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Hi, everyone. We're going to get started. Thank you so much for your patience. Can you just give me a heads up that you can hear us if you just write in the chat? Um You can hear us and everything's good from our side. Thank you. Ok. So today we have our second webinar today for trauma and orthopedics presented by P Society by our guest speaker, Doctor S Raj. And he's a graduate from King's College London. He graduated in 2021. And since graduation, he's pursued an interest in trauma in orthopedics. He is currently act two surgical trainee working for the West Midlands scenery, which includes Warwick and Coventry. Since um graduation. Um SID is actively involved in clinical academic and educational side of trauma and orthopedics, which includes nationally regionally and we're very happy to have him international today as well. So, thank you so much for joining us and thank you doctor for um being happy to present this webinar for us. I'll let you start and at the end, we will have a feedback form. So if you guys could kindly um fill that out and that will generate a certificate for your attendance. Thank you once again and we can get started. Cool, thanks Tina. So, um for having an introduction, is there a bit of a, oh, you can just or know in the chat? Um uh I've just been having issues with trying to upload my phone to um metal website. So the way do you want us to present from us and then I'll have the chat off on the side, uh, so we can present. No, no, it should be fine. Ok. Uh Yeah, if, if, if, if you're able to present it, that'd be good as well. And then I can just click through it. Yeah. Uh, you won't be able to click through it. You'll just have to say to Julie, um, if she can click through it, just say next to her. Ok. Brilliant. Let's get started. Thank you. Can everyone see the, the first line? Oh, all right. Um, so we'll just go on to the next slide. So, uh, I said, I may see you two as, um, he knows currently said and we'll talk a bit about, uh, three separate things in this talk. So an over view of ics, which is the se especially of surgery that I'm interested in. Um, and then we'll talk about the NHS in particular as well. Then secondly, I thought I'd give you a bit of a flavor of TN O. I'm not sure what sort of stage of training everyone's at. So I've sort of pictured at a level where it's a bit of anatomy, a bit of clinical knowledge and you'll see how, um, way in, um, the field of trauma in orthopedics and in, and in surgery in general. Then thirdly, if you are interested in d in specific, uh, specifically, we can, um, chat a bit about how to prepare for a career in t, in the context of the next side, please. Um, The side, II can't see anything for this particular side but can uh what stage of training they're at what year of medical school or if you're a doctor? Um if you're preclinical or um in your clinical years, that'd be good to know. So while, while you guys typing that, let's talk through this. So to or to orthopedics is one of the largest specialties in the UK National Health Service. Um It's only behind ophthalmology in terms of uh being a treatment specialty with the greatest number of attendees. So 6.67 million um in appointments are made per year in the NHS. For in the UK, there's a population of 67 to 70 million. So that's 1% of the population being seen in the UK NHS for term and orthopedic conditions. So it's huge. Um MS please. So if, if we have to divide it up, um there's really two aspects to t so in the management of fractures and emergencies, conditions like of joints. So septic arthritis, that would fall under trauma or an emergency. And then you've got the elective side, um the orthopedic. So, elective procedures such as joint replacement, um deformity corrections in pediatric patients or even in patients where you're trying to preserve their functions such as in um knee deformities as, as you age, try and decrease um the need for arthroplasty or at least postpone the the need for arthroplasty, which is joint replacement. So this image here on the left shows an example of um a dynamic hip screw, which is a procedure usually done um for fractures and then on the left uh sorry, the the left being the image on the left and that's actually a right hip and then the image on the right being a left hip, which shows a total hip replacement, which is usually a procedure done in the elective setting for people who have arthritis of the hip. So um that's sort of the two aspects of to. So please, um so with TN O in the NHS, you'll see patients in primary secondary and tertiary care. So even if you don't decide to do TN O, and you decide to do one of the other specialties or even um um general practice, which is a primary care, you will see a lot of patients with musculoskeletal presentations. So it's worth knowing about this while you're in medical school and as a junior doctor as well. So um 21% of all practice conditions, um, are musculoskeletal presentations next, um, side piece. And I think one of the cool things about TNL, uh is that it's truly multidisciplinary specialty. So you'll be working with anesthetist in theater intensivist. So itu doctors, when you've got sort of patients with major trauma, they're admitted in ICU. Um, and they're, they're seriously unwell and you need to find that balance between damage control sur surgery and sort of total care um orthopedics. So, um so they've come up with early appropriate care where you liaise with the anesthetist itu and you do the right amount of surgery without sort of causing further harm to the patient in case of polytrauma. So multiple limb um and life threatening injuries, you also work closely with nurses to make sure patients are safe um before they're discharged. Um Plaster room technicians do AAA great deal, especially in the fracture clinic setting. Um They're the ones who will put on really nice plasters that are um and without making a mask usually better than uh I as a junior doctor, then you also work closely with um primary care doctors such as GPS and um radiologists as well. Sometimes when you need um inter interpretation of specific scans as well. So it's a, it's a truly multidisciplinary specialty and um ii don't think you get to miss out on much by doing this specialty. Um Next slide, please. So we'll move on to thinking about conditions and having looked through the comments, it looks like a few clinical years, third year, I assume is sort of on that cusp between preclinical and clinical. So the key conditions, you know, so this is um this is really a graph um or a figure from the British orthopedic Association and it again, it divides up trauma and orthopedics into TN O. and within that the, the sort of branches that are coming off orthopedics, you get to see all of the subspecies that are there within it. So if you're ATN O consultant, which is what I aspire to be one day. Um And if you aspire to do TN O, that, that would be the same for you. There are load, there are loads of different specialties, subspecialties within the field that you'll be exposed to while in training and then you will also get to subside if you choose to. So it's from top to bottom the spine. Um So upper limb that can be divided into shoulder, shoulder and elbow, then the hands or hands and wrists. Um We've already spoken about the spine. So then you can focus on the pelvis, pelvis and acitab, um hips, hips and knees. And then you've got things like soft tissue, knees or soft tissue, uh shoulders as well, usually for athletes or things like ACL or cuff injuries. Um and then you can go on foot and ankle. Some people focus on P and bone tumors as well. And that's another sort of subspecialty within t so huge range of things. And you a bit of a flavor of each as you rotate through training in Children orthopedics. And if you, you like a particular specialty, you try and gear yourself up um through research in that specialty. So, next slide, please. So I thought we'd talk about some case based discussions just to keep it a bit education and, and if you haven't really had any exposure, exposure to KN O so far, I thought it would be nice to just go through this. So this is an X ray. If um anyone would like to just post on the chat spot, diagnosis, bonus points if you try and sort of describe the x-ray um in a way you would in a sort of trauma meeting a anyone, any ideas, what's, what's happened? Yeah, it's, it's enough. Very nice. So, w what kind of kn is this anyone? We'll, we'll give it a minute and then II can crack on. Yeah. Very good. That's a really good description of it. So it's transvaal. So through the neck. Um and this is an