, which is, which is the uh be away standards of trauma. Uh The boost guidelines. If there's a fracture with a neurovascular or neurological compromise, I'll talk about that first neurological compromise. You're taking them to the theater, you don't have to take them to immediately you take them to the theater, you fix the fracture, you identify the nerve. If you are experiencing nerve uh repair, you fix it. If you're not, you tag it, send it to someone uh down the line after you fix the fracture to fix the nerve. Now, vascular when it comes to vascular and there's a fracture. And you know, for a fact that it is a horrible or going to critical ischemia or it's cut. For example, you take this patient the here called vascular. Both of you are going in and you're putting a scaffolding like I mentioned and they're putting a bypass all right now, dislocations are most important. Now, shoulder dislocations are the most common that you'll see. And mostly A&E won't even call you because they would have reduced it and send this patient to your, uh to your uh fracture clinic. Why are hips and knees so important? Now, I'll talk about knees first. I'm going to hip very, very, very, very quickly. And then we'll go into septic because I believe I've been talking for an hour. Knee dislocations are the most important and the most worrisome of all of the dislocations because there is a squishy thing at the back of your knee called the popliteal artery. And if you read any textbooks and remind yourself of how it passes through the popal fossa, it is fixed well fixed and some people say crucified on the femur and on the tibia. So any type of movement that goes uh either or or other way will cause proper shearing of it. And that's why a knee dislocation, even if it's reduced, whatever you will make sure to do a vascular examination and obviously neurological as well as well because you're good doctors, but vascular is the most important thing because it is most likely to be damaged. Hip dislocations are if it's a native hip, meaning there's no prosthesis in it, it's a high energy trauma. So again, we're uh we're putting a trauma hats on. We're making sure that this uh you do, this is an isolated injury but it's a high energy mechanism. So mostly what the classical teaching of the native hip dislocation is uh someone putting their feet on a dashboard and car crash and that causes a procedure dislocation. However, knee uh hip hips aren't usually meant to dislocate because they, you know, they're very, very well fixed. So definitely if it's a native hip, it's broken there, the top of as well. So you have to look out for however, if it's a prosthetic hip, for example, someone's had a total hip replacement and that's been dislocated. My God. I love reducing them in A&E. Uh One of the reasons why I'm in north part is because I reduced one in A&E. And after that, that instant gratification of when you put it back in. It's amazing. But please, please, please give proper sedation, ask your A&E colleagues for help. They are, they are human beings at the end. Even though they chose a horrible specialty, shoulder dislocations. Everyone, uh everyone knows uh how to do it. You must have seen so many movies in which they literally just punch themselves and it goes back in. That's a joke. That's not how you do it. It's a proper mechanism. But again, pain relief and sedation. Are your friends septic arthritis? I apologize. I know my time is uh uh up and I'm uh uh I'm, I'm going, going on and on. Septic arthritis is very important to diagnose immediately. And again, this is a surgical emergency because of the fact that septic arthritis can lead to osteomyelitis if treated on, on uh treated uh if untreated. And then most importantly, septic arthritis will also cause horrible sepsis. So in, in pediatric patients, and I think uh my colleague uh from last time, would have already told you about this, that there's a very good criteria called the called the coccus criteria. You need to know it. There are four things and that gives you probabilities of how uh of how much this patient has a probability of septic arthritis. But then you're not giving antibiotics on this patient. Septic. You're putting a needle in, you're aspirating and then you're washing up. However, if you have a high level of suspicion because of that amazing criteria that you guys all know you're taking this patient to the theater overnight because you cannot wait because the more you leave septic arthritis, the more it will cause destruction of the joints. And uh did I mention sepsis? I did mention sepsis, uh sepsis. You don't want to kill patients. That's not our job. That's all you need. Uh Anyway, this is the most important part of the lecture. Now, f I apologize sincerely, you're gonna be my eyes for this. Sure. Now I have a few MC Qs for you uh because I like to torture people. Uh So just a few, I promise they're very easy. They've, I've talked about all of them if you don't mind. I would really appreciate it because I will feel like I haven't spo uh I haven't spoken to these amazing walls around me and it will be something that I, if you are able to take even 20% of what I've said today. I think I will be happy with the fact that, you know, my, my medical education degrees are being put to use. Now first M CQ, please don't be shy. There's no right answer. Of course, there is one. But I will not make fun of you. Now, what is the most important sign of compartment syndrome? Is it nerve damage? Is it vascular damage? Is it skin changes, twitching of the leg or pain? Please answer in the chat and then I will move on and face. So please, if you don't mind uh answering as well or if you uh if you wanna tell me what everyone else is saying. Sure guys, what would you think a to e the? Yeah, but 25% chance of it of getting a right. Did I say the right? 