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Hi, everybody. Um, would someone be able to just let me know in the chat if you can hear me? Ok. And then I will try and share the powerpoint and hopefully that will work. Yes. Ok. Ok. Ok. I think we'll make a start. Hopefully you can all hear me, but let me know in the chat, please. Oh, perfect. I can see some responses. Um, you guys can hear. Excellent. I will, um, flip over to the powerpoint if you can't see it. I don't think I'll be able to see the chat. So if someone could unmute and let me know that would be amazing. So I will switch over now. Um, so my name is Hannah. Um, I'm currently in F two and, um, today we'll be talking about trauma. So, um, we're going to cover, this is kind of the MLA content that will be included. So, um, mainly the focuses on different types of fractures and soft tissue injuries and I can't really cover obviously every type of fracture and, and tissue injury. Um, but I've tried to pick the most common ones and the ones I think are probably more likely to come up in kind of a or um uh multiple choice questions, that kind of thing. Um And then also compartment syndrome, which is um kind of the the key orthopedic emergency. So that's what we'll um will cover. So if we get started with just the basic types of fracture, um so there are many, many different names and um you'll often hear like when you're, when you're working on the wards and things, um the orthopedics will say, oh, it's this type of fracture and it's, it can be very confusing. Um And often you don't really know what each one means and they kind of combine different words. So these are the kind of generic terms that can apply to any different type of fracture. So, um we'll just run through those. So firstly, we've got um here the Fischer fracture, which is also called a hairline fracture, um which is probably what you've heard it called more commonly. Um And this is just a small crack in the surface of the bone. Um You often can't even see these on an X ray. So um they can be quite hard to kind of diagnose, but um it's mainly done by the, the kind of clinical story of of what's happened when there's been kind of a minor trauma or um possibly a bit of an overuse injury of it, especially at the top of the foot, like that kind of thing. Um So tho those are your kind of hairline fractures. Um Then next to that, we've got an impacted fracture, which is where you have the fracture and then you have different fragments of bone as you can kind of see around that fracture line. Um This is where the those fragments um drive into each other. Um So it's often done in a high force injury where there's been a high pressure and then different fragments and they kind of compress into each other. And so that's your impacted fracture. And then you've got the transverse fracture, which is a straight line break across the bone. So you can see that quite clearly in that picture. And then you've got a segmental fracture which similar to the, the transverse, but you've got two of them, you've got two of those breaks um with, oh sorry, I keep pressing two of those breaks with a floating piece of bone in between the two. So that's kind of your segment. So that's a segmental fracture. Um Then you've got the oblique fracture which is a diagonal fracture across the bone. Um So that oblique just means kind of going diagonally. Um Then you've got an oblique with offset, so that's where it's um slightly displaced. Um So you can kind of see there that the bone is not aligned anymore. It's, it's pointing in the wrong direction. Um Then you have a comminuted fracture where you have three or more fragments. So you can kind of see here, the red line is the fracture line and then the white is obviously the bone. So you can see there's three small fragments there and then obviously your main bone above and below as well. Um Then there's the green stick fracture where it's just a break on one side of the bone and that causes the other side of the bone to bend. So you get a slight bend, it's not really well pictured on, on this diagram, but um so fracture on one side causes the other side to bend. Um And then you've got a longitudinal fracture. So that runs the whole length of the bone. Um And that often comes from a really large impact injury. And so those are just your types of fractures. So they can be used to describe pretty much fractures on any bone. So they're, they're kind of the basics of, of fractures. Um The, the general principles of fracture management kind of apply to many different types of fractures, the, the kind of basics of it and then the physicality of how you do that vary depending on the fracture. Um I'm just quickly gonna go back to the chat just to check. No one's saying they can't hear perfect. So let's carry on. Um So uh the first thing that you see with any fracture, um So you've seen it on an X ray, you've identified that there's a fracture somewhere. Um The first thing you're gonna do is reduce the fracture. So that just means to restore the alignment of that limb. Um So this