intracapsular um neck fracture and the reason I brought up neem fractures, it, it's technically intracapsular and, and we'll, we'll talk about why as well. Um So if we go to the next slide, hip fractures, I thought would be a really good way to sort of get you into an idea of what um managing trauma in the, the UK NHS is like. So hip fractures are one of the most common injuries here. You have 70,000 people sustaining these almost every year. Um They usually need to be admitted to trauma. Then it comes into that multidisciplinary team thing that I was talking about where you also have Ortho geriatricians, which are medical geriatric, do doctors that focus on patients and sometimes after surgery as well to try um further injuries such as fragility fractures, which is the same hip fractures usually are um on them quite quickly. So, within 36 hours uh type of surgery as per guidelines. Um and, and, and the whole, the whole thing is that this is this is quite an important um type of fracture to be aware of because the 1520 years um the survival rate injury at 30 days, 11% is because as you've approach to this, um that figure has actually dropped to 6% as 2023. Um So s only 6% of patients um die at one month after sustaining a hip fracture. Now in the UK NHS. Um And I think that's a really good example of optimizing uh internal orthopedics um working in a multidisciplinary team to good patient out. So, next uh slide, please. So I thought I'd talk a bit about um blood supply to the neck of the femur. So this is bringing anatomy bit of clinical relevance as well. Cause we're, we're talking about hip fractures. So, what is the main blood supply to the, uh, head of the femur wanna type it? It's, it's one of the ones that are labeled, which is, which is, which are sort of the main, main ones. And then of those, there's one that sort of contributes the most, um, in adults. Very good. Yeah, it's the medial femoral circumflex artery. Yep. So, femoral artery is correct. So it's the deep which comes off um the the femoral artery itself and then it that splits up in the media and lateral femoral circumflex arteries. If you click the the next slide, um you'll see it's mainly the media, the artery artery of ligamentum pas which comes off the ob obturator artery also contributes. Uh but that's more so in Children. And then the lateral cir femoral artery also keeps um significantly in adults. Um So those uh the media and lateral are the ones that can be disrupted by an intracapsular um neck of feur fracture. And that's, that's often why you end up having to go down the route of a a hip replacement in the context of a neck of feur fracture. But we'll, we'll talk about that as well. So, next slide, please. So, like I mentioned before, the uh ligamentum teres artery is more common in Children and that comes off the ob and, and, and it's not that it's more, it's more prominent blood supply in Children um neck side, please. So hip fracture guidelines. So this is just an example of a any time um you're thinking about conditions, usually in the context of the NHS someone somewhere would have p published a guideline on how patients, especially for, for common things which which a hip fracture is. Um So these are developed by nice which is the National Institute for healthcare, health and care excellence based on it. This is part of the whole concept of evidence based medicine and, and that's what you should always try and aspire to practice. Um and ultimately on to the fracture pattern which is intracapsular versus extracapsular. Um So we'll, we'll talk about that and try and bring um an a clinical relevance together again. So next, so this is an example of a, an different fracture patterns that you can have inside um in and around the femur. So could fracture, which is labeled femoral neck to which uh correctly points a V fracture and you can have a and runs um probably from the between the or subtrochanteric um which is usually five centimeters below the level of the less, less five. So intra is described uh fracture that happens proximal the hip joint um cap attaches to the femur. So that usually that that joint capture is attaching at the in intertrochanteric line usually. So any of that. So anything inside the hip joint cap is intracapsular, anything distal to that intra intertrochanteric line. Um or the ba cervial line which means that's usually extra, that's what um an intra intra fracture. Um I see with the Trant is a perfect example of an um next time, please. So again, this is just defining extra capsa. So anything that's trochanteric or subtrochanteric would be extra capsa that region there he anything to of the he next slide and these are just other ways and fancy names for um the um femur fractures. But usually you just need to develop category. Is it in intra, is it extra will usually determine your management? Um You, yeah, uh there is a much more to be said on this side side, please. So talking about intracapsular fractures, which is what that first x-ray I showed you was that was probably a garden three fracture. So g the garden classification system is to determine to what extent a an intracapsular fracture is dis can anyone type in the comments? Why? Why do you care how an intracapsular fracture is? How would you treat a garden to compared to a go? What, what are you thinking about? And what are you worried about just in broad terms and feel free to type? It's a pretty safe environment if you don't know it. Um Just to venture a guess, what do you care? How displaced an intracapsular fracture is give it, give it a minute. Yep, bleeding, bleeding is the thing to talk about. Yep, that's perfect. So for management So internal fixation versus T hr in, in the right candidate. So if it's significantly displaced, yeah. Perfect. He know as well, blood supply is disrupted. So that, that's the thing you're worried about in a garden for the blood supply would, is unlikely to be preserved and you run the risk of ava necrosis. Perfect to the femoral head. So if left untreated and you have, if you have a garden for fracture and if you left it untreated, firstly, the patient wouldn't be able to immobilize. So there's all the risks of being bedbound, um risk of chest infections, urinary tract infections and just muscle atrophy. And it's not a good outcome. And, and that, that is how um patients would essentially die 100 years ago prior to the um you know, the advancements made in hip fracture surgery. So comparing that to a garden two fracture where there's lead fracture that is intra non displaced, you now have the option of trying to preserve that femoral head by just fixing it. So, in the context of intracapital to try and put some metal work in and the original femoral head. So no replacement and then that you have is a hip replacement. And there are two types of hip replacements which we'll broadly speak about is a hemiarthroplasty and one is a total hip replacement. So, before we sort of delve into to all of that, what is the difference between replacement uh in between a hemiarthroplasty and a total hip replacement. You just have to put it simply. What's, what's the difference? How many arthroplasty best, total hip replacement? What, what, what understand by those terms? Anyone? Yeah. Really, really good. So, a total hip replacement using the femoral head and acetal, a hemi arthroplasty. Yeah. I, so if you think about, if so on the video, so if that's the femoral head and this is the acitab that it goes into a hemi arthroplasty is just replacing the femoral head. A total hip replacement replaces the ace tablet component as well. The x-ray that I'd I'd shown you earlier but I ha I have you up. So next slide please. So it comes down to the management of these factors and that, that's why going back to the initial question. Now, why does it matter if the is undisplaced or displaced? So, in young patients, which you don't really have to define by an age, but u usually it's patients under the age of 50 that sustain an intracapsular fracture, usually from a high energy mechanism such as a road traffic accident or other sort of um serious trauma fracture that may be undisplaced displaced, but either way in a because you don't want to put in um a hip replacement in a young patient patient, the lifetime risk of revision, which means they may need another um hip replacement at some point um because they don't tend to last forever. Previously, numbers were thrown around such as a hip replacement. Last for 10 years. Now, it's probably closer to 20 years. And more studies have come out on this and people are constantly trying to replacement in the population. If you have a displaced, you're worried