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Hi, everyone. Um Can you guys hear me and chat? If someone could put in the chat if you can hear me? That'd be great. One of the attendees can say yes, great. Thank you. So, um sorry, it's running a bit late. So, um um welcome everybody. Good evening. So my name is David and I'm the current president of the University of Leicester Orthopedic Society. Um I have the pleasure of introducing Mr Pradhan, a um ST five TN O registrar surgeon in the East Midlands South rotation who has kindly taken time. However, his is he schedule to deliver us this very interesting and informative talk on um common fractures which are seen in TN O on calls. So if you have any questions or any um anything which you'd like to say, just feel free to put in the chat. Um But yeah, thank you. Um Heard of you. Yeah, thank you. Thank you very much for the uh kind introduction, David. So, yeah, um essentially I'm gonna be giving a talk. I'm just gonna start sharing my slides in a second. Um But as we were just discussing, I actually can't see any of the questions once I start showing the slides. So David will kindly moderate and just if you can flag up any questions as we go along, that would be fine as well. Um So, but just so everyone on the chat knows that I actually can't see anything once I start presenting. Um So yeah, let me just share the presentation. Good. Um Can everyone see this? Yep. Here we go. Perfect. Um So yeah, so my talk today is going to be surviving trauma and orthopedic on calls and to interrupt. Could you possibly put it on start slide show just because we can see your other? Yeah, perfect. Yeah, perfect. Thank you. Yeah, amazing. So I'm just gonna have a bit of an outline as to what I'm going to cover in this talk. So I'm gonna briefly talk about my background and why I feel like I can be here and talk about orthopedics to you guys. Um One orthopedic on call consists of. So essentially what the components of an on call are common fractures which we see on, on calls and then a bit at the end about a career in trauma orthopedics and sort of um timelines and how to get into training. Um But essentially this is all stuff which when I was sort of final year or fourth year in med school would have probably not known and would be keen to know about from the contents of my talk. So a brief sort of slide about my background. So I actually grew up in Leicester. I'm from Leicester. Um I went to uni at Kings um did med school there six years including my inter year. Um Then I did foundation years in Oxford. Um Then I did core training back in London. So I was at the Royal London as well as um Barnett and Stanmore for my core training years. And then I got a reg number in the East Midlands South rotation. It was my top choice because I wanted to come back home and um I did well in my interview. So ended up here. Um so orthopedics and surgery in general is a bit of a conveyor belt is a bit of a chain. So looking forward now, I'm a registrar, I'm thinking about, you know, fellowship and being a consultant. So it's endless hoop jumping, but I can reassure everyone that it is fairly rewarding once you do get through the hurdles. Um So what does an orthopedic on call consist of? So I actually thought, let's let's break this down and actually go back even further. So in any orthopedic surgeon's day or week, um it's mainly consisting of four things, four elements and have your ward rounds where you see your patients who have been admitted on, on your consultant's take, um you'll have clinic which you will be um sort of a mix of fracture clinic as well as elective orthopedic clinic. You'll have your operating days where you're obviously doing your, either your elective or your trauma operating and then you'll have your own call. So the on call can consist of a variety of shift patterns. It can either be a day on call where you're working from 8 to 8 a night on call where you're working from 8 p.m. to nine AMA weekend shift, which again is sort of a mix of those two. And then currently where I work in Northampton, we have 24 hour shifts where you start at 8:08 a.m. on one day and then you finish at 1 p.m. the next day. So you do your eight A on call and then you have either a clinic or a theater session in the morning and then you do that sort of from eight, from 9 a.m. to 1 p.m. Um The reason why they have that sort of system is because, um, as a registrar in orthopedics, you're considered mainly to be off site in quite a few hospitals, which basically means from 8 p.m. till 5 a.m. you're meant to be off site. So you can, um, just basically let the sho be the first bleep holder and everything, all the referrals will come through to them. Um I think that's a bit of an idealistic system and I certainly have never left the hospital at 8 p.m. and returned at 5 a.m. And I often find that, um, you know, the sho does need a lot, a bit of support, which means that you end up staying until about 11 pm midnight and then getting a couple of hours sleep and then being back at work in the morning. Um, so yeah, when you're on call, you do have a bleep and your and your on call commitments mainly consists of seeing patients in A&E on the TNA wards or on medical wards doing things in the treatment room, if there's any small procedures and occasionally taking patients to the theater who may need emergency surgery. However, the indications for that are becoming less and less with time. So the