can be done in lots of different ways. So, traction um is, is the most common one. So that might be through kind of manual traction um or through using kind of equipment. So it depends how severe the fracture is and how, how big the break is. Um often you will need analgesia to do this. Um, because obviously it's very painful because you're kind of putting that bone back together. Um, you can use local anesthetic if it's quite a severe fracture or even a regional nerve block. If it, if it's really, really severe or sometimes just some conscious sedation is enough just to, um, put, make the patient a bit sleepy. Um, and then they, that you can kind of kind of do it without, without them knowing what's going on too much. Um But obviously they will need analgesia as well in that situation. Um So once you've reduced the fracture and you've got that bone aligned how it should be. Um, you then want to hold it in that place. Um, so you can do this with things like splints or plaster casts. Um So that was kind of the most common ones. If you think about an arm fracture or a leg fracture, your, your, your basic fractures, then you put them in a cast afterwards. Um, you then want to re X ray to check that, that fracture is um the, the limb sorry is aligned um and is not displaced or anything. And once it's in the cast, so, you know that that cast is holding it in the right position. Um You don't wanna place a full circumference cast for the first two weeks because you need to leave a gap for swelling. Um So which is why you'll often see, um for example, in an arm fracture, the top half will be the, the kind of hard cast and then underneath will just be a bandage. Um because you need to allow room for swelling. Um because if you don't, then there's a risk of compartment syndrome. Um So you need to leave that gap and then you can convert it to a forecast after the two weeks if, if needed. Um if there's a risk of axial instability. Um So this means rotation of the limb. So if you have a two fractures, so like a, a tib and fib fracture together or a radial and ulnar fracture together, um that fracture could rotate and so those bones could kind of twist around. Um Even if it's, there's a cast on there, those bones could still twist. Um So in this situation, you would need to go above the joint that's affected. So if it's a radial and ulnar, you'd need to go above the elbow um to stabilize that whole limb, not just the, the lower part. Um to stop the rotation of the bones. So other things that you should always consider when treating people with a fracture is their weight bearing status. So, can they walk on that leg that's broken or do they need to not put any weight through that leg? And if they can't, for how long can't they? Um It's also important to think about weight bearing in upper limb fractures, which often is forgotten because people think you don't walk on your hands, obviously. Um, but you do use your hands for lots of things like pushing yourself up to standing and, um, yeah, lot, there's lots of things you use your hands for that you do put your weight through. Um, so you do still need to give a weight bearing status for upper limb fractures. Um, so often in, in kind of non severe fractures, um, they will be weightbearing but it, it really just varies. And as a, as a junior doctor, if you're treating someone with a fracture, um, but you're not working in orthopedics, um, the physios on board will hand you for the weight bearing status so that they know, um, what that patient can do and it's something that is often not, um, written down by the orthopedic team. So you do sometimes have to call and check that. Um So that's really important if you ever have someone with a fracture to make sure you clarify the weight bearing status. Um You also need to think about thromboprophylaxis if they are nonweight bearing. Um, and if that's gonna be for a significant period of time, um, particularly with lower limb fractures, if that means that that patient isn't going to be walking around as they normally would and doing exercise as they normally would. Um, then you might wanna think about some VT prophylaxis, whether that be something like enoxaparin and they need injections if, if it's really severe and maybe they're gonna be bedridden for six weeks, um or something like Ted Stockings if, if they're still able to do some things, but they're just not at their full mobility. Um You also should warn patients of features of compartment syndrome um because this is a risk with kind of any fracture and especially if you're putting on a cast and um that that limb is, is kind of immobilized and, and in a kind of compressed area, um you should warn them of those symptoms so that they know that if they experience those and will come on to Compartment syndrome later. So, um we go that way, but then they know if any of that happens that they need to come to hospital straight away. Um And then obviously rehabilitation and physiotherapy, um which varies widely depending on the injury. But um that's always something that the patient is going