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Trauma and Orthopaedics emergencies

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Summary

In this on-demand teaching session of medical professionals, a comprehensive discussion on orthopedic case study involves an 80-year-old female patient named Beryl. She had a mechanical fall and is suspected to have suffered from hip and wrist fractures. The teaching session delves into her history, from her medical background as a type-2 diabetic, among other things, to her lifestyle and her family history of medical conditions. The importance of considering her frailty and proper pre-operative procedures, such as obtaining chest X-rays and ECGs to assess her ability to withstand anesthesia, is emphasized as it could have significant impacts on her mortality and morbidity risks. The session also looks at her examination findings, discussing in detail the possible implications of her physical symptoms. X-Ray analysis and the details of hip fractures, including displacement, are analyzed closely, providing students with practical tips to effectively assess these images. The session offers a rounded approach to orthopedic patient assessment, promoting multidimensional consideration and careful management to improve patient prognosis. This teaching session is a must-attend for medical professionals keen to advance their knowledge and expertise in orthopedics and geriatric care in a practical, case-based approach.
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Description

The Acutely Ill Patient is a teaching series which will cover 10 medical and surgical sub-specialties in 10 sessions, focusing on severe conditions.

This session is will focus on Trauma and Orthopaedics emergencies, brought to you by St George’s Surgical Society.

This teaching is for revision purposes and increasing healthcare practitioners’ confidence in dealing with medical emergencies. Please check your Trust Guidelines for any clinical application.

Learning objectives

1. Understand the unique considerations when dealing with geriatric patients in an orthopedic context, including anticipating their potential post-surgery needs and necessary lifestyle adjustments. 2. Recognize the possible presence of osteoporosis in female patients who experienced bone fractures, and consider their past medical history to discern the best course of action for treatment. 3. Be able to correctly identify and interpret the results of a hip X-ray, distinguishing key component parts and accurately identifying the extent of displacement in intracapsular hip fractures. 4. Have a comprehensive understanding of the factors involved in clerking an orthopedic patient, particularly the significance of a patient's past history, risk factors, and present symptoms in determining their diagnosis and appropriate course of treatment. 5. Understand the importance of obtaining a thorough medical history and conducting a careful physical examination for patients in orthopedics, notably when these patients are elderly or have complex medical histories.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

That we just go in for the physical surgery. There's a lot more different factors we're looking for. So your whole history examination findings will be completely different in your documentation. Um But this should be a nice breakdown. So this is the case today. So we've got Beryl, an 80 year old patient who's presented following a fall. She's been unable to wait there. Please take a history and examination from her. So we've done uh fools before. So I won't repeat things too much because we tried to get the most out of these sessions. So it was a mechanical fall in this case. So you can exclude the risk factors for a fall. This kind of chest pain, palpitations, dizziness or standing. She was just in a church car park. She slipped on some ice and fell onto her right hip. She's been able to wait there since she had to be caught, picked up by an ambulance. Her right hip is painful and it's sharp pain that's worse and moving an eight out of 10 head is clear and she's also holding her right wrist. So the main thing to look for, um, clerking an orthopedic especially in the case that this is the main things are excluding those negatives and just moving on with the actual examination findings. These are surgical patients. She's an 80 year old. So the main thing is she's going to be quite complex in her other symptoms. So past medical history, she's type two diabetic. So we're thinking of where we've touched on, on previous sessions. What blood, um, medications do we need before surgery? Which ones do we stop? So, glipiZIDE can cause hypoglycemia. So we can consider stopping it while she's starved. She's got ischemic heart disease. Now, with all patients who present in orthopedics, especially in the acute trauma cases, they should all have a chest X ray and an ECG because to help optimize them for general anesthetic because most of these patients, if they're breaking a bone, they're quite frail. So that's why always, always get the test. These patients may need work up. And there is a reason we have a built in special phys, er, specialty with orthopedics with the Ortho geriatricians. Cos we need to optimize these patients cos they have very significant mortality and morbidity risks. I've put him as well in this case that she's got a hysterectomy, especially in women who are breaking their bones. You want to think that osteoporosis risk factors. Very important thing to think of here. It helps work out that she's had that in the past she had no anesthetic complications then. But that may have been about 20 years ago but also about her estrogen risk factors. Uh She's an ex smoker again. She's has Brandy every night and this is a weird case. Again, I had more on a geriatric post that you can prescribe alcohol in some hospitals to these patients. Cos if they've been having a small amount of alcohol every day for all of their life, they're technically addicted and they may have the drawer. So it's funny things to ask that elderly people can have that as a bit of an odd part to their history also in our family history. Again, what I mentioned about the Eastern risk factors is breast cancer. Very different things to think about. Now, this is why I said the history gets a bit different when you're in an orthopedic clerking. We really need to know how she moves. You should always do a clinical frailty score. You should always look at their mortality risk factors. There is a Nottingham hip prognostic factor that we look at in hip fractures to help see what are their mortality morbidity risks. So I want to know before they came in where they independent because nine times out of 10, they're going to be off their baseline when we're discharging them from hospital. So do I need to if she's already immobilizing with a stick and she's independent? Does her house of stairs? Are we going to have to get ot in people who have hemi arthro part or hip replacements, they can't bend too much. They may need razors on the toilets. It's simple things, but they can really delay discharges. And in these category of patients, the longer they're in hospital, their mortality risks just go up and up and up. So that is why our history is a bit different today and why I didn't get you guys to kind of go through it just because it's more picking out what's different. What are the things that I focus on when I'm seeing these patients? Cos you can actually talk to them very quickly. There are a lot of things you need to pull apart. They are important for the long term management. So that's a bit of my history. These are her examination findings, they're quite bombed off. So she's got a shorten and externally rotated leg and then obviously deformed wrist again from the history. I wouldn't be too surprised, but I'll be quite happy with a shortened and externally rotated leg. What that stands for? No. Ok. So these are your classic presentations in an M CQ. So this is usually