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Mhm. Hello. Hello. I think I'm live. I hope you're all doing well. Um Yeah, welcome back. This is our TNO progress test or MCQ revision series. Um I'll just give it one or two more minutes just to see if there's anyone that's going to come a couple minutes late. Um, but yeah, same thing as as always. Um go onto this next slide. Yeah, same thing as always. So I've got 20 questions this evening. A bit of a range of difficulties for them. So hopefully you'll find it useful. Yeah, and as always all done on polls. So it's all completely anonymous. If you have any questions at all throughout, please just put them in the chat. I might not see them straight away but I will see them and I'll try to get to them. Um So yeah, any questions at all, please just pop them in the chat. Um And then yeah, that's, that's pretty much it. Um Right then let me get ready. Let's go. We might as well get started. Let's go for the first question. Okay. There we go. So I'll give you a minute for this one. So 15 seconds left. All right. There we go. So a bit of a difficult question, this one it seems. Um So let's go through it. Um So the correct answer is actually a hemiarthroplasty on this one. Um So that's, it's probably helpful if we just go through the different types of hip fractures and how we treat them all. Um So you can see from him quite a bit of text and then image that um if we start off generally with hip fractures, I'm sure some of you will already know this probably better than me, but you can break a hip fractures down into intracapsular and extracapsular. And the way that distinguish is there's the lesser trochanter here that you can hopefully see. And the greater trochanter up here, if you just sort of draw an imaginary line between them. Anything above from that is intracapsular a uh straight here. Anything below is extracapsular. So those are your two types and then you can break them down even more. So don't worry about these intracapsular ones. These I don't think we need to know for med student level about the extra capsule owns you've got subtrochanteric, which is here or intertrochanteric, which means it's going between those two try Cantor's that we talked about. Um So those are the free sort of types I have in my head. So I have subtrochanteric, intertrochanteric and intracapsular, okay. And each fracture is created slightly differently for the hip. It seems if this is all new to you or you're struggling with, it can seem quite daunt in. Um May be difficult to remember. The main thing that you need to really need to try, get your head around, which helped me is, or you've got to think is if there's a fracture that's going this way, so it going along that way, you just want to put a nail or a screw or something perpendicular to it. That's, that's pretty much as simple as it is. Um So if we start with subtrochanteric fracture, there's a line literally just here, straight line there. And then you put an interim medullary nail in which goes directly perpendicular. Same thing for intertrochanteric, you go directly perpendicular to the fracture line and you do that with a dynamic hip screw. Now get into what this case was. Um So this, this one was a displaced intracapsular fracture of the hip. Now, most intracapsular fractures are displaced, but some can be undisplaced. And hopefully what that means is basically, if it's displaced, the bones have just moved apart and if it is displaced because the bones have moved apart, you worry that the arteries travel along the neck of the femur, uh the head of the femur here, you worry that if it's displaced, then those arteries have been severed and if they've been severed, then you're worried that avascular necrosis is going to happen. So in majority of cases, they're displaced and what you would do if it's displaced. So like this patient here, it then depends on whether they're mobile or not. Okay. So the definition if their mobile that's classed as anything up to using a hands like a stick that you can just walk around with anything more than that, then you get classed as non mobile. Okay. So non mobile, you do hemiarthroplasty and mobile, you do a total hip replacement. So if I go back, you can see it says she appears frail and normally walks with the aid of a Zimmer frame. So it's only slightly more than a stick really. But it is more than a stick. So for that reason should be classed as non mobile. So that's why you do a hemiarthroplasty. Okay. So hopefully that makes sense. Um Let's see if there's there's no questions yet. So I'll move on. There is another hit question coming up though. So can test, test yourself out again. Yeah, and that's a dynamic hips group if anyone hadn't seen it. Um But you can, you can see there for intertrochanteric, you can see how that if you put a nail there that would be perpendicular to the French line, right? So again, I'll give you a minute. If there's any questions, please just put them in the chat and we can go through them 10 seconds. Okay. Here we go. So again, it's a bit of a bit of a split, split answers here, but a few of you seem to have got it. Um So the clue that you might have got is obviously this is a T E N O session. Um So in terms of differentials, you're too big differentials, or at least in my head anyway, when approaching this question, you've got a DVT, obviously, with unilateral leg swelling, a cup, calf swelling and then you got compartment syndrome. Okay. So those are the two big differentials you have. And now what's going on is it is actually compartment syndrome here and the key sort of MCQ exam knowledge and you've got Oskin knowledge as well is you've got weak pulse is okay and you've got the fact that they're constantly asking for painkillers. Um So if you've got compartment syndrome is very, very painful and painkillers do very little for you. So those are two big clues that point you towards compartment syndrome. Um In addition, she's also had trauma to the leg. Um So if you've got trauma to the