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Hello, everybody. Uh, welcome to our third talk, um, for the Orthopedic Society. Er, today's talk is gonna be done by Hamza, um, who's our fellow committee member. Um, and it's gonna be on the common conditions of the lower limb. Er, if you've got any questions, uh, pop them in a chat function. Um, it's open to everyone and, um, does it take it away? All right. All right. So, hi, everyone. My name is Hamza. I'm the wellbeing officer, um, for the orthopedic Society. And today I'll be giving a presentation on the common Ortho conditions of the lower limb. Ok. Um, so might as well just start off just double checking. Everyone can see my screen, right. Take those a year. Um, I just can't make this. Yeah. So today we're just recovering the lower limb, um, the lower limb, uh frac normal, your fractures, uh, and your hip, your Ortho uh osteoarthritis and your normal general things you need to know regarding that, uh, as well as some other s um, other conditions that you really need to understand before you actually go into, um, the OS as well as your normal uh, questions for P EQ you got the knee and you've got the foot and ankle, uh, add some radiology through out the slides. Uh, there's actually more radiology on the upper limb as well. Um, things I've highlighted are things that normally come in in exams or key information and if you don't need to me to explain something again, just put in the chart. Ok. That's cool. So, it won't be really going through anatomy cos, uh, I think you just need to know that prior. So before you even start the TN O stuff, just make sure you just go over your anatomy, know which bones, what, what's the function, which ligament is? What, what's the function? Um This is more of a run through, through TN O and more of a fast track. There's more things you really need to know before you go into the exams. Er, this doesn't cover everything. So just use all the resources as possible, use your work or your lectures, pass me and other things, a mix and blend. Everything is what's I think how the majority of people are just stick to one resource. OK. Going on to fractures. So on the right hand side, there's more things that you're familiar with, but we'll start on the left. So make sure you know, you have some fractures, you're transversely linear, oblique, not oblique display, spiral green stick, communicate, communicate. Um you just need to know the classification of each. So you, if you see on X ray, you know what it is. Uh common things on x-rays you'll see is your transverse er your transverse, you communicated if there is a really um like a road tr, a road tr accident, your green stick are normal something you see on Children. So that will go to the PF here um your obliques. So we seen as well, but it's mostly those three OK? For peds fractures. Um This is normally, you'll normally see it pop up on your past med questions or your ques med questions. I would say you'll need to know it uh especially when you go into pe or four, but it's just good to know so you can differentiate between different factors. Um Fracture healing is I ain't gonna go through the explain the whole thing, but you see every year it does come up on every single exam paper so far which I've had. Um we just visited as uh you had a fracture, there will be bleeding inside that area. That's the hematoma. You as a result, the inflam inflammatory reaction comes apart and you get uh invasion of osteoblast os of your class, making a soft callus and a hard callus. And then we get some lama uh um lamellar bone forming over here. And uh as a result, it starts to remodel and you mo mostly get a really strong bone later on. Um This is just acronym that is used, but this is just all self spy stuff you just need to memorize. Um can't really say too much about it moving on to the hip. So this is what we get really or um so there's two types, so there's intracapsular and extracapsular. Your intracapsular will happen around here where from where head is and before the um uh the chant and you got the uh bit and sub, sub and this will all be extra area and how I like to make my life easier. Er is when I look at a fracture in the hip, I wanna see if it's uh displaced or undisplaced. So I, once I find that out, I know where to put in the classification. So for um intracapsular fractures, we use the guard classification, there's a nice visual here. Um I normally have this in my head. It makes a bit, things a bit more easier. So I always think of it as oh if it's displaced or non displaced, if it's not displaced. So it's not two separate bits. I know I gotta look at the power fracture line. If it's complete, then I know it's a two. If I know it's partial, I know it's a one. If it's displaced, then I know if it's fully displaced and it's fully broken off, that's a four and if it's not fully broken off, but there is a full fracture line and it is separated slightly. I know it's a three um in your chin O MDT S, you normally see, er, two and three, you rarely see four. that's more. If you go to Birmingham and read massive trauma centers, you'll be seeing that a bit more. Um, uh, now how are we gonna manage these intercapsular fractures? So, rule of thumb is if it's one and two and your, uh, one and two, and is you're non displaced, so you're gonna do internal fixation screws or hemi arthroplasty. You can see the, er, hemiarthroplasty here and your screw. I don't have a picture of a screw here. But you, um, if you Google it, it's just legit big nail screws which tie the bone together, you're three and four because it's displays, you can do a hemi or you could do a four hip replacement. But the main caveat is that if you mostly have limited mobility, then you do af hi er, four hip replacement, a hemi and, and 12, if you're really unfit, these sort of decisions are normally explained thoroughly in the MTT. So if you get a chance to go into the MDT and TNR, even if it's only one day, um when there will be four edges and going to consultants and other, um, other people around, they'll be explaining why they would have, why they would do this instead of this. So it's good to go to it and just understand why you wouldn't do a certain procedure. Um, otherwise this is just more information about what he is and what uh what total hip replacement is. Just remember, our total is your acetabulum as well is replaced and um people with really severe