until proven by X ray, but clinically you say someone came up straight leg race has a painful hip and a short, externally rotated hip. It's a fracture. If it's internally rotated and they're a younger person with high trauma, you have a high suspicion for a dislocation. So that in a way it's always shortened because if you think of where their capsule gone where they've usually got the length of the neck of the femoral neck, it's been crushed. So that's why it's shorter. They're holding it in a position of comfort. And that's why that external rotation helps relieve that pressure when they've got the hematoma. And then with wrists, the main thing you'll see, usually just a bad bruise and it can have some say the deformities. So a dinner fork deformity, the main thing you'll see in this patient, she's an 80 year old frail old lady. You just go to see it's completely malaligned and she's holding it, they're usually holding it secretly like this cos everyone focuses on the hip. So she'll be holding that secretly. And sometimes as I say, it's just bruising. So make sure you fully in these patients don't just see them as you'd see a 25 year old is falling on some ice. Some may say a fall from standing height is actually a silver trauma and a silver trauma means you have to see them as any trauma called. So you do a full A to E atl S guidelines that you see whenever they come in because she could have fallen even from height. You warfarin, I have a head injury, bleed out and die. So that is why Silver trauma is a very interesting performer to look at the get about reducing those risks of these patients as they walk in the door. Yes, she's only fallen from height. But how long has she been on the ground? Well, she got her already going on. She's broken two bones quite obviously. She's definitely a very frail vulnerable patient. Yeah. And the main thing is an examination next bit that always freaks medical students out is where they come to their orthopedic basement. And a consultant will say to them present this X ray and no one knows what to do. They rabbit in the headlights not knowing what to do. So again, as I have done with E CG, the main thing I want you to take away is breaking everything down. So where do we start with any x-ray start with simple stuff. It's an X ray. So it's a plain film radiograph, it just sounds better. It sounds like you understand what you're talking about. You also want to say the patient demographics, you want two patient identifier to show it's anything same with the blood test, everything you need two patient identifier, then you move on to the date it was taken. So hopefully this one will say today it's Beryl Smith, an 80 year old lady. Then you say your view. So for any x-ray, especially in orthopedics, you should always have two views. So you want an ap and a lateral view of the hip, you want a full view of the pelvis, especially in this patient because she may have a pubic rami fracture. You want to compare your two femoral necks to help with plan, especially if you're looking at an operative fixation such as a hemiarthroplasty or a total hip. Because you need more planning in that regard, you need to see the full pelvis. You want to see both GTs. You want to see a good length of the femur because she's mentioned her mum had breast cancer. Is this full? Was it just a very minimal for it's actually got lytic lesions. And if you're worried about that, you may need a whole x-ray of the femur. So there's a good, there's never a reason not to get an X ray. It's such a low radiation and it gives you so much information. So before we've even spoke about what we can obviously see what's wrong, we've already ascertained a lot from this. You can also see bit of bowel. You can see if they're catheterized, which they usually are pre op. You can see if they've got some traction. But the main thing to focus on here is on the right hand side, is anyone confident in the room with what this is and capture fracture? Yeah. So where's your capsule? So with the capsule you've got to do if it's attachment. So you've got your cancer here. So your capsule is going over like this. So yes, it is in, you can see the neck here with any fracture, any bone that's broken, start with it. Simple as you can say, is it displaced? Yeah. Is it translated at all? So translation, displacement, you talk about whether it's moved. So translation again is moving but displacement is more about the two ends meeting, but you can have the ends touching but it's still moved. So it's about your degree of displacement. Angulation is how far it's moving. And again, the distal tip has moved away. You want to talk about again, it's hard to say just with one view to say about displace and angulation, you need both to say. But the main thing to say is that it shortened displace because with intracapsular fractures, the thing that used to be used, I've seen it less used and disproved is the garden classification comes up things still in your exams but I don't know if I'm gonna side. No, I didn't. Ok. So it might come up later. But it helps you saying whether it's partially or fully displaced because it helps with management, especially when you're looking in this kind of category of patients. If it was a, if it was me who broke my hip, I would have very different options to barrel if it was slightly or completely displaced. But for her, it's less important. Why is it important to know about displacement in the hip fractures in intracapsular hip fractures? Yeah. Why does it impact the management? Can you use the screws or would you have to replace that? Mhm It's exactly that. But you have to replace the head. The key thing here is your bloods above the hip. So, like you do with your humerus, with the femoral neck, there are circumflex arteries that go around the femoral head. And so you can get avascular necrosis in a younger patient. The main thing is to preserve the anatomy as much as possible because they may need a hip replacement down the line. So if you start them on that ball, they're gonna need a new hip in 10 to 15 years. But if you can preserve their native anatomies using cannulated screws in an undisplaced fracture, you have better outcomes in the long run. But in Barrel, she's already got ischemic heart disease. She's an ex smoker. She's 80 she's got a displaced neck, frac uh neck of feur fracture. The blood supply is already going to be compromised and that's why she's more of a candidate for. Then you lead on to your total hips and your hemi. Traditionally in barrel, we'd always say a hemi. There is research and interesting movements from some of my old bosses which say they're pushing more for total hips in people who are very functional beforehand. And that's why that clinical frailty score. I understand what they're like. Pre op is very important. Cos she could have been in this day and age say she was 7075. She could be great. She could be with her grandkids going on a motorbike doing everything but she's broken her hip. You'd want to give her a good few years in a hip. But anyway, that's a controversial issue. This is her wrist again, breaking it down, working out which side is right, which is left s forward. Always think thumb is an easy way to orientate yourself. Same where it is. Again, you can't fully decide on this is what I was mentioning earlier because you haven't got a lateral view. So again, you want a pa usually instead of an ap um and a lateral view of the wrist shortened, it's extra articular. So you're looking in this part here to see if the fracture line is going through. Sometimes you need act. You've also got a fracture here. Does anyone in the room know what that is? Is that OK? Is that meant to be the um hang on? So that's the right hand. So, so is that the radial styloid necrosis? So the right word, wrong bone? Oh No. So remember scaphoid think radius, you've got a distal radius fracture. That's extra articular. It is shortened and displaced. And you've also got a displaced ulnar styloid fracture. Is that