leg and that's more point you towards Compartment syndrome, as opposed to DVT, if she said if it said that she was suffering from a malignancy or have been on a long haul flight, then that may be pushing towards DVT a bit more. Um So it's Compartment syndrome and that's what's going on. So, in terms of the management, so for anyone that doesn't know compartment syndrome is when you have excess bleeding into the compartment is particularly lower limb. Um in the calf and it's all surrounded by fascia, the muscles all surrounded by fascia and you've got bleeding within those muscles. But because the fashion can't expand that blood that just keeps gathering and gathering, gathering and it keeps putting the pressure building, the pressure up in those muscles. If you leave it too long, ok. Within about 4 to 6 hours, the muscle will start to die. Ok. So that's why you need to do urgent treatment. And the only treatment you can do for um Compartment syndrome is an operation where you just open the fascia and you let the blood come out and the pressure or resolve, okay. Um So it's a clinical diagnosis. So you don't do any investigations for, if it's good where you can do, you can measure the pressure of it. Um But that's not one of the options here. Um So it's a clinical diagnosis. So you'd go for your fasciotomy because if you did the x rays, it will just delay treatment and little worse outcomes if you did it on ultrasound, the same thing, um If you kept the leg elevated, that's not going to stop the bleeding. And equally, if you started them on Apixaban, that's just gonna make more bleeding. Um So, so that's what's going on. Um So, you know, hopefully that makes sense, the two biggest fractures, the two fractures that you should worry about compartment syndrome developing as a complication uh in the tib if there's a tibial fracture. So, like lower leg just going on here and you can get it in the arm if there's supracondylar fractures, but it's mainly the leg to worry about. Um, yeah, next question. Uh, let me put the time around and I'll answer your question. Rebecca. It's a good question. I haven't thought of it. Exactly. Um, it's, I believe, I guess it can stretch to some degree but it's not, it's not supposed to stretch. So it's not just accommodating that extra increase in size. Um It's a good question though. Um I'll probably try Google, I'll try Google it around the next question and we'll see. Um, but a good question for 10 seconds. Right. Well, some people seem to have got this one seems to be, you know, some people have got this so well done. Um So it's Lachman's Lightman's test for this one. Um So first of all, what's going on, um, so young, young, young patient's come in injury with the knee. Um, funny feeling, popping sound, immediately, swelling can no longer wait there. So, for this and tender, so for this, it sounds like an ACL to, those are the sort of classic symptoms of an ACL to a meniscal tear can present very similarly. There's slight things that you can look out for, particularly on M C cues that to distinguish them which will go through. Um So Lachman's test. So it's the best test for a query ACL tear and, and it's slightly better than the anterior drawer test. That's what you might have seen in textbooks or on, on past. But before the difference is Lachman's test, you do it with the knee flexed 20 to 30 degrees where as anterior drawer test it's at 90 degrees. Um, Lachman's test is slightly more reliable. Okay. So empty can test if we go through the rest, that's for supraspinatus muscles for when you're doing the shoulder exam. Mcmurray's test. So that's the one that's done for mental test. Okay. And it does present very similarly. So particularly in young people from a twisting injury. So mainly sort of playing sports or landing funny and you get the sort of instability and the knee pain, but the difference is particularly for MCQ questions is the time it takes for the swelling to occur. Okay. So an ACL tear, it's immediately swollen, the swelling comes on very, very quickly and this will tear there is swelling, it just takes slightly longer, okay. Um So that's the key thing for MCQ is how to distinguish them posterior drawer tests. So that's them for PCL tears and from the history, it doesn't sound like it's a PCL injury and the sweet test is just looking for a fusions. So we already know that it's swollen. Um So it would be a positive test but it's not going to tell us what's going on. So, yeah, so hopefully that makes sense next question. Uh, 15 seconds left. Okay. Yeah. Oops, sorry, I didn't put the pole, didn't put the pole. Thank you for that. George. Just give you a couple of seconds just about your, your answers in. All right. There's a bit more, bit more of a split, split pool of answers here. Um So what's going on aseptic loosening of the hip is what, what the answer is here. So let's go for it. So, a septic loosening of the total hip placement is the most common reason. A total hip replacement needs to be revised or, you know, revisited, um needs to be fixed. Um So if you ever see a complication of total hip replacement as a question and that's one of the options. If you don't know at all, you can just based on the fact that's the most common, but specifically, it presents with hip pain and that pain radiates down into the knee. Um which is what this picture is. Um if you look at the other courses, so why it's not these so avascular necrosis of the femur, particularly thinking of like the head of the femur and that is a complication of the initial fracture. So, like I was talking about on the first question, you've got those arteries on the neck of the femur of the head of the femur. And if you displace the fracture, then it's gonna rupture those those arteries leading to avascular necrosis. But because we're 18 months down the line, they've had a total hip replacement, meaning that the head of the femur has already been removed. So it's less. So it's not going to be that. And avascular necrosis further down in the