arthritis. Um And when, because of the actual too much movement and walking with the arthritis, they basically shave down the whole acetabulum. So they normally have a um a um total hip replacement which is new, some new information, which I was just seeing. So I hope that's OK. So overall in intercapsular fractures guidance classification, we either use internal fixation or hemi or if it's displaced, we either use a hemi arthroplasty or for replacement. OK. Moving on your extra couple of factors obviously happen here. So where the line is to the sub uh sub area is this is the, so that we're looking at now if it's stable, uh fracture is stable. OK. Um uh And it's so if it's between the greater uh greater and lesser, we look at a dynamic hit screw. So if we put dynamic hit screw here, it just allows control compression. So it will be like a screw here with some area and some gap. So every so often the uh the actual screw would just slowly tie and push in together, push in together and slowly heal the fracture as well. Um which is actually a good way of actually healing it over the time. It's not too severe and it's, the patient can actually, it's not gonna be too painful for the patient. The sour cho is, uh, just a, um, a nail. It's a big rod that goes in and just holds it together and some reinforcement as well. Um, I haven't seen any of these yet personally, but a lot of people do normally go for this. Like you normally see this is more common than that. Um, the screw is just a little bit more favorable because it's a easy healing and you can track it as well. Um Now we've got an open fracture now on your uh um objectives, uh your il os, you need to know some of this stuff, but I'll just explain what the main things are for your examination. So, open fractures basically is where the fracture is open to air and things can get inside it. Ok? So there can be direct uh direct contact with other things. Um may not be uh others, blood may not be like debris and shrapnel or if you've had a road traffic accident and you've got like mud. Uh and like other body secretions you can actually get on or uh inside the room side. Um It, it's good to understand if it's a or, or how the fracture actually happened. So if it's a in to out or out in, it just makes things a bit easier to understand. Um To always ask that question to yourself. Is this fracture? If something came into the fracture or did something come out of the fracture. So did the bone pop out or did something go inside it and cause a bone fracture? Um Your investigations are just your normal blood tests. Your make sure you do a culture, make sure your group is safe clotting. Uh You'll always do x-ray, sometimes you'll do act. Um, but remember the patient is in acute trauma. So you see a x-ray might be the only thing right now to do until you stabilize the patient. Um The classification, I'm not going to, that's quite, you just got to memorize that. Um I'm not too sure if you need to know the full thing. I've always learned that because on pass, there will be loads of questions on this. Um Just no, the the main thing is knowing the initial management, which I'll go over it. Um So you've got a person with an open function. What are you gonna do? First thing stabilize the patient cos they're gonna be in agony and they're gonna be in too much pain to even say any few words. So make sure you give them analgesia, calm them down. Um And it's basically energies and supportive care fluids because the BP will be dropping and things like that. Um So you there may need some re enlightenment, uh re enlightment and splinting. So you can actually uh stop the bleeding and come uh just stop the, just maintain the neovascular status and make sure it not gets any worse? Ok. And the main thing in your examinations would be a broad stretch of antibiotic, give a tetanus vaccine and make sure that the room is covering the Sal Les. That's your three, what you've gotta say in your, uh, um, in your written paper, uh, photograph the wound as well. Um, you'll always do a photograph before or after enjoying the whole thing. Er, and you probably later on you're gonna need the Bible on the wound. So that's literally cleaning the wound out with all sorts of um uh antibiotics, antiseptics and completely wash out the wound with all the other materials. So it's nice and clean. So for, for good healing and hopefully there's no other infections down the line and, and make sure to stabilize the patient. So by the, by the time you've done the room clean out and the patients are a bit stabilized, that's when they'll get their vascular surgeons in to make sure there's no vascular compromise. And if there is, they'll come into play and start um uh putting things together, basically stitching certain things together and um ablating certain areas of uh plastics will be getting involved for graft over the top. So make sure there's wounds are healed. Nice and um, so nice when you can go out piece, you don't want a massive er, chunk of your leg coming out, obviously. So you've got a nice graft and so it's nice, secure and prevents any further infections. Um, I think, yeah. So overall open hip fracture, you might need to get your head around this, uh, classification. Know if it's an in to hour out in and make sure you give supportive care anergies, your pain, uh, allergies, your fluids, make sure they're nice and stable. Make sure you put, uh, um, and your BP, antibiotics, tetanus vaccine. And the saline goes over the area and from that you might need to do a department, then you can call in your friends or family with the vascular surgeons and plastics to stabilize yourself. Ok. Uh, I can't see no chart here. So I'm just gonna assume, carry on, um, osteoarthritis and another general, um, general things you need to know now. Ok. So osteoarthrosis, um, everyone's seen it how they smelt it. And, um, this causes, and the whole pathophysiology of osteoarthritic did come on our paper last year. Um, you might just need to, it just basically explains the chondrocytes and osteophytes how that occurs. But the main cause of osteitis is probably overweight and overuse. So, if too overweight, it causes two compression, it causes grinding of the cartilage and it causes pain and then if you got too much exercise or person who's physically active, too much, sometimes it just cos sh you're sharing away the, the bone and the, uh, the cost yourself. Ok. Um, uh, your blood test, what