hand like this? Yeah. OK. Oh Yes. Measure stick out. Always way to or yourself. You will ask for something in a and they will scan what they scan. So it's really hard to, that's why we always check what films. So she's got two breaks which we expected. What are we gonna do? And this is where again people get, oh, surgery fix it. I don't know if I could teach any of you online in this to sound sophisticated, to sound intelligent. Break everything down. There are four Rs of orthopedics in acute trauma management. Resuscitate. This is where I was going on about Beryl. This is a silver trauma. I would want to be managing her as per atl S principles. Putting out a silver trauma call and seeing her initially in recess to check for any other injuries she could have fractured her pelvis somewhere else where she could have other fractures, hematomas building up. There could be more going on. Once you've resuscitated, they're going to be in pain. So you need to reduce the fractures that you can with the wrist much more simply you're going to give her a neurovascular block. So you're going to give a hematoma block. Some people say that a beer block that you may have heard about. I've never seen one or is a hematoma block. You then want to use traction, countertraction, reduce it back slab. That is the next R restriction. So you want to minimize that movement. Cos every time that fracture hematoma moves those two ends, it's gonna be painful. So that's your third R and then the final one most important is rehab getting the physios in early. My gran broke her hip over the summer. Um Biggest frustration of my life. I was on holiday. She had a lovely DHS. They reg called me the day of the operation, but she would not engage with the physio. She's very stubborn, very smart. 85 year old lady she would not engage. And now she's got from living in a house, nice house in Leicester, going up the stairs, playing golf. She is now living downstairs with a commode and she's now on more medications than she's ever been on. Being on no medications all her life to 85 physio is what keeps you healthy. It keeps you walking, it keeps your quality of life, everything. So rehab, rehab, rehab. So just to reestablish those four rs resuscitate, reduce, restrict, rehab, easy to stick by again. I said I'd touch on about the things to examine with these patients because you're taught, which is the right answer in an orthopedic examination. You're going to stay with the hip. You're going to say I want them to do certain movements. I want them to lift their leg up. I want them to flex abduct. Certainly to rotate. Beryl's not gonna do this for you. So get you through your o skis, your exams, you're gonna have to practice, look, feel, move special test, do it, just practice it because you rarely get to do an evening clinic. The main thing for her, if you're unsure about a hip fracture, if she cannot straight leg raise, you'll be getting act hip. If you can't see it on the X ray is neurovascular status. Cos that is where you say to me if they cannot feel and they have no pulse distally. I'm running, I'm not just going to say, oh gee a and I'll be there in a belt but the Mirax Clinic, if there is any question of neurovascular status, this is an emergency. You need to get that out and in your documentation, you want to be very clear that what pulses you can feel and what nerves you can feel. I want you to say with the hip fracture, whether you can feel the DP the dorsalis pedis and the sorry pt. So I've got a bit of a cold and then saying whether you can feel in the first web space, the dorsum and the sole of the foot. Very simple. But I know all the nerves then distally are intact in the wrist nerve distribution. I want median radial and ulnar nerve distribution. I always go for Thenar eminence side, hypothenar, eminence mao topical stuff box clearly document it before and after reduction and then pulses. You want to fill radial and ulnar and for both a capillary refill every single fra you see that should be clearly documented whether they feel a light touch in those nerve distributions. What pulses you felt distally and eye cap refill every single time. Yeah, that's a question. Mhm You can also do light sedation and a recess for those that are more difficult manipulations or more for your dislocations. If you've got like a hip dislocation, you need proper proper sedation to be able to get that in. Because if there's any tension, you're not just gonna pop it in position of the back slab. So as I said, with the wrist, you're gonna give you a block. So some local it directly in the hematoma. The best thing you do is three people. I spent my life as orthopedics and I'm sure I will want to go back to being in an sho there covered in back slab because I was stuck doing everything on my own to reduce the risk. Well, you need three people. One person on counter traction, one person traction and positioning, they'll help with molding. And the third one, usually a nurse helping you with a back slab that you should measure yourself before because nurses do not do back slabs. Well, and I've dealt with too many plaster irritations to the skin with blisters that just broke my heart. So again, because no one ever teaches you how to do a back slab. You want your protective flare, which is the stocking not as important in a trauma will protect that skin, not too tight but good over and over. See it half and half covering it in with your wool to measure the amount of back slab. You need to say you in this case, you've got a broken wrist. I use a piece of wool that I measure out from here to around here, make it job free in the knuckles. And I tear that and then I use that to push my back slab where I went 8 to 10 layers of back slab where I cut a little slip for the thumb. If you don't want to over restrict that, I was taught when I was at the Royal London for a course that they prefer more radial, radial back slabs rather than doing the classic dorsal back slab. Depends on the unit, depends on the people. But I quite like radio, radio cos you're provided there's three point stability of where the main fracture is. I'm not too fussed by the styloid. I'm never gonna put a screw in that. It's too small, but that will need plate of potential and that will cause her pain. So make sure you've got good mobility, they'll teach you or they did in the past bit of deviation, bit of palmar flexion moving away from that, just want a good solid back. That is part of those three point pressures. So you're molding when you're pulling your thumb here, if you're struggling to manipulate, use the anatomy. So around the bones is a periosteum, right? It's like an elastic capsule for a lot of fractures. If you push it first, you'll then get a bit spring in the periosteum that allows you to then pull it out and put it in a better position. So you may push before you pull. Funny thing. These are things you'll pick up when you're in A&E or when you're all sh os. But things I didn't learn to close on the job in the middle of the night. So, take care of what you will, uh, will we fix Beryl? Will she need surgery for her wrist if she just broke her wrist? Yeah. No extraarticular risk. Usually with a good manipulation. If you maintain your alignment, both ap lateral, get good like things. There's rules, you can look up online for how much shortening is acceptable, angulation and spacing if they fit within that criteria, six weeks in a cast and she could be carry on intraarticular in a younger category of patient. Yes, because they're just too at risk of arthritis, their hands, they use for everything. Then you're gonna use a plate and screw a barrel. I wouldn't because she's not gonna benefit from it from it. She's 80. She's already arthritic and it's extra articular being the key point. Um Yeah, so that's the wrist. We then move on to the hip. I did mention that. OK. So this is where we move on to the hip, break down your fractures again inside the capsule, outside the capsule. We've already mentioned that