on on call itself, what does that consist of? So what kind of things do you see on the on call? So, um of, of course, understandably you see fractures, I see you see bony pathology, but you also do see quite a lot of soft tissue injuries and soft tissue management is a big part of the on call as well. You can also see infection and tumor cases which are rare but important things to manage. And then you may be asked to see ward patients managing POSTOP complications or managing patients on the ward that for example, the medical team has asked you to see, um and then considering medical management of your own orthopedic patients, which may be postoperative. So looking at soft tissue management, um there is a big, big overlap between orthopedics and other specialties. And I think soft tissue management really highlights the overlap between orthopedics and plastic surgery. So, um, it's for example, any lacerations, any tendon injuries in particular, with the hand, those are quite often a sort of a joint venture. And it really depends on which hospital you're in as to which unit or which specialty will cover those things. So, in Leicester, we are quite privileged that we have a really excellent orthopedic hand unit. Um So quite a lot of the orthopedic or a lot of the hand injuries will be dealt with by the orthopedic team. Um And it's only on a couple of days, I think over the weekend where those cases are then managed by the plastics team. So, lacerations, tendon injuries, thinking about flexor injuries and extensor tendon injuries, these will all be managed by orthopedics in the East Midlands. Whereas for example, if you were in London, those would be mainly managed by the plastics teams. In terms of soft tissue management, you also have things like hematomas, pretibial lacerations which you may need to manage. Um And again, for a lot of these, the usual management tends to be non operative with um basically wound dressings, potentially a single debridement or de roofing. Um and then carrying on and allowing the tissue viability, nurses to do regular wound dressings to help with recovery. Um Probably the most important thing to mention with soft tissue management on and on call is ruling out necrotizing fasciitis. That is probably one of the few soft tissue injury, soft tissue um, emergencies which come through to the orthopedic team. And it's something that shouldn't be missed. Neck fash often presents as a very severe form of cellulitis. So you might see somebody presenting with a red rash that then evolves over an hour or two and forms blisters becomes sort of dark and dusky in appearance and may have sort of pus filled blisters and the patient is acutely unwell. So it's really, really important that as an orthopedic registrar or as an orthopedics, h you're able to rule out necrotizing fasciitis from a benign cellulitis. You can appreciate the two conditions are on the same spectrum. But a world apart dealing with cellulitis, which essentially just need some antibiotics and asking the patient to safety net themselves versus something which needs emergency surgery within an hour of diagnosis and certainly has a sort of a life threating prognosis if it's not caught early and dealt with appropriately. So other things, infection and tumor management. Again, this is sort of related to soft tissue stuff. Um But again, thinking about septic arthritis, which again is an extremely common presentation to your orthopedic oncall. Take these can often be ward referrals. So the medical team might be managing the patient for something else and then they'll ask you, oh, the patient has a painful swollen knee or unable to move it. Could you please rule out septic arthritis. Um, it can be quite frustrating because um a painful swollen knee could be present for a variety of reasons. It could be something as innocuous as a reactive swelling to an infection. Someone has elsewhere in their body, it could be gout, it could be pseudo gout. Um And of course, it could be septic arthritis. So it's really, really important that you use both clinical and biochemical markers as well as imaging to make sure that you hone in on diagnosis and rule out septic arthritis. The most important things to think about with septic arthritis are X ray imaging. Is there an obvious effusion? Is there any obvious pathology such as a fracture which may be causing the swelling? Is there a big lesion? Is there a tumor which is causing the swelling? Which again, you wouldn't want to put a needle to aspirate and then you have to think about the markers. What's the CRP, what's the white cell count? Are they significantly raised to make you concerned about an infection? What's the patient's temperature? Are they septic? Are they pyrexial? Are they in agony with this? So it's all things to consider. And then ultimately, the real definitive thing with septic arthritis is putting a needle into the joint, doing an arthrocentesis and um sending it off to the lab to look for gram stain culture and essentially to see if any bugs are grown. So with septic arthritis, it's really, really important that if you are managing this in the A&E se um setting that you don't start the patient on antibiotics straight away. This often means that you need to uh get in touch with the medical team and prevent them from starting antibiotics empirically, just to treat a global infection as it can basically ruin your blood cultures and stop you from finding an organism. Another