to need. So, um coming on to specific management. So I've only included a couple. Um these are the, the really common fractures that are seen in hospital. Um And this is the management. So for a proximal humerus fracture, you use a collar and cuff, which is seen here. Um So it just goes around the neck attaches to the wrist and keeps the arm in that position um to stop the clavicle. Uh Sorry, not. Yeah. Well, I guess the clavicle but the, the proximal humerus moving around too much. Um for a clavicle fracture, you use the poly sling. Um So you can see here the whole arm goes into this sling and that just sits around the shoulder. Um Again, keeping that arm still um in that position. But with this one, you need a bit more stability um because you don't want that clavicle moving whereas with the proximal humerus fracture, um it, it, there's a bit more movement in that one. Um And for a below uh for a wrist fracture, you will use a below elbow plaster. In most cases, apart from obviously, if it, if it's both um both bones affected, then you would go above elbow. But the below elbow is more common and that's just seen there. Um So another really common type of fracture is the distal radius fracture. Um So there are two types of distal radius fractures. So you've got the Colley's fracture and the Smith's fracture. Um this image of the x rays of a collis fracture. So you can see um here that the um bone, there's a dorsal displacement of the bone fragment. So it's a bit difficult on these pictures. I've got another picture later that kind of shows it more clearly. Um But you get this thinner fork deformity of the arm. So it kind of looks like that shape and then you can see the fork below, fork below. So you can kind of see how it has that bend in it. Um This is really commonly done by falling onto outstretched arms. So somebody who's tripped over, put their arms out to break their fall. Um And that's resulted in this wrist fracture and it kind of pushes the bone upwards and that causes that fracture. Um The Smith's fracture is kind of the reverse. So it's if you had fallen backwards, placed your hands behind you and fallen onto your hands that way. Um So these are the kind of pictures showing the difference. So you can see in the collis fracture, um the radius kind of goes backwards and in the Smith's fracture, it goes inwards so backwards towards the skin in, in that coli and inwards towards the bone in the Smiths fracture. Um The management of these is usually by a closed reduction and cast if the fracture is stable. Um But if it's an unstable fracture, um and a closed reduction isn't keeping it um reduced, then you would need to do an open reduction and fixation. So that would um involve uh an operation and um fixing it with something like a nail or whatever it needed. Um If there's concern of the actual wrist joint itself being involved, um you should do a CT to look in more detail at, at those wrist bones. So next up, we will talk about neck of femur fractures. So these are so, so common to see in hospital. Um There's, they're really, really prevalent amongst the elderly, um especially females who are postmenopausal, who have really weak bones, they're osteoporotic and they have a fall and it doesn't take much force to result in a hip fracture. So, um these patients will often present after a fall. Um Normally they've kind of fallen onto their side um and they are unable to wait there. Um The kind of classic presentation is that the affected leg will be shortened and externally rotated compared to the other leg. Um Your first kind of test would be a hip X ray but if that's normal, um but they are still unable to wait there. And the physios usually are the ones who kind of have concerns that they're just not able to put any weight through that leg, then you will need to do act to either confirm or rule out a neck feur fracture. Um It usually they are seen on, on x rays, but if there is still concern, then ct will kind of confirm it. Um Most hospitals now also um have Ortho geriatricians who are elderly care doctors who specialize in neck of femur fractures and looking after those patients, um this is really important because people come in with a hip fracture. And then obviously that's kind of the priority to, to fix that. Um But you still should consider the cause of the fall. So why did they fall? Did they have low b low BP? Was it just a trip or they just fell? Or you know, all of those things that a geriatrician would normally look at when somebody has a fall could get missed if they just kind of came in, had their operation and went home again. So it's really important to have that kind of thorough geriatric assessment um at that same time. Um and also looking at bone protection plans. So, um so quite often these patients will come in and they've already been on a bone protection, which clearly has not worked because they've still got a fracture. Um So you might need to consider an alternative or perhaps they're not taking it or, you know, so you should look into that a little bit more as well. Um So looking