the, we're gonna focus at the first bit inside the capsule and this is on the right, the garden classification as I say is being removed, but it does help with your learning to break everything down. So one and two undisplaced. So one is a partial fracture. Two is a full fracture through the whole femoral neck, but undisplaced three is partially displaced, four, fully displaced one and two is where you use screws where it's just the principle where you don't need to replace it because those arteries are still running around the head. And so they're gonna provide nutrients to the head. You're not gonna worry about APM. And so you just use screws to help maintain that alignment of the fracture. Using basically is a way of just pulling it together and holding that fresh stability. Don't get too stuck in your stage about different screws. What they do stick in your head. Conservative management fixing it. So that's plate and screws replacing it. I think it's the best way to break it down at your level to kind of understand what's going on. Different screws, different plates. I've only just learned at my own, of course. So don't, but get too stressed about it. Three and four, we moved on to touch earlier in a young patient. You want to maintain that anatomy. So it's the same t as one of the two. You may have gone through the blood supply, but you're gonna risk it, you're gonna hope they're young enough to maintain it. Middle age is a total hip and the final is a hemi which is a half hip replacement. You just replace the head and the neck, you don't replace the acetabulum to your socket. Happy with that. Yeah, extra caption of fractures. So outside you break down again, you've got your interenteric and your subtrochanteric inter you go for your DHS unless it's unstable or there's some other factors which I won't go into today. Subic is a nail. You can also with a nail have fixing screws into the head as well. It's called a gamma nail. They'll throw that around. But the main thing of a nail is you're maintaining relative stability as compared to absolute cos the fracture can still move. The rod is taking all the weight bearing. These are the x rays that you'd look for. So on a is a dynamic hip screw. So you can see your bra line going here through the chanters or dynamic hip screw. Mainly it's causing this compression or standing off the fracture site. You call it trapped in here with your distal screws, put your gamma nail on the right. So this is what I said, like gamma this bit. But your main thing is you've got a nail going all the way through the marrow to take the weight. And then you've got a hemi on the right hand side, a half hip replacement. You don't really need to know more than that at your stage. I would say just introduction. But what are you gonna be? You're gonna be f one soon enough. What do you need to know about these surgeries. Great to get involved. But the main thing is gonna be these patients that are you on your wards? And I was an F two in orthopedics where when they did the surgery, the bosses were done, you never saw them again. Everything was on you. And what are the most important things to start? VTI cannot hammer home enough. There is a nice guideline for a reason. I don't know what they use in this trust and my old trust we would always use a Rivaroxaban or Apixaban for 35 days as per night. From the date of operation, clots are very high. In this case, patient, we have had patients who were bleeding risks and we've stopped and played with it who I have seen lost in the past. It is really, really important to prescribe BT as per nice. Sometimes the isn't clear call the operating surgeon because it is just one of the key key things to clarify. If there's any confusion, go with nice guidance and you will be back. It's very, very clear as I mentioned with migraine, but with all patients PTO T, it's so, so important rehab is what keeps these patients in hospital and when they're staying in hospital, they get a hat, they get a UTI cos you don't talk to them because they're still constipated cos they're not moving and these are the patients who come home. The surgery could be very simple but if we don't get the right teams, the right medical management, POSTOP. This is where the problems come in and that's where orthopedics are very lucky that there's orthogeriatrics who help. But they are a very overworked service in my old trust. It was two F ones and a consultant for a major trauma center of orthopedics. It is a lot of them to deal with so support your colleagues as much as you can. Cos there will be so much more going on POSTOP HB and renal profile. The reason you want your user knees is because they might be dehydrated if they've lost a lot of blood. POSTOP X rays. Again, no one ever teaches this in med school. You do X rays throughout a DHS and an iron nail. So you don't need to check it POSTOP. You do one in a total hip and a hip replacement because you don't do the x-rays throughout. What are you looking for in those X rays? Ok. Would you see by the, you do an X ray to make sure you haven't cracked the bone nearby. People say it's to look for leg length discrepancy, all these other things. My boss in my old place said no, we just checked, we haven't really screwed up anywhere as long as it looks. All right, it's in place, it's in joint. There's no other cracks that we didn't expect. That's what we're happy with. Leg length discrepancy. Is a thing. The physios are very much on this. They provide orthotics and shoes because unfortunately sometimes they are slightly misaligned. The aim is not to be, you do check and there are tests in a heavy. But, um, that's why, again, why that's so important. And painkillers send them home and painkillers are laxatives, cos they never take the painkillers, they're always constipated. They get uti again. Speaking from my experience, I had to my gran was like, I can't do the physio. Well, she didn't take the dihydrocodeine. It's very frustrating even when you come from experience. So they're the main things as an F one, you should be checking the op note and make sure you're done because as I say, if you do have an orthopedics job, the bosses depend on you for your medical knowledge and it's imperative and that be on the right is just to show everyone involved with anyone who's an orthopedic patient is I think one of the most involved specialties with everything. Very much, a joint care method. Yeah, that's that. Oh, so I mentioned in the clerking some people do is a Nottingham hip score mortality. Morbidity is great. If you were breaking your hip, you are very, very frail the old way. They used to quote it is that in 30 days, 10% would die and in a year, 30% would die. Now, I think stats are improving, which is why I couldn't find that stat to prove it on the screen. But that was what we used to throw around and there was a reason. So this on the left is the Nottingham Hip score, what they use to kind of work out your risk factors of dying, looking at age malignancy comorbidities. But as you can see on the graph and the light within a year, you know, you're losing a good 40% of people at high risk. And how many people do you know who are old? Have a low HB and have comorbidities and one and two have cancer now. So 40% are dying within a year according to this graft at high risk. It's an important thing to consider and always say to the patients when you're consenting, when you're a bit more senior, a risk of a hip fracture surgery is death. Always put it in because it's such big because no one talks about and it's not the surgery per se. It's the break and the whole thing. So yeah, I have to hammer home a few folks, but that's stuff. Are we happy on the case? The different things to look at in a history, examination, findings and the basic things just with histories. Think of the whole patient as a whole. What were they like in their activities of daily delivering school? Nottingham Hip school. Four hours are the main things to have my home. But I spoke