femur. I don't know, I don't think it would be that. I think that would be very unlikely. Um, iliotibial band syndrome. Okay. So some of you might know what this is. Don't worry if not, but that presents generally with hip pain and it's a tight sensation on the lateral aspect of the fire where you're iliotibial band is, but that's slightly different here. We've got a 68 year old woman, but typically iliotibial band syndrome is a young person who does a lot of long distance running or exercise. Um So not unlikely to be that infection of the joint replacement is a good, a good idea for what it could be. But because like I said, we're 18 months down the line, unlikely to suddenly just develop an infection there. Um And peri prosthetic fracture. So that's a fracture involving the new replacement. So like a new fracture. Um But because she's able to wait their, she's walking, unlikely to be a new fracture. Um So don't worry about this too much. The main thing is if you see an MCQ question where patients had a total hip replacement and something's going wrong, likely it's a septic loosening of the total hip replacement. So, yeah, next question. Any questions just pop them in the chat. Um I'll put the pole in before I forget. There we go. Um I had a quick look, Rebecca about why the swelling of the leg in compartment syndrome. If the fashion can't expand, I can't get a definitive answer within a minute of looking. I'm sure there is some reason for it, but I'm unaware, but it is a really good question. Um So I'm not quite sure. Um But they would go five seconds. All right. It looks like pretty much nearly everyone got this one. Um So disk itis, um which is what's going on here. Um So let's have a look through it. So the main things that are pointing towards disguises here are they've got a low grade fever, okay. There's elevated white blood cells, elevated CRP and there's a history of IV drug use. So there's a key things that pointed towards disguise. Okay. So obviously it's infection of um one of the discs. Um and all that points towards it generally. Well, I'll list all the differentials up in a second, but none of them have a uh an infective, none of them should present with some sort of infective picture. Um So even if you were just looking at the fever and the white cells and the CRP, you could point towards it from that alone. But IV drug use or history of it is a key thing for disguise because it massively increases the chance of it. Um Okay. So if we look at the different roles, so bony Mets, um definitely worth thinking of bosque. Is anyone with like thoracic back pain or just back pain in general? You want to make sure that your ruling out a cancer or metastases? But again, it doesn't explain the infective picture. So, and there's no mention of any other symptoms going on or any other previous cancers. Um inflammatories, spondyloarthropathy fees. Um So that could present with back pain with a raised LP. So that could explain that generally, it involves more than one joint. And secondly, you have stiffness as with any inflammatory one, you have stiffness and back pain that would improve with exercise and be worse in the morning after rest and it doesn't mention anything to do with that. So, because it's not mentioned it unlikely to do that. Um lumbar disc herniation. Um So for someone in that age, and you'd expect it to be more of an acute onset following like strenuous exercise and because the disk is hernia and is pushing out onto the spinal cord, so you'd expect from an MCQ point of view, you'd expect them to say some neurological deficits that are going on, um which it doesn't and then spinal fracture. Um So spinal fractures generally, it's either going to be caused by trauma or it's the one that's elderly with osteo process or osteoporosis and a young person. Um It doesn't mention either of these. Um Unlike wise on the MRI, there's no sign of a fracture. I'd be impressed that if you could work out a fracture from an MRI, I'm not sure I could just straight away and then MCQ question. But yeah, just a picture of it doesn't, isn't, doesn't really sound like a fracture. Um So yeah, so hopefully that makes sense. Um Yeah. Oh yeah, next question, like I said, any questions at all, please just pop them in the chat. Um Otherwise I'll just keep talking through it. But if you want me to explain something again, um just let me know and I can either do it then there and then we can come back to it at the end. Let me get the pole in the chair. 10 seconds. All right. Again, a bit of a mixed picture here. Um So that might have been challenging questions these, so let's go through it. So, cubital subtype tunnel syndrome is a world unto those. Got it. Um This one obviously testing you on elbow pathologies which as a general rule, unlikely to really come up in your M C Q s and if it does probably just going to be one question, um but if you have time, it's worth just doing five or 10 questions on past med because there's a few things that you can pick up quite quickly and that point towards the correct diagnosis. So let's go through it. So from the history here. Um It says this is accompanied by tingling in the little and the ring finger. So the two fingers at the end. Um Now hopefully you will piece together that, that indicates that there's something going on with the ulnar nerve. Okay. That's the nerve that supply in those two fingers because you've got the funny bone sensation and the tingling in those fingers. That's what's going on. It's something with the ulna nerve. Okay. So we can rule out a couple of them just because of the fact that they've got nothing to do with the all the nerve so lateral become the litis and it's obviously sort of the side where your thumb is so that all enough isn't traveling there. It's on the raid that will be on the radio side, median nerve entrapment syndrome. The clues in the name that it's not involved in the all the nerve and again, radial tunnel syndrome clues in the name is not involved in the all the nerve. So you just