at the kind of details of the fracture. So if we just look at the anatomy first, so you've got two types of neo feur fracture, you've got intracapsular and extracapsular. So intracapsular is defined as anything above the intertrochanteric line which runs from the greater trochanter to the lesser trochanter. So if you imagine a line here which is kind of seen here as the boundary between the green and the red area. Anything above that. So in the femoral neck or femoral head will be an intracapsular fracture. Anything below that line is extracapsular and that is further divided into intertrochanteric, which is the area between the greater and lesser trochanter in this green area. Um And anything below that is subtrochanteric. So you're heading into more of the actual femur there. Um So that's how you kind of divide it and it is important to know um what is affected because it does change the management. Um So just looking at intracapsular in a little more detail and you have the garden classification um which uh classifies them into four types of fractures. So grade one would be an incomplete fracture. So it doesn't go the whole way through the neck. Um And it's non displaced. A grade two would be one that does go the whole way through. So it's a complete fracture but it's not displaced. Then the type three is one that is a complete fracture and partially displaced and type four is a complete fra fracture, fully displaced. So the head is completely off the neck. So the management um so nice guideline guidelines kind of tell you what the management is for each different type. Um But the the kind of basic way of thinking about the management is if it's a displaced intracapsular, so that would be um kind of a type four. Um, you will do a hemiarthroplasty, um or a total hip replacement. So to kind of decide which one to do you consider the patient's level of function before the injury if they were very independent, um, not very frail, um, very mobile, doing lots of things independently. Um Then you are more likely to do a total hip replacement because that will allow um that patient to keep up that level of independence for longer because you've replaced that whole joint, it would last a long time. Um Especially in younger patients, you'll consider that more as well, but really, it's the the level of function that that does it. Um The reason that you go for an arthroplasty in this case is because the highest risk of avascular necrosis is in a displaced intracapsular fracture. Um That's because the um medial circum circumflex femoral arteries lie inside the intracapsular femoral neck. So if that is fractured, you've got a really high risk of necrosis in that head. Um So you want to replace that whole head um to avoid avascular necrosis um in a non displaced intracapsular fracture, um most often you'll go for a, a hip screw. But again, you can consider an arthroplasty if they were very independent before their injury. Um for all the same reasons that it will last longer and allow them to be more independent for longer. Um in an intertrochanteric um fracture, you will go for a dynamic hip screw or a short IM nail. So, um in these fractures, it's more about fixation. You're not replacing that joint, you're just fixing that bone. Um And then a subtrochanteric, you'll go for an IM nail. So again, it's just about fixation um Fine. So that's all of that. Does anyone have any questions on any of those bits before we move on to the next bit on soft tissue injuries? Ok. I'm gonna take that as a no and head back to the presentation. So, um, onto soft tissue injuries. So I try to include the most common ones, um that could come up in an ACY and um, you can kind of get quite well from a clinical history and examination. You can kind of diagnose this without lots of investigations. So, um, one really common presentation is a bursitis. So the bursa are sacs that sit where there might be friction usually between tendons and bones, for example. So at a joint where those 10 where you're using that joint often and those tendons and bones are rubbing on each other, you have this bursa, this sac to prevent them rubbing on each other. Um, bursitis is when you get inflammation of this bursa, um which can be due due to trauma, can be due to infection, but most commonly is due to chronic overuse of that joint. Um So if you're, you know, you do a job where you're often bending your elbow, then you're at risk of an electron and bursa, for example, um the bursa are usually very thin. But in bursitis, they get thicker because they become inflamed and they sometimes have edema around them. So the joint can appear swollen. Um If the joint is infected, it will be swollen, warm and painful. Um, so bursitis is one cause infected. Bursitis is one cause of kind of painful, swollen, hot joint. Um The elbow, shoulder and knee are the most commonly affected and you will get a limited range of motion in those joints. So this is just a diagram showing you um a healthy bursa versus one with bursitis. So you can see it's a lot bigger. Um they sit on the kind