enough and I've got a sore throat some questions. So I'll read out for those online man presents following a fit. He's unable to move his right hand and shoulder. He supports his arm with the other hand and his shoulder appears square. What has he got a fractured neck of humerus, anterior shoulder dislocation, posterior shoulder dislocation, subluxation of the humeral head, long thoracic nerve injury. Ok. Sorry, I just, ok. I don't think it's e what would he present Like, I mean, there would be be no scarring. I mean that there wouldn't be so much deformity with that I think is the long that is that the one that controls your pec place your serrate, it's like one of your muscles or one of the, the um no, that before um I don't think it's a fracture. I don't know, I was gonna go with a fracture but because with this location isn't there like rotation like they say I, yeah, so I would go with the French. No. Um no. What is subluxation? And I'm glad you asked that it's gonna be one of my questions. If no, I mentioned it subluxation and dislocation that people get very confused about. Again, it's not taught properly. A dislocation fully out of the joint. There is no congruity with the joint subluxation. There may be partial congruity subluxation. People especially if they have say Danlos can pop the shoulders out in and out all the time. It pops almost out of the joint subluxed So that's why I'd say this one isn't long. Thoracic nerve injury, cirrhosis anterior. You were correct, presents with winging of the scapula. So that's when you get them to push against the wall and you'll see the scapular coming out. That is a long thoracic again. Unlikely. So we move on to the other three. He's a man picture. I should have been more clear with his age, but he's quite young. He shouldn't be breaking it if he's had a hu and he hasn't had a huge trauma, he's had a fit. And that is the main thing to think of squaring of the shoulder is usually a dislocation. But the fit makes it the less common option, which is posterior shoulders. Usually in a normal person, say if he'd had a rugby tackle, we have an anterior shoulder dislocation. But people with epilepsy and recurrent fits are more likely because of the contractures. And the way the fit goes can have a posterior and again, it appears square, he's holding his arm like this. And that's why the answer for this one is C I wouldn't if you put bi would probably say you're correct also because anterior is more common. Posterior is very rare. But in this question, the way I put it in was to mention hips go posterior as well. Just the way the capsule forms they can go anterior. But more commonly, it's posterior shoulders are anterior. It's an easy way to remember a few exams in this case, uh the history because it's a fit is just the only differential in this one but say it's posterior, it is a catchment of patients who will have it. Um they present slightly differently. But in this case, that is the main differentiator is the fit of the history. Next one. So you've got a woman with a twisting injury to her left leg while skiing, she's got mid calf, swelling and tenderness is unable to weight bear what she got. Trimalleolar spiral fracture of the distal tullar, a bleak fracture of the distal tibia ma nerve fracture or a medial mal fracture. The one D is. So I'm gonna guess it a five in the room of greens. OK? I can call in just a second because I think there's I'll do differential between the spiral and again, thank you so much for asking. These are good questions today. OK. Easy way history skiing. She's twisted it twisted. Imagine spiral. She's got that picture. The radiographic way oblique is obviously just a straight line. So it's there rule of two thirds, one thirds. So a spiral you can see with that fracture pattern has gone. Well, you've got a big spike, but you're looking at the way the line goes and it's more than two thirds longer than the actual shaft bone. So, you know, you've got a line that is longer than the shaft. So it hasn't just gone through as a a blunt force, you've got a longer fracture line. And so because it's longer than that, just direct things into the shaft. That is why it's a spiral. But the easiest thing for this is a, you can even see if you can in the middle, there's a hairline as well where it's twisted. So much more force has gone through. So you've got a crack in the middle as well. You also mention that mas nerve fracture, no one ever mentions it. It's a weird one. It is a syndesmotic injury where you will have a lower impact. So you may have a lateral malleolus fracture or you may have a medial malleolus fracture and the force goes through. It's actually usually a medial malleolus fracture. It goes through the syndesmosis and you actually have a proximal fibular fracture. So a mazer nerve is important to get an X ray of the knee. Commonly, it's a skateboarder twisting as well because the force has gone through cinders mos of the big ligament in between the tibia and the fibula and it's gone up and come through the tip, which is where it's coming through the fibula. You have a lower medial mal injury going up to the nasal nerve, leave you the other two as well. Medial malleola. So if we're happy with our malleoli, yeah. So the 23 no bits posterior, medial and lateral. So we know obviously it's not involving the ankle joint itself is above it. And that's why it's on the distal tibia, nerve, medial malleolus through the syndesmosis coming out of the proximal fibula. And you can feel crept as well when you examine them in the top of their leg. That's what happened to my mum. She, that's so funny. She got an ankle fracture. Wait, the proximal. That's so funny. Yeah, because she went, she was skiing and then she, um, she hurt, she fracture her ankle and then like six weeks later, she just couldn't understand why she was in so much knee pain and then she went back and then they found out that it radiated up there. Yeah, I'm gonna tell her there we are. So what happy today is the very first thing I said as an injury to the medial before. Ok. And then through the syndesis and then proximal fibula. Thank you. So you always have a story. I know I hate to be that person. No, it's annoying for that person. Not that person. He was 57 times. I just seem to be cooking these things that come up. 3310 year old boy, he's fallen on an outstretched hand. Forearm is stiff, hand is deformed. He's got numbness in his palm by his thumb. What has he got? Mhm That's what Wednesday pros twice because I feel that isn't your breath to do. So your test for? Yeah. Mm OK. So should we help break it down? OK. What bone is this hum. So what's this in that elbow joint? There's your electron part of your ulnar and here's your radial head. Can we see the break here? I see it here. So it's part of your humerus. So we were saying here about the collis, collis is a distal radius fracture. So we can exclude that. One more common in old people. Green stick is where we think about elastic bone. So you see a different patch pattern. This is a pure break. So we can exclude this one and then left with these three. Everyone always gets confused with these ones. But the main I I've got a the next slide shows what exactly you throw that down. This is a supracondylar fracture and in a 10 year old boy of this age set with a four outstretched out, he's looking like this who has also got numbness in the his palm by his thumb. What nerve is damaged here? Palm thumb median. So remember your media nerve because it is in the middle. He is broken here by his humerus and it is displaced. This is another classification which you don't need to learn. It's called the Gartland classification. Similar to the hip one but not, not displaced, minimally displaced, fully displaced. It's very simple classification helps with fixation. This patient has got neurovascular deficit. What did I say at the beginning of this talk, I'm running there. This is a kid with Nevas he needs fixing overnight. I'm calling the boss to come in to