left there with cubital tunnel syndrome and medial epicondylitis. And that's because the all the nerve travels through the medial aspect of the elbow. Okay. So that's why you keep in medial epicondyle lights in, in as a differential. Now, the big way to distinguish it, okay. So, cubital tunnel syndrome to his compression of the all manner that that's what's going on. Um And it's made worse by the flexion of the elbow which makes sense right there, nerves going through the elbow. If you start aggravating that joint, you're going to start causing more compression over it. You can see here, it says symptoms are worse when the elbow is bent for prolonged areas. Okay. Now, medial epicondyle lightness. So that is tendonitis of the common flexor tendon. Now, don't worry if you forgot your anatomy, but just remember that the common flexor tendon is on the medial is on the yet medial aspect of the elbow. And the common extensor tendon is on the lateral aspect of the elbow. Ok. So if we just focus on the medial one, the common flexor tendon, now that can involve the all the nerve just by nature of the fact that the all the nerve is in very close proximity to it. Now, that's made worse though with flexion and pronation of the wrist. And the reason for that is because obviously the common flex attendant is connected to all the muscles or the flex the muscles in the forearm. So when they're working, when those muscles of flexing flexing the wrist, that is putting more pressure on the common flex attendant, which in turn is putting more pressure on the, on the nerve. Okay. So that's the way that you distinguish those two. Um It's not as high yield knowledge for your M C Q s. So don't worry if this is new and you're stressed about other things that you need to learn. Um Hopefully that's helpful for a few of you. Um Right. Next question. Unless there's any questions. Yeah, next question. All right. There we go. 20 seconds. Thank you. Five seconds. Anyone wants to get the last answers in. All right. Let's go for a few of you got this and the generic seems I've got this one. Um, so it's treatment with an NSAID and start physiotherapy. Um, so what's going on? So it tells us in the MRI and we've got a prolapsed disc and that's causing sciatica from the history. Okay. Um So n so it's a physiotherapy that is the first line treatment for sciatica and it's also the first line treatment for back pain in general, okay. Um But you're going to start with that. Um, you start of answers and you start zero and the reason you start with those two because it's successful, 90% of the time, just those two things alone can stop, can cure it or reduce the symptoms. Um If we look at the other cause the other options. And so a few of you put routine referral to neurosurgery to fix the disc so you can do that, but that would be second line. So if that hasn't worked, the nsaids and physiotherapy, then you refer on and specifically you're going to just refer it to the spinal surgery. So it could be neurosurgery that could be orthopedics. Um, and it could be for an injection or it could be for an operation to fix it okay. But that's second line over options, start oxyCODONE. So hopefully you will know. And if not, hopefully now, no, don't give opiates for back pain. Okay. And they're not that great, treating the pain. And you've obviously I'm sure you're all aware that there's the risk of dependency. So never really give opiates for back pain. If you can give any pain killer for back pain, it's an sets unless the country indicate is just be careful of that one. But yeah, the other options, emergency admission to neurosurgery, hopefully you will realize patient's stable here, no signs of quarterback whiner. So it doesn't need an emergency admission and reassurance and discharge. So the reason that you can't just send them out on the way without giving them nothing one, obviously you want to give them something for the pain, but to the small risk that, that worsens at that disco worsens and if it does, it could progress to Korda Equina syndrome. So you want to do something and that's what the physio comes in for. Um So yeah, hopefully that makes sense. So just remember quarter equina or back pain in general first line treatment is any nsaids and physiotherapy right next question. Yeah. So five seconds. All right. It's the majority of you got this one, but it's a bit of a tricky one. Um If you've never come across it before, then it's a very difficult one. Um But world into those that got it. Echocardiogram is what you're gonna do here. Okay. So, like it says in the history, there's a sewer abscess going on. Um, we've disguised us in the picture as well. Um With staph aureus found in the blood. Okay. So, so those abscesses um very rare to occur by themselves. It's normally even linked to someone that's got Crohn's these, that's one cause but the other cause the most common cause is spread in the blood of staph aureus from somewhere else. And that normally comes from endocarditis. Okay. That's the most common cause there. So if you see someone with a, so it's abscess, you think could it be Crohn's, could it be linked to Crohn's or is it endocarditis now? Because it's, you would know that there's a spread of staph aureus here that's pushing you even more even further towards um endocarditis. Okay. And, and obviously looking at these imaging modalities here, the best way to look for endocarditis is an echocardiogram. Um HIV, serology. Um The reason that that's listed probably there is a differential is because infective endocarditis is linked to being um immuno suppressed. If you've got HIV, then you're immuno suppressed, which means and you can more likely to get endocarditis. Um But like it says in the question, you're looking for a source of the infection um which is going to come from the end of carditis. So hopefully, that makes sense. Um Yeah, yeah, I'll leave it for a couple questions if anyone's got any. Um, no, fine, we'll move on. Um, here we go. It's a bit more and not everyone to, a couple of people have gotten it right. 