that the femoral head will go into avascular necrosis, even if you try to fix it because that blood supply that we talked about the different arteries that are contributing blood to the femoral head are likely going to be disrupted and bone healing is unlikely to be achieved. So, if it's displaced, and you think about these factors based on the nice guidelines which outlined there on the right, you may offer a hemi arthroplasty or a total hip replacement. In order to offer a total hip replacement, the patient needs to um be able to walk independently um using a stick or without a stick, but no, no worse than that, at least as good as walking with a stick. They shouldn't have any sort of conditions or comorbidities that makes the procedure unsuitable for them. So, what you think about is um not being cognitively impaired. So, a patient with dementia is a poor candidate for a total hip replacement because they are likely to dislocate it and to total hip replacements are usually easier to dislocate than a hemiarthroplasty. So usually you don't offer a total hip replacement to somebody who's medically unstable because one, it's a longer procedure and two, a patient that cannot follow the total hip replacement. So you can't flex your hips below 90. So you can't have a deep squat. Um I have mention you forget that you have a total hip replacement. You may they put your legs into all conditions and the hip. Um and the new nice guidance that you should only offer a total hip replacement. If you believe that patients will be able to carry out their activities of being able to get on with their day to day life independently beyond 22 years off that operation. So it's a bit of a clinical judgment there, whether a patient gets a half hip replacement or a total hip replacement. Um Next slide, please, if you have any questions as well, just feel free to on the chat. So is it um an example of an internal fix probably in a young patient, three cannulated hip screws to try and just fix the hip. So they haven't replaced this patient's femor head. As you can see, it's still their own femor head and their own, they've just tried to fix a fracture which you can't really see in this case. And this is that description I had about a hemi arthroplasty, which is that metal head that you can see without any change to the A tab, which is the socket that the um femoral head is en located into or you have a total hip replacement or a total hip arthroplasty, you have um an at of the cup, usually a poly um Eline um liner and then a a femoral head that's going into that. So that, that's an example of total on the and either of these suitable options for displaced femoral neck fractures. Ok. We've spoken a bit about intracapsular neck of femur fractures, excites. So I want to try and describe this fracture. All of you should be able to give at least a single answer on this. So because we've spoken about intracapsular versus extracapsular. So what kind of fracture is this extra capsule? Yeah. Really good. Any idea what kind of extra capture fracture? This is? Yeah, it's Yeah. Yeah, it's almost subtrochanteric. But the the specific name for this type of pattern is called reverse oblique. So if you think about the obliquity being the line between the great tranter at the top and the lesser trochanter that's now fractured and displaced. Um This is a reverse trochanteric fracture because it's it's uh in the reverse sort of plane to the trochanteric line. Reverse, yeah, re reverse oblique. Um fema fractures the way just good. So would be the treatment options for the, would anyone think about a hip replacement in this case or is that not really an appropriate option? What would you be thinking about? Ok. Yeah, I am now really good. So that's an intramedullary nail that would um w which I'll show you an image of in a second and that would enable you once you've reduced the fracture into a good position, reducing the fracture means trying to restore normal anatomical alignment and then fixing um fixing it with an intramedullary. Now, really good next slide, please. So we spoke about intra caps and extra capsules. So now we're in the realm of extra capsule fractures. It's um a reversibly fracture which I may have an image of on the next slide, please. No, I don't. So going into extra caps, we'll, we'll talk a bit about the management of these. So uh I you have intratrochanteric, which is that line between the greater and lesser tranter and subtrochanteric or unstable intratrochanteric patterns such as the reversibly pattern which you've just seen or a fracture that has subtrochanteric extension, which this technically kind of does. It's a reversibly fracture with extension because it's going further down the level of the lesser trochanter. Um subtrochanteric a fracture that's more than five centimeters um distal to the lesser uh tranter. So putting all that stuff to one side because we've, we've seen that fracture pattern. Now, an intratrochanteric fracture is usually considered a relatively stable fracture pattern for which you can treat with a dynamic. We'll have images of both of these. Um If you're a visual learner like I am because this is just a lot of text. So next slide. So again, we've spoken about but just take a second to appreciate that inter truck fracture pattern. That's the kind of fracture pattern that would do really well with a dynamic hit group. Again, that that would be number four on the image on the left. Um And it's that line uh in the image on the right, which is like if it goes into that sub fracture region, it's definitely going to be um for an intramedullary. Now, next side please. These are two examples, different um fixation options that you have ma labeled um on the image that's a dynamic hip screw. So that's, that's what it's known as dynamic hip screw or a sliding hip screw because it essentially allows the fracture pattern to compress as the patient weight bears. So that would allow a patient that has that fracture pattern if fixed correctly to weight, bear the day after their operation and, and that's kind of the aim and we haven't really spoken about that, but the aim of, of trying to fix these fractures or replace the joint if they have an intra caption eem fracture is to try and mobilize the patient so that they're not bedbound like they would have been 100 years ago and die of other medical causes such as chest infections, urinary tract infections, muscle atrophy and and so on. So image a that's dynamic hip screw. Um and that's the screw running into the femoral head supported by a plate laterally. And you've got some bicortical screws that help the plate sit flush onto the bone. The image image B. Um That's an example of an intramedullary T FN. Um And what you have there is a lag screw going into the femoral head and then you've got the nail itself running into the medulla of the bone. Um And that's secured by one distal locking screw, that's again, bicortical and both are really good options based on the fracture pattern, next side piece. So this is a summary which I hope is pretty useful um because we've covered a lot of content. And if you haven't had a trauma and orthopedic um placement, um I hope that this really helps sort of give you an overview of neck fractures. And if you see fractures like this in the future, you're at least thinking about is it intracapsular? Is it extra capsular? What are the treatment options? And, and, and what are the treatment goals? Is this the right operation for this patient? So, parallel implants that, that you see there, that's the kind of internal fixation that you would do for a young patient with an intracapsular fracture. Um that's hopefully relatively undisplaced. The sliding hip screw, also known as a dynamic hip screw. You can still see the fracture there that's running between the greater trachaner to the lesser trachaner. That's the kind of fracture pattern that is amenable to a sliding or dynamic hip screw, the intramedullary nail there is the third option and that's usually for unstable extracapsular fractures such as the reverse oblique pads, um, as the case, um, or the, the spot diagnosis that I showed you earlier. Um, and it's also good for subtrochanteric fractures. And with the intramedullary nail, that's, that's a short nail, you can get longer ones where the dis locking screws are sort of quite disc towards the end of the femur close to the knee. Um, and then the fourth image there is that of a hemi arthroplasty hemi meaning half arthroplasty, meaning replacement, joint replacement. So half a joint replacement of the hip. So he hip hemiarthroplasty replacing the fe the the femoral head but not the acetabular