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Uh, next slide. Yeah, hi, everyone. Welcome to our Thursday sessions for our road to final series. Um, I'm Anna, I'm an F one at uh Manchester Royal Infirmary. I've got Harry and I, um, and we'll be talking through M SK orthopedics with you. So, um, next slide, how it will work. I hope that, um, some of you've been before to one of these sessions, um, we're changing things up a little bit for this one. Usually we would run through 15 MC Qs and then, um, talk through the answers at the end, giving you enough time to answer them in between. Um, but we've been getting some feedback that, that can be understandably quite difficult to pay attention through the entire time, especially coming home from a long day of placement. Um, so we've decided that we'll do 10 M CQ so we can keep it to an hour. Um, and that we would do question answer, question answer and hopefully that will be better. Um, at the end, we'll just give you some, uh, feedback forms to complete. And then if you could just let us know if you prefer that kind of format that would be very, very helpful. Um, so we've sort of been questions on, um, common presentations as per the ma content map. So it should line up really well with, um, whatever curriculum that you've got based on your, um, med school finals. Because, you know, we've got people from all sorts of med schools here today. So, if, should we just get started then, um, next slide, please, Harry. So these are the MC Qs. I'll give you a minute per question and I'll start polling now as well. So, um here we go. Um, a 30 year old female presents to the emergency department with sudden onset severe pain and swelling in her right knee. She denies any recent trauma but reports a mild fever for the past two days on examination. Her right knee is warm erythematous and significantly swollen range of motion is limited due to pain. The test results reveal a white blood cell of 13.4 and CRP of 85 which of the following investigations would be most appropriate to confirm the diagnosis in this patient. I'll give you all a minute. Got one response so far. Can everyone see the poll? Ok. It's completely anonymous if that helps. Ok, that's a minute. Can we go to the next slide, please? So the answer is joint aspiration with synovial fluid analysis is any, does anyone have an idea of what they think is going on? What they think the diagnosis is just put it in the chat. Be brave. OK. We're not sure or too shy to say. So we'll just move on the next slide. Um So we'll talk through what this is. Acute joint mono arthritis. So when you've got a red hot and swollen um joint and it's affecting one joint mono, oh perfect. We've got some answers through. So we've got, we're thinking septic arthritis, maybe. So. Yeah. So this can be broadly split up into three categories. So either septic arthritis, which can obviously be bacterial fungal or even mycobacterial uh, crystal arthropathy. So that's our gout, pseudogout and trauma can also cause a, um, acute joint monoarthritis as in he mysis. So I'll just go through quickly, um, each of these pathologies. So if we go to the next slide we'll start off with, um, oh, yeah, let's start off with a focus history. So, what kind of questions are we going to ask? Um, for people with, um, acute joint monoarthritis? Would you mind just pulling up that mental, um, link carry to follow the link? Yeah. Mm. No. Do I have to share? Yeah, maybe. Ok. Otherwise you can just do it. Yeah. If it doesn't work, um, a lot of people might be just on their phones anyway. I've got it up here. So if anyone puts in, um, a little word, then we can figure it out. So any, any ideas what we would ask in a focused history for something like an acute joint moth arthritis. So you've come here this, um, we've got this lady who's come in, um, and she's got this hot swollen knee. What are we gonna ask her? And to know it's like a very common situation in oy as well because it's quite easy to ask questions about something like this. So I, and I'm not sharing but it says I did get um, a submission in my word card. It says bilateral. So that's really important. Is it just affecting one joint or both joints or more than one joint? So, should we do next slide, other things we might want to ask. Um How soon did it come on if we're thinking, if she's, for example, she's come in and she's um it's developed overnight, that's much more likely to be something like gout, um which uh quite often presents sort of that quickly. Um Any other joints involved. So, yeah, this is um someone else is um you know, bilateral. So it's extremely unlikely for it to be more than one joint in septic arthritis, as you can probably assume. And usually things like gout only affect one joint, but they can affect more than one joint at a time. I think you'd have to be very unlikely to have septic arthritis in more than one joint at one time. Um So I wouldn't say it's impossible but very near impossible. Um, recent trauma to the joint. So, obviously, trauma, we picked up, um, that as a category for acute joint monoarthritis and that can be, that can lead to he arthrosis. But if you've also had recent trauma in terms of recent joint injection, you know, if you've got osteoarthritis and you've been recently treated with a joint injection, you were potentially introduced bacteria into the joint which can predispose you to something like septic arthritis. Um, what goes along with that really is chronic joint inflammation as in past medical history. So, if you've got um for example, osteoarthritis or existing even gout, rheumatoid arthritis in that knee, that can also predispose you to septic arthritis. Um And as well as past medical history, obviously, if they have a past medical history of gout, you're going to be thinking of gout. Um renal disease also predisposes you to a uric acid accumulation. So that would um also lean you towards gout maybe um a past medical history of IV drug use as well. That's significant for a septic arthritis um due to hematogenous spread um and or bleeding disorders as well. That that goes along with past medical history. So that would increase your risk of hemarthrosis as then bleeding into the joint. Um and finally, sexual health history, which may not be the easiest thing to slide into a history. But is it is important because it can lead to um things like reactive arthritis and chlamydial infections that can lead to joint arthritis. Um Perfect. Let me just double check. Um If we've got anything else here. Yeah, fever. So, systemic upset is really important as well. You're more likely to have systemic upset and things like sepsis and pseudogout not really seen in gout, to be honest. So we've got in this lady's history. What, what did we have? We had mild fever for the past two days, we had um elevated inflammatory markers as well, including a raised white cell count. Um So both of those really lead us to believe that it could be septic arthritis, which is what people put in the chart, which I'm very happy to see. Um, could we move into the next slide? So what kind of investigations are we gonna do? Well, the question kind of pointed us that way, didn't it? I gave some and the answer in this case, um was joint aspiration, sinus fluid analysis. Now, we can split up investigations in terms of bedside labs and imaging. I'd encourage you to always approach your um clinical scenarios like that. Um especially in ay, so in terms of bedside, we can think of anything in the chat, just popping whatever you think would be relevant for investigations for an acute joint mor arthritis in the chart. This is not as scary as a question because I gave you some options at the beginning. No. OK, let's move on next slide. So, um obviously, joint aspiration, synovial fluid analysis, that's obviously the first one that comes to mind. Um, and you should always do this before giving antibiotics. Another really important point here is when you're the F one