do a fixation where we just say we fix it because you don't need to do more. If you're interested in orthopedics online, it's two crossing wires. Some people say you don't have to cross. But that is what I've been taught. If it is undisplaced, you want to immobilize the joint above and below. So you want it above elbow back slap. But this patient numbs the median nerve, help support that he has got a deficit. So he needs fixing overnight. So this is a supracondylar fracture. People on the chat good stuff. And this is the breakdown. I struggle to remember these eponymous names. This is the only way I can remember the difference between Monia and G. It's the only way, it's the only way new I used to say is the galaxy is out the world. So that's why it's distal again. That's how I try to remember it. The main thing to remember with these two, these are a fracture and a dislocation that pitch before was a pure fracture. So we'd know we could exclude this proximal Montela distal gy. But it's mainly about your radio ulnar joint dislocation with an associated fracture. But just this is for your next because I used to get confused. I still do so had like, OK, next question, marathon runner time of place cos it was the London marathon obviously over the weekend pain is second two. He ran a week ago. Ali Frank B. Plantar fasciitis C March fracture. D sew stress fracture. E Jones fracture. So, is it A or D? No, I'm not sure of it. Are there any of those that, you know, I know what this is, isn't it when you read something? And like, it's just not in your brain anymore, isn't stress usually like, thank you. Where is that? Now? You can get stress fracture in your mhm OK. You get stress fractures there where the clue and the name stress, it's just overwear of a joint that shouldn't be having that much weight go through it. C noise is that the word that's bothering you? Desmoid is a posh word for bunion. So hasn't everyone taught you that the patella is the biggest seso bone in the body cos it's a joint over where there's loads of worse and you can have CBO bones in a foot because people have bunions all the time. You can have them removed. Wouldn't bother me. But we can see here the fracture is in the second toe. Does it project? Well, sorry. It looks like there's kind of deformity of, there's a little bit of arthritis here. This is callus. So you can see the break here. We said it was a week ago. He's clearly quite healthy. He's running marathons. This is a callus forming around here. So this is the break. Not that well, there's a little bit here as well. This is callus forming. The break is here a Jones fracture of the fifth. So we can exclude that work. Eponymous, I can learn. Don't worry, plantar fasciitis you'll see in really obese people rolling the tennis ball to help relieve it is just pain, no fracture. Liz Frank is a ligament and it is between your 1st and 2nd metatarsals. So you'd get widening there, you carry, get associated fractures at the second and third. But the main thing is it's a ligamentous injury because of its importance, stability, you need to fracture. Uh Fix it. Wait, so this is what is this? This is a March fracture because it's of the second, there's no widening of one and two. These are all evenly distributed as a foot. So, you know, there's no widening. This is not in this frank. The key thing is a history. He's presented a week later. He's got some signs of healing. It's an arch fractures of the second. Sorry. So the, so the March fracture is specific to the second. It can be any of the, it's to the second. Oh, it's always a um is that something wrong with the fifth? Um I think he's got a beginning of a bunion actually. So you see there's that kind of whitening. I don't know if they are there. Um It looks better on my screen. I think he's got the beginning of the bunion. It's just a bit of calcification of the skin around there, the actual bone if I was to zoom in and I spend my life paying with projections and that to look for these hairline fractures. But it's not. No, I think that's just a bad to last question. Another fish pain and decreased mobility of the right wrist is tender below her thumb. He was I thought you get pain, right? No, I don't know what her name. Someone online is saying he personally, I think maybe see how a decreased mobility pain. What is fall on outstretched outstretched hand, scape foot? I would go for scape foot below the thumb. And this one again, I don't think it's projected very well. They've got some very much redness over the A SB and I don't think it's projecting very well. So that is why it's a scaphoid things. You're looking for pain and the anatomical stuff, but pain on telescoping. So that's where you force the thumb into that. So you're causing pressure of that joint. They're the main things I'm looking for in a scaphoid fracture. They may not be um clinically visible on an X ray when you first get it. So you may make a decision to either splint or put them in a back slab just to help protect it because of the risk of a vascular necrosis. There are rules of displacement in a scape foot where if it's not that displaced, you can just leave it and use conservative management. But if it is significant, displaced in a dominant hand. In a young adult, you will look to produce some screws and fix it. Older people. You can just do serial x rays. If you're really concerned, they are significantly painful there. Like I had one who was a semi professional football player to ct it to prove otherwise. First metacarpal. So, feeling of your bones is this one here. So you've got your carpals here. You can feel 123. So it's obviously your distal or proximal phalanx in your thumb. So it's a bone here. It's more in the thumb. The key thing is that is you say below the thumb because if you feel about your thumb movements, they have the pain here. Sprain wrist wouldn't be that it would be more generalized pain, swelling around the wrist. The patient would be saying I'm tender there. So that's more suspicion of that uh distal radius fracture. They'd be having more going on. They wouldn't be saying about their thumb at all. They'll be all in there. Scapholunate. Dislocation is again a very important thing because it means it's very unstable. They usually have pain in the middle of their palm here and you'll see on X ray widening between your scaffold and lunate. It's called the Terry Thomas sign. No one knows who Terry Thomas is it before even my time. I know I'm very old, but it's a man who had a big gap in his teeth. So a big hole in the middle of your palm. It's a scalar dislocation. This needs fixing and is, well, the dissociation is, it needs, it needs fixing. You can also hear about ser uh the perilunate dislocation which is the apple in the cup. Have I heard of that? No, again, very more plastics. But it's an important thing to look for is an emergency. So you have to reduce that and the longer you don't reduce it, the risk of median nerve damage and instability. But the main thing to go for if it's ever a fu with pain below the thumb, sorry, I didn't project but a SB issues, but they're the main NC QS onto the scenario. So this was my life for a year being a trauma team, hems coming in. You've got, what should I call them, Elvis? You've got Elvis who's come in. He's a 25 year old man who, whilst intoxicated was on his delivery driver, er, on his moped, his delivery driver and he slipped in the rain, fell onto his arm and he's got an open fracture. We brought him to a major trauma center. I don't know what speed he was going, bone's sticking out. So we brought him to, to George's, you're the biggest major Trump center, sort of out. You're the orthopedic. He's the only one called cos um, it's not a fracture, it's your problem. What do you need to do? That's very good on your right. Elvis is 25. Yep. No, genuinely. This is the kind of path you have to get in. I wanna make sure a trauma call is put out on the 22, I trauma team which involves a general surgeon, orthopedic