25 20% 20%. My math is horrible. I'm famous for it. Ask anyone, I promise guys, not more than five minutes left. You guys can resume what you guys were doing, chilling, living life, not knowing about uh chronic heart syndromes anymore, not hearing about chronic colitis syndromes anymore. Anyone I would say I would say e in terms of excessive excessive pain. Ok. Good. Anyone else? I think it's uh I think it's the twitching of the leg. DEA also says e excellent. Anyone else? Anyone else typing? No, not at the moment. Ok. That's fine. All right. It is a very good, very good star students, star students. Yes, it is. Pain. Twitching of the leg. My God, who I or what is that? Skin changes? Come on. Everyone has skin changes in their legs. If you are of a certain age, you will have uh skin changes, vascular nerve damage. I've mentioned there's the last sequel of events and if you have gone that far, you're too late. Now, what is the most sensitive investigation in Cauda ecua syndrome? Is it a bladder scanner? Is it a perrectal examination? MRI scan, blood test or ct scan? Din Din MRI? Ok. Very good. Anyone else I'd also say MRI? Well, now you're cheating things. Uh Yeah, I'm sorry. Ok. So it is an MRI scan. So uh if I just want to reiterate more sensitive investigation is an MRI scan. More sensitive examination is the perrectal examination. It's especially perianal numbness. All right. And bladder scanners, your friend as well. But you know, people say different stuff as we all know, someone said 200 someone says 100 someone says 300. If you open the literature, please don't open that kind of worms, you will hear everything but most likely it is 202 150. Now, what would you do in the first hour of seeing a patient with an open fracture? This answer has two correct answers but one is for fun. One is the right thing. Now, number A is called for help. Number B is check neurovascular status. Number C is give IV antibiotics and tetanus D x-rays E ct scans f splint the fracture again. As mentioned, there's two right answers in this one. I will, I will give it to you. Yeah, then then is gone for a OK. I would say I would say a and you can also think about c very good anyone else. What does rain? I think typing, not typing sha I alone brand. It says a OK. So yeah, I'll give it to you. So unfortunately, this has two correct answers. One is yes, call for help. Uh But then yes, but the basic thing is IV antibiotics. You have to give it in the first hour, call for help is when you see the patient. But then in the first hour you have to give IV antibiotics and tetanus. And uh the standards uh for the post guidelines for open fractures clearly says you have to give this in an hour for like the maximum uh effect of morbidity mortality. Now, what is the most sensitive investigation in septic arthritis? I apologize. I did not uh I mentioned it a little bit but I didn't go into detail because of the fact that I was way over my time but you have five choices. One is blood test, joint aspiration, x-ray ct scan, ultrasound. I think I mentioned uh II did mention it but I couldn't reinforce it. Sorry guys. What's the best way of looking inside a joint looking what's inside it? So then has said B OK. Very good. Anyone else I'd say B Yeah. Come on man. Yes, it is. Joint aspiration. You uh you aspirate the joint, uh knees are easy, hips, you need an X ray, 100% ankles, easy, wrists, easy, but hips, shoulders, easy hips, you need uh you need x-ray. Brilliant. Yes, it is joint aspiration. Very good guys. Now all of the M CS are finished. You guys did wonderful of my talk for emergencies. You have to know what is the most important question, which is who are you going to call all of these emergencies should not be dealt by yourselves. You are just there to identify them. If you have a high level of suspicion for all of these things that I mentioned. You should escalate as soon as possible. If you have uh if you're an F one, you go to an F two or an sho if you're an sho you go to a register. If you're a register, you go for uh you go for the consultant. If you're a consultant, you can ask for other consultants, it's fine. You'll be alright, but you cannot deal with this salon. So you need help. So you escalate and that's what you have to do. OK. Remember your uh friendly neighborhood orthopod? We're very nice, very nice bunch. OK. No, that's my talk guys. Thank you very much for listening. Does anyone have any questions in anything about orthopedic emergencies or life in general? Or orthopedics in general? I will answer to the best of my ability. Yeah, guys, Raina Ivan. D any questions you can place it in the chat if you'd like. You're welcome, Rina. No problem. What's my favorite operation? That is a very good question. Hip replacements and knee replacements. Best surgery known to man. Uh It is the most revolutionary surgery uh, of the century. I'm not making this up. It's actually been coined as it. Uh So yeah, hip replacements and knee replacements. Uh because the surgeries are awesome. Uh The, uh, when you just, uh, uh, when the patient, you see the patient before they're in horrible pain and then after that, you see them again in clinic and their pain is gone. They're walking. Amazing. Love it. So, arthroplasty, uh, hip replacement and knee replacements love him. And