because you will be the F one eventually. Um, and you suspect as septic arthritis, it's very important or even gout, it's very important never to do a joint aspiration of a prosthetic joint. So, if they've ever had a knee replacement and their, um, in, in their knee were not going around sticking needles and that because that can predispose to prosthetic infection, which can be life threatening and very complicated to treat any joint aspiration to do with a pros prosthesis needs to be done in a sterile environment in theater. You should definitely be calling the orthopedic surgeons. Um in terms of what you would see on the analysis, um we've got a little white cell count here. So if there's, if it's absolutely raging with white cells, we know that's the most, most likely going to be septic arthritis. Um Obviously gout and pseudo gout, they're still inflammatory responses. So you're going to have a raised white cell count. Um But um it's less likely if the white cell count is under 500 in terms of investigation is really important to send off an FBC for your inflammatory markers. These can signify whether there's any renal disease. Um CRP obviously to trend the in inflammatory markers. Um Blood cultures, obviously, if we suspecting septic arthritis, um and baseline X ray and ultrasound as Well, if we, if we can't get the um asper off the first, um I know some people put X ray for this question. It is important to get an X ray in terms of a baseline investigation, but it won't help us confirm the diagnosis. So that's why synovial fluid analysis is the correct answer in this case. OK. Next slide please. Yeah. So we talked a bit about septic arthritis already. Um And I mentioned the abnormal damaged joint prosthetic joints, um any immunosuppression and someone who has an IUD you causative organism. So miss common staph aureus, um strep group, a gram negative and go go gonococcal um bacteria as well. Um In terms of treatment, we're just gonna keep aspirating it until dry, slam them with some very strong broad spectrum I IV antibiotics until we get our sensitivities. We're gonna give him enough analgesia. Um And that should do it and we need to repeat our blood cultures after 48 hours to make sure that the um infection is either gone or would go in the right direction. Next slide, please. Um So yeah, the other thing we need to think about is gout. So gout is a disease where there's too much uric acid in the blood. And that can either be through um under secretion by the kidneys, but can also be due to a production because of inherited factors. Um eating a diet rich in purines. Um It can also be found in tumor lysis syndrome and also psoriasis, um acute, manage, acute, we really split it up as acute management and long term management. So if someone comes to you, the first presentation of gout, we need to be giving them nsaids, um we need to be giving them colchicine and we can consider oral cortico steroids only if the above has failed. So that's your second line treatment. It's actually off license to treat um gout. So long term management, people get kind of confused about allopurinol. Now, if they've never been on allopurinol before, we don't start them during the acute flare. However, if they've had flares before and they're usually regularly on allopurinol, you just continue the allopurinol during the attack. Um And then this in a fluid analysis, we're going to see needle shaped crystals that are negatively bent. That means when you shine a light on it um parallel, it will turn yellow and at 90 degrees the crystals look blue. It's quite pretty actually. Um And so that's gout and we can move on to pseudo gout, which is next. Um And on food analysis, we have a rhomboid shaped crystals which are blue, just also quite pretty, I don't know. Um Management is largely the same. The only difference here is that there isn't any specific treatment to prevent attacks like allopurinol, it's not gonna work in this case. Um It's a calcium powers ate deposition disease um which is a sort of a calcium salt and then that gets deposited into the cartilage. Um And then we can see that as chondrocalcinosis on x rays, so bright white spots in the cartilage. Um Usually this is affecting the knee but can affect the wrist whereas gout usually classically affects the um big toe. Um I think that's, is it or is that what you call it? There's like an old timey word for that. Um And is usually pseudogout is usually associated with hyperparathyroidism or hemochromatosis. Cool. Uh Next, so you've got question two now. So a 67 year old woman attends the general practice for a follow up blood test which was requested by the Ortho geriatricians following a distal radius fracture. The fracture occurred after the patient slipped and fell in the bathroom from Sunday height. She is otherwise well. And then there's some blood test results for you to look through and we're going to see what is the most likely diagnosis out of those five. I'll give you a minute to answer and I'll start that poll as well. Yeah, we should be able to send the slides out as well and yeah, we'll send the feedback form um towards the end of the session too. I don't have anything in my pool yet guys. Thank you. OK. OK. I'll stop you there. So we are kind of torn between osteoporosis and pagets. Oh, I think osteoporosis just edged out there. Um So next slide we reveal the answer. It is indeed osteoporosis. So what are we gonna look for here? So let's look at the calcium. Yeah, sorry, sorry. Harry calcium first, which is in normal range, which is good. The phosphate which is about normal, higher end of normal but still normal our alp again, higher end of normal but still normal. Um our parathyroid hormone which is normal and a urea slightly raised or CRE creatinine, slightly raised. So we could say this, this is largely a normal blood test um results and we've just got mild renal dysfunction. So why, why is that osteoporosis? Well, let's go through the um basic metabolic bone diseases. Next slide please. Harry. So, um I've done this because someone specifically requested for me to go through me metabolic um bone disorders, which I'm happy to go through. So let's start with osteoporosis, which is um just reduce bone mass and mineral density. Um And the risk factors are usually female sex. Um That's because as you, as you age you, um estrogen is protective of bone mass and when you age your estrogen levels decrease and that puts you at risk for osteoporosis. Um and it's associated with medications like corticosteroids, sri S PPI S antiepileptics and some um other hormonal drugs. The hallmark of osteoporosis on labs that you won't see anything. There's no biochemical changes that you can see. Um osteopetrosis is a sort of dense brittle bone disease. Um It's due to a failure of normal bone resorption because of the defective osteoclasts. So, you've got our osteoclasts, which are bone breaking cells and osteoblasts are bone building cells. Um So, because we've got defective osteoclasts, um they basically break down all the bone and then the osteoblasts sort of build it back up, but it's all done in a very chaotic way. So that's why we get um overgrowth of cortical bone which fills a marrow space. So usually we've got nice spongy trabecular bone in the bone cortex, but that's actually gets filled in with um the cortical bone, the bone on the outside. Um So what this can result in is things like cranial nerve impingement if you think about it because um of narrowed foramina, the skull. So you can get all sorts of, you know, third nerve palsies, fifth nerve palsies as a result of this disease. Um And it can lead to um in severe diseases that satisfy their calcium um deficiency. The next one is Paget disease, um which is similar, but um serum, serum, calcium phosphorus and parathyroid hormones, levels are normal. Um There's sort of a mosaic pattern of woven in the mall bone and you can get long bone chalk stick fractures and it increases your risk