you're gonna do is just make, uh, before you even do you most likely you'll do an X ray first thing, but you just do a blood test to exclude any other infected causes. Make sure that there's no sepsis, there's no, make sure you always do a blood culture and make sure there's no infection going on. Um, and potentially if it's, uh, there osteoarthritis in the foot, uh, foot area, you might want to just double check, there's no gout or anything like that. Um, obviously gout presents really much more painfully and it's much more cured. Um, the conservative management, obviously, you say to your patient comes in your, um, lifestyle oscopies, weight loss, physiotherapy, your heat and ice packs, joint, poor analgesic gels, things like a vol. That's what you give to a patient. Um, medical management for osteoarthritis also comes in rheumatology. It's quite heavily covered in that too. But the main thing is you give paracets more paracets which doesn't work, give topical nsaids like Ibuprofen gel, Voltarol. Um, and then maybe later on, you might need a steroid injection and make sure, you know, with several injections that don't stop acronym and the coverage that we, the protective things we put towards it. So we make sure like PPIs, things like that. Um, surgical management is, uh, your last line of osteoarthritis and this is normally it wouldn't be straight away in four weeks. You'll get a surgical replacement. You'll try the all, all options, the conservative man, uh, management, then your medical, um, medical management first. So it'll probably be around 6 to 8 months or maybe, maybe a year before if it doesn't, anything hasn't helped. So, um, osteo osteotomy just cut in shape. Uh Arthrodesis, a joint effusion, but more or less you're gonna see a joint replacement, arthroplasty. Um, ok. Well, well, ok, I thought about that. Ok. So if you look at this X ray, you can just see the osteophytes there, you see the loss of joint space as well. And uh some we kind of see some os chondral cyst here as well. I mean, just remember that when you do your, well, if, if you see a uh osteoarthritis x-ray, just make sure you just put them four points down, you'll get the mark day and night. Um moving on to something that is a bit more year threeish. Um You got a compartment syndrome. But before we go into that, I just wanna OK, when we talk about compartment syndrome, it's your compartments in the areas. Just have a good look at that before we go in. So remember what pressure builds up in one of these areas. And as a result, it's going to cause vascular compromise and neuro compromise all in your vascular bundles. OK? OK. So you've got high pressure in the first compartment and cut off blood flow to areas that need blood flow area needs in the uh uh nerve innervation. OK. And this is normally a very acute problem um, high dramatic trauma injury when you're being crushed or like a car crash or, um, like building sites, things like that. Um, ok. So this is no, nine out of 10 is normally acute, your acute scenario and it's gonna be too much pain for the person to handle. Um, medications aren't gonna really help it. You know, your morphine probably want to handle it. Your, um, your oxyCODONE is not gonna really handle it either. It's gonna be too severe, painful, painful person. Um, one of your main key investigation when it comes to exams and this will probably be one of your um, multiple choice questions is you need et over 40 is very diagnostic. If your pressure is more than 40 in that fuser compartment, then you know it's compartment syndrome. Ok? And let's go with uh acute component syndrome. So how it's gonna present is gonna be too painful for the patient patient. Uh It normally happens on the thigh, forearm feet area, but you all the time you'll see a thigh image to be honest. Um And the five things you wanna look for is your five ps, right? So it's gonna be dis uh it's gonna be really painful, it's gonna be paresthesia. Um It's gonna be pale because of the vascular compromise, ok? There's gonna be so much pressure in there, it might be solid, it'll be rock solid in that area and o be paralysis. Ok? Um On your questions on past meed and ResMed, things like that. The if it's 12 of these peas is le it's less likely but make sure you fix your thinking with the scenario. If you know it's compartment syndrome, it smells like compartment syndrome. It is compartment syndrome, ok? You don't really need to have every single point here. Um And if you how you're gonna manage, this is first you wanna elevate the legs of the heart. So don't put your legs like this. That's a no, no, right? You wanna put them at heart level? OK? So main it maintains BP. Um because all for if you put a a angle like this, the blood's gonna flow down, OK? And it's gonna cause more pressure, it's, you don't need that, ok? And you'll, how you're gonna resolve this issue, how you're gonna remove the pressure is a fasciectomy. Now, this happens in every single um Chicago Mayor episode, I'd probably remember. So the legit poor incision at the leg, probably like three points and relieved the pressure of the leg or the, or the arm or the uh or the thigh. And from that, once they relieve the pressure straight to operating, OK, to make sure there's no um dead tissue. If there's dead tissue like necrotic tissue, they would have to keep it cutting out and then it's cutting suture. That's the main thing. Um Otherwise for compartment su there's nothing else for it. Um They might, you might need to come back to the operating theater here and there on scheduled visits to make sure there's nothing else uh compromise later on. But otherwise it's just make sure you take the pressure. If the patient is in pain, you are to uh make sure they elevate the uh put the leg at heart level and make sure you put the fasciectomy emergency, er, emergency fasciectomy. And from that explore if there's any muscle damage, necrotic tissue. Um I think in a couple of questions, they do put on the like on the blood test, the oh the um it'll be like rhabdomyolysis or there's a lot of myoglobin in inside the blood uh blood test. That's just basically indication for you to think of. Oh muscle tissue is dying. So, ie it is linked to compartment syndrome. That's probably one of the weird questions that you'll get. Again. Obviously, you don't really need to know the compartments, but just for memory, you just know that there's an anterior compartment, uh