component, not the socket. So if you're describing that to patients, you say what we're offering you is a half hip replacement that replaces the, the ball but not the socket of your hip joint. Um And patients total hip replacement, you're placing both components usually with a line in between as well. Um It's technically lo longer procedure technically more. Do you need um an arthroplasty trained surgeon to be doing that? Um Definitely in the UK. That that's the case and you need to be thinking about dislocation risk as well. So usually you would offer that operation to patients who are pretty fit, healthy, can withstand a longer general anesthetic or longer um operative procedure and will be able to follow the total hip replacement um precautions postoperatively. So u usually you don't want to flex beyond 90 degrees or flex your knee beyond knees in one go. So a deep squat where you're trying to sit on a low chair. If you think about that, that's the kind of position in which your total hip replacement or even your hip replacement can pop out, um, with enough sort of abduction or abduction added to it. So, so next side, so, unfortunately, this is APD, we won't be able to, um, run the, uh, gift that I had on here. But if you read, um, I'll, I'll read, read it out and then if you, if you'd like to put in the correct option that you think it is. So you have a 71 to 8 accidents and emergencies in the UK or elsewhere or, er, after a fall onto her right knee, she describes pain on the outside of her right leg. She's able to wait there, which means she can stand, walk around how she's not able to Dorsey flex her foot. So if that's the foot, she's not able to lift it upwards to the sky. Ok. So which nerve is most likely affected? And this is the kind of sort of spot diagnosis where as a preclinical student, if you've paid attention to the anatomy, um, and you know what nerve is supplying what muscles, it will really help you when you're making a clinical diagnosis. Cool. Hina said c anyone else? No, a nerve? Ok. A, a anyone else, I'll give it a minute or so. If you have any questions at all post that in the chat, then I can answer that. Ok. Neck side. Yep. It is common perineal nerve next side, please. And this just is an example to demonstrate the importance of knowing your anatomy quite well. So if someone's complaining of pain on the outside of the leg, after having a fall, they're unable to dorsi flex their foot, which is essentially a foot drop. Um One of the things you should be worried about is the common perineal nerve, whether that's completely lacerated or just being compressed, um by which could be a fracture, hematoma or um the, the bone itself. Um And the worry here is that sh would not be able dorsiflex their foot and that can be um quite devastating. You usually need to put the foot in a foot drop splint. So that foot is held at neutral because otherwise when they walk, the ankle will sort of point downwards. And that can essentially one of the issues that you can have with that is it can shorten the um achilles tendon. And if, if you don't put them into a foot drop spin as well, they can have a sort of lasting stiffness and deformity as well. So that's the common perineal nerve there that wraps around the fibular head and then divides into the deep and superficial perineal nerve, which is demonstrated with the image on, on the right and tho those go on to supply the deep perineal nerve uh will go on to supply your um Dorsey flexor of the foot. So tibialis an here extens to join Longness, extensive long. That's what allows your foot to go up up to the sky. Ok. Next slide, please. So foot drop, it's usually a result of the weakness of the foot. Dorsiflexor mus muscles. We just mentioned most common cause of foot drop is a common perineal nerve palsy, which is probably what is ha has happened. In this case, you can have an L5 radiculopathy as well, which is where the um nerve root itself is impinged, uh or a sciatic nerve lesion, but that would be associated with other symptoms as well because the sciatic nerve supplies a lot of muscles, all of uh and the branches of which supply all of the, the um uh the nerves uh supply all of the muscles in the uh lower leg. So, distal to the knee, uh you can have a superficial superficial or deep perineal nerve lesion. Um And sometimes with a stroke, you can also get a foot drop as well, but there would be other signs and symptoms with this. So what I'm just trying to demonstrate here is trauma and orthopedics. It's a clinical special obviously, but knowing your anatomy is key. So knowing the cause of nerves and where possible injuries can occur will help you make diagnoses really well. Next IP uh So those two nerves labeled there the one on the top, that's the sciatic nerve. Um The extra arrows that have been added in the black arrows at the top. And the next side, please. That's the, the tibial nerve which runs down the back of your leg. The sciatic nerve, like I said, divides into the common perineal nerve and, and the tibial nerve. Next side, please. This is another spot diagnosis. I think the last one. So what we have here is an 18 year old man who's been stabbed in his left buttock presents to A&E or Ed, the wound is sutured and two weeks after the incident, he comes to the orthopedic outpatient clinic and he's got a waddling gait. So when you have a look, he's got a bit of wasting of his buttock muscle. Um And on examination, he's not a not able to abduct his thigh. So what, what nerve do you think is most likely to have been injured? And for bonus points, what, what kind of gait do you think he has? Cool, really good, good. So, the obturator nerve is not the right answer in this case because that runs medially. Um and supplies sort of the abductors ad duction um of, of the thigh. That's what allows your thigh to come back in towards your other leg. Um Whereas the superior gluteal nerve supplies the abductors. So gluteus, medius, minimus intensive fascial arta that allows your leg to go out wide. Um I think of somebody just stretching their leg out wide, that's usually your abductors. So next side, please. So, again, importance of knowing your anatomy. So you've got the gluteal muscles in this region. Gluteus, maximus, medius, minimus, and fascial superior gluteal nerve roots of which are L5 S one will supply um your abductors. So, gluteus, medius minimus, the inferior gluteal nerve supplies your gluteus maximus with nerve roots L5 to S two. And um it's really important to know nerve roots for exams to an extent. But also when you're trying to identify uh any spinal pathology, so sometimes it can be um a peripheral nerve problem. Sometimes it can be a central nerve problem. OK. Next slide please. So yeah. Um you know, got this right. So this is a Trendelenburg gait. So the way to remember this is that the pelvis drops on the unaffected side. So you have um weak gluteus medius muscles on, on one side. In this case, in the image, it's on the right side patient that's trying to walk. Um And as they do, there's the pelvis on the left side will drop um because the opposite side has a weak gluteus medius and isn't able to account for that in the movement. Um And it's a, it's a very sort of obvious um sign once you see it uh either in fracture clinic or in a neurology clinic as well. So next side please. And obviously just wanted to hear that I haven't con um covered all of the conditions that exist in trauma orthopedics. So sorry, is there, is there a question? Weakness of gluteus medius, very weakness, gluteus medius. But that is as a result in in the um spot diagnosis as a result of the superior gluteal nerve being injured. Um So going back to this slide, sorry. So key conditions in trauma and orthopedics, we haven't covered everything and it's it would be really difficult to do that in a one hour talk. But if you are interested and you want to sort of brush up on your knowledge of orthopedics before you go um to at and o placement, either as a med student or as a junior doctor just worth reading. Uh And I would categorize these in emergencies. So major trauma, just be aware of things like ATL S. So the advanced trauma, life support, that's um sort of the guidelines that we follow when you get a patient that comes in with multiple um system injuries. So things like broken ribs, um pelvis fractures, multiple open fractures to the legs. Um And that that can be quite a serious patient syndrome is really worth um knowing about um that's when the blood supply distal to a compartment is potentially compromised because of um intra compartment or intrafascial um swelling. And those patients seen urgent um decompression of