of joint area. Um and this one's inflamed and hot. Um So signs of an infected bursitis, um I already kind of said being warm. Um but you might also get systemic features. So they might be feeling really unwell, they might have a fever, they might have low BP. All your kind of classic signs could have signs of sepsis if it's really severe. So they can, can present really unwell. Although it is uncommon, um signs of traumatic bursitis would be a really rapid onset swelling of that joint. Um In that situation, you're probably gonna wanna rule out other things like a fracture. But um traumatic bursitis could be one differential in in those situations. Um The management of bursitis usually, um, just consists of resting the joint and taking nsaids to reduce the inflammation, um, icing the joint and you can use elastic banding once you're returning to the activity that caused the injury. So, um, if it's playing tennis, then when you're playing tennis, you wanna bandage up that elbow to kind of keep compression there to reduce inflammation of the bursa. If it's infected, then you will need to aspirate the joint to identify what's causing the infection and then treat that with antibiotics. The surgery is rarely used in this case. But um you can do an incision and drainage of the bursa if it's not improving with those conservative techniques and the bursa can be removed if it's really severe, but it's very uncommon, usually conservative management is enough. So then we've got the rotator cuff injury. So these people will often present with a deep achy pain in the shoulder. Um It results from wear and tear of the shoulder joint. And what you will see is a limitation of the movements that are supported by the rotator cuff muscles. So, we've got the, the four muscles here. So, supraspinatus, infraspinatus, Teres minor and subscapularis, um each of those has a role. So when you're examining somebody and you suspect a rotator cuff injury, you're going to want to ask them to do all of these movements as listed. I won't read them all out. Um But for example, lifting your shoulder out to the side if somebody cannot do that, that suggests a rotator cuff injury because it suggests that the supraspinatus muscle is affected. Um So yeah, those, those, it's, it's kind of external rotation and elevation of, of the arm of, of the two key ones to assess for. Um this is caused where you get a tear in the tendon that attaches one of these muscles um to the bone. So it doesn't have to be that all the muscles are affected. It can just be one of them, but it's where that tendon that's attaching the muscle to the bone is affected, so that muscle can no longer help the bone do its movement. So the management for this is an X ray to rule out other causes like a fracture. Um You can do an ultrasound or an MRI to give you a detailed picture of, of the muscles and the tendons. Um to confirm that this is the cause. Um treatment consists mainly of rest ice and physio. Um but you can try steroid injections which are sometimes helpful and in severe cases, you can do a tendon repair or a tendon transfer. Um and you can even do a shoulder replacement if it's really severe and it's really affecting somebody's quality of life. Um that is an option, but it's less common. Most commonly. These are managed conservatively and improve really well with physio. So then we've got the achilles tendon rupture. So, um this diagram just shows you where the achilles tendon runs, so it runs from the muscle here um down to the heel. Um And these are the movements that the achilles um allows you to do. So, dorsiflexion and plantar flexion. So in an achilles tendon rupture, it's often um during motion or during sport, that kind of thing. Um And you get sudden onset pain in the heel and calf area. Some people even say that they hear a pop, which is the tendon snapping. Um, the ankle will appear more dorsiflexed when it's relaxed and just dangling down. So it would be more dorsiflexed. So it would be pointed upwards here, whereas normally it would be dangling down. Um, you may also actually be able to feel a gap. So if you feel the kind of back of back of the um, ankle there, normally you can feel the tendon, but you might actually feel a gap where it's ruptured and it's no longer sitting there. Um, plantar flexion may be affected so they may not be able to point their foot downwards. Um, they won't be able to stand on their tiptoes, um, because it helps with that movement as well. Um And you can do this Simmons calf squeeze test, um, which is where you hang the feet over the edge of the bed and squeeze the calf muscle. If the achilles is intact, the ankle will plant a flex. So point downwards. But if it's ruptured, it won't. Um And you can do an ultrasound to confirm the diagnosis. Um So the management again is, is all the all the same things really for all the soft tissue injury. So rest ice nsaids elevate. Um and you can do surgical management where you reattach the tendon. But obviously, in this case, you risk infection and all the all the side effects of surgery. However, in