superficial posterior compartment and you know that's the deep posterior compartment. OK? It it helps when you're just trying to monitor around uh what the what the stents saying. OK. Now we've got another weird one that happened that is very year threeish is Osteomyelitis. Um your stems normally will have someone who's probably like a IV drug user or who's had recent um surgery. Excuse me. Um It's a bacterial infection. So obviously your uh inflammatory markers are gonna go high, there will be all sorts of different bacteria in your blood films, things like that. You might have that on your stems or questions. Um by this is a direct contamination of the bone. Ok. So normally post orthopedic or operation post, uh I and then let me know to be a high drug user. Um, it will present like an infection like fever pains, um, redness in the area, but there will always be some swelling as well. Um, risk factors is your open factors, orthopedics, prosthetic joints. Um, it's a big problem for diabetes patients, IV drug use patients and immunosuppression, immunosuppressed patients. But that's with every single, more or less, every single orthopedic uh or any sort of operation. There is, um, you're more at risk if you're more immunocompromised. Ok. Um, with your diabetes, uh you diabetes, things like, um, diabetic foot ulcers. This is what you want to be wary of. So when you do your foot examination, uh or your os, if it's, if they say, oh, this person has an ulcer, you go to the examiner says, ok, I'm doing, uh, I'm just feeling the temperature with increased uh increased temperature in the area to see if there's any signs of osteomyelitis. That would be the one of the key indicators. Um, uh, investigation wise, MRI because you can see the tissue as well as the bone. Um, and you obviously your wi your blood tests are all gonna be all over the place. So you make sure you do a blood culture and your C RPS probably gonna be high. Your white cell is gonna be there as well. Um You do a bone culture just make sure the bones are healthy or not. Um But when it comes to management, this is what you need to know. 100% is surgical department is the main thing. So cut the area open, clean it out, make sure there's no other infer infectious material and suture it back up. You're gonna give six weeks of fluxil and you might wanna give her rifampicin. But just remember, fluoxil is the main one and because with all infections with all POSTOP problems, your infection most likely won't go with the first round of antibiotics. So therefore you might need to know your second line. So just remember your ficin or your clindamycin. Um Yeah, I can't really see this because it's blocking the window. But um quite mostly in my life, I just need to know about it. It mostly happens with people with prosthetic joints. Um So just be wary uh if the pa in the stem of the history, er, if the person has a prosthetic joint or not. Uh So, ok, osteomyelitis run that up is infection to the infection and inflammation to the bone, most likely POSTOP. Um or things like diabetic falls is, is eroded into the bone. Uh You're gonna do an MRI, you're gonna do a blood culture according to your normal bloods to see what's going on. Main story of treatment is your surgical department. Antibiotic therapy. That's the main thing. And remember it's not always gonna go, the infection is not always gonna go away with the first round of antibiotics. So obviously you just remember a second round just for a reminder, just think of a fic or another big antibiotic. Um OK. Septic arthritis. Um your classic uh um you're having some of your scenario situations, your acute situations uh inside your med block or your ta block. So, arthritis. So you've got infection in the joint and it's the same thing if it looks like it looks like septic arthritis. If it smells like septic arthritis, it is gonna be it. Ok? So it's normally gonna be a staph infection, but you don't know that until you get to get the blood culture done. Um, area is gonna be red hot. It's normally gonna be unilateral, it's gonna be slow, swollen. Um There might be some itching exploration around the area as well. Uh And it's gonna be painful to the touch, it's gonna be hot to the touch. Ok? Um And you won't be able to bear weight on it. So the patient will be limping or they will just be sitting down, be uh wary if the patient has any fa pulse like chemo or if they're going through, uh if they have diabetes or if they've had, uh, if they're IV drug user or they've had a replacement recently, your scenarios normally do have some sort of either immunocompromised or they recently out of surgery. Um, make sure you do your routine bloods, your FBC user using these C RP, uh your urate for gout just to cover that. But your main thing is your sepsis. Six. So give three, take three, for the actual, um, culture wise, you might wanna do a fluid analysis as well. So just aspirate the fluid, aspirate the joint and you're gonna come stand and culture to see what it is. Um for all your scenarios in the future and all your differentials if they ask you for investigations, just always say, do you do a BJ? Um You, you always get that lactate. Uh That's just one key thing you just got to remember cos it always comes up in some question, a follow up question and ask you. Um obviously you do sepsis six. you give your antibiotics given them over to 4 to 6 week. No, normally you'll give it an IV. Um If it's a infected um joint, you'll probably have to do a debridement and wash out. It depends if the if, if you see improve, if you don't see improvement in the actual join. Um Otherwise it's quite uh self-explanatory if you see a red hot, single unilateral joint recent and you are uh immunocompromised Ring. The alarm bells. Think of sepsis, do all the rest of investigations of that and give the, and make sure you always do your, your samples, then your antibiotics and just make you escalate. Um, yep. Cool. So, for the knee now, um, this is basically all the stuff you need for the knee. Um, some of the main ones that you'll get, um, questions about ACL. Um, so your ACL, obviously you just go back to the anatomy if you don't know what it does. Main thing is prevents that anterior um mo um translation movement. OK. So if it's your joint, this is your knee starts you moving that way. OK. Um How can the ACL tear if you're doing? If you're higher acceleration, you suddenly move on the weight bearing