10 seconds if anyone wants a final stop at it. All right, let's go through this one. Um, so most majority got this one, but it's a bit tricky, um, sciatic nerve and that's the nerve that's most likely to be damaged. So let's go through it. Okay. So the sciatic nerve is follows behind the femur, okay. So anyone that has a posterior hip dislocation, um which is most likely in this case just by nature of how they felt the mechanism of the actual injury. Um If you can imagine because you've got the sciatic nerve behind the hip. If the hip pushes backwards, then it's going to stretch that nerve out and damage it and that's what's going on here. Now, the reason the other things that you can do is thinking of what does the sciatic now do and then look at the symptoms and does it match up? Okay. So one, it's a common complication of posterior hip dislocations. Um So you can, you could have got the answer just from that knowledge there. And, and two, when you're looking at it, you've got pain in the posterior aspect of the left thigh and radiating down the posterior and lateral aspects, which is what the sciatic nerve is responsible for the foot drop, that it mentions the foot drop is caused by injuries to the common peroneal nerve. But that comes off the sciatic nerve. So if you've got an injury at the sciatic nerve, then that injuries just gonna, it'll still be there when you go further down the train and that's what's happening there. So that explains the foot drop. Looking at the other nerves, you don't have to worry about what each of these nerves due for your M C Q s. But just in case any of you were thinking of these, it's a femoral nerve. That's what that's responsible for. And optiray to nerve obturator nerve is maybe the only other one to think about and remember for your M C Q s. And that's because it's associated with anterior hip dislocations. Okay. And those are symptoms there how it presents. So, obturator anterior hip dislocations, sciatic nerve, posterior hip dislocations and uh about that and that nose, the other features of the other nerve injuries, but I won't worry about them too much. Yeah. Right. Move on to the next one. There we go. All right. 10 seconds. All right. And so uh let's see. So a bit more mixed again, a bit mixed here, but a few people have got it. It's well done to those that did. Um So his legs shortening an internal rotation here. And so if we look through the history and we know that it's a hip dislocation. But now is it anterior or posterior dislocation looking at how she had the injury, the mechanism of the injury? If you can imagine if you're in a car is going quite fast, hits something and then your, you need it, the dashboard and your upper body is pushed forwards to your hips, sort of pushed backwards. That would be a posterior dislocation. So hopefully, that makes sense if you just think about how the injuries occurred. So then it's how does hip posterior hip dislocation present? Okay. So I'm sure when you sort of seen external rotation, leg short and things like that, your mind might just jump straight away to a hip fracture. Um But it's a hip dislocation here. Um And the way that that presents a posterior hip dislocation is leg shortening with internal rotation. Okay. Whereas a hip fracture, you'd get leg shortened with external rotation. Okay. If you're only going to remember any one thing, remember how it presents for a hip fracture because that's more likely to be tested. Um which to repeat is um like leg shortening with external rotation. Um But this is how a posterior hip dislocation would present. So just worth being aware of the different ways that can hip injuries can present. Um Yeah. Right. Mhm 20 seconds fine or five seconds. That, all right, let's go through it. So a few more of you seem to have got the sponsor well done. Um So Super Acromial impingement or just impingement that's going on here. So if we look, if we look, go through them and eat all of them, um, so this is sort of classic picture of impingement. Okay. Um So it gives you some information about the different types of swimming strokes, which can give you a clue, but specifically for the examination findings, anytime I see anyway, any time I see pain and shoulder abduction from 90 to 120 degrees, you're thinking of impingement, some supraspinatus impingement or subacromial impingement. Um That's like a classic classic mcq or Rosky um presentation of that condition. Okay. Um So yeah, like I said, it's a classic picture of that. Um Just from that alone would be as soon as I see that it's one of those questions where you're just looking for super spine area. So, um anything that's impingement got it in um rotator cuff test was one of the differentials. It says the final sentence, no weakness of the rotator cuff muscles. So unlikely to be that glenohumeral instability. Um So that can lead to like an impingement type syndrome longer term. Um But like I said, the history is just classical for impingement, subacromial impingement. Um um a acromioclavicular degeneration. Um There's another differential work being aware of in an off ski. Um Hopefully, you know, that that's too close associated with all these symptoms, specifically sort of the clicking grinding and a positive scarf test um for your examinations. Um So it should, should hope, say that in the, in the question stem if you had that, if you have this question come up in your, in your MCQ exam. Um And the other one is calcific tendinitis. So I didn't really know too much about this until making the slides. Um, but apparently that can present quite similarly. Um But the difference here is, it's extremely painful and much more painful than here to the point where any, any palpitation or any movement causes extreme pain. And you can see here it says no pain on palpations. So that's what its ruling out with that statement there. So if you see a question like this with extreme pain in the shoulder, then you can start thinking of calcific tendinitis. Um