surgical emergency to think about in orthopedics and something which from the time of decision making to surgery to operation should be at one hour is uh flexor sheath infections. And these are often um very obvious unwell patients with a big diffuse swelling of their, of their digit being unable to bend or extend their finger, something to look up are something called Cana signs. So that's K A nav A L signs and these are basically markers which help understand whether the patient has an infection that is present within their flexor sheath. And again, it's something which is a very good prognostic indicator as to how a patient will do. Um And if for example, if they do have all five of the signs, then it's extremely likely that they will require urgent surgical management. Other things to think about are cellulitis bursitis. And again, that comes in with your septic arthritis presentation where a patient where a colleague may say, oh, I've got this patient with pain, swollen knee and it just turns out to be a bursitis or a cellulitis and certainly not something which is deeper in the joint. So, you know, distinguishing and differentiating between conditions is extremely important on your own. Co then comes on to lesions. And again, similar to what I've just said, it's really, really important to know which lesions to worry about, which lesions not to worry about and often that's done on imaging. So getting an X ray is really really important for these patients and getting a CT chest Abdel S to make sure that there's no metastases in any other of the organs. And again, speaking to your regional Sarcoma center to get a definitive plan for what needs to be done next. If there isn't a primary origin for the lesion, then it's often necessary that a biopsy is required to make sure that we can actually know exactly what that lesion is. So war management, I'm sort of looking at the other side of the on call is away from A&E. So on the wards, you can often get called by the nurses or by your F one or your F two to look at the ward management of patients. And to think about things like chest infections, DVTs or P ES myocardial infarctions. And then thinking about postoperative complications like bleeding, hemorrhage, postoperative constipation and ileus and thinking about wound management. So all of these are things which you actually develop as a foundation doctor. So, you know, any orthopedic sho registrar should be able to manage all of these conditions. Um well, or at least to be able to refer them onwards to the medical registrar or the medical team. And to be honest, that's what happens in the majority of cases where after the initial first line management is given on the ward, a lot of the top three conditions at least would get managed by the medical registrar. So coming on to the um the bony bits now. So actually talking about bones, which is all about what orthopedics is about. So thinking about common fractures and fracture management. So the three fractures which I'm going to touch upon in my talk today are going to be neck of femur fractures, um ankle fractures and wrist fractures. So those are probably the three most common types of fractures that you will see on your ankle. So looking at neck of femur fractures, so these can be divided into their location. So it's really, really important that they have an X ray in A&E and the X ray can tell you as to where the fracture line goes. And therefore what kind of fracture it is on? Um a broad sort of scale, you can look at these fractures as either intracapsular or extracapsular and within extracapsular fractures, they can either be in intertrochanteric or subtrochanteric as you can see on that picture, the management of fractures or sorry, the the diagnosis of fractures really guide the management. So in these pictures, we can see a variety of these fractures. So on the on the left, we can see somebody with an intracapsular subcapital fracture. On the middle, we can see someone with an intertrochanteric neo feur fracture um that is sort of extending and has taken off the left sub. Um And then on the right, we can see a diaphyseal femur fracture that's gone through the midshaft. So the management of fractures dramatically changes based upon where the fracturing pattern lies. So for your intracapsular neck of femur fractures, you need to manage them with a hemi arthroplasty. And that's because the um femoral head, blood supply is at risk. And therefore, there's a large risk of AVN with these. And therefore, you need to replace the whole thing with the intratrochanteric um neem fractures. They can either be managed with a DHS um or a short nail. Um And then for your subtrochanteric fractures, your diaphyseal fractures, they do need um to have a long nail. Um And again, an image on the right, I've kind of put up because this is something which I just found off um Google images. And to be honest, it was actually, I was a bit surprised by the metalwork that they've inserted there as really the nail length should extend all the way down to the knee. Um And essentially in this image, what they, what whoever's fixed this has done has created a stress riser just under the nail. So actually that I would say that's a sub optimal fixation. It really needs to come all the way down to the isthmus past the isthmus and into the flare of, of the condyles there. So that's what the to of pit fractures moving on to ankle fractures. So these can be sort of subdivided