the, the, the, the fascia so that the muscle can essentially breathe uh necrotizing fasciitis or known as flesh eating bacteria. Um That's a surgical emergency as well. If you've got sort of a red hot, swollen bit of skin somewhere, potentially, let's say on the leg and it starts spreading rapidly. The patient's ridiculously unwell. They probably needed an urgent um debridement in theater. Focusing on the lower limb. We've spoken a bit about hip fractures and a bit about proximal femur fractures. You can get fractures obviously to the distal femur as well. Um You can also get f the acetabulum, which is technically a pelvic fracture, uh tibial and fibular fractures or ankle, um foot and ankle fractures. These are other things to be aware of. You can also get injuries of the um ligaments in and around the knee and the ankle. So other things to think about upper limb would read up on clavicle fractures and when you need an operation, um shoulder dislocations and humeral fractures, risk fractures such as distal radius fractures. Um And it's worth knowing sort of what are the indications for operation and non operative management. Um And then other emergency I would say are septic arthritis where you've got an infection of a joint. Um And you, you really need to think about how you manage to say patient appropriately. Coquina syndrome is a um a syndrome which means a group of sort of characteristic features where patients um can have long lasting disability to their bladder and bowel and even lower limb function if not treated because um you essentially have a compression at the level uh or at, at a level above where they called equina. Um nerve roots exit, pediatric fractures are also worth knowing about. Um good thing about pediatric fractures is that kids heal up really well. So a lot of them um get away with non operative management. Um but obviously some, some conditions such as supraconal fractures that are significantly displaced will require um uh surgery next side, please. So we've covered um TN O in the NHS as an introductory topic, thinking about key conditions in TN O and II. Just hope from this. Obviously, II wasn't able to cover all of trauma and orthopedics as a topic. But um we've touched on hip fractures, which is probably um one of the biggest topics that you'll come across as a medical student and as a junior doctor. Um I in the context of TN O and um the last side hopefully has given you some pointers of where to read around before atn O placement. So if you're thinking about a career in TN O and I have um sort of prefaced in the context of the UK and, and the NHS, um we can talk about some tips here. So next studies. So career in TN O in the UK. So there's usually this, this route which is the CT pathway. So, certificate of completion of training and I've taken this slide from um an I MG website that I referenced there at the bottom. But usually you graduate from medical school and then you go on to do the foundation program, which is a two year program in the UK. It's the equivalent of intern internship training. Else where if you've done that during your second year of your foundation program, you would apply for um core surgical training, which is another two year program, you sort of get some exposure to theaters, clinics, um and really just brushing up on basic fundamental skills in and around surgery on calls clinics, um and inpatient management of surg. During this time, you also need to complete your MRC S and become a member of the Royal College of Surgeons. Uh This is specific to the UK and then hopefully you get a higher surgical training post uh in other countries, this would be called a residency at six years intro in orthopedics. And you rotate through the different subspecies I spoke about. So you get six months, let's say in spine, six months in hands, six months in pediatrics and you, you rotate through these. Um and hopefully you find one that you, you particularly like um and once you've done your exit exams, which are the Fr CS Fellow Royal College College um surgeon exams, you would then get a CCT, which is a certificate of completion of training in tr orthopedics, which is to say that you're ready to be a day one consultant in tr orthopedics. Uh what this image doesn't have though is the concept of fellowship. So after you've done all of these tr um all of these years of training, you would then go on to subspecialise uh by doing a fellowship, let's say in hip and knee, um joint replacement or um if you're interested in foot, ankle, you spend foot and ankle surgeon really as an apprenticeship where you're trying to increase your exposure to a special subspecialist field with internal orthopedics so that you can then start as consult with the in this field and develop your practice over a number of years. Next side, please. Uh There are other routes as well for getting into um things like specialty training. So there's Crest, which is where you don't uh necessarily do the foundation program or the core surgical training program. Um But you complete MRC S and you have a certain number of years and you have a consultant, sign off the experiences that you've had and say, yep, this um this colleague of mine is uh competent enough to start special training if uh deemed appoint at interview um it by national recruitment. So next slide please. So in terms of preparation, so let's say if you're all medical students and you're thinking about going to the foundation program, you'll need to apply for the foundation program. Um I think as of this point, it's uh you will need to do the UK MLA as well, which is the med medic medical licensing assessment. Um and then possibly go through the random number generator where you can be placed um potentially anywhere in the UK. And that's a two year program. And hopefully during that time, you are able to sort of get a favor of what it's like working in the NHS, what it's like working in other sub uh other, I wouldn't say subspecialty, sorry, other specialties such as medical specialties, understanding how to manage, you know, medical issues with patient uh with patients. Because ultimately, as af one F two, even act one ct two, you will be directly involved in the management of inpatients and they will tend to have medical issues as well. You may also get some exposure to A&E or the emergency department, which is really useful exposure to general practice as well, is really useful to see primary care and see how that functions. Uh Because when you discharge your patient, that's usually who the patient will go and see. So very important to have sort of a holistic view. Um so that you are able to deliver sort of high quality care for your patients next slide please. And one of the things you can look at at this stage is um the core surgical training, self assessment, scoring guidance. So these are the sort of um that you're so on and help you get a course surgical training job. Similarly, you can also read about the orthopedics ST three National Recruitment um self assessment. So things that are between these two, it's worth reading about and planning how you'll tackle them. So I think the principles are really to try and develop um an overall portfolio that's well balanced um that demonstrate that helps sort of demonstrate that you are a well balanced trainee that is trainable um and is interested in a given. So some of the principles read between the two is that between courses, training and ST three is that you need to demonstrate um surgical evidence, have an E log book, e log book.org. Um That's the website in which you can start recreations even as a medical student. So it demonstrates that you have um you are committed to a surgical specialty and once you're a core surgical trainee, it helps you demonstrate which procedures you've done from start to finish, either with your supervisor scrubbed in or academically, it's worth doing sort of high quality presentations at conferences. And if you're so converting these to publications in peer reviewed journals that are usually PUBMED index, people talk about ID. It means that you've published something that is in a journal that is index on PUBMED, which is usually it sort of indicate a good standard of publication. Um be aware of solidary journals that will email you and say we'll publish your work um for X amount of money and find out it's not PUBMED indexed. Um And they've just made some money off you audit. So, uh it's different research in that you are assessing current practice usually against an established guideline. So a closed loop audit or two cycle audit means that you, you have something like, let's say hips there are guidelines on these um such