of osteosarcoma as well. Um Then we've got these diseases as a result of hyperparathyroidism. Um So, that's sorry. One second. Um So if we got primary hyperparathyroidism, we've got an abnormal overproduction of parathyroid hormone. Um So that raises our parathyroid hormone which raises our serum calcium and lowers serum phosphate. Um and that can result in symptoms like bone pain but can also lead to pathological fractures. Um Secondary hyperparathyroidism is elevated in a sort of like compensatory mechanism for low calcium in chronic kidney disease. Um and low calcium happens in CKD because of poor excretion of phosphate and um reduced production of Vitamin D So that's why we need to um over secrete our hyper parathyroid hormone, sorry, so that we can um absorb more calcium, but that can obviously result in um decreased bone mass and cause um pathological fractures as well. Next slide. Yeah. So this is um we'll just quickly go with osteoporosis, which is um as I said, reduced bone mass and mineral density and I went through the risk factors there. Next slide, we need to assess the risk in osteoporosis as well. And we can do that by assessing the 10 year fracture probability. We can do that with either the q fracture risk score or the um Frax score. So nice would recommend you calculate the frax risk score in any woman over 65 and any men over 75. But you can obviously do that in younger patients if they've got um the aforementioned risk factors. Um we would then according to their frax score, if they're intermediate risk or high risk, um go on to measure the bone mineral density and we do that with something called a Dexa scan um and a Dexa scan, we we can calculate the T score and the Z score. So next slide, the T score is a number of standard deviations. The patient's bone density is from the mean bone density of a 30 year old adult. Whereas the Z score is um age and gender control um matched control. So, but we actually use at score to assess whether someone needs to be on a medical treatment with bisphosphonates. So this is the interpretation of the T score, which is useful because it often comes up in those MCQ S. Um So anyone with at score of below minus 2.5 should really be started on medical management um with oral bisphosphonates. Um the initial initial length of treatment usually um could be max actually, sorry. I think I've got the slide on. Yeah, osteoporosis management. Um Well, we obviously always start with conservative. So conservative management for osteoporosis is regular exercise. You need to counsel your patients that you know, you shouldn't stop doing whatever you were doing. It's actually really important to continue exercise because that strengthens your bones. Um specifically weight training exercise. Um because swimming and cycling, things like that, they don't improve bone density. Um stopping smoking is a big one, reducing alcohol intake, making sure you're eating enough um have enough calcium intake and if not, you should be supplemented with calcium and Vitamin D and then as I said, in those with severe osteoporosis, with risk factors and um T score t score of less than two minus 2.5. Um We should be starting bisphosphonates as well. Um So that's typically five years for oral bisphosphonates and three years um for those receiving I VZ alendronic acid and the patient should be continued being reassessed during this therapy as well. Next slide, please. So we've got the next question. A 63 year old female presents to the emergency department with unremitting lower back pain accompanied by shooting pains down the back of both legs. The pain which started a few months ago was intermittent first and associated with her legs occasionally giving away her observations are as follows. 100 and 30/80 99 BPM respirate of 1610 of 36.8 on examination, there's a reduced turn in lower limbs, ankle and knee reflexes cannot be listed. She has a past medical history of breast cancer treated with radiotherapy type two diabetes, um mellitus and of capitis. What is the most likely diagnosis? Yeah. Ok. So we've got a lot of metastatic spinal cord compressions. You've got degenerative, some a couple thinking and a couple thinking called equina syndrome as well. So I feel like I was kind of mean with this question, I'm not gonna lie, but I'll explain everything the next slide, please. So it is actually called uh equina syndrome. So the, so Yeah, let's actually start with this, let's go with red flag symptoms. We can try our menter, um, again and I can read them off. Um, or we can just type in the, um, chat and I'll read them out whatever you like. I guess if you're shy you can just do it. I mean, to me, since I'm not showing it to anyone. So, what do we hear? And I read, um, in a back pain history that we think? Oh, that doesn't sound right. Oh, let's get you sorted right now. Should we go back aside? Should we pick out anything that's worrying from her history? No. Ok. So some things are standing out to me. So she's got unremitting lower back pain. So that's quite worrying. Any unremitting, um, pain, to be honest, is a red flag symptom, whether it's affecting your back headache is obviously one. that's worrying too in a limb, unremitting pain. It's all that's all quite bad, especially when it's severe pain. Um, bilateral sciatica. So, sciatica is quite common, but bilaterals are not as common. So that's also sort of something I've picked up on in the history. Um, and occasionally legs giving away. That, that doesn't sound great either though. That's what we call intermittent neurologic neurologic claudication. Um, anything affecting sort of your motor function of your nerves that should also be raising, raising a red flag in your head. Um, and we've got hyperreflexia on examination as well. So motor neuron signs. The other thing is she's got a past medical history of breast cancer as well. So I know a lot of people and that's probably what people have picked up on and um put metastatic spinal cord compression. But I'll explain the difference between Coral syndrome and metastatic spinal cord compression as well to do next slide, please. Yeah. So that's uh sort of covered that all. So these are the conditions that we need to be thinking about when we're thinking red flag symptoms with back pain, so called equina. So it's typically, you know, classically associated with your sad anesthesia, urinary retention, incontinence and bilateral neurological signs. Um spinal stenosis, which is the intermittent neurological claudication that um I brought up earlier. Um ankylosing spondylitis is also an important condition to be picking up on early as the earlier you pick up the better outcome for the patient. Um So typically morning stiffness and nighttime pain are classically associated by closing spondylitis. Um spinal infection as well. So, if they've got, if they're systemically unwell or have a history of IV drug use can be associated with things like FTI um and a spinal fracture, obviously unremitting pain that's sort of relieved by lying down flat. Um We're thinking could be spinal fracture and obviously, any preceding trauma would help us point in that point us in the right direction. Um Can we get the next side, please? Thank you. So this is I was gonna explain the sort of um difference between um cord equina and metastatic spinal cord compression. So obviously, we're thinking this could be a tumor that's pressing on the nerves in the back. But where exactly will lead us to the presentation, the exact presentation. So corda equina obviously is the bundle of roots at the bottom of the spine, the lumbo sacral nerve roots. Um and it's called the coral because apparently, supposedly it looks like a horse's tail. Um I don't really see that, but we can just take the ans is the word for it. Um because they're, they're peripheral nerves. So they're not actually part of the CNS, it will cause a lower motor neuron pattern of weakness, which is what we saw in the questions. Um She