into unal bimalleolar and trimalleolar fractures. So essentially thinking about fractures of which of the malleoli are fractured. So if you look at uni maeota fractures, they can, they are most predominantly either medial malleoli fractures or lateral malleolar fractures. Um for medial malleolar fractures. Um There is a classification system called the Hertz Whisky or something like that. There's a, there's a long name for it, which isn't really used. And really, you look at medial malleola fractures as either being undisplaced or displaced. Um And in terms of their management, if they're undisplaced, you can just manage them in a walking boot. But if they are displaced, then they will require surgical fixation with two screws, fixing the fracture fragments, looking at lateral malleolar fractures. So that's going on the other side where the fibular is, um these can be subdivided by either the web of classification or the lor cancer. And, and, and again, that describes um the position of the fibular fracture as well as the uh medial ma fracture as well. So with Weber, you should be really looking at three types of Weber, A Weber B and Weber C. So this is um it in correspondence to where the syndesmosis is. So with Weber A fractures being below the level of syndesmosis B being at the level of the syndesmosis and C being above the level of the Synder. So Weber A are normally stable injuries and can be managed non operatively in a walking boot. Weber B require a further one week follow up X ray in fracture clinic to check whether they're stable or unstable. So in a week's time, if you see a Weber B, you'd bring them back to fracture clinic, you'd get a weight bearing X ray. If there was any sort of displacement or shift on that X ray, you would opt for operative management in, in the majority of these cases there isn't and then you can manage them more operatively as you would a web array where the C fractures are inherently unstable. Often it means that there is um you know, destruction or displacement of the symptosis and on a whole, they do need operative management. So as I briefly touched up on law cancer earlier, again, that's a classification mainly for bimalleolar ankle fractures where both the medial and the lateral sides are gone. Um And again, um it can be subdivided into, into the four log Hansen um criteria. The most common type that we see is a fracture in, in such as seeing in that before image there, which is a supination, external rotation type injury where you have a fracture that is sort of transverse through the medial malleolus and an oblique fracture through the fibula. And again, that can be fixed with a plate plate and screws on the lateral side where the fibular is and with uh a one or two cannulated screws on the medial side where the tibia is that medial mal fragment is, you can also get trimalleolar fractures of the ankle. And again, these are fractures which involve both the medial malleolus, the lateral malleolus and the posterior malleolus. So the posterior malleolus is a part of the tibia, which is right at the back which you can see in the lateral radiograph on that picture there. And often if the chunk is big enough, they do need require operative fixation. This is normally classified according to the Mason Malloy classification system. Um And again, that is subdivided into three main categories with the type one being a shell at the posterior um side. Uh Often these do do not require operative fixation and you can sort of ignore that fragment and just deal with the medial and the lateral sides. Then you have type two A which is um involvement of the posterior malleolus with a posterior lateral fragment. And two B which is involvement of both a posterior lateral fragment as well as a posterior medial fragment. Both of those types do require fixation to ensure stability of the ankle joint. And then type three is essentially a pong fracture which again, would require um surgical management at the back. So um going forward, quickly talking about risk fractures. So again, these can be mainly subdivided into intra articular and extra articular types. Um There is a classification system for them called the Freyman classification. However, that isn't sort of necessarily used in day to day practice. And really um the things that we look out for are whether the fracture is intra articular, extra articular and whether it lies outside normal parameters. So what is a normal parameter? So a lot of you, I'm sure, probably don't know what the normal sort of measurements of a radius should be or what it should look like. And again, that really guides operative management. So normally a quick way or um sort of easy way of remembering what the number should be is um sort of 1111 22 is the way I remember it. However, the actual numbers are slightly more or less plus minus one than the, the 1111 22. What 1111 22 essentially means is it looks at different parameters on that a PX ray on the left side and it measures different heights and different sort of angles. So the first thing to look at is the radial height. And again, that is one of the elevens or on this, if you're looking at a more accurate measurement, the 13 millimeter and radial height essentially looks at the height of the radius above the height of the ulnar. So on a whole, at the level of the highest part of the radius and the highest part of the ulnar, there should be a 13 millimeter difference between those two points. And