But if you can't remember anything from this, this question, just remember, this is the classical picture of impingement, which is super Spinatus impingement of a wise termed subacromial impingement. Um Yeah. All right. Next question. All right. Five seconds. Okay. All right. Let's go through this one. So what's going on is the first question? Could it be uh meniscal tear or could it be an ACL tear? Um Like I said before, both present quite similarly, both present sort of younger people, sports exercise, twisting movement, which sounds like it could have been here. Um Both have sort of a popping sensation. We could come presenting both of them and they both have swelling. Now, if you remember what I said before, it's the time of the swelling can be used to distinguish between them. Um, but it doesn't really give us a timeframe so I can't really use it here. However, it does say that the patient is unable to fully extend her knee now in my head. And when I've seen it in practice, I see that for both meniscal tears and ACL tears. However, on pass med, it has the inability to fully extend your knee as more of a municipal municipal tear feature. Okay. So unable to fully extend the knee is more associated with meniscal tears. Now, the thing is it doesn't really matter whether you thought it was a meniscal tear or an A C old hair because they're both assessed by an MRI scan. Okay. So that is the correct answer for this one if you look at the other things, okay. So an ultrasound scan isn't gonna be that affected just because the knee's swollen. Okay. So you're going to just be seen loads of fluid through the scan. And so that's not ideal joint aspiration. If you're thinking more a rheumatological cause or a septic arthritis, then maybe you could think of that. Um an X ray, it's not ideal really if you're thinking of Meniscal Law ACL tears and you, you won't really be doing HLA testing. Uh So, yeah, it's MRI there. All right. Next question. If you guys have any questions. If I'm going too fast or going too slow. Um Either way, please let me know or if you want me to repeat anything, I can repeat it now or I can repeat at the end of the session. It's not a problem. Yes. Um Yeah, there'll be a record available for ketchup. Um Yeah, I'll put the feedback form in though if, if you plan, if you have to leave shortish, um please just fill out the feedback form if you can, but there will be a recording for catch up content if you need to leave. Uh, if you need to leave early. Um So no, no problem. Um But the time is up there. So we'll go through this one. Um So again, mixed picture. Um Now what it is, it's all on the proxy in. So if you remember from before, when we were talking about the sciatica question, the first land management for back pain is an oral NSAID plus physiotherapy. Um Obviously, it doesn't mention anything about physiotherapy air, but it's oral and said. So a few of you put topical ibuprofen and I think where you might've been tripped up with is because that is, I believe first line for osteoarthritis of the knees, you can start with topical Ibuprofen first for that. Um But when dealing with back pain and the first line drug that you always do is an NSAID. Okay. You always start on an NSAID first. Um If you need to escalate it, then you then onto a week. Oh Pia. So you could then go naproxen plus codeine and then it's plus minus paracetamol if you want at that stage. But don't give paracetamol just by itself for back pain because it's not that effective. Okay. It's n sets that you need for back pain. Um, and obviously the most likely thing that's going on here. Hopefully that you got from history is it's just normal muscular scalable back pain. Yeah. So yeah, next question. Yes. So Ibuprofen is an NSAID but it's oral NSAID that you need to give first line, not topical NSAID. It's um so yeah. Um and Naproxen is an insert. Um So. Alright. 10. Oh I've not put the pole in. All right. Okay. Sorry I didn't put the pole in that. Um I'll give you a second, give me a couple of seconds. No one's got the correct answer for this one. So maybe it's a bit of a tricky one. Someone's got it there. Someone's got it right. Let's go through it. So what's going on here? Um I'll Australia down first. So, you know, MRI um but from the history, it sounds like this is likely to be osteo my latest or infection of the bone. Um Now look at this, you've got an elderly male who is um diabetic um who's been so diabetic currently on treatment, but they've got an infection slightly tacky. So you're thinking could this be some sort of septic picture as well because of the fever, because of the heart rate and a deep also on the ill in someone with diabetes, you've got to think of osteomyelitis. Um, as, as what's going on. Okay. And I'll stay on my light as the first line investigation for it is an MRI. Okay. Um, so if you don't, hopefully, you know what Osteomyelitis is, but if you don't have to say it's an infection of the bone, mainly seen in people with diabetic feet and don't be fooled by the fact that it says, um he, he hasn't noticed it and seems unconcerned, he hasn't noticed it because he's got a diabetic foot and he's not got any sensation in the foot. So he's not feeling it. If he could feel it, it would be very, very painful, I imagine. And so other other things that you could do the biopsy, the reason you don't do a biopsy is because because they've got a diabetic for it's going to be poor wound healing. It's not ideal. So if you start going in and taking chunks out, it's gonna just cause more damage to that area. Okay. And you're also not going to be able to see the depth of the infection. So the reason you want to do an MRI, you want to see how deep is this infection um in the bones. Um And a biopsy is not going to tell you that um similarly for a CT. Um So you can do a CT, but you would do that second line if an MRI wasn't available. Um Just because MRI gives you more information, repeat the examination, you could do, we're not going to get anything from it