um was hyperflex. Um She, she was hyperreflexive, she didn't have um she was a reflexive as well. So that's pointing us towards equina. We've also got um something called called Conus meis um syndrome as well. And that's when we've got a um you can see that's above the cord equina and that's if there's a mass pressing on the Conus medullaris, um you would classically get um a mixture of upper and lower neuron signs. That's because that's where the spinal cord is turning into the peripheral nervous system. So, depending on where exactly the lesion is, you could be, for example, um Aeroflex at the ankle, but hyperreflexic of the knee, for example, it just depends um because it's affecting the actual spinal cord. Um metastatic cord compression is affecting the spinal cord, which we know is part of the central nervous system. So that means that it will cause upper motoneuron um symptoms. So, does anyone have any upper motor neuron symptoms that we can put in the chart? So, yeah, we've got hyperreflexia, hypertonia. Perfect. Yeah, spasticity important to know really early on it can present with um more lower motor neuron signs. But as it progresses, they will like like in a stroke progress to upper motor neuron signs and symptoms. Uh but in this case, it was yeah, again, plantar extensive plantar reflex as well. Perfect. So there's some, there's different things. I mean, obviously, in this case, it we're thinking it could be due to malignancy, but there's a number of things that can cause compression um of the nerves in the spine. So, obviously, malignancy is one, a primary tumor, metastatic um tumors, lumbar stenosis, um which is just narrowing of the spinal canal in the lumbar region, which could be due to things like osteoarthritis. Um spinal trauma again from vertebral fractures, disc disease. So any herniation of the disc, um impinging on the nerves that can cause a corda, equina um and sort of uh infections as well. So, yeah, if you've got an abscess in the spine and epidural hematoma as well, they can all cause um these sort of syndromes that we just talked about um next slide, please. Oh, actually, just briefly what we want to do in called equina syndrome. We need to do pr examination to um assess their neurological function, um a full neurological examination, but specifically, you need to do apr exam um to test for anal sphincter tone and um perianal sensation. You also need to do um a post void bladder scan which will help you um gather whether you've got any urinary retention as well. Um And all suspected called of Corona syndromes that you need to get an urgent MRI. And that's true of Conus medullaris and also MSC as well. And um the definitive management would be surgical decompression next slide, please. Sorry, I'm taking up your time. We'll try and get through these next ones quicker. Um So we've got a 15 month old girl who started to walk over the previous six weeks. However, her parents have noticed she's a waddling gate. Her six week check was normal. Um Observation of gait shows a left side limp with apparent shortening of the leg. She was delivered by vertex delivery at 38 weeks. Um She was born with a CALC, the valgus foot deformity of her left foot, which was treated with gentle stretching, which of the following statements about developmental dysplasia of the hip is false, right? So we've got some CS, some Ds and some es so the answer is D so it's actually it keeps the hips flexed and abducted. So away like that and that just pops the, the knee and hip joint back into place. Um Xray is actually the preferred imaging modality in infants greater than 4.5 months. Um And that's just because of bone development. Um next slide. So I'll just go through some quick um sorry, um pathologies and hopefully doesn't even know what this is at all this picture. So this is Calcaneovalgus deformity. Um That's just when the um Calcanea valgus, um the ligaments are too tight and that just usually self resolves in the first few months of life. And this is actually is associated with development or dysplasia of the hip. Um And you just need to passively stretch the um ankle and it just resolves by itself. Um Next, and this is Talar peas or club foot that which needs surgical correction in the first few months of life. Next slide and this is flat foot or P planus as well, which um doesn't require really any, usually doesn't require any surgery can be corrected with splints and things. Um And then most importantly, we've got developmental dysplasia of the hip, which is what the question was about. Um We've got 22 diagnostic tests that we do to screen for mental dysplasia of the hip. It's done actually, um at birth. So usually the next day the doctor should come around and check the baby and you get checked for a developmental dysplasia of the hip but also at the 6 to 8 week check. And we do these two tests, next slide which is sorry about this really creepy cartoon, but it just goes over both tests quite well. So we've got the Barlow test which aims to dislocate the hip and then the Orte Lani test which is like in the P carus, we flex and abduct the hips to relocate and you'll feel this clunking sensation when you put the hips back into place. Um Next slide, please. Um Yeah, so just quickly the common, most common congenital musculoskeletal abnormalities. Um Yeah, the development of the especially of the hip is usually, as I said, just a diagnosis and screening tests. Um It can be bilateral but can be unilateral, but when it's unilateral, you can see um leg length inequality. Um And as the disease progresses, it should really be picked up the 6 to 8 week check. But when it's not picked up such as in the questions, um there you can see a limp and then early onset arthritis. But I think Harry's got um a question about Limph as well coming on next slide. Um This is quite a difficult question. I don't know just because of time, we, we could skip it and come back to the end if we've got time, I think. Yeah. Yeah. Is that OK? Let me just skip ahead. No, no spoilers. OK. So I try to let me know. I don't know if there's any questions or anything. So question six a 12 year old obese boy is in this hospital with a limp. Uh He reports pain in the right knee and hip with limited internal rotation. Bloods are all unremarkable. So given the most likely diagnosis, what is the gold standard I standard imaging modality to confirm the diagnosis. So we've got MRI hip, an AP view of the knee, an AP view of the hip, an ap and lateral view of the knee and an A that for you of the hip, I'll let you know what the pulse says, looks like everyone's sticking with ea good stuff. Yeah. So it is the ap lateral hip X ray. Um And the, the reason behind that is basically, it's a general rule of thumb. Um in orthopedics especially is you want two views um to make sure that you don't miss a, a fracture or pathology or, or certain condition. And quite often these two views would be an AP view, anterior, posterior view, uh lateral view of the affected um joint. Um In this case, it is a hip um because this uh child has something called SUFI. So when we look at sort of the the limping child or someone presenting with a limp, we can split it up into either a painful or painless limp. And then there are a number of different causes. Uh your your standard ones, just trauma infection, um something called P disease. You've got an unstable CP, uh which stands for a slipped upper femoral epiphysis. You've got D DH development dysplasia of the hip. Um We've got a leg length discrepancy, a stable CP and also neurological functional causes. So the sort of main ones that you could get, um, ask about in an exam, uh We've got CFI, first of all, uh slipped up a femoral epiphysis. So that's when you've got the epiphysis, which is the end of the bone. Um and the metaphysis, which is usually where the bone widens um that basically slips um off the epiphysis um at the level of the growth plate, which is where it's more common more