knee, you can snap um sudden twisting on the weight bearing knee, but not in static movement. Uh how it's gonna present. So, the key thing you wanna look at in a history in or in the stem of the question is to know how fast the swelling started. If it's a rapid swelling, your alarm should be thinking ACL if it's more, a long time, took a couple of hours, think of more medial collateral ligament, that sort of area or your meniscal tear. Ok. Um When it comes to your examination on your Aussies, um even if it, if the scenario doesn't look like it's a AC LTAC L tear just always offer to do these two, special tests. So you do a Lachman's test. Er, I've included two links on the next slide just to make sure you have a good, uh, look at it and make sure you practice it as well. Cos the examiner will know if you've practiced it before or you haven't. So once you put pressure on the knee and you move it, um uh you put anterior movement on it, anterior pressure and if it's pain, then you've got such high suspicion. And once you do the anterior jaw test, uh where you bend the knee and you put pressure and you push it up, er, that is a more sensitive test towards ACL tear cos there will be really acute pain, um investigations for majority of your knee, uh knee problems. Uh MRI is gonna be gold standard, ok? Because not, not only we can see the skin, we can see the bone and we can see the ligaments there, ok? And you know, your ACL always um is near the, your fibula, you can see it, just remember that's your landmark. So you know it'll be there. If you can see that broken bit here, you can see it here. That's your ACL, ok? Um You won't be really given an MRI to look at or CT S like I almost would be a uh x-ray for your things with regarding the abdomen. That's when I'll say to make sure you look at a lot of abdominal uh CT S uh MRI S. OK. Uh For TN O it's mostly x-ray. So how are you gonna manage your ac alter? So make sure you rice, you rest, you rest that leg, you ice that leg to calm down, that swelling, you compress that leg to calm down. That swelling. You elevate it to make sure the blood flow is moving. Ok? OK. Your conservative management will just make sure you do physiotherapy rehabilitation. You've got strength of quad steps, uh, because you don't, you don't wanna have muscle wasting. Ok. And there'll be like a quicker pad, knee splint for discomfort. Um, your surgical management is gonna reconstruct it with a graft. Uh, if it's really acute problem, you might wanna, um, suture the whole thing back to together. Um, then it goes together. Um, I've not seen one of these before personally. Um, but I was warned that a lot of patients even once they have their ACL repaired and they go back to and they have the post, uh, surgical, well, um, post surgical regime of physiotherapy and rest and having time off school or something like that. They don't, normally, sometimes they don't wanna go back in it because they have posttraumatic osteoarthritis. So that might be one of these scenarios that patients still has pain in their leg and a crying sensation in the leg. Post ACL injury, posttraumatic osteoarthritis should be alone. Bells ringing. Ok. Your PCL obviously, is your more of a more of the greater stabilizer in the knee uh prevents the poster poster translation. So, and your hyperflexion. So that way, uh um it's more of a high energy trauma. Um you have more knee pain, swelling does happen, but it's not as, as, not as fast as swelling compared to ACL. ACL is quite dramatic, sudden onset um swelling. Um your investigations when you do, I mean your examination, you also look for posterior sags, you get your both your knees together, put them in a bend position. So if this is your knee, you look at it, you look at it from this point of view. Is there any sag with that knee? Ok. And you also do um just do Amri as well, OK. Uh But when you do a posterior jaw test, when, when you're pushing, uh you're pushing forward and pushing backwards. So make sure ACL ACL, OK? Um MRI are your main thing because your AP cell is so thick and is the major stabilizer and is more likely to tear again because uh if you do, if you did not, if you just put a normal suture in, it's more likely most likely to tear again. So therefore, you're most likely to put graft inside to just replace the whole PCL. So the graft just put in there. OK? Um Your M CL, your uh medial collateral ligament is one of the most injured um ligaments in your knee. OK. So your MCI remember is your medial cholesterol ligament. So it prevents your valgus. Um It's a virus stabilizer. So here's your knee, here's your knee. Here, here's the lateral side, your force pushing this way, it just prevents it going in. OK? For your virus trauma. OK? You'll hear sudden pop. If that M cl goes, it'll be swelling a couple of hours later on the joint line, um will be disturbed as well. And this word laxity that's here, I'll go into that again a bit, uh, a bit later on. OK. But there will be joint laxity or in fact, in, in common sc Yeah. Um, how we're gonna grade? OK. How are you gonna grade your M CL injury? Is your grade 123. Just know that one. There's no loss of M cl integrity. Everything's OK. You've just been, it's just injured two, there's increased laxity, there's a morbid tear three is there's a complete tear, er, and there's very, lots of laxity in the joint. OK. Now let's go into special test, your s test when you put pressure on your leg, when you put pressure this way, uh your pressure moving this way and this way there will be a gap here. OK? There'll be, you'll see a gap this opening here. If there is a gross laxity and there's lots of gapping, then we know there's something wrong, it's a complete tear. OK? But the only way when you do your OSC and you do your knee examination, just say, ok, um If there was gap, then the patient, if the doctor says, ok, there's increased gapping inside the um media on, on the lateral area or the media area. Just not how you always say that. Ok, I'll do Amri MRI to confirm if there's any um injury uh if there's any uh complete tests. Ok? Um With your how you on protocol for management is a bit long to remember, but it's kind of the same thing repeated three times. So you create one injury where there's just basically not really any, just slight minimal tage, you're just gonna give you topical nsaids. So, obviously your, uh, Ibuprofen gel or, uh, anything similar to that and rest and exercise