really. Um You might get a few small things but you're not gonna get the big pieces that you want to know, which is how deep is that infection. Um And an ultrasound um ultrasound generally avoid for looking at the bones because not that great for looking at harder objects. It's more for soft tissues. Um So yeah, so hopefully that makes sense. So just all you need to remember is osteomyelitis. First line investigation is an MRI. Yeah. Next question. Good. And what if you seem to be getting this one 15 seconds? Final couple of seconds? All right, let's go through this. So we have an undisplaced intracapsular fraction. Okay. Has internal fixation you do. Um So if you remember before what I said and so I'll show you the next slide, we'll go back to that table and the graphic. But for an intracapsular fracture, the first thing that you need to work out, is it displaced or is it undisplaced? Now, if it's displaced, which it is in the majority of cases, then you start worrying about is the patient active and mobile or they non mobile. But for an undisplaced intracapsular fracture, you can just go straight in with internal fixation okay. If you go back to this slide here, this, this is what we're looking at this top one here on displaced intracapsular fracture. Um And the reason that you can just do an internal fixation and you don't have to worry about taking it out because it's undisplaced. You're not worried about those arteries being severed. Um So you, you're fairly confident and happy that there's good blood supply, still go into the neck of the femur and the head of the femur. So you can leave it in place. You just put a nail in place to stop it wobbling about whilst it's healing. Um So yeah, so hopefully that makes sense. Um Realistically though. Um You need to remember this via MCQ is because it can come up in mcq in real life practice is unlikely to have an undisplaced hip fracture because the force it takes to break your hip isn't likely just going to knock it out of place. Um But yeah, right next question. So we've got four more questions. I'll just put the feedback pole feedback form in the chart. If you do have to rush off, please please fill out the feedback form. Anything you think went well, please put it down. Anything that you think could be improved, please put it down. Um But yes, you have to rush off. No problem. Thank you for coming along. Um And for those that are happy to stick around should hopefully be only over 10 minutes or so. Mhm. A few quicker questions at the end. Uh, everyone seems to be getting it so well done. 10 seconds left. All right. So let's go through this one. So it wasn't to those that got it. And, yeah, weight loss, simple stretch exercises and rest in the heel. Um, so if we look through it, so what's going on is what, what's causing this, um, it's likely to be plantar fasciitis, which is the most common cause of heal and foot pain. Um, other differentials that you could think of under investigation for diabetes. So you've always got to think, could this be a diabetic foot unlikely that you're going to have increased pain in diabetic folks, numbness, reduced sensation. Another differential that you could think of is maybe a fracture in the foot, but normally it's the metatarsals that are fractured, which wouldn't normally present as heel pain. And they normally would say that there's a clear source of trauma or reason for that fracture. So that's why you sort of think of plantar fasciitis is the most common cause and the other causes aren't that likely in this case? Now, what do you do for plantar fasciitis? The first line treatment is weight loss, uh, make sure you're healthy BM I stretching the feet out, stretching that, uh, fashion out as much as you can, um, and rest the heel. Okay. That's the first line treatment for plantar fasciitis. Um, some of you put this final option here and suggest stretch. And so it's very similar except prescribing some pain relief as well. Um, generally you could give pain relief. That's quite smart. However, you don't give entered to anyone with asthma. Okay. And that's the reason why that one isn't, isn't correct. Um, and again, if that doesn't work, then you can then refer onto an orthotics unit. But again, this second option wouldn't be correct because it's got ibuprofen in as well. Um So yeah, so it's weight loss, stretch exercises, rest to heal and then you couldn't, you can review them later on. That's, that's a reasonable thing to do. Um Yeah, next question. Mhm. Alright. 15 seconds. All right. Well, let's go for it. So a few of you got this, but if you've got the different options, so don't worry. Um, so the actual answer is chest physiotherapy and adequate analgesia through a refresher. Um The reason the reason that you do that to prevent, um, an infection happening is because obviously to prevent, you've got your mucus that goes in your lungs and the mucus catches, catches, catches like the bugs and stops them going into the lungs. Now, that mucus is only effective if you start clearing it out. Part of the reason that part of the way that we clear the mucus out deep breaths, um, in order to get all the way in and help move, move the mucus up if you're unable to take deep breaths and it massively increases the risk of you getting a chest infection. Okay. Um, so you do, you need to make sure that they're on adequate analgesia and adequate pain relief so that they can take those deep breaths without that sort of catching your breath because of the pain and the physiotherapy as well will just help to clear some of that mucus as well. Okay. So it's, it's one of those things you don't have to worry about too much, but now that, you know, hopefully that sticks with you. So anyone with a rib fracture, make sure the pain is under control. Um, firstly and then get them on physiotherapy whilst they're in hospital to stop them getting the chest infection. Um, other things that you can do. So CPAP is more for sleep apnea is not really a treatment for, for this or prevention for it. The issue here isn't that they're not getting enough oxygen. That's not, you know, that it's not that they're not going to get an infection because they've got low oxygen. So that's not the case. So it's not see and then its prophylactic antibiotics. Now, sometimes you can, some people give prophylactic antibiotics, but the evidence isn't really that great for it. And with the whole thing about antibiotic resistance, it's just avoided generally until you have an infection. Okay. So rib fractures just make sure there's adequate analgesia and chest physiotherapy. Um All right. Next question. Alright. 