commonly in Children. Do you usually get pain in the hip and also the knee? Uh It's more common in boys than it is, is in girls. It's most prominently in someone who's a teenager and typically it's an overweight hyper gonad adult boys. So if you ever see uh from an example point of view, an obese child coming in with a limp, your sort of alarm bells should be ringing for SUFI. It can also happen in girls. Usually these are tall, thin girls. Um In the past medical question, there may be associated endocrine disorders as well. And so if we look at the diagram here, we can see sort of a normal femoral epiphysis in the um socket here, a normal growth plate and the metastasis where the uh bone widens at the femoral neck. And then you've got where you've got slippage of that. So you quite clearly see, um, slippage here. And another thing you can notice because quite often, um, in x-rays, things like fractures, slippages, dislocations aren't always that obvious. It's very much about anatomical planes and anatomical lines. So, you've got something here called Klein's line and a normal cli line is where you see this imaginary line which goes through the greatest tranter of the femur here and it intersects through the epiphysis, through the femoral neck and through um the neck of the femoral head. Whereas when you've got slippage, you can see that the cline line does not transect uh the femoral head here. So hopefully, we can appreciate here if we go from the, from the um greater we transect the family we had there was in SUFI, we can see, we, we don't uh and treatment is usually percutaneous pin fixations. So they would literally um hammer in pins to hold um the burn back in place. Uh We've also got Perth disease. Now, this quite simply is a vascular necrosis of the femoral head and the two main areas that you might see a vascular necrosis, at least presenting in exams would be your neck of femur and also your scaphoid in your hand. And the reason why why that happened is because you've got limited blood supply to these areas. So what you've got in the femur is, you've got the circumflex arteries, the arteries that wrap around the neck of femur. And when you get, for example, a hip fracture or trauma, you can uh have transection or interruption to this blood supply. And because we have what we call a one way blood supply. So there's any blood going to the um head of the femur in one direction. If this blood supply is interrupted, then we'll have no supply to the bone. And, and as a result you get this necrosis of the femoral head or bits of bone basically die. Um So people with Perth disease, they're usually a bit a bit younger. So in the first few years of life, importantly, you will have a, a very painful limp, you'll get a loss of abduction. So them moving away from the body and a loss of internal rotation, you can get slight, slight leg length discrepancies as well. It's a lot more prominent in males as well. Only 50% in 15% doesn't present bilaterally. Um And most recover about treatment. Um Not at the moment, there isn't really a known cause. Um there's a few sort of related things, genetics and, and things like that, but there is no sort of known cause um for Perth disease. Um but usually, um it, it's conservative management does the trick physiotherapy. Um I've seen earlier, it's usually self limited and then we've got D DH which um Anna's already gone over. So, I, I'll skip over that just in the interest of time. So uh question seven. So you've got a 30 year old lady presenting to eye casualty with blurry vision that started when she woke up. Um She's got a past medical history of rheumatoid and she takes methotrexate. Um So on examination, her left eye is red and she's got severe photophobia. Um slit lamp lamp examination shows increased chamber cells and chic precipitates. Uh So given the most likely diagnosis, what is the initial treatment? So is it steroid eye drops? Do we increase her methotrexate dose? Do we give all steroids? Do we give mono antibody treatment or do we give all um acyclovir? So we've got mostly A's 66% and then a couple of Bs and CS as well. Ok. Good stuff. So most of you are correct. So it would be steroid eye drops. Um So obviously this is an M SK related talk. So we will have an ophthalmology talk later. But obviously when it comes to red eye and M SK, there's not too many different things it could be. Um And quite often questions. Now they're becoming a bit more tricky and we're getting these sort of two step questions, but it's not just enough to know the diagnosis but then how to treat it or the imaging to what imaging to do like in the previous question. So, yeah, when it comes to M SK related red eye, the big one to be aware of. Uh the one that's is considered a medical emergency is uh uh anterior uveitis. Um You may also see it um uh being called iritis. Um So it's essentially inflammation um of the anterior portion of the uvea. Hence the uveitis, uh which forms the iris, hence iritis and also the ciliary body and your sort of main symptoms to look up in the questions then is a very sudden onset. Hence, in this question, this this lady had it when she woke up, a painful red eye, a very painful red eye, severe photophobia. Quite often, the um uh eye will be tearing as well and you'll uh the the patient or the person will often have very blurred vision. Now, it is associated with this HLA B 27 which I'm sure everyone's had enough at the moment. So your rheumatoid, um your ankylosing spondylitis. So people who have these conditions are more predisposed to developing uveitis. Um Things like uh most people, only person, most people have it only in one eye. Most people, it happens to sort of young adults that's when it will, will first appear. And yes, as, as most of you have said, you'd give um steroid eye drops. So something like dexamethasone, um and uh cycloplegics, um like atropine cyclopentolate, uh which dilate the people and help relieve some of the symptoms. Um If repeated steroid courses don't work, they can do things like injections and things like that, but usually, uh, a very, um, vigorous steroid regime where you, you know, you'd have drops sort of every hour for a week, every other hour, for a week, six drops a day for a week. 54321 usually, um, is enough. Um, so very quickly because I know this is an echo related. So just so you can appreciate where the inflammation is, the iris and the, and the ciliary body uh in front of the lens here. Um And, and when you examine someone's eyes, this is typically what you'd see. So you've got the red eye um this um circumferential redness, the ciliary flush, uh inflammatory cells which we'll see on um slit lamp and something called a your adhesion, your car, it precipitates between the lens and the pupil, which as you can see here, distort this normally nice circular um people that you have here, so you can see it sort of distorted here. So that's anterior uveitis, very important um medical emergency, but also very easy to identify, especially in, in questions and very easy to manage. So, an important one. So, next question, a bit more tricky. Uh 45 year old. Um he has been admiss after he's knocked off his bike, his ankle is grossly deformed. He's got bilateral malleolar tenderness with severe ankle swelling and he's got tenting of the medial soft tissues. So, what's the most appropriate initial management? So, is it application of compression dressing and physiotherapy is the application of an external fixation device. Is it immediate reduction or application of a back slab? Is it surgical fixation or do we apply a full leg plaster cast uh cast? So it looks like most people are put in C OK. Yeah, good stuff. Yeah, those, those your chemo stuff. Um So what we've got here, um it's important to identify as an unstable ankle injury. So the ultimate treatment is surgical fixation. But what we're concerned about is the initial management. So any time you have a displaced fracture, you first want to