or rest, the physiotherapy and return to normal activity within six weeks. Your grade two is a bit more. Um, you put like a knee brace on it, on the area and you make sure you do your physiotherapy rest. It takes about 10 weeks. Your grade three where you got complete, uh, is where you're more likely to get avulsion, er, a distal avulsion. Uh, and you might need to do surgery for that. That's, uh, sometimes they explained to the MTT. If you might have one in the MDT, they might, uh, you might wanna ask them some questions of why they've done certain things. So why they did surgery on this patient? They said compared to this patient with a grade three injury. Ok. Um, it takes the longest to get back to recovery you do for out to, um, so you do physiotherapy, you rest as well. Um, go back to normal. So just remember 6, 1012, that's it. Um, the main reason why M CL injuries are so important, um, to make sure they're, uh, they're stable because if your M CL goes and you've had a repair, but it's not completely done. You had, had the appropriate physiotherapy or you haven't had the appropriate regime to get back to normal. Um, you're more risk of falling head injuries and that and damage the stuff now. So that's one of the main things you'll be worried about your meniscal tears. Now, uh I think it's the last one on the knee itself. So your meniscus here is your main shock absorber. All the pressure that you put down in your leg is gonna, depending on that shock in that shock absorber there. So the impact is taking all that impact. Ok. Um, this is normally to, um, mostly younger patients. I've only seen one person and the person, I think the person was probably around 25 to quite young, um, presentation is that it's just gonna be a tiring sensation, a sudden onset. There'll be swelling, there'll be tenderness, uh, there might be some redness as well, but the main thing is that they'll be locked into flexion, so there'll be flex, they won't be able to extend their leg. Ok? Um The main thing with meniscal tears is how you're gonna diagnose the, you do a test and you more tests, um, to get these right is a lot of practice. Um uh, yeah, if you get these right, there's a lot of just make sure you do it properly because they'll know if you've practiced or not. Ok. Same thing with the other knee examination. So after these tests, you put compression, you lay them down, stomach down. OK? Um You assess if there's any clicking sensation on your pain. So you put pressure down on the leg and you turn it left and right or pressure and you uh put the foot up and you twist it left and right to see either the medial or lateral. Um So um meniscal tear to confirm, you'll do a mcmurray's test and you put the leg up, you twist it as well as extend it up. That twisting is uh to test if there's any uh any uh twisting sensation or any tears along the area and extending it will cause pain. OK. Um Remember you're putting a vuls stress on this area, OK. Uh I know I do various tests to stress. You do uh various stress to test opposite sides. Um Again, Google it, youtube it, how to do it properly and see it done as well. Uh on the assessment units. Um Again, MRI to confirm your examiner, your er physical examination uh, if you tell that's the one centimeter, then how, you know, is one centimeter, is that one centimeter, you know, on the, uh, on your, um, MRI will be on the notes. Ok. Less than one centimeter. We've had your just rest ice, ice and compression and elevation for your large meniscal tears. It will be arth arthroscopic surgery. Uh, most likely it will be, obviously, um, if it's a larger, if it's a larger tear, maybe some sutures may uh maybe trimmed down if it's a smaller tear. Um But your main things are your things like uh to look out for pulse and um post surgery, especially with all um knee uh knee uh surgeries, the DVTs, make sure they have the prophylaxis. Um make sure you always test the neuro uh uh innovations do a new exam, pre uh pre and post and also just make sure you just check the pulse and everything like that. Everything, there's all nice blood flow to the. So there's no damage. Um So, yeah, so obviously, meniscal tears, it's a tear on the lateral or medial side. You won't be able to weight, bear pain on uh any extension and flexion because if you lock into flexion, it's quite tender, um, you won't be able to wipe out all you do a test and he test after test, you're putting pressure on it, moving the leg on the, um moving the legs or the knee has pressure on it and, uh, test you put vs and various stress to test out if there's any sort of positive signs. Always do MRI to confirm ARSC surgery sharing down the meniscus, we are suing some areas in that would be the main area. Um, before I go on, just a reminder with, oh, your TN O, your general surgery and just the whole surgery block. And so a lot of your, um, marks come, uh, within the OS Q and the actual S PSE Q come from, uh, how, uh, it's your POSTOP, POSTOP complications. So, if you really go through that, you'll be quite set on the exam, to be honest, because there's a lot of questions or POSTOP complications for every single may that be general surgery or TN O. It will be a lot a marks come from it and there's a whole quest, there's a whole station, endoscopy for it as well. Um, let's just youtube just actually see what the links are. See how the examination are the ankle and foot were near the end of it. Um, these are your main ones. Um, there are some other ones but these are the main ones. Ok. Um, yeah, cool. So, a tendonitis and a, a tendon rupture. So if you are painful back heel and it's red and it's causing you a lot of problems, it causes a lot of problems when you plant off flex or plantar flex, you're planting your foot down and you what you're doing every time you're planting your foot down, it's causing these micro tears. And after that, it becomes thickened fibrotic because obviously, inflammation happens, your body is trying to repair itself. Um, it loses the elasticity, the width black feature. And from that, you're more risk of terror. It, you're more of risk factors if you're obese, if you've got really poor foot by choice, uh, if you're quite unfit as well. And obviously your past med classic question of ciprofloxacin causing acute tendinitis. Um, you're more at risk of tearing it. Ok. And for Gleason is the only thing you can really do is your painkillers and your relax and ice. Um, for