the ap similarly, um when we talk about 22. So out of the 1111, 22 the 22 part comes from the radial inclination which again is looked at on the A PX ray. And that is if you draw a line that is um from the tip of the radial styloid, so right at the tip of the radial styloid going down um and a line crossing parallel with the articular surface of the radius. So if you, if you drew that sort of line that would measure about 2223 degrees, then looking at the lateral, another sort of 11 is the volar tilt. And as you can see on the, on the X ray on the right side, there is a slight shift going in the palmar direction which is known as the volar direction. Um and that is therefore about an 11 degree tilt of a deadline going plum straight down the radius. So there is a slight 11 degree tilt going to the right of that image, which is the volar side. If there was a slight tilt going to the left, then that would be considered a dorsal tilt. And that would be uh sort of a worrying finding essentially. And obviously the more that um the more parameters that are off or the more parameters that are sort of out of this spectrum, then you know that there is potentially um the great a greater chance that this patient will require surgical management or surgical fixation because the greater the abnormality and the parameters likely is that the greater the functional deficit that the patient will have. So another way of um sort of classifying or, or thinking about these parameters is the La Fontaine classification system. And La Fontaine basically looked at how unstable a fracture was. So if the initial displacement of, of any fragment was more than a centimeter, or if it was more than five millimeters shortened, or if there was a lot of dorsal angulation more than 20 degrees, um or if there was an associated ulnar uh distal ulnar fracture, then this would suggest that the um fracture was unstable. However, it's really, really important to appreciate that in particular with the wrists and also to a smaller extent ankles, they are a gray area and there is a lot of thinking involved before you go and operate on a patient. So a patient may have all of these criteria from La Fonte. They may have dorsal angulation more than 20 degrees. They may have shortening, that's, you know, more than a centimeter, but they may be 95 they may be extremely frail and they may not be fit enough for an anesthetic. And therefore, you really have to look at the patient you have in front of you and manage them according to their needs, their function requirements as well as their sort of morbidity. So for example, there may be some cases where you want to operate on a patient, but they're just not fit enough. And therefore you have to go down the non operative route and basically treat them with a cast. Instead, this is just a slide to show the um sort of differences between what looks, what an in on the left and what an extra articular fracture is on the right. So one that does not communicate with the joint surface, as you can see with the, the fracture on the left, it does on the one on the right, it doesn't. So that was a bit of a whistle stop tour through on calls. And uh I think half an hour of that was, was, was pretty quick in, in terms of um covering that. But if you have any questions, just sort of um your feedback today and we can have a chat. Um This sort of final slide again is about sort of careers in trauma and orthopedics. And really the journey begins right at medical school and thinking about, you know, if you want to pursue a career in surgery, having those sort of tick boxes for your CV and your portfolio and making sure your core training application is sort of robust um and working on your um sort of numbers as a foundation doctor as a core trainee in terms of getting to theater and doing your cases for your log book, which is super important. Um But it is a journey it carries on. I think I'm over halfway down from the path. So I'm sort of seeing the light at the end of the tunnel with this journey. But again, there's still a lot more to go and that's why it's really, really important that you don't sort of forget to have fun and you do have to sort of just make sure you have a good work life balance, make friends with people at work. So work is enjoyable and just try and have a good time whilst balancing everything else that comes with it. Um But yeah, if anyone has any questions about either the presentation in terms of um the common things that we see in our on call or anything from a career perspective, feel free to um just fire me a question. Thank you very much. Great. Thank you very much. Yeah, that was a very, very informative, interesting um talk. Thank you very much for that Mr uh Pradhan. Um If anyone has any questions, feel free to put in the chat and um yeah, can you see the charts? Yeah. Yeah, I can see it now because I've stopped sharing. So, yeah, that's a very good question. So what is a stress riser. So a stress riser is essentially where you have a segment of the bone that isn't protected by any metalwork in a fix. Um And essentially what happens is that extra bit of bone that's either at the end of the bone or the side of a bone that isn't protected, then has a focus of all the patients, pressure or all all the patient's weight. Um And then that area forms an area of weakness where they could have a fracture in the future. So essentially, when you think about fixing in that, in that case, which