as all patients should be operated on within 36 hours, right? So you go to your um trauma orthopedic uh database, you look at the hip fracture patients, you see when they've been reviewed by um atn O Registrar or Senior House Officer in A&E and when they've had their operation and then you essentially try and introduce an intervention um to try and improve the amount of time that it takes between pain being admitted and having their operation. So that would be the first audit being looking at how much time it takes. Then you introduce an intervention and then your second audit is re auditing that. So you're closing that loop and seeing if the intervention that you've introduced actually improves um the, the overall sort of standard of care that you're delivering for hip fracture patients in that case, higher degrees as well. Um Pretty useful. So you can do things like uh an, a part-time MSC. Um So I'm aware that uh Barth, so Queen Mary has a trauma M se uh Oxford Al also has um a muscular skeletal sciences. M se so worth looking out for these and you can do these part time alongside your training um as a foundation doctor or, or a core trainee, but obviously, it's time consuming and you need time to work life balance as well. Um Leadership as well is important. So you can be um demonstrate leadership locally regionally nice and um just sort of develop those skills that are transferable in the context of being um a surgical trainee. So as a registrar, you may have to lead trauma calls. Uh you may have to lead um theater briefs before you, you're uh going to operate, you may have to lead the operation yourself as well. Um And all of this should o obviously be done under adequate supervision, but you still need to have those leadership skills teaching as well. So, um like you guys are doing with the Pa Sophia group, it's really good to be involved in teaching, um setting up teaching programs, inviting people to teach, delivering, teaching yourself as well. So if you're a clinical student teaching some preclinical content, that's really good. If you're a foundation doctor teaching some clinical content, uh um medical, you are going to sit their exams really good as well. But anytime you're doing sort of teaching audits, um academic work, I think it's really important that you do do it in topics that you're interested in. Um otherwise it can be, it can really drag and you just won't have a good time. And these are the kinds of things that I think can lead to, to burn out. And, um, it's just really important that any sort of extra activity you're doing. Yes, there's a, an element of doing it for the CV. But you should really try and target things that you're interested in. Um, because one, it's more enjoyable that way and two, it will line up with the things you want to do long term and, and you're able to sort of be true to yourself with what you want to do as well. Next slide, please. So an example is let's say you're in medical school. So year one and two, at least in, in the UK, you focus on preclinical sciences, really try and get your anatomy right, your physiology, right? Uh Because these things will come back to help you in things like the MRC S exams, year three in the UK, you have the option of integrating, which is where you take a year out to do a relevant degree. Um and then you can conduct some further research. So some people do an anatomy. I did mine in Gena medicine and innovation. So I got to do a bit of lab based research. Um Yeah, 4 to 6, those are your clinical um placements. And while you, while you're on your clinical placements, it is a really good opportunity uh especially if you're interested to go in scrub in, see if this is the kind of environment like. And then start to develop um, a portfolio that's geared towards surgery. SSE is in the UK, it's a student selected components. You can also have electives where you spend a period of time, your medical school abroad um in a special like, so you get to travel. Um and some of this can be expensive. So there are usually grants to apply for um where certain organizations will fund part of your travel at least. Um, And it's, it's a really good experience. Unfortunately, I didn't get to go on an international active because my was doing um and you should also be trying to get some prizes as a medical student um that can be research prizes that can be through clinical distinction, um that can even be in sports as well. So all of these things are really transferrable, but just try and develop yourself holistically in a way that is interesting for you. Um You can also develop your E log book. So when you go and scrub into theater record that, but overall, you're just trying to develop basic clinical academic leadership and teaching skills that will sort of hold you in good stead as a junior doctor and for the rest of your career, next slide, please. So once you get into the foundation program, I think really use F one, especially your first rotation as an as an opportunity to settle in, really understand what the role of an F one is. It may be a bit disappointing for some people when they find out it's a very admin heavy job. It's, it's more about being organized than being clinically sound. Um At least that, that was my experience of it because the people making decisions are usually the senior house officers or the registrars or the consultants. Um And you're there really just there to, to learn how the system works. Um And then do sort of some of the more I'd say admin or uh service provision like jobs which include taking bloods, uh doing discharge letters, a lot of discharge letters, prescribing meds, um prescribing meds for discharge and so on. But don't uh be dis uh dissuaded by doing these things because eventually you will get to sort of and get more involved with, especially that you're interested in. You can use F one as an opportunity to do the first bit of the M RT S exam. I would recommend this. Um because that's the point at which medical and you have that primary clinical knowledge and enough clinical knowledge as well to crack on do some courses as well. You come to the UK. So basic surgical science is a really good course that I think all surgical trainees need to do at some point, try and go to some conferences, try and do some other, try and do some teaching but try and break these up. So you're not sort of piling all of these on in one go and uh running the risk of burnout. How come, how early should we start studying anatomy? Final year of med school? Um Sort of learn anatomy as a preclinical student. But for the context of the MRC S part A, I would recommend doing it um towards the end of your final year and just early aspects of your F one. And the thing about anatomy is you'll have to learn and relearn it so many times. Even now, I'm, I'm act two for um an operator of the anatomy because I haven't had as much experience as a consultant or a registrar has because they would have had years of doing an approach to a, a certain aspect of the body. Um And then for my interviews as well, it's really important that I know my uh orthopedic anatomy in and out. So it's a constant sort of iterative process. You learn it for an exam, you forget a bit of it and then you relearn it again. It's sort of like the Krebs cycle, but I think Krebs cycle but brachial plexus. Um so going back to this, I hope that answers your question. Uh If you have any other questions as well, guys feel free to post that in the comments F two. The aim is to be a safe sho so you, you take up uh it's, it's a bit of a promotion from F one to F two because now you are the person that is potentially leading on calls, taking referrals, seeing patients independently and then discussing that with your registrar or consultant. Um And this is also another opportunity for you to finish off the mis so part B which is an OSK style exam. So it's more of a practical exam um courses as well that you can do. So remember I mentioned ATL S this is what allows you to sort of manage um or be aware of how to manage patients that have high energy trauma in the context of uh A&E and then a postgraduate certificate as well. You can do. So some people do a postgraduate certificate in medical education. Fortunately, or unfortunately, now it's be, it's not become enough to teach you now also need to be trained in teaching and that's where things like APG cert um fits in and that can cost uh a bit of money if you're paying for that out of pocket. Another way of doing that is through things like the specialized foundation program where your deanery will pay for it. And then ultimately, as NF two, your aim is to apply for course surgical training