reduce the fracture um to prevent soft tissue injuries and help reduce the swelling before you then go into surgical fixation. So as a general rule of thumb, that's what you want to do for your unstable um fractures. Now, this sort of question is supposed to cover trauma and of course, trauma is a very big subject. We have sort of um the uh session on trauma, but I just want to go through what I think would be some of the common things that would come up in sort of finals UK MLA stuff. Um So another sort of resort of a traumatic injury are your neurovascular injuries and of course they cover a wide range of conditions, but you want to, they're high risk in patients who have limb fractures, long limb fractures, uh who've had trauma, surgery to the limbs. Um people in casts splints, constrictive dressings, uh, crush injuries, gunshot wounds, and, uh, the five sort of ps of neurovascular assessment. And if someone has one of these, then you want to suspect if there's neurovascular compromise is, uh a painful limb limb paralysis, paresthesia. So, reduced sensation, uh, pulselessness and uh, power. So those would be your indications of someone having a neurovascular compromise. Uh, and then, uh, generally speaking, principles of factor management, um, reduce hold and rehabilitate. Um So anyone sort of has a fracture? And you're asked about the ma management, uh you want to reduce the fracture, as mentioned in the question, you want to hold it in place. Um Usually this is through or if open reduction, internal furcation, in other words, plates and screws and then you want to rehabilitate. Um things you want to be wary of when it comes to managing a patient is um are a diabetic, do they smoke? Uh These all affect bone healing, wound healing, things like that. So, immobilize the fracture, um including the proximal and distal joints, um checking your vasculitis, as previously mentioned, um especially after you reduce the fracture and you, you hold the uh affected limb in place. Analgesia, analgesia, analgesia, the most important uh medication as an orthopod uh manage the infection as well. Give tetanus if required as well. Um If there's open injuries, that's when you'd also want to introduce your IV brought back to antibiotics. And you may need to, to do some wound dement as, as well. Um So yeah, your open fractures there in emergency, they need to be divided and lavage within six hours of injury. So when it comes to sort of trauma management, we've covered what you do. If someone's got a displaced, displaced fracture, we've covered what you do if someone has an open fracture and we've got with regards to more, more so is ay if someone presents with a fracture, how you'd management, how you manage, how you would manage them, generally reduce whole rehabilitate. Um surgical intervention, replace the screws, open reduction, internal fixation. Make sure they're not checked if they're diabetic or, or if they're a smoker, make sure they've got pain relief. Um make sure there's adequate uh rehabilitation after that. So those key points can't really go wrong and then very quickly you just wanted to go over some general fractures which um you may have come across of in sort of um review and past med and all that stuff and could very well come up. So we talked briefly about um per disease, avascular necrosis of the femoral head. And we mentioned that scar for fractures are also another risk of that. I'm sure everyone's heard of fu for on an outstretched hand. Um So often requires multiple views. Again, going back to um the, the previous question. So, you know, orthopedics very much the, the same principles across the board. Um So again, uh most of the blood spot from the scape void is from the dorsal carpal branch, which is a branch of the radial artery. And it's this retrograde blood supply. So once this is cut off, there is no sort of jaw blood supply to the bone. So if that's cut off, then you risk avascular necrosis. You've got your collies fracture, which is your dorsally displaced distal radius or your dinner fork deformity. And hopefully here you can appreciate the shape of the hand and the shape of the dinner fork. Um And again, surprise, surprise, open reduction, internal fixation with plates and screws is um how you would manage that. Um And then on the opposite side, you've got Smith's fracture, which is a distal age fracture, but it's less common than a Collie's fracture, but it's when you've got a volar fracture. So volar being the palm side, dorsal being the back of the hand. So Cols is dorsal and Smith's is um palmer. Um You've got Monte and Galii fractures. So your Monte fractures are your proximal ulnar fractures and your gallii are your, is your distal radial fractures. Um And again, unstable injuries or if again, you've got clavicular fractures. Um Most common us medial two third, distal one third. And that's because that's the thinnest part of the, of the bone. Um No attachment to musculature or, or ligaments. And again, principles of treatment are particularly in an unstable fracture which you've got here, place some screws and then very obviously here you don't forget your dislocations. So hopefully it's quite, um, easy to, to gauge that. This is a dislocated shoulder here. So that's a very quick wooster stop tour of your common fractures. There's a few of the like pots fractures of the ankles, boxer fractures, which is your fracture of your little finger, particularly when people are, are drunk. Uh, and they get into a fight and they try to punch someone and they come in with a, with a painful, painful little finger. So uh question nine. So 45 year old lady visits her GP with two history of pain in her arms, shoulders, neck and back reports, headaches, fatigue throughout the day. Um So routine birds including a thyroid function and rheumatoid factor. E sr are all normal. So what's the most likely diagnosis? And hopefully this is a bit more of a easy one. So we've got mostly A's. Yeah. Yeah, good stuff. So, so fibromyalgia was part of the UK UK MLA sort of M SK content map. So just, just a quick word on fibromyalgia cos hopefully it's fairly a more sort of simple one. So it's often diagnosis of exclusion. So you um give a diagnosis of fibromyalgia once everything else has been ruled out. So you've got essentially a widespread pain fatigue, lethargy at specific anatomical sites. Usually it's like the so uh the shoulder girdle and the hips as well and the knees. Um It can get mixed up with sort of menopausal symptoms, this idea of, of, of brain fog as well, but you don't usually get the sort of the mood swings. Um And typically fibromyalgia can present in, um, women who are a lot, a lot younger. Um, the exact cause is unknown. Um, but treatment, it's mostly conservative, um, aerobic exercise, strongest evidence base CBT and again, medication to manage the pain. Um, so I'll keep that one brief, but hopefully that's just a quick and concise. Um not on fibromyalgia. So my last question, uh a 60 year old male was admitted to the emergency room before four. So on examination there, right. Hip tenderness on movement in all directions, hip X ray confirms an intratrochanteric fracture. So what's the best management option? And you've got a total hip splint and back uh back slab hemi arthroplasty steroid injection or a dynamic hip screw. So I think we're very much split between A&E fine. So in this case, for an intratrochanteric fracture, the answer is ea dynamic hip screw. So I can almost guarantee that everyone's had a question on AFA hip fracture. And I put my money on. If there's any orthopedic related question, you'll get asked it, it would be a hip fracture and how to manage it. And it sometimes can be very confusing. But um with most things, it just comes down to where the fracture is and, and being familiar with your anatomy and the words associated relative to where in the hip, uh where on the femur, the fracture is so far as general principles, identifying a fractured