I think that'll be elective but trauma if I was to say, mm, I don't know. I think all the trauma, uh I'm all right. But, uh, I'm ok with all the type of trauma. Don't mind anyone else. No one else at the moment. Oh, very good. Very good question. II spoke to face about this before. Uh You guys came on. Uh No, I did. I II never even thought of seeing no uh as a blatant thought when I was in medical school. Uh I was uh I always, ever since I was a child. Uh I think I always wanted to do neurosurgery and uh I'm sorry, I'm gonna make the same joke but it has nothing to do with the fact that my father's a neurosurgeon. Uh So I played with the brain, uh like classic brain models as a child. My first one of my first few books was about CT scans and the brain models, uh and different brains of different animals and stuff. Er, I think, er, after I did med school and I came to the country, I got a job in neurosurgery and I hated it. Uh not because of the specialty. I think the specialty was amazing. I, but I just couldn't fit in, I just didn't think it was me. Uh I just wasn't happy. Uh So, uh yeah, a lot of struggle and I got a course surgical training number, which in TNL. Uh So because I geared all my portfolio towards neurosurgery, that kind of helped me because if you see the per person's specification on neurosurgery, it's, it's a bit crazy. Like why do you have to do it that much? You don't have to. So, uh I got course surgical training and I was in orthopedics. Never did orthopedics before in my life had most of my friends in orthopedics who said, oh, yeah, you look like an orthoped. And I was like, I don't know if that's a, uh, insult or, um, are you trying to, uh, if it does, if that's a good thing or a bad thing but hated my first six months of Ortho cause that's when COVID COVID hit and I was in an MTC. Uh and uh they took us to A&E and they didn't want us back basically. Uh But then when I went into CT two, I was working in AD GH, I met really good consultants, one of which I'm still in contact with. He's a very good, uh he's my mentor. And uh the best part about that CT two was uh the reg would go home and sleep. So you would take care of everything, you would take care of the wards, you would take care of the referrals, you would do everything. So that's what made me want to do to, you know, because after my first year I actually wanted to swap the general surgery, uh because I loved my general surgery placement so much. Uh But then, yeah, so when I, when I did CT two, I think three months in, I was like, yeah, I can't do anything else. Uh You know, the, yeah, that's uh and the rest is history now. Uh orthopedic training. Yeah. Thank you. II wanted to ask what's since, since starting, what have you, what has, what has been the most challenging aspects of the career, uh for TN O and none of it, I don't think anything is challenging unless you make it. Uh So what I had done was, um, firstly, that's a very good question. I think, uh, I still struggle quite a lot with work life balance uh, in the sense that my, uh, my wife is very nice. Uh She's Canadian so she, she, she can't help it. Uh And then I think my priorities have changed quite a ever since my son was born. But can I be honest, as I'm on annual leave, it's the middle of the night here and I'm still giving a talk. So uh like they understand that I can't think of anything else. It's, it's something. Uh uh so I think that's the most challenging part. But other than that, I think everything else I is challenging unless you make it. Uh and II have a very simple uh life, uh have a very simple life like uh a statement that goes on in my head like a mo like a model which is, it's not about extremes, it's about consistency. So if you were, if you worry about your homework all the way at the end of when it's due, you will be, it will be at the extreme of when it's due and you will be in the extreme stress and it's about consistency. If you were at a page a day, you'll be absolutely fine. And then also I think challenging, uh for se three, the second I came in was, oh my God. What do I wanna do in orthopedics? Because there's so many subspecialties. So, yeah, I think everyone would have guessed what I want to do. Yeah. Thank you. That's very insightful. Yeah. Any more questions? No. Yeah, I think. um Yes, thank you from Ivan and Rena. Yeah, brilliant. I mean to hear. Thank you so much. I think that's, that's been a super useful, useful talk for us and and very engaging. Find it quite entertaining and yeah, thank you so much. Um Yeah, that concludes our series. Um I sent feedback forms into chat so um that would be able to provide to her with some, some feedback which is very useful. Um So yeah, make sure make sure those are done. Um But yeah, yeah, also the email as well. Um Yeah, so I'm very, I'm very d with my emails. Uh So anyone have any issues? Anything else? If you guys are U HB students or anything else, you just wanna come have fun or just watch me in action or anything, just wanna have a chat. That's my email more than happy for you guys to come. Uh I'm in trauma week from Monday so you can pop in the mmuh I work in uh the new Middle Met so you can guys, you guys can come in any time more than welcome. All right guys, I'm a head off. It's midnight here, I'm gonna leave. Uh take care. Uh Hope everyone learned. I know it. It's a lot even if it's something I'm happy. All right guys, take care of yourself. Thank you so much. Thank you. So thank you for arranging all of this. It, it was, it was very well done. Thank you. Thanks. Thanks. Bye bye bye.