and get into training. Once you're act, you can settle in b and try and become comfortable on call in clinic and in theater. Um And the reason why I say it's important to try and do your exams early sooner rather than later, it's better to try and um get it done because once you're act, the expectation is that you should get it done as soon as possible. So, if you've gotten it done sooner than that, you can reuse your ct time to train on calling in clinic and in theater, which is sort of the three main environments. You'll be as a registrar and obviously you'll be doing wood stuff as well alongside that. So where can you do the basic surgical science course? So usually it's run by the R CS and they have um outposts. So for example, I did mine in Warwick because that was the closest center to me. Some people do the Basic Surgical Sciences course at the R CS in London have a look on the website. I'll try and find a link for it afterwards and I can post that in the chat. Um But you can, you can do it in uh in a lot of places. I think they have it internationally as well for IM GS. Is it doable to land a junior job without experience? So obviously, um full disclosure, I'm not an I MG. So I haven't been through that process but um having seen some Im GS that have come to the N HSI, I've seen them do uh clinical attachment experiences. So that's where you spend a few weeks at a center uh where you just get a taste of what it's like to work there. And then uh IM GS usually use that experience to then apply for a job often at the same center uh and justify why they want to do a job and the experience they've had and why they would make a good candidate. Um, as an I MGI, think another way of getting in is just by getting into training. So foundation program, course surgical training. These are other options for you as well. Any other questions? Yep. Free. So, going back to this, the CT two, which is where I'm at right now. It's, it's quite challenging, I think because you're trying to do all of your ward work and be a good senior House officer. But you're also trying to start to think like a registrar and make those um clinical decisions on call in clinic in theater and even on the ward. And you also have to go through the process of applying for ST three. And throughout all of this, uh you will have to do interviews. So you'll have to do an interview to get into course surg training and another interview to get into ST three and what they really like in sort of UK interviews, at least from what I've seen is structured answers. So when somebody asks about you and your achievements, I of that is the camp structure. So it's clinical academic management and personal. So talk about your achievements in those categories and it just divides up your answer really well and people know what, what to expect for each section that way spies is another acronym. So when they're talking about ethical scenarios, so let's say in an interview, you get asked, um you know, you have a colleague that's being bullied, what would you do in this case? And they, they confide in you. So you need to spies which means seek information, prioritize patient safety, take initiative, escalate the situation. Um I forgot what the S stands for but you, you can look that up um star as well, which has to do with situation task assessment and, and response. Um And these are the kinds of things that sort of make you look sli at interview. Obviously, I need to revise up because I forgot what the S INSP stands for. But um it's just really good to have structures for interview answers next slide, please. So I think a summary is that there are plenty, plenty of routes um especially um for training in the UK. So, and there are plenty of opportunities. So try and make the most of any opportunity you're given anywhere you are. There's no such thing as bad clinical experience in my opinion. Um Obviously, there are bad work environments, but you can sort of learn a lot from any clinic yet. Um And I think the main thing to be is to be proactive and I think this quote by Eisenhower is really good. So plans are nothing but planning is everything. So you need to make plans um, like I've mentioned above. So thinking about the MCS exams, thinking about electives as a medical student. Um, thinking about the courses that you'll need to do, uh, to stand out. So basic surgical sciences, ATL S and other courses that you're interested in. So, please. So I think, yeah, we've covered three sections. I promised I would. Sorry, it's um, I'm sorry, I was late, I was late and sorry that the, the session itself was a bit longer than an hour, but hopefully you haven't uh fallen asleep. And if you have any questions, feel free to ask, I don't know if there is an xi but feel free to have a Yeah, cool. Uh That's a typo by the way, it's meant, but it come out as pods. But there you go. Any questions. If you have any other questions, I put my email on there. Feel free to email me. I'm, I'm happy to, to help in whatever capacity I can. Um in terms, what are the possible complications after hip surgery? How long will be the recovery process? And when should the patient come for the follow up? Yeah, good question. So if we're talking about hip replacement surgery, let's say in the context of hip fractures, complications that we usually consent patients for quite a few. So specific to hip replacements, I think the risks are that of dislocation, implant, loosening, failure of the implant and, and fractures associated with the implant and then sort of the generic risk with any procedure and especially with it. Um, orthopedic surgery is that of pain infection. So, infection is a major one in hip patients because if you get an infected joint, um, with metal work in there, that's a nightmare scenario. And the prognosis for that can be quite poor if um, not treated appropriately. So, pain infection, bleeding, stiffness of that joint is possible scarring. You obviously have a scar from the incision site, damage to other structures. So it's possible that you can injure nerves and blood vessels or tendons in the area. Um And then the previous risk that I mentioned. So, dislocation, loosening failure of the implant fracture from the surgery itself as well because there is a bit of sort of rotational uh elements to pulling and abducting the hip, um putting a bit of traction on the hip. And if you are thinking about a frail elderly patient, you can, if, if, if done in you capture to their um their femur elsewhere or um their, their hip and pelvis elsewhere as well. Um The recovery process depends on patient factors really, it's really difficult to say some patients are up as early as day, one, postoperatively unable to go home soon after that. In terms of follow up, it it depends. So usually the patient needs a follow up um in the um in the fracture clinic, if they're having their dressing reviewed at 1 to 2 weeks, um, for removal of sutures as well, potentially at two weeks. And then usually with the operating surgeon at 6 to 8 weeks, hope that answers your question. It's different for elective as well. Um Next question is, what was the most challenging part for you in orthopedics residency? So, I haven't gotten into orthopedics residency yet. I'm in. But my, the most challenging part so far I think it's, um, trying to strike a balance between all of the, um, so clinical academic management and personal aspects of your life. Um, and I think as you become a senior sort of house officer and you're close to becoming a registrar, the expectations are kind kind of doubled in that people are expecting you to think like a registrar and make safe clinical decisions, but they're also expecting you to continue and crack on with your, um, ward jobs and managing inpatients safely. Um, so I think the expectations are quite high, the closer you get to applying for residency. How did you get involved in research slash publications as I mentioned or foundation? Um, as I mentioned, I think I used some of my time um, in placement to chat to people who had published things. And I think the best thing to do whenever somebody offers you a project is, um, look into what they've done and what their sort of completion rate is because if they haven't published much and they're asking you to do the leg work for a project. It's unlikely that that is going to lead to a publication unless they have a good track record of seeing projects through the completion and publication. So um choose who you work with very carefully and then um look them up on PUBMED, pubmed.gov. Um just to see how many publications they had and what they published before and what sort of methodology they're comfortable