neck of femur, you've got a shortened and externally rotated leg, you've got groin pain, hip pain, uh being completely unable to wait there, pain on palpation. Um A common test is being unable to straight leg raises about there being a lot of pain. One thing that's very important to assess the nature of the fall. So if it's a low, low impact versus high impact fall, uh and that can influence management as well. So, um this is AAA general sort of um look at the, the hip joint, so your head, your head, your neck, your great cancer and your later to cancer. Um You know, you've got your previous symptoms here and your issue here. Now again, not a lot of hip fractures are very obvious. So, on radiology, again, there's certain things that you can use as a, as a clue as to what causes a hip fracture. One thing in a hip fracture is because you've got shorten and externally rotated leg and hopefully, you can appreciate it on this xray is in a hip fracture. We can see the lesser cancer a lot more in a fractured hip than we can in a less fractured hip. And hopefully, if, if you think about the leg being externally rotated, you can appreciate that this will expose less Trant more. So the staging for a hip fracture is often the garden fracture. So you've got a garden stage one, which is a sort of undisplaced hip fracture. Um but only a partial fracture of the femoral neck. Your garden two is a still undisplaced fracture, but we've got a complete fracture of the femoral neck. Garden three is when you've got partial displacement. The garden four is when it's completely fallen off. And I guess out of everything, if you want to know what you do and what cases, it's just learn this diagram. This is probably the best diagram that I found with regards to your anatomy and what you would do for certain fractures. So you've got your hip joint here, your femoral head. Um And what you've got this line here between the great and the lesser can basically determines whether you're intracapsular. So within the capsule of the hip joint or extracapsular outside the capsule of the hip joint. And then when you've got your intracapsular and your extracapsular, you can um split that further. So you've got your intracapsular fracture which can either be uh undisplaced or displaced. So you've got two different types of fractures there. Then you've got an intraenteric fracture here. You've got a sub trochanter fracture, sub meaning underneath the trochanter. So, electric your fracture in the trochanters or an intratrochanteric fracture, which is where the questions uh which is in the question stem and then you've got a subtrochanteric fracture underneath the trantas. So those are your sort of uh three regions, a fracture. You can get a fracture here, a fracture here and two types of fracture here, displaced or undisplaced. So you have four fractures and you'd all manage them differently. Um Just a quick word. Again, going back to radiology, again, fractures aren't always not obvious. Um So as well as the lesser cancers being more, more unclear, you could have got this sort of imaginary anatomical line called Shen's line. Now, this is a line that's drawn between the inferior border. So the lower border of the superior pubic ramus. So you have pubic ve on here, superior, inferior, so inferior border of the superior pubic ramus and it goes along um along the tra to foramen, the this hole here, the inferior medial border, so inferior underneath, medial on the inside of the body. So inside border uh uh border of the neck of femur and what you've got and a fracture. Hopefully, you can see here if you've got loss of front line. So there's loss of this continuity from the inferior board of the um superior pubic ramus and the inferior media board of the neck of Femur. And you've got, again, a, a very prominent trichantha. So surgery is the gold standard treatment. Um So let's go through it one by one. So if you've got an intracapsular fracture, so a fracture here right on the neck of the femur, if it's an undisplaced fracture. You can use internal fixation. Now, if it's a displaced fracture, a more severe fracture, a less stable fracture, you would either do hemi arthroplasty or total hip. So he arthroplasty is just where you replace the, the head of the femur or the ball. And the total hip is also when you replace the, the surface um of the pelvis. So the socket, so arthroplasty is just your ball and your total hip will be the ball and socket replacement. Um Whether you do one or the other from my understanding depends on the age and the mobility of the patient. So if you've got an elderly, an elderly person that doesn't move better to do an arthroplasty, er less invasive, better recovery. If you've got a younger person who's a lot more mobile, then do a total hip. That's the general rule of thumb. Then we've got your extracapsular fractures. So, moving down here now. So whether you've got a, usually if you have an intratrochanteric fracture, you do a dynamic hip screw. If it's subtrochanteric, you do an IM nail um and then some points um for further management. When we talk about uh uh fracture management, when we come to the, the rehabilitate section, we want to allow weight bearing immediately, post surgery. And again, we wanna look at long term treatment. Typically, hip fractures happy in um happen in elderly people. So your fact scores falls assessment, osteoporosis, bone production and cover if they need it. Um So very quickly on fact healing, that's a dental rule of thumb. So your, your first week is your inflammatory process, your formation of the hematoma and your inflammatory a um week two and three is where you get your formation of a callus and, and your softer bone forming and that develops to your union f um phase. So that is where you get the actual um mending of the fracture and the two ends of the bone sort of joined together. So you've got a sort of a stable fracture of a fracture which is still weak. You've got consolidation two weeks after that. So you've got this sort of soft spongy bone, which is replaced by the lamellar bone, um the harder bone and then year two years um after the fracture, you'll still get continual remodeling. So your, your bone absorption by your osteoblasts, uh sorry, your bone absorbed by your osteoclasts and your bone deposition by your osteoblasts. And so these are, are, are different types. So this is your um dynamic hip screw. So, going back to the question. So, plate and screws and what you've got here is something called a lag screw here and a compression screw here. So as the name suggests, you get compression um of the bone brings the sort of two ends of the bone between the fracture together, which helps promote healing. So that's the sort of principle of that. And then you've got your hemiarthroplasty, which is just the ball of the ball and socket joint that's been replaced. And then you've got your total hip replacement, which you do in your younger, more mobile population, which is your ball and your socket replaced. So hopefully that's cleared up. Um Your, we just had a quick question um If that's ok. Um Someone's just asked, when do we use internal fixation with DHS um versus internal fixation with I am now. So from, so paper suggests that internal fixation is sorry, an IM nail is less invasive for much better healing from what I've seen. An IM nail is typically done for subtrochanteric fractures, whereas trochanteric fractures is a DHS. So that's what I've seen myself. That's, that's what I've seen as well. So, um and I don't know if you want to go back and do your question or not. We've kind of, I don't, I don't know, we, we can do, I'm conscious, we've kind of run over. Um I'll send so the feedback is available for you to complete. Now, I'm going to just link to our social media as well. I'm happy to go over the question that we missed. Um But you're also feel free to go. Um I can talk through it anyway because they'll all be recorded as well. Um But