I, which I showed where, where I mentioned that stress riser, that nail had it been a little bit longer, would have protected the distal end of the bone and would have therefore stopped it from being an area of weakness where when the patient puts their weight down, um could potentially fracture. I hope that makes sense. Yeah. Very good question. Yeah. Um In a Weber Bee, do you apply a boot in the week before the follow up appointment? That that's a good question. So normally for a Weber Bee, what I do is if you see them in A&E, um they're normally in a lot of pain. So, um we and in most A&E s you'll put them in a um below knee plaster of Paris and, and you'll keep them non weight bearing for a week. So you let everything settle down. You, you just sort of let them hobble around on crutches and then when you bring them back in a week and then you, um, remove the plaster of Paris, you get an X ray where they're weight bearing and then you bring them into your clinic. Uh And then you make that decision, whether you're gonna put them in a boot and allow them to weight, bear as pain allows or whether they need fixation. Cool. Um I've got a question actually. So, um, it's more about a personal question. So what would you say are the biggest challenges that you faced as a, um, orthopedic surgeon throughout your career? What would you say? Um, I think that that's actually a really, really good question and I think, um, you are gonna face a lot of challenges and, and I think it's, it's, it's silly to hide away from the fact that there are hurdles through every step. So, um just the portfolios and trying to get all the points in them I would say is probably a big hurdle, but what the biggest hurdle is and I think it's more a modern day problem, which certainly our generation and you know, the ones that people coming in after us are going to face is, is service provision and essentially as a junior doctor as an F one or an F two or even as a core trainee when I was in London, being treated as, you know, just a cog as being treated as somebody who's there to provide service due to discharge summaries, see the patient on the ward, prescribe the medications and sort of go home as opposed to like a real sort of engagement with the system, engagement with conditions, treatment with pathology, engagement with the patients on a deeper level. And I think unfortunately, that only really came to me as an ST three. And, and I think, you know, that is a real shame because you have four years as a doctor from when you finish in me school and you start F one F two and you do your poor training where you miss out on, on a huge chunk of this responsibility and this sort of shared learning and, and I think that it is ultimately a big obstacle to us because what it does is it sets you back um because you are then learning operative skills and you're learning to step up on your sort of knowledge in the short years of registrar training. Um And I think really that it's something to be said for the, for the medical system here. So one thing I would say is um always be hungry for knowledge and for skill and to learn opportunity will come when you least expect it. And I think it's really important that even though you don't have to push yourself and sort of ruin your work-life balance. But to look for opportunities where, for example, if you have a day off or you have a slightly light, a lighter shift to seek opportunities and say, look my on call is not heavy at the moment. I'm just going to pop to theater and then go and assist in this case or go and do this case or learn this technique or see this. And I think that's the only way you'll learn. Um speaking with a few more questions. So how might I progress my portfolio whilst being in preclinical years? Um So I think preclinical years are a fantastic opportunity to really get ahead. And I think if you are thinking of orthopedics and they're attending things like this in preclinical years, I think, I think you're already in a very, very good position. Um Things to do to progress to your portfolio in your preclinical years would probably be to try and pick up audit projects when you're on a clinical attachment or to try and pick up something that will end up being a paper and try to do a retrospective review or a survey questionnaire or try to do a systematic, you just pick up on these simple sort of projects which aren't sort of anything major in terms of, it's not going to take up a year of sort of phd level research, but certainly something you can just churn out in a year or two. And that would be a really good way of getting things in your portfolio. Um I think loads of things which I did my preclinical years, you know, really set the, I would say the foundation stones for my later development. And, you know, I was doing things like being part of society. I was in my final year, I was president of Surgical Society at Kings and I was all the way through. I was doing different things on committees. Always involved getting my suturing skills up, you know, learning how to suture and even going on basic suturing courses would be really good. Um And then trying to get yourself in theater, it's really difficult as a preclinical student to try and do that. But certainly if you can do sort of shadowing periods or if you can try and get in somewhere, then that would be really good. But the other things, the more sort of academic things such as the audits and the papers, certainly you can