all your en topical nsaids, just say a topical ibuprofen. You don't really need to put a percentage, er, on it, to be honest, uh, at this stage. Um, now achilles tendon rupture, so achilles tendon ruptures quite sudden. Ok. Um, it's when you put a lot of pressure on it and it causes it to basically snap. Uh, it, sometimes it doesn't really snap fully like that. So like just like a tear. Um, so before you do like a jump or you do it while running, that's the classic sort of scenario. Um, uh, so sometimes it's like a popping sound like something went like, oh, my leg went, that's a popping sound. Um, but to be honest, you can, if you're running at a really high speed and you're not gonna really hear your leg, your, the tendon pop, but it's one of the things they put in your stent, ok? Um On examination the power when they're testing your power of your leg, your plantar effects and power is gonna be non level, ok? Um And the classic test is yours test. So you put the patient lay down, your feet are hanging and you squeeze the calf, ok? Once you squeeze the calf on the one that's not affected or causes the plantar legs and the one that is affected, there will be no plantar flexion. So here on, if you can see your mass, OK? Because the tendon is so close to the skin, ultrasound is sufficient. OK? You don't need to just waste time and money on a CT unless there's a problem up upwards. OK. Um How are we gonna manage this now? OK. So this is another again, one of the low management plans that we need to know and is this word about equinus is where you need to wrap your head around it. So the initial management for two weeks. So obviously, you give your analgesia for the patient, um immobilize the that area, but you're put in a full equinus position. So if you think about equinus, it, bring your panel, give me one second if you can see my camera, see how it's like that in that sort of position. It's stuck in that situation. It's put all the way down. It is and you most likely to be on crutches, cos you can't walk like that. Um, just so it heals up. Ok. After those two weeks are done, you put into a semi equinus. So it's more or less than halfway. Ok. And that's held for around four weeks now, for, at this moment in time a lot. Uh, you've had two weeks, you had four weeks or four or five seats, you around six weeks. Now, if there's no improvement, they might wanna put again for another four weeks. But, uh, in ideal world after that, another four weeks you pulled, er, your legs, your foot is in a neutral position. Now, held it for another four weeks and by that time your basic, your, your tendon will be more or less fine, uh, with the additional physiotherapy and uh other exercise for you. If you have a delayed presentation and you've had like a la delayed presentation, you might wanna go straight through surgery or if you've had like this poor chap, this whole thing's completely tear is completely snapped. We're gonna do a full repair. Ok. Um, I hope that's ok for a case tendonitis. It kind of takes once you do when you do questions, it gets a bit confusing. I'll be honest. Um, but just go through it, watch videos and it will be mostly OK. Uh, angle fracture. So this is your classic question that comes out all the time. So let's break it down. So angle fracture is just three types. You very well, this classification, OK. You're always gonna do a AP X ray. Yeah. Um You're always gonna assess when you get that fracture, you're always gonna assess the neurovascular. Um Well, what's the neurovascular situation? Is there any problems or the lack of sensation in the foot if there's any lack of appropriate reception or can they feel the vibration? Ok. Uh When you do that opportunity and foot uh is the blood flow going around? Is the refill time good? That's what your first thing we look for. And there's what about this thing called a syndesmosis? OK. Your syndesmosis is basically a fibrous joint here. OK? Your fr joint and your classification rotates around where the fracture is around the syndesmosis. So we a is below the syndesmosis. OK? See that's there. And this is your least type your least serious fracture. This is your type of fracture where it's OK? It's calm, it's blessed. You're just gonna relax, you might wanna put AAA cast around it. Probably not. And a little bit of physiotherapy and relaxation will be good. OK? We be, and we see this is where it gets a bit more problematic. Your, we be, if it's more complicated M MA is at the SSIs, OK? It's at the level. Um If you think they set a rule of thumb, if you think the, if there's a webers be just double check, go, make sure you go back to that question when you do exam to make sure you know that it's not build up above the Syders, just make sure you wear your glasses and look at it properly. Um, so if it's at syn desmosis is most likely gonna be conservative management, but we's BS tend to sometimes because of the, where the fracture is, is most likely to be more problematic. We kind of do a surgery instead like a sea. We have AC management. OK? And whoever c is obviously, it's in as much as here and it's way above which is problematic. You're gonna go into surgery. End of story. Um Your management obviously check the neurostat uh before try to reduce the fracture as soon as possible. Um If you go into like, um if you ever get the chance to go into A&E and things like that, you might see 12 reductions, it's probably mostly on the hands, but you never really see on the foot. Um In my, what I've seen um just to realize the fracture, but remember if you do a reduction, you check the neurovascular neurovascular status again, OK. You do your X ray again, uh always um monitoring what's going on, basically writing down what's going on, what's the patient had. Uh So that's a complete story. That's how uh when you look back on it, uh put in a below the knee back slab to support it and just obviously replace the uh redo the x-ray conservative management. So A is um sometimes b well, you explain that uh they're not really fit for um those are not fit for surgical intervention, but to be honest, this is less serious. OK. You know, your B and C is your open reduction internal fixation and obviously just to achieve a neovascular neovascular state, uh neovascular sound, um we call it uh post um surgery. There's fire, what's going on. Um Yeah, so these are normal what you would do for ction, internal fixation. But first remember this