non surgical management, there is a higher risk of re rupture. So there, there are kind of pros and cons one of both. Um And you really have to look at the patient and what would be best for them. So, you know, in a professional footballer, surgical management probably is the way to go because they're a very high risk of rupturing that, that tendon, they're probably quite keen for it to get fixed quickly. Um And they'll take those risks of surgery, but in a kind of frail older adult, the risk of surgery would actually be higher than the risk of re rupture. So, um just a little bit on sprains. Um this is just where a ligament is stretched or torn. Um, you get pain in the injured area which can be worse when they are weight bearing. Um You can see bruising and swelling. So quite often people think that it's a fracture and they think that they've broken their leg when actually it's, it's just a sprain, but it can present very similarly. Um So we always wanna do an X ray to rule out an injury to the bone. Um and the treatment again is all the same rest ice compression, elevation and analgesia. So now on to the final part of the presentation. So um we will talk about compartment syndrome. So this is your classic orthopedic emergency. So um just a bit on the kind of background of how this happens, then we'll get onto the symptoms and management. Um So fascial compartments are compartments in the limb that contain muscle nerves and blood vessels. If there's an injury to one of these things like a muscle injury, it causes swelling. This obviously results in increased pressure within that fascial compartment and the fascia cannot stretch. So this results in compartment syndrome because you essentially have a locked space that's then got swelling inside and an increase in pressure, but nowhere for that to go because that fascia cannot stretch. If that pressure gets high enough, the blood vessels inside that compartment can be compressed and that cuts off the blood supply to that area. Um And this obviously then gives way to necrosis and that tissue will die and that limb can die and be lost. So that is why compartment syndrome is such an emergency because you need to decompress that compartment to release that pressure to prevent that necrosis from happening. So this is just some diagrams um of the compartments of the legs. So there's four compartments um the anterior lateral, superficial posterior and deep posterior compartments. Um So you can see in this image how they they lie looking through the leg and then here um how they lie um looking at the leg. So causes of compartment syndrome can really be anything that can cause swelling. So, fractures, crush injuries, muscle injuries, a severe sprain or a bandage or cast being too tight. So really anything that can affect your limb can cause compartment syndrome. The symptoms um are categorized into these five ps. So you get pain, which is disproportionate to the injury and doesn't improve with elevating the limb or analgesia. You can also get paresthesia, um which can be a loss of sensation or weakness in the affected area. Um You get pallor so the limb can appear paler than it normally does. Um pressure, which we would say is swelling and paralysis. So they're unable to move that area. Um This is often a late sign and a very, very bad sign if, if it's reached that point. Um So the management, so you can look at the boast guidelines. So it's the British Orthopedic Association something I'm not sure what, what it all stands for. Um But they have really good guidelines on lots of orthopedic conditions. Um So I'd recommend looking at them um if you want more detail. Um but the kind of key things you wanna do to begin with is remove any tight bandages and casts that might be um causing the um causing the compartment syndrome. You can elevate the limb to try and reduce that swelling, to get that fluid flowing downwards. Um But the ultimate treatment is an urgent fasciotomy, but obviously, you can't do that immediately. So these are other steps you can take in the kind of interim before, before that patient is taken to theater. So the incision during a fasciotomy should be made along the entire length of the compartment that's affected. Um And you want to cut into that fascial layer to relieve that pressure. Um You can then look for any necrotic tissue um and debride it. So take that dead tissue away. Um and then you would leave the incision open um and cover it with a dressing, don't close it straight away because that increases the risk of compartment syndrome happening again because you're closing that compartment. Um So you want to leave it open to allow for that pressure to come out and not, not get compressed again. Um The patient may require multiple debridements. If there's lots of dead tissue, you might remove what you can see on day one and then the next day, you might have to have another look check for any more dead tissue, remove some more. Um And then you can close that incision once the swelling has decreased. So that might be after several days. Um So obviously, in