surgeon. Any, um, major trauma team. If they're available, a nurse, you can help. You wanna make the radiologist aware, they may need ap, scan, all they report to do and they need to be seen in recess. So you're saying who you want there? Oh, ok. So have you ever called that number? You get through to switchboard is all it does. Same with. If you want to put out a major hemorrhage call, say you want to put out a cardiac arrest call, you say what you want. So you say I want a put a trauma call out to too switch will know who they want to call. Sometimes they don't, sometimes any not everyone comes, you may have a pre alert. You may be the ed consultant and get told you've got someone who's got an open fracture. You're gonna say make sure the orthopedic S hr and registrar are called, I've had it where we had someone who's eviscerated. So it bowels out general surgeons were called and it was me the orthopedic sho and the major trauma sho having to deal with it. So sometimes it's about being very clear if there is something you're worried about saying, make sure all teams are aware of this one. Coming in. Information is power that's called the Golden hour with trauma, which is what limits mortality. Getting people in the right place with the right people around early saves lives genuinely. So, if you're the first one, you've just had the pre alert fracture, don't just see, see these do your own, you'll find what I found. People just leave you. They get bored and they go, well, it's your case. You, you've got this. And as I said, how many times was I alone backs stabbing many times. It's not the way it should be. We're a trauma center. We work together, we support each other as teams. I hung around. I'd hope people hung around for me as well. Sometimes it doesn't happen. So, getting help early. So, yeah, so it's a trauma call. We're gonna manage as per ATL S principles. So, obviously we've taught, I've hammered home about ae the slight adaptation is to think of your c spine. We don't know how fast Elvis was going on his motorbike, but I'd want to have triple immobilization of the C spine. So collar locks tape and then we move on to our usual say now onto your bit airway, how do you check your air airway? He's talking to you? 92% and 18 decreased air entry on the left hand side, central, uh slightly dull at the base. Yup. Five. What? Right now we're, yeah, we're getting in the past. So this is all good. So this is all these are your findings. So with breathing, we've given oxygen, what do we need? We, so a SA come up. So now they're 100%. Um have we given oxygen ABG and what's the other thing we want? We've got decreased from the left and he's got some dullness at the base and X ray decreased on the left, on the left. Uh This is trauma. So it's ap OK. So the rotation name, date of birth time. Yep. Um This is Elvis's taken just now. That inspiration is good. Yeah. Um penetration is OK. As well as you can see that much. Mhm That an exposure is. But now you can't see the diaphragm bases. So we've done our right, but I'm gonna say I've seen the base. It's fine. You can see there's no blunting of the diaphragm on the left. See, um there's nothing to show that you see. So the trachea central um and looking at the lung fails lumbar cancer. Yeah, they're quite present everywhere. They're quite like you can see the long walk all the way to the edge. I would, I would concur with that. Um There is, I think so. Is there rib fractures on the legs of the? Oh, I don't know. OK. So uh so it's a posterior and it's three of the 123756 and seven maybe. Correct. Yeah. Sorry. Little bit. Yeah, this is the main one I'm looking at. Yeah. How do you, how do you come? So is the way I check you always like that actually. Does he have a, I think he does have extra one. So first grade, 2nd, 3rd floor, second floor, I think he has his ma I would say 6th, 7th. Great. Uh but yeah, good spot. So that's why he's got decreased air on the left hand side because he's not breathing in as deeply. Nothing more than that. ABG anything bothering you with that crazy too but no 10 just it. Um This is what I can't remember. I think it's just normal. Yep. Um Is this oxygen just no or is that less? No? Remember less than eight is your type one? C two is greater than six. So less than eight abnormal. So you got your type 18. He doesn't, he's good. He was 92%. This was what we took and remember before we gave the oxygen now it's 100%. This is all in keeping with the fact that he's just not breathing very deeply. This isn't bothering me. I'm not significantly concerned at this point. So I'm happy to move on to see where you're gonna ask me all of these things. So he remember and I thought really good says be like you've already got the pattern. I want the sats, I want the resp I know you would have said to me that I want the BP and the heart rate separately, moving up the arm cannulas two large cannula in each had to keep it a fossa. This, I think this is all becoming part of your natural pattern. Now, bloods you'd want full blood count, renal profile, LFT S group seven and clotting because we're thinking about an open fracture in the back of my mind crossing the screen as well because if it was an older person, we could be worried about pre the surgery, but they're the main things for circulation. What else do we need a circulation? Ecg Yeah. Um, we're happy with that BP. Yeah. Yeah, he's 25. He's alright. He's always maybe a little bit high but like just he's in pain and yeah, how do we feel about grades of shock? Not happy with grades of shock. Ok. So there are four grades of shock. So what is shock? Ok. That's an easy question. No, no defined for me. Shock. Is it just low BP? Is it because they have because of an inability to, to fuse the organs because they have no, no stop. Ok, you had, it shock is end organ dysfunction due to hypoperfusion and learn your definition. It's a very reason when people get confused and then your grades of shock are 1234. It's the tennis rules. So less than 50 gosh, the notepads come out one, less than 15% 215 to 3330 to 40% blood volume loss, grade four, greater than 40%. The difference. And the easy way to know is when you're getting into grade three is when they drop their blood systolic BP, it looks at heart rate. So using your round things of heart rate, tachycardia is the first thing to go up in your grade one shock. So he could be grade one shock. He's got normal papillary refill. It also uses whether they're confused. So in grade two, they get a bit agitated, confused in grade 34 because the brain isn't being confused, they can even be comatose urine output is another way to do it with catheterizing your trauma patients. If you're ever worried, best way to get a fluid establishment and to know whether they're gonna kick off, there are numbers, you learn respiratory rate goes up as well. His was 18. He's five. So we're looking at more of a grade one shocking him. Tennis rules blood loss. So if a normal person, we say how many pints of blood they have, it's 15% of their blood volumes cos you could have a pregnant woman who is hyper hypervolemic. So she has to lose more percentage of actual blood even though she may be a slight woman. So that's why we use percentages. It's a table. I'll show you at the end. So you can take a picture. Here's your E CG that you asked for that. Uh So it's regular and then, yeah, it's regular. It's sinus about 100 BPM. No. A OK. Yes. Is narrow. Um, a, a few questions and he's, um that's probably not. Again, this is where in real life. I have my piece of paper on me to check my baseline. I would say this is normal sinus rhythm, which I'd expect in all this. Um because we know his heart rate, we felt it. We've asked for it. This just helps confirm things and we're not at that level of ischemia that we've had in previous scenarios where if their heart's beating too fast, they're not perfusing the heart also a circulation again, not for what you'll learn for your exams. But when you do progress to be surgeons, hopefully, when