10 seconds. Everyone seems to have got this one so I'll try to go speed through it but no go. Yeah. Um so well done. So yeah. So what's going on here? Skate fide fracture? Um The majority of you guys are well done. Um The key things that point to escape high fracture, okay is full on an outstretched hand um which isn't unique to skateboard fractures but is associated skateboard fractures, but specifically pain that's localized to the anatomical snuffbox. If you see that and fall on an outstretched hand, just be thinking of a skate five fracture. Okay. Now, the X ray here had an extra after two hours but didn't show you anything. Now, it can be quite common or it's not uncommon for skate avoid fractures not to show on an X ray immediately after the fracture. So that's why if they're still in pain, but the X ray is negative. You just arrange a follow up X ray. Um So, yeah, 10 days, two weeks later and to confirm it and these other fractures, I won't spend time going through them all. You don't generally don't have to learn all the different risk fractures, fear MCQ exams. Um But if you've got time, it can be worth looking up and other colleagues fracture or Greenstick fracture for Children, but I won't worry about these two here. The looney and Barton's. Um So, yeah. All right. Next question, I'll just put the feedback from again in. So if anyone has to leave again, very much appreciate if you could just fill in the feedback from um any, any positives, any, any negatives. Um Yeah. Right. Hmm. So I got this question one more five seconds. All right. So if you have, you got this one. Um So yeah, so it's full weightbearing immediately post up. Okay. So they've, they've done some studies that have shown that the longer you wait without weight bearing, the worse or the more likely is that you can have complications. Okay. So the whole point of doing your hip operation is to get you back up as soon as you can. Um, it just shows that it's better function longer term. Um So yeah, so anyone's had, uh, hip fracture operation, you want to get them full weightbearing immediately post up specifically as well because they've got a D H S, the way that DHS works is that by standing and by having that full weightbearing of that sort of activates if you will the DHS and tightens it. Um, so generally for a hip hop, you want to get them straight up on the feet, especially the case for DHS. Um So yeah, it's a final question. So it looks to be a bit of a tricky question. This one. Um, someone's got it. Someone's got it though, right? Five seconds. There we go. So it's a bit of a tricky one. I'm sure you will know what carpal tunnel syndrome is. But knowing five individual features of it is quite difficult. So, is wasting of the hyper fine art amendments, which is the one that's not associated with it. Okay. So carpal tunnel syndrome, as I'm sure you all know the median nerve travels through, through the carpal tunnel, carpal tunnel and what's going on is it's just compressing the median nerve. So Tinel's on, I'm sure, hopefully, you know, from your hand and wrist exam, that's where if you tap that part of the wrist, just tapping it elicits that pain and and that is associated with it, compression of the media nerve. That that is what call tunnel syndrome is. Um flexion of the wrist reproduces the symptoms. Okay. So when you do that, that movement, when you get them to hold it like that for a minute, that brings on the pain. So that's valid and then it's weakness of form reduction. So any of you put this one, but that is the case, okay. And that kind of links with this third uh waste with, they're wasting the hypothenar eminence. So Fiona eminence, the muscles there are supplied by the media enough, okay. And the muscles that are in this Fiona eminence is partially responsible for um bring for from um from uh as you know, the peanut eminence there. Um that's, that's supplied by the median nerve, whereas it's the hyper Fiona eminence on the other side. And that's the all the nerve, okay. Just all the nerve that's responsible for the hypothenar eminence. So, if you have anything with median nerve, it's not going to change the hyper fino eminence. Um, so that explains that one. Um Yeah, so, so hopefully that makes sense. Don't worry about all these different things of the couple tunnel syndrome and I just wanted to make sure you knew the main ones. Um, so, yeah, hopefully that makes sense. That is the end of the session. So I won't take any longer of your evenings. Um, but good luck for your exams if you don't see before we got our final, final session next Tuesday on vascular surgery. Um So I'm just gonna cover triple A's when to screen them. What to do with the symptomatic things like that, peripheral arterial disease and then a club over vascular questions. Um So hyper Fiona equals medium nerves know. So it's the fianna eminence, this one here that is median nerve and it's hypothenar eminence this one here and that's the ulnar nerve. Um, that's the ulnar nerve that's responsible for hypoferremia. Um So hopefully that makes sense. Um But yeah, the only thing is feedback form. If you could please fill it in, like I say, any positives, any negatives, anything that can be improved on, please just pop it down. Um If you've got any more questions, please let me know in the chat or if you want me to revisit anything. Um Just let me know. Um, but if not have a nice rest of your evening.