that meantime, you need to keep that incision wound very well dressed um and covered so that you're not increasing risk of infection. Um This shows you how to do a emergency fasciotomy. So, um this technique is called the two incision, four compartment fasciotomy. So you'll do one lateral incision and one medial incision. And this should cut through all four compartments. So if you're not sure what compartment is affected and you just need to decompress, you wanna make sure you cover all four compartments. So that is how you would do so. Ok. So that is everything I have a little quiz. But does anyone have any questions before we do the quiz? Ok. So I can see one question uh from Ahmed. Um is pseudo Atro atrophy reflex, sympathetic dystrophy common with compartment? I don't think so. II am not sure on that though. So I don't want to say yes or no. Um Just having a quick look, that's the same as complex regional pain syndrome. Um So yeah, I don't know, I don't know the statistics on that. So I don't wanna give an answer. Yes or no. Um I would imagine it but it probably can happen. But yeah, I'm not sure. I don't as far as I'm aware in all my research on compartment syndrome, I haven't heard it being a common thing but I'm sure it can happen. Ok. Right. Um I think we, oh hang on. We've just got another question. Most of the five ps overlap with the six ps of acute limb ischemia. Is there any way to differentiate if we don't know about compression and trauma injuries? Ok. So yes, they do overlap. But if you think about it, it's because actually compartment syndrome is limb ischemia in a sense just from a different cause. So, um when you have an ischemic limb from a vascular cause, you're not getting that blood supply to that limb. Um So you're getting those symptoms of ischemia in compartment syndrome, you are also not getting blood supply to that limb, but it's because of compression of the um the vessel rather than a vascular problem inside the vessel, it's compression of the vessel. So those symptoms you're seeing are because of a lack of blood flow to the limb. Um So they will be the same but the cause is different. So I think if you don't know about compression or trauma injuries, if the patient just presented you with a, a pale limb, you know, a pale pulseless et cetera, um then, and there's no history of trauma, then it's unlikely to be compartment syndrome. Um and more likely to be vascular. Um But you would then obviously in that situation, if you're suspecting acute limb ischemia with the vascular course, you would do things like a Doppler and stuff. So you would then have that diagnosis if they were all fine and actually the pressure in the vessels were was fine and all of that, then you might want to consider other things. But I think the way the patient presents would tell you what one is more likely if that makes sense. But, uh, yeah, the symptoms do overlap because essentially it's the same process happening just with a different cause. Um, and any thoughts about trauma stations, um, in oss history and examination, I think, I think a trauma station is unlikely to come up in an ay, I was thinking about this um while I was preparing this and I don't see how it could really be done because a lot of orthopedics and the management of these fractures is more specialist. And as an F one, you wouldn't be expected to be managing any of this by yourself. I think it's more likely to come up in a kind of M CQ style um question rather than in an osk. But if, if it were to come in an ay, um the key things in the history obviously to, to talk about the mechanism of the injury when it happened. Um Socrates for the pain, um thinking about any other injuries, like if it's a, a car crash, for example, they might come with leg pain, but you need to think about how much force there was, whether there might be other injuries and all of those things, you, you kind of primary survey of the patient, but all of these things are, I think above the level of what would be expected as an F one. So I don't think it would be likely to come up in an osk. Um, maybe something more like a rotator cuff injury where you could do your kind of full upper limb, um, musculoskeletal examination, um, that could come up, but so a really good place to watch and, and learn about those examinations is the versus arthritis website if you haven't come across it. Um, it's really good, has some really short videos and breaks it down into like the shoulder exam, the elbow exam, hand exam, knee hip, it's really, really good. So I recommend that for um examination skills of, of the different joints. Um But yeah, I think unlikely to come up in an ay. Ok. If there is no more questions, I will go back to the quiz. It's only four questions I think. And it's just multiple choice. Um You can put your answers in the chat if you want to or you can just think it in your head. It's nothing too serious. It's just running, running through a few of the, the key points. So you are the F one on orthopedics. A 30 year old woman presents to A&E after a cupboard fell