you're doing your trauma surveys of circulation, you check all the causes of bleeding, the chest, abdomen, pelvis, long bones and on the floor five places to look for. So this is Elvis's chest. So obviously we've already done his chest of breathing. We know we've got a chest X ray is fine. We're looking at his tummy, we're looking for an extension. Any bruising, any signs of retroperitoneal bruising. What's the thing in the middle? And where does the pelvic binder go? Gold stars? Yes. And it should always be on, always, always, always be on it and fitted properly. This is the open fracture. We've been talking about that. Elvis has got, it's not bleeding profusely. So we're not too worried about it. The main thing is now we've finished our, we're in our circulation now, we need to limit any further blood loss from this wound. Cos he's maintaining very good. His lactate is two. He's perfusing. Well, it's a grade one shock. I would say. How would you manage this? When you saw him like bandage about he's oozing. But any wound you see a wound in the street, direct compression. First thing to do, if it's bleeding, there are certain guidelines with open fractures that you will come to them. But the main thing is it's an open wound. It is involving open bone underneath. The two main things to take away from an open fracture are antibiotics within the hour and joint orthoplastic approach. So you want to get pictures with clinical photography and plastics involved as soon as these are the main things I'll take away with open fractures. So the direct compression of wheezer bleeding, I have antibiotics for an hour. This is usually co amoxiclav. But for your exams, if you ever say antibiotics, you don't need to learn the lens as per trust guidance gives you a big tick if it's a really dirty wound. So he's fallen in the street. He could have big bits of road grit in there. You could take those out with a pair of forceps at the bedside. Don't go delving in gross contaminants. The things that are very superficial, wash it with a bag of saline, get a little bit of initial washout done. Cos you might be worried this is an exposed joint even more clinical photography and something that I'm very passionate about because in hand over when I was on plastic. So we didn't know what was going on. You did a picture close up and far away, showing the joint above and below. So proper ways you can get the operative planning. Then we move on to all the rest of our orthopedic management, our four hours resuscitation. So we've already, we're in the middle of resuscitation. We're in a reduction. So this bone can't stay outside the body, it will die. So we need to reduce it. So once we've washed it out with a liter of saline, we've got some pictures. We use traction counts, traction to pull it back in. You can get an X ray before this. Usually they say you should never reduce blind. If you've got a neurovascular intact limb, I've seen people just reduce it, especially in A&E but you should ideally have an X ray before document a neurovascular assessment, median radial ulnar nerve, see your X ray and then reduce with the image guidance and then recheck your neurovascular status, post reduction once it's in the back slab. So to dress it before you go to put your back slab on. When you're reducing it with traction countertraction, you want some saline soaked gauze and then you do your back slab as normal above and below the joint. So in this, I'd want to have an above elbow back slab and that's the main way I would manage this. But I was the sho on at the moment. So we've managed that circulation, all his bloods are ticking on. We're gonna move on to disability and exposure all quite happy blood sugar is fine. Blood temperature is a bit raised but nothing too significant P said about head injury. Just to remind you of all of the nice guidelines about head injury. He does have a significant trauma history. So he may not fall into the CT head within one hour. He will always fall within an eight hour. So he may need regular G CS monitoring initially. So he will need a CT head at some point. This is his um X ray. So we have got this bone very high up here. Is your elbow joint. Should this bone be that high feeding question? No. And we can see the break here in the ulnar. We've got a widening of the radioulnar joint and a fracture of the ulnar. What is the name of this fracture? You want the picture of the thing? Um Come on. Uh like one of them has an A and one of them GIS wherever it's far, it's the way I remember it is all the way that pitch teaches you but Monte, it's proximal So this is a Monte open fracture. So what was sticking out? There was probably the radial head. So what do we do? We've done, we've put a backstab on. It's like very pretty as you can see, rib fractures, people underestimate how painful these are. It is very important to give these patients the analgesia early. Why if people aren't, are in pain and not breathing in deeply? Why is that a problem? Exactly that, especially in the elderly, they break ribs all the time. This is why I did a bit of research into this about really getting the right painkillers on at the right time in these patients. Because if you, we had a good rate of failed discharges in my old trust, you give them the right painkillers at the right point, fit with them, stop them, coming back from infections, stop them, coming back from painkillers. They are painful in my old trust as well. We had a whole policy for giving blocks directly into the nerve and the major trauma team was very good directly. Given that analgesia cos they need it and it really helps their long term recovery with that fracture. Are we happy in a cast? Yeah. Yeah. Who are able to reduce it? It's been reduced? Hm. And now we've put a back tab on can IX ray it again? It's a good position. Um Do we want to do some internal fixation before even that he needs a proper washout and debridement. So it's an open fracture. So there are key reasons you'd usually this fracture. He's on the road. There are no gross contaminants. He's neurovascular intact. He would be the first one on my trauma list the next day where we would wash out, wash out the wound, wash out the joint. If it's washed e debride, the wound edges by plastics, if the tissue is opposable, so you can close the wound, then I can put metal in because of the biofilm by bacteria seeding in there because metal is just a home for bacteria. If the wound cannot close, I would then stick with conservative management or consider an external fixator. Probably not in this morph if it was a lower limb. But the main thing would be is letting plastics put on a fat dressing, maintaining their wound, helping them prep for that and maintaining a reduction and restricting the joint to help with healing down the line. So with this, the operation he needs for sure is a wound washer and a bride plus minus fixation. If the wound closes and if plastics are happy, if this was more of a puncture and it closes directly, we're very happy to put in a fixation. But because this is quite an extensive wound, he may need longer management. Say Elvis fell into the Thames. Can I wait till morning to do is wash out and the bride? No. So there is a category of patients with grossly contaminated wounds. So it's more marine sewage and like farming. They're the wounds you take overnight cos they need washing out now because of the amount of bugs that grow in there. But if it's just someone who's fallen like Elvis in the street, you can wait till morning if you've done already, at least wash out in A&E. And I'm happy I've removed gross contaminants. They're the ones he can wait and then down the line, once the wound is closed or he needs a flap or he needs grafting when there's good soft tissue coverage of the bones, then I can look and fix it, which he will need because he's got a joint disruption. He's really well in the joint and it has gone approximately and he's got a fracture. So to maintain stability, play the screws.