start doing very early and I certainly did that. So my third year, I had my first international oral presentation. I went to Milan. Um, and it was a pediatric or a pediatric surgery thing. So it wasn't even anything to do with orthopedics, but it was just something which helped develop my skills, made me aware of, you know, public speaking and in a domain which was in a room full of, you know, very senior surgeons and it just helped to sort of do those things early. Um Why did I choose to, you know, so that. That's, that's a very good question. Um, I think in med school from second year onwards, I always knew I wanted to be a surgeon. Um, I don't know what it was, but I was, I was pretty dead set that, um, I would, I would be some, some form of surgeon. I think initially I started off wanting to do general surgery because, um, you know, when we did cataract dissections, that was the thing that interested me the most loved, you know, dissecting the pancreas and, and looking at the bowels and be like, oh, this, this is cool. Um, but then as I did my clinical attachments, I realized actually it's a lot of longer hours. It's a lot of nighttime operating, it's a lot of emergencies and it's very little reward. There's always something going on and there's always something they might have to end up doing five or six pr s on a shift. And that didn't seem to sort of make me enthrall to do it. So my sort of things I enjoyed in my clinical years and I certainly, one thing I did in my clinical years, which I would recommend doing is don't be bogged down by the specialty you're in. So if you're doing a cardio cardio respiratory firm or you're on neurology, then once you've got your sign offs or you've, you've turned up to your neurology, things, do extra things. So in my third year, I was on my cardio respiratory attachment in Ashford in Kent. And, and I had all my log book sign offs done in three weeks. I went in hard, you know, listened to all the murmurs, listened to all the crackles. And I was like, right, I'm done. And then I realized, well, actually I've got this free time on my hands instead of sacking off and going down to the pub, let me actually explore other things. So I made friends with one of the orthopedic and team members are just rocked up to trauma, trauma meeting all morning. And it, and it is scary cos you know, you don't know anybody there. It's the first time you're doing it, you're worried. They're just, they're gonna be like, who's this medical student in the corner? Why are they're there and tell you to, you know, jog on. But, but actually most people are very happy to see you and certainly when I see medical students and they're keen and they're eager and they wanna learn more often than not. I'm like, yeah, come stro in. Um, you know, let's, let's, let's do this and let you know, show them things. So I think it's really important, um, you know, to keep an open mind, but I digress from the question. Why don't you see a no. Um, I think to keep it in sort of two sentences, um, I enjoy fixing people. I enjoy fast, sort of, you know, seeing big change I enjoy working with power tools. Um, so you using drills and, um, you know, using sores is really exciting. II could never do anything. Um, sort of fine. I didn't want to do, I didn't want to do hand surgery or I didn't want to do, um, sort of ophthalmology because that was sort of too fine for me. Um, and yeah, essentially it was just sort of the, the case mix, seeing the patients operating on them. Um, you know, making people happy and using big sos. Um how important are the ova ankle rules? So actually the funny thing is with ankle fractures, normally they are seen by the A and D team. So the Otto the ankle rules are predominantly used by A&E doctors. So I would not worry about sort of those sort of rules in particular with ankles. And also there are some c spine rules that you need to know about as well. Um in terms of your own practice because realistically what will happen is the A&E doctors will see them, they will get an X ray, they'll diagnose it and then it'll come to you. So you'll never be sort of the first port of call for someone coming in with ankle pain. So no one will expect you to see someone just sort of limping in through the front door. They will always have sort of a fracture and then they'll say, ok, fine, we'll refer this to the orthopedic team and then they'll come to you for a sort of recommendation, uh, any recommendations slash resources to read for how to manage fracture clinics. Um, yeah. So II would recommend uh a couple of things. So, er, in, let me check on my phone. Actually there is a very good app called. Um, where is it? Mhm. I haven't used it in a while since I was in sho called Ortho Flow. Um, and it looks something. Oh, sorry. The screen is just white, white. I don't know if you can see it. It's not really working but essentially, um, it's, it's uh, yeah, that's not working. It's, it's an app called, or Flow. So I would, I would have a look at it. I think it's like 499. Um, but it's a really good resource for, um, sort of knowing in basic fracture management. So that would help fracture links. And then textbook wise, I would recommend a textbook called Mray. Um, it's a really, really good book for knowing how to manage things in fracture and also on the on call. So I would probably say off the flow. Mres are probably your two biggest ones. And then, um, online free resources would probably be, or