on her leg. She's in significant pain, not being controlled with morphine. Her foot is pale and she has reduced sensation. What would be your immediate management? Oh, and your options are trial stronger analgesia. Order an X ray, elevate the leg and cool your registrar or perform a bedside fas fasciotomy. Ok. So just looking at the answers, I can see a lot of CS coming through. Um which yes would be the right answer. I think in this situation, the biggest worry is that this could be compartment syndrome. Um So you wanna do what you can in the immediate, so elevate the leg, but the key thing would be call your registrar because this is an emergency that you will not be able to manage yourself. Um You cannot do a, a fasciotomy. Um And you shouldn't. So um you want to call your registrar and get them there straight away and tell them that you suspect compartment syndrome. They can then come and assess if they actually think you've got some time, then you can think about things like ordering an X ray. But if they agree that they're concerned about compartment syndrome, they can then get the patient straight to theater and organize that fasciotomy. So next question, a 45 year old man has a proximal humerus fracture on his x-ray. What is the management? So you've got poly sling collar and cuff or plaster cast? OK. So we've got lots of people saying B which is the correct answer. So that was a nice simple one. But this is the kind of thing I think would be more likely to come up in an M CQ. So um the kind of different types of fractures and how you would treat them, I think would be more common than this coming up in an ACY um which garden classification is a neo feur fracture, which is a complete fracture and partially displaced. So is it 123 or four? So complete fracture partially displaced? Ok. So lots of people saying c so garden three, which is the right answer. So the easiest way to kind of remember the garden class Garden classifications is that one and two are not displaced. Um But I know in sorry, I'm telling you it wrong now. One and two are not, are both incomplete fractures. Um And oh gosh, I'm getting myself in a muddle. Now let me get the slide back up cos I don't wanna tell you the wrong things. Um Here we go. So one and two are both not displaced. One is incomplete, two is complete and then three and four are both complete fractures, but three is partially displaced and four is fully displaced. So that was then OK. So next question, I think it's the last one, which of these two movements may be affected in a rotator cuff injury. So two of these are correct. So internal rotation, external rotation, elevation of the arm to the side um which would be abduction or elevate the arm out in front of you, which would be extension. OK. So lots of people saying B and C which are the correct answers. So that is everything. So I will come back. Um Are there any more questions? Um how fast is compartment syndrome we've just had? And so it can really vary. Um because it depends on how quickly that if it's the muscle, for example, how quickly that swells enough to increase the pressure enough to then compress the blood vessel. So it really can vary and vary on what structure is affected, what mechanism is. Um So there's, there's no real answer to that. However, once you've identified it, um it's an emergency because if the blood is not flowing to that tissue, that tissue is dying in all the time that that's going untreated. So once it's identified, you need to treat it as quickly as you can, but there's no time frame on how quickly this happens. Um Yeah. So it, it really can vary depending on, on what is swelling, what is causing the, the pressure. Oh, thank you, Paul. Um Yeah. Thank you guys. Thank you for engaging with the quiz and the questions. Um I hope it's been helpful. Um This will be uploaded on here as the session recording. Um But we will also be uploading the slides to um I think a med it's, is it, there's a new, a new website that's coming that's linked with mind the bleep, but I can't remember what it's called, something like MLA something. Um So we'll price details of that on Instagram and things when, when it's when it's all ready, so you'll be able to see it, but this will be on here on medal. Um But thank you all so much. There will be a feedback form, uh which I think if I do this, you should all have the form now. So I'd be really grateful if you could do some feedback. Um But yeah, thank you all so much and you will get a certificate of attendance as well once you've given the feedback. Um, but yeah, thank you so much, everybody and have a good evening and I hope your finals all go well. Um, but yeah, I wouldn't stress too much about orthopedics in Aussies. I think it's unlikely but definitely in written papers and CQ si think, um, is it easy place to, to get marks? I think? Ok, I'm gonna end the call now, which hopefully you'll still be able to click the feedback link, but I'll leave it there for a minute just in case. Um, but I'm gonna turn off my camera and mic, but thank you so much, everybody.