is the one that's gonna go to surgery. Ok? For opioid reduction, internal fixation, that's basically what we need to know because every opioid induction, internal fixation is different for every single joint. So just know it has induction, internal fixation. Um I hope that was ok. Um It sound, it looks too uncomplicated than it should be. But just me just keep, if you keep it simple, like with everything in TN O, if you keep it simple, you'll most likely get the mark if we try to complicate it. Um You'll just end up shooting yourself in the foot, ironically, um your foot fractures. These are your normal, typical multiple choice questions. So make sure you just take a screenshot and close occlude it on your, on your anky or something like that. So you do you live fracture? Just think of it as oh, something's fell on my foot. Like, I don't know, like a massive person just fell in your foot. Oh, no big, uh, machinery just fell in your foot, multiple fractures to the area, multiple bruising, very painful. Always check the neurovascular compromise in that your Jones fracture. Um, if you wear high heels and you tripped up the stairs, made it fool yourself. This is what kind of your situation is gonna be dealing with fifth metarsal fracture. Your stress fractures are. You normally see them in like, um, M Ma fighters, you see them quite a few in M MA fighters. It's basically like your, the opposite to the boxer's fracture in hand. Um, you'll see like colors for, but it will be like a line here. It will always just be a line. It would really be, you might see 12 odd bits of, uh, bone, but normally there's a nice line. Ok. Uh, your Carneal fracture now is when you jump from a height, it's not jumping from a curb. You're jumping from somewhere like around 5 ft 6 ft and you land straight on your feet, uh, or like you land on your heel, um, at the moment and, and it's quite dramatic, you can just see it, it's day and night, you can see it and I think that's ok. We got one more left, ok. By the way, I hope that's all. Ok. You, that's all the information, you know, for the, uh, you, you're gonna need to know for these. You don't need to know them too in depth. They give you M CQ questions, your, your multiple choice scores, again, multiple choice, the classic ones. But um, a little bit of information more about these, your, all your toes, your toe problems, sometimes they can be environmental or genetic. Ok. So your curly toe is most likely to be genetic, but your mullet toe is more likely to be environmental. So, um, if you work on a building site, um, if you're in a country where barefoot is quite normal and you get caught, if your toe gets caught. Um, I actually don't know if these two are environmental or, or gene genetic. I think the claw toe is more genetic. II would assume. So I again, screenshot them, make them into closed collusions and make sure you know them. So once you see it, you know what it is. So it's, it's the one to little extra marks ending points about this and know uh scenario. Now, um, uh, it's just make sure investigations know your specific in the investigations. Remember if it's like the knee, you're always gonna do MRI if it smells like compartment syndrom, use a needle mammetry, test the pressure. Um If it's, you're thinking infection in the joint, you're gonna be thinking, ok, get your sepsis sick. I need a lactate and I need a blood culture. I'm gonna aspirate the joint. Ok. Um, go to your fracture clinics. Go to your fracture clinics, uh, go to your fracture clinics. Yeah, I'm sorry. Um, and go to your MDT S as well. Um, if you go to the MD tube, you're basically gonna be covering TN O from start to finish. Ok. In terms of that specific area. So they will go through the, what the patient's history, they'll go through the X ray, they'll go to why this surgery and why not that surgery. And they'll also zoom in and see the, uh, things that you may not see within your inexperienced eyes when it comes to looking at radiology. And there's always gonna be more than one person's opinion and one person explaining things, which is very good for someone who, if you don't understand where someone's highly, who's very good at that subject, you don't really understand what they talk and talk, how high on the board, there'll be, always be another person who will kind of dumb it down for you. Um, and obviously once you've seen up, seen all the X rays and see the management and what they're gonna do to the patient, you will nine out of 10 will see it on the day. You'll see that patient next, unless there's some complication, which is always good. Um, that's all ok. I'm gonna stop sharing now. Ok, I'm gonna stop sharing that. Um, I hope that was ok. Is there, is there any questions or anything like that? I don't see anything on the chest. Um No. Well, hold on. That was a really, really good, really good talk today. Um, it's just took one question on whether they may recording or slides. Um, and yeah, so after this session, uh, it will end in a minute and then, um, we'll put it on, onto our on demand section on our page on Medal. Um, Hamda has also got a feedback form, um, uh, which I've linked in the chat. So you, if it would be great if you could do that as well. Um, yeah, any closing remarks. And, um, not really, I think the only thing just remember with TN O is the same sort of management. I mean, same sort of investigations for each of that area of the joints. So your hip is gonna have specific investigations, your knee is gonna have specific things, your ankle gonna have specific things and with TN O, it's just, you don't need to know it too in depth, you need to know, to know the, the story of the patient. Ok. And the main thing, it's not too many points, it's not like general surgery where there's just too much, too intricate details. Um, but overall there are, there's gonna be another session on upper limb most likely next week, but we'll put that on the Instagram. Yeah, it'll be, it'll be next Thursday. Um, if that date works well. Um, and, uh, we'll go over the upper limb just how we did lower limb today. And er, yeah, spread the word regarding the or peak society. We already started last year. So, er, up and coming. So spread the word around, bring your notes and leave some feedback on that form and we can hopefully adapt it to how you want it. Lovely. There's no further questions. Uh We call it a day and enjoy the rest of your evening. Thank you.