with, what methodology you're comfortable with. But really use it as a learning opportunity. As long as you're proactive uh reliable and you're able to sort of communicate with your research team. Well, you'll, you'll keep getting opportunities, I think. Um You just, you need to be honest about what, you know, what, what you don't know and try and do as much work as you can before you hit the point of saying, II don't know. Um It's easier for your colleagues to edit, especially your research colleagues to, to edit work you've done rather than you asking a bunch of questions and it's a blank. Nothing's been written down. So just be proactive with it as a foundation doctor, it's the exact same. But you have less time, I think then I have much less time uh now as a core trainee than I did as a foundation and much less time as a foundation doctor than I did as a medical student to do things like research and audits. Um So make the most of it if you're still a medical student. So use your time wisely, get some research done um that in areas you're interested in, try and do an and get some research done there. Um Yeah, and just uh be proactive and um just work hard. I think next question is as an sho what is your role in preparing a patient for surgery, pre op and POSTOP management as an sho level? Yeah. Really good question. And I think as an sho you are heavily involved um in preparing a patient for surgery. So my role now is, let's say I see a patient uh that has a hip fracture just running with the theme of the day. I would sure that the patient uh is reviewed thoroughly. So I'd assess them, take a full history. So ask about allergies, medical history, past medi um uh past medical conditions as well. Uh when they last ate in case they need to go to the theater that day and events leading up to the injury. So trying to ascertain whether if they've had a fall, that's a fall and then they've fractured or if they've had sort of uh pathological fracture and then they've had a fall or if they've had other injuries that we should worry about such as a head injury or if they've had so sort of chest pain and then had a full or dizziness, palpitations, taking a thorough medical history, doing a thorough clinical examination to identify any other injuries that need to be treated, then requesting and chasing up appropriate investigations of blood tests, um like full blood count, kidney function, uh and then optimizing these preoperatively. So if they need a blood transfusion, ensuring that that's arranged, um and then after that, arranging any uh necessary scans and investigations, so it's um usually you would get see plain film x rays and if complicated fracture pattern, you may even get a CT. Uh if you're worried about a history of cancer, you may get a full length of the, the fe femur as well in the context of hip fractures. Um And then what I tend to do after that is have a conversation with the patients about surgery. So the rule in the NHS really is if you're consenting a patient for surgery, you should be competent enough to describe the benefits, risks and be able to do. Um So you've talked about what the proce procedure is, so name of the procedure intended benefits. So usually you explain for um to decrease pain and to try and restore mobility. Then the risks, as I mentioned before, pain, infection, bleeding, stiffness and so on. And then you would mark the patient as per the wh O checklist. And then the other thing that you would have to talk about usually, uh if, if you feel confident to so as an ho or it can be a registrar consultant having that discussion is that of uh resuscitation. So patient um would like to be resuscitated or not, but also reminding them that ultimately, it's a medical decision and list listing the patient for theater. And then if you have the opportunity to do so as well, go down to theater assist and when competent to do so, try and do as much of the procedure as possible with adequate supervision and then postoperatively it will be requesting things like blood so that uh they have bloods put out for day one POSTOP, checking up on your patients always check up on patients that you've seen on call uh or in um or have operated on because you should try and take that responsibility and see um and ensure that any patient that you're seeing has pretty high standard of care un under you. And then postoperatively, you may have to deal with any complications that they um which can be something as mild as pain or blood loss and requiring transfusion or an infection that needs to back to theater. So just taking the antibody um for any patients with POSTOP complications or if everything goes, which hopefully does ensuring that um the patient has adequate um medi prescribed and adequate follow up planned. So as an sho you really are involved with almost every bit of that um patient pathway j just because of the way the it is you may not be involved in every out of a given patient's pathway but you will definitely be involved with certain aspects of a given patient's pathway. But your role can range from start to finish. Basically. Hopefully, that's, uh, I know II spoke for a bit but hope. But hopefully that gives you a good idea of what uh your role can be in preparing a patient for surgery. Next question. So sorry if the question is d I just don't know a lot about residency here, but I heard that you have to change that every 6 to 12 months. You, you change hospitals or cities, I'm not sure. But can you speak on that? So, yeah, this is, it's the pros and cons of training, uh normal training program, you may end up having to rotate around. So, um in the foundation program, for example, when, when I, when I was in F one, I had to rotate every four months. Um luckily not too many different hospitals, um and then I would have to between jobs as well. So there's a bit of an adjustment period usually in the first couple of weeks when you start a new job, but once you sort of get the hang of it, um it, it, it is quite ok. The, the challenges I think come when you have, you know, a new team that you're not familiar with a long commute because that can be quite tiring if you have to, to drive or um take public transport for a significant amount of time. So usually over an hour is quite um can be quite tiring, especially if you, if you're thinking like going to work post um for, for night shifts and then finishing a long shift and then driving back in the morning when you're exhausted. Um But yeah, rotational training, the the benefits of it though. However, are that you do get to see how things are done in different units. Um You get to sort of expand your professional network um and you get a range of different experiences. So things like university hospitals or major trauma centers are really busy places um often with difficulty. Um So more difficulty getting surgical experience as an sho whereas a district general hospital, I think the training you get as an sho is really good. Um But then the care that is available, there is often not at a subspecialist or tertiary level. The patients do end up having to be referred out and that can be a little bit, let's say um challenging in that you don't get to see the entirety of the patient's journey and you don't get to learn that subspecialist, subspecialist aspect of patient care. So, yeah, next. Uh any any other questions? I don't think we have any more questions, but um I'll take the opportunity to give a um concluding um message. Thank you so much. Um Sid for um hosting the webinar today and taking the time out to share your expertise knowledge and all the advice that you've you've given. It's been really insightful and extremely helpful and that thank you so much for answering all the questions and taking time out after work, especially after a long shift. Um We're really, really fortunate to have people like yourself um willing to engage with us. So, um thank you and um hopefully we can have you again in a future webinar. And if there is any questions, I um you said that you're happy to share your email. Um But thanks, it's on there. Yeah, thanks. Uh Yeah, thanks so much for having me. Uh I posted it in the chat and you also had a question about uh where you can do basic surgical skills. So that's let me post that on the chart as well as promised. Thank you. All right. Yeah, but if there's um nothing more, um Thank you everyone for joining in. If you can take a few minutes to complete the feedback form and my team will send over your um attendance certificate, have a good evening and um take care, see you soon on our next webinar. Thanks. Thanks again for having me. Take care. Bye. Thank you. Bye. Take care.