yeah, go, go ahead. I'm sure you go about it, but we are doing some um particularly um with the, doing your, at the moment or just, um, and the show very quickly. Um So, so, yeah, we do or have done it. So it would be very interesting if you could help us out with some research. And also if you would be, there's a form you have to fill in, which basically is your view on how research has been delivered by your university. How many hours of study they've allowed? Um, and what you've done an independent study. Now, I appreciate you interested in a medicine or whatever research, be more and more of a thing. But if you are interested this next um do that I've is if you want to help get involved with. So I know that training, that um collaborative authorship is something that's becoming actually scoring points. So if any of you are interested in research, collaborative authorship, um you can fill in that form and I, I'll, I'll basically drop you a message in a few weeks time. And all that we ask is that you distribute that questionnaire to your peers. We haven't decided on the final number, but you know, you, you get sort of 1520 responses, not a whole lot and then we can give you a collaborative authorship on it. Um Hopefully, papers and presentations that we're, we're hoping to do in the future. Um But yeah, the whole sort of theme of that is just seeing what student perception of the UK MLA is. Um how competent they feel how much support they've been given from universities and, and how they've sort of been revising themselves. So, if you're interested, that's there, it help us out a lot. So, so feel free to, um, ok. Um, yeah. Sure. Yeah. And, and just let us know if you prefer this sort of format where we do question and answer rather than all the questions and all the answers that would be really helpful too. So, um we'll just go back to question five. I know someone's asked. Could we share the first five sides, please? But um the recording will be available on me so you can go back and take that in your own time as well, go through them in your own time. So, we've got a 28 year old female presenting to A&E with a suspected right ankle fracture. She was out at a dinner where she was wearing heels, um and she tripped and fell causing immediate pain and an inability to weight, bear on her right ankle. An X ray of her ankle shows an oblique fracture of the distal fibula at the level of the syndesmosis with no widening of the distal tibia fibular articulation. What is the likely direction of force on the foot that has resulted in this injury? I kind of alluded to that. This is a very difficult question. Um But I am happy to just still go through it. Um They would be very mean to ask you this question, but it's still quite interesting to know about. Um, I'll give you a couple of minutes whoever's left. I, no worries, Alicia, thank you. Cool. So we're very much split on all of the other. I thought we've got one for every, um, letter. There's absolutely no way I would have got this. Um, the only reason I know about this is because I'm currently doing a trouble orthopedics rotation. Um, so it is actually supination and external rotation. Um If Harry, can you go a few slides down? I think it's the one that says Weber, yeah, just continue going. So this is explaining the mechanism of injury, but I will actually want to start with this slide. So I don't know if you've ever heard of the Weber classification of ankle factors, which is how it's usually classified as in the most common, most sort of famous one that um we talk about. So we've got Weber A Weber B and Weber C classification of ankle fractures. And that um really refers to whether the fracture is at the level of the syndesmosis um below or above the level of the syndesmosis. And syndesmosis is the fibrous tissue that joins the tibia and the fibula together. So, if it's below the syndesmosis, that is um a Weber a fracture, so you can see that little band running joining the fibula and the tibia together, the syndesmosis and the fractures just occurred. Um below that and Weber a fractures are usually quite stable fractures. So they can be treated sort of conservatively with an application of C. Um whereas Weber B and C which are um at the level of syndesmosis and above the levels of the syndesmosis respectively are often unstable factors that do need to be treated um with either internal or external fixation. Um The other way to be to classify these injuries, which is what the question is alluding to is using the law H classification. So um there's very specific sort of um mechanism of action that results in these fractures. So in this case, it would be supination and extra rotation or external rotation injury that's caused this fracture. So we can, so can we, I've got the, I've got the question here. Actually, let me just pull it up. So she was out at the dinner where she was wearing heels where she tripped and fell causing immediate pain. Um So she's wearing heels. So if we go to the next slide this Oh Yeah, yeah, that one, sorry, I should have just put them in the right order. That would have been helpful. So this is just demonstrating supination and xray rotation. So you can imagine she's just rolled on onto the outer um edge or the lateral edge of her ankle, her foot, that's supination and extra rotation going through externally rotating the foot as well. It's difficult to demonstrate on camera, but I feel like this picture demonstrates it nicely. So what's first going to happen? Next slide is um there's going to be stress put through that tibial fibular ligament. Um this and desmosis causing a fracture through the distal fibula. So that's step one next. And if it continues to externally rotate, we can see that this posterior malleolus of the tibia that's going to fracture as well. So we're going sort of in a, if you can imagine like a clockwise direction around the foot. So we're starting laterally, then we're going posteriorly. So the next would be medial, the next slide, that's the medial side of the tibia, the medial male, an avulsion fracture. So that means the ligaments torn that piece of the bone away um causing an fracture. So those are the four stages of a Weber B fracture or supination X rotation fracture um which is really complicated. But I thought it's quite interesting actually, once you break it down to how exactly the injury causes each stage of the fracture. And it depends just how much of a high energy force it is obviously the more it progresses around that circle from lateral, posterior medial, the more unstable the fracture and the more that you would need a sort of early intervention next slide. And yeah, so this just covers the um other um mechanisms of injuries for Weber A and Weber C fractures as well. But I won't get into that since it's very late. And II appreciate all of you um joining us, this, this is just um an X ray of them. She can talk we're talking about. So you've got a um fracture of the distal fibula and at the level of the osmosis, um there, there can be a widening, you said there wasn't a widening between the tibia and fibula, but that can be present. We can see a slight line um that the red arrow is pointing towards and that's um represents a fracture of the posterior malleolus. And we can see sort of soft tissue swelling where the yellow arrow is pointing suggesting there could be injury to the medial collateral ligament as well. So it could potentially be a stage um, three or stage four fracture. We would be fracture. All right, that's everything guys. Thanks again for taking the time to um join us this Thursday evening. Um Do we know what's on next week? Do do let me just pull it up. Um So we're running this series every Thursday at 7 p.m. Um The next one is P. So we've got the next few weeks, we will be on PED. So we would love to see you again. And um we'd also love if you could fill out those forms for us as well. All right. Thanks so much, everyone. Thank you. Take care. Bye bye.