bullets, which is something which, or registrar sort of just no, no to use. If you see something that you're not sure about or is weird and wonderful, then you just auto bullets it and there's a nice sort of summary pages to presentation investigations and treatment. So that, that, that's, um, something I recommend. Sorry, my voice is going cos I'm been speaking so much. Um, so II just had a question. Um, what, what, what sort of advice would you give to, um, medical students that are in the chat right now, in terms of one progressing to, you know, you have touched on it already. Yeah, I think again, it's, it's all gonna be the things which I mentioned in the preclinical question just um getting stuck in. I think, I think, I think it's really, really important. Um Oh yeah, I think this sort of, oh yeah, I'll answer that question in a minute. So in terms of medical students, I would say get your audits done, get your portfolio stuff sorted early, you know, you try and do your teaching things, try and get your prizes, try to get in your, getting into theater, trying to do your suturing, doing all of those things, doing a surgical elective. Um just showing commitment to, to, to the surgery, showing commitment that you're keen and eager to pursue a career in orthopedics. So, I mean, I think anything that does that and pushes those domains was really important. One thing which I did even in medical school was to look at the core training, application, portfolio checklist and even in med school, I was trying to take off some of those things. So I think one thing you can do is have a look at that, look ahead, look at the next stage, look at the next hurdle and see, actually, you know, what do I need to, to, to get to that stage and, and, and to cross that hurdle. Um, so, yeah, er, any tips on how to maximize time on a TNA placement? Um, so, yeah, II think that slightly is, is a separate question to what I'd say for medical students. So if you're on a placement, I think it's really important to set yourself goals and objectives for the placement. So even if you're um so I did ATN O placement as an F two, then I did about 18 months of TN O as a core trainee. Um And then obviously as a registrar, that's all I do. So um as af two, I only had four months of it. So four months is quite a short time to, to, you know, really get, get your grips into TN O, but I probably spend a month doing things similar to what this chat was about. Looking at the, you know, fracture presentations, learning about sort of, you know, what you see soft tissues wise or you see frac bony injuries wise and getting a good understanding of, of the, of that pathology, not just necessarily just doing discharge, summ knowing, you know, what management plan is required for uh neck a fe fracture or what follow up would they need or, you know, what duration of thromboprophylaxis do they need or that kind of stuff like there's getting really stuck in with the clinical side, then I would from the get, go try and get an audit present project or, or a sort of a research project going, you know, early trying to, you know, see if there's anyone in the department who's doing research and getting stuck in with them and trying to see if you can help them with something or even if it's data collection to get your name on a project that would be really good. Um And then setting goals for theater. So again, I think it really depends on what stage you're at. So as an F two, I would probably say getting into theater and, you know, trying to be good at suturing, trying to be competent at suturing and trying to do small steps of a procedure. So certainly for a DHS, um which is a dynamic hip screw, which we do for our, for our hips. I would be keen for, you know, an F two to try and put some of the screws in or to try and, you know, help with putting the metal work in. So I think, you know, there's certainly things that can be done and then certainly as a core trainee, I'd be expecting core trainees to be doing operations, supervised and doing things from sort of skin to skin. Um Certainly simple things like D HSS or sort of bits of a hemi. Um So yeah, I think really you have to divide it and think about almost your interview strategy, which is your camp structure. So thinking about clinical academic managerial and personal. So thinking about how you can try and progress each of those domains during the time on TN O. Right. Yeah, thank you. Yeah, that was very thorough um answers and that's really yeah, much appreciated from the students and I'm sure um if there's, if there's uh any last final few questions, feel free to ask if not, um you can call it, call it there. What I'm gonna do is I'm gonna leave my um email address, my work email address in the chart. Um If anyone has any questions uh or to be honest, if anyone has any feedback, I would be grateful if they can just sort of ping me an email just to say whether they either like this talk or whether it was out of shit or whether they want more of this sort of thing. But yeah, I'm more than happy to take some feedback. Great. Awesome. Thank you. Yeah, thank you everyone for attending. Um Yeah, much appreciate it. And thank you again, Mister uh Pradhan for uh taking some time from his busy schedule to talk to us. It was be very informative. Thank you very much. Yeah, I'm glad I'm glad it was helpful. Very helpful. Thank you. It's very Interesting. All right guys. Thank you. Bye bye. Take care. Thank you. Yeah.